Handbook of cognitive behavioral therapy. Vol. 2, Applications 9781433833502, 1433833506

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Copyright © 2021 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. The opinions and statements published are the responsibility of the editor and authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 https://www.apa.org Order Department https://www.apa.org/pubs/books [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from Eurospan https://www.eurospanbookstore.com/apa [email protected] Typeset in Meridien and Ortodoxa by TIPS Technical Publishing, Inc., Carrboro, NC Printer: Gasch Printing, Odenton, MD Cover Designer: Mark Karis Library of Congress Cataloging-in-Publication Data Names: Wenzel, Amy, editor. Title: Handbook of cognitive behavioral therapy / edited by Amy Wenzel. Description: Washington, DC: American Psychological Association, [2021] | Includes bibliographical references and index. | Contents: v. 1. Handbook of cognitive behavioral therapy: overview and approaches— v. 2. Handbook of cognitive behavioral therapy: applications. Identifiers: LCCN 2020033268 | ISBN 9781433833526 (v. 1; hardcover) | ISBN 9781433833502 (v. 2; hardcover) Subjects: LCSH: Cognitive therapy—Handbooks, manuals, etc. Classification: LCC RC489.C63 H356 2021 | DDC 616.89/1425—dc23 LC record available at https://lccn.loc.gov/2020033268 https://doi.org/10.1037/0000219-000 Published in the United States of America 10 9 8 7 6 5 4 3 2 1

CONTENTS

About the Editor ix Contributors xi

I. APPLICATIONS TO CLINICAL POPULATIONS

1

1. Depression 3 Daniel R. Strunk, Benjamin J. Pfeifer, and Iony D. Ezawa

2. Cognitive Behavioral Therapy for Anxiety Disorders

33

Kamila S. White and Vien Cheung

3. Obsessive-Compulsive Disorder

67

Christine Purdon

4. Cognitive Behavior Therapies for Posttraumatic Stress Disorder

99

Anke Ehlers and Jennifer Wild

5. Eating Disorders

149

Madelyn Ruggieri, Courtney McCuen-Wurst, and Kelly C. Allison

6. Addictions 177 A. Tom Horvath

7. Bipolar Disorder

207

Cory F. Newman

8. Psychosis 247 Neal Stolar and Rebecca M. Wolfe

9. Insomnia 291 Jason G. Ellis, Michael L. Perlis, and Donn Posner

 v

vi Contents

10. Cognitive Behavioral Therapy for Anger Management

331

Michael J. Toohey

11. Suicide Prevention

361

Abby Adler Mandel, Shari Jager-Hyman, and Gregory K. Brown

12. Adult Attention-Deficit/Hyperactivity Disorder

389

J. Russell Ramsay

13. Cognitive Behavioral Therapy for Chronic Pain

423

John D. Otis, Alex E. Keller, and Lydia Chevalier

14. Cognitive and Behavioral Treatments for Obesity

453

Jena Shaw Tronieri

II. MODALITIES AND SETTINGS 15. Cognitive Behavioral Group Therapy

477 479

Elizabeth J. Pawluk and Randi E. McCabe

16. Cognitive Behavioral Couple and Family Therapy

513

Frank M. Dattilio and Norman B. Epstein

17. Cognitive Behavioral Therapy in Primary Care

549

Robert A. DiTomasso, Scott Glassman, Christina Berchock Shook, Anna Zacharcenko, and Michelle R. Lent

18. Cognitive Behavioral Therapy for Inpatient Wards

589

Aaron P. Brinen

19. Cognitive Behavioral Therapy Delivered Using the Internet

607

Gerhard Andersson and Per Carlbring

20. Combined Cognitive Behavioral Therapy and Pharmacotherapy 633 Jesse H. Wright, Stephen S. O’Connor, Jessica Reis, and Michael E. Thase

21. Cognitive Behavioral Therapy Supervision

669

Donna M. Sudak and Robert P. Reiser

III. APPLICATIONS TO DIVERSE POPULATIONS 22. Children and Adolescents With Externalizing Disorders

697 699

R. Trent Codd III and Nathan Roth

23. Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders

725

Amber Calloway, Nicole Fleischer, and Torrey A. Creed

24. Cognitive Behavioral Therapy With Older People

751

Kenneth Laidlaw

25. Veterans and Military Service Members

773

Maegan M. Paxton Willing, Larissa L. Tate, and David S. Riggs

26. Cognitive Behavioral Therapy for Lesbian, Gay, Bisexual, and Transgender Populations Trevor A. Hart, Julia R. G. Vernon, and Tae L. Hart

795



Contents  vii

27. Ethnic Minority Cultural Adaptations of Cognitive Behavioral Therapy 823 Gayle Y. Iwamasa

28. Cognitive Behavioral Therapy for Religious Individuals

843

Moses Appel and David H. Rosmarin

Conclusion: Roots in the Past and Vision for the Future

871

Amy Wenzel

Index 879

ABOUT THE EDITOR

Amy Wenzel, PhD, ABPP, is a licensed clinical psychologist, owner and director of the Main Line Center for Evidence-Based Psychotherapy, faculty member at the Beck Institute for Cognitive Behavior Therapy, and certified trainerconsultant with the Academy of Cognitive Therapy. She has authored or edited 25 books and treatment manuals, many on cognitive behavioral therapy. She lives in the Philadelphia, Pennsylvania, suburbs. Visit http://dramywenzel.com and http://mainlinecenter.com for descriptions of her books, videos, trainings, and clinical practice. Follow her on Facebook at Dr. Amy Wenzel, Clinical Psychologist and on Twitter @dramywenzel.

 ix

CONTRIBUTORS

Kelly C. Allison, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Gerhard Andersson, PhD,Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden Moses Appel, MA,Center for Anxiety, New York, NY, United States Aaron P. Brinen, PsyD,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States Gregory K. Brown, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Amber Calloway, PhD,The Penn Collaborative for CBT and Implementation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Per Carlbring, PhD,Department of Psychology, Stockholm University, Stockholm, Sweden Vien Cheung, MA,Department of Psychological Sciences, University of Missouri, St. Louis, MO, United States Lydia Chevalier, PhD,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States R. Trent Codd III, EdS, BCBA,Cognitive-Behavioral Therapy Center of Western North Carolina, Asheville, NC, United States Torrey A. Creed, PhD,The Penn Collaborative for CBT and Implementation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Frank M. Dattilio, PhD, ABPP,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States  xi

xii Contributors

Robert A. DiTomasso, PhD, ABPP,School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States Anke Ehlers, PhD,Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom Jason G. Ellis, PhD, EBSM,Northumbria Sleep Research, Department of Psychology, Northumbria University, Newcastle, United Kingdom Norman B. Epstein, PhD,Department of Family Studies, University of Maryland, College Park, MD, United States Iony D. Ezawa, MA,Department of Psychology, The Ohio State University, Columbus, OH, United States Nicole Fleischer, MS,Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States Scott Glassman, PsyD,School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States Tae L. Hart, PhD,Department of Psychology, Ryerson University, Toronto, ON, Canada Trevor A. Hart, PhD, CPsych,Department of Psychology, Ryerson University; University of Toronto, Toronto, ON, Canada A. Tom Horvath, PhD, ABPP,Practical Recovery Psychology Group, La Jolla, CA, United States Gayle Y. Iwamasa, PhD, HSPP, VHA Central Office, Department of Veterans Affairs, Washington, DC, United States Shari Jager-Hyman, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Alex E. Keller, MA,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Kenneth Laidlaw, PhD,Department of Psychology, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom Michelle R. Lent, PhD,School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia PA, United States Abby Adler Mandel, PhD,Department of Psychology, The Catholic University of America, Washington, DC, United States Randi E. McCabe, PhD,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Courtney McCuen-Wurst, PsyD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Cory F. Newman, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Stephen S. O’Connor, PhD,Chief, Suicide Prevention Research Program, Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD, United States



Contributors  xiii

John D. Otis, PhD, Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Elizabeth J. Pawluk, PhD,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Maegan M. Paxton Willing, MPH, MS,Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States Michael L. Perlis, PhD,Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States Benjamin J. Pfeifer, PhD,Michigan Medicine/VA Ann Arbor Healthcare System, Ann Arbor, MI, United States Donn Posner, PhD, CBSM, DBSM,President, Sleepwell Consultants, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States Christine Purdon, PhD, Department of Psychology, University of Waterloo, Waterloo, ON, Canada J. Russell Ramsay, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Jessica Reis, MD, Residency Training Program, Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY, United States Robert P. Reiser, PhD,Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States David S. Riggs, PhD,Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States David H. Rosmarin, PhD, ABPP,McLean Hospital/Harvard Medical School, Belmont, MA, United States Nathan Roth, PhD,Department of Psychology, Western Carolina University, Cullowhee, NC, United States Madelyn Ruggieri, MS,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Christina Berchock Shook, PsyD, ABPP,VA Center for Integrated Healthcare, Syracuse, NY; School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States Neal Stolar, MD, PhD,Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Crozer Health, Upland, PA; nPSYGHT, King of Prussia, PA, United States Daniel R. Strunk, PhD,Department of Psychology, The Ohio State University, Columbus, OH, United States Donna M. Sudak, MD,Department of Psychiatry, Drexel University, Philadelphia, PA, United States Larissa L. Tate, MS, MPS,Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States

xiv Contributors

Michael E. Thase, MD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States Michael J. Toohey, PhD,Clinical Psychology PsyD Program, Antioch University Seattle, Seattle, WA, United States Jena Shaw Tronieri, PhD,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States Julia R. G. Vernon, BA,Simon Fraser University, Burnaby, BC, Canada Amy Wenzel, PhD, ABPP,Main Line Center for Evidence-Based Psychotherapy, Havertown, PA, United States Kamila S. White, PhD,Department of Psychological Sciences, University of Missouri, St. Louis, MO, United States Jennifer Wild, DClinPsy, Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom Rebecca M. Wolfe, MA,Serious Mental Illness Research Group, Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, United States Jesse H. Wright, MD, PhD,Director, University of Louisville Depression Center, Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY, United States Anna Zacharcenko, PsyD,School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States

I APPLICATIONS TO CLINICAL POPUL ATIONS

1 Depression Daniel R. Strunk, Benjamin J. Pfeifer, and Iony D. Ezawa

D

epression has a long history among mental health disorders, with a documented legacy dating back thousands of years to the time of ancient Greece (Hippocrates, 1923–1931, p. 185). In modern times, the disorder now ranks among the most common and greatest overall contributors to disability in industrialized countries (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators, 2016). In the United States, recent estimates suggest a 12-month prevalence of about 7% and a lifetime prevalence of about 16% (Kessler et al., 2003). The classic form of clinical depression, major depressive disorder (MDD), is defined by a distinct episode lasting two weeks or longer that includes either sad mood or anhedonia and a total of five symptoms from a list of nine, which also includes sleep disruption, change in weight or appetite, fatigue or loss of energy, psychomotor retardation or agitation, difficulty concentrating or indecisiveness, feelings of worthlessness or inappropriate guilt, and recurrent thoughts of death or suicide (American Psychiatric Association, 2013). These symptoms must cause clinically significant distress or impairment of functioning in social, occupational, or other important roles. These criteria allow for a remarkable degree of variability across people who are defined as experiencing depression. Those with depression vary in their experience of specific symptoms as well as the duration and intensity of those symptoms. Depression is a highly heterogeneous disorder with regard to both symptom presentation and etiology (Lorenzo-Luaces, 2015). Onset of MDD can occur at any age; however, during puberty, risk of onset increases substantially, with https://doi.org/10.1037/0000219-001 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

 3

4  Strunk, Pfeifer, and Ezawa

girls experiencing significantly higher rates than boys (Kessler et al., 2003). In some cases, MDD presents as a chronic disorder, whereas for others, episodes of depression remit and recur over time. Chronicity of depressive symptoms is associated with increased risk of comorbid personality, anxiety, and substance disorders, as well as reduced likelihood of full symptom remission following treatment (Klein & Black, 2017). Risk of recurrence is higher among those with more severe symptoms, multiple prior episodes of MDD, or residual symptoms during remission (Strunk & Sasso, 2017). Although some have suggested that MDD be considered primarily a highly recurrent or even chronic disorder, evidence also indicates that a substantial portion of cases are characterized by a single time-limited episode with no subsequent recurrences (Monroe & Harkness, 2011). In accordance with the heterogeneity observed in the symptoms and course of depression, there is also considerable variety seen in approaches to its treatment. Among these, the cognitive aspects of depression have attracted a great deal of interest, with research efforts in this area developing into a major theoretical perspective in the 1960s. Beck suggested that depression is characterized by overly negative views of one’s self, world, and future. Subsequent research has shown that people with depression tend to experience more negative thoughts than those without depression (Beck & Bredemeier, 2016), and focusing on negative thoughts appears to prolong depressive episodes (Nolen-Hoeksema, 1991). Researchers have debated whether the less positive views of those with depression tend to be inaccurately negative (as Beck had suggested) or might instead be realistic (i.e., the depressive realism hypothesis; see Alloy & Abramson, 1988). Although findings have been mixed (Moore and Fresco, 2012), there is evidence that patients with a clinically significant level of depression tend to exhibit key negative biases and that these biases may be particularly pronounced for emotionally engaging self-relevant judgments (Strunk & Adler, 2009; Strunk et al., 2006). Depression is also associated with increased elaboration of negative information and impaired ability to inhibit or disengage from negative cognition, even when it is irrelevant to the current task (Joormann & Gotlib, 2010). Those with depression also tend to engage more often in generally maladaptive emotion regulation strategies, such as avoidance, rumination, and suppression, and they use generally adaptive strategies, such as problem solving or reappraisal, less often than those who are not depressed (Aldao et al., 2010). Findings such as these support a view of depression in which cognition and emotion play central roles. In this chapter, we review several of the most prominent models of cognitive behavioral treatments for depression, addressing their theoretical rationale, evidence of treatment efficacy, possible mechanisms, and recent efforts to disseminate these treatments. We also address some of the special issues facing cognitive behavioral therapists working with patients with depression and discuss the impact of some of the most common comorbid conditions.1 Clinical examples are disguised to protect patient confidentiality.

1



Depression  5

MODELS OF COGNITIVE BEHAVIORAL TREATMENTS FOR DEPRESSION The models underlying cognitive behavioral approaches share a view that thoughts, behaviors, and emotions are fundamentally and dynamically interrelated, and that these relations can be leveraged to bring about meaningful improvement in dysfunctional or distressing psychological states. Some cognitive behavioral treatments aim to correct overly negative views thought to be associated with depression. Others are directed at promoting acceptance of these experiences rather than changing them per se. Still others aim to identify and leverage individual functional associations thought to maintain each individual’s depression. Although formalized cognitive behavioral therapies are less than half a century old, these foundational concepts have deep historical and philosophical roots. The Stoics of ancient Greece and thinkers from the Taoist and Buddhist traditions highly emphasized the relations between emotions and thought. For example, Epictetus (ca. 125/1955) wrote, “Men are disturbed not by things but by the views which they take of them” (p. 19). Leveraging the relations between thoughts, emotions, and behavior to treat psychopathology became a primary focus in clinical psychology during the 20th century. Freud developed a highly influential approach to the treatment of psychological distress by targeting unconscious cognitions through psychoanalysis. Although the primacy granted to unconscious drives is not part of most cognitive behavioral conceptualizations, the more fundamental insight that clinical improvement may be possible through individual verbal psychotherapy sparked significant development in psychotherapy theory and practice for the decades that followed. Many post-Freudian approaches have emphasized the role of effortful changes to maladaptive cognitive and behavioral processes in order to treat psychopathology. Although some behaviorists initially eschewed cognition as inessential and overly subjective, later theorists successfully integrated cognitive and behavioral approaches to understanding and treating mental health disorders. Among the various maladaptive processes examined in this integrated cognitive behavioral tradition, there has been a special interest in the role of inaccurate cognitions in causing psychological difficulties. For example, Lazarus, a student of the behaviorist Wolpe, suggested that behavioral change may either precede or follow the “correction of misconceptions” that is the primary aim of psychotherapy (Lazarus, 1972). Ellis’s rational-emotive psychotherapy explicitly connects “activating events” to “emotional consequences” via “intervening beliefs,” which may lead to dysfunction when based upon faulty assumptions (Ellis, 1957, 1962). Thus, cognition and cognitive change have occupied a central place in the cognitive behavioral models for decades. The most widely studied and disseminated of the cognitive behavioral psychotherapies is Beck’s cognitive therapy (CT; Beck et al., 1979), which was heavily influenced by these developments. We now discuss its application to the treatment of depression.

6  Strunk, Pfeifer, and Ezawa

Cognitive Therapy Aaron T. Beck (1967) put forth a cognitive model of depression that emphasized unrealistically negative views as playing a central role in the etiology and maintenance of depression. On the basis of this model, Beck et al. (1979) developed an active, structured psychotherapy aimed at correcting these negative thoughts and beliefs—a treatment they called cognitive therapy (CT). In CT, therapists and patients work together to identify the patients’ negative thoughts and beliefs and use a variety of cognitive and behavioral strategies in an effort to foster more realistic views. The primary focus in CT is on patients’ current problems, although attention can be directed to either the patient’s past or the therapeutic relationship as needed. Sessions are structured with therapists and patients working together to set and follow an agenda at each session. Rather than adhering to a highly prescribed session-by-session guideline, the CT manual calls for a flexible, principle-based approach in which each patient’s treatment is informed by their specific goals and individual case conceptualization. CT includes behavioral strategies, with these strategies being used primarily as a means of bringing about cognitive change. Among the most important of the behavioral strategies used in CT are self-monitoring and behavioral experiments. Self-monitoring involves patients recording their activities and moods, typically each hour across a number of days. Using self-monitoring data, the therapist and patient can work together to identify information that could be used to evaluate any of the patient’s negative predictions. Therapists can also use such data to help patients break down challenging activities into smaller, more easily accomplished parts. A particularly compelling approach occurs when a patient’s negative thoughts or beliefs can be effectively tested through a behavioral experiment. Behavioral techniques also often play an important role in addressing sleep difficulties. Finally, role-play and behavioral rehearsal can be important strategies in working with patients to develop assertive strategies for addressing interpersonal challenges. The primary focus of CT is working to identify, evaluate, and respond to negative thoughts and beliefs. Patients are taught to pay special attention to their automatic thoughts. Therapists introduce thought records as a vehicle to record the patient’s thoughts and feelings related to specific situations. Thought records also serve as key aids in the process of reevaluating one’s automatic thoughts, guiding patients through a series of questions that can help them arrive at more complete, accurate reevaluations of their initial thoughts. As treatment progresses, therapists work with their patients to identify and evaluate patients’ schemas or core beliefs. Patients’ specific thoughts are understood as being influenced by their schemas (i.e., basic cognitive structures that organize information; Beck et al., 1979). Recognition of one’s core beliefs is thought to promote recognition and successful responding to one’s automatic thoughts as well as ultimately fostering change in these beliefs.



Depression  7

Behavioral Activation and Problem-Solving Therapy Behavioral activation (BA) is a therapy that emphasizes the use of focused activation strategies to help depressed patients approach and access sources of positive reinforcement in order to reduce depressive symptoms (Martell et al., 2001). BA is based in the contextualist tradition (see Ferster, 1973), defining depression as the result of unconditioned responses to an environment either devoid of positive reinforcement or saturated with punishment. Emphasis is placed on the role of avoidance behaviors in particular, which further reduce the availability of positive reinforcers and intensify depression. BA promotes increased activation as the remedy for this cycle of avoidance and depression. A key distinction between BA and CT, which includes many of the same behavioral techniques, is the therapist’s aim in implementing behavioral change. In CT, a primary target of behavioral change is cognitive change (Beck et al., 1979; Hollon, 1999), whereas the rationale for BA suggests that behavioral change alone is sufficient to treat depression. Problem-solving therapy is a cognitive behavioral intervention based on the relational/problem-solving model of stress (Nezu et al., 2013), which identifies effective problem solving as an important moderator of the effects of life stress on negative physical and mental health outcomes. The treatment is primarily focused on improving (a) the patient’s problem orientation, defined as a set of generalized beliefs, attitudes, and emotional reactions to problems in living and one’s ability to cope with them, and (b) problem-solving style, which refers to the patient’s cognitive and behavioral tools for coping with stressors. The program begins with didactic presentation of the developers’ model of problemsolving training, which includes discussion of effective problem orientation, problem formulation, generation of alternative solutions, decision making, and solution implementation and verification. Patients are assisted in implementing these tools in domains relevant to their lives, including the use of homework assignments to help generalize skills. Cognitive Behavioral Analysis System of Psychotherapy The cognitive behavioral analysis system of psychotherapy (CBASP; McCullough, 2000) is another package used in the treatment of individuals with depression. James McCullough developed CBASP in an attempt to emphasize the role of interactional issues that were less emphasized in preceding cognitive behavioral theories and treatment approaches to depression (i.e., those that primarily focused on intrapersonal cognitive and behavioral aspects). The model underlying CBASP is that depression is characterized by Piagetian preoperational thinking (i.e., a stage of cognitive development marked by lacking concrete and abstract logical reasoning), which maintains depression. Treatment is focused on helping patients recognize they are disconnected from their environment and environmental consequences/feedback, and their sense of helplessness/ hopelessness is an indication that they have not yet recognized their connection

8  Strunk, Pfeifer, and Ezawa

to the world. The model underlying CBASP represents a blend of cognitive, behavioral, interpersonal, and psychodynamic perspectives. Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT; Hayes et al., 2012) encourages patients to accept their experiences, including their experiences of depression, without trying to change them directly. Using a process called cognitive defusion, patients are encouraged to see that their thoughts convey no inherent meaning. The emphasis on recognizing that one’s thoughts do not convey inherent truth was referred to as distancing in Beck’s CT. In fact, early writings about ACT called it comprehensive distancing. Treatments Focused on Preventing Relapse and Recurrence As we describe in more detail later, one of the key empirical findings regarding CT is that it appears to offer patients not only acute symptom relief, but also effects that endure long after treatment has ended. Rather than working to develop an acute treatment that also offers enduring effects, some treatment developers have used alternative approaches. One alternative is to continue the use of cognitive behavioral treatment after acute treatment has proven successful (i.e., continuation treatment; Jarrett et al., 2013). A second alternative is to develop treatments not intended to serve as acute treatments, but which nonetheless may offer protection from relapse and recurrence when provided after someone has recovered from a depressive episode. Taken together, available evidence suggests that these various kinds of cognitive behavioral approaches appear to provide some protection from risk of relapse following remission (Hollon et al., 2006; Vittengl et al., 2007). In this section, we review three treatments developed for preventing relapse and recurrence: mindfulness-based CT (MBCT), well-being therapy (WBT), and preventive CT (PCT). MBCT typically involves 8 to 10 weekly 2-hour sessions, with daily meditation practiced outside of session. The first few sessions are focused on becoming aware of how the mind wanders and how to refocus it. The next few sessions are then focused on how to handle mood shifts. The last session of MBCT involves encouraging patients to become aware of personal warning signs of impending relapse and to develop specific plans on how to handle this occurrence. This treatment combines techniques from both traditional CT for depression and mindfulness meditation (Segal et al., 2002). The mindfulness aspect of this therapy involves working toward a nonjudgmental awareness of the present moment and environment. Patients are taught to practice meditation and breathing techniques, as well as to become more aware of their thoughts, emotions, and bodily sensations. By practicing these techniques, patients develop the ability to decenter and relate to their emotions and thoughts in a more accepting way. These techniques are practiced with the aim of preventing negative rumination and subsequent depressive relapse. Thus, patients learn to



Depression  9

both adopt more realistic and skillful responses to unwanted thoughts and accept unwanted thoughts in a manner that is thought to protect against rumination and mood worsening. WBT is another prevention effort that involves cognitive and behavioral techniques, but complemented with elements of psychological well-being (Fava, 1999a, 1999b). It is usually conducted over eight weekly sessions with structured homework assignments completed between sessions. The first sessions of WBT involve teaching and encouraging patients to keep a diary to track thoughts, emotion, and behaviors that affect the patient’s sense of well-being. These connections are then discussed and evaluated in session. Patients are also encouraged to increase activities that lend to a positive sense of well-being. Later sessions of this treatment then focus on identifying and discussing thinking errors and finding alternative thoughts. PCT is also a modified form of traditional CBT that was developed for relapse and recurrence prevention of depression (Bockting et al., 2005). PCT typically involves eight weekly, 2-hour sessions conducted in a group-therapy format. The groups usually consist of seven to 12 patients and the therapist. Though PCT is a CBT-based program, PCT is comparatively less focused than traditional CBT on modification of current negative, dysfunctional thoughts. Instead, PCT treatment begins with focus on the identification of core dysfunctional attitudes, assumptions, and beliefs that are often latent, but easily activated, in remission. Once identified, PCT uses CT techniques (e.g., Socratic questioning) to challenge the attitudes, assumptions, and beliefs. In a similar manner as traditional CBT, patients are encouraged to practice techniques outside of the sessions. Moreover, patients are encouraged to keep a diary of positive experiences to help the storage and retrieval of specific positive memories. In addition, the last session in PCT involves developing individual prevention plans. These plans include identification of warning signals for relapse, such as psychological vulnerability factors and expected stressful events, and helpful strategies to use when these warning signals occur.

SPECIAL CONSIDERATIONS WITH PATIENTS WITH DEPRESSION Cognitive behavioral therapists should be mindful of some special concerns related to the treatment of depression. Most significantly, depression can be a fatal disorder. The prevalence of suicide among those with MDD is estimated to be between 2% and 6% (Michaels et al., 2017). Significant risk factors for a suicide attempt include having a specific plan for attempting suicide, being within a year of the initial onset of suicidal ideation, previous suicide attempts, hopelessness, and comorbid psychiatric disorders (Beck et al., 1985; Kessler et al., 1999; Suominen et al., 2004). Joiner’s interpersonal theory of suicide emphasizes three factors that increase risk for suicide: perceived burdensomeness, thwarted belongingness, and acquired ability/access to means of suicide (Joiner, 2005). Therapists must be aware of suicide risk factors, carefully assess

10  Strunk, Pfeifer, and Ezawa

suicidality throughout treatment, and actively work with patients to prepare a crisis plan. It is critical that therapists gain an accurate understanding of the nature, duration, and intensity of their patients’ thoughts, plans, and prior experiences regarding suicide. Inaccurate assessment may obscure the true risk of an impending suicide attempt, with potentially devastating consequences— whether it results in a patient’s death or the termination of therapy following disproportionate action taken by the therapist. Providers of CBT also must contend with the fact that lack of motivation and low energy are common symptoms of depression and may undermine patients’ efforts to make the changes that are a key focus in CBT. Therapists commonly hear patient reports that depression interfered with completing homework, contributed to their arriving late, or caused them to miss sessions altogether. Such experiences can be viewed as “grist for the mill,” or experiences that can be used to highlight the application of CBT procedures for overcoming such obstacles. Strategies such as structuring activities and working to counteract negative views as one undertakes such efforts are especially important. In the vignette below, we illustrate one way a therapist might help a patient to overcome difficulty in completing an early homework assignment. THERAPIST:

Let’s take some time to talk about the homework from last week. How did it go tracking your mood with the activity log?

PATIENT:

Well, I started filling it out, but then it slipped my mind and the week got away from me. I think I left it at home.

THERAPIST: Sounds like you had some trouble with it. Why don’t we start by

going back to the last moment you thought about working on it? Do you remember when that was? PATIENT:

I think it was the day after our last session. I realized that I hadn’t filled it out at all that day—I think I realized it sometime that night, just before bed.

THERAPIST: Okay. That sounds important. Do you remember how you felt at

that time? PATIENT:

I felt really down about it. I was disappointed in myself. Here I am finally in therapy working on what seemed like a pretty straightforward assignment and I can’t even do that.

THERAPIST: I know you were disappointed, but I’d like to point out that

you’re doing a great job identifying your thoughts and feelings now. It sounds like you took not filling out the form as an indication of your inability to do well in therapy. PATIENT:

Well, yeah. If I can’t do this, I didn’t really see how I was going to succeed in this treatment. We’re just getting started, and I’m already falling short.



Depression  11

THERAPIST: Okay, so you took this as a strong indicator about how you’ll do

in treatment. Do you imagine others have struggled with this assignment? PATIENT:

I wasn’t thinking about it, but I suppose some have.

THERAPIST: Absolutely. It’s very common. And nonetheless, people who

struggle with the assignment initially often go on to have very positive results with treatment. Remembering to do the assignment regularly is almost always a challenge for folks. Fortunately, it doesn’t have to be perfect to be useful to us. So, if you miss some time, you can just do your best to fill in what you missed. PATIENT:

Okay, I know we talked about checking in with the form at least twice a day, at lunch and around bedtime.

THERAPIST: How did that work as a plan? PATIENT:

It was okay, but I was busy at lunch and missed the check-in. Then, it seemed like I had really gotten off track with my plan when I looked it over in the evening and there wasn’t much filled out.

THERAPIST: Okay, and once you were off track then you didn’t continue

with the assignment? PATIENT:

Yeah, I thought I had already messed it up, so there really wouldn’t be much point in doing it partially.

THERAPIST: It is true that filling it out more completely is helpful, but we’re

often able to learn a lot from it—even if it’s only partially completed. Actually, sometimes the missing parts are quite informative. Our discussion here has led us to highlight some ways you were thinking about the assignment that served to make it harder to keep up with it. PATIENT:

I guess that’s true.

THERAPIST: I wonder, if we try this again and you miss some time filling it

out, are there some things that would be important to remind yourself of, so that you’re able to keep working on it? PATIENT:

Well, I could remind myself that it’s not uncommon to miss some time when tracking.

THERAPIST: Terrific. I think that’s a great thing to remember. Let’s jot that

down. Could you write that as a reminder on this new activity log I have for you? . . . Any other reminders you would want to note?

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PATIENT:

I could also remind myself that we can still learn from the assignment if I do it partially.

THERAPIST: Super! I think that will be really key. Let’s jot that down too. PATIENT:

Okay, got it.

THERAPIST: I think it could be really helpful to have those reminders at the

ready when you’re working on the form. What do you think? PATIENT:

It could help.

THERAPIST: Nice. Now, why don’t we go back and try to recreate a record of

some of the moods and activities you’ve experienced over the past few days and see what we can learn from that. This vignette was intended to illustrate how a therapist can use a cognitive approach to helping patients identify and overcome obstacles to successfully working on therapeutic assignments. Another concern that can arise in CBT for depression is that patients may either misunderstand or have concerns about the treatment rationale. Two of these merit special attention. First, some patients may misunderstand CBT and believe they are being asked simply to “think positively.” CBT’s focus on weighing evidence for and against negative automatic thoughts and considering more realistic alternatives does not amount to endorsing positive thinking in the absence of supporting evidence. If one simply rehearses positive thoughts to replace negative ones without regard for the evidence, the new thoughts may not be believable and therefore may not promote lasting improvements. In fact, there is some evidence to suggest that among those who respond to CBT, those who show extreme positive thinking have a greater risk of relapse (Forand & DeRubeis, 2014; Teasdale et al., 2001). It may be that those patients whose takeaway from CBT is to replace negative thoughts with positive ones, without a careful review of the evidence for those views, are at greater risk of relapse. THERAPIST: [after discussing the CBT rationale] What’s your reaction to

hearing about the approach we take in CBT? Do you have any thoughts about why it might or might not be helpful for you? PATIENT:

I don’t think so. I guess I can try it.

THERAPIST: You sound hesitant. Are there any parts of the treatment that

you are concerned about? PATIENT:

To be honest, I’ve tried to replace negative thoughts with positive thoughts. It just hasn’t worked for me. So I am not sure what’s going to make it work now.



Depression  13

THERAPIST: Okay, I really appreciate your sharing your concern with me. I

agree with you that just replacing our negative thoughts with positive ones may not be a great strategy. If you try to change your view just by thinking more positively, it can be difficult to sustain, because there’s not much making those more positive views believable. That’s why our approach is a bit different than that. In CBT, we will really emphasize examining evidence to carefully evaluate any automatic thoughts we consider. It’s only following this careful examination of evidence that we would try to formulate new thoughts—thoughts that align closely to what a careful review of the evidence supports. PATIENT:

I feel like my negative thoughts are often more accurate than any optimistic thoughts I might try to come up with.

THERAPIST: Some of your negative thoughts may be true, or may have

important elements of truth to them. To the extent your negative thoughts are true, we’ll talk about the best ways to cope with your situation. But we generally find that for people with depression, even if there’s some truth to their automatic thoughts, there are very often some overly negative aspects as well. So I would just ask that you keep an open mind to see what the process of evaluating your thoughts more carefully might reveal. Often times, people with depression are surprised to see there are different, more realistic ways to look at things. And these changes in their thoughts can often lead to improvements in your mood. Would you be willing to try it out? THERAPIST: Yeah, I guess so. I like the idea that I will be strengthening my

thinking by making it more rooted in facts, instead of just changing it to something more positive. A second potential misunderstanding emerges if patients interpret their therapist’s efforts to evaluate evidence for their beliefs as failing to recognize and appreciate their truly difficult life circumstances. Some patients may respond with frustration if they believe their therapist does not accurately understand the extent of their pain and hopelessness. This is an unfortunate scenario because many cognitive behavioral techniques can be used to alleviate suffering and bolster problem-solving skills even in terribly difficult circumstances. Cognitive behavioral therapists must repeatedly articulate the cognitive behavioral model to clear up such misunderstandings when they arise. Therapists should both be able to distinguish validation of patients’ emotions from validation of the accuracy of patients’ thoughts and beliefs and also be cognizant of the ways CBT techniques can be beneficial even when circumstances are bleak (e.g., major losses such as homelessness or terminal illness).

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EFFICACY OF COGNITIVE BEHAVIORAL TREATMENTS FOR DEPRESSION We now turn to evidence regarding the efficacy of cognitive behavioral treatments. We cover these selectively, focusing on a few treatments that have been particularly well studied. The most extensively studied of these treatments is CT. The strongest evidence for the efficacy of CT comes from trials comparing it with antidepressant medication. Taken together, evidence from these trials suggests that the acute (e.g., 12- to 16-week) effects of CT are comparable to antidepressant medication. However, this comparison has not been without controversy. Findings from the Treatment of Depression Collaborative Research Program (TDCRP) raised the possibility that for more severe forms of depression, antidepressant medication may be more efficacious than CT. In a reanalysis of data from that trial (Elkin et al., 1995), an initial depressive symptom severity by treatment interaction suggested that medication was more efficacious than CT, but only among the more severely depressed patients. Nonetheless, this pattern was not evident in an analysis that pooled data from four trials including the TDCRP (DeRubeis et al., 1999). In a subsequent larger trial focused on moderate to severe depression in outpatients, the investigators failed to find an overall difference between CT and medication, with both treatments showing the same response rate of 58% after acute treatment (DeRubeis et al., 2005). Thus, the best available evidence suggests that CT and medication do not differ in their acute impact on depressive symptoms. This is true both overall and specifically among more severely depressed patients. Whereas initial depressive symptoms do not appear to serve as a moderator of the impact of CT versus medications on depressive symptoms, initial depressive symptoms do appear to be a vital moderator of specific effects of a treatment relative to a control treatment. In an analysis of data from six trials, Fournier et al. (2010) found that the advantage of medication over pill placebo was moderated by initial symptom severity. Medication outperformed placebo at moderate to high levels of depressive symptoms, with the greatest benefit observed among patients in the very severe group (Cohen’s d = 0.47), but this difference was small and nonsignificant for those with mild-to-moderate depressive symptoms. A similar moderating effect has been reported for the comparison of psychotherapy and control conditions; the difference varied as a function of initial severity with the difference only being clear among the more severely depressed patients (Driessen et al., 2010). Thus, the specific benefit of current treatments for depression does appear limited to moderate-to-severe depression. For mild-to-moderate depression, there is little evidence that any treatment offers specific benefits (above those offered by a control condition). Having considered evidence relevant to evaluating the acute outcomes of CT, we now consider long-term outcomes. CT includes a strong emphasis on fostering a set of coping skills that patients can use after the conclusion of treatment to help prevent relapse and recurrence. Across trials examining cognitive



Depression  15

behavioral treatments for mood and anxiety disorders, much of the available evidence indicates that CT has strong enduring effects (Hollon et al., 2006). Following the sample of moderately to severely depressed patients who participated in the DeRubeis et al. (2005) trial, Hollon et al. (2005) examined the patients who responded to CT or medication. Those who responded to medication were randomized either to continue their medication or to switch to a pill placebo. Relapse rates over the 1-year follow-up period were 76% for discontinued medication, 47% for continued medication, and 31% for prior CT. Patients with prior CT were at significantly lower risk of relapse in the year following treatment than patients who discontinued medication. Cuijpers et al. (2013) found a similar pattern of results when aggregating follow-up data from 506 patients across several trials. In this meta-analysis, for every five patients treated with CT rather than discontinued medications, a relapse was prevented. When considering both acute and long-term outcomes, the advantages and disadvantages of CT and medication become clear; the choice appears to be between what could be a time-limited course of CT (that confers enduring effects) or medication continued for an extended period. In fact, patients are often encouraged to stay on medications indefinitely. The comparison of long-term outcomes for medication and CT raises important questions. Are the observed long-term differences in these treatments attributable to the effects of having participated in CT? Or are they attributable to the negative consequences of discontinuing medication? What accounts for prior exposure to CT outperforming discontinued medication? If one assumes that any effects of medication are short-term, then one would be likely to look to what patients learned in CT to explain this difference. However, common clinical trial designs have not ruled out the possibility that medication, well after it has been discontinued, might increase people’s vulnerability to depression (Andrews et al., 2011; Whitaker, 2010). This is because trials have focused overwhelmingly on testing drug–placebo differences to evaluate acute effects and continued–discontinued medication differences following treatment to evaluate long-term effects. Drawing on comparisons of CT and other psychotherapies, there is some evidence that what patients learn in CT specifically may serve to protect them from relapse. In their examination of long-term outcomes in a clinical trial of CT and ACT for mixed anxiety and depression, Forman et al. (2012) found that patients who had received CT reported significantly less depressive symptomatology and better functional outcomes than those who had participated in ACT. Specifically, at the 18-month follow-up, about one-third more CT patients than ACT patients were in the normative range of depressive symptoms, and more than twice as many CT patients than ACT patients were in the normative range of social/occupational functioning. Nonetheless, there is still a substantial need for well-powered, head-to-head randomized comparisons evaluating the long-term effects of CT versus other forms of psychotherapy. In addition to CT, several other forms of CBTs also have established efficacy as treatment for depression. BA, CBASP, and problem-solving therapy are

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among those recognized by the American Psychological Association, Division 12, as having strong research (American Psychological Association, 2018). BA has garnered considerable attention in recent years, perhaps due to the claim that it can be implemented successfully with clinicians with minimal qualifications in the absence of extensive training. An early trial supporting the efficacy of BA was a component analysis study of CBT for depression (Jacobson et al., 1996). In this study, the investigators found no differences in treatment outcome between CBT and BA. In a subsequent trial comparing BA, CT, medication, and placebo, the researchers compared the treatments separately for more and less severely depressed patients. Among the more severely depressed portion of the sample, BA did not differ from medication and significantly outperformed CT (with no differences in the less severe part of the sample; Dimidjian et al., 2006). Longitudinal follow-up of relapse and recurrence suggested that both BA and CT did well, outperforming discontinued medication (Dobson et al., 2008). These results are quite promising for the efficacy of BA. What about the clinical benefits of treatments intended to reduce risk of relapse or recurrence among patients who recently responded to another treatment? MBCT is among the more commonly studied of these treatments. Evidence suggests that MBCT does provide protection against relapse or recurrence, but this is limited to patients who have a history of a number of depressive episodes (Teasdale et al., 2000). A meta-analysis of six trials examining the prevention of relapse following MBCT for depression reported that MBCT patients’ risk of relapse was reduced by 34% compared with those receiving treatment as usual or placebo, and that those patients with three or more prior episodes of depression experienced a relative risk reduction of 43% (Piet & Hougaard, 2011). In addition, a recent component analysis of MBCT failed to find that the specific treatment strategies incorporated into the treatment yielded any better outcomes than a rigorous control condition that lacked those treatment components (Britton et al., 2018).

DISSEMINATION AND IMPLEMENTATION After establishing the efficacy of a treatment, testing its effectiveness is important to evaluating the generalizability of the treatment’s benefits in the “real-world” conditions in which it may be used. Some key limitations common to many dissemination practices for evidence-based therapies have been identified, including poor assessment of treatment fidelity, little follow-up to assess the long-term effects of the intervention, and inadequate development of evidence-based training procedures (Karlin et al., 2012; Rakovshik & McManus, 2010; Shafran et al., 2009). Considerable systemic obstacles to dissemination are also apparent, including insufficient supply of trained mental health professionals, inadequate support for mental health service delivery, enduring stigma toward mental illness and treatment, as well as a potential for cultural incompatibilities with evidence-based practice (Damschroder et al., 2009;



Depression  17

Kanter & Puspitasari, 2016; Karlin et al., 2010; Lewis et al., 2016). Researchers have called for more comprehensive efforts to evaluate dissemination programs (McHugh & Barlow, 2010), and there are several notable efforts for depression underway. We note a few of the larger efforts, which focused on CT-inspired CBT and BA. The single largest dissemination and implementation program in the United States for CBT for depression is the Department of Veterans Affairs (VA) CBT-D program (Karlin et al., 2010). With the goal of training VA personnel (psychologists, psychiatrists, social workers, and advanced practice nurses) to competency, CBT-D includes experiential training workshops to teach the theory and application of CBT, as well as ongoing weekly consultation with CBT experts, following a manual specifically adapted for veterans and service members. The treatment approach is an adaptation of CT for depression. Initial results from this program were that over 80% of therapists who participated in the program completed all elements of training and achieved competency; however, the way in which these efforts impact therapeutic outcomes relative to alternatives is a vital question that remains (Karlin et al., 2012). In the United Kingdom, the Improving Access to Psychological Therapies (IAPT) program is an effort to expand access to psychotherapy based on cognitive behavioral principles among adults with anxiety and depression (Keen & Freeston, 2008; McManus et al., 2010). Several thousand providers have been trained through IAPT, with plans to train thousands more in the coming years. IAPT utilizes a stepped-care model, with separate training programs for high-intensity CBT therapists and low-intensity psychological well-being practitioners (PWPs; Clark, 2018). Many people with mild-to-moderate depression or anxiety disorders first receive treatment from a PWP, which could include computerized CBT, psychoeducational groups, or guided self-help. Those who do not improve are then offered treatment with a high-intensity therapist trained in one of the evidence-based therapies recommended by the National Institute for Health and Clinical Excellence. All therapists receive weekly supervision. Pre-post outcome scores were available for over 90% of patients, and 40% of patients met clinical cutoffs for recovery at posttreatment (Gyani et al., 2013), suggesting the potential promise of such a program. Some have advocated for greater efforts toward disseminating BA as opposed to CT on the basis that BA may require less intensive training that could be completed at a lower cost (Martell et al., 2001). In a recent noninferiority trial (i.e., a trial to test whether one treatment is comparable to another), BA provided by less expert therapists appeared to yield effects over 1 year that were comparable to those achieved with CT (Richards et al., 2016).

COMORBIDITY AND OTHER COMPLICATING FACTORS A commonly raised concern regarding the effectiveness of CBT for depression is whether its effects are attenuated for complex presentations. In addition,

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some have suggested that comorbid conditions are associated with weaker treatment outcomes in CBT for depression, but also that the compromised performance of treatment can be limited by using highly competent therapists (Kuyken & Tsivrikos, 2009). Below, we review evidence for the efficacy of cognitive behavioral treatments for depression in cases with complex or comorbid presentations. Persistent/Recurrent MDD A considerable portion of those with MDD experience recurrences (Strunk & Sasso, 2017). CBT has a documented enduring effect that reduces the risk of relapse or recurrence (Hollon et al., 2005, 2006) and appears to persist for years after treatment (Paykel et al., 2005). Continuation CBT (i.e., continued sessions provided following acute treatment, often occurring less frequently) also reduces risk of relapse (Vittengl et al., 2007). For patients with three or more previous episodes, MBCT appears to be an effective treatment for relapse prevention (Kuyken et al., 2008; Piet & Hougaard, 2011; Teasdale et al., 2000). Unstable remission, prior episodes of MDD, childhood trauma, and early age of onset have been identified as markers of risk for relapse and recurrence that might be used to select patients for relapse prevention strategies or continuation treatment following remission (Bockting et al., 2015). Anxiety Disorders Although CBT is an efficacious treatment for both depression (DeRubeis et al., 2005) and anxiety disorders (Chambless & Peterman, 2004) separately, the way in which comorbid anxiety impacts the treatment of depression has been a source of some controversy. Comorbidity between depression and anxiety is common, leading some to suggest that anxiety and depressive disorders have significant diagnostic overlap (Zajecka & Ross, 1995) and shared etiology (Moses & Barlow, 2006). When anxiety is comorbid with depression, prognosis is poorer (Zajecka & Ross, 1995), there is a greater likelihood of residual symptoms and risk of relapse (Keller & Hanks, 1995), rates of improvement slow, and dropout rates increase (Brown et al., 1996). Generally, those who respond to treatment for one disorder tend to experience improvement in both depression and anxiety (Allen et al., 2010; Emmrich et al., 2012; Tsao et al., 2002, 2005). Nonetheless, a common dilemma facing therapists of patients with comorbid depression and anxiety is whether to tackle one of the two issues first, or whether to try to integrate the treatments in some way. Although not focused on depression specifically, Craske et al. (2007) randomized patients with panic disorder to either CBT for that disorder or CBT that allowed for “straying” to comorbid disorders. The focused form of CBT yielded better outcomes, raising the possibility that treatments might optimize outcomes by focusing on one core clinical problem at a time. Similarly, Gibbons and DeRubeis (2008) found that to the extent to which therapists



Depression  19

providing CT for depression strayed to address anxiety (as opposed to depression), their patients tended to achieve less improvement in both depression and anxiety symptoms. Taken together, these results suggest that various treatment procedures may be effective in cases involving comorbid depression and anxiety disorders, but that switching too frequently between them may undermine overall effectiveness. Personality Disorders There is a commonly held view that comorbid personality disorders (PDs) are a poor prognostic indicator in the treatment of MDD, though findings and conclusions regarding them have been mixed (Kool et al., 2005; Newton-Howes et al., 2006). However, a recent meta-analysis coauthored by those who had been on opposing sides of this issue showed that comorbid personality disorder diagnosis does predict poorer treatment outcome among patients with depression. In their analysis, those with a comorbid personality disorder were more than twice as likely as those without to experience a poor outcome (odds ratio = 2.16; confidence interval [1.83, 2.56]; Newton-Howes et al., 2014). In a large trial of CT for depression versus medication, medication outperformed CT when comorbid PDs were present, but CT outperformed medication among those without comorbid PDs (Fournier et al., 2008). Patients with comorbid PDs had a 44% response rate compared with 66% among medication patients; however, for those who did respond to acute CT, nearly all experienced a sustained response. These results, taken together, suggest that comorbid PDs complicate treatment of depression and make a poorer response likely. Some evidence suggests that medication may have an advantage over CBT in the treatment of depression with personality disorders; however, efforts to replicate such findings are needed. Substance Use Disorders According to the National Epidemiologic Survey on Alcohol and Related Conditions, the 12-month prevalence of comorbid substance use disorders among those with MDD is estimated to be 19% (Grant et al., 2004). In the majority of these cases, the onset of substance use disorders is temporally secondary to that of MDD (Kessler et al., 1997). A recent meta-analysis concluded that combined CBT and motivational interviewing (MI) outperformed treatment-as-usual for alcohol use disorders with comorbid depression (Riper et al., 2014). These results suggest that targeting both substance use and depression simultaneously may be an effective approach, with preliminary evidence that computer-based treatments may have similar efficacy as individual face-to-face CBT/MI (Kay-Lambkin et al., 2009). However, a major limitation in this literature is that many studies of CBT for depression exclude cases involving substance use disorders, particularly substance dependence. As a result, comparatively little is known about whether comorbid substance use disorders interfere with CBT for depression.

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Medical Conditions Numerous studies have posited a link between depression and physical health outcomes. In a World Health Organization survey, results showed that MDD is present in 9% to 23% of those with chronic physical diseases such as cardiovascular disease, arthritis, asthma, and diabetes. Depression is also commonly associated with chronic pain (Bair et al., 2003; Breivik et al., 2006), and patients with depression are three times more likely to be noncompliant with medical treatment recommendations than those without depression (DiMatteo et al., 2000). These findings suggest that depression may compound the effects of serious medical issues. CBT for depression appears to be associated with benefits in the treatment of such conditions; for example, the combination of CBT and supportive diabetes education outperformed supportive diabetes education alone in achieving remission of depression, as well as in follow-up mean glycosylated hemoglobin levels among patients with Type 2 diabetes and comorbid MDD (Lustman et al., 1998). CBT has also been associated with improvements in perceived disability and current pain in the treatment of nonspecific chronic low back pain (Smeets et al., 2006), and it is increasingly a topic of study as a treatment for a variety of chronic pain conditions (Turner et al., 2007). Another area of interest is the use of CBTs, especially mindfulness-based approaches, to reduce depression in cancer patients (Cramer et al., 2012; Shennan et al., 2011).

MECHANISMS OF CHANGE Because psychotherapies are long, complex interventions, evidence of the efficacy of such interventions leaves important questions about which aspects of the treatments are responsible for therapeutic gains unanswered. Psychotherapy process research seeks to address these questions by assessing the degree to which variability in therapeutic procedures is related to therapeutic outcomes. In assessing the fidelity of a treatment (i.e., the degree to which a treatment is delivered as intended), three aspects have been highlighted: (a) competence (i.e., the skillfulness or quality with which the treatment is provided), (b) adherence (i.e., the extent to which the therapist acts in accordance with the treatment manual), and (c) differentiation (i.e., delivery of the intended and not other interventions; Perepletchikova et al., 2007). Of these process variables, adherence and competence have received the most empirical attention. Remarkably, meta-analytic estimates suggest that adherence and competence are not related to therapeutic outcome on average (r of .02 and .07, respectively; Webb et al., 2010). As one evaluates this literature more closely, it becomes clear that there are many important methodological choices researchers make in conducting such research. Investigators have made a variety of choices across studies, yielding a collection of studies that vary considerably in their methods and analytic approach. Because important decisions about a therapist’s ability to provide a treatment are often based on assessments of competence, we focus first on research



Depression  21

examining the relation between competence and outcome. The most commonly used measure of competence is the Cognitive Therapy Scale (CTS; Young & Beck, 1988)—a rating of competence typically made on the basis of observing a single CT session. As noted, the overall evidence for this association has been quite mixed. To our knowledge, only one study has reported a finding that competence predicts subsequent outcome in CBTs for depression (Strunk, Brotman, DeRubeis, & Hollon, 2010). In a sample of 1,247 patients treated by 43 therapists as part of the British government’s IAPT program, they did not find a significant correlation between CBT competence and outcome (Branson et al., 2015). However, when they compared the outcomes of the caseloads of the most and least competent therapists, they did find a small difference in favor of the most competent therapists with regard to improvement in symptoms of anxiety. To place this evidence in context, it is important to consider the factors working against the detection of a competence-outcome association. There have been major concerns raised about the reliability of CTS competence ratings (Jacobson & Gortner, 2000; Schmidt et al., 2018). In addition, variability across patients in the degree to which high-quality therapy is required (or sufficient) to produce a positive outcome likely impacts estimates of the relationship between competence and outcome. In one analysis, therapist competence was more strongly related to outcome among patients whose characteristics suggested that they would be more difficult to treat (Strunk, Brotman, DeRubeis, & Hollon, 2010). Despite the overall lack of evidence for a relation between adherence and outcome, several studies of adherence to cognitive strategies in CT for depression specifically predict subsequent therapeutic gains. In two studies of CT, when therapists in an early session of CT utilized more of a set of techniques termed “concrete” (i.e., problem-focused), patients went on to experience greater overall symptom reduction (DeRubeis & Feeley, 1990; Feeley et al., 1999). Following these studies, a factor analysis in a larger sample suggested three adherence factors in CT for depression: cognitive methods, behavioral methods/homework, and negotiating/structuring (Strunk et al., 2012). Using this structure in a study of session-to-session changes across early sessions of CT, therapist adherence to cognitive methods (i.e., techniques intended to directly facilitate cognitive change) predicted session-to-session symptom improvements (Strunk, Brotman, & DeRubeis, 2010). Additional analyses suggested that this association was not accounted for by any stable patient characteristics (Sasso et al., 2016). Consistent with these indications of the importance of cognitive strategies in CT, therapists’ use of Socratic questioning was found to predict early session-to-session symptom change among trainees providing CT (Braun et al., 2015). Although methodological differences across studies complicate the comparison of findings (Pfeifer & Strunk, 2015), there have now been several studies suggesting that use of cognitive methods or concrete techniques predict subsequent symptom change. Perhaps the greatest controversy regarding the process of change in cognitive behavioral treatments has been over the role cognitive change plays.

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Although Beck hypothesized that CT achieves its effects through cognitive change, some have interpreted the available evidence as indicating that CT does not achieve its effects through cognitive change (Kazdin, 2007; Longmore & Worrell, 2007). The finding that BA achieves comparable symptom reduction to using both behavioral and cognitive interventions (Jacobson et al., 1996) has been taken to suggest that cognitive strategies do not impact symptoms. However, it is possible that cognitive change serves as a mechanism of therapeutic change in one treatment and a byproduct of another change process in the other treatment. Alternatively, cognitive change may serve as the mechanism of change in both treatments. The model underlying CT does not suggest that cognitive change is a mechanism only in CT (see Lorenzo-Luaces et al., 2015). There is evidence consistent with the view that cognitive change may serve to reduce depressive symptoms in CT. Of course, a great deal of research has documented the relation of reductions in negative cognition and depressive symptoms in a wide variety of psychotherapies. However, this might be accounted for by cognitive change serving as a mechanism of therapeutic change or as a byproduct of another mechanism. One of the most compelling findings consistent with the possibility that cognitive change may serve as a mechanism has been obtained in the context of studies examining sudden gains. Sudden gains are large and lasting improvements in depressive symptoms that occur in a single between-session interval. In two separate studies, the sessions preceding sudden gains have been found to be characterized by a high incidence of statements by the patient indicating cognitive changes (Tang & DeRubeis, 1999; Tang et al., 2005). Another key finding in support of the importance of cognitive change involves cognitive reactivity (i.e., patients’ endorsement of negative beliefs following a negative mood induction). Segal et al. (2006) found that patients treated with CT achieved lower levels of cognitive reactivity than those treated with medication, and cognitive reactivity predicted subsequent risk of relapse across both groups. Thus, the evidence does not show that cognitive change is not a mechanism of CBTs. In fact, key evidence is consistent with the possibility that cognitive change may serve as a mechanism of change.

CONCLUSION Cognitive behavioral approaches to treating depression have wielded a tremendous influence in recent decades. These treatments not only significantly reduce acute symptoms to the same degree as antidepressant medication, but they also provide an enduring effect of reduced risk of relapse that surpasses discontinued medication. The cognitive behavioral tradition occupies an honored position as one of clinical psychology’s most well-known and frequently studied models of psychological science, and today it is arguably one of the foremost representatives of the field to the public. The compelling and timeless theoretical rationale, emphasis on collaborative empiricism between therapist



Depression  23

and patient, and basis in well-developed scientific principles are essential elements of the success and popularity of cognitive behavioral treatments. Key issues for the future research include further refining our understanding of how these treatments work and what therapeutic strategies best engage key mechanisms for different patients, better specifying how these treatments can be integrated into a comprehensive model of care, and identifying how these treatments can best be disseminated to meet the tremendous societal need for such evidence-based treatments. Given the greater burden of depression observed in underserved and minority communities, cross-cultural applications of established treatments are an especially important area of focus (Miranda et al., 2003). CBTs have played, and are continuing to play a vitally important role in promoting the well-being of millions of people with depression around the world and are likely to continue doing so for many years to come.

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Smeets, R. J., Vlaeyen, J. W., Hidding, A., Kester, A. D., van der Heijden, G. J., van Geel, A. C., & Knottnerus, J. A. (2006). Active rehabilitation for chronic low back pain: Cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial [ISRCTN22714229]. BMC Musculoskeletal Disorders, 7(1), 5. https://doi.org/10.1186/1471-2474-7-5 Strunk, D. R., & Adler, A. D. (2009). Cognitive biases in three prediction tasks: A test of the cognitive model of depression. Behaviour Research and Therapy, 47(1), 34–40. https://doi.org/10.1016/j.brat.2008.10.008 Strunk, D. R., Brotman, M. A., & DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behaviour Research and Therapy, 48(7), 599–606. https://doi.org/10.1016/j.brat. 2010.03.011 Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429–437. https://doi.org/ 10.1037/a0019631 Strunk, D. R., Cooper, A. A., Ryan, E. T., DeRubeis, R. J., & Hollon, S. D. (2012). The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Journal of Consulting and Clinical Psychology, 80(5), 730–738. https://doi.org/10.1037/a0029281 Strunk, D. R., Lopez, H., & DeRubeis, R. J. (2006). Depressive symptoms are associated with unrealistic negative predictions of future life events. Behaviour Research and Therapy, 44(6), 861–882. https://doi.org/10.1016/j.brat.2005.07.001 Strunk, D. R., & Sasso, K. E. (2017). Phenomenology of mood disorders. In R. J. DeRubeis & D. R. Strunk (Eds.), The Oxford handbook of mood disorders (pp. 37–48). Oxford University Press. Suominen, K., Isometsä, E., Suokas, J., Haukka, J., Achte, K., & Lönnqvist, J. (2004). Completed suicide after a suicide attempt: A 37-year follow-up study. American Journal of Psychiatry, 161(3), 562–563. https://doi.org/10.1176/appi.ajp.161.3.562 Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitivebehavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67(6), 894–904. https://doi.org/10.1037/0022-006X.67.6.894 Tang, T. Z., DeRubeis, R. J., Beberman, R., & Pham, T. (2005). Cognitive changes, critical sessions, and sudden gains in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 73(1), 168–172. https://doi.org/10. 1037/0022-006X.73.1.168 Teasdale, J. D., Scott, J., Moore, R. G., Hayhurst, H., Pope, M., & Paykel, E. S. (2001). How does cognitive therapy prevent relapse in residual depression? Evidence from a controlled trial. Journal of Consulting and Clinical Psychology, 69(3), 347–357. https:// doi.org/10.1037/0022-006X.69.3.347 Teasdale, J. D., Segal, Z. V., Williams, J. M., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulnessbased cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615–623. https://doi.org/10.1037/0022-006X.68.4.615 Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2002). Effects of cognitivebehavioral therapy for panic disorder on comorbid conditions: Replication and extension. Behavior Therapy, 33(4), 493–509. https://doi.org/10.1016/S0005-7894 (02)80013-2 Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2005). Impact of cognitive-behavioral therapy for panic disorder on comorbidity: A controlled investigation. Behaviour Research and Therapy, 43(7), 959–970. https://doi.org/ 10.1016/j.brat.2004.11.013



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Turner, J. A., Holtzman, S., & Mancl, L. (2007). Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain, 127(3), 276–286. https://doi.org/10.1016/j.pain.2006.09.005 Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B. (2007). Reducing relapse and recurrence in unipolar depression: A comparative meta-analysis of cognitivebehavioral therapy’s effects. Journal of Consulting and Clinical Psychology, 75(3), 475– 488. https://doi.org/10.1037/0022-006X.75.3.475 Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 200–211. https://doi.org/10.1037/a0018912 Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Crown. Young, J., & Beck, A. T. (1988). Revision of the Cognitive Therapy Scale [Unpublished manuscript]. University of Pennsylvania. Zajecka, J. M., & Ross, J. S. (1995). Management of comorbid anxiety and depression. Journal of Clinical Psychiatry, 56(Suppl. 2), 10–13.

2 Cognitive Behavioral Therapy for Anxiety Disorders Kamila S. White and Vien Cheung

A

nxiety is a common human emotion and a normal and adaptive part of everyday experience. Anxiety can optimize functioning under pressure, and scientists have long known a moderate anxious arousal improves performance for well-learned, simple tasks (Yerkes & Dodson, 1908). For instance, consider an athlete who performs best in a big game or a student who shows improved math exam scores following cognitive reappraisal (i.e., reframing the exam as an opportunity changes one’s emotional response to it; Jamieson et al., 2010). Athletes and performers use their anxious energy to improve their performance; in fact, those who accept anxiety-provoking events as challenges gain energy from their anxiety and improve their performance (Strack et al., 2017). For most people, anxiety is part of everyday life. Others experience anxiety that is severe or persistent, and the anxiety leads to difficulties with personal relationships or interferes in their ability to function at work or in school. About 40 million U.S. adults were diagnosed with an anxiety disorder in the previous year (Kessler, Chiu et al., 2005). Anxiety that causes life interference, emotional distress, and impaired functioning is often indicative of an anxiety disorder diagnosis (American Psychiatric Association [APA], 2013).1 Several revisions in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) impacted the classification and treatment of anxiety disorders. First, in contrast to prior editions (that were not developmentally based), the DSM-5 anxiety chapter reflects a developmental approach Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-002 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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with disorders now sequenced according to typical age at onset. Second, separation anxiety disorder and selective mutism are newly classified as anxiety disorders in the DSM-5, whereas in prior editions they were among disorders that first appear in childhood. Also, obsessive-compulsive disorder and posttraumatic stress disorder are in new DSM-5 chapters (and no longer classified as anxiety disorders). Third, because panic attacks are a common occurrence accompanying anxiety disorders and other psychological and medical disorders, they are now specifiers in the DSM-5, as appropriate. Finally, the 6-month duration applies for most anxiety disorders. Other changes include changes to increase diagnostic precision including disorder-specific rating scales, changes in morbidity overlap, and efforts to characterize severity and course tracking. Our chapter reviews DSM-5 anxiety disorders and critically examines their treatment using cognitive behavioral therapy (CBT). Following an overview of chief symptoms and epidemiology, we review the methods, theory, and purported mechanisms of change underlying CBT for anxiety disorders. Metaanalyses and efficacy of treatments are reported, as available. We conclude with dissemination and treatments as applied to diverse populations, and we provide statements for application of anxiety treatment and conscientious clinical practice.

GENERALIZED ANXIETY DISORDER Worry is uncertainty or anxiety about real or perceived difficulties. It is adaptive when it helps a person prepare for the future or possible threats. For some individuals, however, worry is maladaptive when it is chronic, disproportionate, and unreasonable. When worry becomes excessive (i.e., occurring on more days than not for at least 6 months) and is difficult to control, a diagnosis of generalized anxiety disorder (GAD) is assigned. GAD impairs quality of life and role functioning and leads to high health care costs (Bereza et al., 2009). Excessive anxiety and worry are the chief cognitive symptoms, and three of six associated symptoms (e.g., restlessness, irritability, sleep disturbance) characterize the physical symptoms of GAD. Individuals with GAD may experience symptoms partly due to an overlap in genetic vulnerability and biological vulnerability related to disturbances in GABA, serotonergic, and noradrenergic systems (Nutt & Malizia, 2001). In other words, those prone to GAD may have an inherited underlying propensity toward neuroticism (Hettema et al., 2004). The lifetime prevalence of GAD is approximately 5.7%, and about 3% of the population suffers from GAD in any 12-month period (Kessler, Chiu, et al., 2005). GAD is a chronic disorder with few patients remitting over a 12-year period (42%), and nearly half of individuals who remit show recurrence (Bruce et al., 2005). GAD is approximately twice as common in women than in men. A large percentage (60% to 80%) of individuals with GAD remember being anxious all their lives, and they report a slow, insidious onset (Roemer et al., 2002; Wells & Butler, 1997). Some research documents the development of



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GAD in older adults for whom GAD is the most common anxiety disorder (e.g., Mackenzie et al., 2011). Cognitive behavioral theory explains why individuals with chronic worry and GAD show common characteristics that maintain the cognitive and behavioral cycle of worry. Among these attributes are a tendency to catastrophize negative events, a low tolerance for uncertainty, an iterative style of and difficulties with problem solving, worry about worry, and other behavioral and cognitive strategies that may be detrimental and sustain the cycle of worry (Borkovec, 1994). GAD is associated with an attentional tendency to interpret ambiguous situations as threatening (Hayes et al., 2010) and to overestimate the probability of negative events. According to the cognitive avoidance model of GAD (Borkovec et al., 2004), clinically significant worry may function as an avoidance behavior in an effort to (a) prepare for or prevent bad events from happening or (b) reduce emotional response (i.e., avoiding feared images or autonomic arousal). In other words, worry may function as avoidance by subduing upsetting imagery and associated autonomic activation. This creates a negative reinforcement cycle (i.e., upsetting imagery followed by worry as cognitive avoidance to escape the possible attentional threat of negative information). Studies have not yet supported all aspects of this model, but the evidence indicates that worry produces short-term relief from the physiological responses to stress (i.e., negative reinforcement). Behavioral avoidance is also a GAD feature that reinforces anxiety and increases the cycle of worry. Worry behaviors include procrastination (e.g., excessive list-making), overpreparation (e.g., arriving at appointments excessively early), and checking behaviors (e.g., reassurance seeking). Intolerance for uncertainty, a cognitive bias that affects how a person perceives, interprets, and responds to uncertain situations, is also a characteristic among those with GAD (Anderson et al., 2012). An intolerance for uncertainty is a common factor observed among other emotional disorders as well (Boswell et al., 2013). Treatment The most well-studied and empirically supported psychotherapy for treating GAD is CBT. In CBT, patients are taught to identify anxiety-related thoughts, images, and beliefs and then search for evidence to create alternative, less anxiety-arousing assumptions or interpretations. As part of homework and experiments, patients test alternative viewpoints and are taught coping methods. One primary goal in CBT for GAD is to interrupt the negative, selfperpetuating cycles of worry and related behaviors. The excessive, uncontrollable worry about future events and outcomes, which is a key feature of GAD, may serve an avoidance function by using worry to reduce arousal to feared outcomes (i.e., negative reinforcement). Patients learn techniques in controlled breathing and progressive relaxation training, visualization, or mindfulness to encourage return of normal parasympathetic nervous system functioning over time.

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CBT for GAD is multimodal and includes psychoeducation, relaxation training, identification and monitoring of worry cues/triggers, cognitive restructuring, and exposure (i.e., imagined or feared images, anxiety-provoking situations, subtle avoidance behaviors, and in vivo, as needed). Psychoeducation introduces patients to the model of factors that perpetuate GAD, informs and corrects misconceptions about anxiety and worry, and educates patients about the causative factors of pathological worry. Relaxation training is significant for GAD patients who experience reduced autonomic functioning and high muscle tension. Patients eventually learn cue-controlled relaxation by progressive muscle relaxation after brief deliberate tension exercises (i.e., 12-muscle group, 8-muscle group, and 4-muscle group). Breathing exercises are often paired with the progressive relaxation treatment. This initial step in CBT is to provide patients with regular practice to reduce overall physiological arousal and a method to help calm anxious arousal. The Socratic questioning method is used to identify and modify thoughts and appraisal in GAD. Excessive worry about future events, a key feature of GAD, may serve as an avoidance function by reducing arousal to feared outcomes (i.e., negative reinforcement). Thus, early in treatment, patients learn to identify anxious thoughts and worry triggers. Worry triggers arise from the environment, thought content (i.e., image, belief), or behavioral or physiological events. Patients detect worry triggers and discern the different characteristics of worry (i.e., cognitions, behaviors, and physiology). This process encourages patients to objectify their experiences and identify ways to interrupt the cycle of worry. The purpose of this treatment component is (a) to disrupt the negative, self-perpetuating cycle of worry and worry behaviors and (b)  to seek evidence to create rational, less anxiety-arousing alternatives to each worry, assumption, or interpretation via cognitive restructuring. During this process of cognitive restructuring, individuals generate alternative hypotheses, identify and modify fearful thoughts, and consider realistic alternatives. The aim is to help the patient tolerate and accept probable, authentic alternatives to their original worry-based concerns and assumptions and then test out the alternatives to the extent possible. Treatment of GAD includes repeated exposure to situations that are avoided or endured with excessive preparation or checking behaviors. Imaginal and in vivo exposure techniques help individuals notice avoidance behaviors and help them become comfortable with their most feared outcomes. For example, if a retired patient avoids watching/reading the financial news for fear it will trigger unwanted fears about personal financial collapse (i.e., bankruptcy, loss of retirement savings), exposure to financial news channels and reading business pages would be an important exposure. After the exposure, the patient can use cognitive restructuring to examine the feared outcome (e.g., bankruptcy) and cognitive errors. For instance, worry may involve probability overestimation (e.g., what is the likelihood of the feared outcome? What are alternative possibilities? Is it 100% likely or less?) and decatastrophizing (e.g., if the feared outcome happened, could I cope? Have I ever dealt a difficult challenge before? How did I cope in the past? How did I manage a difficult circumstance in the past? What steps would I take if this happened?). Part of the therapeutic



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process in exposure and cognitive restructuring is to increase acceptance of alternative possibilities and increase tolerance for uncertainty. An intolerance for uncertainty results from negative thoughts about uncertainty and its consequences, and it involves how a person interprets and responds to uncertain situations and their consequences. Work by Michel Dugas and his colleagues has shown that intolerance of uncertainty is common among those with GAD. In a multiple baseline study, treatment response for GAD treatment using CBT was related to change in intolerance for uncertainty (Dugas & Ladouceur, 2000). Efficacy CBT has been the most studied psychological treatment and is a first-choice intervention for GAD. CBT for GAD is efficacious, as shown in several metaanalyses (Cuijpers et al., 2014; Hofmann & Smits, 2008b; Mitte, 2005). Effect sizes for CBT for GAD are large (ES = 1.8) compared with control conditions, including wait-list control and placebo control (ES = 0.44 to 0.57; Hofmann & Smits, 2008b), and treatment effects from CBT persist for up to 6 to 12 months (Mitte, 2005). Comparative trials show CBT is more effective than supportive therapy (Borkovec & Costello, 1993; Borkovec & Mathews, 1988) and psychodynamic therapy (Leichsenring et al., 2009). Response rates range from 44% to 71% (x = 56%), and treatment attrition is approximately 10.7% (Newman et al., 2011; Westra et al., 2009; Wetherell et al., 2011). Few dismantling studies have examined which components are essential to the efficacy of CBT for GAD. However, some research has found individual components to be comparatively more effective. A few randomized trials have shown that progressive relaxation training did not differ from CBT at posttreatment (Hayes-Skelton et al., 2013; Siev & Chambless, 2007). Cognitive therapy (CT) may be effective as an independent component for GAD (Borkovec et al., 2002) compared with non-CT controls, but the effects were weaker in comparison (d = 63). Finally, studies have successfully modified patient attentional bias using computerized training programs (Amir, Beard, Burns, & Bomyea, 2009), yet these studies have smaller effect sizes and did not use standard CBT. GAD commonly co-occurs with major depression. Treatment response is less than optimal for patients who experience GAD in the context of major depression. This is because these disorders share worry and ruminative features, also known as negative self-referential processing. A recent study compared CBT plus principles from affect science with an attention control condition; the combined CBT condition outperformed the attention control condition at the end of treatment, as evidenced by large effect sizes for both GAD and major depression (Mennin et al., 2018). Patients receiving the combined treatment maintained response at a 9-month followup. Considerations Clinical trials for CBT for children and adolescents with GAD generally suggest efficacy, including a computer-assisted intervention (Khanna & Kendall, 2010).

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Rates of response of generalized worry in later life compared with CBT with younger adults is slightly lower (Stanley et al., 2002). Results by Wetherell et al. (2013) found the sequence of antidepressant medication augmented by CBT led to worry reduction in the short term, and continued medication prevented relapse. However, for many older adults, CBT allowed sustained remission without requiring long-term pharmacotherapy late-life GAD. In a separate group treatment study, CBT was similarly efficacious and included interaction and opportunity for self-disclosure (Wetherell et al., 2003). Treatment components include memory enhancers (e.g., reviews, homework reminders), learning aids (e.g., acronyms) to compensate for reduced memory abilities, and a slower pace of CBT sessions.

PANIC DISORDER AND AGORAPHOBIA Panic attacks are characterized by sudden and acute surges of fear or discomfort that reach peak levels of intensity within several minutes of onset. Unexpected panic attacks occur in the absence of obvious cues, whereas expected panic attacks are elicited by situational determinants. Anxiety involves the activation of the sympathetic nervous system, triggering fight or flight reactivity. Ergo, episodes of panic are accompanied by physical symptoms (e.g., palpitations, shallow breath, chest pain, nausea, dizziness, chills or heat sensations, and paresthesia [i.e., numbness or tingling sensation]) that may resemble myocardial infarction, as well as cognitive symptoms such as depersonalization, derealization, and fears of going crazy or dying (APA, 2013). A minimum of four symptoms are required for a full-blown panic attack, whereas fewer than four symptoms specify a limited-symptom attack. Experiences of panic are common, and a panic attack alone does not qualify an individual for panic disorder (PD). A diagnosis of PD is assigned when an individual experiences recurrent panic attacks, persistent concern about the occurrence or consequences of future attacks (e.g., fears of a heart attack, losing control), and significant behavioral change for a minimum of 1 month. Epidemiological studies estimate the lifetime prevalence of panic attacks and PD in the general population is 13% and 1.7%, respectively (de Jonge et al., 2016; Weissman et al., 1997). Within the United States, rates of lifetime occurrence are higher, at about 3.7%, with women showing two-fold greater risk than men (Eaton et al., 1994; Kessler et al., 2006). Symptoms typically emerge in early adulthood with modal onset between 21 and 23 years of age. A central feature of PD is anxiety sensitivity, or the belief that interoceptive sensations reflect signs of impending harm (Reiss et al., 1986). In efforts to avoid the real or imagined consequences of panic, individuals are hypervigilant for changes in physiological arousal and maintain urges to avoid or escape situations and behaviors that would likely elicit panic. Aversion to somatic sensations associated with anxiety and panic is known as interoceptive avoidance and may include abstinence from arousal-inducing experiences (e.g., strong emo-



Cognitive Behavioral Therapy for Anxiety Disorders  39

tion, caffeine, physical exercise, sexual activity; White & Barlow, 2002). In a subset of individuals with PD, fear and avoidance across multiple situations may reveal an independent, secondary DSM-5 diagnosis of agoraphobia. In rare cases, individuals with severe agoraphobia become housebound. Rates of agoraphobia are thought to be underestimated because of difficulties in seeking treatment; however, PD is highly comorbid with agoraphobia. Patients engage in safety behaviors to prevent feared outcomes and to promote a sense of security (White & Barlow, 2002). Examples of safety behaviors include monitoring the proximity to certain locations (e.g., bathrooms, hospitals), carrying objects (e.g., rosary beads, pill bottles, lucky charms), and attaching “safety” to a support person (e.g., family member, therapist). Interoceptive avoidance minimizes exposure to the conditioned stimulus while safety behaviors mitigate the intensity of the conditioned response. Despite providing immediate relief from panic attacks and panic-like symptoms, both emotion regulation strategies perpetuate distorted beliefs and prevent fear extinction. Thus, CBT for PD includes exposure to physiological arousal and elimination of safety behaviors. Treatment and Efficacy CBT is a benchmark treatment for PDs (Barlow et al., 2000). Efficacy studies show CBT treats PD better than placebo, applied relaxation, and supportive therapy (Barlow et al., 2000; Clark et al., 1994; Craske, Maidenberg, & Bystritsky, 1995). Two of the most well-established and supported forms of CBT for PD are Clark’s CT (Clark, 1986) and Barlow and Craske’s Panic Control Treatment (PCT; Barlow & Craske, 2007). Both short-term treatments involve psychoeducation on the components of anxiety and panic, identifying and restructuring misinterpretations about physiological sensations, and exposure therapy. Dismantling studies have enabled the microanalysis of specific treatment components, and the results for breathing retraining (e.g., training a patient to help decrease hyperventilation symptoms) are mixed. One study found breathing retraining to be nonessential and iatrogenic to outcome. In a dismantling study by Schmidt et al. (2000), CBT with breathing retraining yielded a poorer outcome compared with CBT without breathing retraining. For most patients, breathing retraining is an avoidance behavior that prevents an individual from experiencing the full extent of their physical symptoms. For some patients, breathing retraining can be an experimental procedure (i.e., not a treatment technique). It can help patients test whether breathing (or overbreathing) plays a role in panic attacks. During CBT, patients learn panic attacks are harmless and time-limited symptoms, and breathing is an autonomic nervous system process that does not need (re)training. From a cognitive perspective, panic is thought to arise from interpretations of somatic sensations as signs of imminent harm and loss of control. Autonomic activation enhances physiological arousal, reinforcing distorted cognitions in a positive feedback loop. For instance, perceptions of an elevated heart rate may prompt erroneous beliefs about an impending heart attack. These thoughts

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increase fear and, in turn, produce a faster heart rate. To the patient, this may serve as evidence to confirm the initial hypothesis that “something terrible is about to happen.” Individuals with PD may vigilantly scan the body for somatic sensations that indicate threats of serious physical and mental harm. In CT, exposures serve to elicit cognitive change through the modification of erroneous assumptions. Randomized controlled trials have shown the efficacy of CT over supportive therapy (Beck et al., 1992), applied relaxation, and imipramine (Clark et al., 1994). Moreover, Clark et al. (1999) found that a brief five sessions of CT was as efficacious for PD as receiving the full course of CT. PCT emerged from Barlow’s (1988, 2004) landmark contribution that integrated a “triple vulnerabilities” model of anxiety and encompassed behavioral principles of associative learning. The development of PD is attributed to interoceptive conditioning resulting in anticipatory anxiety or fear of fear (Goldstein & Chambless, 1978). Panic attacks are likened to false alarms, whereby autonomic arousal is activated in the absence of a true threat. Through classical conditioning, initial interoceptive and exteroceptive (situational) cues pair with intense fear; subsequent experiences of physiological arousal prompt the conditioned response of acute anxiety or panic attacks. In PCT, exposure helps to extinguish the feared response and to gather evidence to disconfirm distorted thoughts (i.e., probability overestimation, catastrophizing). Research points to an advantage of in vivo exposure over imaginal exposure. Exposure exercises provide the opportunity for patients to gather information that may disconfirm misappraisals about themselves in situations they fear. PCT integrates skills in exposure (i.e., situational and interoceptive) and cognitive restructuring over time. PCT reduces PD, and its effects are better than supportive therapy, progressive muscle relaxation, and wait-list controls (Barlow et al., 1989; Craske, Maidenberg, & Bystritsky, 1995). An abbreviated version of PCT (i.e., four to six sessions; Craske, Maidenberg, & Bystritsky, 1995) and a brief computer-assisted course of PCT have been effective in PD treatment (Newman et al., 1997). In one study, researchers tested a maintenance CBT aimed at reinforcing treatment gains and preventing relapse in patients who responded to PCT; the maintenance CBT produced lower relapse rates and reduced work and social impairment compared with an assessment-only condition at a 21-month follow-up (White et al., 2013). For patients who failed to respond to an initial course of CBT (i.e., PCT nonresponders), they experienced greater improvement in PD symptoms by switching to SSRI treatment compared with those who received continuation CBT (Payne et al., 2016). In summary, numerous controlled studies show the efficacy of CBT (both PCT and CT) to treat PD; and both approaches yield 70% to 80% panic-free states and high end-state functioning. One meta-analysis compared treatment outcomes of combination CBT and antidepressant treatment to monotherapies and found that combination treatment outperformed both medication alone and psychotherapy alone regardless of antidepressant type and comorbid diagnoses (Furukawa et al., 2007). At 6 months posttreatment, combination therapy was comparable to psychotherapy alone and superior to medication only. These



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results are consistent with research citing the enduring effects of CBT in preventing panic relapse following discontinuation of medication (Choy, Peselow, et al., 2007; Hofmann et al., 2009). Finally, a recent dismantling review and component network meta-analysis of the components of CBT for PD found support for face-to-face CBT and interoceptive exposure, but data were not supportive of muscle relaxation and virtual-reality exposure (Pompoli et al., 2018). Considerations Given the somatic nature of PD, many individuals experiencing panic attribute their symptoms to an organic (e.g., heart attack) rather than psychological etiology. Thus, a vast majority of individuals with panic attacks and PD present to primary care physicians and emergency departments (Katerndahl & Realini, 1995; Wang et al., 2005), resulting in the need for interdisciplinary collaboration and integration of evidenced-based treatments of PD in these settings. Efforts to disseminate CBT show promise. In primary care, CT (Grey et al., 2008) and combination CBT with pharmacotherapy (Roy-Byrne et al., 2005) were more effective than treatment as usual in reducing panic symptoms. Researchers trained therapists in a managed care setting to deliver PCT to their patients (Addis et al., 2006); among treatment completers, patients in the PCT group showed a greater reduction in panic severity and agoraphobic avoidance relative to those in treatment as usual. These studies provide support for dissemination of CBT with brief therapist training, thus increasing the proportion of patients with PD receiving evidence-based treatment in medical settings. Clinical Example Lucia was a 33-year-old, married woman raising two young sons and working part time in education. She came for treatment because of anxiety and panic attacks that had increased in the past 2 years. Two years ago, during her second pregnancy, she experienced a sudden heart palpitation. Lucia recalls feeling terrified that she was dying from a heart attack and that her heart symptoms would harm her unborn child. She was tested and released from an emergency department; outpatient cardiology later evaluated her, and she received a diagnosis of mitral valve prolapse (MVP). The mitral valve (between the heart’s upper and lower left chambers) was not closing smoothly during her pregnancy. Lucia recalls these stressful medical events coinciding with her first full-blown panic attack. A general practitioner referred her for treatment of health anxiety. Assessment Phase Lucia’s therapist was a licensed clinical psychologist. A central tenet in CBT is to cultivate a strong therapeutic alliance and conduct a culturally informed functional behavioral analysis. To build rapport and assessment, a detailed interview

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and self-report battery were completed. The semi-structured interview, Anxiety Disorders Interview Schedule-5L, comprised a diagnosis of anxiety, mood, trauma, and other related disorders. Panic attacks are pervasive and occur across anxiety and other disorders, so differential diagnosis can be difficult. Details collected during the interview and questionnaires helped the therapist arrive at a diagnosis and adapt treatment for Lucia’s individual presentation. Diagnostic Impressions Lucia’s clinical presentation was consistent with a principal diagnosis of Panic disorder (F41.0) and Agoraphobia (F40.00). Medical history was significant for Mitral valve prolapse (134.1) and Asthma, unspecified and uncomplicated (patient-reported). Medications included the following: generic birth control pill (QD) and Advair (inhaler, PRN). Scores on the Panic Disorder Severity Scale and on the Albany Panic and Agoraphobia Questionnaire showed elevated panic attack severity and high situational avoidance and interoceptive fears. On the Anxiety Control Questionnaire, scores suggested low perceptions of anxiety-related dimensions of Emotion, Threat, and Stress control. Scores on the Beck Depression Inventory-II suggested a depressive mood state. Self-report data were consistent with diagnostic interview impressions. Medical Evaluation The therapist recommended Lucia get a medical evaluation during the assessment phase. Some medical conditions may underlie or exacerbate PD, including cardiac disorders (e.g., heart disease, MVP), hormone and metabolic disorders (e.g., diabetes, changes in blood sugar including hypoglycemia), and respiratory disorders (e.g., chronic obstructive pulmonary disease, asthma, allergies); thus, medical evaluation was necessary. Lucia provided the therapist with a signed medical release for communication between the therapist and Lucia’s cardiologist. Following concise discussion between the therapist and cardiologist about Lucia’s cardiovascular health issues (MVP and current health), the cardiologist provided a written letter stating Lucia was qualified for full participation in CBT, including physical activity. Case Conceptualization Lucia’s panic attacks were characterized by symptoms including a pounding and racing heart, hot flush, throat tightness, shortness of breath, and a sense of impending doom. Her main fears were of a loss of control or death, particularly that she may lose control when the panic is unexpected (i.e., when she is driving, when she is sleeping) or she may die (i.e., from a heart problem). Average frequency was three full-blown panic attacks and two to three limited-symptom attacks. Each attack lasted from a few seconds to 15 minutes. Antecedents to her panic attacks were situational (expected) and internal (unexpected), and Lucia spent 70% of the day apprehensive about panic attacks. Internal antecedents included heart rate variations, heart flutter sensations associated with MVP, racing heart, lightheadedness, hunger, thoughts of hospitals, thoughts of open spaces, aloneness, thoughts of not being able to handle a heart attack, and



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fears she could not do this much longer. Situational antecedents included driving on freeways, driving outside safe areas, being alone (at night), physical activity (that provokes cardiovascular activation), and social events (when escape is difficult). Lucia’s cognitive misappraisals included the belief that because the panic attack symptoms resembled the symptoms of a heart attack, she feared she was dying of a heart attack. Some of Lucia’s other cognitive misappraisals included beliefs that the panic attacks would make her lose control and behave erratic or crazy. Behavioral reactions to panic attacks include situational avoidance and escape behaviors. Lucia’s situational avoidance included avoidance of all longdistance driving, night-time driving, being at home alone, most social events, and exercise and cardiovascular physical activities. Her escape behaviors included pulling off to the side of the road, leaving social events early, and calling safe others (her husband and mother). Safety behaviors included wearing a smart watch with cardiac app, pulse checking, excessive planning, air conditioning, and a water bottle. As an example, to cope and reduce her anxiety and fear or when she felt threatened, Lucia would turn up the air conditioning and keep water near. These safety behaviors reduced anxiety in the short term (i.e., less warmth, perspiration, activation, dry mouth), but safety behaviors prolonged her fear and anxiety of nonthreathing situations in the long term. Lucia’s husband had been compassionate but concerned; his support had diminished as the children grew older with more needs. Lucia was working part time, but she reduced her workload. Lucia described difficulty concentrating and sleeping; she felt tearful and sad much of the time. Her low mood included episodic hopelessness, and she had a hard time expressing herself and accomplishing tasks at work and home. Anxiety and panic interfered with Lucia’s social and occupational functioning. Treatment Phase It was mutually agreed to begin evidence-based CBT for PD and agoraphobia, using a modified version of PCT. The goal of PCT was to foster within Lucia the ability to identify and correct maladaptive thoughts and behaviors that start, maintain, and exacerbate her anxiety, panic attacks, and avoidance. To achieve this goal, treatment combined psychoeducation, cognitive techniques, and exposure techniques. Early sessions included psychoeducation and skill-building components. Lucia learned about the fear response (its nature and functions), its nervous system substrates, and how natural fear enhances our ability to survive and compete in life. Panic attacks are inappropriate fear reactions that arise from spurious but otherwise normal activation of the body’s fight-or-flight nervous system; like any fear reaction, they encourage immediate defensive action and a search for the source of the threat. Like others with panic, when Lucia could not find a source of threat, she looked inward and interpreted the symptoms as signs that something was wrong with her (e.g., “I am dying of a heart attack”). Lucia wondered if she was interpreting her heart symptoms as signs that something was wrong with her; she worried, “If my heart beats too hard or flutters too much, will my heart break or give out on me?” The

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therapist and Lucia discussed the integrative model of PD, the three-component model of anxiety (cognitive, behavioral, and physical), a rationale for treatment, and self-monitoring. The next sessions focused on evaluating some of Lucia’s thoughts about of anxiety and fear. Lucia was global and nonspecific in refuting or countering her anxious thoughts. Lucia had two kinds of anxious thought processes: probability overestimation (i.e., Lucia’s prediction that a panic attack may cause her heart palpitations that lead to her losing control of the car and crashing), or overestimating the likelihood of a negative outcome, and catastrophic thinking (i.e., if Lucia were to collapse due to a panic attack, she perceived the consequences would be insufferable and she would die alone). In CBT, she learned to gather facts and evidence to test and refute her feared predictions and their consequences. Based on her past experiences and critical thinking skills, Lucia determined the likelihood (or probability) of a feared event. Further, if the worst outcome occurred, she allowed herself to think about how she would cope with the consequences. To provide clinical context for the cognitive work and to set the stage for exposure, a preliminary fear and avoidance hierarchy (FAH) was drafted. Lucia and her therapist spent several weeks conducting behavioral experiments. Principles and techniques of exposure were discussed, and the interoceptive experiments were modeled by the therapist and conducted in session. Certain physical sensations (like tachycardia, dizziness, smothering) are deliberately provoked by each exercise (like breathing through a straw, spinning, vigorous running for 30 to 60 seconds). Using prediction testing (a component of CT), Lucia would test some of her feared predictions. At the 30-second mark (the halfway point of the 1-minute exercise) when she was running in place vigorously, Lucia stopped in a full-blown panic attack. She sat down, signaling with her hands that she was upset.  The therapist could see she was blinking tears, sweating, and unsteady. The therapist asked Lucia stand up with her feet in a narrow stance (without stabilization) and without holding onto the desk. Within minutes, Lucia seemed astonished to report the panic attack had subsided. This was perhaps the most important moment in Lucia’s treatment: she was provided with disconfirming evidence that a panic attack would cause her heart to break and lead her to collapse on the floor, and she learned that when she dropped to the floor in the past during a panic attack, she had done so of her own volition, as a way of coping. Prior to conducting any trials, Lucia predicted a 65% chance that the first trial of running in place would cause her “heart to beat very rapidly and cause her to drop to the floor uncontrollably.” After completing two trials, Lucia’s predicted probability of dropping to the floor changed to 10%. As she became less fearful of in-session experimental sensations, Lucia practiced interoceptive exposures (experimental and natural) at home (e.g., caffeinated drinks, sexual activity, exercise in warmer spaces). Subjective units of distress symptom (SUDS) ratings were collected. For situational exposure, the therapist adhered to a modified version of the agoraphobia supplement to PCT. To measure treatment progress, Lucia pro-



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vided fear and avoidance ratings on the  FAH developed early in treatment. Each situation on the FAH was rated, including duration and other relevant information (e.g., alone vs. accompanied, time of day), and situations were listed least to most difficult based on fear and avoidance ratings. One item on Lucia’s FAH was “Drive on the interstate to Exit 38B, alone, after dark.” At the end of each session, she selected one item from the bottom of the FAH to practice two to three times before the next session. Toward the end of treatment, Lucia combined internal and external cued exposures. She paired situational exposures with interoceptive exposures (e.g., exercising in a different park, watching an emotional movie at night time, consuming a caffeinated beverage while driving alone). Lucia was reluctant to induce interoceptive symptoms and conduct situational exposures. Effective exposures combined both cues to reduce the risk of later return of fear. LUCIA:

I am afraid to go to the market with my children when I feel my heart racing and palpitations from drinking coffee.

THERAPIST: What worries you about market shopping with the kids and

drinking the coffee? LUCIA:

Well, I’ve practiced market shopping with the kids a lot, and that feels okay. But if I drink coffee, I will feel very anxious.

THERAPIST: And if you feel very anxious in the market, then what? LUCIA:

I am unsure. If I feel very anxious, I might feel like I need to leave. I might need to leave in case something happens.

THERAPIST: It sounds like you might feel you need to leave. Based on what

you have learned about feelings and facts, how else might you manage the situation? LUCIA:

Well, I have learned that I can feel anxious and tolerate challenging situations. Also, feelings are real symptoms, but as we discussed, my panicky feelings are not equal to the facts in this situation.

THERAPIST: That sounds good. And it sounds like you are learning to accept

the anxiety including a fast racing heart with an awareness that you can tolerate it. Is there anything else? LUCIA:

I also know that panic attacks are not likely to cause me to die or faint. And I can ask myself: What’s the worst that can happen? I know my heart can beat very fast.

THERAPIST: And if your heart beats very fast, what does that mean? LUCIA:

I guess, it means my heart rate is going fast.

THERAPIST: This is good. You are learning to tolerate and accept anxiety and

its symptoms.

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SOCIAL ANXIETY DISORDER Some individuals are shy or introverted, and this is a natural quality among the general population. However, the suffering associated with the experience of clinically significant social anxiety disorder (SAD) is more than shyness or social inhibition; the personal anguish of SAD can provoke debilitating fear of interacting with people, and the act of forming social relationships can provoke panic. The impact of severe SAD on occupational functioning and quality of life can be extensive. SAD is prevalent and characterized by an intense fear of negative evaluation from social or performance situations. Estimates show that 10% to 12% of the U.S. adult population is affected during their lives, and SAD can have a severe, chronic course leading to disability, functional impairment, and reduced quality of life (Kessler, Berglund, et al., 2005; Ruscio et al., 2008). SAD onsets in childhood or adolescence, and treatment seeking is somewhat low. Left untreated, a large proportion of individuals with SAD (70% to 80%) meet diagnostic criteria for a comorbid diagnosis that onsets subsequent to the SAD diagnosis; in community samples, the common comorbidities are agoraphobia, major depressive disorder, and substance abuse (e.g., alcohol use disorders; Schneier et al., 1992). Treatment CBT is the most studied and most efficacious treatment for SAD, as evidenced by numerous randomized controlled trials. One aim of CBT for SAD is to identify and modify maladaptive cognitions accompanying social situations. Another aim is to target and reduce behavioral factors that maintain avoidance during SAD. Several theoretical models support evidence-based CBT approaches. According to one model by Rapee and Heimberg (1997), when exposed to social situations, individuals with SAD fear they are in danger of acting inept or undesirable and thus their actions would have negative personal consequences (i.e., social rejection, loss of status). Therefore, when they are in social situations, they are attentive for cues that signal the realization of their fears. They look for sources of negative scrutiny (real or imagined) and maintain a negative view of how they appear to others by attending to the negative cognitive, behavioral, and affective cues of their anxiety. Patients with SAD observe and monitor their physiological processes (e.g., increased heart rate, blushing sensations), and this attentional shift leads to a negative self-concept (Wells et al., 1995). Furthermore, patients then engage in overt (i.e., choosing a written presentation over an oral presentation) and subtle safety behaviors (i.e., wearing a scarf or turtleneck sweater to hide neck flushing) to provide a sense of short-term anxiety reduction. In the long term, however, safety behaviors prolong and maintain anxiety because they prevent the individual from testing the feared outcomes. Hofmann (2007) posited that individuals with SAD fear social situations partly because of a cycle of undefined expectations for performance, increased self-focused attention, and complex cognitive processes including an



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exaggerated probability of a negative outcome of a social situation and a view of their social skills as inadequate. Evidence-based CBT begins with psychoeducation about normal social worries (i.e., the adaptive, shared anxiety that is part of the human condition and which is unnatural to eradicate completely) versus problematic social anxiety (Hope et al., 2010). Patients also learn about the three-component model of anxiety (i.e., cognitive, behavioral, and physiological). The therapist and patient discuss the costs and benefits of treatment success (e.g., less relationship dependency). Factors thought to be related to the patient’s development and the onset of social anxiety include genetics, inherited biological sensitivity, family factors, and social learning history. Early social experiences are explored, and any negative, maladaptive thought processes are examined for signs of perceived personal shortcomings rather than logical consequences of social experiences. For example, therapists ask patients to consider how maladaptive thoughts from past events (e.g., thoughts of not fitting in with social groups, thoughts about being made fun of by peers, and anticipating feelings at social events) impact current functioning. Individuals with SAD may be anxious in social situations for any number of reasons. They may perceive a high, unrealistic social standard; they may have a desire to make an impression on others (but have self-doubt about their ability); or they may be deficient in selecting achievable social goals (Hiemisch et al., 2002). Altogether, this increases social apprehension and self-focused attention, and highly anxious individuals may overestimate the probability of a negative outcome and catastrophize the potential social costs (Clark & McManus, 2002; Heinrichs & Hofmann, 2001). Individuals with SAD view themselves as having low perceived control over their emotional responses, view the social event and its costs more negatively, and view themselves as insufficient in social skills. After social experiences, they use maladaptive tactics to manage their social anxiety, including avoidance and safety behaviors, and engage in post-event worry and rumination leading to increased social angst (Hofmann, 2007). Evidence-based CBT helps patients to detect and restructure automatic thoughts and expectations about social situations. Social anxiety is initiated and maintained partly by a person’s thoughts and expectations in a social situation. Patients are asked to contemplate how their social anxiety might change if their thoughts and cognitive preconceptions (i.e., biases) were to change. Because idealistic social standards and a failure to set realistic social goals are characteristic of SAD, patients consider the evidence for and against their specific social fears before beginning exposure therapy. For example, prior to an interpersonal exchange with a stranger, automatic thoughts might include all-or-nothing thinking (e.g., “I have to impress them”), mind-reading (e.g., “They will think I am boring”), and “should” statements (e.g., “I should be able to talk with a stranger”). After cognitive restructuring and applying rational response alternatives, exposure sessions begin. Before beginning exposure therapy, an FAH of social situations is developed based on anxiety (i.e., ranging from least anxiety-provoking social situations to most anxiety-provoking situations) and

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avoidance (i.e., ranging from least avoided social situations to most avoided social situations). Situational exposures begin with mildly anxiety-provoking situations and proceed over time to more moderately anxiety-provoking situations. The exposure situations can be conducted in vivo (e.g., talking with a store salesclerk), imaginal, or as role plays (e.g., talking with a confederate acting as a salesclerk). If assessment shows the patient deficient in social skills, CBT may include social skills training, which involves teaching social interaction skills through the behavioral techniques of modeling, reinforcement, corrective feedback, and other similar techniques. Efficacy Empirical data show CBT for SAD produces large effect sizes, is superior to no treatment control (i.e., pill placebo), and has a larger treatment impact than psychological comparison therapies (Mayo-Wilson et al., 2014). As examined in meta-analyses of randomized controlled trials, CBT has shown to be efficacious compared with placebo control, with medium to large effect sizes on social anxiety symptoms (Barkowski et al., 2016; Hofmann & Smits, 2008a). One augmentation trial examined a cognitive enhancer (i.e., D-cycloserine [D-4-amino-3-isoxazolidone; DCS]) strategy. DCS is a partial agonist at the glycine recognition site of the glutamatergic NMDA receptor. Researchers compared CBT + pill placebo versus CBT + DCS. Patients received either DCS (50  mg) or pill placebo 1 hour before each of five exposure sessions (that were part of a 12-session CBT group treatment). Results showed high response rates (73% and 79% response rates) and remission rates, and no group differences were apparent (Hofmann et al., 2013). Although CBT group treatment is considered the treatment of choice for SAD, fewer studies have shown individual CBT to outperform group CBT (Stangier et al., 2003). Evidence-based CBT for SAD provides support for either delivery mode (Hofmann & Otto, 2008). Group CBT is conducted by two therapists in 12 weekly sessions of 2.5  hours duration. Individual CBT is commonly conducted in 15 weekly sessions of 1 hour duration. As a complement to CBT, attention retraining is a promising treatment strategy. Randomized trials show that eight sessions of attention retraining to reduce attentional bias (i.e., threat cues) are superior to an attention control condition in reducing SAD symptoms (Amir, Beard, Taylor, et al., 2009).

SPECIFIC PHOBIAS Specific phobias (SPs) are the most common of anxiety disorders. According to the DSM-5, an SP is marked by a persistent fear of specific objects or situations. Phobias precipitate active avoidance of feared stimuli or are endured with extreme anxiety when faced. Intense fear may induce panic attacks and cause impairment in daily functioning (APA, 2013). The five categorical subtypes of



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SP are (a) animals (e.g., spiders, insects, dogs), (b) natural environments (e.g., heights, storms, water), (c) blood-injection-injury (e.g., needles and other invasive medical procedures), (d) situational (e.g., airplanes, elevators, enclosed spaces), or (e) other (e.g., choking, vomiting, loud sounds, costumed characters). Lifetime prevalence of SP is 7.4%, as reported in a cross-national epidemiological study of individuals from 22 countries (Wardenaar et al., 2017), and the prevalence of U.S. adults reporting a lifetime prevalence of SP is 13% (Kessler et al., 2012). The most common SP subtype is animals. Age of onset varies across subtypes. Whereas a younger age onset is typical for animals, enclosed spaces, and blood-injection-injury (median age of initial symptoms = 8 years; Fredrikson et al., 1996; Wardenaar et al., 2017), situational phobias are more common among older adolescents and adults (Sigström et al., 2016). Prevalence rates also vary across age, sex, and race; younger individuals, females, and Caucasians compared with Asian and Latino individuals are more likely to experience SP (Stinson et al., 2007; Wardenaar et al., 2017). The course of SP is chronic, with low rates of spontaneous remission (Goisman et al., 1998; Wittchen, 1988). The condition often co-occurs with and precedes mood, anxiety, and eating disorders (Kessler et al., 1996; Lieb et al., 2016; Trumpf et al., 2010). Despite significant distress and role impairments, many with SP do not seek treatment (Essau et al., 2000; Regier et al., 1993). Of those who use mental health services, a substantial proportion end treatment before symptoms improve. Avoidance is characteristic of anxiety disorders, and fear may prevent full engagement in treatment, as CBT involves some confrontation with the feared stimulus. Treatment and Efficacy Of the available treatments, exposure therapy has garnered the most support and is the benchmark treatment for SP (Barlow et al., 2002). Although there are many variations of exposure therapy, all interventions extend from behavioral models of fear acquisition. Through fear conditioning, a benign conditioned is paired with a stimulus with an anxiety-provoking unconditioned stimulus to elicit a conditioned fear response (Watson & Rayner, 1920). This association is (negatively) reinforced and maintained by avoidance, which prevents the individual from learning new and more adaptive responses to aversive stimuli (Mowrer, 1960b). Rachman (1978) proposed that fear may also be acquired (indirectly) through vicarious learning and information transmission. In exposure therapy, the patient is exposed to feared items on the fear hierarchy in vivo (i.e., in real life) until fear has subsided, thus reducing the strength of the conditioned response. Phobic items are presented in various contexts to generalize fear reduction. To prepare clients for in vivo exposure (and direct contact), therapists can begin with imaginal exposure. Efficacy studies boast medium to large effect sizes at posttreatment (Choy, Fyer, & Lipsitz, 2007). In vivo exposure has produced more favorable outcomes relative to systematic desensitization (inclusive of imaginal exposure with relaxation; Bandura et al.,

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1969; Egan, 1981), vicarious exposure (Öst et al., 1997), imaginal exposure (Emmelkamp, 2003), and control conditions. Advancements in technology have led to novel treatment modalities in exposure through virtual reality (VR). VR is most beneficial when in vivo conditions are costly, unpredictable, or difficult to plan. Therapists immerse patients in a contextually relevant environment that is computer simulated, allowing for gradual exposure in a controlled setting. Studies using VR exposure show it is superior to systematic desensitization (Wiederhold et al., 2002) and imaginal exposure (Emmelkamp, 2003), and is comparable to in vivo exposure (Emmelkamp et al., 2002; Rothbaum et al., 2000). However, research in this line of treatment is still in its infancy, with studies using small sample sizes. The pharmacological agent DCS offers promise to augment exposure treatment for anxiety disorders (Rodrigues et al., 2014). DCS combined with VR exposure outperformed VR exposure alone for patients with acrophobia (i.e., fear of heights; Ressler et al., 2004). DCS improves exposure treatment (compared with placebo) for SP only when administered before exposure sessions (Nave et al., 2012), but not after (Tart et al., 2013). In addition to exposure treatments, cognitive interventions of SP target attributions regarding the safety of stimulus and one’s perception of control over external events. Two core cognitive features of anxiety include catastrophizing and overestimating the likelihood of negative outcomes. Treatment involves identifying distorted beliefs associated with SP, evaluating the evidence of such beliefs, and replacing irrational thoughts with more rational probabilities of outcome. Behavioral experiments often aid cognitive strategies to test differences between expected and observed outcomes. Short intensive CT outperformed interoceptive exposure and was as effective as in vivo exposure to treat claustrophobia (Booth & Rachman, 1992; Öst et al., 2001). In fact, a single session of cognitive restructuring was effective in reducing dental anxiety (De Jongh et al., 1995). The evidence is mixed regarding the advantages of combined cognitive and exposure techniques. Cognitive procedures enhanced in vivo exposure of claustrophobia (Craske, Mohlman, et al., 1995), but they were not incrementally beneficial to treat spider (Koch et al., 2004) or flying phobias (Van Gerwen et al., 2002). However, Mühlberger (2003) found that cognitive strategies plus VR exposure (in combination) resulted in greater reduction of flying phobia symptoms when compared with CT alone. Taken together, the efficacy of CT as a stand-alone treatment or as an adjunct to exposure therapy is still unclear and may depend on the phobia subtype and the exposure treatment type. Considerations Age is a consideration in the treatment of SP. For example, gait and balance decline with age, and older adults are at an increased risk for fall. History of functioning (including motor functioning, prior falls, and head injuries) and other features associated with risk are important to differentiate logical fears



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from a situational phobia. Although SP is more prevalent earlier in the life course (Sigström et al., 2016; Wardenaar et al., 2017), CBT is effective across all age groups. CBT approaches have been effective in treating SP in children (Ollendick et al., 2009) and older adults (Pachana et al., 2007). Medication use is a consideration among older adults, and greater benzodiazepine use has been found among older adults who meet full or subthreshold criteria for SP (Grenier et al., 2011), which is contraindicative to exposure-based fear extinction.

SEPARATION ANXIETY DISORDER Separation anxiety disorder moved to classification as an anxiety disorder from a childhood disorder in the DSM-5. Most infants and young children show distress when separated from their caregivers. As young children develop increasing independence, they are less hesitant and feel less distress in the absence of their caregivers. For some children, however, they feel distress without their caregivers, and they develop fears that something could go wrong (e.g., fear about their health or their caregiver’s health). For a diagnosis, the DSM-5 requires that three of eight symptoms last for at least 4 weeks in children and adolescents, and the symptoms include experiencing distress when away from home or a major attachment figure. Additional symptoms include (a) worry about the well-being of the attachment figure (i.e., kidnapping, self or other getting lost), (b) an unwillingness to leave home, (c) fear of being alone, (d) unwillingness to sleep alone or outside the home, (e) nightmares, and (f)  physical complaints (i.e., headaches, stomachaches). Adults with separation anxiety disorder are typically (over)concerned about their children and partners and experience marked discomfort when separated from them; separation anxiety disorder is assigned if the symptoms onset before age 18. Prevalence of this clinical condition in adulthood is underestimated partly because it was classified under “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence” in the previous DSM (Bögels et al., 2013). In community samples, the 12-month prevalence of separation anxiety disorder is 4% in children and 1.6% in adolescents (APA, 2013). The National Comorbidity Survey Replication (NCS-R) found the lifetime prevalence of adult separation anxiety disorder to be 6.6%, with the large majority (77.5%) reporting an adult onset of symptoms (Shear et al., 2006). Gender differences are less prominent in adult separation anxiety disorder; yet, across development, childhood onset is more common among females, and males are more likely to experience onset in adulthood. Although this condition is prevalent, research on presumed risk factors has focused almost exclusively on child samples. Heritability estimates point to a low-to-moderate specificity, and modest evidence supports biomarkers (i.e., carbon dioxide hypersensitivity, a peripheral-type benzodiazepine receptor binding), information-processing biases (e.g., more threat interpretations, attention selectivity), and temperamental antecedents (i.e., maternal separation anxiety, interpersonal sensitivity; Bögels et al., 2013).

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Treatment and Efficacy Consistent evidence shows CBT reduces separation anxiety, and treatments involving parent training are especially effective for children and adolescents. For example, Pincus and colleagues modified parent-child interaction therapy (PCIT)—an approach in the family of CBTs—to successfully treat separation anxiety disorder in young children (Puliafico et al., 2012). Schneider et al. (2011) also used a disorder-specific CBT with parent training for child separation anxiety and demonstrated that 76% of children with separation no longer met the diagnostic criteria for separation compared with 14% of children in the wait list control condition. To improve access to treatment, researchers have also found empirical success with summer camp interventions for separation anxious children (Santucci et al., 2009). As expected, because DSM-5 only recently permitted this diagnosis in adulthood, clinical treatment studies examining separation anxiety among adults are uncommon. Relatedly, however, research has examined the impact of adult separation anxiety on treatment outcome for other anxiety disorders. In one study, patients with PD and comorbid separation anxiety symptoms were four times more likely to have a poor treatment response compared with those without separation anxiety; this finding remained significant after covarying out other prognostic indicators, including severity of anxiety and agoraphobia, number of comorbid diagnoses, duration of illness, and socioeconomic class (Aaronson et al., 2008). A separate study found that separation anxiety symptoms negatively impacted treatment response for adults in treatment for PD, SAD, and GAD (Kirsten et al., 2008).

SELECTIVE MUTISM Selective mutism (SM) is marked by an inability to speak in specific situations (e.g., school), despite competence in expressive verbal communication in other contextual settings (e.g., home). SM occurs more often in younger children and adolescents than adults. Reticence or shyness are normative in the first few months of a new environment (i.e., school), and among nonanxious children speech increases with comfort. Pathology arises when silence continues despite acclimation to new settings. A diagnosis is assigned if clinical symptoms persist for 1 month or longer and the SM impairs functioning (i.e., in educational or social settings). It can be difficult for teachers to test academic competencies, such as reading, in children with SM. Lack of verbal engagement prevents opportunities to address academic needs and clarify misunderstandings. SM can be diagnosed when the mutism is not better attributed to another condition including communication disorder, autism spectrum disorder, intellectual disability, schizophrenia, or another psychotic disorder (APA, 2013). On the basis of samples drawn from community and clinical settings, the prevalence for SM ranges from 0.18% to 1.9% (Bergman et al., 2002; Kopp & Gillberg, 1997). Like other anxiety disorders, SM is more common among



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females than males (Dummit et al., 1997; Kumpulainen, 2002). SM symptoms remit over time, with a mean duration of 8 years (Remschmidt et al., 2001). Symptoms typically manifest before age 5, but SM often goes undetected until formal education, as children may exhibit normal speech with immediate family members. The mean age of diagnosis is 6.5 years (Ford et al., 1998). The condition is often comorbid with separation anxiety (Steinhausen & Juzi, 1996) perhaps partly because both disorders are augmented by anxiety and avoidance in social situations. Moreover, among children with SM, 70% of first-degree relatives met criteria for social phobia, and 37% reported a history of SM (Black & Uhde, 1995). Although there is similarity, SM is distinct from separation anxiety disorder because in separation anxiety, anxiety occurs when anticipating or separating from home (or major attachment figures), whereas in SM, there is a consistent failure to speak in specific social situations despite speaking in other situations. Children with SM are often willing to engage through nonverbal communication. Treatment and Efficacy Treatment of SM remains an understudied area, with most studies using single case designs. Two trials have shown CBT is effective for SM (Bergman et al., 2013; Oerbeck et al., 2014). Behavioral models conceptualize SM as an avoidance strategy used to regulate emotions in distressing situations (Scott & Beidel, 2011). Avoidance is negatively reinforced when it reduces anxiety (Mowrer, 1960a). Early intervention is critical to successful treatment of SM. Younger children with SM may benefit more from in vivo exposure; this may be because they have difficulty with exercises involving imagery and relaxation because of their developing cognitive skills and interoceptive sensitivity (Compton et al., 2004). From the perspective of CBT conducted from a family systems perspective, SM is caused and maintained by family dynamics. Family therapy interventions seek to identify and change faulty patterns of communication. Edison et al. (2011) examined parental control across selectively mute, anxious, and nonanxious children, and they found that parents of children with SM granted less autonomy and made more power remarks compared with parents in other groups. In one case study, structural family therapy increased speech with distant relatives and friends (Tatem & Delcampo, 1995).

CONCLUSIONS AND PRINCIPLES FOR PRACTICE Mechanisms of Change Identifying mechanisms helps explain how interventions yield outcomes and helps refine treatments by identifying components of effective therapy. Extensive data support the efficacy of CBT for anxiety disorders, yet less is known about the mechanisms of change. One mechanism in GAD is decentering, the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with the thoughts or feelings. In a growth curve

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analysis, researchers found increased decentering was associated with decreased anxiety. Also, changes in decentering preceded changes in symptoms within both treatments (i.e., acceptance-based CBT, applied relaxation), which the researchers concluded may be a common mechanism of action (Hayes-Skelton et al., 2015). One study with PD patients found the effects of CBT on agoraphobia, anxiety, and panic frequency were partially accounted for by reductions in fear of fear (Smits et al., 2004). Other studies provide evidence for unique and distinct changes in self-efficacy and anxiety sensitivity, and subsequent changes in panic symptoms during CBT for PD (Gallagher et al., 2013). CBT for social anxiety modulates brain responses related to cognitive reappraisal, timing, and functional connectivity (Goldin et al., 2013). Dissemination Despite research showing high efficacy of CBT for anxiety disorders, many patients do not receive CBT for anxiety in routine clinical care. Further, even when patients receive CBT in routine care, there is evidence that the treatment is not delivered with adherence. The manualized protocols are highly effective and specific, but they are also somewhat complex and, thus, restrict dissemination. Bridging the gap between research and clinical practice has led to the development of transdiagnostic approaches. Transdiagnostic treatment approaches were developed to be applicable across the emotional disorders. The Unified Protocol is one transdiagnostic, emotion-focused CBT approach that has demonstrated treatment effects, with 73% achieving responder status and 60% achieving high end-state functioning. Results improved further at a 6-month follow-up, with 85% classified as treatment responders and 69% achieving high end-state functioning (Farchione et al., 2012). Norton’s transdiagnostic CBT has also found promising results for anxiety disorder and other emotional disorders, and data from meta-analyses show that transdiagnostic CBT is comparable to traditional CBT treatment (Norton & Roberge, 2017). Application to Diverse Populations The role of culture is fundamental to understanding relevant processes underlying anxiety and its treatment. Cross-cultural research shows that anxiety is a universal emotion and anxiety disorders likely exist in all human societies, with some differences in prevalence and form (Good & Kleinman, 1985; Kirmayer et al., 1995). Yet studies often treat culture, ethnicity, race, or country of origin as research variables that require statistical controls. To extend research in anxiety to benefit the international community, investigators need to examine the social condition and cultural factors that influence the expression and treatment of anxiety. Studies examining the efficacy of CBT have been efficacious among majority White populations for decades (Deacon & Abramowitz, 2004). A meta-analysis of 57 effectiveness studies for anxiety disorders found CBT to be effective across



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samples. Yet African Americans or Caribbean Americans of African descent made up at least 20% of the sample in only 10.5% of the studies (one in six studies), and Latinos made up at least 20% of the sample in only 3.5% of the studies (two studies; Stewart & Chambless, 2009). A few studies have examined the efficacy of CBT cross-culturally. Pina and colleagues (2003) examined exposure-based CBT for Latino and European American youth with anxiety disorders; both groups responded to the intervention. In case studies, culturally sensitive CBT for anxiety has been effective for individuals who identify as gay, lesbian, or bisexual (Martell et al., 2004) and for two individuals who immigrated from China and Central America (Weiss et al., 2011). The United States is increasingly diverse. People of color make up over 36% of the population, many of whom identify as gay, lesbian, bisexual, or transgender. One in five Americans experience a physical disability or impairment (Taylor, 2018). Graham and colleagues (2013) called for enhancing the cultural sensitivity of CBT for anxiety in diverse populations and provided specific suggestions to increase cultural competence. At the core of CBT is the ability to connect with our patients, to respect the diversity of culture and life experiences, and to practice with cultural competence.

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Weiss, B. J., Singh, J. S., & Hope, D. A. (2011). Cognitive-behavioral therapy for immigrants presenting with social anxiety disorder: Two case studies. Clinical Case Studies, 10(4), 324–342. https://doi.org/10.1177/1534650111420706 Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., Hwu, H. G., Joyce, P. R., Karam, E. G., Lee, C. K., Lellouch, J., Lépine, J. P., Newman, S. C., Oakley-Browne, M. A., Rubio-Stipec, M., Wells, J. E., Wickramaratne, P. J., Wittchen, H. U., & Yeh, E. K. (1997). The cross-national epidemiology of panic disorder. Archives of General Psychiatry, 54(4), 305–309. https://doi.org/10.1001/ archpsyc.1997.01830160021003 Wells, A., & Butler, G. (1997). Generalized anxiety disorder. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 155–178). Oxford University Press. Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26(1), 153–161. https://doi.org/10.1016/S00057894(05)80088-7 Westra, H. A., Arkowitz, H., & Dozois, D. J. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8), 1106– 1117. https://doi.org/10.1016/j.janxdis.2009.07.014 Wetherell, J. L., Gatz, M., & Craske, M. G. (2003). Treatment of generalized anxiety disorder in older adults. Journal of Consulting and Clinical Psychology, 71(1), 31–40. https://doi.org/10.1037/0022-006X.71.1.31 Wetherell, J. L., Petkus, A.J., White, K.S., Nguyen, H., Kornblith, S., Andreescu, C., Zisook, S., & Lenze, E. J. (2013). Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. American Journal of Psychiatry, 170(7), 782–789. https://doi.org/10.1176/appi.ajp. 2013.12081104 Wetherell, J. L., Stoddard, J. A., White, K. S., Kornblith, S., Nguyen, H., Andreescu, C., Zisook, S., & Lenze, E. J. (2011). Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: A pilot study. International Journal of Geriatric Psychiatry, 26(8), 869–875. https://doi.org/10.1002/gps.2619 White, K. S., & Barlow, D. H. (2002). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed., pp. 327–378). Guilford Press. White, K. S., Payne, L. A., Gorman, J. M., Shear, M. K., Woods, S. W., Saksa, J. R., & Barlow, D. H. (2013). Does maintenance CBT contribute to long-term treatment response of panic disorder with or without agoraphobia? A randomized controlled clinical trial. Journal of Consulting and Clinical Psychology, 81(1), 47–57. https://doi.org/ 10.1037/a0030666 Wiederhold, B. K., Jang, D. P., Gevirtz, R. G., Kim, S. I., Kim, I. Y., & Wiederhold, M. D. (2002). The treatment of fear of flying: A controlled study of imaginal and virtual reality graded exposure therapy. IEEE Transactions on Information Technology in Biomedicine, 6(3), 218–223. https://doi.org/10.1109/TITB.2002.802378 Wittchen, H. U. (1988). Natural course and spontaneous remissions of untreated anxiety disorders: Results of the Munich Follow-up Study (MFS). In I. Hand & H. U. Wittchen (Eds.), Panic and phobias 2 (pp. 3–17). Springer Publishing. https://doi.org/ 10.1007/978-3-642-73543-1_1 Yerkes, R. M., & Dodson, J. D. (1908). The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology, 18(5), 459–482. https://doi.org/10.1002/cne.920180503

3 Obsessive-Compulsive Disorder Christine Purdon

O

bsessive-compulsive disorder (OCD) is characterized by the occurrence of obsessions and/or compulsions. Obsessions are intractable, persistent thoughts, images, impulses, or doubt, and compulsions are overt or mental behaviors conducted to prevent or ameliorate distress or a dreaded event or outcome, and/or are performed according to rigid rules (American Psychiatric Association, 2013). Although the lifetime prevalence of OCD is relatively low, with estimates ranging between 1.1% and 3.3% (e.g., Ruscio et al., 2010), it is one of the top 10 leading causes of disability in the world (World Health Organization, 1999) due to its costs in time and energy. In their epidemiological study (N = 2073), Ruscio et al. (2010) found that obsessions consume an average of 5.9 hours per day and compulsions 4.6 hours per day. The degree of impairment caused by OCD is on par with schizophrenia (Moritz, 2008). Furthermore, Ruscio et al. found that 28% of their sample had subthreshold symptoms of OCD, suggesting that it has an even greater public health burden than is suggested by merely the prevalence of clinically significant symptoms. In the absence of treatment, the course of OCD is chronic. In a 2-year prospective study, the probability of full remission was 6% (Eisen et al., 2010). Although exposure-based treatment has an efficacy rate of 80% to 95%, treatment dropout rate is an estimated 19%, which reduces efficacy to as low as 60%, and this does not include treatment refusal rates, for which we have very little data (Ong et al., 2016). OCD is associated with significant impairment, it is unlikely to remit in the absence of treatment, and treatment does not benefit almost half of those https://doi.org/10.1037/0000219-003 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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seeking it. This presents a moral imperative to better understand its development and persistence, and better help people engage with and benefit from effective treatment. This chapter reviews the characteristics of obsessions and compulsions, describes cognitive behavioral theories of OCD, provides an overview of the main treatment approaches, and offers suggestions for formulating the problem in OCD, framing treatment, and collaboratively executing it.

SYMPTOMS Obsessions Obsessions are repetitive, unwanted thoughts that the individual seeks to control. Although OCD is rare, obsessive thoughts are a universal experience (e.g., Purdon & Clark, 1993; Rachman & deSilva, 1978). Content areas of obsessions include contamination fears; repugnant obsessions involving themes of sex, aggression, or blasphemy; obsessions involving passive harm (e.g., forgetting to turn off an appliance and causing a fire); obsessions involving symmetry/exactness obsessions (with or without superstitious ideation); and nonsensical obsessions (e.g., snippets of songs, number sequences, an urge to count). Obsessions can occur in the form of verbal propositions (e.g., “Chemicals cause cancer”), images (e.g., an image of one’s house on fire), impulses (e.g., a sudden, unwanted impulse to swerve into the next lane while driving), and doubt, which is characterized by “what if . . .,, “did I . . .,” “maybe I . . .,” and “should I . . .” Although doubt is often considered a subtype of obsessive thought, it is important to keep in mind that, historically, OCD has been referred to as the “doubting disease,” which speaks for the centrality of doubt in symptom presentation regardless of the content of obsessions. Clinically, it is helpful to recognize doubt as a form of obsession that can reflect any of the content areas (e.g., “Maybe I am a pedophile.”; “What if this sunscreen interacts with my hand lotion to create a carcinogen?”; “Did I run over someone back there and not notice it?”; “Maybe these aren’t, in fact, perfectly aligned.”; “Maybe that red stain was blood.”; “What if I am not really in love with my husband?”). Compulsions According to the DSM-5, compulsions are actions performed to ameliorate the distress associated with the obsessions and/or to prevent some feared outcome, and/or are behaviors that are performed according to rigid rules. Types of overt compulsions include washing, checking, repeating, ordering/arranging, counting, superstitious rituals (e.g., ensuring one walks in a clockwise direction), and overt reassurance seeking. Reassurance seeking is essentially checking by proxy, and it can be overt (e.g., asking a spouse whether they love them, asking a spouse if the spouse is sure they saw someone lock the door, scouring the internet for reassuring information such as how long bacteria can live on a countertop) or quite subtle (e.g., asking indirect questions to obtain reassurance, such as questions about the person’s health). Covert compulsions include



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invoking mental images or phrases, mentally reciting prayers or “safe” phrases, mental checking (e.g., for indications of sexual arousal, for the memory of having locked the door properly), and mental reassurance seeking (e.g., reviewing all the characteristics one does not have in common with a pedophile, reviewing the research one has done about germs, closely observing loved ones for indications of good health). Like obsessions, compulsions are almost universal behaviors, but they are performed in a prolonged and/or inflexible manner until their goal is met or other demands supersede them. It is also important to note that compulsions are typically infused with doubt as to whether the goal has been met, whether it is okay to move on, whether it has been done “properly,” and whether one’s memory and sensory experiences can be relied upon to establish the above to the degree of certainty required.

HISTORY The symptoms of OCD have been recognized for centuries, and historical records about many public figures appear to suggest that they may have had OCD. For example, John Bunyan was said to be overwhelmed with obsessive thoughts regarding sin and the devil. Martin Luther was plagued with fears he would blaspheme when praying. Charles Darwin had persistent, repugnant images. Obsessive-compulsive symptoms are mentioned in ancient early texts on mental illness. In 1903, Janet provided a detailed phenomenological description of OCD and the characteristics of its sufferers. Freud considered OCD a neurosis and driven by unconscious conflict between the id and ego, which generate obsessions that symbolically represent the id instinct rejected by the ego, but which represent a threat that the unacceptable id instinct is surfacing. Compulsions are performed to neutralize the obsession and keep the feared instinct repressed. Behavioral theory holds that obsessions elicit an aversive affective reaction, which the compulsion alleviates. This reduction in distress serves as negative reinforcement for the compulsive act. Furthermore, the performance of the compulsion terminates exposure to the obsession, which prevents extinction of the emotional response. Researchers such as Rachman (1971, 1976, 1997, 1998) and Salkovskis (1985, 1989) observed that an obsessive thought in and of itself is only a source of distress to the extent that it is appraised as a threat, which was the catalyst for the development of the cognitive behavioral model of OCD described in the next section.

COGNITIVE BEHAVIORAL MODEL OF OCD The cognitive-behavioral therapy (CBT) theory of OCD is the leading psychological model of OCD. Since Rachman and Salkovskis’s seminal work on cognitive

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appraisal in OCD, the model has been elaborated in response to subsequent research, particularly that on appraisal and on self-perpetuating mechanisms in compulsions. According to the model, obsessive thoughts are appraised as signaling threat of some kind, which evokes distress of some kind. People engage in a range of escape and avoidance behaviors to either prevent the obsession from occurring, to reduce the possibility of a feared event occurring, and to reduce the distress. The most salient of these actions are of course compulsions. All such actions interfere with new learning about the obsession and its appraisal, as well as the need to perform the compulsion. Meanwhile, compulsions become prolonged and repetitive due to several self-perpetuating mechanisms, including poor memory and sensory confidence, which can evoke a doubt-repetitiondoubt cycle. In the next sections, each element of the model is reviewed, and then the way the components operate together to create an insidious cycle is examined. Obsessions, Distress, and Appraisal Obsessive thoughts are highly idiosyncratic in nature but fall into several themes, including (a) contamination (e.g., with respect to germs, dirt, chemicals, bodily fluids); (b) repugnant (i.e., those with sexual, religious, aggressive themes that decidedly go against one’s morals and values); (c) symmetry/exactness (need for objects to be aligned or “just so,” for body sensations to be equalized bilaterally); and (d) concerns about whether one has caused, or will cause, harm due to carelessness (e.g., while driving, locking the house, turning off appliances, preparing food). Obsessive thoughts often evoke anxiety, and when developing the case formulation, as well as when executing treatment, it is useful to be mindful of ways in which anxiety affects both mind and body. For example, anxiety narrows the attentional scope such that threat-relevant stimuli are attended to at the expense of other information; it can result in exclusive focus on highly salient but not necessarily constructive goals; and it makes threat-relevant memories more accessible (for reviews, see Mitte, 2008; Richards et al., 2014). Anxiety, of course, activates the sympathetic nervous system, which results in physiological arousal. Although a response to threat detection, the symptoms of physiological arousal can be readily interpreted as a signal that threat is truly present, thereby enhancing negative appraisal of the thought’s meaning. For clients with repugnant sexual obsessions, symptoms of anxious arousal can readily become confused with symptoms of sexual arousal, which is often experienced as strong internal evidence that the obsession is meaningful and important. Although obsessions often evoke anxiety, it is important to recognize that this is not the case for all sufferers. Some people with OCD feel a sense of disgust or a “not just right” feeling without any sense of foreboding or anxiety, apart from anxiety resulting from secondary appraisal that there must be something wrong if one is feeling disgusted or “not just right,” or that if the feeling



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is not ameliorated, it will interfere with other important goals. Both disgust and not just right experiences respond to exposure with response prevention. However, when establishing the case formulation, it is important not to assume that the client’s obsessive concerns evoke anxiety and instead, to take the time to identify the client’s actual emotions. Beliefs and Appraisal The Obsessive Compulsive Cognitions Working Group (OCCWG; Steketee et al., 2003) proposed six types of appraisal and beliefs as especially important to OCD, including responsibility, importance of thoughts, mental control, overestimation of threat, intolerance of uncertainty, and perfectionism. Responsibility Salkovskis (1985, 1989, 1999; Salkovskis et al., 1995) proposed that obsessions develop when normal thoughts activate overvalued beliefs about one’s responsibility to protect oneself and others from harm. Examples include “Failing to prevent (or failing to try to prevent) harm to self or others is the same as having caused the harm in the first place,” “Responsibility is not attenuated by other factors (e.g., low probability of occurrence),” and “Not neutralizing when an intrusion has occurred is similar or equivalent to seeking or wanting the harm involved in that intrusion to happen” (Salkovskis, 1985, p. 579). These general appraisals lead to situation-specific appraisals of the thought’s occurrence, such as “It would be immoral for me to ignore this thought,” “I must be 100% certain that X will not happen before it is moral to go on to other things,” and “I must stop and deal with this now, before anything else.” Salkovskis (1985, 1989) also made the important observation that people with OCD do not fear harm as much as they fear being responsible for harm. For example, people with checking concerns are typically not bothered when their spouse is in charge of ensuring appliances are off before leaving their house for the day, even though they may estimate that the chance of the spouse overlooking something and a fire occurring as being well above zero. Importance of Thoughts Rachman (1998) introduced the idea of “thought action fusion” to describe the beliefs that (a) having an unacceptable thought increases the likelihood of the negative event represented in the thought coming true and (b) having a morally repugnant thought is the moral equivalent to committing a morally repugnant deed. This overemphasis on the thought’s meaning also manifests in beliefs that “obsessional thoughts indicate something significant about oneself (e.g., that one is terrible, weird, abnormal),” and “negative intrusive thoughts must be important merely because they have occurred” (Thordarson & Shafran, 2002, p. 15). Other examples include “This thought reflects my true evil nature,” “Having this thought means I am a bad person,” “If I think this, I must really want it to happen,” “Thinking this can make the event more likely to

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happen,” “If others knew I thought this, they would think I am an evil person,” and “Having this thought means I am likely to lose control over my mind or my behavior” (Rachman, 1997, p. 793). In one instance, a client with repeated obsessive thoughts about the state of her finances believed that these thoughts would not occur unless there was some truth to them, signaling that she had forgotten an expense or, even if she had not, that the thought was a prophetic warning sign. She also believed that she and her partner possessed personality characteristics, such as self-indulgence, that could result in irresponsible accrual of debt. Mental Control Mental control refers to “over-evaluation of the importance of exerting complete control over intrusive thoughts, images or impulses, and the belief that this is both possible and desirable” (Purdon & Clark, 2002, p. 37). Examples of such beliefs include, “I would be a better person if I gained more control over my thoughts,” “If I exercise enough willpower, I should be able to gain complete control over my mind,” and “Being unable to control unwanted thoughts will make me physically ill.” People with OCD will often appraise the recurrence of a thought as further evidence of their weakness of character and inability to maintain control over important matters. Overestimation of Threat Overestimation of threat refers to the overestimation of the severity and/or the likelihood of the occurrence of negative events (Steketee et al., 1998). Examples of such beliefs, as summarized by Sookman and Pinard (2002, p. 64), include “I believe that the world is a dangerous place,” “Bad things are more likely to happen to me than to other people,” and “When anything goes wrong in my life, it is likely to have terrible effects.” Intolerance of Uncertainty Intolerance of uncertainty is reflected in beliefs such as, “If I am uncertain, there is something wrong with me,” “If I’m not absolutely sure of something, I’m bound to make a mistake,” and “It is essential for me to consider all the possible outcomes of a situation.” These ideas lead people with OCD to seek certainty that the occurrence they fear has not, is not, nor will not occur, and feel the need to do so immediately and at the expense of other tasks. Perfectionism Steketee (1999) defined perfectionism as the “tendency to believe that there is a perfect solution to problems, that doing something without mistakes is possible and desirable and that even minor errors will have serious consequences” (p. 146). Examples of such beliefs as they pertain to OCD include “In order to be a worthwhile person, I must be perfect at everything I do,” “If I fail at something then I am a failure as a person,” “I must keep working at something until it is done exactly right,” “There is only one right way to do things,” and “Even



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minor mistakes mean a job is not complete.” It is important to note that people with OCD may not exhibit a general sense of perfectionism, but rather seek to ensure that their obsessive concerns have been perfectly satisfied and/or their compulsions perfectly completed. In the case of non-comorbid OCD, perfectionism may be closely tied to overestimation of threat and intolerance of uncertainty. Core Beliefs, Assumptions, and Appraisal Beck’s cognitive model assumes that psychopathology is characterized by negative schemas about self, world, and/or future. The term schema refers to an operating framework for a category of people, places, and things in which previously encoded information about that category is stored. Schemas allow for rapid processing of situational information, such that we can quickly anticipate what is going to happen next and prepare ourselves to respond. Once a schema is activated, relevant memories, images, thoughts, and emotions accompany it, along with evaluative or summative conclusions, or beliefs, about that category. Schemas about self, world, and future are central, and they are often referred to as “core” beliefs. Core schemas are represented in summative and evaluative core beliefs (e.g., “I am bad,” “The world is dangerous,” “The future is bleak”). Once a schema has developed, information consistent with it tends to be noticed and encoded (e.g., a dirty look from someone for being a few minutes late), whereas information inconsistent with it tends to be ignored, trivialized, or discounted (e.g., others being unconcerned about one’s lateness). Thus, they can readily give rise to information-processing biases. Interestingly, core beliefs regarding self, world, and future have not been well-explicated in the cognitive behavioral model of OCD. Salkovskis (1985, 1989) identified core beliefs of overvalued responsibility, as described previously, as central to the development and persistence of OCD. Rachman (1971, 1997, 1998) observed that the content of obsessive thoughts often reflect the themes of moral systems (e.g., aggression, sex, blasphemy, cleanliness), and thus, obsessive thoughts, which represent a violation of those moral systems, are likely to be experienced, at least initially, as sinful, disgusting, alarming and/ or threatening and will evoke distress. Whereas most people are able to reappraise the thought as silly, senseless, and meaningless, albeit unpleasant, those prone to developing obsessional problems will appraise the thought as having important meaning and relevance for the self. Purdon and Clark (1999) elaborated on this and argued that obsessive thoughts that threaten one’s self-view are more likely to breach the attentional threshold. Most people will assimilate the thought into their self-view (e.g., “Even a person like me can have a thought like this”), but those vulnerable to OCD may alter their self-view to accommodate the thought (e.g., “Maybe I am a homicidal maniac at heart”). Clark and Purdon (1993) also argued that people with OCD may have a fewer number of domains by which they define themselves (e.g., being a moral person, being a caring person, being a responsible

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person). Thus, thoughts that challenge these domains (e.g., the thought that one may have caused harm) compromise self-worth and will activate attempts to repair potential damage and compensate for one’s failings. This is consistent with Guidiano and Liotti (1983), who proposed that compulsive behaviors emerge as a strategy for gaining approval and self-worth. Indeed, it has been found that obsessions that contradict valued aspects of the self are particularly distressing (Rowa et al., 2005), that OCD symptoms are associated with a sense of incompetence in key self domains (Doron et al., 2007), and that people with OCD tend to exhibit ambivalent core beliefs (e.g., “Maybe I am incompetent”; Bhar & Kyrios, 2007). Given that important schemas are formed in childhood, there is emerging research on the association between attachment and OCD as well as family factors. Doron et al. (2011) found that people with OCD had higher attachment anxiety (but not attachment avoidance) in their adult relationships than people with anxiety disorders, even controlling for depression. Rachman (1976) observed that we are more likely to be criticized for actions for which we are responsible than for actions for which we are not responsible. In their classic analysis of obsessions and compulsions, Rachman and Hodgson (1980) argued that critical parenting heightens the perceived consequences of errors, leading to excessive caution when one is responsible for the outcome, as well as the need for certainty that it has been done well. Salkovskis et al. (1999) identified parental criticism as a pathway to inflated responsibility and similarly argued that persistent criticism increases the perceived cost of being responsible. Guidiano and Liotti (1983) and Ehntholt et al. (1999) generally agreed that when people receive contradictory messages about their self-worth (i.e., when subjected to criticism), the compulsion becomes a means of gaining a positive sense of self. Similarly, McFall and Wollersheim (1979) posited that perfectionism may evolve from the need to avoid being criticized. There is empirical evidence for an association between criticism in family of origin and current family, OCD symptoms, and overvalued responsibility, although the literature is small and approaches to studying the issue are quite varied (Pace et al., 2011). In addition to a need to avoid being held responsible for outcomes and therefore criticized, a critical environment may also lead one to mistrust one’s own judgement and perceptions. If people behave in ways that strike them as quite reasonable and justifiable, and yet they find themselves criticized by authoritative people, they may conclude that their own judgement and perceptions are misleading, flawed, or otherwise untrustworthy. Thus, they may have difficulty achieving an internal, felt sense that they have done something properly or that danger has passed (e.g., Lazarov et al., 2010; Szechtman & Woody, 2004). Taken together, it may be the case that people with OCD exhibit ambivalent or negative core beliefs about the self (e.g., “I am flawed,” “Maybe I am a bad person,” “I am careless”) which generate assumptions (e.g. “If I am in charge things are more likely to go wrong,” “I will be held accountable for negative events, even when they are mostly out of my control,” “If there is a possibility



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that something I do can cause harm I shouldn’t do it”), and rules for living, such as “When it comes to matters of harm, if I do the action to prevent it perfectly I can’t be faulted,” “I can and must control thoughts lest they lead to harm,” “It is immoral to move onto other things until you know for sure you have prevented harm,” and “If I am alerted to the possibility of harm, no matter how remote, it would be immoral to ignore it.” These beliefs and assumptions evoke negative appraisal of the obsessive concern as a threat, which drives the compulsion. The compulsion is done to ameliorate distress and/or prevent harm, but also to preserve self-worth. Thus, there is an imperative for perfection and perceived need for certainty in completing it. A final observation is that people with OCD do not necessarily exhibit a general intolerance of uncertainty, but rather a high intolerance of uncertainty regarding the obsession and the extent to which the compulsion has been done properly. Ameliorative Strategies People with OCD can engage in a wide range of strategies to ameliorate the distress over the obsession, to avoid or prevent feared events, or to avoid or prevent having to do the compulsion, including thought suppression, avoidance, and of course compulsions. Thought Suppression People with OCD generally attempt to suppress their obsessive thoughts, and in fact, thought suppression is a defining feature of obsessions in the DSM-5. Purdon et al. (2007) had people with OCD keep a diary record of their thought suppression attempts over three days and found that suppression attempts were frequent and effortful. The top reasons reported for suppression were to get rid of the obsession before the compulsion became necessary, to prevent anxiety from escalating, and to prevent potential harm. It is generally accepted as psychological fact that suppression results in a resurgence of unwanted thoughts (the so-called “white bear effect), but in reality there is very little evidence that suppression results in an escalation of the frequency of obsessions (for reviews, see Abramowitz et al., 2001; Magee et al., 2012; Purdon, 2004; Rassin et al., 2000). Purdon et al. (2007) found that suppression actually facilitated functioning about a third to half the time; that is, it was effective in managing mood and improving concentration. However, suppression is seldom 100% effective, and there is research suggesting that thought recurrences can reinforce negative appraisal of the thought’s meaning and importance (e.g., “The more I have this thought, the more concerned I become about my personality”; Magee & Teachman, 2007; Purdon et al., 2005, 2011). Invoking the “white bear effect” to explain the persistence is thus not advised, both because the evidence does not bear it out and because it may be quite inconsistent with people’s own experiences of periodic successful thought control. However, when developing the case formulation, it is important to factor in the client’s expectations for thought control and their interpretation of thought recurrences.

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Avoidance People with OCD use a wide range of avoidance strategies to preempt occurrences of the obsession, to prevent harm, and to reduce distress when contact with feared stimuli is unavoidable. Newth and Rachman (2001) observed that people with repugnant obsessions also tend to avoid revealing the content of their obsessions in order to avoid causing the obsession to be acted upon or otherwise come true, out of shame and embarrassment and out of fear of practical consequences (e.g., having their child removed from their custody). One means of avoidance is thought suppression, as previously discussed. In order to avoid experiencing the obsession, people may also avoid places where the obsession is likely to be triggered (e.g., hospitals, playgrounds, public bathrooms, cemeteries), objects (e.g., knives), situations (e.g., being the last one to leave the house, being the one to tend to a wound, being alone with a child, driving, changing a diaper), and people (e.g., people who have or may have an illness, children). The avoidance can be quite subtle as, for example, when one client realized that of the two family cars, he had been avoiding driving the red one because the color red triggered his obsessive concerns about blood. When people with OCD are unable to avoid contact with feared events, situations, objects, or people, subtle avoidance strategies may be used, such as avoiding direct contact with the stimulus (e.g., wearing gloves, using the sleeve to open a door, maintaining distance) or enjoining others to perform tasks within the situation (e.g., changing a diaper). Rachman (1998) observed that as the idea that the thought portends danger persists, the number of external cues that become relevant to the thought increases (e.g., someone with the obsession of stabbing a loved one with a knife may start to view any sharp object as a potential weapon and begin avoiding it). Thus, the range of threats in the individual’s environment increases, which means that the number of triggers for the obsession increases. Avoidance strategies are understandable, but they work against people in the long term. Avoidance prevents new learning about the feared stimulus and helps sustain negative appraisal of the obsession and appraisal of the perceived need to do the compulsion. Avoidance is also time consuming and inconvenient, contributing to the intrusiveness of the disorder. Hypervigilance People with OCD are hypervigilant for triggers for the obsessive concern, for information that harm has or will occur, as well as for indications that the compulsion may not have been successful in averting harm. People can be vigilant for internal information (i.e., body sensations, thoughts) in addition to external information. Ironically, avoidance of triggers requires hypervigilance for those triggers, so avoidance may be preceded by threat monitoring. People with contamination concerns will often track a “contaminated” object (e.g., a handbag that was set down on the floor) and monitor all the places that object has touched so those spots can be avoided or cleaned, or they may constantly monitor the ground or other areas for contaminants in order to avoid contact (e.g., blood, feces, band-aids, chemicals).



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People with symmetry/exactness concerns may track the movements of people in their home so they can follow behind and correct misplaced objects. People with repugnant obsessions may monitor their body sensations for indications of inappropriate sexual arousal, monitor the news for indications that an accident has occurred, or closely monitor their thoughts for indications of a recurrence of the obsession. People with obsessions about illness or contamination may monitor their bodies for symptoms of illness. Avoidance and vigilance monitoring tend not to be included on measures of OCD symptoms, but they are important markers of the intrusiveness and severity of the disorder and the extent to which treatment has succeeded. Like avoidance, hypervigilance is understandable, but it is unhelpful in the long term because it ensures that even the smallest indication of threat are attended to, and this may occur at the expense of important information, such as information about the safety of the situation. Attending to bodily sensations can cause people to notice and react to perfectly normal physiological changes and to misattribute their cause. Monitoring to determine whether harm has occurred is problematic because the null hypothesis (i.e., that harm has not occurred) cannot be proved; the failure to detect indications of harm could simply mean that harm has not been discovered yet. Finally, as discussed in more detail in the next section, repeating an action, such as monitoring one’s body, undermines confidence in one’s sensory experiences. Compulsions Compulsions are overt or covert (i.e., mental) actions that neutralize obsessive concerns and/or ameliorate distress and tend to be conducted in a rigid or ritualized manner. There is a growing body of work suggesting that once a compulsion is performed, several self-perpetuating mechanisms follow. First, a number of studies have found that individuals with OCD have less confidence in their memory, cognitive, and sensory faculties overall than do individuals with another psychiatric diagnosis or individuals with no diagnosis (Hermans et al., 2003; Nedeljkovic & Kyrios, 2007; Nedeljkovic et al., 2009; van den Hout et al., 2008), particularly when referencing OCD-relevant actions such as locking a door (Hermans et al., 2003). People with OCD are then especially prone to doubting whether they have done something correctly and, therefore, are inclined to repeat it just to be sure. Meanwhile, repeating an act compromises memory, sensory, and cognitive confidence in as few as five repetitions, even though actual memory is intact (Coles et al., 2006; Fowle & Boschen, 2011; Radomsky et al., 2006; van den Hout & Kindt, 2003). This effect is especially pronounced under conditions of high responsibility and on tasks relevant to current goals (Boschen & Vuksanovic, 2007; Radomsky et al., 2014). Furthermore, as an act is repeated, the amount of detail that the individual seeks to track in order to form a strong memory later increases, thereby taxing working memory, which makes it difficult to achieve a memory for the action with the clarity desired. Thus, once an action is repeated, confidence that the compulsion has been done properly is

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undermined, and this in turn can readily lead to generalizations about one’s memory, cognitive, and sensory acuity. However, it is important to note that compulsions are handily terminated a great deal of the time. In their study of compulsions conducted in vivo, Bucarelli and Purdon (2015) and Bouvard et al. (2020) found that compulsions yielded a sense of satisfaction and/or a sense that enough had been done to prevent harm more often than not, even when they had been repeated. This intermittent reinforcement schedule is one of the most difficult to break. Furthermore, this bespeaks the fact that compulsions often work for people. When the obsessive concern (and concomitant distress) arise, the compulsion can be a very efficient means of handling it. On the other hand, almost half the time the compulsion does not achieve its goal, which is useful for therapists to note when discussing beliefs about the utility of the compulsion. Although compulsions can “work” in the short term, they prevent new learning about the meaning and importance of the obsessive concern. When the feared event does not occur, it is attributed to the performance of the compulsion. When the compulsion does not meet its goals, sufferers believe that their distress is at least lower than it would have been had the compulsion not been done. The reduction in distress afforded by the compulsion is negative reinforcement for its continued use. Furthermore, the performance of the compulsion terminates exposure to the distress associated with the obsession, which prevents new learning about the obsession and compromises extinction of the emotional response, which would decline on its own without the compulsion. Finally, as noted, the insidious cycle of repetition-doubt-repetition prolongs the compulsion in the moment and undermines general confidence in memory, cognitive, and sensory systems.

CASE FORMULATION The route to successful treatment is the development of a case formulation that identifies the “culprits” in the persistence of the client’s obsessions and compulsions, which the client understands and shares. This allows the client and therapist to ally with each other against the OCD. A good assessment results in a solid understanding of the breadth, range, and severity of symptoms, the beliefs, assumptions, and appraisal of both obsessions and compulsions, and the avoidance, vigilance, and safety strategies used, as well as relevant factors in the client’s life, such as learning history (e.g., parental criticism, fear conditioning). The therapist can also bring to bear research on thoughts and thought suppression; the association between repetition, doubt, and memory/cognitive/sensory confidence; attentional processes (i.e., that anxiety focuses attention on threat-relevant stimuli at the expense of other information); and relevant learning principles such as the role of distress reduction in reinforcing the ameliorative strategies. It is also important to understand the activities that the OCD compromises, so as to introduce positive goals for the individual to strive



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toward, instead of focusing treatment solely on symptom reduction. Once the therapist and client have a solid working formulation that explains (not just describes!) the persistence of the symptoms, the treatment plan emerges into focus. The formulation will develop over time as the client and therapist discover more about these elements and the way in which they work together, but treatment should start with a good working model that clearly identifies the culprits that cause OCD symptoms to persist. As discussed earlier, people with OCD may not be comfortable reporting on the content of their obsessions and/or the extent and nature of their rituals. It is important that the therapist and client have an open discussion about the content of the obsession because otherwise it is difficult to build a case formulation and execute effective cognitive restructuring around the appraisal of the thought’s meaning. If the person has repugnant obsessions, they may find it difficult to disclose content, as mentioned previously. In such cases, it is useful to normalize the content by explaining that many people experience repugnant thoughts and show the client lists of thoughts experienced by people without OCD (e.g., Purdon & Clark, 1993; Rachman & deSilva, 1978). As a first step, the therapist can also ask the client to write the content down and then read it aloud. People with OCD may lack perspective on the extent to which their habits are excessive. For example, they may not know how long most people spend in the shower or how often most people clean their bathrooms and kitchens and, therefore, are simply not aware that their habits are quite different. Some good preliminary or supplementary questions to ask include “Do you tend to use a lot of hot water and/or soap in the shower?” “Does cleaning take you a lot longer than it does other people you know?” “Do the people you live with often tell you that you spend too much time in the shower/cleaning/ordering/ etc.?” “Do you tend to go through a lot of soap and/or hand sanitizer in a week?” “Does it take you a long time to leave the house?” “Does it take you a long time to check everything before going to bed or leaving the house?” “Do you prefer it if others lock up the house rather than you?” “Are there people, places, or situations that you prefer to avoid, or endure with distress if you can’t avoid?” “Do you have thoughts that you have to ‘undo,’ suppress, or ‘correct’?” and “Do you find it hard to stop doing certain actions until you are absolutely certain you have done them well, even it if means being late for other things or keeping people waiting?” To establish diagnosis, structured interviews are the gold standard. However, if there is limited time available and only a quick OCD screen can be conducted, options are available. NICE (2005) guidelines recommend the Zohar-Fineberg Obsessive Compulsive Screen (Z-FOCS), which consists of five questions, has good psychometric properties, and can be administered in 1 minute (Fineberg et al., 2008). The most widely used diagnostic interviews are the Structured Clinical Interview for DSM-5 (SCID-5; First et al., 2015) and the Mini Neuropsychiatric Interview for DSM-5 (MINI 7.0; Sheehan, 2016). The MINI takes considerably less time than the SCID and has excellent reliability. If time is

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limited, the OCD modules from either can be used on their own to establish diagnostic status. There are numerous symptom severity measures, of which Grabill et al. (2008) provide an excellent comprehensive review. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989a, 1989b) is commonly used because it readily identifies the range of symptoms, target symptoms, and level of insight; has well-established norms; and is sensitive to pre- and post-treatment symptom changes. The self-report version of the measure has shown good consistency with the interviewer-administered version (Federici et al., 2010). Given the degree of comorbidity with depression and the potential of depression to compromise motivation, it is advised that depressive symptoms be assessed. The Beck Depression Inventory-II (BDI-II; Beck et al., 1996) is an obvious choice. In order to assess beliefs about obsessive thoughts and their appraisal, the OCCWG developed, respectively, the Obsessive Beliefs Questionnaire (OBQ; OCCWG, 2001; Steketee et al., 2005) and the Interpretation of Intrusions Inventory (III; OCCWG, 1997). These measures can be used to identify targets for CBT and to assess treatment progress. It is important to note that some people with OCD score low on these measures, and some have argued that they represent a subtype of OCD not characterized by negative appraisal (e.g., Taylor et al., 2006). However, it may also be the case that only one or two negative beliefs about and/or appraisal of obsessive thoughts, held strongly, are necessary to evoke clinically significant distress. It is important to use scores on any self-report measures as a guide to further discussion, as opposed to ends in themselves. Once diagnosis and severity have been assessed, the therapist and client begin working on a formulation of the problem. Kuyken et al. (2009) observed that a sound formulation explicates the internal logic of the obsessive-compulsive cycle, is derived collaboratively, creates a simple (but not simplistic) model to explain a complex experience, and helps clients develop a more compassionate understanding of their symptoms and of themselves. Most importantly, the case formulation explicates the mechanisms by which the problem persists, as opposed to simply describing the symptom cycle. In OCD, the formulation must explain what is meaningful about the obsessive concern (i.e., why it captures and holds attention in the first place), why it evokes the aversive emotional response/distress, and why the compulsions are repeated both within and across episodes. To accomplish this, it is useful to have the client keep a diary record of their obsessions and compulsions for a week. Drawing from a nomothetic model of OCD, the client is asked to record the content and form of the obsessive thought (i.e., thought, image, impulse, doubt); the personal meaning and importance of the obsession; the range of emotions it evoked; and the coping strategies used to manage that distress, with particular focus on the compulsions. The client also reports on how often they repeat the compulsions within the episode and how successful the compulsions were in achieving their goal. The client also



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reports on the impact of repetition on memory, cognitive, and sensory confidence. Using these data as a guide, the therapist and client conduct a detailed cognitive-behavioral assessment of their OCD with the goal of developing a strong working case formulation. The case formulation identifies the obsessive preoccupation, the appraisal of the obsessive thought, the subsequent emotions, and the ameliorative strategies used and their emotional, behavioral, and  practical consequences, and the beliefs and assumptions generating the appraisal.

DESCRIPTION OF MAIN TREATMENT APPROACHES AND THEIR PROCEDURES According to United Kingdom’s National Institute for Health and Care Excellence (NICE; 2005) and the American Psychiatric Association (2007) guidelines, the psychological treatment of choice for OCD is cognitive therapy (CT), which includes exposure with response prevention (ERP). ERP refers to exposure to the obsession while the compulsive ritual is prohibited. In CT+ERP, negative appraisal of the thought’s meaning is addressed via standard cognitive restructuring techniques and behavioral experiments, while the aversive emotional response to the obsession is extinguished through ERP. The NICE guidelines recommend a stepped approach, such that milder cases receive a brief (i.e., 10 therapy hours or less course) of CT+ERP with structured self-help materials or telephone contact with a therapist, or they receive group treatment. For people who fail to benefit from such low intensity approaches and for those with more severe symptoms, a choice of either a more intensive course (i.e., 10+ therapist hours) of CT+ERP or a course of selective serotonin reuptake inhibitors (SSRIs) is recommended. When symptoms are so severe that the person is unable to leave the house, telephone sessions are recommended. Family members are almost invariably involved in the client’s compulsive rituals by providing reassurance or assisting in or conducting safety, checking, cleaning, and avoidance rituals. Family dynamics may also play a role in treatment outcome. For example, when the sufferer’s family environment is characterized by over-involvement, hostility, and high criticism, treatment outcome tends to be poorer (for a review, see Purdon, 2012). Furthermore, although family members may genuinely wish for the client’s suffering to be relieved, they may find adjusting to changes in the client’s behavior and perspective difficult and may unintentionally behave in ways that undermine treatment. For example, they may find it difficult to give up providing reassurance or protecting the family member from responsibility. If possible, it may be useful to meet with key family members to help them develop a compassionate understanding of the client’s symptoms and the way treatment will help overcome them, and to instill hope. Once treatment is underway, family members need to have a clear understanding of how best to respond to reassurance, avoidance, and other behaviors

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that maintain the client’s OCD. Family members should be discouraged from being complicit in rituals but without taking a mocking, critical, or harsh tone, which tends to exacerbate rituals (Amir et al., 2000). Family members can, instead, be encouraged to be firm but supportive (e.g., “You are asking me for reassurance, and we have agreed that it doesn’t help you overcome your OCD for me to provide it. I know you are strong, you are doing great, and you can ride through the anxiety. I have confidence in you”). Family members can also be given basic instruction in ERP and can coach clients in between sessions. Van Noppen and Steketee (2003) and Renshaw et al. (2005) have advocated for a multifamily behavioral treatment in which family members are trained in exposure to rituals, contracts to improve communication within the family, and reducing hostile and antagonistic responses to OCD. Guidelines for this approach are outlined in these respective papers. Setting the Stage for Treatment The first phase of treatment involves identifying the specific targets of treatment, or the culprits, presenting the treatment plan, and setting the stage for treatment. CBT of OCD requires people to refrain from the strategies that they have used to cope with distress, which they believe serve to prevent harm, and which, in turn, reflect highly important goals and values. Unless the rationale for this is obvious and compelling, they are vulnerable to refusing treatment, dropping out, or continuing with treatment while avoiding its anxiety-evoking elements (e.g., Maltby & Tolin, 2003; Vogel et al., 2004). Avoidance strategies and compulsions advance valued goals (e.g., to protect the family from harm, to prevent sin, to be a good parent), and many clients may fear that treatment will require that they work against these goals. Once the formulation has been developed, it can be useful to identify the valued aspects of self or important goals that are being advanced by the compulsions (e.g., expressing caring via elaborate checking rituals to ensure safety) and those that are being compromised by the compulsions (e.g., conscientious punctuality that is compromised by habitual lateness due to checking routines). The former can be understood as an important reason that the compulsions developed and persist, whereas the latter is the reason the client has sought treatment. The overall goal of treatment is to help the client advance the former without compromising the latter. Once the therapist and client are in agreement as to what the culprits are and how they compromise valued goals, it is important to discuss that treatment involves taking risks. These risks include not engaging the OCD “voice” and thereby risking ignoring a genuine threat, terminating ameliorative strategies before achieving a sense of certainty, and tolerating the ensuing doubt (thereby risking that harm may have, or could in future, occur). The goal of treatment is to help people learn to take the same acceptable risks that people without OCD take and that they themselves take on matters outside obsessive concerns. Furthermore, people with OCD tend to overestimate risk, particu-



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larly when they are the ones responsible for the outcome, and they feel a moral imperative to prevent that harm, no matter how small its probability. In setting the stage for exposure and behavioral experiments, it can be useful to develop a reasonable estimation of threat, not for the purposes of reassurance, but rather to establish that the obsessive concern typically has a very remote risk of occurring. Consider Ms. K., who was preoccupied with concerns that she may have a bank overdraft and checked her account balance, credit card statements, and her wife’s spending multiple times per day. The therapist and Ms. K. sought to estimate the probability that at that moment in time her expenses outweighed their income. Ms. K. reasoned that for this to happen, (a) her wife would have had to have spent more than $300 in the past week, (b) Ms. K. would have had to have miscalculated their income, and (c) there would have had to be expenses of which she was unaware. Ms. K’s estimations of each event were, respectively 0.08, 0.10, and 0.05. Thus, even with a 10% chance that Ms. K. had miscalculated their income, the probability of her feared event happening was 0.08 × 0.10 × 0.05 = 0.0004; the chance that the event would not happen was 99.996%. Yet the probability that Ms. K. was compromising important goals in the service of assuring herself that an event of minute probability had not occurred was 100%. The therapist can then discuss the probability that Ms. K. could have gotten into a bad car accident on her way to the office, which she estimated to be about 2% but said it was negligible compared with the inconvenience of not driving. This could be discussed as an example of how Ms. K. takes fully acceptable, normal risks on a daily basis; Ms. K. felt no moral imperative to stop driving even though it carried considerably more risk than having an overdraft. Thus, there may not be a moral imperative to act on the obsessional thought any more than there is to act on the thought that there is a 2% chance of getting into a car accident. Having established this, the client and therapist can examine the values and goals that are being supported by the compulsion and those that are thwarted by the compulsion. Consistent with Egan et al. (2014), the therapist can draw a graph with a horizontal line that reflects the goals and values supported by the compulsion, as well as an intersecting vertical line that reflects the goals and values compromised by the compulsion. Each line has anchors of 0, which means “not succeeding in meeting these goals at all,” and 100, which is labelled “fully meeting these goals.” The client rates themselves on each line and plots the point of intersection. This exercise often helps clients realize that no matter how much effort they put into compulsions, they are unable to achieve the goals the compulsions support, as they are oriented almost exclusively to how they fall short while typically having perfectionistic standards for goal attainment. Therefore, the point of intersection is typically in the lower two quadrants, and often in the lower left quadrant. Treatment aims to help the individual move into the upper right quadrant. The benefit of illustrating this point is that it helps people be assured that in order to overcome OCD, they do not have to give up the very values and goals that define them (e.g., they do not have to

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compromise their religious traditions, they do not have to care less about their families). A second benefit is that it addresses what is often the white elephant in the therapy room, which is that compulsions both work and are expressions of important goals and values, as opposed to purely shameful behaviors that must be annihilated at all cost. Active Treatment The ultimate goal of active treatment is to help the client develop a defiant and airtight stance against the OCD. For Ms. K. it would be, “Yes, OCD, you might be right, I might be running further into debt, but probably not, so I am going to accept that risk and just get on with the immediate and important things I know need my attention right now rather than checking my bank balance.” Exposure With Response Prevention Pyschoeducation about the self-perpetuating mechanisms of compulsions is an essential prelude to conducting exposure. This will have been part of the case formulation but should be a continued focus of discussion, and in helping the person recognize that repetition is a major culprit in OCD, persistence can assist with motivation for ERP. In ERP, the obsession is evoked, and the person is prohibited from conducting the compulsion. Once the distress declines substantially, the process is repeated until the obsession causes little to no distress. ERP can appear deceptively simple, and in the absence of a strong working case formulation, therapists can make the mistake of simply having people expose themselves to any stimuli that make them uncomfortable. However, this can miss the point entirely. Consider the obsessive concern “Maybe I’m gay and am ruining my partner’s future by staying with her.” In order to avoid triggering the obsession, people with this concern may avoid naked images of same sex people, just as the person phobic of dogs might dislike and avoid a dog park. In both cases, the target of exposure should be the primary fear, not a secondary fear of a stimulus that evokes the primary fear. The primary fear for our OCD clients was that the thought “Maybe I’m gay” signaled something important and meaningful about their sexual orientation, which in turn meant that their heterosexual relationship was fraudulent. Exposure should target the doubt about being gay while prohibiting attempts to achieve certainty that they are not gay. If required, stimuli can be used to evoke the obsession (e.g., pictures of same sex people), but extinction is of the response to the obsessive doubt, not the pictures, just as when working with someone who is afraid of dogs, extinction is to the fear of dogs, not dog parks. The case formulation is of central importance in determining what to expose the client to and in what order. The therapist must first ask, “What does the client need to achieve new learning about?” Ms. K. would benefit from new learning as to (a) whether having the thought that her bank balance might be low truly signals imminent and clear danger and requires immediate action, (b)  whether she has a moral imperative to drop everything to prevent that



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danger, and finally, (c) whether or not her distress would truly fail to dissipate unless she did her compulsions. The next question in ERP is where to start. Therapists often have clients develop an exposure hierarchy starting with stimuli and situations that cause moderate distress and lead up to those most feared. One downside of this approach is that, at least initially, the prospect of having to face the dreaded situation at the top of the hierarchy can reduce motivation to progress (e.g., “If I do step four this week I’ll have to do that last step in just a couple of weeks!”). It can also lead to defining treatment goals in terms of progress on the hierarchy as opposed to reclaiming one’s life. It can be more useful to build exposure around the client’s treatment goals (e.g., to get to work on time), identify the compulsions that get in the way of those goals, and identify the factors that influence distress when the client’s obsessions occur (e.g., proximity, presence vs. absence of other people, home vs. other places). The therapist and client can then identify a starting point (e.g., exposure to thoughts about one’s bank balance when at home and after having checked once that day) and build on that each week, with flexibility for the client to move ahead between sessions as long as they are clear on the goals and purpose of the exposure. Furthermore, safety behaviors can be built into exposure. In traditional approaches to ERP, all safety behaviors are prohibited (Foa & Kozak, 1986), which can make exposure very difficult to accept. There is now fairly clear evidence that judicious use of safety behaviors does not impair extinction and may in fact reduce treatment fears (e.g., Milosevic & Radomsky, 2013a, 2013b). Safety behaviors can be worked into an exposure hierarchy or template (e.g., touch the floor with thick gloves, then thin gloves, then a tissue, then the bare hand). The target of exposure is typically uncertainty as to whether an undesired event has happened, is happening, or will happen or an intrusive feeling (e.g., disgust, not just right) that the person believes needs to be resolved before moving on to other activities. In traditional exposure models, the compulsion is prohibited, but there may be merit in having the client complete the compulsion but stop before they get the sense that it has been done properly, inhibiting further compulsive behavior. This will help the client achieve new learning about both the obsession and the necessity of the compulsion, as well as build tolerance for uncertainty around whether or not the compulsion has achieved its goal. For example, clients with contamination fears can be enjoined to contaminate their hands, wash their hands once (according to recognized hygiene guidelines), and then sit with doubt and uncertainty as to whether their hands are still contaminated while further washing is prohibited. The next step might be to then repeat the previous steps, but then to touch the face with their hands despite not being sure whether their hands are clean. Eventually exposure can involve no washing at all. The therapist is well-advised to conduct exposure in session so the client knows what to do between sessions and heads into the more difficult work in between sessions with mastery experience and a solid understanding of how to execute exposure. In session, the therapist serves as a coach and facilitator.

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First, it is useful to revisit the values and goals graph to help the client recognize what goals will be advanced by overcoming the compulsions and, realistically, how much failing to do the compulsion will compromise the goals served by the compulsions. Prior to beginning exposure, the client and therapist review the terms of exposure, which are that the therapist and client collaboratively specify the exercise, that the therapist neither forces the client to do anything nor springs any surprises, and that the client refrains from compensating for the exposure later (e.g., by doing extra rituals once home). Open communication and collaboration will be facilitated by clarity about how exposure will target key culprits. Furthermore, the client and therapist can discuss the many ways the client is advancing the goals served by the compulsion, but in other ways, as well as whether reducing compulsions moves them significantly lower on the goals and values plot. When commencing exposure, the therapist models the desired behavior first. This makes the exercise clear, models a non anxious response to the behavior, and enhances the alliance. During exposure, the therapist is warm and supportive, using statements such as, “You’re doing a really good job” and “If you can hang in a bit longer this is going to pay off even more.” The therapist asks the client to report on their distress level using whatever scale works best for the client. The therapist watches the client’s body language to gauge when distress is increasing or decreasing and ask for ratings accordingly. ERP can also provide a rich environment in which to identify the key cognitive culprit appraisals in action, so when distress increases, the therapist can ask what thoughts were going through the client’s head. Once the situation or stimulus results in significantly less distress, the challenge can be increased. When the exercise is over, the therapist and client evaluate the initial predictions in light of what actually happened and discuss what that means about the appraisal of the obsession and the perceived need to do the compulsion. Finally, the therapist and client plan between-session exposure sessions. One common mistake in ERP (or CBT in general) is that the between-session work is prescribed by the therapist in the last few minutes of the session. Treatment is far better served when the therapist reserves ample time to develop between-session exercises collaboratively with the client, with clear identification of what idea is being tested and the opportunity to discuss practical considerations. With respect to pacing and timing, research shows that massed exposure is more effective than spaced (10 times per week is much more effective than 10 times in 10 weeks; Antony & Swinson, 2000). The client will thus want to conduct at least one exposure per day. The therapist and client will also want to plan how to increase the challenge throughout the week if required. When the client returns for the next session, it is imperative that the first part of the session process the between-session work. What was done and what was learned from it? The session then builds on that new learning. If family members are involved in the compulsions that have been targeted in ERP, it is useful to have them join the client for a session. The goal is to help family members better understand why the compulsions persist and the role of



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ERP in treating them. The therapist and family members can discuss how best to support the client through ERP. A key reason why family members participate in rituals is that they find it difficult to see their loved ones suffer. It can be helpful to provide psychoeducation about extinction and frame ERP as “short-term pain for long-term gain.” Cognitive Restructuring Salkovskis (1999) stated that the goal of cognitive restructuring is for the “patient and therapist to work together to construct and test a new, less threatening explanation of the patient’s experience, and then to explicitly examine the validity of the contrasting accounts.” As in ERP, the therapist must be mindful of what exactly to target in cognitive restructuring. The most important rule is that the content of the obsession, and the probability of the feared event, are not the targets for cognitive restructuring. Rather, the appraisal of the obsession that gives rise to the distress, the perceived need to take immediate action, and the intolerance of uncertainty as to whether harm has been averted by the compulsion are. For example, Mr. L. was a 30-year-old man who had had a severe and intractable bladder infection for over a year that significantly affected his life in all domains, and he developed contamination fears around contracting another infection. A previous therapist had asked him what would be the worst outcome of an infection, to which he replied that it would be the need for a colostomy. The therapist proceeded to target his fear of having to get a colostomy, deeming it as dysfunctional (e.g., “What is so bad about that?”). The client dropped out of treatment. The culprit in OCD is not fear of something terrible happening to oneself or a loved one, but rather the ideas that the thought is the vector through which harm will occur, that immediate action is required no matter how minute the probability of harm, and that it is morally or otherwise imperative to perform the compulsion and achieve certainty. In the case of Mr. L., the culprits were the ambivalent core belief that he may be a weak and ineffectual person, appraisals such as “as long as the risk of contracting infection is not zero I must guard against it,” and intolerance of uncertainty with respect to whether his cleanliness rituals had protected him from infection. With appropriately targeted cognitive restructuring, Mr. L. improved dramatically. As in cognitive interventions for any other type of problem, the crux of change is in the client’s ability to generate alternative ways of viewing a problem or thinking about a situation. The therapist’s role is to facilitate insight through guided discovery, not to provide alternative and more constructive ways of viewing anxiety-provoking stimuli and situations. If the therapist provides alternative and more optimistic ways of viewing a problem or thinking about situations, clients could have reactions such as, “She’s my therapist, she has to say that” and “But he doesn’t know all the bad stuff about me!” Although it may take considerably longer for the client to produce alternative explanations and balanced alternatives to OCD-related thoughts, therapy will ultimately be more efficient.

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Cognitive restructuring techniques include the downward arrow technique (i.e., asking successive questions through which the core personal meaning or importance of an event is revealed), Socratic dialogue (i.e., dialogue in which hypotheses about a situation, person, or thing are examined and rejected or accepted), evidence weighing using thought records (i.e., identifying a key hypothesis and examining the evidence that supports it and that which does not support it), and core belief continua (i.e., identifying a core belief about the self and placing it on a continua between worst and best exemplars of that category). As in all cognitive restructuring, the goal is for the client and therapist to develop hypotheses that best account for all relevant internal (e.g., memories, body sensations) and external information, as opposed to that which the OCD system makes available in the moment. There are numerous excellent resources for cognitive restructuring strategies for specific subtypes of OCD (e.g., Antony et al., 2007; Bream et al., 2017; Munford, 2004, 2005; Purdon & Clark, 2005; Rachman, 2006; see also Vol.  1, Chapter 8 of this book). Treatment can readily combine ERP with cognitive restructuring, and between-session work typically involves both exposure exercises as well as thought records for obsessive concerns and the need to perform the compulsion. Once the client has become adept at responding to the obsessive concern with relative indifference and has a host of new experiences that disconfirm previously held ideas about the meaning of the obsession and the importance of the compulsion, the therapist and client may choose to work on negative schema. Greenberger and Padesky’s (2016) continuum approach works well for this. For example, consider the schema “Maybe I’m incompetent.” The therapist and client can first identify the qualities that contribute to competence. Often clients initially have a very narrow range of criteria by which they evaluate where they stand on the continuum (e.g., financial success). The therapist and client can work to identify other relevant qualities (e.g., being organized and efficient at work, managing a household well) that contribute to evaluations of competence. The therapist and client can then draw a line anchored at the left by “least competent person” and at the right by “most competent person” (e.g., Hitler and Mother Teresa, respectively), and then have the client identify people they know who would fall toward the left and right anchors, such as a coworker whose lack of initiative and knowledge created a lot of work for others on the left and the leader of their church on the right. The client then plots friends, spouse, and family members, and then finally themselves. Given that people tend to associate with others who share their values, clients invariably end up plotted in the vicinity of the most important people in their lives. This makes the initial statement of the schema less tenable. It also presents the opportunity for some behavioral experiments. For example, the client in this case can be tasked with recognizing and recording indications of her competence and bring a broad range of information to bear on that judgement. Ms. K., for example, soon recognized that she tended to ignore or discount indications of competence.



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OUTCOME DATA CBT for OCD is generally efficacious. In their authoritative meta-analysis, Öst et al. (2015) found that CBT had a large effect size of 1.33 compared with placebo. In a large-scale study comparing group treatment with “pure” cognitive therapy (CT), ERP, and wait-list control, McLean et al. (2001) found that ERP was marginally more effective than CT both post-treatment and at a 3-month follow-up, and that both were superior to no intervention. However, there were more dropouts in the ERP condition. They suggested that CT in group format may not be the most ideal means of offering treatment and that there may be advantages to offering CT individually. Warren and Thomas (2001) reported an 84% treatment response with ERP + cognitive restructuring in a routine clinical practice setting, suggesting that the treatment is fairly generalizable to settings at which most people receive their care. Van Balkom et al. (1998) compared the efficacy of adding CT or ERP to medication (fluvoxamine) at Week 9 to that of each psychotherapy alone and to a wait-list control. All treatment groups were found to be equally effective as compared with the wait-list control. In a double-blind, multisite treatment efficacy study comparing the relative and combined effects of ERP (with discussion of appraisal during exposure) and clomipramine, Foa et al. (2005) found that ERP and ERP + clomipramine had completer response rates of 86% and 79%, respectively, and were equal in efficacy but superior to a placebo. In their meta-analysis of CBT for anxiety disorders, Hofmann and Smits (2008) found that CBT relative to placebo had a strong effect size of 1.37, and in fact was more efficacious in treatment of OCD than most other anxiety disorders. In their comprehensive review of the treatment efficacy literature, McKay et al. (2015) concluded that there is considerable evidence for the efficacy of ERP-based CBT, although they note that ensuring adherence to exposure is critical to outcome.

MECHANISMS OF CHANGE Rhéaume and Ladouceur (2000) examined change in appraisal of the obsession in relation to changes in the frequency of checking rituals in participants receiving ERP versus CBT in a small (N = 15) time series analysis. They found that for all those in the ERP group and for one third of those in the CBT group, change on at least one type of appraisal preceded a decrease in checking rituals, although for each participant, decreased checking rituals also preceded change in appraisal at least once. Wilhelm et al. (2015) found that beliefs about the need for perfection and for certainty and schemas relevant to dependency and incompetence mediated treatment response. These findings support the link between appraisal and compulsions asserted by cognitive models, and they also suggest that changes in appraisal and core beliefs may actually cause change in use of compulsive strategies. Thus, appraisal appears to play an important role

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in treatment success. Of course, exposure may also operate on more general constructs, such as self-efficacy, and improved flexibility may improve interpersonal relationships, which can alleviate mood symptoms.

APPLICATION TO DIVERSE POPULATIONS In their comprehensive review of transcultural aspects of OCD, Fontenelle et al. (2004) concluded that its core features are consistent across cultures with little variation, but the content of obsessional concerns may vary. For example, there is a preponderance of religious and aggressive obsessions in middle eastern countries and Brazil. Thus, the CBT model of OCD should apply well to people from all cultures. However, as in any treatment, it is important for the therapist to identify their own culturally based assumptions and be sensitive to cultural differences in their clients that can have an impact on treatment, while at the same time not assuming that the client conforms to the norms of their culture. Therapists best be sensitive to and aware of salient cultural differences, such as gender roles, responsibilities and obligations to family, understanding of and attitudes toward mental health, and understanding of and attitudes toward professionals. The “bottom line” is that therapists will do well to identify and avoid acting solely on their own cultural assumptions. It is important to work within the client’s value system, particularly when developing exposure exercises. As discussed earlier in the chapter, compulsions may be an expression of important values. People with strong religious observance may experience certain obsessional content as especially repugnant, believing that even the thought’s occurrence is sinful. For clients who believe that having a sinful thought is equivalent to sinning, the therapist and client need to focus on the overvalued and excessive meaning and importance of the thought; the client may be permitted to engage in appropriate atonement, just as a client may engage in a “normal” hand wash after using the toilet. In some religious traditions, viewing pornography is proscribed, and yet it is not uncommon for therapists to include viewing pornography as part of exposure to repugnant obsessions. The client is best served if the therapist is aware of the client’s values and works creatively to develop exposure exercises and behavioral experiments that achieve new learning but do not compromise important values.

CONCLUSION OCD is heterogenous in its presentation and can be very complex, with numerous factors involved in the persistence of both obsessions and compulsions. However, with careful assessment of the idiographic presentation of the symptoms and the factors in their persistence and use of a strong case formulation as a compass in each session, cognitive and behavioral techniques, particularly



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ERP, can be very effective. A key to successful treatment is helping the client overcome obstacles to fully engaging in exposure, such as family factors, fear of compromising valued goals, and core beliefs that are activated by failing to do compulsions. Although there are many resources on conducting ERP, not as many focus on development of a comprehensive case formulation, particularly identification of core beliefs and assumptions, and the factors involved in the persistence of compulsions, such as repetition and memory confidence.

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Nedeljkovic, M., & Kyrios, M. (2007). Confidence in memory and other cognitive processes in obsessive-compulsive disorder. Behaviour Research and Therapy, 45(12), 2899–2914. https://doi.org/10.1016/j.brat.2007.08.001 Nedeljkovic, M., Moulding, R., Kyrios, M., & Doron, G. (2009). The relationship of cognitive confidence to OCD symptoms. Journal of Anxiety Disorders, 23(4), 463–468. https://doi.org/10.1016/j.janxdis.2008.10.001 Newth, S., & Rachman, S. (2001). The concealment of obsessions. Behaviour Research and Therapy, 39(4), 457–464. https://doi.org/10.1016/S0005-7967(00)00006-1 NICE. (2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (Clinical guideline 31). The National Institute for Clinical Excellence. Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667–681. https://doi.org/10.1016/S0005-7967(97)00017-X Obsessive Compulsive Cognitions Working Group. (2001). Development and initial validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory. Behaviour Research and Therapy, 39(8), 987–1006. https://doi.org/10.1016/ S0005-7967(00)00085-1 Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory: Part I. Behaviour Research and Therapy, 41(8), 863–878. https://doi.org/10.1016/ S0005-7967(02)00099-2 Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43(11), 1527–1542. https://doi.org/10.1016/j.brat.2004.07.010 Ong, C. W., Clyde, J. W., Bluett, E. J., Levin, M. E., & Twohig, M. P. (2016). Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say? Journal of Anxiety Disorders, 40, 8–17. https://doi.org/10.1016/ j.janxdis.2016.03.006 Öst, L.-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014. Clinical Psychology Review, 40, 156–169. https://doi.org/10. 1016/j.cpr.2015.06.003 Pace, S. M., Thwaites, R., & Freeston, M. H. (2011). Exploring the role of external criticism in obsessive compulsive disorder: A narrative review. Clinical Psychology Review, 31(3), 361–370. https://doi.org/10.1016/j.cpr.2011.01.007 Purdon, C. (2004). Empirical investigations of thought suppression in OCD. Journal of Behavior Therapy and Experimental Psychiatry, 35(2), 121–136. https://doi.org/10. 1016/j.jbtep.2004.04.004 Purdon, C. (2012). Assessing co-morbidity, family, and functioning in OCD. In G. Steketee (Ed.), Oxford handbook of obsessive compulsive and spectrum disorders (pp. 275– 290). Oxford University Press. Purdon, C., & Clark, D. A. (1993). Obsessive intrusive thoughts in nonclinical subjects. Part I. Content and relation with depressive, anxious and obsessional symptoms. Behaviour Research and Therapy, 31(8), 713–720. https://doi.org/10.1016/0005-7967 (93)90001-B Purdon, C., & Clark, D. A. (1999). Metacognition and obsessions. Clinical Psychology & Psychotherapy, 6(2),102–110. https://doi.org/10.1002/(SICI)1099-0879(199905)6:2 3.0.CO;2-5 Purdon, C., & Clark, D. A. (2002). The need to control thoughts. In R. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment (pp. 29–43). Elsevier/Pergamon. https://doi.org/10.1016/B978008043410-0/50004-0 Purdon, C., & Clark, D. A. (2005). Overcoming obsessions. New Harbinger Press.



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Purdon, C., Gifford, S., McCabe, R., & Antony, M. M. (2011). Thought dismissability in obsessive-compulsive disorder versus panic disorder. Behaviour Research and Therapy, 49(10), 646–653. https://doi.org/10.1016/j.brat.2011.07.001 Purdon, C., Rowa, K., & Antony, M. M. (2005). Thought suppression and its effects on thought frequency, appraisal and mood state in individuals with obsessivecompulsive disorder. Behaviour Research and Therapy, 43(1), 93–108. https://doi. org/10.1016/j.brat.2003.11.007 Purdon, C., Rowa, K., & Antony, M. M. (2007). Diary records of thought suppression by individuals with obsessive-compulsive disorder. Behavioural and Cognitive Psychotherapy, 35(1), 47–59. https://doi.org/10.1017/S1352465806003079 Rachman, S. (1971). Obsessional ruminations. Behaviour Research and Therapy, 9(3), 229–235. https://doi.org/10.1016/0005-7967(71)90008-8 Rachman, S. (1976). The modification of obsessions: A new formulation. Behaviour Research and Therapy, 14(6), 437–443. https://doi.org/10.1016/0005-7967(76)90090-5 Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793–802. https://doi.org/10.1016/S0005-7967(97)00040-5 Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36(4), 385–401. https://doi.org/10.1016/S0005-7967(97)10041-9 Rachman, S. (2006). The fear of contamination: Assessment and treatment. Oxford University Press. https://doi.org/10.1093/med:psych/9780199296934.001.0001 Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233–248. https://doi.org/10.1016/0005-7967(78) 90022-0 Rachman, S. J., & Hodgson, R. J. (1980). Obsessions and compulsions. Prentice-Hall. Radomsky, A. S., Dugas, M. J., Alcolado, G. M., & Lavoie, S. L. (2014). When more is less: Doubt, repetition, memory, metamemory, and compulsive checking in OCD. Behaviour Research and Therapy, 59, 30–39. https://doi.org/10.1016/j.brat.2014.05.008 Radomsky, A. S., Gilchrist, P. T., & Dussault, D. (2006). Repeated checking really does cause memory distrust. Behaviour Research and Therapy, 44(2), 305–316. https://doi. org/10.1016/j.brat.2005.02.005 Rassin, E., Merckelbach, H., & Muris, P. (2000). Paradoxical and less paradoxical effects of thought suppression: A critical review. Clinical Psychology Review, 20(8), 973–995. https://doi.org/10.1016/S0272-7358(99)00019-7 Renshaw, K. D., Steketee, G., & Chambless, D. L. (2005). Involving family members in the treatment of OCD. Cognitive Behaviour Therapy, 34(3), 164–175. https://doi.org/ 10.1080/16506070510043732 Rhéaume, J., & Ladouceur, R. (2000). Cognitive and behavioural treatments of checking behaviours: An examination of individual cognitive change. Clinical Psychology and Psychotherapy, 7(2), 118–127. https://doi.org/ccv442 Richards, H. J., Benson, V., Donnelly, N., & Hadwin, J. A. (2014). Exploring the function of selective attention and hypervigilance for threat in anxiety. Clinical Psychology Review, 34(1), 1–13. https://doi.org/10.1016/j.cpr.2013.10.006 Rowa, K., Purdon, C., Summerfeldt, L. J., & Antony, M. M. (2005). Why are some obsessions more upsetting than others? Behaviour Research and Therapy, 43(11), 1453–1465. https://doi.org/10.1016/j.brat.2004.11.003 Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94 Salkovskis, P., Shafran, R., Rachman, S., & Freeston, M. H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: Possible origins and implications for therapy and research. Behaviour Research and Therapy, 37(11), 1055–1072. https://doi.org/10.1016/S0005-7967(99)00063-7 Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. https://doi.org/10.1016/ 0005-7967(85)90105-6

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Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27(6), 677–682. https://doi.org/10.1016/0005-7967(89)90152-6 Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(Suppl. 1), S29–S52. https://doi.org/10.1016/ S0005-7967(99)00049-2 Salkovskis, P. M., Richards, H. C., & Forrester, E. (1995). The relationship between obsessional problems and intrusive thoughts. Behavioural and Cognitive Psychotherapy, 23(3), 281–299. https://doi.org/10.1017/S1352465800015885 Sheehan, D. V. (2016). Mini international neuropsychiatric interview (MINI) 7.0.2. Harm Research Institute. Sookman, D., & Pinard, G. (2002). Overestimation of threat and intolerance of uncertainty in obsessive-compulsive disorder. In R. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment (pp. 63–89). Elsevier/Pergamon. https://doi.org/10.1016/B978-008043410-0/50006-4 Steketee, G. (1999). Overcoming obsessive compulsive disorder: A behavioral and cognitive protocol for the treatment of OCD: Therapist protocol. New Harbinger Press. Steketee, G., Frost, R. O., & Cohen, I. (1998). Beliefs in obsessive-compulsive disorder. Journal of Anxiety Disorders, 12(6), 525–537. https://doi.org/10.1016/S0887-6185 (98)00030-9 Szechtman, H., & Woody, E. (2004). Obsessive-compulsive disorder as a disturbance of security motivation. Psychological Review, 111(1), 111–127. https://doi.org/10.1037/ 0033-295X.111.1.111 Taylor, S., Abramowitz, J. S., McKay, D., Calamari, J. E., Sookman, D., Kyrios, M., Wilhelm, S., & Carmin, C. (2006). Do dysfunctional beliefs play a role in all types of obsessive-compulsive disorder? Journal of Anxiety Disorders, 20(1), 85–97. https://doi. org/10.1016/j.janxdis.2004.11.005 Thordarson, D. S., & Shafran, R. (2002). Importance of thoughts. In R. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment (pp. 15–28). Elsevier/Pergamon. https://doi.org/10.1016/B978008043410-0/50003-9 van Balkom, A. J. L., de Haan, E., van Oppen, P., Spinhoven, P., Hoogduin, K. A., & van Dyck, R. (1998). Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive compulsive disorder. Journal of Nervous and Mental Disease, 186(8), 492–499. https://doi.org/10.1097/00005053199808000-00007 van den Hout, M., & Kindt, M. (2003). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41(3), 301–316. https://doi.org/10.1016/S00057967(02)00012-8 van den Hout, M. A., Engelhard, I. M., de Boer, C., du Bois, A., & Dek, E. (2008). Perseverative and compulsive-like staring causes uncertainty about perception. Behaviour Research and Therapy, 46(12), 1300–1304. https://doi.org/10.1016/j. brat.2008.09.002 Van Noppen, B., & Steketee, G. (2003). Family responses and multifamily behavioural treatment for obsessive-compulsive disorder. Brief Treatment and Crisis Intervention, 3(2), 231–247. https://doi.org/10.1093/brief-treatment/mhg017 Vogel, P., Stiles, T. C., & Götestam, K. G. (2004). Adding cognitive therapy elements to exposure therapy for obsessive compulsive disorder: A controlled study. Behavioural and Cognitive Psychotherapy, 32(3), 275–290. https://doi.org/10.1017/ S1352465804001353 Warren, R., & Thomas, J. C. (2001). Cognitive-behavior therapy of obsessivecompulsive disorder in private practice: An effectiveness study. Journal of Anxiety Disorders, 15(4), 277–285. https://doi.org/10.1016/S0887-6185(01)00063-9



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Wilhelm, S., Berman, N. C., Keshaviah, A., Schwartz, R. A., & Steketee, G. (2015). Mechanisms of change in cognitive therapy for obsessive compulsive disorder: Role of maladaptive beliefs and schemas. Behaviour Research and Therapy, 65, 5–10. https:// doi.org/10.1016/j.brat.2014.12.006 World Health Organization. (1999). The “newly defined” burden of mental problems (Fact Sheet no. 217).

4 Cognitive Behavior Therapies for Posttraumatic Stress Disorder Anke Ehlers and Jennifer Wild

I

n the initial days and weeks after a traumatic event such as physical or sexual assaults, terrorist attacks, severe accidents, disasters, or war zone experiences, most people will experience at least some symptoms of posttraumatic stress disorder (PTSD) such as intrusive memories, sleep disturbance, feeling emotionally numb, or being easily startled (Rothbaum et al., 1992). Most people will recover in the following months, but for some the symptoms persist, often for years (Kessler et al., 1995). What prevents these people from recovering? Cognitive behavioral theories of PTSD have identified factors that prevent change (e.g., Ehlers & Clark, 2000; Foa & Rothbaum, 1998; Resick & Schnicke, 1993) and can be successfully addressed in cognitive behavior therapy.1,2

DEVELOPMENT OF COGNITIVE BEHAVIORAL THEORIES AND TREATMENTS FOR PTSD When PTSD was introduced into the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980), effective cognitive behavioral Clinical examples are disguised to protect patient confidentiality.

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The development of this chapter and evaluation of CT-PTSD were supported by the Wellcome Trust (Grants 069777 and 200796) and an NIHR Senior Investigator award (AE). We thank David M. Clark, Ann Hackmann, Melanie Fennell, Freda McManus, Nick Grey, Emma Warnock-Parkes, Hannah Murray, Alice Kerr, and Richard Stott for their collaboration.

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https://doi.org/10.1037/0000219-004 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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therapies (CBT) for phobias and other anxiety disorders had already been developed (for a review see Öst, 2008). Research on the treatment of PTSD benefited from these advances and led to the development of a range of effective CBT programs for PTSD. Keane’s and Foa’s groups (Foa et al., 1991; Keane & Kaloupek, 1982) pioneered the systematic application of in vivo exposure and imaginal exposure to the treatment of PTSD. Resick and Schnicke (1992) were among the first to apply principles of cognitive therapy to PTSD. Several other authors developed further treatment programs that involved a range of exposure and cognitive interventions (e.g., Blanchard et al., 2003; Bryant et al., 1998, 2008; Marks et al., 1998; Tarrier et al., 1999). Besides these trauma-focused CBT (TF-CBT) programs, other CBT experts applied principles of anxiety and stress management to the management of symptoms of PTSD (e.g., Veronen & Kilpatrick, 1983; Meichenbaum, 1997). Early exposure treatments build on the hypothesis that exposure would facilitate extinction of conditioned responses to trauma reminders and reduction of emotional and physiological responses to trauma memories through habituation (e.g., Keane & Kaloupek, 1982). Avoidance behaviors are thought to prevent extinction of the conditioned responses. There is evidence that people with PTSD show delayed extinction and overgeneralized conditioned responses in conditioning studies, and that delayed extinction predicts subsequent PTSD when exposed to trauma (see Lissek & van Meurs, 2015, for a review). However, several theorists pointed out that conditioning alone is insufficient in explaining all the symptoms of PTSD, including the features of reexperiencing symptoms that are central to the disorder. Several theorists proposed that (a) features of trauma memories, (b) negative meanings of the trauma (interpretations, appraisals, beliefs), and (c) avoidance play a role in maintaining PTSD symptoms. Foa and colleagues proposed an emotional processing theory of anxiety disorders and PTSD (e.g., Foa & Kozak, 1986; Foa & Rothbaum, 1998) that forms the theoretical framework for prolonged exposure (PE). They postulated a specific fear structure—a network of associations in memory—that includes excessive stimulus and response elements as well as pathological meaning elements. For example, a survivor of a motor vehicle accid ent may associate the color of the car that hit them and difficulties breathing (as experienced when the airbag opened) with danger and respond to them with anxiety. The fear structure of trauma survivors with PTSD is also thought to include two basic dysfunctional cognitions, namely, the world is completely dangerous (e.g., “It is dangerous to drive”) and the self is totally incompetent (e.g., “I can’t handle any stress, my PTSD symptoms mean that I am going crazy”). According to Foa and Kozak (1986), the fear structure can be changed by activating it and presenting information that is incompatible with its elements (e.g., habituation to driving through prolonged exposure) so that it is integrated into the fear structure to replace pathological elements with realistic ones (e.g., “driving is no more dangerous than it was before the accident”). Resick and Schnicke (1993) proposed that changes in cognitive schemas are central to the understanding and treatment of PTSD. They suggested that



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although cognitive accommodation (modification of existing cognitive schemas) is necessary to integrate the traumatic event, people with PTSD overaccommodate trauma-relevant information by inaccurate and overgeneralized belief changes such as “people are either totally in control or out of control of life events.” They may also show inappropriate assimilation by modifying the perception of the trauma to sustain their previous beliefs. For example, people with PTSD may conclude that an assault was their fault because of a prior assumption that people get what they deserve because the world is fair. They may mistakenly attribute the cause of the assault (i.e., agency) to themselves and thus inappropriately assimilate it into the preexisting fair world schema. The personal meanings of trauma and their close relationship with features of trauma memories are central to Ehlers and Clark’s (2000) cognitive model of PTSD. This model is described in greater detail below as an example that illustrates the close link between theory and practice in evidence-based TF-CBT programs.

COGNITIVE BEHAVIORAL TREATMENTS FOR PTSD The current evidence suggests that several versions of individual trauma-focused cognitive behavior therapy (TF-CBT) are highly effective and are therefore recommended as first-line treatments for PTSD. On the basis of a systematic review, the APA Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (2017) strongly recommend individual cognitive processing therapy (CPT; e.g., Resick & Schnicke, 1992; Resick et al., 2002), cognitive therapy (CT; e.g., Ehlers et al., 2005, 2014), prolonged exposure therapy (PE; e.g., Foa et al., 1991, 2005) and cognitive behavioral therapy (CBT) that combines imaginal exposure, in vivo exposure, and cognitive work (e.g., Blanchard et al., 2003; Bryant et al., 2008). Eye movement desensitization and reprocessing (EMDR; Shapiro, 1989), brief eclectic psychotherapy (BEP; Gersons et al., 2015), and narrative exposure therapy (NET; e.g., Neuner et al., 2008), a CBT protocol developed for refugees, are conditionally recommended. Other recent guidelines such as the Clinical Practice Guidelines of International Society for Traumatic Stress Studies (2019) and the UK National Institute for Health and Care Excellence (NICE guidelines (2018) make similar recommendations. While the different TF-CBT programs differ in their emphasis on certain treatment procedures, they overlap in treatment targets and hypothesized mechanisms. Schnyder et al. (2015) suggested that effective trauma-focused psychological treatments have the following six common ingredients: • Psychoeducation: Therapy usually starts with psychoeducation about the nature and course of posttraumatic stress reactions and normalizes clients’ reactions to their traumas. • Exposure: While all TF-CBT programs facilitate the client’s engagement with the trauma memories by talking about the trauma and its meaning, they differ widely in the amount of exposure to trauma memories. In imaginal

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reliving, a core technique in PE, clients visualize what happened during the trauma while giving a verbal account of what is happening, including their own thoughts, emotions, and reactions. Repeated narrative writing can also be used as an exposure technique (e.g., Blanchard et al., 2003). PE, NET, BEP and many of the TF-CBT programs reviewed in the APA guidelines emphasize repeated exposures, whereas CPT and CT-PTSD emphasize cognitive work. CPT can be delivered effectively without the repeated writing of a trauma narrative that constituted part of the original protocol (CPT-C; Resick et al., 2008). As described below, CT-PTSD (Ehlers & Clark, 2000) uses only a few imaginal relivings and/or the writing of a narrative to access the moments in memory that are linked to the client’s personal negative meanings and to update these with evidence for less threatening meanings. In addition to imaginal exposure, in vivo exposure to situations that the client has avoided since the trauma is another central element of PE, and dismantling studies have shown that it enhances efficacy of TF-CBT (Bryant et al., 2008). CT-PTSD includes in vivo behavioral experiments designed to test a client’s appraisals, including overgeneralized appraisals of danger. • Changing personal meanings: While all TF-CBT programs aim to change negative meanings of the traumas, they use different methods to achieve this aim. For example, in PE, the emphasis is on repeated imaginal exposures, followed by a discussion of what the client has learned from the exposure. In CPT and CT, negative meanings of the trauma for the client’s view of themselves, other people, and the future are the focus of treatment and addressed with a range of techniques as described below. • Dealing with a range of emotions: Early PTSD theories and treatments emphasized the role of fear in PTSD. However, guilt, shame, anger, grief, or sadness are also common and addressed in most TF-CBT programs. Cognitive therapy programs build on the hypothesis that different emotions have different underlying beliefs or appraisals, which are identified and targeted in treatment. • Emotion regulation: Schnyder et al. (2015) also suggested that traumafocused treatments improve emotion regulation and coping skills. Some programs include skills training designed to help clients tolerate the exposure, such as breathing training in PE (Foa & Rothbaum, 1998) or relaxation in BEP (Gersons et al., 2015). Two treatments that were developed for PTSD related to childhood abuse include a period of skills training before exposure to the trauma memories: training in affective and interpersonal regulation in STAIR/MPE (Skills Training in Affective and Interpersonal Regulation plus Modified Prolonged Exposure; see Levitt & Cloitre, 2005), or training in distress tolerance in Dialectic Behavior Therapy for PTSD (Steil et al., 2011, 2018). However, other efficacious treatments such as NET or CT-PTSD do not include such skill training. • Changing memories: Schnyder et al. (2015) suggested that the creation of a coherent narrative of the trauma is another common ingredient of effective



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trauma-focused treatments. For clients with multiple events, a timeline can help the client see the traumas in the context of other events in their lives (e.g., in NET, CT-PTSD). Besides the specific treatment components, it is important to note that TFCBT shares nonspecific factors common to all psychological treatments: therapist support and a trusting relationship where clients feel safe and understood, the generation of hope through the treatment rationale and the therapist’s encouragement, and the client’s commitment to spend time and take action to get better. These are likely to contribute to changes in cognitions such as “I cannot trust anyone” or “My life is ruined” and to a reduction of avoidance and other behaviors that maintain PTSD, which thus contributes to improvement.

AN EXAMPLE OF TRAUMA-FOCUSED CBT: COGNITIVE THERAPY FOR PTSD Ehlers and Clark’s (2000) model suggests that PTSD develops when individuals process the traumatic experience in a way that gives rise to a sense of serious current threat, which is accompanied by high arousal and strong negative emotions such as guilt, shame, anger, or fear. The sense of current threat is driven by two key processes (see Figure 4.1).3 First, excessively negative appraisals (i.e., personal meanings) of the trauma and/or its sequelae (e.g., reactions of other people, physical consequences of the trauma, initial PTSD symptoms) that extend beyond what anyone would find threatening/horrific about the event. People with PTSD typically experience a range of negative emotions, which depend on the type of appraisal (Ehlers & Clark, 2000). Perceived external threat can result from appraisals about impending danger (e.g., “Nowhere is safe,” “I cannot trust anyone”), leading to excessive fear, or appraisals about the unfairness of the trauma or its aftermath (e.g., “I will never be able to accept that the perpetrator got away with it”), leading to persistent anger. Perceived internal threat often relates to negative appraisals of one’s behavior, emotions, or reactions during the trauma or to the perpetrators’ or other people’s humiliating or derogatory statements, and may lead to shame (e.g., “My actions are despicable,” “I am a bad person”) or guilt (e.g., “It was my fault”). A common negative appraisal of consequences of the trauma in PTSD is perceived permanent change of the self or one’s life (e.g., “I have permanently changed for the worse”), which can lead to sadness and hopelessness. In the case of individuals who have experienced multiple trauma, personal meanings tend to become more generalized (e.g., “I am worthless,” “I do not matter,” “I deserve bad things happening to me”), leading to an enduring sense of degradation, defeat, or low self-worth. The appraisals Video illustrations and treatment materials are available at https://oxcadatresources. com. The description of treatment procedures has been adapted with the publishers’ permissions from earlier chapters by Ehlers (2013) and Ehlers & Wild (2015).

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can become more embedded in a person’s belief systems over time. For example, if an early life trauma has led a person to feel that they are damaged in some way or unlucky in life, experiencing further trauma is likely to confirm this belief. The second source of perceived current threat are characteristics of trauma memories. According to Ehlers and Clark (2000), the subjectively worst moments of the trauma are poorly elaborated in memory; that is, poorly integrated into the context of the trauma and within the context of previous and subsequent experiences. This includes information from the trauma itself that changes the meaning of these moments (e.g., that they were forced to comply with the perpetrator and that is why they did not fight back). As a consequence, people with PTSD remember the trauma in a disjointed way. When they recall the worst moments, they typically do so without much contextual information; in particular, it is difficult for them to access information that could correct the impressions they had or predictions they made at the time (e.g., “I am going to die and my children will be alone”). In other words, they do not naturally update their memory for these moments with what they know now (e.g., “I survived and am still looking after my children”). This disjointed, decontextualized recall has the effect of inducing a sense of threat similar to the threat they experienced during these moments and making them relive the same emotions and high arousal as though the trauma were reoccurring now rather than being a memory from the past (Ehlers et al., 2004). This includes “affect without recollection” where people with PTSD reexperience emotions and show behaviors from the trauma without realizing that they are responding to a memory. Ehlers and Clark (2000) also noted that intrusive trauma memories and other reexperiencing symptoms are easily triggered in PTSD by sensory cues that overlap perceptually with those occurring during trauma (e.g., similar sounds, colors, smells, shapes, movements, or bodily sensations) and often do not have a meaningful relationship with the trauma. They suggested that this is a result of cognitive processing during trauma when people are attuned to perceptual features of the experience (i.e., data-driven processing), leading to strong perceptual priming, which lowers the threshold for spotting similar perceptual patterns in the environment. Through learned associations, the stimuli become associated with strong affective responses, which can generalize to other similar stimuli. The two processes (i.e., perceptual priming and associative learning) are thought to lead to easy detection of similar stimuli in the individual’s environment and poor discrimination from those encountered during the trauma (in particular, those that share common perceptual features). According to Ehlers and Clark (2000), the symptoms are maintained because people with PTSD use understandable but unhelpful cognitive strategies and behaviors to control the perceived current threat or their PTSD symptoms. These correspond in meaningful ways to the problematic appraisals they may



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have about their trauma, symptoms, or future safety. The strategies include rumination, effortful suppression of memories, avoidance of reminders, safety behaviors (i.e., excessive precautions), and substance use. These cognitive strategies and behaviors prevent change in the unhelpful appraisals or nature of a person’s trauma memories and may increase symptoms, thereby keeping the sense of current threat going and maintaining PTSD. Figure 4.1 illustrates the three factors (i.e., appraisals, memory characteristics, cognitive/behavioral strategies) that maintain a sense of current threat and PTSD symptoms according to Ehlers and Clark’s (2000) model. Cognitive therapy for PTSD (CT-PTSD) targets these three factors. The model serves as the framework for an individualized formulation of the client’s problems and treatment. The model suggests three treatment goals: • Modify excessively negative appraisals (meanings) of the trauma and its sequelae. • Reduce reexperiencing by elaboration of trauma memories and discrimination of triggers. • Reduce behaviors and cognitive strategies that maintain the sense of current threat.

FIGURE 4.1. Treatment Goals in Cognitive Therapy for PTSD Appraisals of trauma and/or sequelae identify and modify

Trauma memory elaborate

Triggers discriminate

Current threat: Intrusions Arousal Strong emotions reduce

Dysfunctional behaviors/cognitive strategies give up Note. Pointed arrows stand for “leads to.” Round arrows stand for “prevents a change in.” Dashed arrows stand for “influences.” From "Trauma-Focused Cognitive Behavior Therapy for Posttrau­ matic Stress Disorder and Acute Stress Disorder," by A. Ehlers, in G. Simos and S. G. Hofmann (Eds.), CBT for Anxiety Disorders: A Practitioner Handbook (p. 166), 2013, John Wiley & Sons (https://doi. org/10.1002/9781118330043.ch7). Copyright 2013 by John Wiley & Sons. Reprinted with permission.

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Core treatment procedure (described in greater detail below) in CT-PTSD includes4: • individualized case formulation—therapist and client collaboratively develop an individualized version of Ehlers and Clark’s (2000) model of PTSD, which serves as the framework for therapy. Treatment procedures are tailored to the formulation. • reclaiming/rebuilding your life assignments from the first session onwards to address the client’s perceived permanent change after trauma, which involves reclaiming or rebuilding activities and social contacts. • changing problematic appraisals of the traumas and their sequelae through guided discovery, behavioral experiments, and surveys. • updating trauma memories is a three-step procedure that includes (a) accessing memories of the worst moments during the traumatic events and their currently threatening meanings, (b) identifying information that updates these meanings (either information from the course of events during the trauma or from cognitive restructuring and testing of predictions), and (c) linking the new meanings to the worst moments in the memory. • discrimination training with triggers of reexperiencing involves systematically spotting idiosyncratic triggers (often subtle sensory cues) and learning to discriminate between “Now” (cues in a new safe context) and “Then” (cues in the traumatic event). • a site visit to complete the memory updating and trigger discrimination. • dropping unhelpful behaviors and cognitive processes, which commonly includes discussing their advantages and disadvantages and behavioral experiments where the patient experiments with reducing unhelpful strategies such as rumination, hypervigilance for threat, thought suppression, and excessive precautions (safety behaviors). • a blueprint that summarizes what the client has learned in treatment and includes plans for dealing with anniversaries and any setbacks. Format of Treatment CT-PTSD is usually delivered in up to 12 weekly individual treatment sessions for clients who reexperience a small number of traumas, and more sessions (usually up to 20) for clients with multiple traumas and complex presentations. Therapists should allow 90 minutes for sessions that involve work on trauma memories so that the client has time to refocus on the present before they leave. Weekly measures of PTSD symptoms, depression, and cognitive processes (appraisals, memory characteristics, responses to intrusive memories, Video extracts of the procedures and therapy materials can be accessed at https://oxcadatresources.com.

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and safety behaviors) are helpful in monitoring the effects of interventions and spotting remaining problems. An alternative is daily intensive treatment (2 to 4 hours per day) for up to 7 working days, which is also effective (Ehlers et al., 2014). Guidance for remote delivery of CT-PTSD via videoconferencing or telephone is found in Wild et al. (2020). Therapeutic Style and the Therapeutic Relationship The therapeutic style in cognitive therapy is collaborative and centers on guided discovery. Client and therapist work together like a team of detectives who set out to test how well the client’s perceptions and ideas match reality. Together, they consider the client’s cognitions like hypotheses, exploring and evaluating the evidence the client has for and against them. The aim is to collaboratively generate a less threatening alternative interpretation. Socratic questioning is essential in this process of guided discovery and involves the therapist gently asking questions that help the client to consider their problems from different perspectives, drawing their attention to information that is relevant yet likely outside their current focus, and helping them to reevaluate a previous conclusion or construct a new idea (Padesky, 1993). For example, clients who believe that they are likely to experience another trauma consider the alternative hypothesis that the perceived “nowness” of their intrusive memories gives them the impression that another trauma is likely to occur but is not evidence of an impending trauma. Generating an alternative interpretation (i.e., insight) is usually not sufficient to generate a lasting emotional shift. Therefore, the cognitive therapist will emphasize experiential learning and plan behavioral experiments to test the client’s appraisals, which they will carry out in or out of the office. Behavioral experiments are very important for helping the client experience new evidence against their threatening interpretations. These experiments are often the most compelling tests of a client’s unhelpful appraisals. CT-PTSD follows these general principles with some modifications. Because many clients with PTSD feel they can no longer trust people, therapists need to take extra care to establish good therapeutic relationships and make sure the client feels safe in the therapeutic setting (as subtle trauma reminders can make the client feel unsafe in many situations). Because CT-PTSD focuses on changing cognitions that induce a sense of current threat after trauma, careful assessment of the relevant appraisals is necessary. Clients may have unhelpful beliefs (e.g., perfectionism) that are not relevant to their sense of current threat and thus do not need to be addressed in treating their PTSD unless they hinder the client’s engagement and progress in therapy or are important for maintaining comorbid problems that would interfere with the treatment of PTSD. Importantly, the main problematic appraisals that induce a sense of current threat and that need to be addressed in therapy are usually linked to the worst moments during the trauma. The nature of memory recall and cognitive avoidance influences what clients with PTSD remember about their traumas, which in turn may influence their problematic appraisals. In addition, disjointed recall

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makes it difficult to assess the problematic meanings by simply talking about the trauma. It also has the effect that insights from cognitive restructuring may be insufficient to produce a large shift in affect. Thus, work on appraisals of the trauma is closely integrated with work on the trauma memory in CT-PTSD. Developing an Individual Case Formulation and Treatment Rationale At the beginning of treatment, the therapist and client discuss the client’s symptoms and treatment goals and start developing an individualized case formulation.5 The therapist normalizes the PTSD symptoms as common reactions to an extremely stressful event and explains that many of the symptoms are signs that the memory for the trauma is not fully processed yet. The therapist asks the client to give a brief account of the client’s traumas and starts exploring the personal meanings (“What was the worst thing about the trauma?” “What were the worst moments and what did they mean to you?”). The Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999) is helpful in identifying cognitive themes (i.e., appraisals such as negative view of the self, self-blame, permanent change, and overgeneralized sense of danger) that will need to be addressed in treatment. The therapist also asks the client about the content of their intrusive memories and what they mean to the client. This question is important because intrusions point to moments that are essential for understanding the sense of current threat; they are often the moments that clients reexperience yet omit from their trauma narratives. To identify problematic strategies that contribute to the maintenance of PTSD, the therapist asks the client what strategies they have used so far to cope with their distressing memories. Suppression of memories, avoidance, safety behaviors (i.e., excessive precautions), and numbing of emotions (including substance use) are commonly mentioned, as is rumination (dwelling on the memories). The Response to Intrusions Questionnaire6 (which measures suppression, rumination, and numbing; e.g., Ehring et al., 2008) and Safety Behaviours Questionnaire (which assesses excessive precautions; Dunmore et al., 2001) can help to identify strategies that need to be reduced in therapy. The therapist then uses a thought suppression experiment (asking the client to try hard not to think about an image such as a green rabbit or a black and white cat sitting on the therapist’s shoulder) to demonstrate that suppressing mental images has paradoxical effects. After discussing this experience, the therapist encourages the client to try to experiment with letting intrusive memories come and go during the next week (an exception to this homework assignment are clients who spend much time ruminating about the trauma, as they need to learn the distinction between intrusive memories and rumination first). The therapist uses the information gathered so far to develop an individualized case conceptualization and treatment plan with the client, which relates to the three main processes (appraisals, memory, and maintaining cognitive Adapted with permission from Ehlers and Wild (2015).

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Available at https://oxcadatresources.com.

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strategies/behaviors) in the model and contains the following core messages in individualized form using the client’s words as much as possible (adapted from Ehlers, 2013): • Many of the client’s current symptoms are caused by problems in the trauma memories. Therapy will help the client to get the trauma memories in a shape in which they no longer pop up as frequent unwanted memories. They will feel like memories of the past rather than something that is happening now. • The memories of the client’s traumas and what happened in their aftermath influences the client’s current view of their self and the world. The client perceives a threat from the outside world, a threat to their view of themselves, or both. In therapy, the therapist and client will discuss whether these conclusions are fair representations of reality and will consider the possibility that the trauma memories color their perception of reality. • Some of the strategies that the client has used to control the symptoms and threat are understandable but counterproductive and maintain the difficulties the client is having. In therapy, the client will experiment with replacing these strategies with other behaviors that may be more helpful. The graphic presentation of the treatment model shown in Figure 4.1 is usually not presented to the client, as it is quite complex. Instead, different parts of the model, such as the vicious circle between intrusive memories and memory suppression, or the relationship between beliefs about future danger, safety behaviors, and hypervigilance may be drawn out for the client to illustrate particular maintenance cycles that the client is trying to change. Modifying Excessively Negative Appraisals of the Trauma and Its Sequelae Reclaiming/ Rebuilding Your Life Assignments People with PTSD often feel stuck at the time of the trauma and that they have permanently changed for the worse and have become a different person since (e.g., Dunmore et al., 2001).7 Related to this perceived permanent change, clients with PTSD often give up activities and relationships that used to be important to them. This withdrawal from previously important activities in the client’s life usually goes beyond avoidance of reminders of the traumatic event. Some activities may not have been possible in the immediate aftermath of the event, and the client has not taken them up again. Giving up these significant activities maintains the perception of permanent change by providing confirmation that the client has become a different person and that their life is less worthwhile since the trauma. Reclaiming/rebuilding your life assignments is discussed in every treatment session. The aim of the initial discussion in the first treatment session is to map the areas where clients would like to reclaim or rebuild their lives. Therapist and Adapted with permission from Ehlers and Wild (2015).

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client then agree on an achievable first step in one of these areas and develop the first homework assignment. The therapist refers to the client’s treatment goals, which usually include an improvement in the ability to work or study and in their relationships. This intervention helps to instill hope that the client will be able to improve their quality of life. It also helps the therapist get an idea of the client’s life and personality before the trauma so that they can build on previous strengths and interests. If clients have lost much of their former lives since the trauma (e.g., loss of significant other or home, life-changing injuries, the trauma occurred when they were very young), it is best to refer to “(re)building your life” as these clients may say they can never get back what was lost, that they never had a life, or that their former life was not one they wish to reclaim. This intervention has some similarities with behavioral activation (Jacobson et al., 2001) but focuses on meaningful and pleasant activities that were lost since the trauma to help clients retrieve specific memories of their former selves and address their sense of permanent change (Kleim & Ehlers, 2008). Changing Meanings of Trauma by Updating Trauma Memories CT-PTSD uses a special procedure to shift problematic meanings (i.e., appraisals) of the trauma—the updating trauma memories procedure.8 This involves three steps: To access the personal Step 1. Identifying threatening personal meanings.  meanings of a trauma that generate a sense of current threat, the moments during the trauma that create the greatest distress and sense of “nowness” during recall (hot spots) are identified through imaginal reliving (Foa & Rothbaum, 1998) or narrative writing (Resick & Schnicke, 1993), and through discussion of the content of intrusive memories. The personal meanings of these moments are explored through careful questioning (e.g., “What was the worst thing about this?,” “What did you think was going to happen?,” “What did this mean to you at the time?,” “What does this mean to you now?,” “What would it mean if what you feared most did happen?”). It is important to ask direct questions about clients’ worst expected outcomes, including their fears about dying, to elicit the underlying meanings, as this guides what information is needed to update their trauma memory. Imaginal reliving and narrative writing both have particular strengths in working with trauma memories, and the relative weight given to each in CT-PTSD depends on the client’s level of engagement with the trauma memory and the length of the event. In imaginal reliving (Foa & Rothbaum, 1998), clients visualize the traumatic event (usually with their eyes closed), starting with the first perception that something was wrong and ending at a point when they were reasonably safe again (e.g., the assailant left; being told in hospital that they were not paralyzed). Clients describe (usually in the present tense) moment by moment what is happening in the visualized event, including what they are feeling and thinking. This technique is powerful in facilitating emotional engagement with the memory and accessing details of the memory, Adapted with permission from Ehlers and Wild (2015).

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including emotions and sensory components. The therapist facilitates controlled engagement with the trauma memory so that the client maintains awareness of the present surroundings. In CT-PTSD, the therapist will usually guide imaginal reliving of the traumatic event two or three times to access the hot spots with sufficient detail to assess their problematic meanings and then will move on to the steps of updating their meaning. This is different from prolonged exposure therapy, in which more sessions are devoted to reliving the traumatic event (Foa & Rothbaum, 1998). Identifying hot spots and their meanings may take longer if clients suppress their reactions or skip over difficult moments because, for example, they are ashamed about what happened. An alternative method of accessing the personal meanings of the event is writing a narrative (Resick & Schnicke, 1993). This method is used when the traumatic event lasted a long time and reliving the whole event would not be possible. The narrative covers the entire traumatic time period and helps to identify the moments or events with the greatest emotional significance so that their meaning can be explored further. Narrative writing is also particularly suitable if clients dissociate and lose contact with the present situation, are very confused about what happened, or show very strong physical reactions when remembering the trauma (e.g., clients who were unconscious during parts of the trauma may feel very faint; see Murray et al., 2020 for details of the treatment of PTSD following treatment in intensive care). Writing a narrative on a whiteboard or computer screen with the support of the therapist can help introduce the necessary distance for the client to take in that they are looking back at the trauma rather than reliving it. Narrative writing is also especially helpful when the client is not clear about aspects of what happened or the order of events because the therapist can interweave a discussion about the different ways the event may have unfolded. Reconstructing the event with diagrams and models and a visit to the site of the trauma (which provides many retrieval cues) can also help in such instances. The narrative is useful for considering the event as a whole and for identifying information from different moments that have implications for the problematic meanings of the trauma and for updating the memory (see Steps 2 and 3). After completing therapy, clients at times find it helpful to refer back to their updated narrative when memories are triggered, such as around anniversaries of the trauma. For clients who dissociate and those with high shame or an enduring sense of degradation, trigger discrimination or initial cognitive restructuring may be conducted first to facilitate the memory work. Step 2. Identifying updating information. Once a hot spot and its meaning are identified, the next step is to identify information that provides evidence against the problematic meanings (i.e., updating information). It can be something that the client is already aware of but has not yet linked to the meaning of this particular moment in memory, or it may be something the client remembers during imaginal reliving or narrative writing. Examples include knowledge that the outcome of the traumatic event was better than expected (e.g., the client did not die, is not paralyzed), information that explained the client’s or other people’s behavior (e.g., the client complied with the perpetrator’s instructions

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because he had threatened to kill him; other people did not help because they were in shock), and the realization that an impression or perception during the trauma was not true (e.g., the perpetrator had a toy gun rather than a real gun). Information and explanations from reliable sources or experts (e.g., cars are built in a way that makes explosions after accidents very unlikely; certain distressing procedures in hospitals were done to save the client’s life) can also be valuable in identifying updating information. For other appraisals (e.g., “I am a bad person,” “It was my fault,” “My actions were disgraceful,” “I attract disaster”), guided discovery to generate an alternative perspective is necessary. Cognitive therapy techniques such as Socratic questioning, systematic discussion of evidence for and against the appraisals, behavioral experiments, discussing hindsight bias, pie charts, or surveys are helpful. Imagery techniques can also be helpful in widening the client’s awareness of other factors that contributed to the event or in considering the value of alternative actions. For example, assault survivors who blame themselves for not fighting back during the trauma may visualize what would have happened if they had. This experience usually leads them to realize that they may have escalated the violence further and the assailant may have hurt them even more. Step 3. Active incorporation of the updating information into the hot spots. Once the therapist and client have worked together to identify updating information that the client finds compelling, it is actively incorporated into the relevant hot spot. This can be done as soon as the updating information has been identified for that particular hot spot, for example, in the same session as the first reliving. Clients are asked to bring this hot spot to mind through imaginal reliving or reading the corresponding part of the narrative and then to remind themselves, prompted by the therapist, of the updating information (a) verbally (e.g., “I know now that . . .”), (b) by imagery (e.g., visualizing how one’s wounds have healed, visualizing the perpetrator in prison, looking at a recent photo of the family or of oneself, visualizing the person who died in the trauma in a peaceful place where they are no longer suffering), (c) by performing movements or actions that are incompatible with the original meaning of this moment (e.g., moving about or jumping up and down for hot spots that involved predictions about dying or being paralyzed), or (d) through incompatible sensations (e.g., touching a healed arm). To summarize the updating process, therapist and client create a written narrative that includes the new meanings for each hot spot and highlights them in a different font or color (e.g., “I know now that it was not my fault”). Changing Appraisals of Trauma Sequelae For some clients, a main source of current threat comes from threatening appraisals of the aftermath of the traumatic event. These appraisals are modified by the provision of information, guided discovery with Socratic questioning, and behavioral experiments. For example, some clients believe that intrusive memories are signs that they are going crazy or losing control (e.g., Ehlers et al.,



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1998). Their failed attempts to suppress the intrusions are seen as further confirmation of this appraisal. Others interpret some people’s responses after the event as signs that no one cares for them or understands them or that other people see them as inferior (Dunmore et al., 2001). Such appraisals can be modified through education about the symptoms of PTSD, Socratic questioning, surveys, providing new information, and behavioral experiments. Memory Work to Reduce Reexperiencing Memory work focuses on elaboration and updating trauma memories and discrimination training with trauma triggers. Imaginal Reliving and Narrative Writing The updating trauma memories procedure described above helps elaborate the trauma memory. Retrieving the memory and talking about it helps to make it appear less vivid and intrusive. Clients may observe that some of the sensory impressions from the trauma fade away (e.g., colors or taste fading). When the hot spots have been successfully updated, clients usually experience a large reduction in reexperiencing symptoms and negative emotions and an improvement in sleep (Woodward et al., 2017). Identification and Discrimination of Triggers of Reexperiencing Symptoms Clients with PTSD often report that intrusive memories and other reexperiencing symptoms occur “out of the blue” in a wide range of situations.9 Careful detective work usually identifies sensory triggers that clients have not been aware of (e.g., particular colors, sounds, smells, tastes, touch, body posture, or movement). To identify these subtle triggers, client and therapist carefully analyze where and when reexperiencing symptoms occur. Systematic observation by the client and the therapist in the session and through homework is usually necessary to identify all triggers. Once a trigger has been identified, the next aim is to weaken the link between the trigger and the trauma memory. Weakening the link involves several steps. First, the client learns to distinguish between “then” and “now”—that is, to focus on how the present triggers and their context (i.e., now) are different from the trauma (i.e., then). This leads them to realize that there are more differences than similarities between then and now, that now is very different from the trauma, and that they are responding to a memory of then, not current reality (now). Second, intrusions are intentionally triggered in therapy so that the client can learn to apply the then-versus-now discrimination. For example, traffic accident survivors may listen to sounds such as brakes screeching, collisions, glass breaking, or sirens, that remind them of their car accidents. People who were attacked with a knife may look at a range of metal objects. People who were shot may listen to the sounds of gunfire generated on a computer. Survivors of bombings or fires may Adapted with permission from Ehlers (2013).

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look at smoke produced by a smoke machine or a cigarette. People who saw a lot of blood during the trauma may look at red fluids. The then-versus-now discrimination can be facilitated by carrying out actions that were not possible during the trauma (e.g., performing movements that were not possible in the trauma, touching objects or looking at photos that remind them of their present life). Third, clients apply these strategies in their natural environments. When reexperiencing symptoms occur, clients remind themselves that they are responding to memories. They focus their attention on how the present situation is different from the trauma and may carry out actions that were not possible during the trauma. Site Visit A visit to the site of the trauma completes the memory work.10 This visit is done in person where possible or via Google Street View or Google Earth if not (e.g., if the trauma happened in another country). Visiting the site can help correct remaining problematic appraisals because the site provides many retrieval cues and helps access further information to update the appraisals. The site visit also helps complete the stimulus discrimination work. Clients realize that the site now is very different from then, which helps place the trauma in the past. Imagery Work Imagery can be a powerful way to update hots spots (e.g., visualizing a person who died at peace, visualizing how the body has healed/renewed itself after the trauma). In addition, if reexperiencing symptoms persist after successful updating of the client’s hot spots and discrimination of triggers, imagery transformation techniques can be useful. The client transforms the trauma image into a new image that signifies that the trauma is over. For example, with the help of the therapist, a client may transform their image of impact in a car accident to an image of a recent birthday celebration with their children to signify that the client is safe now, their trauma is in the past, and their fears that their children would lose a parent did not happen. Transformed images can provide compelling evidence that the intrusions are a product of the client’s mind rather than perceptions of current reality. Image transformation is also particularly helpful with intrusions that represent images of things that did not actually happen during the trauma (e.g., transforming images of the future that represented their worst fears such as images of a client’s children growing up sad and alone or images of people’s reactions at their funeral). Dropping Dysfunctional Behaviors and Cognitive Strategies The first step in addressing cognitive strategies and behaviors that maintain PTSD is usually to discuss their problematic consequences.11 Sometimes these consequences can be demonstrated directly by a behavioral experiment. For Adapted with permission from Ehlers (2013).

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Adapted with permission from Ehlers (2013).

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example, the effects of selective attention to danger cues can be demonstrated by asking the client to attend to possible signs of danger unrelated to the trauma. An assault survivor may be asked to stand by a busy road for a few minutes and attend to signs of potentially risky driving. Clients find that this exercise makes them more aware of a range of possible dangers. They then reflect on what this means for their own efforts to scan for signs of danger, typically specific to their trauma, and consider the possibility that the world may not be as dangerous as they assumed. They discuss with the therapist the alternative hypothesis that their intrusive trauma memories lead to the impression that they are in danger. This discussion leads to further behavioral experiments in which they test their appraisals. For example, a person may test “If I do not look carefully for people who look like the assailant, I will be attacked again” by walking to a local shop whilst dropping their hypervigilance and any safety behaviors. They are encouraged to use the then-versus-now discrimination to deal with any reexperiencing symptoms that may be triggered during the experiment. Clients usually predict a very high chance of being attacked and are surprised to find that no one attacked them. Note that the focus of the discussion is on whether the prediction was correct rather than on anxiety levels. In other instances, a discussion of advantages and disadvantages of the strategy is a helpful start. For example, when discussing rumination with the therapist, a client may generate the perceived advantage that dwelling on questions like “Why did it happen to me?” and “If I had done X, could I have prevented the trauma from happening or influenced the outcome?” will help to prevent another trauma. The client may then reflect on the fact that the rumination has not generated any answers, makes them feel worse, wastes a lot of time, and prevents them from moving on with life. This process motivates clients to experiment with moving to other activities when they notice the first signs of rumination. Tailored Treatment As the CT-PTSD case formulation is tailored to each individual, it can be applied to a wide variety of presentations, traumas, and cultural backgrounds and can incorporate comorbid conditions and the effects of multiple traumas. For example, comorbid depression may be related to some of the client’s appraisals of the trauma and other life experiences (e.g., “I am worthless”) and cognitive strategies (e.g., rumination). Comorbid panic disorder may have developed from interpretations of the reexperiencing symptoms (e.g., reexperiencing difficulty breathing leading to the thought “I will suffocate”). And comorbid OCD may be linked to appraisals such as “I am contaminated” and linked behaviors such as excessive washing. The cognitions and unhelpful coping strategies associated with comorbid symptoms are incorporated into the individual case formulation and addressed in cognitive therapy. An example is given in the case illustration. Cultural beliefs may influence an individual’s personal meanings of trauma and their attempts to come to terms with trauma memories in helpful and unhelpful ways. Treatment is tailored to the individual’s beliefs, including their cultural beliefs.

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CT-PTSD allows for flexibility in the order in which the core treatment procedures are delivered, depending on the individual formulation and client preference. The memory updating procedure usually has a fast and profound effect on symptoms (Woodward et al., 2017) and is generally conducted in the first few sessions, if possible. For patients with severe dissociative symptoms, training in trigger discrimination is conducted first, and narrative writing is preferred over imaginal reliving. In addition, for certain cognitive patterns, the memory work is prepared through discussion of the client’s appraisals and cognitive processing at the time of the trauma. For example, if clients believe they are to blame for a trauma and their shame or guilt prevents them from being able to describe it fully to the therapist, therapy would start with initial cognitive work (e.g., guided discovery, surveys, spotting self-criticism) to weaken these beliefs sufficiently to enable the client to engage with the memory work of these appraisals. If a client experienced mental defeat (i.e., the perceived loss of all autonomy; Ehlers, Maercker, & Boos, 2000) during an interpersonal trauma, therapy would start with discussing the traumatic situation from a wider perspective to raise the client’s awareness that the perpetrators intended to control and manipulate their feelings and thoughts at the time but are no longer exerting control. For clients displaying complex features of PTSD, other problems may need to be addressed as an initial priority, particularly if reexperiencing symptoms and coping strategies are currently placing a client at risk, for example, as with severe dissociative episodes, excessive use of substances, self-harm, and risky sexual behavior. In addition, a comorbid condition that is a clinical priority and would interfere with the successful or safe delivery of CT-PTSD, such as severe depression with acute suicidal intent or acute psychosis, would require prior treatment. In some cases, it may be necessary to prioritize other problems or events for a few sessions during treatment if they become the client’s primary problem.

SPECIAL CONSIDERATIONS When Should CBT for PTSD Be Offered? In the first 12 to 18 months after a traumatic event, there is a substantial rate of natural remission (up to 50%) from PTSD symptoms (Kessler et al., 1995). This raises the question of when treatment should be given and who should receive early treatment. People with mild PTSD symptoms in the first weeks following trauma have a higher chance of natural recovery than those with severe symptoms (Rothbaum et al., 1992). Thus, a period of active monitoring is recommended (e.g., NICE, 2018)—that is, offering follow-up assessments to check whether the symptoms have declined naturally or whether treatment is indicated. For people with severe PTSD symptoms in the first weeks after trauma or those meeting diagnostic criteria for acute stress disorder, a course of TF-CBT has been shown to be effective (e.g., Bryant et al., 1998; Ehlers et al., 2003; Foa et al., 1995). Individual or group debriefing for trauma-exposed individuals is not effective in preventing PTSD (NICE, 2018).



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Dissociation Dissociative experiences in response to memory triggers are common in PTSD, and clients differ in the severity of dissociation. Some feel unreal, numb, or have ‘out of body’ experiences, but remain aware of their current environment.12 Therapeutic strategies for this milder form of dissociation include normalization of the experience as a common response to trauma (the therapist may want to link dissociation to freezing in animals who face predators); cognitive restructuring and behavioral experiments to modify interpretations of the experience such as “I am going crazy,” “I live in a different reality to other people,” or “The real me died, and I am an alien/ghost now”; and trigger discrimination. It can also be helpful to guide clients who had out-of-body experiences during imaginal reliving to return to their body and perceive the event from the perspective of their own eyes. If clients lose awareness of the current situation completely and feel and behave as if the trauma were happening again, this can involve significant risk to self and others and needs to be assessed carefully. Adaptations of the treatment procedures in CT-PTSD include a strong emphasis on trigger discrimination from the outset of therapy and the use of objects or strategies that remind them of the here and now, helping them stay aware of the present (e.g., touching a small toy or pebble from a beach, using room perfume, watching a recent video of their children, or listening to music when memories are triggered). The therapist explains that strong emotional reactions linked to the trauma can occur without any images of the event itself (e.g., strong urge to leave a situation, strong anger) and guides the client to become increasingly aware that these are signs that trauma memories are being triggered. The work on trauma memory updating is adapted to allow the client to remain aware of the present safe environment. For example, therapist and client may write a narrative on a whiteboard or computer in small steps in combination with stimulus discrimination strategies, and the updates for each hot spot are then included in the narrative in a different color and read out together. Risk to self and others is assessed and precautions are agreed if indicated. Multiple Traumas Many clients with PTSD have experienced more than one trauma, but not all traumas are necessarily linked to their current PTSD.13 To determine which traumas need to be addressed in therapy, the therapist and client discuss which traumas still bother them (i.e., are represented in reexperiencing symptoms or are linked to personal meanings that trouble the client). This discussion also provides a first assessment of problematic meanings that link several traumas. For example, repeated trauma may lead to generalized negative appraisals such as “There is something about me that attracts disaster” or “I deserve bad things to happen to me.” Client and therapist discuss which trauma to start with. This Adapted with permission from Ehlers (2013).

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Adapted with permission from Ehlers and Wild (2015).

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would usually be a trauma that the client currently finds the most distressing or a trauma during which an important problematic meaning originated. The therapist also may assist the client in developing a timeline of their life and trauma history, to facilitate the identification of focal traumas. The therapist also notes whether elements from other traumas come up when the client relives the identified trauma, as these may have influenced its personal meanings. Once the hot spots from the identified trauma have been updated, the therapist checks whether this decreases the reexperiencing of other traumas that carry related meanings. The remaining traumas that are still distressing or relevant for problematic appraisals are then addressed in turn. Dissociation may be pronounced and will need to be addressed with the methods described above. Work on reclaiming/rebuilding the client’s life is especially important after multiple traumas, as these clients may lead very restricted lives and may need much support from the therapist as well as problem solving about how to best build up a social network, reengage in the job market, and so forth. Work on maintaining behaviors is also especially important as clients may show extreme forms of these behaviors (e.g., chronic hypervigilance and complete social withdrawal). For clients with long-standing multiple traumas, additional work on self-esteem may be helpful (e.g., keeping a log of things they did well or positive feedback from others). Physical Problems The injuries contracted in the traumatic event may lead to ongoing health problems that significantly affect the client’s life.14 Chronic pain is common. Sometimes the traumatic event leads to a permanent loss of function, for example, difficulty walking, inability to have children, or blindness. Clients often need help in adjusting to these physical problems and the impact they have on their lives. This may require additional treatment strategies such as pain management or coping strategies similar to those for coping with chronic illness. Cognitive distortions such as overinterpretation or overgeneralization of the negative impact of the loss on their lives (e.g., “I am useless,” “My life is worthless now”) may need to be addressed in therapy. For other clients, the physical injuries may have compromised their appearance, which may have negative effects on their job or social life. They may need support in learning to adapt to these changes. It is also not uncommon for clients to perceive a loss of attractiveness or a disfigurement that is greater than the objective change. For these clients, video feedback is used in CT-PTSD as it helps clients update the image of how they believe they appear to others (which is influenced by the trauma memory) with a more accurate image. Clients watch themselves in a short video recording, with the instruction to watch themselves objectively as if they were another person they do not know. For example, a client who believed that his facial scars were repulsive saw bright Adapted with permission from Ehlers and Wild (2015).

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red scars when he visualized how he would appear to others. His face was filmed with different red objects in the background. Comparing his face with the objects made him realize that the scars no longer looked red and were much less visible than he had imagined. Surveys are helpful in testing clients’ beliefs about what other people think about their appearance. For example, the client agreed with the therapist that some other people could watch the video recording and answer a series of questions about his appearance, starting with neutral questions and ending with direct questions about the client’s concern: “Did you notice anything about this person’s appearance?” “Did you notice anything about this person’s face?” “Did you notice that he had scars?” “What did you think about the scars?” “How much, out of 100%, did you think he looked repulsive?” The therapist fed back the responses in the following week and the client was relieved to find that no one thought he looked repulsive and most people had not even noticed the scars. Other health problems that existed before the traumatic event may influence the course of treatment. For example, clients with some medical conditions, such as poorly controlled diabetes, may find it hard to concentrate for long periods of time and require shorter sessions or sessions with frequent breaks. Clients with chronic heart conditions may require a more graded approach in recalling the trauma and visiting the site where the trauma occurred than clients who are physically healthy. Comorbidity Many clients with PTSD have comorbid conditions that need to be addressed in treatment.15 Depression that is secondary to PTSD will usually resolve with treatment of the PTSD. However, in some cases, depression may become so severe that it needs immediate attention (i.e., suicide risk) before PTSD treatment can commence. In some trauma survivors (especially after multiple traumas), depression may dominate the clinical picture to the extent that it makes a treatment focus on the trauma impossible and warrants treatment first. Depressive symptoms most likely to interfere with PTSD treatment are severe suicidal ideation, extreme lack of energy, social withdrawal, inactivity, and poor concentration. The first goal in treatment will be to lift the client’s mood sufficiently so that TF-CBT can commence, for example with behavioral activation or antidepressant medication. Anxiety disorders such as panic disorder, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, or social phobia may be preexisting conditions or develop as a complication of PTSD. The therapist needs to determine whether the comorbid anxiety disorder needs treatment in its own right. If this is the case, the case formulation and treatment plan will need to integrate the treatment of both the PTSD and the other anxiety disorders. It is not always easy to determine in the initial assessment whether patterns of avoidance are Adapted with permission from Ehlers and Wild (2015).

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part of the client’s PTSD or part of another anxiety disorder. An important question is “What is the worst thing that could happen if you . . . (encounter the feared situation, do not take special precautions).” In PTSD, the client’s concern would usually be another trauma (“I will be attacked again,” “I will die in another accident”). Other concerns suggest other anxiety disorders, for example, panic disorder (“I will have a heart attack,” “I will faint”) or social phobia (“I will make a fool of myself,” “People will think I am weird”). It is often difficult to determine whether or not a panic attack or strong anxiety response in a certain situation constitutes a reexperiencing symptom, as clients are usually not aware of the subtle sensory triggers of reexperiencing. In these cases, an ongoing assessment of the need for separate work on the other anxiety disorder is needed as treatment progresses. In most cases with comorbid anxiety disorders, treatment starts with the TF-CBT program. An important exception are clients with panic disorder who believe that a catastrophe will happen if they become very anxious or put their body under stress—for example, believing that they will have a heart attack, will faint, or go crazy. These misinterpretations often need to be addressed before working on the trauma memory as these clients are unlikely to engage in treatment or may drop out if their concerns are not addressed. Many clients with PTSD use alcohol, cannabis, or other substances to numb their feelings or distract themselves from trauma memories. This may include heavy smoking or even consumption of caffeinated beverages in large quantities. Substance misuse is not a contraindication for treatment. Treatment of the PTSD will help clients with reducing their substance use. The therapist will need to incorporate the substance use as a maintaining behavior in the case formulation and address it together with the other maintaining factors in the overall treatment plan. However, if physical substance dependence has developed (i.e., the client has withdrawal symptoms, tolerance, and acquiring and consuming the substances takes up much of the client’s life), withdrawal is usually necessary before the client can benefit from the treatment described here. If in doubt, a useful strategy is to explain to clients with very high substance use that it will interfere with their capacity to process the therapy sessions and to benefit from the treatment. The therapist will need to educate clients about the negative effects of the substance on their symptoms (e.g., alcohol may help the client get off to sleep, but it will lead to more awakenings at night and feeling irritable and emotional the next day; cannabis may make the client feel more unreal or more paranoid; smoking leads to brief relief, then increased anxiety; caffeine can lead to irritability, poor sleep, and poor concentration). The therapist should then ask whether clients would be willing to reduce their substance consumption before treatment commences. Many clients will agree to give it a try if they have the prospect of receiving help for their PTSD. These clients often find that the reduction in substance use in itself has a positive effect on their symptoms. If the client does not feel able to reduce the substance consumption, treatment will need to target the dependence first.



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CLINICAL EXAMPLE Lara, a 46-year-old Spanish woman living in the UK, was sexually assaulted in her flat in front of her 10-year-old daughter. During the attack, she was forced to fondle her daughter. The perpetrator, well known to the police, had been on parole following imprisonment for sexually assaulting women. After the attack, he was caught, arrested, charged, and sentenced to life imprisonment. Prior to the attack, Lara had been addicted to heroin for 10 years and had supported herself on and off with prostitution. She had received treatment for drug dependence and had been abstinent from alcohol, drugs, and prostitution for 4 years prior to the trauma. At the time of the assessment, 10 years after the assault, Lara’s daughter was studying at university and Lara was working as a nurse. The diagnostic assessment with the Structured Clinical Interview for DSM-IV (First et al., 1995) showed that Lara was suffering from PTSD, social anxiety, dysthymia, and generalized anxiety disorder, all of which had developed after her attack. Symptoms included unwanted memories of the rape; for example, of her daughter’s face, looking terrified, as she watched what was happening to her. About once a week, she had nightmares about being attacked again. These woke her, and she was unable to return to sleep. Lara avoided thinking about the attack, and she had lost interest in socializing with colleagues, seeing friends, and practicing yoga. She felt distant, numb, and cut off from other people. Lara had difficulty falling and staying asleep, irritability, and difficulty concentrating. She was overly alert and jumpy in response to loud noises. The symptoms that most bothered her were the memories of being raped, which also triggered memories of her work as a prostitute. The intrusions of the trauma and prostitution triggered rumination and confirmed her pretrauma beliefs that she was a disgusting, bad mother, who was careless, selfish, and stupid. After periods of rumination, she felt low and had thoughts of taking her life. Her goals for treatment were (a) to stop the memories of the rape and prostitution, (b) to feel less guilty and ashamed about what happened during the trauma and her prior work as a prostitute, (c) to try yoga again, and (d) to socialize with work colleagues. Case Formulation According to Ehlers and Clark’s (2000) Model The cognitive assessment revealed the following factors that contributed to Lara’s sense of current threat. Appraisals Lara blamed herself for the attack. She believed that she should have been able to prevent the attack, that it was her fault, and that she was careless and stupid (belief rating: 100%). Lara believed that she had let her daughter down by fondling her and that she was a bad mother (90%). She believed that the repetitive nightmares, frequent memories, and inability to stop questioning herself

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meant that she was “losing it” and would never recover and socialize with other people (90%). Trauma Memories Lara’s main reexperiencing symptoms included images of her daughter’s terrified face as she was being attacked. The images meant that her daughter Anna was damaged and that Lara had not protected her; that she had let her down. The nightmares were about being attacked again and when she had them, she had periods of dissociation and felt as though the trauma was happening again and that she was about to be raped. As a result, she forced herself to stay awake for the rest of the night. Lara was tearful when she described her worst memory of the rape in the first session. She remembered that she had been forced to fondle her daughter but was unsure how helpful she had been in ending the attack and was unable to access information that revealed she had protected her daughter from being raped. Lara reported that her intrusive images were triggered by seeing photos of her daughter when she was a child, reading news reports of sexual assault, conversations about sexual abuse scandals, fictional TV programs featuring prison life, seeing similar-looking people as the perpetrator, children screaming, and scissors. Sometimes images came out of the blue, suggesting there were triggers she had not spotted yet. Maintaining Behaviors and Cognitive Strategies A range of cognitive strategies and behaviors maintained Lara’s PTSD and low mood: • suppression of trauma-related images and memories • rumination and self-criticism • safety behaviors and hypervigilance • withdrawal from social life and other activities When images of the trauma came to mind, Lara tried hard to push them away. She told herself not to think about the memories, which kept them in mind and triggered periods of rumination, during which she overanalyzed her past, berating herself for drug abuse and prostitution whilst caring for a young child. The rumination and self-criticism made it impossible for her to access information that could help to update the memories and their meanings, and maintained her sense of guilt, shame, and sadness. Her feelings of guilt and shame caused her to withdraw socially, which maintained her low mood. Lara took unnecessary precautions (safety behaviors) to keep herself and her now grown daughter safe. She called her daughter several times a day to check that no one had approached her with threatening behavior. She avoided dating. She was hypervigilant at home, double-locking her doors and checking local news stories to keep up-to-date on crime in the area. When she was



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woken by a nightmare, she avoided going back to sleep, which caused her to feel irritable and have difficulty concentrating the next day. Lara felt ashamed of what the perpetrator had done and ongoing shame linked to her past. She believed people could see that she had been raped and that she was “losing it” when they looked at her. As a result, she avoided eye contact at work, socializing, and taking part in activities, such as yoga, where other people were present. She felt detached from others, felt unsafe when she was around men, and had stopped going out with friends. Comorbid Conditions The cognitive assessment suggested that many of the factors maintaining Lara’s PTSD were also maintaining her social anxiety, dysthymia, and generalized anxiety disorder. Her appraisals that she was a disgusting, bad mother who had failed her daughter and was careless, selfish, and stupid, and her rumination on these self-critical thoughts as well as her withdrawal from friends and previously enjoyed activities maintained her dysthymia. Lara worried about bad things happening and this generalized to situations unrelated to the trauma. She worried about being knocked off her bike on the way to work and sustaining a permanent injury. She worried about her health, her daughter’s health, and the consequences of developing an injury or having poor health, which caused her to worry about finances and her job. Her appraisals that other people could see she was “losing it” and that she had been raped made her anxious around other people. She believed she would say something stupid, which would confirm other people’s view of her as being stupid. Her avoidance of socializing and making eye contact at work maintained her social anxiety. Treatment Lara attended 12 sessions, lasting between 60 and 90 minutes each. Work on Appraisals Interpretation of symptoms. S  ome of Lara’s appraisals concerned interpretations of her symptoms: “I’m losing it.” “I’ll never recover and socialize with other people.” These were addressed with the following interventions in Session 1: Normalization of symptoms: Intrusive, distressing memories and nightmares are normal after trauma. They are a sign that we need to work on the trauma memory to help you process it and put it in the past, which will make the memories less intrusive. Information about the nature of trauma memories: Trauma memories often feel like they are happening now and give you a sense that there is immediate danger. For example, one of your trauma memories is seeing your daughter’s terrified face as you were being attacked. This brings back the feeling of danger because when you saw her looking terrified during the trauma, you were in danger. Her terrified face was a sign that you were still in danger. You did not know then how the trauma would end and you believed you

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would be killed. The feeling that you are in danger now when the memory comes to mind is coming from the trauma memory. Reclaiming your life assignments. Examples of the activities Lara built up over the course of therapy included (a) yoga poses in a standing position at home for 15 minutes twice a week, then half an hour, then with a friend at her home, and toward the end of therapy, with a friend at the gym, including poses where she lay down, and then by herself at the gym; (b) a telephone chat with a friend, then a coffee with a friend at her house, then in a café, then lunch with colleagues at work; (c) researching courses on training as a yoga instructor; and (d) booking a holiday. These activities helped to reduce the strength of Lara’s belief that she would never recover or socialize again. She was encouraged to focus her attention externally when she tried these activities, paying attention to signs that people were responding to her in a kind and friendly manner, which helped her to feel less anxious around other people. Engaging in activities helped to increase her social contact, improve her mood, and loosen the belief that people could see her past. Self-blame for assault. Lara believed she should have been able to prevent the attack—that it was her fault (100%) and she was careless and stupid (100%). These were linked to particular moments during the assault that were identified with imaginal reliving and updated over two sessions. In Session 2, Lara described the trauma in imaginal reliving. Lara had been living in an area in London with higher than average rates of crime. She had been at home alone with her daughter when someone knocked at the door. The person said they were a police officer investigating a burglary in the area and asked if they could ask Lara a few questions. Lara opened the door, and the man feigning to be a police officer attacked her. He raped her and asked her to fondle her daughter. Lara was lying face down on the floor, and as she moved to start to fondle her daughter, she saw a pair of scissors. She grabbed them, and with all her strength, she pushed the man off her back and chased him out of her flat and down the street. A neighbor called the police and the man was arrested, charged, and imprisoned. To access updating information, the therapist used Socratic questioning, asking the following: “How did you get out?,” “When during the trauma did things change?,” “Did you save your daughter from being raped?,” “What does this say about you as a mother?” Lara realized that although being asked to fondle her daughter was a worst moment during the trauma, it was also a turning point, signifying the moment she was able to turn the situation around and save them. It was in this moment that she saw the scissors and was able to chase the perpetrator away. She realized that although she had briefly fondled her daughter, she had protected her from being raped. The therapist and Lara constructed a pie chart to look at all of the contributing reasons for why the attack happened. Lara was asked to apportion responsibility as a percentage to each factor before apportioning responsibility for her



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own actions. Lara concluded that she was not responsible for the attack and that the responsibility lay with the perpetrator, the police, and the justice system for giving the perpetrator parole when he was still risky to the public. In the next session, Lara relived the hot spot (being asked to fondle her daughter) in imaginal reliving and linked the updating information to this moment in memory. To generate updating information for Lara’s appraisal “I am careless and stupid” (100%), the therapist constructed a survey with Lara in which they wrote a brief description of the trauma and followed it with questions. The survey asked people to rate out of 100% how careless and stupid they would consider someone to be for opening their door to a man stating he was a police officer investigating crime in area. The survey also included questions asking what other people would have done in a similar situation. The therapist reviewed the survey in Session 3. All respondents indicated that they thought the person was 0% stupid and that they would have done the same thing. Lara had predicted that no one would have opened the door and that everyone would have thought a person who fell for the perpetrator’s introduction as a police officer was entirely stupid. Learning that other people would have done the same thing and that they too would have wanted to be helpful to the person claiming to be a police officer helped Lara to reassess her belief, which she rerated as 0%. In the next session, Lara relived the hot spot in imaginal reliving and linked the updating information to it: that it is normal and understandable to open the door to the man claiming to be a police offer, that it is exactly what other people would do, and that it is a sign she is a helpful and concerned citizen. “I am a bad mother.” L  ara believed that she had let her daughter down by fondling her (80%) and that she was a bad mother (90%). In Session 3, Lara described in imaginal reliving the moment the perpetrator asked her to fondle her daughter. The therapist elicited the worst meaning of fondling her daughter and Lara revealed that it meant that her daughter was now damaged, that her life was ruined, and that Lara was a disgusting, bad mother. To access updating information, the therapist used guided discovery, asking Lara to describe her relationship with her daughter and her daughter’s relationship with friends and her romantic partner as well as her daughter’s achievements. Lara revealed that Anna thought very highly of her and that she was proud that her mum had been able to achieve so much, having a difficult past with drugs, and that she admired her work as a nurse, saving people’s lives. Lara also described her daughter’s achievements, the main one being that she was studying political science at a respected university. She also had supportive friends and a boyfriend of 2 years whom Lara liked. The therapist asked Lara to write the updating information on a flashcard and take a picture with her phone so that she could remind herself of it. Lara concluded that her daughter was doing well, that she was not damaged, and that her life was not ruined. She rerated her belief that she had let her daughter down as 40%. The therapist then guided Lara to relive the worst moment and to link all of the updating

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information they had discovered to the worst moment. Lara described the worst moment with her eyes closed, and in the present tense, she then included the updating information about why the event happened, what other people would have done, and how much Anna had achieved as well as what she thought of Lara. Lara relived the worst moment with updating information a few times in this session. Her rerated belief after linking the updating information to the worst moment in imaginal reliving was 0%. To update the belief that she was a bad mother, the therapist constructed a survey, asking people what they would think of a woman who had been raped in front of her daughter and then forced to fondle her for a few minutes before seeing a pair of scissors and chasing the perpetrator away. They were asked to rate out of 100% how much they believed this woman was a bad mother and to indicate what they think they would have done in similar circumstances. The therapist discussed the results of the survey with Lara in Session 4. An extract from this therapy session is below. THERAPIST: Lara, before we read through the survey results, I’d like to ask

how much you believe you are a bad mother? LARA:

Very strongly. 90%. I feel awful about being forced to fondle Anna during the attack. I let her down completely.

The therapist then read the survey responses out loud to Lara. After each question, she asked Lara how the response made her feel and how they fit with her belief that she was a bad mother. When the surveys had been read, the therapist used Socratic questioning to help Lara reevaluate the belief that she is a bad mother.

THERAPIST: So we’ve read through all the responses from the eight people

who completed the survey. What have you discovered? LARA:

Well, no one rated me as a bad mother. They actually commented on how brave I was during the attack, that I may even have saved my daughter from possible rape and death.

THERAPIST: Exactly, and overall, what did people think of your behavior of

fondling your daughter—did they see it as evidence that you are a bad mum? LARA:

No one thought I was a bad mum for being forced to fondle Anna. Everyone thought that I was brave for grabbing the scissors soon after he made me fondle her and chasing him out.

THERAPIST: Exactly. And what did people think they would have done in a

similar situation?



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LARA:

I was surprised to discover that most people—seven out of eight people—thought they would have been too paralyzed with fear to fight the attacker.

THERAPIST: So no one rated you as a bad mum. All eight people thought you

were brave and that you saved your daughter from being attacked and possibly raped. And seven out of eight people thought they would have been unable to fight back and protect their child in this situation. Lara, I’m wondering what does this say about whether or not you are a bad mum? LARA:

Looking at it this way and hearing about what other people think and would have done, I don’t think I am a bad mum.

THERAPIST: How much out of 100%, do you believe you are a bad mother? LARA:

Much less. About 10%.

THERAPIST: And what makes you a 10% bad mother, Lara? LARA:

The choices I made when Anna was a toddler, choosing to work as a prostitute to support my heroin habit. I feel so ashamed about this.

THERAPIST:

I understand. We’ll look at this in a little more detail in a moment.

To address her self-blame linked to prostitution, the therapist asked Lara what her mental and emotional state was at the time when she was heavily using heroin. Did she have capacity to make healthy choices? The therapist guided Lara to discover that the physiological addiction to heroin gave her little choice for healthy behaviors at the time. The therapist and Lara concluded that when people are in the throes of heroin addiction, their capacity to make healthy choices are limited, that the heroin makes choices for them. Prostitution seemed understandable as a means to pay for the habit and avoid horrendous withdrawal symptoms. To address Lara’s shame linked to prostitution, the therapist used guided discovery and Socratic questioning, illustrated in the therapy extract below. The therapist is aiming to help Lara discover that her choices are more similar than different to other people since this will reduce the sense of shame. THERAPIST: I’d like us to come back to this belief that you’re a bad mother.

Considering the survey we’ve just run through, you’ve rated the belief that you’re a bad mum as 10%. LARA:

Yeah, 10%. It helps to know that other people don’t judge me for being raped in front of Anna and they don’t rate me as a bad mother, but I can’t change that I was a prostitute when she was a toddler.

128  Ehlers and Wild THERAPIST: I can see you feel badly, Lara. I’m wondering what you believe

prostitution says about you as a person? LARA:

I’m weak. I allowed myself to be violated and to be paid for it. I was not true to my values, and I’m clearly different to other people now because I was a prostitute and was addicted to heroin.

THERAPIST: Well, let’s start with “I’m weak.” What have we learned so far

about how the trauma ended? LARA:

I grabbed a pair of scissors and chased the perpetrator out eventually.

THERAPIST: Yes, that’s right, and what did we learn in the survey about what

other people might do if they were in a similar situation? LARA:

Most of the people said they thought they would freeze and would be unable to fight back.

THERAPIST: So you ended the trauma, saving your daughter by grabbing the

scissors and chasing the perpetrator out of your flat. Other people think they would have frozen and been unable to fight back in similar circumstances. How does this fit with being weak? LARA:

Well, it doesn’t, and I know I protected Anna in that situation. But when she was really young, I made money having sex to support a habit and didn’t value the choices I was making then.

THERAPIST: And what have we learned about how heroin drives behavior? LARA:

I now know that my state of mind at the time was unhealthy because of heroin and that my choices were being driven by heroin.

THERAPIST: That’s right and how does this make you feel? LARA:

It helps a bit but it doesn’t change the choice I made to have sex for money.

THERAPIST:

Lara, do you know people or have you heard of people who have carried out acts they don’t value, who weren’t true to themselves and their values and who were paid for it?

LARA:

I don’t know. Maybe. I have a friend who works for a company, I don’t want to say the name, but they are well known for avoiding corporate taxes and employing kids in China in horrid work conditions. He keeps working for them all the same, supporting their productivity.

THERAPIST: And does he value his work or the decision to keep working

for them? LARA:

No, he’d rather work for another company.



Cognitive Behavior Therapies for Posttraumatic Stress Disorder  129 THERAPIST: So why does he keep working for them? LARA:

Because he needs the money. They pay well.

THERAPIST: And did you need the money when you worked as a prostitute? LARA:

Yes, I did.

THERAPIST: Any other people you know or have heard about on TV who go

against their values in the work that they do? LARA:

Well, I think most of the people who work for this company that I mentioned know about their corporate tax evasion and what’s going on overseas and they keep working for them anyway. They employ at least one million people.

THERAPIST: So a lot of people choose to go against their values, to be paid for

work they may not value? LARA:

Yes, that’s true.

THERAPIST: So would this make you more similar or different to other peo-

ple—that you chose to work in an area you did not value so that you could make money? LARA:

I guess that makes me more similar.

THERAPIST: I would agree. Let’s come back to this point you made about

being violated and being paid for it. I understand it makes you feel completely different from other people. Let’s think about this a bit more. Have you heard of women who stay in horrendous marriages and have sex with husbands they do not value or care for because they enjoy a lifestyle they’d otherwise be unable to afford? LARA:

I have heard of this. I don’t know how they do it. Year in, year out.

THERAPIST: So would you say they are choosing to be violated for money? LARA:

Yes, that is what’s happening.

THERAPIST: So the behavior of having sex for money—is this similar or dif-

ferent to some other people? LARA:

It’s similar.

THERAPIST: That’s interesting. And what does this tell us about you, Lara?

Are you similar or different to other people? LARA:

I’m more similar when I look at it this way.

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THERAPIST: That’s right. And I’d like us to turn to your addictive behavior for

a moment. I’m wondering if there are habits other than heroin that might be addictive? LARA:

Alcohol. Smoking.

THERAPIST: That’s right. Anything else? LARA:

I don’t know.

THERAPIST: Have you heard of people becoming addicted to video games or

binge watching Netflix series or even being addicted to caffeine—not being able to get through the morning without a cup of coffee? LARA:

I have. But these aren’t harmful though.

THERAPIST: Some behaviors are addictive in the short term and some in the

long term with varying levels of harm. Looking at addiction in this way, would you say that most people have experienced a form of addiction? LARA:

Yes, I hadn’t thought of it like this before. My daughter is addicted to her phone!

THERAPIST: And that is another example of a behavior with addictive fea-

tures. So would you say you are more similar or different to other people? LARA:

Put like this, I am actually more similar.

THERAPIST: I would agree. Considering this new information, Lara, how

much do you believe now that you are a bad mother because you worked as a prostitute in the past? LARA:

I don’t! Let’s say 2%. I don’t think it will ever be 0% because of the situation I was in at the time, but I can see that past prostitution does not make me a bad mum and I am more similar than different to other people.

Memory Work to Reduce Reexperiencing Imaginal reliving, transforming images, and visiting the block of flats where the trauma took place by Google Street View helped Lara to identify hot spots and update the worst meanings linked to each one. She learned that she had done everything possible to protect her daughter and to prevent her from being attacked, and she had been successful in keeping her safe. She learned through updating the memories that her actions were nothing short of heroic and that is how they were seen by people who completed the surveys. In Session 5, Lara learned to transform frightening images with new information. She practiced turning from the image of her daughter’s terrified face to



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an image of her studying at university with friends. The updated image captured the updating information, which was that Lara had protected her from being attacked, that her life was not ruined, and that she was not damaged. In Sessions 6 and 7, Lara explored with the therapist triggers for intrusive memories. Through observation and attention to sensory similarities between possible triggers and the trauma, she spotted a range of triggers she had not noticed before. Examples included lying on her stomach, which she had been forced to do at the time of the trauma; being pushed from behind, which had happened at the time of the trauma; activities which made her short of breath, such as running upstairs or up a hill, since the perpetrator had forced her face down from behind and she had found it difficult to breathe; and sex scenes in television programs and films. The therapist helped Lara discriminate between the triggers today and the trauma in the past, focusing on their differences (stimulus discrimination). In-session work included running up and down stairs whilst focusing on where she was now, how it was different to the time of the trauma, and how her breathlessness signified fitness rather than danger; looking at romantic scenes in everyday television programs and focusing on how the characters were consenting to be close; going out of the office with the therapist with the therapist gently bumping into her from behind; as well as seeking out men who looked similar to the perpetrator and focusing on how these people today were different from the trauma, which helped to discriminate between the triggers today and the past trauma. In Session 8, the therapist guided Lara to revisit the block of flats where she was raped on Google Street View to practice discriminating between then and now. This helped Lara to discover experientially that the trauma was in the past and that the site looked different now. There was nothing visibly dangerous in the Google Street View image of the block of flats, which were captured in daylight in the summer, and the flat doors had been painted blue, which was different to residents’ black doors at the time of the trauma. Work on Maintaining Behaviors and Cognitive Strategies Suppression. The therapist addressed Lara’s maintaining strategies as early as Session 1, beginning with suppression in response to intrusive images and memories. The therapist asked Lara to think about anything she wanted to for 60 seconds except a bunny rabbit with a green bow and floppy ears (thought suppression experiment). Lara discovered that suppressing the rabbit only made it come to mind more often, and that the same was most likely true for the memories she was trying to suppress, which helped her to experiment with dropping suppression as a strategy. Rumination. To address Lara’s rumination and self-criticism, the therapist elicited recent examples when she had ruminated and criticized herself. The memory of her daughter’s terrified face triggered memories of the rape, which then led to memories of herself as a prostitute and triggered episodes of rumination. When the memory came to mind, Lara would question why she was a disgusting, bad

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mother who had made selfish choices. She criticized herself for taking up heroin again after she had made it through the pregnancy without it and criticized herself for failing to give Anna a safe environment during her toddler years. The therapist set up a behavioral experiment to test the effect of ruminative thinking versus concrete thinking on her mood. Lara discovered that thinking in a ruminative way made her feel low and led to no plan or action. She spotted that her triggers for rumination were seeing photos of her daughter when she was very young, which triggered the memory of her rape and her prostitution, and lying in bed at night. With the help of her therapist, she learned to spot when she was ruminating and to use the awareness as a cue to break the cycle. She would remind herself of new information with updating imagery and become active when possible with yoga stretches that required her to balance her weight, thus absorbing her full attention. She also spotted her self-critical thoughts and in response, she read the flashcard on her phone, which captured her daughter’s pride and gratitude. She then practiced self-compassion, speaking to herself with the same kindness that she would extend to a friend in similar circumstances. Safety behaviors and hypervigilance. Lara’s safety behaviors, hypervigilance, and avoidance were addressed by considering the hypothesis that her trauma memories made her feel like her daughter was in danger. She experimented with reducing her checking with a series of behavioral experiments incorporating stimulus discrimination in session and for homework. She learned that her daughter’s safety was unrelated to her telephone calls or the trauma, and that focusing on the differences between her life at university and the trauma helped to reduce Lara’s anxiety about her safety. She experimented with reviewing news reports of crime one day and not the next, discovering that checking the reports made her feel more rather than less anxious, which helped her to stop checking altogether. She continued to double lock her doors at home, but she stopped checking whether or not they were locked since she learned that checking kept her mind focused on danger, which made her more anxious. Lara practiced focusing on the here and now and looking at a recent photo of her daughter, reminding herself that they were safe and the trauma was in the past when a nightmare woke her. She then experimented with returning to sleep and discovered that she was able to sleep, that she did not reenter the nightmare, and that overall, she felt less irritable and better able to concentrate the next day. As the trauma memory was updated, the nightmares reduced in frequency. Social withdrawal. Reviewing the responses people gave on her surveys gave Lara the confidence to enroll in a yoga instructor course. She experimented with asking questions on the course, focusing her attention on how people responded to her rather than on how she was feeling. The experiments helped Lara to see that people responded to her in a kind and friendly manner, and that no one judged her now or in the past, which made her feel much more comfortable in social situations.



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Outcome At the end of treatment, Lara no longer suffered from PTSD, social anxiety disorder, dysthymia, or generalized anxiety disorder. She occasionally felt sad when she thought about her daughter’s early life. However, reminding herself of her daughter’s achievements and that her early life was a short period during which Lara met her basic needs with unconditional love helped her to feel more compassionate toward herself. One year after treatment ended, Lara had successfully completed an advanced yoga instructor training course. She now runs yoga retreats in Spain and Morocco.

EFFICACY AND EFFECTIVENESS OF CBT FOR PTSD Degree of Change With Treatment There is good evidence from randomized controlled trials (RCTs) that individual CBT is efficacious in reducing the severity of PTSD symptoms, with large effect sizes. For example, a meta-analysis by Watts et al. (2013) reported a large controlled effect size of g = 1.26 (g = 1 is equivalent to a symptom change of 1 standard deviation) for pre- to posttreatment changes with CBT across 54 trials with 2585 clients. Analyses of subsets of CBT programs showed mean effect sizes of 1.63 for programs primarily focusing on cognitive interventions, 1.08 for those using primarily exposure, and 1.36 for those using both exposure and cognitive interventions. EMDR (Shapiro, 1989) also showed a large effect size of g = 1.01. EMDR has overlapping elements with TF-CBT in that it includes series of brief 30 sec exposures to images of the trauma while clients focus on an external stimulus, typically therapist-directed lateral eye movement, and identifies alternative positive beliefs to replace negative beliefs. Comparison of Outcomes for Different Treatments According to meta-analyses, trauma-focused treatments are more efficacious than other psychological treatments such as stress management, supportive therapy, or hypnotherapy (e.g., Cloitre, 2009; Tran & Gregor, 2016; Watts et al., 2013). NICE (2018) found a substantially better outcome (effect size SMS = 1.64 for self-reported PTSD symptoms and 1.35 for blind assessments) for TF-CBT programs compared with wait lists. Across trials of clients with single event and multiple traumas, 60% of clients no longer had PTSD at the end of TF-CBT. Non-trauma-focused CBT also led to greater changes in PTSD symptoms than wait lists, but with smaller effect sizes than TF-CBT (SMS = 0.93 for self-reported PTSD symptoms and 0.59 for blind assessments). TF-CBT was superior to supportive counseling (SMS = 0.58 for self-reported PTSD symptoms and 1.04 for blind assessments) and present-centered therapy, which focuses on the client’s current problems rather than the trauma (SMS = 1.29 for self-reported PTSD symptoms and 0.65 for blind assessments).

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Long-Term Outcomes Studies of the long-term effects of TF-CBT programs have also shown encouraging results. A meta-analysis of 32 studies with 72 treatment conditions by Kline et al. (2018) suggested that all active treatments showed long-term efficacy and advantage over control conditions, which were maintained throughout follow-up. Nevertheless, more data on long-term outcomes are needed (Bisson et al., 2013). Treatment Acceptability In addition to the efficacy, the acceptability of treatments is an important clinical criterion in the evaluation of treatments. Overall, trauma-focused treatments are associated with somewhat greater dropout rates than non-traumafocused treatments. Compared with the mean dropout rate of 13% for all psychological treatments, TF-CBT programs showed mean dropout rates of 23% in RCTs (Bisson et al., 2013). While dropouts cannot be unambiguously interpreted as a sign of poor treatment response, data suggest that dropouts have poorer outcomes than completers (e.g., Ehlers et al., 2013). Thus, while TF-CBT programs were highly efficacious, a significant proportion of clients did not complete the treatment protocol and are thus likely not to have received the full benefits. These data suggest that client engagement needs careful attention in TF-CBT. However, there is heterogeneity in dropout rates across TF-CBT studies, which may be a function of client group, therapist experience with the treatment model, and/or treatment protocol. For example, Schnurr et al. (2007) observed a greater dropout rate of 38% for PE in an RCT of women veterans or active duty staff than most other RCTs of PE, and the authors point out that the chronicity of the sample, broad inclusion criteria, and use of nonexpert therapists may have contributed to greater dropout rates and smaller within-group improvements. CT-PTSD has been shown to have a very low dropout rate (3% on average) in several RCTs in adults (Ehlers et al., 2003, 2005, 2014; Ehlers, Wild, et al., 2020) and children (Meiser-Stedman et al., 2017; Smith et al., 2007). Three effectiveness studies (Duffy et al., 2007; Ehlers et al., 2013; Ehlers, Grey, et al., 2020) in routine clinical services showed higher dropout rates (around 15%) than the RCTs of CT-PTSD, but rates were still below the average for RCTs of TF-CBT of 23% (Bisson et al., 2013). In women who had been sexually abused during childhood, Cloitre et al. (2010) found that training in affect regulation and interpersonal skills decreased dropout rates in PE compared with supportive counseling followed by PE (15% versus 33%). However, there was no comparison group that started PE immediately. Treatment Guidelines On the basis of these results, international treatment guidelines recommend trauma-focused treatments as first-line psychological treatments for PTSD (e.g.,



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American Psychological Association, 2017; Australian Centre for Posttraumatic Mental Health, 2007; International Society for Traumatic Stress Studies, 2019; NICE, 2018; Stein et al., 2009; U.S. Department of Veterans Affairs & Department of Defense, 2017). Some of the recent guidelines recommend non-traumafocused CBT programs (such as present-centered therapy or stress inoculation training) or pharmacotherapy as second-line treatments (International Society for Traumatic Stress Studies, 2019; NICE, 2018; U.S. Department of Veterans Affairs & Department of Defense, 2017).

Effectiveness Studies Stewart and Chambless (2009) reviewed effectiveness studies of anxiety disorders in clinical practice, including six studies of PTSD, and found that the outcomes in clinical settings were in the same range as those in efficacy RCTs. There was a small inverse relationship between clinical representativeness of the samples and outcome (i.e., there was some loss in effectiveness in clinically representative samples). Some RCTs were conducted in clinical settings and found comparable outcomes to RCTs in academic settings (e.g., Foa et al., 2005, PE; Neuner et al., 2008, NET). Similarly, outreach programs after the Omagh and London bombings (Brewin et al., 2010; Gillespie et al., 2002) found similarly large effects for CT-PTSD on PTSD symptoms as those observed in RCTs (intent-to-treat pre-posttreatment effect sizes of around 2.5; Ehlers et al., 2003, 2005, 2014; Ehlers, Wild, et al., 2020; Meiser-Stedman et al., 2017; Smith et al., 2007) with over 70% of the clients remitting from PTSD. Three further effectiveness studies (Duffy et al., 2007; Ehlers et al., 2013; Ehlers, Grey, et al., 2020) implemented CT-PTSD in routine clinical services. The samples treated in these studies included a wide range of clients including those with complicating factors such as severe social problems, ongoing objective danger, very severe depression, borderline personality disorder, or multiple traumatic events and losses. Therapists included trainees and experienced therapists. Outcomes remained very good, with large intent-to-treat effect sizes of 1.25 and above. Around 60% of the clients who started therapy remitted from PTSD. These results, and those of Schnurr et al. (2007) and Steenkamp et al. (2015) for PE and CPT, are in line with Stewart and Chambless’s conclusion that there is some loss of effectiveness in clinically representative samples compared with RCTs. The reasons remain unclear and require further investigation. They could include client factors (e.g., chronicity, comorbidity, attitude to treatment), therapist factors (e.g., experience with PTSD treatment, commitment to trauma-focus of the intervention), quality of treatment delivery, social factors (e.g., financial problems, stability of living situation, ongoing threat), and organizational factors (e.g., limits to number or length of sessions in the service). It is noteworthy that the clients in the effectiveness studies did not receive more sessions on average despite the complexity of their problems. There was also evidence that the treatment for clients with multiple traumas and social problems was less trauma-focused than for other clients in the same cohort (Ehlers

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et al., 2013). Thus, the dose of trauma-focused work they received may have been less than ideal. Does TF-CBT Make Some Clients Worse? Clinicians are sometimes concerned that focusing on trauma memories in TF-CBT may risk making their clients worse. However, the empirical data suggest that TF-CBT is safe. The percentage of clients whose symptoms worsened with TF-PTSD in RCTs was close to zero, and smaller than in clients waiting for treatment (Ehlers et al., 2014; Jayawickreme et al., 2014). Similarly, studies of clients treated in routine clinical care also showed that hardly any clients experienced a mild degree of symptom worsening over a course of TF-CBT (e.g., 1.2% in Ehlers et al., 2013), and it remains unclear whether this was due to treatment or new life events/stressors. Different Modes of Treatment Delivery TF-CBT is usually delivered once or twice a week, but other delivery formats have also been found to be efficacious. For example, CT-PTSD has been successfully used in an intensive format, where therapy is delivered daily over the course of 5 to 7 working days (Ehlers et al., 2014; Murray et al., 2017), and in a briefer self-study assisted16 format (Ehlers, Wild, et al., 2020). PE has also been found to be efficacious in an intensive format (Foa et al., 2018, Hendriks et al., 2018). Web-based interventions (e.g., Knaevelsrud & Maercker, 2007; Lange et al., 2003; Litz et al., 2007; Wild et al., 2016) have also shown encouraging results. Virtual reality is promising tool for exposure therapy (Rothbaum et al., 2001). Comparisons of CBT With Medication There is evidence that pharmacological treatment with antidepressants, especially SSRIs, has small to moderate effects in PTSD. For example, the meta-analysis by Watts et al. (2013) reports a controlled effect size of g = 0.48 for SSRIs, and that by NICE (2018) reports placebo-controlled effect sizes of SMS= 0.26 for self-reported PTSD symptoms, and 0.28 for blind assessments. The improvement observed with TF-CBT is greater than that observed with medication, and the combination of TF-CBT with medication yields better outcomes than medication alone (e.g., NICE, 2018). However, there is no evidence that the combination of TF-CBT with medication leads to better outcomes in PTSD than TF-CBT alone (e.g., Hetrick et al., 2010; Rauch et al., 2019). Zoellner et al.’s (2019) RCT found that PE was superior to sertraline on most outcome measures. In addition, client preference was an important factor in treatment outcomes in that participants who were assigned to their treatment of choice had better compliance and better outcomes. The self-study modules will be made available at https://oxcadatresources.com.

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MECHANISMS OF CHANGE Excessively negative appraisals about what the trauma and its aftermath mean about the self or other people are addressed directly or indirectly in most forms of TF-CBT. A review of 65 treatment studies (Brown et al., 2018) found that psychological treatments lead to changes in both PTSD symptoms and negative posttrauma appraisals, and that the degree of change in symptoms and appraisals is correlated. They identified 15 studies that investigated whether cognitive change during treatment drives symptom change, or vice versa. Eleven of these studies supported cognitive mediation of symptom change, in that change in negative posttrauma appraisals predicted subsequent change in PTSD symptoms, but not vice versa. For example, Kleim et al. (2013) used bivariate growth curve modeling of session-to-session measures of unhelpful appraisals (as measured by a short version of the PTCI; Foa et al., 1999) and PTSD symptoms in a sample of 268 clients treated with CT-PTSD. In line with cognitive theories, decreases in the PTCI predicted subsequent symptom change in the following session, whereas there was no significant effect of symptom improvement on subsequent change in appraisals. One study reviewed by Brown et al. (2018) showed the opposite pattern of prediction (reverse mediation), and three studies supported both mediation and reverse mediation. Thus, change in problematic posttrauma appraisals appears to be a mechanism common to effective trauma-focused psychological treatments. Wiedemann et al. (2020) replicated Kleim et al.’s (2013) results in a second consecutive cohort of clients treated with CT-PTSD and also investigated whether the results extend to the other factors proposed in Ehlers and Clark’s (2000) model: qualities of memories and maintaining behaviors such as safety behaviors, rumination, numbing and thought suppression. The results also supported these factors as mediators of symptom change.

APPLICATIONS TO DIVERSE POPULATIONS TF-CBT has been shown to be effective in the treatment of PTSD following a wide range of traumas. There has been debate about whether people who suffered prolonged or multiple traumas or those whose traumas happened in childhood need different interventions than those with PTSD following discrete events in adulthood. However, a meta-analysis of RCTs (Ehring et al., 2014) showed the same pattern of results for adult survivors of childhood abuse with PTSD as other meta-analyses of PTSD treatments: trauma-focused psychological treatments were more efficacious than non-trauma-focused treatments. TF-CBT programs led to large improvements in PTSD symptoms (Hedges’s g = 1.34). Similarly, several RCTs showed large effect sizes for outcomes for refugees who had experienced multiple traumatic events (e.g., Neuner et al., 2008). A meta-analysis (Thompson et al., 2018) supported the use of individual traumafocused psychological interventions such as NET and EMDR in this population, with a mean effect size of SMD = 1.14 compared with inactive controls.

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There is, however, evidence to suggest that veterans or military populations may benefit less from psychological and pharmacological treatment for PTSD than civilians (Watts et al., 2013; Steenkamp et al., 2015). A meta-analysis of RCTs by Steenkamp et al. (2015) reported that while the first-line psychological treatments CPT and PE led to moderate-to-large improvements in PTSD symptoms (d = 0.78–1.10) in this population, only 28 to 40% recovered from PTSD. The benefits of these treatments compared with non-trauma-focused treatments such as present-centered therapy were also less pronounced than in studies with civilians (see also Foa et al., 2018; Schnurr et al., 2007). TF-CBT programs have been successfully adapted for children and adolescents (e.g., Cohen et al., 2018; Foa et al., 2008; Smith et al., 2009). One of the common adaptations concerns the education of parents about the child’s PTSD and how they can support their child through treatment. A meta-analysis by Gutermann et al. (2016) concluded that there is good evidence that a range of TF-CBT programs, especially when conducted in individual treatment with the inclusion of parents, are highly effective for trauma symptoms (see also Gillies et al., 2012; NICE, 2018). Long-term follow-ups indicated the maintenance of treatment effects (Gutermann et al., 2017). When treating clients from a different cultural background to that of the therapist, therapists need to be aware of culture-specific beliefs and may need to adapt some of the treatment procedures accordingly. For example, Schnyder et al. (2016) discuss that survivors may be exposed to (self-)stigma in the aftermath of trauma as result of culture-specific meanings linked to trauma and trauma-related disorders. This may make them reluctant to talk about their traumatic experiences. In treatment, they may instead be willing to write or use other ways of accessing the painful memories such as drawing. Community and family cohesion are especially important for recovery in some cultures. The authors point out that while awareness of culture-specific aspects is important, premature cultural stereotyping is unhelpful, and the general principles of TF-CBT are applicable across cultures.

DISSEMINATION TF-CBT programs have been successfully disseminated into clinical services and to other countries. PE is the most widely disseminated TF-CBT program to date (Foa et al., 2013). However, dissemination programs of TF-CBT have difficulties and obstacles to overcome, and some decreases in overall effectiveness have been observed under some conditions. In an early attempt to disseminate TF-CBT, Clark and colleagues trained local clinicians who did not have experience with treating PTSD in CT-PTSD after the Omagh bomb in Northern Ireland, using a workshop followed by subsequent case supervision. This training enabled the clinicians to achieve similarly good outcomes with their clients as those observed in RCTs of CT-PTSD (Gillespie et al., 2002). Similarly, Foa et al. (2005) successfully trained community therapists working at a rape crisis center in PE through workshops and



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weekly supervision and found that the community therapists achieved the same outcomes with PE as therapists from Foa’s academic center. These studies show that it is possible to train therapists who are inexperienced with PTSD and TF-CBT programs through workshops and case supervision. Weekly measures of PTSD symptoms were important in the training effort, as they are not only helpful in monitoring the effects of the intervention, but also in convincing clinicians who were skeptical about a trauma-focused approach of its benefits in leading to fast improvement (Clark, 2018; Foa et al., 2013). Foa et al. (2013) discussed the successes and challenges encountered in the dissemination of PE, including the adaptations to other cultures. They highlight the importance of the quality of training (which requires case supervision of at least a few training cases besides a manual and workshop), high-level organizational support, and an appropriate infrastructure for the maintenance of dissemination efforts. In the United States, both PE and CPT have been disseminated into the Veterans Administration health care system through a large training initiative (Karlin et al., 2010). The National Child Traumatic Stress Network (https://www.nctsn.org) aims to make Cohen et al.’s (2018) TF-CBT program more available for young people with PTSD. NET has been successfully disseminated in Uganda through the training of lay counselors (Ertl et al., 2011; Neuner et al., 2008). In the English National Health Service, TF-CBT has been disseminated into the Improving Access to Psychological Therapies (IAPT) program. This program aims to implement empirically supported psychological treatments for depression and anxiety disorders including PTSD. It established a new work force by training over 10,500 new psychological therapists and deploying them in new services. IAPT treats over 560,000 clients per year, obtaining clinical outcome data on 98.5% of these individuals, and places this information in the public domain. Around 50% of clients treated in IAPT services recover, and two-thirds show clinically worthwhile benefits (Clark, 2018). Schnyder et al. (2016) and Foa et al. (2013) pointed out that when disseminating empirically supported psychotherapies for PTSD across cultures, limited resources and a poor health infrastructure in many low and middle income countries pose a challenge. Possible solutions include training lay therapists from the community (e.g., Neuner et al., 2008) and web-based interventions or telemedicine (e.g., Knaevelsrud & Maercker, 2007; Lange et al., 2003; Litz et al., 2007; Wild et al., 2016). Therapists attitudes such as skepticism toward evidence-based interventions and overestimation of the risks of exposure to trauma memories can also impede the implementation of TF-CBT (Foa et al., 2013; Schumacher et al., 2018).

CONCLUSIONS AND FUTURE DIRECTIONS Knowledge about the best ways to treat PTSD has rapidly accumulated over the last decades, and a range of TF-CBT programs have been shown to be

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efficacious and effective and are now recommended as first-line treatments in international treatment guidelines. The majority of clients treated with TF-CBT programs achieve clinically significant benefits that do not only include a very large reduction in PTSD symptoms, but also improvement in comorbidity, everyday functioning, and quality of life. Nevertheless, it remains an important challenge for future studies to determine why some clients or groups of clients achieve little or smaller benefits, and why there is a certain loss of treatment effects in effectiveness studies. Studies of mediators and moderators of treatment effects are likely to help with further development of treatment strategies and techniques for those who achieve suboptimal outcomes, and they may help develop criteria for individual decision making on which treatment to offer. There are aspects of treatment delivery that require further research. For example, the recent revision of the International Classification of Diseases (ICD-11; World Health Organization, 2018) distinguishes between PTSD and complex PTSD. While the treatment programs reviewed in this chapter were designed for a wide range of presentations, including those that meet the ICD-11 complex PTSD criteria, further investigation is needed to determine whether additional treatment techniques are helpful and if phased interventions have benefits or disadvantages. NICE (2018) also recommends studies of stepped care and sequencing of treatment. Access to TF-CBT in the community is still limited due to the high prevalence of PTSD and a lack of trained therapists. The dissemination of these effective treatments therefore remains a challenge, and the best way to train large numbers of therapists in delivering one of the effective TF-CBT programs needs to be studied further. The current evidence shows that a combination of workshops, treatment manuals, and case supervision are required to train therapists to a sufficient standard of competence. It is likely that online training materials will increasingly play an important role in dissemination efforts. Similarly, technological tools such as online therapy or virtual reality have shown promising initial results and have the potential to greatly improve access to treatment such that systematic evaluations are warranted.

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5 Eating Disorders Madelyn Ruggieri, Courtney McCuen-Wurst, and Kelly C. Allison

C

ognitive behavioral therapy (CBT), as applied to eating disorders, is based on Beck et al.’s (1979) conceptualization of CBT as “an active, directive, time limited, structured approach used to treat a variety of psychiatric disorders” (p. 3). Just a couple of years later, Fairburn (1981) adapted the approach for the treatment of bulimia nervosa (BN), and later for binge-eating disorder (BED; Fairburn et al., 1993). The core of this treatment has endured as the front-line approach for BN and BED. Arguably, anorexia nervosa (AN) has been the subject of more popular interest than BN and BED, and the focus of its treatment was originally psychodynamic (Bruch, 1970). CBT is also now a recommended treatment for AN in adults, but the evidence for its efficacy for this disorder, as we review later in the chapter, is inconsistent.1 BN is characterized by repeated episodes of consuming objectively large amounts of food within a limited time frame paired with feeling a loss of control. Additionally, the use of compensatory behaviors intended to prevent weight gain, such as laxative use, self-induced vomiting, and compulsive exercise are employed (Lampard & Sharbanee, 2015). BN was first clinically described as we currently recognize it in 1979 by British psychiatrist Gerald Russell. Dr. Russell was treating patients with AN when he began seeing patients with “powerful and irresistible urges to overeat” in addition to an extreme fear of becoming fat (Castillo & Weiselberg, 2017, p. 85). Dr. Russell categorized these particular patients as being in a “chronic phase of anorexia nervosa” with a poorer prognosis, more resistance to treatment, and dangerous Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-005 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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physical comorbidities (Castillo & Weiselberg, 2017, p. 85). Dr. Russell later retracted this statement, stating that individuals diagnosed with BN had a more favorable prognosis compared with individuals with AN. He also recognized BN and AN as separate eating disorders (Castillo & Weiselberg, 2017). The lifetime prevalence of BN is 0.28%, with an estimate of 0.5% in women and 0.15% in men, using the DSM-5 criteria among a nationally representative sample in the United States (Udo & Grilo, 2018). By comparison, the lifetime prevalence of AN is 0.8% overall, with 1.4% among women and 0.1% among men (Udo & Grilo, 2018). Purging disorder is similar to BN, except that the meals prompting the inappropriate compensatory behaviors are not “objectively large.” Instead, persons with purging disorder vomit, use laxatives, or use diuretics after eating a meal or a snack (Keel, 2007). These behaviors are still quite serious, even without including the objectively large amount of food in the criterion. The prevalence of purging disorder is estimated between 1.1% to 5.3% among women, with no estimates among men (Keel, 2007). Development of treatments are still underway for purging disorder, so the same CBT approach for BN that is discussed below is typically applied. BED is also characterized by recurrent episodes of consuming an objectively large amount of food in a short period of time paired with a feeling of loss of control. During binge episodes of overeating, individuals often eat much more rapidly than normal, eat until uncomfortably full, consume a large amount of food even when not physically hungry, eat alone due to embarrassment related to the amount of food consumed, and feel disgusted, depressed, or guilty after these episodes. However, unlike those with BN, those with BED do not use compensatory behaviors (American Psychiatric Association [APA], 2013). BED was first identified by Dr. Albert Stunkard (1959), who later worked with others to establish the first diagnostic criteria for the disorder (Spitzer et al., 1993). Although the disorder was previously identified as an “Eating Disorder Not Otherwise Specified,” it was characterized as its own disorder in the DSM-5 in 2013 (APA, 2013). AN is characterized by extreme food restriction that leads to a significantly low body weight. Typically, persons with AN develop very strict rules about what, when, and how much of any specific food they allow themselves to consume. There is no specific diagnostic cutoff for body mass index (BMI) or percent of expected weight in the DSM-5 criteria, but mild AN would be specified by a BMI of 17.00 kg/m2 or higher, moderate would be 16.00–16.99 kg/m2, severe would be 15.00–15.99 kg/m2, and extreme would be a BMI below 15 kg/m2 (APA, 2013). For an individual who is 5 ft 5 in., this would translate into weights of ≥ 103 lb for mild, between 96 and 102 lb for moderate, between 90 and 95 lb for severe, and ≤ 89 lb for extreme. Individuals with AN have a strong fear of weight gain or becoming fat. They also place a very high value on their shape and weight for self-evaluation, accompanied by very little insight into their actual shape and size and the seriousness of their low weight as it relates to their medical, psychological, and social well-being. There is a restrict-



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ing type and a binge-purge type, where persons restrict most of the time but also have periodic binge-purge episodes. If all the criteria for AN are met, a diagnosis of AN will override a diagnosis of BN, BED, or purging disorder. Night-eating syndrome (NES) consists of a delayed pattern of eating, such that individuals consume at least 25% of their intake after the evening meal, and/or they wake during the night to eat at least twice per week (Allison, Lundgren, O’Reardon, et al., 2010). Persons with NES are aware of their nighttime eating; if they are sleepwalking and eating or have very limited awareness, it would be considered sleep-related eating disorder (SRED), which is a parasomnia (American Academy of Sleep Medicine, 2014). The diagnostic criteria indicate three of the following features should also be present: (a) lack of appetite in the morning/skipping breakfast more than half the time; (b) a strong desire to eat between dinner and bedtime; (c) initial onset or middle insomnia at least half the time; (d) the belief that one must eat to fall (back) asleep; and (e) low mood or worsening mood as the day progresses. Distress regarding this behavior should also be present. Although NES can be diagnosed comorbidly with the other eating disorders, careful consideration of other primary causes should be determined, such as medications (i.e., sleep agents such as zolpidem) or other causes of insomnia. Prevalence of NES is estimated at 4.6% in men and 3.4% in women among participants in the Swedish Twin Registry (Tholin et al., 2009), and 3.8% of men and 4.3% of women among a U.S. university sample (Runfola et al., 2014).

BULIMIA NERVOSA Underlying Theory We start with BN because its treatment serves as the foundation of CBT for all of the eating disorders. The cognitive behavioral theory posits that the core psychopathology of BN is related to overvaluation of shape and weight, or judging one’s self-worth mostly by weight and body shape, thus ignoring perceived performance in other domains of life (Cooper & Fairburn, 2011; DuBois et al., 2017). In turn, overvaluation of shape and weight can result in dietary restraint and restriction, body checking, and preoccupation with thoughts about shape and weight (Cooper & Fairburn, 2011). Individuals with BN tend to marginalize other areas of their lives due to this focus, which becomes a losing proposition given that controlling one’s weight and shape completely is difficult, if not impossible, thus maintaining low self-esteem. This overly dependent self-evaluation based on shape and weight leads to the behaviors that characterize BN (Murphy et al., 2010). One aspect of BN that is not directly related to overvaluation of shape and weight is binge eating. The cognitive behavioral theory posits that binge eating occurs in response to attempts to adhere to extreme dietary rules. Breaking these rules strengthens patients’ beliefs that they lack self-control, which maintains the core features of the psychopathology (Fairburn et al., 2008; Murphy et al., 2010). Binge episodes often occur in response to negative mood states

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and act as a temporary mood neutralizer. This response can result in habitual binge-eating when negative mood states are present (Fairburn, 2002). BN often goes unnoticed, as individuals with the disorder are at or above the normal weight range. In addition, those with the disorder often do not have medical complaints that would warrant visiting a physician (Castillo & Weiselberg, 2017). When individuals do seek treatment for the disorder, the literature shows that the treatment of choice for BN is CBT (Cooper & Fairburn, 2011). CBT-BN is utilized with individuals who can be treated on an outpatient basis. Treatment typically lasts up to 20 sessions, with maintenance or booster sessions following less frequently, as needed. With some individuals, progress is limited by maintenance factors associated with the core psychopathology of BN, including clinical perfectionism and low self-esteem (Fairburn, 2002), which are discussed below. Main Procedures Treatment is relatively short term (about 20 sessions delivered over 16 weeks on average, with some variability) and is based on a structured manual to be led by a trained clinician. Treatment can be divided into several stages, as described by Fairburn et al. (2008). Stage one involves establishing a therapeutic relationship, as well as the introduction of self-monitoring. Detailed logs of all food and beverages consumed, accompanied by associated thoughts and feelings are established in this first stage. Psychoeducation on the ill effects of rigid dieting and purging behaviors is provided, and implementation of a more regular eating pattern and healthy food choices are also introduced. Ideas about healthy shape and weight are discussed, and weekly weighing is established. The first several sessions are delivered twice per week to establish momentum. Stage two aims to help individuals deal with the dysfunctional thoughts and triggers that drive their dieting behaviors, such as rigid rules around food that lead to binge eating. The cognitions typically addressed are targeted to (a) create insight into the impact of overvaluation of weight and shape and its consequences, (b) develop other aspects central to one’s self-concept, (c) challenge body-checking and feelings of “fatness,” (d) examine etiological factors for overvaluation, and (e) develop skills to address eating disordered attitudes and thoughts. During stage three, progress is reviewed, and realistic planning for the future is discussed (Fairburn, 1995). These final sessions may be delivered every other week. More recently, an updated form of CBT has been developed called enhanced CBT (CBT-E). CBT-E was developed in response to the finding that many eating disorders have similar core psychopathology (Fairburn et al., 2003), and thus a more inclusive treatment was developed to treat all eating disorders using a “transdiagnostic approach” (Fairburn et al., 2008). The CBT-E model suggests that the core psychopathology of BN may be maintained by (a) mood intolerance, (b) clinical perfectionism, (c) low self-esteem, and/or (d) interpersonal problems. In the first model, the impulse to binge and purge is due to mood



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intolerance; binge eating and purging functions to regulate emotions. Clinical perfectionism refers to striving toward extremely high standards in every domain of one’s life. The term “clinical” refers to perfectionism becoming problematic when attempts to pursue these high standards continue despite negative consequences. Perfectionistic standards with regard to weight and shape would then lead to disordered eating. Core low self-esteem refers to an insidious negative view of self-worth. In the CBT-E model of treatment for BN, core low self-esteem differs from low self-esteem in that it is unconditional, which is more pervasive as opposed to being situational or limited in scope. Individuals with BN characterized by core low self-esteem are not affected by changes or improvements in the state of the disorder, as they believe these eating patterns are part of their identity (Cooper & Fairburn, 2011). In other words, core low self-esteem contributes to hopelessness about one’s ability to change, which may negatively affect treatment. Interpersonal problems contribute to core low self-esteem while creating negative mood states, leading to binge eating and purging behaviors (Lampard & Sharbanee, 2015). Cooper and Fairburn (2010) stated that most patients will benefit from the original CBT for BN approach, but for those presenting with more complex pathology, initiating the broadened treatment is useful. Efficacy Research on the effects of CBT-BN indicates that half the patients make a full and lasting recovery, with the most significant effect being the reduction of the frequency of binge episodes and compensatory behaviors (Fairburn, 2002; Fairburn et al., 2008). In a systematic, quantitative review of psychotherapy for BN, Hay et al. (2009) identified CBT as significantly superior to no treatment or wait-list control for the proportion of patients in remission from binge eating, RR = 0.69, 95% CI [0.61, 0.79]. When compared with other psychotherapies, including hypnotherapy and psychoanalytic or psychodynamic therapy, CBT has been shown to be more efficacious in the treatment of BN symptoms, RR  =  0.83, 95% CI [0.71, 0.97]. CBT was also superior to no treatment or wait-list control in reducing depressive symptoms, SMD = –0.69, 95% CI [–1.09, 0.30], whereas it was favored, but not statistically significant, over the previously listed psychotherapies in reducing depressive symptoms, SMD = –0.28, 95% CI [–0.57, 0.00]. CBT-E therapy is considered “enhanced” because, as mentioned above, it incorporates strategies to improve outcomes associated with hindrances to change, including mood intolerance, clinical perfectionism, low self-esteem and interpersonal problems, in addition to focusing on overvaluation of shape and weight (Murphy et al., 2010). In a trial conducted by Fairburn et al. (2009), 154 participants were enrolled in a two-site randomized controlled trial (RCT) involving 20 weeks of treatment and a 60-week follow-up period. The two forms of treatment were enhanced, with the “focused” approach targeting disordered eating psychopathology exclusively, and the “broad” version targeting

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one or more of the associated problems, in addition to the core psychopathology. Participants in the control condition had an 8-week waiting period prior to treatment. Results were based on global EDE change and showed that patients in the wait-list control group demonstrated little change in symptom severity (–0.09), whereas those in the active conditions (focused and broad) displayed significant and equal change in symptom severity (–1.51 vs. –1.53, respectively); this change was maintained during follow-up. One form of therapy that has been used as a comparator for CBT is interpersonal psychotherapy (IPT). IPT is an evidence-based psychotherapy for disorders in which interpersonal difficulties are maintaining factors. With regard to eating disorders, patients can become more isolated from their peers due to their eating disordered attitudes and behaviors, resulting in psychopathology that persists because it goes unnoticed. In addition, interpersonal problems can exacerbate or cause low self-esteem, which tends to increase efforts to control shape and weight (Murphy et al., 2012). IPT can be used as an alternative to CBT-BN, but treatment often lasts longer (approximately 8–12 months longer), and treatment responses tend to be slower in the beginning, but similar over longer follow-up periods (Fairburn et al., 2008). In a study conducted by Agras et al. (2000), 220 patients meeting criteria for BN were randomized to 19 sessions of either CBT or IPT and evaluated for 1 year after treatment. Results indicated that CBT was significantly superior to IPT at treatment end for the proportion of individuals recovered (29% vs. 6%) and remitted (48% vs. 28%). For treatment completers, the proportion recovered was 45% in CBT versus 8% in IPT. However, at the 1-year followup, there were no significant differences between the CBT and IPT treatment completers. Special Considerations With This Population CBT-BN has been tested in adolescents and adults. There do not seem to be any contraindications for its use based on gender or race/ethnicity. As noted above, if certain core psychopathologies are present, the broad version of CBT-E should be employed (NICE, 2017). Mechanisms of Change In the original CBT-BN model, changes in overvaluation of shape and weight and dietary restraint are the two most important mechanisms of change (Lampard & Sharbanee, 2015). Studies have shown that changes in these two factors relate to changes in BN symptoms, such as reductions in binge eating and compensatory behaviors. CBT-E utilizes different modules that are meant to treat different maintaining factors of BN, in addition to treatment of the core psychopathology. For example, the mood intolerance module is intended to lead to changes in mood, which will then lead to reductions in binge eating (Lampard & Sharbanee, 2015). Peterson et al. (2017) showed that improvement in emo-



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tion regulation, or the ability to tolerate momentary negative mood states and self-directed behavior from baseline to midtreatment and to posttreatment follow-up, predicted improvements in global eating disorder scores. Application to Diverse Populations Statistics on the prevalence of eating disorders in minority populations are scarce. This may be due to a historically biased view that only White women suffer from eating disorders or that few studies have been conducted with significant numbers of people from varying racial and ethnic groups and men (Ham et al., 2015). Following completion of diagnostic interviews by a national representative sample of adults in the United States, Udo and Grilo (2018) reported that, on the basis of DSM-5 criteria, the lifetime prevalence for BN was 0.28%. Prevalence of any eating disorder was greater for women than for men after adjusting for various demographic variables including age and race and/or ethnicity. Adjusted odds ratios did not differ significantly by race and/or ethnicity for BN. The same study examined these differences for AN, showing significantly lower adjusted odds ratios for non-Hispanic Black (AOR = 0.48, 95% CI [0.33, 0.72]) and Hispanic (AOR = 0.19, 95% CI [0.11, 0.33]) respondents than for non-Hispanic White respondents. Finally, for BED, Udo and Grilo (2018) reported lower lifetime (AOR = 0.60, 95% CI [0.38, 0.92]), but not 12-month, adjusted odds ratios for non-Hispanic Black compared with non-Hispanic White individuals. Case Example “Erica” reported starting to binge and purge with vomiting during her freshman year of high school. She was attending a high-pressure private school that she found challenging, but she was supported by her family, and she was particularly close with her father. Tragically, her father died in an accident, and she was having trouble coping. She started to eat emotionally, and she started gaining weight. After eating sweets in the evening, she would try to restrict what she ate the next morning, fearing she would continue gaining weight. She was active as a soccer player, and she also enjoyed running in the off season. Over her high school years, her binge-and-purge episodes continued, but she was able to hide them. She presented for treatment her senior year in college, afraid that she would continue this pattern even after she graduated. It had started to sink in that this was not just a temporary fix but a cycle that had taken on a life of its own. Erica described experiencing stress related to her coursework and her relationships with her mother and her peers. By now, her mother knew of Erica’s disordered eating, but she was uncertain how to address it. They bickered over concerns for Erica’s well-being and the financial burden the binge episodes were causing. Erica’s mood was also affected by these binge-purge episodes, which negatively influenced her body image further. This led to trying on

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outfits for up to an hour before going out with friends or avoiding social events altogether. Finally, with school, if she felt overwhelmed by starting a project or studying for an exam, she would be triggered to binge, followed by vomiting. She would then feel ill and end up watching shows or movies in her room by herself, leading to missed deadlines and poor grades. Therapy began with a log of her eating and purging behaviors to identify her pattern of eating and the triggers for her binge episodes. Erica identified several episodes from the previous week. The therapist spent time reviewing a particular episode with her that involved baking brownies for a fundraiser for her club soccer team (see Figure 5.1). She also felt overwhelmed because she had a paper due the next day and did not know where to start. She began eating the brownies and was unable to stop, finishing the whole pan. She felt disgusted and overly full, but she thought it would be okay because she could get rid of the calories and the feeling of being too full if she just vomited. Afterward, she was exhausted and shut herself in her room to watch shows the rest of the night. She felt sad and ashamed the next morning when she had to ask her professor for an extension for her paper. First, psychoeducation was provided regarding the limited effectiveness of purging to compensate for the calories consumed. Next, the therapist used a thought record to help her identify the situation—having a paper due, but not knowing where to begin. Next, she identified her feelings, which included feeling anxious, overwhelmed, and tired, as well as her automatic thoughts. These thoughts included, “I can’t come up with a good idea for how to start my paper. Whatever I write, it won’t be good enough,” and, “The brownies look so good, it will be okay if I just eat one.” After not being able to stop and eating the pan of brownies, she identified these thoughts: “I feel disgusting. If I just throw up, I will feel better and will be able to get on with my night.” After vomiting she FIGURE 5.1. Food Intake and Binge/Compensatory Behavior Log Time Location 12:00 pm

Dining Hall

6:00 pm

Home

8 pm

Home

What did you eat?

Binge? Compensation?

Comments

Salad with chicken, vegetables and oil & vinegar

Egg white (2) omelet with cheese and vegetables Full pan of brownies

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Note. Example from a patient with bulimia nervosa.

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I was stressed about writing a paper and had just made the brownies for my club’s fundraiser. I wanted to just eat one, but I couldn’t stop. I felt so full that I had to make myself vomit. Then I was relieved, but exhausted. I didn’t feel up to doing any schoolwork.



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stated, “I am worn out and can’t concentrate. I don’t feel better and don’t feel up to writing.” The therapist helped Erica identify alternative responses to each thought, also asking her to recognize and tolerate her negative emotions. For example, although she was feeling anxious about writing, her homework for the coming week was to open a document and start typing her ideas out, no matter how tired or overwhelmed she felt. She believed that once she was sitting and writing, she would be able to complete the assignment, so she agreed to this homework task. Erica was also having trouble resisting vomiting after normal meals given the frequency of her episodes. She stated that even any “normal” sized meal made her feel uncomfortable. The therapist used exposure exercises to have her sit after meals and engage in conversation or go somewhere where she was unable to purge to prevent compensation from occurring. Finally, the therapist helped her use these tools to address her body image issues and improve communications with her mother around her eating and weight concerns so that Erica’s need to be secretive about it would lessen and she could start to rebuild her relationship with her mother. A joint session was held to help facilitate communication between Erica and her mother, as well. As sessions progressed, Erica was able to show good understanding and use of the CBT skills, decreasing her binging and purging episodes over time. She was still having periodic episodes in response to stressors or when home alone with access to baked goods or granola bars (two of her most difficult trigger foods), but she was pleased with her progress and felt more confident about graduating and moving into an “adult life” without the burden of BN. She felt more confident in her body as well, as she generally felt more in control and less depressed. She had even begun dating a fellow student as the sessions concluded.

BINGE-EATING DISORDER Underlying Theory Theories of the psychopathology of BED are based on cognitive behavioral theory and the restraint model (Grilo, 2017). According to cognitive behavioral theory, BED, similar to the models for AN and BN, can be characterized by an excessive attention to weight and shape, a desire for control associated with eating behavior, and/or emotional dysregulation (Fairburn, 2017; Haedt-Matt & Keel, 2011; Haedt-Matt et al., 2014; Wilfley et al., 2000). Although overvaluation of weight and shape is not included as a diagnostic criterion for BED, its presence typically indicates a more severe form of the disorder (Mitchison et al., 2018). Additionally, there are particular cognitive and behavioral differences observed in those with BED that are not observed in those with AN nor BN. Wilfley et al. (2000) found that individuals with BED have significantly lower cognitive restraint of eating (i.e. deliberately restricting food in an effort to align with rigid rules regarding eating) scores compared with those with AN and BN. Further, persons with BED are more likely to report eating in secret,

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being unsatisfied with their weight, feeling fat, being unhappy with their shape, and experiencing discomfort with seeing their body compared with individuals with AN, BN, and persons who have overweight or obesity but who have no eating disorder. Compared with those with AN and BN, people with BED do not have a significant desire to have a completely flat stomach and report less distress and less avoidance of eating (Wilfley et al., 2000). Whereas the cognitive behavioral theory of binge eating suggests that thoughts and feelings about body shape and size and other emotional distress become triggers for binge episodes, the restraint theory suggests that dieting increases the likelihood of binge eating. As a result of a calorie deficit, either through dieting or skipping meals, hunger levels increase, leading to a sense of loss of control once eating is allowed. The more frequently this restriction occurs, followed by a binge episode, the more likely it is for a cyclical pattern to develop (Polivy & Herman, 1985). However, not all persons with BED have a history of restriction. Thus, binge eating could also result as a means of controlling or distracting oneself from experiencing emotional dysregulation. Main Procedures CBT for binge eating focuses on the cognitive distortions often exhibited in those with eating disorders (Fairburn, 2017), such as concerns about shape and weight, “all or nothing” thinking, perfectionism, and low self-esteem. Given the influence that weight and shape have on the way individuals with BED view themselves, treatment focuses on improving self-confidence and discovering alternative influences on self-worth other than weight and shape. Treatment also focuses on creating more regular healthy eating habits and identifying and resolving triggers associated with maladaptive eating patterns. CBT for binge eating was adapted from CBT-BN (Fairburn et al., 2008), as described previously. As with any manualized form of treatment, it is important to follow the protocol for optimal effectiveness. A meta-analysis by Vocks et al. (2010) examining various forms of treatment for binge eating found CBT-based psychotherapy and structured self-help to have a strong effect on reduction in binge eating. Evidence suggests that following a structured program may be a useful first-line approach to treating BED, and also that using a self-help approach based on the manual holds promise and may also increase access to CBT care (Grilo, 2017). Special Considerations With This Population A majority of those with BED have other psychiatric and medical comorbidities, independent of weight status (Kessler et al., 2013). There is a strong evidence base of a high comorbidity rate between psychological disorders and BED, with the most common disorders being mood, anxiety, and substance use disorders. Additionally, BED is associated with medical comorbidities, such as dyslipidemia and Type 2 diabetes; however, the evidence is not as consistent for



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medical as for the psychopathology comorbidities (Devlin, 2017). Although comorbidities are important to consider when conceptualizing a clinical case, they do not necessarily have an effect on treatment outcomes (Kessler et al., 2013), as discussed in the section on mechanisms of change. As with the other eating disorders, individuals with BED often have complex presentations, with binge eating representing only one of many health concerns. Efficacy CBT is considered the leading psychological approach to treatment for eating disorders by both the American Psychiatric Association (Yager et al., 2012) and the National Institute for Health and Care Excellence (NICE, 2017), with CBT for BED proven efficacious in eliminating binge episodes in about 60% of those who receive treatment (Fairburn, 2017). In addition, CBT for BED has been shown to reduce eating-disorder-related psychopathology, including depression. CBT for BED has largely been proven superior against controls such as medications and behavioral weight loss in binge eating outcomes. It is important to note that while CBT for BED is efficacious in improving the aforementioned symptoms, it is not particularly helpful for weight loss (Grilo, 2017). A meta-analysis by Vocks et al. (2010) that included 1,973 participants found CBT more efficacious in reducing binge-eating frequency (d = 0.82, 95% CI [0.41, 1.22]) and days with binge eating (d = 1.04, 95% CI [0.70, 1.38]), as well as increasing binge-eating abstinence (d = 6.83, 95% CI [3.50, 13.33]) compared with untreated control groups. CBT also was found to reduce binge-eating-related psychopathology such as depression (d = 0.36, 95% CI [0.08, 0.64]), to a lesser degree, and concerns about weight (d = 0.85, 95% CI [0.43, 1.27]) and eating (d = 1.43, 95% CI [0.84, 2.01]). CBT for BED did not significantly reduce dietary restraint scores, shape concern, or body mass as compared with those without treatment. Vocks et al. (2010) also found that self-help CBT significantly reduced binge frequency (d = 0.84, 95% CI [0.37, 1.30]) and concerns with weight (d = 0.85, 95% CI [0.43, 1.27]) and eating (d = 1.43, 95% CI [0.84, 2.01]), while increasing binge abstinence (d = 25.77, 95% CI [9.74, 68.15]). Additional improvements observed with self-help CBT include decreased dietary restraint scores (d = 0.68, 95% CI [0.09, 1.26]) and concerns associated with shape (d = 0.66, 95% CI [0.25, 1.07]); however, this self-help form of therapy did not significantly reduce depressive symptoms. Brownley et al.’s (2016) systematic review and meta-analysis found therapist-led and structured self-help CBT for BED more efficacious in decreasing binge frequency and increasing binge-eating abstinence compared with wait-list controls (58.8% vs. 11.2%, RR = 4.95, 95% CI [3.06, 8.00]). Therapistled CBT also significantly reduced global eating disordered attitudes and behaviors (strength of evidence, moderate; no relative risk reported), but not depressive symptoms or body mass. Multiple studies have found no to minimal effect of combining medication with CBT compared with CBT alone for the treatment of BED (Devlin et al., 2005).

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Mechanisms of Change Although CBT for BED has been established as one of the leading treatments for binge eating, there is a paucity of literature on mechanisms of change. Grilo et al. (2012) examined moderators and predictors of response to CBT treatment. They found the most predictive and moderating trait of binge eating remission in CBT treatment was the overvaluation of shape/weight, whereby those who had lower scores of overvaluation of shape/weight were more successful at treatment end. Several demographic variables, including education status and older age of onset of the disorder, were associated with higher rates of binge remission. However, Grilo et al. (2012) found that psychiatric disorders, personality disorders, and obesity failed to predict or moderate BED treatment outcomes. Medical comorbidities, which are also often found among those with BED, have not been examined as predictors of treatment efficacy. A systematic review by Vall and Wade (2015) examining predictors of efficacy among various BED treatments found several significant factors. First, higher weight suppression (i.e., the difference between an individual’s highest weight and current weight) was associated with more binge episodes. Second, more frequent binge eating at baseline predicted worse binge-eating outcomes at end of treatment. Third, higher motivation to change and less eating disorder pathology predicted better outcomes. Finally, several psychopathology measures at baseline predicted better outcomes, including lower depressive symptom scores, higher BMI, higher self-esteem, lower weight/shape concerns, older age of onset, shorter duration of the disorder, less comorbid psychopathology, and better interpersonal functioning. It is important to note that while the majority of studies examined in this systematic review included forms of CBT, the authors did not exclusively examine CBT, including other forms of treatment as well. Kober and Boswell (2018) argued that neural processing features and certain areas of the brain, such as the ventral striatum, amygdala, insula, and orbitofrontal cortex (Boswell & Kober, 2016), now often measured in brain imaging studies, may also provide insight into treatment outcomes. They offer that impairments in cognitive control and increased emotional reactivity, food-cue reactivity, and cravings are likely related to emotion dysregulation, which in turn may cue binge eating. However, more research is needed to pair outcomes with imaging studies to outcomes in CBT trials for BED. Application to Diverse Populations A randomized placebo-controlled trial by Grilo et al. (2014) evaluated the effectiveness of a weight-loss medication (sibutramine) and a self-help form of CBT, alone and in combination, in an ethnically diverse primary care setting (55% non-White) for the treatment of BED. Although sibutramine was associated with greater weight loss compared with placebo, none of the treatments differed in binge-eating outcomes. Demographic factors, such as age, sex, race, and education, did not predict any changes in outcomes. It appears that CBT for



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binge eating is equally effective across different demographics, but more studies would be valuable to confirm these results. Clinical Example “John” is a 40-year-old African American man with a BMI of 42.1 kg/m2 (5 ft 8 in., 285 lb) who meets the criteria for BED. He works as a delivery person for a local paper product manufacturer whose primary clients are various restaurants in the area. Each day while making deliveries, he is offered food (e.g., pizza, sandwiches, baked goods, etc.; see Figure 5.2). John usually skips breakfast to control his weight. He often packs what is considered a normal sized lunch, such as a turkey and cheese sandwich, small bag of chips, a granola bar, and soda, but he typically eats it around 10:00 a.m., well before he originally intended. Later on, he continues to snack on the foods offered to him from various restaurants. For example, he may eat a slice of pizza around 11:30 a.m., then a side of French fries and large (12 in.) cheese steak around 1:00 p.m. This pattern continues throughout the day. John finishes his shift around 4:00 p.m. and has dinner with his wife and two children at their home around 5:45 p.m. However, about twice per week, John will stop, without his wife knowing, at his favorite Italian chain FIGURE 5.2. Example of Behavioral Chain for Binge-Eating Disorder

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restaurant for an all-you-can eat dinner after 4:00 p.m. During these occasions, he eats about five breadsticks, three large bowls of salad, and two large pasta entrees. Once he begins eating, he reports feeling immense pleasure and inability to stop. He orders the second pasta and tells himself that he will buy it now but save it for his lunch tomorrow. However, once the food arrives, he always ends up eating that portion before he leaves. He keeps these episodes from his wife, using cash instead of charging the meal. This routine has become a secretive, affair-like relationship with food. When he returns home and eats dinner with his family, he has a regular plate of food (i.e., two grilled chicken breasts, one cup of macaroni and cheese, and a baked potato). Often, he will follow dinner with dessert, such as two ice cream bars or a one-eighth portion of pie, from about 5:45 p.m. to 6:00 p.m. He reports having his restaurant meal before his “actual dinner” because he is embarrassed about overeating in front of his family. This way, he can enjoy his large meal by himself without the shame and guilt he experiences from eating large amounts in front of others. Although John feels pleasure while eating, he feels guilty and disgusted afterward, and his eating is negatively impacting his relationship with his family. John has experienced nine binge episodes per week, on average, for the past 2 years. In treatment, the therapist began by reviewing the CBT model for the treatment of BED. The therapist reviewed a food log form to track his intake throughout the day, including when, what, and how much he was eating, and what triggers may have been present before eating. Next, they completed a behavioral chain to make the chain of events explicit. Completing these exercises increased his awareness regarding his belief that restricting in the morning would be healthy, but in fact, it was prompting him to eat his lunch early, producing dichotomous thinking that he had ruined his plan for the day, so he might as well eat the food that was offered to him at the restaurants. He was assigned to begin eating a nutritionally sound breakfast and continuing to pack his lunch and snacks. Dysfunctional thought records were introduced next to modify these automatic thoughts, including the opportunity to generate alternative responses he could use in those situations. Each week, he completed these tools to provide opportunities during each therapy session to use each difficult eating situation as a learning tool, and to illustrate progress when he successfully resisted loss-of-control eating episodes. As he progressed through treatment, he gained momentum by internalizing his successes and building self-efficacy for his ability to decline food offers from the restaurants. The therapist also helped John focus on alternative activities he could do after work when he was feeling compelled to stop at the restaurant. This intervention included planning a different route home so he would avoid driving near the restaurant and setting up an exercise routine for himself with his children or his wife, when possible, during that time instead. He also generated other ideas for filling that time, like accomplishing household tasks that had been lingering or starting a hobby that he had not participated in for a while. The final target of treatment included targeting his body dissatisfaction. Following the use of Socratic questioning (i.e., asking key questions to draw out



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answers to the patient’s own questions and to uncover assumptions that may be the basis for one’s automatic thoughts), John was able to describe the pressure he was feeling from his wife and his own standards to preserve a muscular physique that he had when he was several years younger. He viewed himself as a failure with his 30-pound weight gain over the previous 2 years, and he was developing health issues, such as high blood pressure and hyperlipidemia. The therapist used thought records to help John modify his discomfort with his body, as well as emphasize healthy eating habits and physical activity that would help to address his growing health concerns. Finally, marital issues that contributed to his secretive, disordered eating behaviors were addressed, and the therapist assigned John exercises to talk with his wife regarding the impact of her language regarding health behaviors and body shape and size expectations on his emotional and physical functioning. A typical thought was “My wife won’t know that I ate it, so I might as well have it now so that I don’t overeat in front of her and risk having her comment about it.” An alternative thought that he eventually generated was “Just because my wife doesn’t know, doesn’t mean that I don’t end up feeling badly about it. I will feel better if I say no now, and I will not feel like I’m hiding things from her and my kids.” John found success by instituting a regular eating schedule and by typically packing his own meals and snacks. He developed the ability to decline foods that were offered to him on his deliveries, and the business owners stopped offering food so frequently as his responses remained consistent. He physically felt better and less sluggish by the end of the day, so he was more open to going home and spending time with his children and being active with them or by himself. He also felt as though a burden had been lifted between him and his wife, as he was not spending money for binge episodes and hiding his behavior. John was able to communicate more openly with his wife about comments and rules that she had regarding weight and eating that were maintaining his secretive eating behaviors, raising her awareness of the paradoxical result that her comments were having. She was able to prepare meals and snacks that provided more satiety for John, and to support his packing and preparing of meals and snacks for work. Overall, John reduced his binge episodes to about once per month. In the final sessions, the focus was on his ability to recover from infrequent episodes and learn from the triggering event, emotion, or thought to continue preventing binge episodes from occurring most of the time.

ANOREXIA NERVOSA Underlying Theory After Fairburn adapted Beck’s CBT for depression for use with BN, others in the field (e.g., Garner & Bemis, 1982, 1985) provided a treatment manual of CBT for AN. The formulation of CBT for AN is similar to that described above for BN and BED; overvaluation of weight and shape, which are rooted in low self-esteem, lead to a strong drive or desire to control one’s weight and shape through extreme restriction of food intake. Thus, the cognitive disturbance

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—extreme dissatisfaction with weight and shape—leads persons with AN to make choices to restrict their intake or compensate inappropriately after eating (the behavior). This becomes a cycle that is quite difficult to break. Persons with AN differ from those with BN and BED by their achievement of a very low body weight. To reach such a low weight, individuals typically have certain personality features, such as perfectionism, and a temperament that can sustain such self-deprivation. Their low self-esteem is often tied to feelings of social unease and ineffectiveness, and they often lack an awareness of their feelings (a lack of interoceptive awareness), such that they are unable to express their emotions constructively. They then turn their distress inward and try to put their focus on controlling their eating in order to control their weight and shape, which is conceptualized as a strong drive for thinness. AN-restricting subtype is manifested by strict restrictive behaviors, and AN-binge-purge subtype is characterized by dietary restriction most of the time, interrupted by binge-purge episodes, which also can become cyclical. Once caught in this cycle, eating causes increasing discomfort—both cognitively, with negative thoughts about one’s value as a person if they eat something “bad” or too much of a serving, and physically, with increasing gastrointestinal discomfort as weight loss and starvation become severe. Persons with AN obsess about food and planning what and how they will eat the little amount of food that they allow themselves, and their worlds generally become smaller. They isolate themselves more to focus on their food and weight goals and become less able to eat or socialize with others because of their extreme eating rules and rituals. However, they are living in a trapped world where they believe the only way they can increase their self-esteem is to control their weight and shape. Main Procedures CBT for AN consists of the same phases of treatment as described above for BN; however, the first goal of treatment for AN is always weight gain. This is so for obvious safety reasons, but also for efficacy reasons. If someone is starving, their thinking becomes increasingly rigid, and it becomes difficult to engage in talk therapy in an effective manner. Thus, in the first phase, the rationale for CBT is described, and psychoeducation is provided on the biological, psychological, and social underpinnings of the disorder. Persons with AN are often reluctant to engage in treatment, as their loved ones may be more distressed by their symptoms than they are, so an appraisal of their motivation for treatment is useful. This phase is also a time to build the therapeutic relationship by focusing on setting collaborative goals for improvements. This can be challenging for those with AN because they may not want to gain weight, but in outpatient treatment, clear goals should be set for progression of weight gain. A skilled therapist will set about this task in an empathic and open manner so that patients have a voice in expressing their goals and desires for regarding their eating disorder and their desired quality of life. The therapist can carefully highlight how the eating disorder has increasingly taken on its own life, and how it



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initially may have felt to the patient that they were in control, but now the AN is in charge. As this conversation progresses, along with weight gain, patients can start to disengage from the AN thoughts and behaviors, and they improve their ability to express longer term goals and desires for their lives outside of weight and shape. Weight is taken at each treatment session on a regular schedule—typically at the beginning of each session. If patients are reluctant to see their weight, desensitization to seeing the number becomes part of the therapy. Homework is also an essential part of the treatment, and patients must understand from the outset that there will be goals and tasks to practice at home, such as increasing the number of meals, increasing their calories and nutrients, and decreasing physical activity, which will be reviewed and problem-solved at their next session. This homework also includes self-monitoring of all food eaten, where it is eaten, as well as details about one’s automatic thoughts and possible triggers for restricting or binge eating and purging. From these records, the therapist and patient can work together into the second phase of treatment to identify feelings, self-deprecating thoughts, and patterns of interpersonal exchanges that maintain the eating disorder. They can then work to establish alternative ways of cognitively assessing these situations so that healthier eating patterns can replace the dysfunctional ones, and skills for managing one’s feelings and interpersonal interactions can be implemented. During this phase, a weight gain goal is clarified, and a meal plan is set. Collaboration with a nutritionist and physician is recommended to implement the meal plan and weight regain goals safely. The weight goal should be a range based on past weight history before onset of AN, as well as other health parameters, such as resolution of amenorrhea, if applicable. An action plan should be developed with the patient to identify the necessary steps to increase the likelihood that the prescribed meals and snacks will be eaten. These can be used to problem-solve situations where patients are experiencing obstacles to enacting their eating plans or other homework assignments, which prevents them from reaching their goals (e.g., weight gain, improved social skills, decreased body dissatisfaction). Thought records are used in this phase to identify and restructure cognitive distortions, such as “If I eat three meals a day, I will be fat and disgusting” or “If I go out after I have eaten, my stomach will be so bloated that everyone will notice.” The content of these thoughts can relate to eating, body dissatisfaction, or everyday stressors or interpersonal problems. Modifying these thoughts and generating alternative responses is an ongoing process, with hope that the patient will continue to use this strategy even once treatment has ended. Several behaviors are targeted with thought-restructuring exercises, including body checking, which can take on the form of extended periods of time pinching oneself or scrutinizing oneself in the mirror, picking at one’s clothing so that it is not too form-fitting, and seeing if parts of one’s body are touching (e.g., thighs) or hanging (e.g., arms or stomach). Excessive exercising is also targeted, with an initial moratorium on exercise until weight has approached the desired

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range. Exercise can be reintroduced at that time, with attention to rigid thoughts that sustain the excessive nature of exercise typically seen with AN. Finally, the behaviors associated with undereating, such as choosing low-fat foods, moving food around on the plate and cutting food into small pieces during the meal, and any variety of methods used to consume smaller quantities of food than prescribed, are addressed in this phase of treatment. The therapist would start with validation of how difficult it is to stop using these behaviors, followed by challenges to discontinue the use of these behaviors that maintain the psychopathology. Once patients have approached their weight goals and they are normalizing eating behaviors, the last phase of treatment shifts toward deconstructing the schema that maintain AN. Weight restoration is typically accomplished before the disordered attitudes regarding body weight and shape and low self-esteem are significantly improved. This treatment phase focuses on identifying other aspects of oneself outside of shape and weight that they value, as well as longerterm life goals and ways in which AN is not consistent with those values and goals. A visual, typically a pie chart, can be used to identify one’s current valuation of all aspects of oneself, as well as the version of the chart that one aspires to without having the AN (see Figure 5.3). Further work on interpersonal interactions and regulation of emotions is also targeted in this phase of CBT for AN, such that one can increase self-efficacy and not rely on AN symptoms as distractors from solving problems effectively in the real world. Therapy typically ends with sessions every other week to help patients practice and maintain their skills. Booster sessions may be scheduled as needed following treatment end. Efficacy Unfortunately, there have been relatively few studies of CBT for AN and limited development of the theory, perhaps because of its low prevalence and the historically high dropout rates observed in treatment (Galsworthy-Francis & Allen, 2014). In general, CBT or CBT-E for AN show significant gains in BMI, eating disordered attitudes and behaviors, and mood, but these outcomes are not typically significantly better than comparison treatments, such as IPT, family-based therapies, and specialist supportive clinical management. With CBT for AN, BMI shows increases between 0.9 to 2.1 kg/m2 (e.g., from a BMI of 16.0 to 16.9–18.1 kg/m2) from baseline to treatment end (Byrne et al., 2017; Fairburn et al., 2013; Zipfel et al., 2014). This has not been superior to the gains shown with specialist supportive clinical management, ranging from 1.4 to 1.5 kg/m2 (e.g., from a BMI of 16.0 to 16.4–16.5 kg/m2; Byrne et al., 2017; McIntosh et al., 2005; Schmidt et al., 2015), or Maudsley model anorexia nervosa treatment for adults (MANTRA), with gains ranging 1.4 to 1.8 kg/m2 (e.g., from a BMI of 16.0 to 16.4–16.8 kg/m2; Byrne et al., 2017; Schmidt et al., 2015). When examining the proportion of participants who reach a BMI of 18.5 kg/m2, CBT is not superior to other treatments statistically, but there seems



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FIGURE 5.3. Visualization of Current Versus Desired Self-Schema in a Patient With Anorexia Nervosa

to be more separation when using this measure, with 59% in CBT-E, 44% in MANTRA, and 48% in specialist supportive clinical management reaching this marker of weight normalization (Byrne et al., 2017). In a systematic review of CBT for AN, Galsworthy-Francis and Allan (2014) included just 16 treatment studies that had been conducted between 1995 to 2014, with only five of those being RCTs. Comparison between therapies and examination of long-term outcomes was difficult, they reported, due to the high treatment dropout rates, particularly with follow-up data. Thus, no statistical comparisons across studies were reported. Galsworthy-Francis and Allan (2014) further confirmed that CBT often produced significant gains in BMI, disordered eating pathology, and some general pathology. This was not superior to results from other approaches (e.g., dietary counseling, nonspecific supportive management, IPT, behavioral family therapy), but less dropout was observed in the CBT treatment conditions in four of seven controlled studies, particularly as compared with inpatient treatment and nutritional counseling. They also suggested that one reason CBT does not perform significantly better than other approaches with AN could be that the large amount of psychoeducation and use of cognitive skills, such as thought restructuring, may be too difficult in light of the cognitive rigidity associated with starvation in this disorder. However, it appears that CBT for patients with severe and enduring AN (duration of more than 7 years) show similar outcomes as patients who do have this high level of impairment and disability (Calugi et al., 2017). Calugi et al. (2017) reported that among 66 inpatients, 44% of the nonsevere (n = 34) and 41% of the severe (n = 32) groups reached BMIs greater than 18.5 kg/m2, indicating a weight in the “normal” range, with 32% and 33%, respectively, having minimal eating disorder pathology at a 12-month follow-up. Overall, the data are not convincing that CBT for AN is superior to other treatments, but it also is not inferior to other treatments. It may be more

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acceptable to patients, as evidenced by slightly lower treatment dropout rates (Galsworthy-Francis & Allan, 2014), so it certainly remains one of the best options available at this time for adults with AN. Mechanisms of Change CBT for AN first targets weight regain so that rigidity of thinking is reduced and the substance of treatment, such as modifying dysfunctional thoughts regarding overvaluation of weight and shape and extreme restraint of eating, can ensue. As specific examples of triggers and eating disordered attitudes and behaviors are modified and skills are taught for generating alternative responses, the underlying schema (i.e., one’s framework for conceptualizing oneself and one’s view of the world) of what the individual values and strives for in life can shift from control of one’s body weight and shape to more varied and productive goals. These mechanisms are hypothesized based on the cognitive theory of eating disorders (Fairburn, 2017; Fairburn et al., 2008). More data are needed to confirm these pathways. Special Considerations With This Population Outpatient care for patients presenting with very low BMI (below 17 kg/m2) would typically be contraindicated. A full assessment of medical stability and safety should be undertaken in conjunction with a physician to determine the appropriate level of care in these cases (e.g., hospitalization or partial hospitalization; NICE, 2017). Application to Diverse Populations As Galsworthy-Francis and Allan (2014) commented in their review, most studies of CBT for AN did not report race or ethnicity, let alone the impact of age, sexual orientation, or gender identity (most studies report over 90% of participants are women). It is unclear how these factors may impact CBT outcomes for AN.

NIGHT-EATING SYNDROME Underlying Theory The core feature of NES is that the typical daytime pattern of food intake is delayed, which interrupts the normal diurnal sleep-wake cycle. Persons with NES feel compelled to eat to fall asleep initially or to fall back to sleep during the night. NES is conceptualized as an eating disorder with features of sleep (insomnia) and mood (depressive) symptoms. Thus, CBT was adapted for NES based on the approaches for each of these disorders. Allison et al. (2004) described four of the most common themes reported by persons with NES before their nocturnal eating episodes. These included expe-



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riencing (a) specific food cravings (e.g., “I know that jar of peanut butter is in the cabinet—I can’t fall back to sleep now until I have some”), (b) feeling anxious or agitated (e.g., “I am still worried about how my meeting at work will go tomorrow and can’t sleep, but if I eat, that will help me fall back to sleep”), (c) feeling the need to eat something so one’s stomach feels full (e.g., “I just need to put something in my stomach, and then I will be able to sleep”), and (d) feeling the need to eat to fall back to sleep (e.g., “I will be a wreck at work tomorrow if I don’t get back to sleep soon—I know I can fall back to sleep if I eat something, so that is what I will do”). Unfortunately, persons with NES often experience shame, disgust, and distress after nocturnal eating, particularly in the morning. Many describe feeling as though they have a “food hangover,” causing them to delay their eating in the morning, thus perpetuating the cycle. Main Procedures As with the previously described approaches, in the first stage of CBT for NES, the therapist develops the therapeutic relationship, explains the rationale for CBT, and educates the patient on the basic techniques of CBT (Allison, 2012). These techniques include monitoring sleeping, eating, and mood patterns, along with the automatic thoughts associated with these events (Sessions 1–4). The Nighttime Eating Assessment—which presents a series of visual analog scales that the patient completes before eating at night to identify mood states that might be triggering the urge to eat—are to be completed for the first 2 weeks of therapy. This exercise helps to identify other targets of therapy so that skills can be developed to undermine the patient’s typical pattern (Allison, 2012). Thought records are used to construct alternative thoughts and responses to the urge to eat at night, and the use of social support is encouraged. In addition to identifying the stressors and thoughts that precipitate unwanted eating, the patient is asked to complete food logs to detail their circadian pattern of food intake. Patients are encouraged to move their first meal of the day earlier (e.g., if nothing is eaten until 2:00 p.m., a lunch at noon would be prescribed), with successively earlier meals assigned in subsequent sessions. The therapist explains that although regulating the daytime eating schedule is not sufficient to stop the nocturnal ingestions, it is necessary to break the delayed pattern of eating. In addition, the therapist encourages behavioral experiments (i.e., homework designed to modify beliefs about the pros and cons of behaviors, and debunk dysfunctional thoughts that sustain those—usually negative—behaviors) to address the nighttime awakenings and ingestions, including attention to the energy and nutrient content of the snacks. A “kitchen is closed” time is also chosen, indicated with a verbal declaration and by turning the lights off. Patients are encouraged to brush their teeth and move to another area of the house after that time. A behavioral chain describing the specific steps in a patient’s nocturnal eating episodes, along with ways that the patient can break the links, is also completed and given to the patient for reference at home.

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If patients have overweight or obesity and have a desire to lose weight, calorie tracking with their food log is instituted at Session 3, with typical goals of 1,200–1,500 calories for women and 1,500–1,800 calories for men. At weights above 250 lb (113 kg), adjustment of these calorie goals is made accordingly. Clinical experience has suggested that implementing a calorie goal improves motivation for change and therapy compliance among those seeking treatment for NES, as part of their distress regarding their nighttime eating is its negative influence on their weight gain. Restraint and overvaluation of weight and shape are not as extreme in those with NES as in BED and other eating disorders (Allison et al., 2005), so encouraging a structured behavioral weight loss component does not seem contraindicated for this disorder. In the middle stage of CBT for NES (Sessions 5–8), the work centers on firmly establishing the skills that have been developed in the first phase. Depressed mood and dysfunctional thoughts about eating continue to be monitored and addressed through the use of thought records, together with continued use of behavioral interventions. Behavioral experimentation is essential for decreasing the occurrence of evening and nighttime ingestions. Although the actual methods may differ based on the layout of the patient’s house, the presence or absence of family or roommates, and what food is available, each approach involves stimulus control of food, including strategies such as preparing preset, portion-sized snacks and placing them on the counter or in the front of the refrigerator; locking or hiding away desirable food at night; or engaging in another activity until sleepiness returns. Thoughts regarding fear of weight gain and lack of hunger with regard to starting to eat earlier in the day, and with regular daytime meals and snacks, is also addressed. If depressed mood is present, these symptoms are treated with the same thought records and behavioral activation/change of typical routine outlined previously. Negative beliefs about weight and shape, if present, are also be attended to throughout the therapeutic process, as these beliefs are often intricately tied to negative affect. The final stage of therapy, Sessions 9–10, transitions to biweekly sessions. The therapist reviews progress and helps the individual generate possible triggers for relapse. Therapists also aim to increase self-efficacy regarding the patient’s ownership of the progress they have made, so that they can maintain their progress outside of the therapeutic relationship. Efficacy One study has tested CBT for NES, with a 10-session treatment delivered over 12 weeks among 25 participants (Allison, Lundgren, Moore et al., 2010). Intention to treat analysis showed significant reductions in the percentage of food intake consumed after dinner (from 35% to 24.9%), number of weekly awakenings (from 13.5 to 8.5 per week), and weekly nocturnal ingestions (from 8.7 to 2.6 per week; Allison, Lundgren, Moore, et al., 2010). Among participants with overweight or obesity, a 3 kg weight loss was also reported, with caloric reductions from 2,356 per day at Session 3 (the first time calories are tracked)



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to 1,759 per day at treatment end. More studies are needed to confirm these results. Mechanisms of Change CBT for NES seems to work by recalibrating an individual’s temporal pattern of eating, such that the nocturnal drive to eat, which becomes habitual over time, is diminished and patients no longer feel compelled to eat, even if they continue to wake up during the night. The treatment uncouples the urge to eat during the night from the act of falling asleep initially or falling back to sleep, so that even if they have problems initiating sleep or waking during the night, they are able to do other soothing activities in order to resume sleep (Allison, 2012). These mechanisms are based on the CBT theory of NES, so these pathways should be tested further. Special Considerations With This Population Some persons with NES report that their first moments of awareness do not occur until they are standing in front of the refrigerator, whereas others are fully aware from the moment they wake and rise from bed. Persons with reduced awareness typically are not able to identify automatic thoughts until they are about to eat or are already eating. Treatment of nocturnal ingestions focuses on increasing awareness progressively earlier in the waking process so that patients can access and implement the CBT skills during the nocturnal eating episodes. Behavioral approaches, such as placing a bell or some other type of alarm on the door may be used in some cases to raise awareness before they are even able to leave the bedroom. Persons with NES who have normal weight seem to endorse more severe symptoms; a higher proportion of their intake occurs after dinner because they seem to be restricting more during the day than persons with overweight or obesity. Persons with NES who have normal weight also report higher levels of compulsive exercise to compensate for their nocturnal ingestions. Thus, those with NES with normal weight may need to pay more attention to compensatory behaviors and fear of weight gain than those with higher weights (Allison, Lundgren, Moore, et al., 2010).

DISSEMINATION OF CBT FOR EATING DISORDERS CBT has been evaluated through numerous RCTs and is regarded as the “gold standard” treatment for BN and BED, but there remains limited access to effective, evidence-based versions of this treatment. Some barriers include the availability of resources, namely doctoral-level therapists, inadequate training for therapists, and lack of competence and consistency in adhering to the treatment protocol (Fairburn & Wilson, 2013). Therefore, efforts to address these

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barriers are pivotal in the transfer from evidence-based research to clinical practice. Self-help or guided self-help using evidence-based treatment manuals are also valuable in disseminating these treatments (Peterson et al., 2009). The primary manual for self-help CBT, developed by Fairburn (2013), includes information about the disorder and manualized instructions for implementation of treatment. Given the severity of AN, professional help is typically recommended. CBT and CBT-E trainings are offered through the Centre for Research on Eating Disorders at Oxford (CREDO, https://www.credo-oxford.com), and professional conferences, such as the Academy for Eating Disorders (https://www. AEDweb.org), can be valuable tools for therapists to learn this treatment. There are few self-help CBT treatments for AN, with little outcome data currently available. Much work is needed to disseminate CBT for NES given it is not wellrecognized (Goncalves et al., 2009). A self-help book is available (Allison et al., 2004), as well as a treatment manual (Allison, 2012).

CONCLUSION AND FUTURE DIRECTIONS CBT is the first-line treatment recommended for both BN and BED. The evidence is less clear for the treatment of AN, as CBT reduces symptoms but is not superior to other therapies. Even though it is the most commonly recommended therapy for BN and BED, the proportion of those patients who enter remission with treatment typically ranges between 50% and 60%, leaving a need for other therapies, given the large minority of patients whose symptoms persist. Accessing treatment can be difficult, however, so it is important to note that self-help manuals may be helpful, particularly in milder cases of BN and BED. More work is needed to validate treatments for purging disorder and NES.

REFERENCES Agras, W. S., Walsh, T., Fairburn, C. G., Wilson, G. T., & Kraemer, H. C. (2000). A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57(5), 459–466. https:// doi.org/10.1001/archpsyc.57.5.459 Allison, K. C. (2012). Cognitive-behavioral therapy manual for night eating syndrome. In J. D. Lundgren, K. C. Allison, & A. J. Stunkard (Eds.), Night eating syndrome: Research, assessment, and treatment (pp. 246–265). Guilford Press. Allison, K. C., Grilo, C. M., Masheb, R. M., & Stunkard, A. J. (2005). Binge eating disorder and night eating syndrome: A comparative study of disordered eating. Journal of Consulting and Clinical Psychology, 73(6), 1107–1115. https://doi.org/10. 1037/0022-006X.73.6.1107 Allison, K. C., Lundgren, J. D., Moore, R. H., O’Reardon, J. P., & Stunkard, A. J. (2010). Cognitive behavior therapy for night eating syndrome: A pilot study. American Journal of Psychotherapy, 64(1), 91–106. https://doi.org/10.1176/appi.psychotherapy. 2010.64.1.91



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Allison, K. C., Lundgren, J. D., O’Reardon, J. P., Geliebter, A., Gluck, M. E., Vinai, P., Mitchell, J. E., Schenck, C. H., Howell, M. J., Crow, S. J., Engel, S., Latzer, Y., Tzischinsky, O., Mahowald, M. W., & Stunkard, A. J. (2010). Proposed diagnostic criteria for night eating syndrome. International Journal of Eating Disorders, 43(3), 241–247. Allison, K. C., Stunkard, A. J., & Thier, S. L. (2004). Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. New Harbinger Publications. American Academy of Sleep Medicine. (2014). International classification of sleep disorders (3rd ed.). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books9780890425596 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Boswell, R. G., & Kober, H. (2016). Food cue reactivity and craving predict eating and weight gain: A meta-analytic review. Obesity Reviews, 17(2), 159–177. https://doi.org/ 10.1111/obr.12354 Brownley, K. A., Berkman, N. D., Peat, C. M., Lohr, K. N., Cullen, K. E., Bann, C. M., & Bulik, C. M. (2016). Binge-eating disorder in adults: A systematic review and meta-analysis. Annals of Internal Medicine, 165(6), 409–420. https://doi.org/10.7326/ M15-2455 Bruch, H. (1970). Psychotherapy in primary anorexia nervosa. Journal of Nervous and Mental Disease, 150, 51–67. https://doi.org/dnfrks Byrne, S., Wade, T., Hay, P., Touyz, S., Fairburn, C. G., Treasure, J., Schmidt, U., McIntosh, V., Allen, K., Fursland, A., & Crosby, R. D. (2017). A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine, 47(16), 2823–2833. https://doi.org/10.1017/S0033291717001349 Calugi, S., El Ghoch, M., & Dalle Grave, R. (2017). Intensive enhanced cognitive behavioural therapy for severe and enduring anorexia nervosa: A longitudinal outcome study. Behaviour Research and Therapy, 89, 41–48. https://doi.org/10.1016/j. brat.2016.11.006 Castillo, M., & Weiselberg, E. (2017). Bulimia nervosa/purging disorder. Current Problems in Pediatric and Adolescent Health Care, 47(4), 85–94. https://doi.org/10.1016/ j.cppeds.2017.02.004 Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavior therapy for bulimia nervosa. In C. M. Grilo & J. E. Mitchell (Eds.), The treatment of eating disorders: A clinical handbook (pp. 243–270). Guilford Press. Cooper, Z., & Fairburn, C. G. (2011). The evolution of “enhanced” cognitive behavior therapy for eating disorders: Learning from treatment nonresponse. Cognitive and Behavioral Practice, 18, 394–402. https://doi.org/10.1016/j.cbpra.2010.07.007 Devlin, M. (2017). Binge eating disorder. In K. D. Brownell & T. B. Walsh (Eds.), Eating disorders and obesity: A comprehensive handbook (3rd ed., pp. 192–195). Guilford Press. Devlin, M. J., Goldfein, J. A., Petkova, E., Jiang, H., Raizman, P. S., Wolk, S., Mayer, L., Carino, J., Bellace, D., Kamenetz, C., Dobrow, I., & Walsh, B. T. (2005). Cognitive behavioral therapy and fluoxetine as adjunts to group behavioral therapy for binge eating disorder. Obesity, 13(6), 1077–1088. https://doi.org/10.1038/oby.2005.126 DuBois, R. H., Rodgers, R. F., Franko, D. L., Eddy, K. T., & Thomas, J. J. (2017). A network analysis investigation of the cognitive-behavioral theory of eating disorders. Behaviour Research and Therapy, 97, 213–221. https://doi.org/10.1016/j.brat. 2017.08.004 Fairburn, C. G. (1981). A cognitive behavioural approach to the treatment of bulimia. Psychological Medicine, 11(4), 707–711. https://doi.org/10.1017/S0033291700041209 Fairburn, C. G. (1995). Overcoming binge eating. Guilford Press. Fairburn, C. G. (2013). Overcoming binge eating: The proven program to learn why you binge and how you can stop (2nd ed.). Guilford Press.

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Fairburn, C. G. (2002). Cognitive-behavioral therapy for bulimia nervosa. In C. G. Fairburn & K. D. Brownell (Eds.), Eating disorders and obesity: A Comprehensive handbook (2nd ed., pp. 302–307). Guilford Press. Fairburn, C. G. (2017). Cognitive behavior therapy and eating disorders. In K. D. Brownell & T. B. Walsh (Eds.), Eating disorders and obesity: A comprehensive handbook (3rd ed., pp. 284–289). Guilford Press. Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Bohn, K., Hawker, D. M., Wales, J. A., & Palmer, R. L. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry, 166(3), 311–319. https://doi.org/10.1176/appi.ajp.2008.08040608 Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Palmer, R. L., & Dalle Grave, R. (2013). Enhanced cognitive behaviour therapy for adults with anorexia nervosa: A UK-Italy study. Behaviour Research and Therapy, 51(1), R2–R8. https://doi.org/10. 1016/j.brat.2012.09.010 Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behavior therapy for eating disorders: A “transdiagnostic” theory and treatment. Behavior Research and Therapy, 41(5), 509–528. https://doi.org/cdjcss Fairburn, C. G., Cooper, Z., Shafran, R., & Wilson, G. T. (2008). Eating disorders: A transdiagnostic protocol. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 578–614). Guilford Press. Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 361– 404). Guilford Press. Fairburn, C. G., & Wilson, G. T. (2013). The dissemination and implementation of psychological treatments: Problems and solutions. International Journal of Eating Disorders, 46(5), 516–521. https://doi.org/10.1002/eat.22110 Galsworthy-Francis, L., & Allan, S. (2014). Cognitive Behavioural Therapy for anorexia nervosa: A systematic review. Clinical Psychology Review, 34(1), 54–72. https://doi.org/ 10.1016/j.cpr.2013.11.001 Garner, D. M., & Bemis, K. M. (1982). A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research, 6, 123–150. https://doi.org/10.1007/ BF01183887 Garner, D. M., & Bemis, K. M. (1985). Cognitive therapy for anorexia nervosa. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 107–146). Guilford Press. Goncalves, M. D., Moore, R. H., Stunkard, A. J., & Allison, K. C. (2009). The treatment of night eating: The patient’s perspective. European Eating Disorders Review, 17(3), 184– 190. https://doi.org/10.1002/erv.918 Grilo, C. M. (2017). Psychological treatment of binge eating disorder. In K. D. Brownell & T. B. Walsh (Eds.), Eating disorders and obesity: A comprehensive handbook (3rd ed., pp. 314–319). Guilford Press. Grilo, C. M., Masheb, R. M., & Crosby, R. D. (2012). Predictors and moderators of response to cognitive behavioral therapy and medication for the treatment of binge eating disorder. Journal of Consulting and Clinical Psychology, 80(5), 897–906. https:// doi.org/10.1037/a0027001 Grilo, C. M., Masheb, R. M., White, M. A., Gueorguieva, R., Barnes, R. D., Walsh, B. T., McKenzie, K. C., Genao, I., & Garcia, R. (2014). Treatment of binge eating disorder in racially and ethnically diverse obese patients in primary care: Randomized placebocontrolled clinical trial of self-help and medication. Behaviour Research and Therapy, 58, 1–9. https://doi.org/10.1016/j.brat.2014.04.002 Haedt-Matt, A. A., & Keel, P. K. (2011). Revisiting the affect regulation model of binge eating: A meta-analysis of studies using ecological momentary assessment. Psychological Bulletin, 137(4), 660–681. https://doi.org/10.1037/a0023660



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Haedt-Matt, A. A., Keel, P. K., Racine, S. E., Burt, S. A., Hu, J. Y., Boker, S., Neale, M., & Klump, K. L. (2014). Do emotional eating urges regulate affect? Concurrent and prospective associations and implications for risk models of binge eating. International Journal of Eating Disorders, 47(8), 874–877. https://doi.org/10.1002/eat.22247 Ham, J. C., Iorio, D., & Sovinsky, M. (2015). Disparities in bulimia nervosa: Who is left behind? Economics Letters, 136, 147–150. https://doi.org/10.1016/j.econlet.2015.09. 017 Hay, P. P., Bacaltchuk, J., Stefano, S., & Kashyap, P. (2009). Psychological treatments for bulimia nervosa and binging. Cochrane database of systematic reviews, 4, CD000562. https://doi.org/10.1002/14651858.CD000562.pub3 Keel, P. K. (2007). Purging disorder: Subthreshold variant or full-threshold eating disorder? International Journal of Eating Disorders, 40(Suppl.), S89–S94. https://doi. org/10.1002/eat.20453 Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C., Hudson, J. I., Shahly, V., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Benjet, C., Bruffaerts, R., de Girolamo, G., de Graaf, R., Maria Haro, J., Kovess-Masfety, V., O’Neill, S., Posada-Villa, J., Sasu, C., Scott, K., . . . Xavier, M. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 73(9), 904–914. https://doi.org/10.1016/j. biopsych.2012.11.020 Kober, H., & Boswell, R. G. (2018). Potential psychological & neural mechanisms in binge eating disorder: Implications for treatment. Clinical Psychology Review, 60, 32– 44. https://doi.org/10.1016/j.cpr.2017.12.004 Lampard, A. M., & Sharbanee, J. M. (2015). The cognitive-behavioural theory and treatment of bulimia nervosa: An examination of treatment mechanisms and future directions. Australian Psychologist, 50(1), 6–13. https://doi.org/10.1111/ap.12078 McIntosh, V. V., Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., Frampton, C. M., & Joyce, P. R. (2005). Three psychotherapies for anorexia nervosa: A randomized, controlled trial. The American Journal of Psychiatry, 162(4), 741–747. https://doi.org/10.1176/appi.ajp.162.4.741 Mitchison, D., Rieger, E., Harrison, C., Murray, S. B., Griffiths, S., & Mond, J. (2018). Indicators of clinical significance among women in the community with bingeeating disorder symptoms: Delineating the roles of binge frequency, body mass index, and overvaluation. International Journal of Eating Disorders, 51(2), 165–169. https://doi.org/10.1002/eat.22812 Murphy, R., Straebler, S., Basden, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal psychotherapy for eating disorders. Clinical Psychology & Psychotherapy, 19(2), 150–158. https://doi.org/10.1002/cpp.1780 Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy for eating disorders. Psychiatric Clinics of North America, 33(3), 611–627. https://doi.org/10.1016/j.psc.2010.04.004 National Institute for Health and Care Excellence (NICE). (2017). Eating disorders: Recognition and treatment: clinical guideline methods, evidence and recommendations, version 2.0. Retrieved August 31, 2018, from https://www.nice.org.uk/guidance/ng69/ Peterson, C. B., Berg, K. C., Crosby, R. D., Lavender, J. M., Accurso, E. C., Ciao, A. C., Smith, T. L., Klein, M., Mitchell, J. E., Crow, S. J., & Wonderlich, S. A. (2017). The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self-directed behavior, and selfdiscrepancy within the mediation model. International Journal of Eating Disorders, 50(6), 636–647. https://doi.org/10.1002/eat.22669 Peterson, C. B., Mitchell, J. E., Crow, S. J., Crosby, R. D., & Wonderlich, S. A. (2009). The efficacy of self-help group treatment and therapist-led group treatment for binge eating disorder. American Journal of Psychiatry, 166(12), 1347–1354. https://doi. org/10.1176/appi.ajp.2009.09030345

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Polivy, J., & Herman, C. P. (1985). Dieting and binging: A causal analysis. American Psychologist, 40(2), 193–201. https://doi.org/10.1037/0003-066X.40.2.193 Runfola, C. D., Allison, K. C., Hardy, K. K., Lock, J., & Peebles, R. (2014). Prevalence and clinical significance of night eating syndrome in university students. Journal of Adolescent Health, 55(1), 41–48. https://doi.org/10.1016/j.jadohealth.2013.11.012 Schmidt, U., Magill, N., Renwick, B., Keyes, A., Kenyon, M., Dejong, H., Lose, A., Broadbent, H., Loomes, R., Yasin, H., Watson, C., Ghelani, S., Bonin, E. M., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Beecham, J., . . . Landau, S. (2015). The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83, 796– 807. https://doi.org/10.1037/ccp0000019 Spitzer, R. L., Yanovski, S., Wadden, T., Wing, R., Marcus, M. D., Stunkard, A., Devlin, M., Mitchell, J., Hasin, D., & Horne, R. L. (1993). Binge eating disorder: Its further validation in a multisite study. International Journal of Eating Disorders, 13(2), 137– 153. Stunkard, A. J. (1959). Eating patterns and obesity. Psychiatry Quarterly, 33, 284–295. https://doi.org/10.1007/BF01575455 Tholin, S., Lindroos, A., Tynelius, P., Akerstedt, T., Stunkard, A. J., Bulik, C. M., & Rasmussen, F. (2009). Prevalence of night eating in obese and nonobese twins. Obesity, 17(5), 1050–1055. https://doi.org/10.1038/oby.2008.676 Udo, T., & Grilo, C. M. (2018). Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of U.S. adults. Biological Psychiatry, 84(5), 345–354. https://doi.org/10.1016/j.biopsych.2018.03.014 Vall, E., & Wade, T. D. (2015). Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 48(7), 946–971. https://doi.org/10.1002/eat.22411 Vocks, S., Tuschen-Caffier, B., Pietrowsky, R., Rustenbach, S. J., Kersting, A., & Herpertz, S. (2010). Meta-analysis of the effectiveness of psychological and pharmacological treatments for binge eating disorder. International Journal of Eating Disorders, 43(3), 205–217. Wilfley, D. E., Schwartz, M. B., Spurrell, E. B., & Fairburn, C. G. (2000). Using the eating disorder examination to identify the specific psychopathology of binge eating disorder. International Journal of Eating Disorders, 27(3), 259–269. https://doi.org/ btzshh Yager, J., Devlin, M. F., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P., & Zerbe, K. F. (2012). Guideline watch: Practice guideline for the treatment of patients with eating disorders (3rd ed.). American Psychiatric Association. Zipfel, S., Wild, B., Groß, G., Friederich, H. C., Teufel, M., Schellberg, D., Giel, K. E., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Löwe, B., Tagay, S., von Wietersheim, J., Zeeck, A., Schade-Brittinger, C., Schauenburg, H., Herzog, W., & the ANTOP study group. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. The Lancet, 383(9912), 127–137. https://doi.org/10.1016/S0140-6736(13)61746-8

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I

n this chapter, the term addiction, which has various definitions, will stand for the term problematic addictive behavior. Figure 6.1 presents the continuum of problematic addictive behavior. This continuum can be divided between each term in the right-hand column. Although the boundaries between each pair of categories may be fuzzy, overall the progression of categories is clear. If divided under abstinence, below that division is use. If divided under moderation, below is problematic use. If divided under subclinical (or misuse), below are diagnosable disorders. If divided under mild substance use disorder (SUD), FIGURE 6.1. The Continuum of Problematic Addictive Behavior

Note. SUD = substance use disorder, DSM-5 (American Psychiatric Association, 2013); abuse and dependence are terms from ICD-10 (World Health Organization, 1993).

https://doi.org/10.1037/0000219-006 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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below is the ICD-10 code (F10.2 for alcohol dependence) for a moderate or severe disorder, and if divided under moderate SUD, below is addiction: Some clinicians will choose to use the word addiction [emphasis in the original] to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation. (American Psychiatric Association, 2013, p. 485)1

CBT can be provided for any problematic addictive behaviors or substances. Behaviors are also termed processes or activities and include gambling, pornography, sexual activity, video gaming, shopping, and others. For ease of presentation in this chapter, alcohol use will often be the addictive behavior discussed. CBT can also be provided regardless of severity. As cases become more severe (as they move down the chart in Figure 6.1), the intensity and frequency of treatment may increase and the setting may change, but treatment itself from a psychological perspective is not fundamentally different. Treatment should be offered even if the individual has only subclinical use. Focusing on subclinical use is not a trivial matter in clinical practice because the number of individuals in this category may be larger than that of all the SUDs combined. Many of these subclinical individuals might be prevented from developing a SUD if they are willing to seek services and appropriate services are available. Figure 6.1 views addictive behavior as not necessarily problematic. Nonproblematic addictive behavior (moderation) is a type of habit that causes negligible problems but arises as problematic addictive behavior does, in response to repetitive desires. These desires in their strongest form are termed urges or craving. Craving will be the term used in this chapter for the entire continuum. If a substance or behavior is initially pleasurable to the individual, it is addictive (desirable) for that individual without necessarily leading to problematic behavior. Alcohol is unlikely to become an addictive substance for an individual who immediately gets sick from it. However, most of the substances or activities we popularly (and in the DSM) consider addictive (e.g., alcohol, caffeine, cocaine, opiates, gambling, etc.) are pleasurable to most individuals, across a wide range of doses, routes of administration, settings of use, and other variables. Repetitive craving is the basis of addictive behavior, and significant problems are the basis of problematic addictive behavior, which, if severe enough, is diagnosable. With enough repetition, any addictive behavior may become problematic, meaning that the benefits of use have become outweighed by the costs. The initial transition from beneficial to overly costly addictive behavior (i.e., moving toward the bottom of Figure 6.1) may happen slowly or quickly. An individual may fluctuate up and down Figure 6.1 indefinitely. Individuals who present for treatment have generally been toward the bottom of Figure 6.1 for long enough—with enough personally painful problems and with enough ineffective efforts at self-change—that help-seeking becomes desirable. Fortunately, most individuals move back to the top (abstinence or moderation) on their own (i.e., they resolve their problematic addictive behavior through Clinical examples are disguised to protect patient confidentiality.

1



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natural recovery). Self-guided change has recently been suggested (Bishop, 2018) as a more descriptive term. This chapter views self-guidance as the foundation of change. CBT, or any addiction treatment, is not an example of “art perfects nature” but of “art augments nature.” Individuals unable to fully accomplish self-guided change can complete the process by participating in CBT or other treatment approaches.

HISTORY CBT, specifically for addiction, became a significant presence in the scientific literature approximately in the 1980s with the work of Abrams and Niaura (1987), Marlatt and Gordon (1985), Monti et al. (1989), and others. However, these publications often describe their foundation as social learning theory (Bandura, 1969) rather than CBT specifically, and they describe themselves as providing relapse prevention or social skills training rather than CBT. Nevertheless, these publications share with contemporary CBT for addiction an emphasis on the primary role of learning processes in the development and resolution of addiction. This emphasis diverges from the general practice of the addiction treatment industry, then and now, which emphasizes addiction as a disease with primarily biological roots. The focus of emerging CBT for addiction was on developing the psychological components of treatment, while accepting that biological and social components were significant but perhaps largely unchangeable. From the CBT perspective, a full biopsychosocial approach to addiction is needed, but one oriented toward issues the individual can actually address, which are primarily psychological. CBT, nevertheless, incorporates the biology of substance use (e.g., substances can be intoxicating, some can lead to physical dependence, response to a substance is dose-dependent) and social processes (e.g., it can be very difficult to act contrary to one’s identity group or the social demands of specific situations; when there is an attempt to restrict freedom the individual will make great effort to regain freedom). The full expression of the contemporary CBT approach (for any problem, and for addiction specifically) is founded on the fundamental human learning processes, including respondent conditioning, operant conditioning, modeling, and cognitive mediation. Respondent conditioning occurs when a stimulus that elicits an automatic response (e.g., food eliciting salivation) is paired closely in time with a neutral stimulus (e.g., a bell). With enough pairings where the bell rings and the food quickly arrives, the bell alone can elicit salivation. Operant conditioning occurs when a positive or negative experience quickly follows a specific behavior. If the experience is positive, the behavior increases; if negative, it decreases. If I earn money for a behavior it tends to increase, but if I get fined it tends to decrease. Modeling occurs when we observe someone (a model) engage in a behavior new to us and we learn about the behavior by observing it. This process is also called observational learning. Cognitive mediation occurs when the “facts” of a situation are appraised (and possibly changed

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substantially) by the observer. The interpretation or behavior that follows is based on the appraisal rather than immediately on the facts. You may appraise someone’s behavior as kind, but I may appraise it as manipulative. My appraisal may be based on my experience with that person, or with others who previously engaged in that behavior, or with others whom that person reminds me of, or on other aspects of my learning history. Because we can cognitively mediate our own cognitive mediations, we can change them. Mediation of mediation is at the heart of CBT. Cognitive behavioral therapists assume that learning helpful or unlearning unhelpful behaviors involves these fundamental learning processes, that human behavior is largely learned in specific contexts, that unhelpful thoughts and beliefs can also be changed using fundamental learning processes and guided practice, and that effective treatment needs to be personalized to each individual based on adequate assessment (Rotgers, 2013).

UNDERLYING THEORY CBT, as the name implies, combines behavioral and cognitive approaches to client change. The underlying theory assumes that there have been disturbances and a lower level of adaptation to the present, in both behavior and cognitions (both thoughts and beliefs). What was adaptive in a previous context or a shorter time frame may be no longer adaptive, for instance, because the context has changed or the individual has aged and more mature behaviors are expected. In CBT for addiction, specifically, the behavior of primary concern is continuing to engage with the addictive behavior (e.g., drink alcohol, use cocaine, go to the casino). The cognition of primary concern is the belief that “I need this substance/behavior in order to accomplish my goals.” CBT, thus, has multiple foci, all in the service of resolving addictive problems: (a) reducing or ending the addictive behavior, (b) building up an alternative set of beliefs such that “I don’t need this in order to accomplish my goals,” and (c) developing skills or changing situations such that the need is met in other ways (or matured out of). Typically, the third focus requires the most therapeutic emphasis. In many cases, the third focus requires a CBT approach to another disorder—most commonly anxiety, depression, or trauma. As for behavior, cognitive behavioral therapists are open to the possibility that the client may be able to shift up the continuum (see Figure 6.1) enough to moderate stably, rather than necessarily needing to abstain. At present, there appears to be no reliable way to predict who will succeed in moderating and who will need to abstain. A difficult clinical situation arises when the client for an extended period unsuccessfully pursues moderation. In these cases, the discussion needs to reemphasize the original goal of resolving problems. A comprehensive CBT model of addiction includes a focus on proximal situational factors as well as distal background factors (Wenzel et al., 2012). Because genuine early success may result in rapid termination of treatment (e.g., “I get



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it, why do I need to come back?”), the clinician may not have time for a complete CBT conceptualization of the client. However, when slow or no progress is occurring, or a client has returned after a premature termination, conducting treatment with reference to a comprehensive model is invaluable. What are the typical internal or external events that occur before engagement in the addictive behavior? Proximal factors include anxiety, boredom, and tension, or being out with friends, coming home after a difficult day, or seeing a beer commercial. What positive expectancies arise? These might include “I’ll be able to cope if have a drink” or “I will enjoy myself once I have a drink.” These expectances are a type of belief because they typically are not fleeting and have often been considered at length by the client. What (fleeting) automatic thoughts then arise? These might include “Just a little one” or an image of a previous enjoyable drinking experience. What craving (desire, urge, tension) then arises? Like hunger, this craving orients someone toward the object of the craving. What “permissions” then arise? These might include “No one will find out this time” or “Screw it, it doesn’t matter anyway.” Finally, what preparatory actions does the individual engage in? These might include going to the liquor store or calling a friend to go out. Despite the proximal factors at any particular moment, drinking is not inevitable. It can be interrupted by situational changes. Perhaps a loved one calls with an urgent need for assistance, or it is suddenly raining heavily, or the client realizes they are out of cash (and they do not want to use an ATM or credit card for fear of their partner discovering the expense). Drinking can be interrupted by internal changes as well. Actually, each of the just-mentioned situational changes activate helpful beliefs or priorities: “I deeply care about this loved one, and he is more important than drinking” or “I hate going out in the rain; I don’t want more conflict about my drinking.” Sometimes these internal changes arise in a way less directly connected to external cues, such as when the client is headed out the door to drink, sees something that reminds them of someone who would be upset about their drinking, and a line of thinking results in the decision to override the craving. If craving could not be overruled, then all of us would be at the mercy of whatever desire, craving, or impulse happened to enter our minds. If a simple summary of CBT for any emotional issue or disorder is, “I am not at the mercy of thoughts that enter my mind; I can evaluate and modify them,” then a simple summary of CBT for addiction is, “I am not at the mercy of cravings that enter my mind; I can act by balancing the short-term satisfaction of using against the longer term satisfactions associated with the priorities in my life.” A fundamental challenge for all human beings is how to balance our desires for satisfaction right now with acting on longer term goals. Addiction exemplifies this challenge. In most moments, life will be better, at least for a short while, if I engage in addictive behavior (Heyman, 2009). Against that near-certain pleasure and satisfaction, I can weigh the importance of my longer term interests. Am I willing to delay the likely gratification from the “right now” activity, for the less certain but bigger gratification to be experienced later?

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What can make the “right now” satisfaction even more compelling is a history of distal factors that predispose us to find intoxicated states highly desirable. These distal factors can include difficult circumstances or outright trauma growing up; dysfunctional basic beliefs about the self, others, or the future; a childhood or teenage history of observing others engage in problematic addictive behavior; and personal “success” using addictive behaviors to cope or escape (leading to positive expectancies about them). If the clinician does not have significant personal experience with problematic addictive behavior, a comparable experience may be how easy or hard it is to cut back on eating when quite hungry and when not especially hungry. Individuals with a large number of distal factors are often quite eager to escape the tension that they may live with on a daily basis. As adverse childhood experiences accumulate, addiction is a common outcome (Felitti et al., 1998). For these kinds of clients CBT for addiction will, for the most part, be focused on issues covered in the other chapters.

MAIN PROCEDURES This summary of CBT for addiction describes an ideal course of basic individual psychotherapy. The summary is intended for clinicians who are familiar with CBT or addiction, but not both. Extended presentations of CBT for addiction include Walters and Rotgers (2013), who summarized evidence-based treatments for addiction (i.e., motivational interviewing, contingency management, CBT, 12-step facilitation, couples and family approaches, and medications). Miller et al. (2011) also covered brief intervention and a wide range of broader treatment issues (including settings, treatment matching, case management, promoting adherence, coping with resistance, and ethical issues). Denning and Little (2012) focused on harm reduction, an approach that helps clients improve (i.e., move up in Figure 6.1) without necessarily reaching one of the two highest levels. Wenzel et al. (2012) presented group CBT using a cognitive therapy framework. Sobell and Sobell (2011) combined group CBT with motivational interviewing. O’Farrell and Fals-Stewart (2006) presented a couples’ approach. Smith and Meyers (2004) described an approach for working with families to motivate loved ones to enter treatment. Client workbooks may be useful for both client and clinician; options include Epstein and McCrady (2009), Horvath (2004), and Monti et al. (2002). In addition to gaining current knowledge about CBT for addiction, the clinician will also benefit from an increased capacity to understand addictive experiences. The clinician may not be “in recovery”; even if the clinician has past addictive problems, about half of similar individuals do not use the term “in recovery” to describe themselves (Kelly et al., 2017). Regardless of whether this term is used, the clinician’s self-assessment about where on Figure 6.1 they



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have been for various substances and activities at different times in life, and in particular, any current struggles with keeping addictive behavior from becoming problematic, increases the capacity for empathic understanding of clients (Horvath, 1994). Many clinicians ignore addiction in their clients or actively attempt to avoid it. However, in most clinical settings, addiction is likely to be a component of many cases. Addiction issues (from subclinical ones to severe SUD; see Figure 6.1), like depressive symptoms, anxiety symptoms, “stress,” and relationship problems, are expectable aspects of clinical practice. Further, many clients with addiction do not identify it along with other presenting problems, or they may actively hide it. The clinician needs to screen for addiction initially, be alert for signs of it later, and be confident that providing basic addiction treatment is within their skill set. Clients are poorly served if the clinician immediately refers them out because “I don’t treat addiction.” For many clients, attending a first session is a major step forward. Facing the unknown again with a new provider may require more courage than many clients can muster. The moment of motivation, which can fluctuate rapidly with any clinical problem but especially addiction, needs to be acted upon quickly when it appears. Fortunately, basic addiction treatment is not difficult for someone already trained in CBT, and it is, similarly, not impossibly challenging for clinicians using other therapeutic approaches. There remains the option to refer the client at any time for more intensive treatment. Furthermore, addiction is remarkable in that the intensity of effective treatment is not highly correlated with the level of addiction. Clients with a severe SUD may be effectively treated with a brief course of basic treatment or even a brief intervention. For instance, in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), four sessions of motivational interviewing were as effective as 12 sessions of CBT or 12-step facilitation (Project MATCH Research Group, 1997). Clinicians can use the concepts and techniques from this chapter knowing that in general they will do no harm, and that they often may be sufficient to address the addiction presented, with no further treatment needed. Viewing addiction treatment in this way is to view it, as already noted, as an adjunct to self-guided change, the process by which most individuals resolve addiction. The clinician strives to identify what has halted self-guided change and assists the client in creating plans for getting beyond these obstacles. Although the addiction treatment industry generally appears to view treatment as essential to change, this perspective is not consistent with the self-empowering stance of CBT. In CBT, we help clients resolve current problems and prepare for future problems. We do not insist that everyone has the same needs; hence, we do not provide addiction “programs.” We do not provide more help than is needed; hence, clients are free to end treatment when it has served them sufficiently (and are free to return as needed). If treatment can be helpful, too much or a nonindividualized approach could also be harmful.

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Treatment primarily addresses the dysfunctional belief “I need this [addiction].” Treatment also addresses beliefs like “I’m defective” (and the sense of shame, guilt, and demoralization) and “I will never have other sources of satisfaction” (and the sense of hopelessness and despair). Most addiction clients have attempted to cut back or stop. If unable to do so, they typically draw negative conclusions about themselves and their futures, and these beliefs need to be addressed. Addiction clients often expect to be criticized and labeled (e.g., “alcoholic”), and they may be highly sensitive to this possibility. The clinician can frame addictive problems as arising from a combination of factors including chance and situation (e.g., “Your first friends in college happened to be drinkers, so as a shy person of course you wanted to fit in and used drinking to do it”) and difficultly with balancing short-term and longer term satisfaction. Addiction is viewed not as a unique problem for that individual, but as an apparently universal human challenge. Just as engineers translate the findings of theoretical and applied physicists into actual products and processes, clinicians translate the findings of psychological scientists for the benefit of specific clients. In so doing they need to be aware of the differences between subjects in clinical studies and clients in actual clinical practice. This distinction exists for any disorder, but it is especially important in addiction treatment. Resolving problematic addictive behavior is fundamentally about establishing and maintaining motivation. When motivation is high enough, treatment is not needed. Clients come to treatment when they are ambivalent about change, or they would have changed already (Miller & Rollnick, 2013). They are motivated enough to seek initial consultation, but perhaps not much more. Subjects in clinical studies are highly selected and well-prepared for the treatment they experience. Subjects typically do not begin treatment until a significant degree of assessment has occurred. The assessment process may also include significant socialization about how to be a successful client. Subjects have also screened themselves as generally appropriate for the treatment they expect to experience. By comparison, many clinical practices will initially screen and evaluate nearly anyone. Because a very wide range of clients can show up, screening, assessment, socialization, treatment planning, relationship building, history taking, and other tasks all need to occur in the initial session, or there is little hope of keeping the client engaged for additional sessions. Subjects in treatment studies may often be motivated by the opportunity to receive free treatment. In return for having no financial burden, these subjects may be fairly tolerant of the study process established by scientific investigators (which may appear to have little connection to their immediate needs). Clients in clinical practice may be significantly more demanding. They want to feel respected and understood, to focus on the issues of concern to them (not to the clinician), and to have a therapist who seems sensible to them and who uses methods that make sense to them. Overall, they want to experience good value for their time



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and money (Norcross & Lambert, 2011). Consequently, I focus first on the initial session, in the hopes of engaging clients effectively so that they will return for additional sessions if needed. Fortunately, CBT begins even in the initial session by establishing a foundation for identifying and changing the fundamental dysfunctional belief, “I need this [addiction].” The Initial Session If the client has not volunteered information about addiction, it is necessary to screen for it. In some clinical situations, screening is accomplished by having the client complete screening instruments prior to the session. The clinician can review the responses with the client, paying particular attention to the nonverbal behavior in that discussion. If there are no screening instruments, then “What problems do you have from substance use or other addictive behaviors like gambling and video games?” is a straightforward question, but one that may not gather the information the clinician needs to be helpful. Shame, guilt, and demoralization about the possibility of change may often lead clients to withhold information about addiction, even if they have other primary presenting problems. An alternative screening question is “What substances and activities do you enjoy?” A noncommittal response can lead to an elaborated question, such as, “I’m thinking about caffeine, nicotine, alcohol, cannabis, cocaine, heroin, methamphetamine, and other substances, and activities like gambling, pornography, video games, shopping, and so forth. Which ones of these do you enjoy?” If the process of answering this question reveals client hesitation, the therapist can address this hesitation directly. Options include questions like “Is this an uncomfortable question to answer? Are you concerned that I will criticize your choices? Are you concerned about what I will do with that information?” The following statements may be useful: “You told me about your (depression, anxiety, stress, relationship) problems. Sometimes problematic addictive behavior contributes to these problems. Because we want to find a complete solution for you, it is important I understand the big picture of your life. There may be connections between your various behaviors that you didn’t realize. Fortunately, I will make almost no demands on you. Even if we do discuss changing some of your addictive behaviors, the choice to do so, or not, will be yours. In any event, all of us at times act on our short-term interests when we would do better to give more attention to our longer term interests. There are not too many people who save too much for retirement! We are all by nature drawn to short-term satisfaction. We can focus on helping you adjust that balance so that your longer term satisfactions get the attention they need.” If the client screens positive for addiction, there is probably insufficient time in the initial session for a complete functional analysis (described more fully later in this chapter). However, a limited functional analysis can be achieved by asking, “What do you like about drinking?” This question suggests that the

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therapist will focus on drinking as an adaptive effort that has significant positive results for the client (or the client would have stopped it). Individuals do not continue with addictive behaviors they do not enjoy or that do not bring some benefit. Only enjoyable behaviors (e.g., drinking, gambling) are engaged in long enough, and large enough, doses to become coping methods. Ultimately these behaviors lead to the belief that “I need this” in order to cope with problems or achieve goals. In these initial interventions we are beginning to identify this client belief. The answers to “What do you like about it?” are often straightforward and easy to understand: “It helps me relax. I can’t socialize without it. I can unwind after a bad day at work with it. It makes me more creative. It gives me energy. It allows me to fit in.” The clinician can acknowledge (e.g., “That makes sense!”) how the client has, indeed, benefited from drinking. Drinking initially provides the kinds of benefits just described, but it may become problematic over time as harmful side effects occur. Additionally, the original benefits may diminish, sometimes substantially. The session now needs to transition to asking about what problems may have arisen from drinking: “So alcohol helps you relax, and you appreciate that relaxation very much. Alcohol has been a good friend in this way, and perhaps other ways as well. I’m curious though, has alcohol also led to any noteworthy problems?” Whatever problems are reported should be responded to empathically: “That’s too bad. That was hard on you. You didn’t realize that would happen and be so upsetting.” It is now time for a summary statement, such as “To summarize our discussion, you experience [these benefits] from drinking, and you don’t like [these side effects]. Have I summarized accurately?” The client may agree and spontaneously draw a conclusion, such as “I need to think about my drinking more. It’s time to cut back on alcohol” or “It’s time to stop drinking.” If such a conclusion is not offered, the client can be asked, “Given this complex relationship with alcohol, what is your plan with it?” If the session is primarily devoted to drinking (perhaps because it was the presenting problem), then treatment planning might begin immediately. If there are other more significant problems to address, then addressing drinking may be deferred: “It appears we should move on from drinking for now. If you track your drinking until next session, even if just mentally, we can discuss it again next time.” Self-monitoring is a way for the client to keep concerns about drinking in mind. Most problems need continued attention for resolution. The exact placement of the client on the continuum of problems (see Figure 6.1) is not generally a crucial issue. If there are more addictive problems than the client wants, then treatment is warranted from the clinical perspective, even if the problems do not meet medical necessity as an insurer might define it. Ideally, five accomplishments emerge from the initial session. First, the client and therapist construct a prioritized list of mutually agreed upon goals (based on “What’s wrong?”) and a tentative plan for achieving them (i.e., “How



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do we fix it?”). In CBT, this list and plan is often termed a case conceptualization. Second, the session needs to establish for the client that the therapist is understanding and not punitive or critical. Perhaps the therapist is helpful in articulating the client’s experience, even beyond what the client was able to express. The session also needs to establish, third, that the therapist is working on the client’s behalf (and is concerned about the client); fourth, that the therapist is respectful; and fifth, that the therapist is trustworthy. If these conditions are met, then the client can conclude that the sessions are helpful and worth a return visit (Norcross & Lambert, 2011). If the client is well advanced in self-guided change, the initial session may be the only one needed. The elements addressed in the next section may then need to be included, very briefly, in the initial session. Continued Sessions If resolving addiction is on the goal list, how much therapy time it merits will depend on the other goals being addressed. The idea that addiction is a “primary problem” and must be addressed before other problems, even if accurate in a few cases, may not align with the client’s priorities. In such cases, making progress on other goals may keep the client involved long enough to allow returning to goals about addiction. In general, from the client’s perspective, treatment involves building and maintaining motivation to change, learning how to cope with craving and manage high-risk situations, addressing related issues (e.g., anxiety, depression, trauma), achieving greater lifestyle balance (to prevent a recurrence of problems), improving relationships, and enhancing meaning and purpose in life. From the psychotherapist’s perspective, there are potentially numerous technical questions to address, including level of care, frequency and intensity of treatment, ancillary services, how to conduct exposure sessions (for coping with craving), psychiatric and addiction medications, treatment techniques for various comorbid problems, involvement of family members, harm reduction techniques, attendance in mutual help groups, communication with other providers, and so forth. An addiction specialist may well be needed, as someone to refer to or as a consultant. Nevertheless, because addiction treatment is an adjunct to a naturally occurring process, these technical questions may never emerge or may evaporate quickly. As with many activities in life (such as chess and psychotherapy), beginnings and endings are easier to describe than “the middle game.” The following tasks are presented for consideration when progress does not occur or seems to reverse itself. In longer term cases, progress is rarely smooth, and fluctuations should be expected. Cycling back to tasks that once appeared completed is common. After each recurrence, for instance, the immediate intervention can be, “What did you like about it?” Trust is also not an all-or-nothing matter. It may take some time for the client to reveal information that is crucial to success, but that the client was not ready to utter.

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Time on task is also very much affected by client sophistication, resources, and circumstances. As already noted, because the client’s motivation to change is the single most important aspect of achieving a good addiction outcome, if that motivation becomes strong and stays strong, many aspects of a “complete” CBT for addiction can be abbreviated. Progress made on co-occurring problems can also be highly motivating because the belief “I need this addictive behavior” can become less accurate as alternative coping methods are developed. If the addictive behavior is needed less, addictive problems become more prominent and further increase motivation to change. As with other CBT, sessions need to be structured (to a degree consistent with client preference) to include items like a check-in about events since the last session (especially cravings and high-risk situations), an update on projects from last session and any ongoing projects, an agenda for the working time of the immediate session, plans for continuing work between sessions, and a review of progress to date on the goal list and of the session just conducted. Some clients are highly talkative, and the clinician may need to guide discussion discreetly toward the above topics, possibly in random order, rather than follow a stated session agenda. Functional Analysis A functional analysis connects the antecedents of a behavior, the behavior itself, and the consequences of the behavior (ABC) in an effort to understand how specific situations lead the client to expect that the addictive behavior will be reinforced in them. Most addictive behaviors are strongly reinforcing because of their biochemistry, and they often come to be strongly associated over time with multiple situations. Nicotine in cigarettes is a clear example of the power of learning in addiction. Although nicotine itself is a relatively weak intoxicant (i.e., no one is advised not to drive or not to sign a contract while under the influence of nicotine), it can become associated with so many situations (at least before the advent of significant smoking restrictions) that quitting can be a challenge nearly everywhere. One of the advantages of “going off to rehab” is that it removes the client from cues to use, such that abstinence in a facility is much easier to maintain than in the normal environment. Unfortunately, recurrence of addiction upon discharge is common because typically clients in residential treatment do not engage in any exposure therapy to practice facing, resisting, and forming new associations with cues to use. The limited functional analysis suggested above, to ask about the benefits (i.e., rewards or consequences) of the addictive behavior, recognizes that the biochemical effects may be more important to understand than the cues that elicit the behavior, especially if the behavior is daily or near daily. In some cases the cue is a time of day, regardless of immediate environment. A complete functional analysis (Smith & Meyers, 2004) includes antecedents such as (a) external triggers (i.e., with whom, where, when) and (b) internal triggers (i.e., what were you thinking and feeling), the behavior itself (i.e.,



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what, how much, over how long), and consequences such as (a) short-term positives (i.e., enjoyment with whom, where, when, pleasant thoughts, pleasant feelings) and (b) long-term negatives (i.e., interpersonal, physical, emotional, legal, vocational, financial, and other). A blank form to facilitate functional analysis may be brought into session. An easy-to-recall version of the ABC is to use the journalism questions (i.e., who, what, when, where, why, and how) with respect to relevant antecedents, behavior, and consequences, with particular emphasis on thoughts and feelings at each step. In some cases, the answer to the question “What do you like about it?” will be sufficient as a functional analysis. If an immediate reduction in addictive behavior occurs, therapeutic time may be best employed in other areas. Presumably, in these cases, treatment will focus on building the client’s capacity to achieve the benefits of the addictive behavior by other means or reducing the need for these benefits. To whatever extent the functional analysis is completed, it is used for making changes that will reduce the addictive behavior. Examples include “Oh, I get it. I have been drinking to relax. I just need new ways to relax” or “I see that most of my excessive drinking occurs on the weekends, with only two people, and only if we are watching sports. It’s so obvious when you put it down on paper. Maybe I can change that routine to help me reduce drinking until I’m strong enough to handle those situations.” Moderation Training In CBT for addiction, either abstinence or moderation is an option and can be considered from both the behavioral and cognitive aspect of CBT. The behavior may be reduced or stopped. The cognition “I need this” can become modified either to “I enjoy this but don’t need it” or “I can live without this.” In the addiction treatment industry, it is still commonplace to hear “moderation isn’t possible.” Even if moderation after severe SUD is viewed as impossible, there should be little argument that moderation after subclinical use is possible. A review of the evidence about who can most easily moderate is beyond the scope of this chapter, but a CBT perspective assumes that moderation is possible starting from any category in Figure 6.1 (Heather & Robertson, 1983; Rotgers, 2013). In practice, the more important questions are (a) how much effort will be involved in accomplishing moderation and (b) whether the benefits of moderation will have been worth the effort. Even if someone appears not to be a good candidate for moderation, it is crucial not to dictate abstinence or moderation to the client. Doing so may arouse psychological reactance (Brehm & Brehm, 1981). The result can be a client focusing on “I need to show you I can moderate” rather than focusing on “I actually don’t need this addictive behavior.” With respect to this issue, CBT adopts the perspective of motivational interviewing, meaning that the cognitive behavioral practitioner views this decision as belonging to the client. At present, the most sensible course regarding abstinence or moderation appears to be to suggest to the client that moderation is indeed possible, but

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that it may not be worth the effort involved for the minor benefit likely to be obtained and at the costs likely to be experienced in what may be a trial-and-error process of successive approximation to the desired goal. If the client is already close to further major negative consequences, moderation plans need to be considered carefully. Relevant questions include ones about motivation, past history of moderation success, past history of persistence in the face of obstacles, current circumstances and the likelihood of strong cravings being elicited in them, whether the substance or behavior is illegal, and the likely reactions of significant others to moderation and to any slips or relapses that occur (Horvath, 2004). A family session on this subject may be worthwhile. In most cases, abstinence is easier to accomplish than moderation. Once use begins, it can become very difficult to maintain the belief that “I don’t need this.” Even if someone aims to moderate, an initial abstinence period of 30 or even 90 days helps fortify a full set of adaptive beliefs. Abstinence is generally easier because after about 90 days craving has often diminished to near zero, multiple social encounters have been negotiated without using, and new relevant habits have been established. A difficult clinical scenario emerges when the client is “working” on moderation but repeatedly not achieving it. In such cases, it is crucial to evaluate, via functional analysis, the episodes of excess. If the client wishes to continue in treatment, the focus may shift from moderation training to harm reduction. Client workbooks specific to alcohol moderation training include Miller and Munoz (2004) and Rotgers et al. (2002). Moderation training for other substances is even more controversial in the addiction treatment industry than it is for alcohol, but the same general approach applies. In the case of other substances, such treatment might be termed harm reduction rather than moderation training. Co-Occurring Problems Does the goal list accurately represent what the client needs to work on? Here, input from the clinician to educate the client about problematic addictive behavior, and about cognitive behavioral case conceptualization, is essential (Beck et al., 1993). Ideally, the goal list includes both new behaviors and new beliefs. Creating the goal list is itself a motivational intervention. The client may not appreciate that one consequence of addictive behavior is an increase in emotional or behavioral problems. Indeed, these problems may resolve when addictive behavior is reduced or ended. In many, if not most addiction cases, the primary focus in sessions is co-occurring problems (which include co-occurring disorders). The other chapters will thus be highly relevant to the clinician treating addiction. However, clients do not care whether a diagnosis applies to their pressing problems; they just want help with them! If we focus on co-occurring disorders alone (all clients have the broader category of co-occurring problems), then in addiction treatment settings, most clients have additional diagnoses. In a mental health setting, comorbidity is lower but still common.



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Coping With Craving For some clients, craving is not a critical issue. However, for other clients, “I need this” becomes especially believable when craving is present. When a client experiences intense craving, almost nothing else is in the client’s awareness. Does the client understand craving sufficiently in order to cope with it effectively? A powerful, yet typically safe, approach is to discover past experiences of successful coping with craving. These experiences generally occur when a sudden change in situation brings to mind a priority higher than the addictive behavior. For instance, the client may have planned to get intoxicated, but then their ex-spouse called with a last-minute request to watch the children, who, for this individual, are a high priority. Ideally, a discussion of such episodes will clarify the roles of three accurate beliefs about craving: (a) it is time-limited, (b) it is not harmful, and (c) it does not force the client to do anything. Careful interviewing can elicit the client’s experience of the accuracy of each belief. The same set of accurate beliefs applies to panic attacks. Each client’s priorities, situations, and degree of self-control are different, but we assume that there are at least a few situations, even in the most severe cases, when other priorities will assert themselves. If addictive behavior is, in fact, the client’s highest priority at all times, then treatment is pointless. But this state of affairs is highly atypical and might be classified as suicide-by-addiction rather than addiction. If the client is physically dependent on the substance (e.g., alcohol), then control might be exhibited as allowing withdrawal to occur, or drinking just enough to prevent significant withdrawal symptoms, or tapering off over time. Once past success coping with craving is identified, then practicing coping with craving becomes less risky (but, in any event, should be undertaken cautiously). One way to begin this practice is to elicit craving at the beginning of a session (to allow time for it to dissipate) and then to move the discussion on to other topics and not address the craving at all, allowing the simple passage of time to result in diminished or evaporated craving. Although redirection, counter-argument, and distraction techniques can be used against craving (Horvath, 2004), many clients may wonder if they can apply these techniques well enough. However, all clients can simply wait until craving goes away. Monitoring craving and the responses to it would normally be a routine task in ongoing CBT for addiction. Ultimately, the client needs to have confidence that all routine life situations can be engaged without strong concern about craving, and that cravings that arise “out of the blue” can also be managed. Ongoing graded exposure therapy may be the most straightforward method to achieve this confidence. One very simple exposure method (which might also be termed willpower training) is to suggest that once the decision to engage in the addictive behavior is made, the client set a timer before acting. For instance, even if I have decided to drink, I can set the kitchen timer for 5 minutes before doing so. After the timer goes off, I can drink or set it again (for any period of time). Over time, I can set the timer for increasingly longer times, until eventually when it goes off

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my mind has moved on and the craving has evaporated. In offering this suggestion, it is important to have the initial timer setting be quite short, seconds if necessary, so the client has a success experience. Relationships Although there may be a bias among clinicians for individual addiction treatment, the outcomes for couple or family treatment are at least as good (but beyond the scope of this chapter). Given that, for most individuals, there is no more important source of satisfaction and meaning in life than relationships, even if significant others are not in session, treatment should include a focus on improving these relationships. Resources for improving relationships, for both clinicians and clients, are easily available. Lifestyle Balance Addictive behavior is often used to redress quickly an imbalance that has built up over time. For instance, sleep deprivation leads to fatigue, which can be overcome by stimulants. Excessive concentration on work leads to tension, which can be resolved by drinking. Many clients need to review their knowledge of and habits regarding sleep, exercise, and nutrition, as well as other health habits and basic balances in life such as work versus play, social versus alone time, new projects versus maintenance activity, family time versus time with friends, activity versus contemplation, and so on (Horvath, 2004). Achieving better balance reduces the risk of craving, which in turn reduces the risk of recurrence. Meaning and Purpose in Life Ultimately, the purpose of resolving problematic addictive behavior is to live with greater purpose and meaning, which will lead, as a byproduct, to increased happiness. In the midst of major addictive problems, the client typically focuses almost entirely on a short time frame (hours to days). As change occurs, that time frame can increase, ultimately to a focus on activities that may extend beyond the client’s lifetime. The discussion of ultimate values and beliefs, and the day-to-day activities they imply for this client, may not typically be considered part of CBT. However, a well-entrenched addiction may require very high levels of persistent motivation to displace it, and such motivation may need to be based on the client’s ultimate values and beliefs. Many 12-step participants state that their motivation to change is ultimately founded on their acceptance of guidance from a “higher power.” Although theistic values and beliefs are not necessary for resolving addictive problems (even in individuals who are theistic), the 12-step approach demonstrates how focusing on ultimate beliefs and values is motivating. The identification of ultimate values and beliefs circles the client back to the search for motivations to change. Early in the change process, short-term motivations are identified (e.g., “I won’t be hung over in the morning”). As progress occurs, an ultimate value might emerge (e.g., “If I’m not drunk tonight and hung over tomorrow, I can



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be a much better father to my children”). Ideally the clinician repeatedly reflects back to the client progress toward higher or ultimate goals. Initially, clients are motivated to escape the pain that brought them into treatment (the precipitating event). However, over time, the pain of the precipitating event fades in memory, and craving tends to reassert itself. Until it does, there may be a “honeymoon period,” when the clinician can help the client gain greater confidence in experiencing longer term satisfactions in order to leave problematic addictive behavior behind.

SPECIAL CONSIDERATIONS WITH THIS POPULATION Medical Considerations Ideally, each client is also under the care of a physician. If so, the nonmedical therapist need only stay in contact with this physician as needed. It may be necessary to strongly (and perhaps repeatedly) encourage the client to seek such care. Beyond all the possibilities for medical complications from substance use, the primary treatment concern is withdrawal from alcohol or other central nervous system (CNS) depressants (e.g., benzodiazepines like Xanax or Valium, or barbiturates). If a client stops these substances suddenly, a withdrawal syndrome may develop. Severe withdrawal syndromes may be fatal, especially in someone medically compromised. Withdrawal from opiates, which have similarities to CNS depressants but also significant differences, is quite uncomfortable but rarely fatal. Nevertheless, even in these cases the client should be referred to a physician. By comparison, significant withdrawal from stimulants and most other substances will be uncomfortable but not dangerous. Therefore, substances can be divided into two broad groups: (a) those that can be stopped suddenly and (b) those that need to tapered over time or have medically managed detoxification. The CNS depressants and opiates can be compared to scuba diving. With enough time at significant depth, the body accommodates to the pressure of the water (a kind of “depressant”) and cannot return quickly to the surface without significant negative consequences (the bends). Other substances are like taking a hot air balloon ride, which can end safely with a quick return to the original altitude. Some clients are not willing to seek medical care, often for privacy reasons. They may have experience managing withdrawal symptoms or may be able to taper successfully. In some cases, they may know substantially more pharmacology than the psychotherapist. Nevertheless, referral to a physician is ideal. Medication-assisted treatment (MAT) also involves a physician. In this approach, the patient is given a medication that substitutes for the original substance (e.g., methadone or buprenorphine for opiates) or one that interferes with what has been the typical use of the substance (e.g., disulfiram, naltrexone, or acamprosate for alcohol; naltrexone for opiates). The use of a substitute has been controversial because the client is not abstinent. However, substitutes are perhaps more effective than any other approach to treating opiates, to the

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degree that once a substitute is in place clients often no longer seek psychological services. Clinicians whose MAT clients discontinue psychotherapy can reach out to them with an open invitation to return when the time seems right. Residential Treatment, Outpatient Treatment, and Ancillary Services Generally, recommendations about these options should be made by addiction specialists. Residential treatment is overemphasized in the United States and does not provide, in most cases, increased effectiveness when compared with outpatient (Miller & Hester, 1986). Families may believe they know best and that “rehab” is definitely needed. However, other options may achieve the peace of mind they are seeking and also help the client. Admission for detox (detoxification) may be an essential first step (per the physician involved). It can be accomplished, typically over a span of days, and sometimes as an outpatient, without continuing on in residential treatment. Mutual Help Groups For many clients, the availability of free mutual help groups is a powerful adjunct to treatment. Clients should be encouraged to consider one or more mutual help groups and attend if these groups appear helpful. The most widely available groups are Alcoholics Anonymous (AA) and the several dozen offshoots of it, including Narcotics Anonymous (NA), Cocaine Anonymous (CA), and Gamblers Anonymous (GA), collectively known as 12-step groups. AA itself is effective if the participant is sufficiently engaged (Kelly, 2017). Although 12-step groups are often the only mutual help group referred to, there is now evidence that other groups are equally effective. In a 1-year longitudinal study comparing four mutual help groups (i.e., AA, SMART Recovery [Self Management And Recovery Training], LifeRing Secular Recovery, and Women for Sobriety), participants equally involved in each group had comparable outcomes (Zemore et al., 2018). These three relatively new options are significantly different than AA in varying degrees, including (because of a decreased [or no] emphasis on spirituality) conversational meetings, and a self-empowering (rather than a “you-are-powerless-over-this-disease”) orientation. SMART, in particular, is highly compatible with CBT (Horvath & Yeterian, 2012). However, in most localities, these groups are not readily available, and their online versions may be insufficient for many people. Fortunately, participation in mutual help groups, 12-step or otherwise, is not essential for change. Although the differences between, for instance, AA and SMART appear to be substantial on the surface, it now appears likely that all of these groups work because of the common factors available in any mutual help group, especially the acceptance into the group’s social network (Kelly, 2017). Therefore, these groups cannot be distinguished on the basis of their effectiveness or their mechanisms of behavior change. However, many individuals will find one group



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superior to the others because of the approach to change it uses. AA’s powerlessness, spiritual approach or SMART’s self-empowering, CBT and motivational interviewing approach appeal to rather different groups of clients. Nevertheless, some individuals attend both groups. Genetics Although genetics can be a powerful influence in the development of problematic addictive behavior, they have a small role in addiction treatment. Perhaps because of the influence of the idea that “addiction is a disease,” many clients are interested in the genetic impact on their addiction problems. Just as many other behaviors and traits do, addictions run in families (Enoch & Goldman, 2001). Individuals who especially enjoy one or more substances (not all individuals enjoy all substances) probably inherited the biochemistry that allows for this enjoyment. These individuals may also have a high natural tolerance for one or more substances, which postpones negative consequences from the substance until higher doses are used. Impulsivity-related traits, including lack of premeditation, sensation seeking, and lack of perseverance, are genetically influenced and associated with having addictive problems (Kale et al., 2018). In treatment, these genetic differences should be acknowledged and addressed to the extent they can be addressed. Outdated Terms and Treatment Techniques Although there are many media portrayals about how family members or professionals need to “confront” addicts and alcoholics in order to break down their denial and initiate recovery, this approach is not part of CBT and not supported by evidence (Smith & Meyers, 2004). Moreover, “addict,” “alcoholic,” and “chemical dependency” remain widely used terms. The DSM-III supported the use of better terms, and DSM-5 continues that support. The language used to describe our clients influences how we interact with them and how they think about themselves (Kelly et al., 2016). By using current and nonstigmatizing language (such as the language in Figure 6.1, except abuse, dependence, and addiction), we increase the chances that treatment will be helpful. Confrontation (“You MUST stop drinking”) is still widely used, but it can be counterproductive: “When one’s freedom is threatened there is a natural tendency to reassert it” (Miller & Rollnick, 2013, p. 143; Brehm & Brehm, 1981). A motivational interviewing approach is much more likely to help the client remember how longer term goals are not being served by current addictive behavior (Miller & Rollnick, 2013) and to consider making new choices. In this approach, denial is understood as a description of a type of interaction between clinician and client, rather than as a trait of the client. Denial can disappear when the clinician changes how the discussion is being conducted by using autonomy-supportive language. If we do not insist our clients accept a label (addict or alcoholic), do not generalize from having one or a few substance

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problems to having problems with all significantly intoxicating substances (chemical dependency), and do not confront them because they are in denial, but rather inquire about what is important to them both now and in the future, we can build an alliance in which their energy can be used to address their problems and change, rather than to fight off our attempts to control their thinking.

OUTCOME DATA CBT is approximately as effective as any other treatment for addiction. The evidence for its effectiveness now spans decades (Carroll & Kiluk, 2017). In a meta-analysis of 53 randomized controlled trials of CBT for alcohol and illicit drug disorders, Magill and Ray (2009) found that Across studies, CBT produced a small but statistically significant treatment effect (g = 0.154, p < .005). The pooled effect was somewhat lower at 6–9 months (g = 0.1 15, p < .005) and continued to diminish at 12-month follow-up (g = 0.096, p < .05). The effect of CBT was largest in marijuana studies (g = 0.513, p < .005) and in studies with a no-treatment control as the comparison condition (g = 0.796, p < .005). (p. 516)

Even though no treatment is more effective than CBT for addiction, there are several treatments as effective. All three arms (i.e., CBT, 12-step facilitation and motivational interviewing) of Project MATCH (Project MATCH Research Group, 1997) had approximately the same outcomes, even at 1-, 2-, and 3-year follow-ups. Imel et al. (2008), in a meta-analysis, found that a wide range of rather different treatments for alcohol problems appeared to be equally effective. Even if CBT is no better on average than some other addiction treatments, might it be better for specific types of individuals? One of the goals of Project MATCH was to identify variables that might be used to match clients to the three types of treatments offered. No highly clinically significant matches were found. Other attempts at matching have also yielded minimal results. For now it appears that, just as with mutual help groups, clients will need to sort themselves into treatments. For clients seeking a fact-based, self-empowering, and reasoned approach to change, CBT is likely to be appealing. Clinicians can confidently use CBT for addiction but should refrain from stating that it is better than other approaches. Nevertheless, CBT is likely to remain a treatment of choice, and an option offered by competent clinicians and much sought out by clients for years to come.

MECHANISMS OF CHANGE Just as mutual help groups for addiction, despite their significant differences on the surface, may have the same mechanisms of change, so too with addiction treatments (or at least with alcohol treatments, where there are sufficient data



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from which to draw conclusions). If we assume that CBT for alcohol problems offers a unique approach by helping clients identify and change dysfunctional thoughts, beliefs, and behavior, then we should find that CBT (a) is better overall; (b) is better for some definable group; or (c) changes thoughts, beliefs, and behavior in expected ways. However, there is insufficient evidence to firmly support any of these ideas for CBT in general (Wenzel, 2017). As Imel et al. (2008) concluded in their review of alcohol treatment specifically, Although a lack of evidence in regards to treatment differences cannot fundamentally resolve the polemic between the models of treatment, our findings suggest that additional head-to-head comparisons of bona fide psychological treatments are unlikely to provide further answers. In addition, our findings are consistent with: (a) mixed findings in regards to matching specific client diagnostic traits to treatment characteristics and (b) a failure to find consistent patterns of theory specific mediation and moderation of treatment effects . . . research that looks beyond the therapeutic rationale as a guide to the psychological mechanisms responsible for change, to potentially more universal change factors may be increasingly beneficial. (p. 541)

For now, we need to preserve and advance CBT and other established treatments because they are working, but recognize that we have much to learn about treatment. One promising mechanism of change in CBT for addiction is the use of homework. Homework has long been considered an important aspect of CBT for addiction (Beck et al., 1993). Carroll and colleagues found that “participants who completed more homework assignments demonstrated significantly greater increases in the quantity and quality of their coping skills and used significantly less cocaine during treatment and through a 1-year follow-up” (Carroll et al., 2005, p. 794). Beyond homework specifically, CBT for addiction includes components that may yet be identified as mechanisms of action, including examining and preparing for high-risk situations (including refusal skills), changing inaccurate beliefs about craving, and emphasizing the autonomy of the client and the choices available. In order to advance the clinical practice of CBT, common clinical errors (Kim et al., 2016) need to be avoided. These errors include insufficient functional analysis, an insufficient goal list and case conceptualization, challenging seemingly irrational thoughts rather than investigating them, and not staying on the course set by the goal list and case conceptualization if problems arise (rather, such problems should be investigated and resolved or a course correction made). If CBT proves to provide factors beyond common factors of change, by avoiding these errors we increase our chances of providing these unique factors.

DISSEMINATION The use of CBT in specialty addiction treatment facilities is widespread, if only because of relapse prevention training. However, the underlying ideas of relapse prevention (which includes a harm reduction orientation) may not be

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given much weight. Rather, relapse prevention may be taught as a set of techniques. This chapter’s approach to CBT appears not to have been disseminated widely. How soon this situation will significantly change is hard to predict. Kiluk et al. (2017) found evidence that CBT4CBT (computer-based training for cognitive-behavioral therapy) improved treatment outcomes when added to treatment as usual: “In this methadone maintained sample, those with poorer quality skills in response to certain high-risk situations at baseline appeared to improve their coping strategies following CBT4CBT compared to standard methadone treatment alone” (p. 87). This software could be disseminated inexpensively. The opportunity for the dissemination of CBT for addiction to the large number of psychotherapists who already know CBT is promising. Some of these psychotherapists may need to move beyond the belief that addiction needs to be treated only by individuals with lived experience and only by using a 12-step, disease model approach. SMART Recovery is also disseminating CBT concepts (including those of REBT [rational emotive behavior therapy], DBT [dialectical behavior therapy], ACT [acceptance and commitment therapy], and others). However, it may be some years before SMART meetings are very widely available. Nevertheless, SMART may be the most effective method for disseminating CBT concepts and treatment because its meetings are free and open to the public. As participants in SMART cycle in and out of the U.S. treatment system, they may insist upon services consistent with their experiences in SMART.

APPLICATION TO DIVERSE POPULATIONS Any CBT for any disorder is capable of being completely personalized to the individual client. However, because CBT emphasizes using scientific facts, reasoning, and identifying and modifying unhelpful thoughts and beliefs, these emphases may resonate with privileged populations (who view them as skills that helped them attain and maintain their current societal position), rather than the underprivileged. However, CBT has been offered in large, federally funded addiction treatment studies, using community-based samples with diverse populations. For instance, in Project MATCH the outpatient arm of the study (952 subjects) was 28% female, 64% single, 80% White, 49% unemployed, and had 13.4 years of formal education (SD = 2.2 years; Project MATCH Research Group, 1997). In these studies, CBT works as effectively as other treatments. Above and Beyond in Chicago is an example of CBT in a diverse community setting. Since being established in 2015, this community clinic has served over 2,000 clients, a largely African American and underprivileged population, with substantial levels of illiteracy, past incarceration, and past homelessness. Clients are free to choose 12-step or SMART Recovery track. The SMART track is chosen by approximately 90% of clients (D. Hostetler, personal communication, January 30, 2018).



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SMART Recovery also has emerging groups in prisons and other correctional settings and was the subject of a large study (N = 5764) in the Australian prison system (Blatch et al., 2016), where a significant portion of the population is underprivileged. Participants who attended both a SMART training program and a SMART mutual help group had significantly lower percentages (compared with controls) of reconviction for general offenses (21%) and for violent offenses (42%).

CLINICAL EXAMPLE This idealized version of an initial interview and treatment plan may substantially underestimate how much time might be needed with some individuals. Issues addressed here in a few sentences might require entire sessions. THERAPIST: How can I help you? CLIENT:

I want to know if I’m an addict or not.

THERAPIST: Unless you have freely chosen that term it’s often unhelpful.

Everyone’s addictive problems are unique. How about if we focus on the problems you have and how to solve them? CLIENT:

Well, I have lots of problems: Alcohol, especially vodka, meth sometimes, food a lot, and sometimes gambling. I smoke weed every day too, but I don’t really think that’s a problem. Do you?

THERAPIST: Your substance use is up to you. I’m glad weed does not seem to

be causing major problems. CLIENT:

But that’s the thing: I pretty much get into trouble with anything addictive. Even TV! I binge watch shows and even YouTube. That’s why I think I’m an addict. I used to shoot coke and smoke heroin too, but they scared me too much, so I quit.

THERAPIST: Congratulations, that’s a big accomplishment. CLIENT:

I suppose so, but all these other problems too! Booze is now the worst. My doctor told me my liver is starting to get bad. Maybe I’m just an alcoholic, not an addict.

THERAPIST: That’s another probably unhelpful term. What would you like to

do about your drinking? CLIENT:

I’d love to moderate. I just don’t know if I can.

THERAPIST: How often have you tried? CLIENT:

Many times. Sometimes I’m successful, sometimes I’m not. If the craving gets strong, I just give in.

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THERAPIST: I could teach you techniques for coping with craving. But, actu-

ally, you already know about them. You just don’t realize it. You were successful with coke and heroin, right? CLIENT:

Yeah. That was interesting. It was like a switch got flipped in my head. I did have cravings, sure, but I had made up my mind.

THERAPIST: How were you able to make up your mind so firmly? CLIENT:

I could see where the coke and heroin were leading me. Two friends OD’d, and one went to prison for dealing. I’m smarter than all of them, but it seemed like in time even being smart wouldn’t keep me out of trouble.

THERAPIST: That’s impressive. You made a long-term decision, based on how

you want your life to go, and you stuck with it. CLIENT:

Yeah, actually I’m kinda proud of myself. But not with alcohol! I never liked the other stuff as much as I like booze.

THERAPIST: That often happens. Many people have one or a few favorites.

The rest are easier to deal with. CLIENT:

I get it. Alcohol is the tough one for me.

THERAPIST: What do you like about drinking? CLIENT:

Where do I begin? When I’m amped up, it calms me down. When I’m bored it gives me a lift. I can’t imagine partying without it, or winding down without it. When I’m stressed, it’s the best. Once I get going that’s all I want to do. I do moderate sometimes, but sometimes I just go for days.

THERAPIST: Alcohol is valuable for you. You like what it does for you. CLIENT:

I do. I really do.

THERAPIST: Did something happen recently that led you to call me? CLIENT:

I’m too embarrassed to talk about it. But let’s say that, if I don’t change, I’m going to get kicked out of the house. I think she means it this time. And I actually want this relationship. It’s the best one I’ve ever had. I love her, and I know she loves me. But not my drinking!

THERAPIST: I’m sorry, that’s a painful spot to be in. You love her, and you

love alcohol, and having both is looking difficult. CLIENT:

She says I need to work on my demons. Like I’m possessed! But in a way I am. My dad was a boozer. He never beat me, but I always thought he would. When I got to be 10, I finally realized he was always too drunk to do anything more than scream at



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me. But by then a lot of damage was done. I’m still way too scared, too much of the time. I guess booze really helps with that. THERAPIST: I’m sure it does. Alcohol may be cheaper, faster, and more effec-

tive for anxiety than anything else on the market. Unfortunately, it has some unfortunate long-term negative effects. CLIENT:

I’ll say. But yes, the booze really works. I don’t know what I’d do without it.

THERAPIST: Actually, you may know more than you realize. After all, you

quit coke and heroin. How did you do it? Somehow you learned to live without them. CLIENT:

True. But alcohol will be harder.

THERAPIST: Sounds like you might be deciding it’s time to change. CLIENT:

I don’t want to get kicked out of my place. She’s right, really. Alcohol is killing me. And I really don’t want to lose this relationship!

THERAPIST: Are you changing for her or for yourself? CLIENT:

You ask tough questions!

THERAPIST: I hope they’re helpful. That’s actually an important question.

We’ll probably talk about it more. CLIENT:

I do want to be a better partner. I do want to keep this relationship. I do want to keep my health. I do want to end up not like my old man. Huh! I guess I do want to change. But could I still moderate?

THERAPIST: No one seems to know how to predict with much accuracy

whether any individual can moderate. But we can find out in your case by trying, if that’s what you want to do. CLIENT:

Some doctor once told me moderation was impossible for someone like me. What do you think?

THERAPIST: We can find out by trying. But keep in mind that trying moder-

ation and not succeeding would be risky. How many more benders do you think she will tolerate? CLIENT:

I’m lucky I’m still alive now! Just joking, she’s not violent. But I’ll never forget the look on her face after the last one.

THERAPIST: She got your attention. One option to consider is an extended

period of not drinking. I’m thinking a year, but it’s your decision. It would create good will at home, and it would give you time to

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learn what you need to learn. Then at the end of that time you could reconsider the whole issue. CLIENT:

Actually, that sounds sensible, but it still scares me. Alcohol is a lot to give up. In some ways, it’s been the best friend I ever had.

THERAPIST: I believe you. CLIENT:

Still, as you said, I did it with coke and heroin. Oh, did I mention cigarettes? I quit smoking over 3 years ago.

THERAPIST: Congratulations, another big accomplishment. How hard was it? CLIENT:

Unbelievable! I knew I wasn’t going to smoke, but wow! What a pain! And for weeks!

THERAPIST: How often do you want to smoke now? CLIENT:

I almost never think about it anymore. Gee! That’s pretty good, isn’t it!

THERAPIST: I agree. And it shows you what’s possible. In fact, when it’s all

done, you may say that smoking was harder to change than drinking. CLIENT:

I had a friend tell me that. She quit heroin and cigarettes. She liked heroin more, but cigarettes were harder.

THERAPIST: So are you ready to take on this project? CLIENT:

As ready as I’m going to be. But I’ll need help.

THERAPIST: Understood. Let’s review a moment. You came here because you

don’t want your relationship to suffer from drinking. You like drinking in many ways, but the costs have become too high, in particular because your relationship is very important to you, and you also want to keep your liver. You are ready to abstain for now. I proposed a year, but we didn’t finalize that timeframe. For now, would you consider a month? CLIENT:

I could do a month. I’ve done that before.

THERAPIST: Good, we can reconsider in a month. You’ll need to learn how to

wind down from stress without alcohol, and there may be other skills to learn as well. That will be some of our most important work. You’ll also need to think about how important this change is for you, rather than just your partner. Does my summary sound accurate? CLIENT:

Yes, thanks.

THERAPIST: Okay, one immediate item is your recent drinking and the possi-

bility of withdrawal symptoms. Did you drink today?



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CLIENT:

Nope. I tapered off last week. I haven’t had a drink in four days. I’ve tapered before, because a few years ago I had withdrawal symptoms. They weren’t severe, but they were pretty uncomfortable. So I’m okay now.

THERAPIST: Good. And when do you see your medical doctor next? CLIENT:

Should I go again?

THERAPIST: That would be safest. I encourage you to do so. CLIENT:

Okay, I’ll get an appointment.

THERAPIST: And if you misjudged about withdrawal symptoms, call your

doctor or go to the emergency room immediately, okay? CLIENT:

Thanks, but I’ll be fine.

THERAPIST: Understood. Let’s spend the rest of today making an initial plan.

We may not get to everything today, so let’s begin by deciding when to meet next. What do you think? CLIENT:

I don’t know, what do you think?

THERAPIST: How is tomorrow? CLIENT:

Really? Fine by me.

THERAPIST: You’ll see, before long we may hardly be seeing other, perhaps

only once a month. But it’s good to start strong. CLIENT:

That’s good, actually. I only have one night to get through right away.

THERAPIST: Here’s my proposed agenda for the rest of this session. How does

this sound? Let’s talk about how to get through the rest of today, including how to relax tonight, how to cope with craving, what to tell your partner about this session, and how soon we might have a couple’s session. Sound okay? CLIENT:

Yes, that’s good. Especially the part about a couple’s session. I think she’d like to meet you.

THERAPIST: Good to know. If we have time today we can also discuss what

your other goals for being here are, including all those other substances and activities you mentioned, whether you will attend a mutual help group like SMART or AA, whether addiction medications or psychiatric medications might be helpful, and what to talk about with your medical doctor. Soon, you can also tell me your drinking story and your life story, including where you see your life heading. We’ll also talk about—and this will be a big part of our conversation—what healthy habits you can add to your life and, most importantly, what your life is

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going to be about if drinking isn’t in the picture. I know this is a lot to keep track of, but that is my job. For now, you just need to get through tonight, so let’s talk about that. CLIENT:

Sounds good. Here we go!

THERAPIST: Let’s start by considering what would be helpful tonight, based

on what you’ve already accomplished with smoking, coke and heroin. . . .

CONCLUSION CBT for addiction (problematic addictive behavior) has a well-established scientific history and foundation, is as effective as other addiction treatments, addresses the underlying belief that the addictive behavior is needed in the client’s life (and related unhelpful beliefs), can be used in a highly flexible manner (including the options to pursue harm reduction and moderation as well as abstinence), and can be used with underprivileged populations. For clients who prefer a fact-based, self-empowering, and reasoned approach to addiction treatment, CBT may be the treatment of choice.

REFERENCES Abrams, D. B., & Niaura, R. S. (1987). Psychological theories of drinking and alcoholism. Guilford Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books9780890425596 Bandura, A. (1969). Principles of behavior modification. Holt, Rinehart & Winston. Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. Guilford Press. Bishop, F. M. (2018). Self-guided change: The most common form of long-term, maintained health behavior change. Health Psychology Open, 5(1),1–14. Advance online publication. https://doi.org/10.1177/2055102917751576 Blatch, C., O’Sullivan, K., Delaney, J. J., & Rathbone, D. (2016). Getting SMART, SMART Recovery® programs and reoffending. Journal of Forensic Practice, 18(1), 3–16. https://doi.org/10.1108/JFP-02-2015-0018 Brehm, S. S., & Brehm, J. W. (1981). Psychological reactance: A theory of freedom and control. Academic Press. Carroll, K. M., & Kiluk, B. D. (2017). Cognitive behavioral interventions for alcohol and drug use disorders: Through the stage model and back again. Psychology of Addictive Behaviors, 31(8), 847–861. https://doi.org/10.1037/adb0000311 Carroll, K. M., Nich, C., & Ball, S. A. (2005). Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. Journal of Consulting and Clinical Psychology, 73(4), 749–755. https://doi.org/10.1037/0022-006X.73.4.749 Denning, P., & Little, J. (2012). Practicing harm reduction psychotherapy: An alternative approach to addictions. Guilford Press. Enoch, M. A., & Goldman, D. (2001). The genetics of alcoholism and alcohol abuse. Current Psychiatry Reports, 3(2), 144–151. https://doi.org/10.1007/s11920-001-0012-3



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Epstein, E. E., & McCrady, B. S. (2009). A cognitive-behavioral treatment program for overcoming alcohol problems. Oxford University Press. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245– 258. https://doi.org/10.1016/S0749-3797(98)00017-8 Heather, N., & Robertson, I. (1983). Controlled drinking. Methuen. Heyman, G. M. (2009). Addiction: A disorder of choice. Harvard University Press. https:// doi.org/10.2307/j.ctvjf9xd9 Horvath, A. T. (1994). Comorbidity of addictive behavior and mental disorders: Outpatient practice guidelines (for those who prefer not to treat addictive behavior). Cognitive and Behavioral Practice, 1(1), 93–109. https://doi.org/10.1016/S1077-7229 (05)80088-4 Horvath, A. T. (2004). Sex, drugs, gambling & chocolate: A workbook for overcoming addictions (2nd ed.). Impact. Horvath, A. T., & Yeterian, J. (2012). SMART Recovery: Self-empowering, sciencebased addiction recovery support. Journal of Groups in Addiction & Recovery, 7(2–4), 102–117. https://doi.org/10.1080/1556035X.2012.705651 Imel, Z. E., Wampold, B. E., Miller, S. D., & Fleming, R. R. (2008). Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive Behaviors, 22(4), 533–543. https://doi.org/10.1037/a0013171 Kale, D., Stautz, K., & Cooper, A. (2018). Impulsivity related personality traits and cigarette smoking in adults: A meta-analysis using the UPPS-P model of impulsivity and reward sensitivity. Drug and Alcohol Dependence, 185(1), 149–167. https://doi. org/10.1016/j.drugalcdep.2018.01.003 Kelly, J. F. (2017). Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction, 112(6), 929–936. https://doi.org/10.1111/add.13590 Kelly, J. F., Bergman, B., Hoeppner, B. B., Vilsaint, C., & White, W. L. (2017). Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence, 181, 162–169. https://doi.org/10.1016/j.drugalcdep.2017.09.028 Kelly, J. F., Saitz, R., & Wakeman, S. (2016). Language, substance use disorders, and policy: The need to reach consensus on an “addiction-ary.” Alcoholism Treatment Quarterly, 34(1), 116–123. https://doi.org/10.1080/07347324.2016.1113103 Kiluk, B. D., DeVito, E. E., Buck, M. B., Hunkele, K., Nich, C., & Carroll, K. M. (2017). Effect of computerized cognitive behavioral therapy on acquisition of coping skills among cocaine-dependent individuals enrolled in methadone maintenance. Journal of Substance Abuse Treatment, 82, 87–92. https://doi.org/10.1016/j.jsat.2017.09.011 Kim, E. H., Hollon, S. D., & Olatunji, B. O. (2016). Clinical errors in cognitive-behavior therapy. Psychotherapy, 53(3), 325–330. https://doi.org/10.1037/pst0000074 Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70(4), 516–527. https://doi.org/10.15288/jsad.2009.70.516 Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. Guilford Press. Miller, W., Forcehimes, A., & Zweben, A. (2011). Treating addiction: A guide for professionals. Guilford Press. Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment. Who benefits? American Psychologist, 41(7), 794–805. https://doi.org/10.1037/0003-066X.41.7.794 Miller, W. R., & Munoz, R. (2004). Controlling your drinking: Tools to make moderation work for you. Guilford Press.

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Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Preparing people for change (3rd ed.). Guilford Press. Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence. Guilford Press. Monti, P. M., Kadden, R. M., Rohsenow, D. J., Cooney, N. L., & Abrams, D. B. (2002). Treating alcohol dependence (2nd ed.). Guilford Press. Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy, 48(1), 4–8. https://doi.org/10.1037/a0022180 O’Farrell, T. J., & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. Guilford Press. Project MATCH Research Group. (1997). Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58(1), 7–29. https://doi.org/10.15288/jsa.1997.58.7 Rotgers, F. (2013). Cognitive-behavioral theories of substance abuse. In S. T. Walters & F. Rotgers (Eds.), Treating substance abuse: Theory and technique (pp. 113–137). Guilford Press. Rotgers, F., Kern, M. F., & Hoeltzel, R. (2002). Responsible drinking: A moderation management approach for problem drinkers. New Harbinger Press. Smith, J. E., & Meyers, R. J. (2004). Motivating substance abusers to enter treatment. Guilford Press. Sobell, L. C., & Sobell, M. B. (2011). Group therapy for substance use disorders: A motivational cognitive-behavioral approach. Guilford Press. Walters, S. T., & Rotgers, F. (Eds.). (2013). Treating substance abuse: Theory and technique. Guilford Press. Wenzel, A. (2017). Innovations in cognitive behavioral therapy: Strategic interventions for creative practice. Routledge. https://doi.org/10.4324/9781315771021 Wenzel, A., Liese, B. S., Beck, A. T., & Friedman-Wheeler, D. G. (2012). Group cognitive therapy for addictions. Guilford Press. World Health Organization. (1993). ICD–10 classification of mental and behavioural disorders: Diagnostic criteria for research. Zemore, S. E., Lui, C., Mericle, A., Hemberg, J., & Kaskutas, L. A. (2018). A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. Journal of Substance Abuse Treatment, 88, 18–26. https://doi.org/10.1016/j.jsat.2018.02.004

7 Bipolar Disorder Cory F. Newman

T

he symptoms that comprise bipolar disorder, though not always wellunderstood in the past, have both fascinated and frightened sufferers and observers throughout history, and have been associated with tragic heroes from Greek mythology to temperamental Romantic Era writers, artists, and musicians (Jamison, 1993). Kraepelin (1921) pioneered a scientific approach to the study of this area of psychopathology, painting a bleak picture of an unglamorous life of inexorable neurocognitive deterioration. Decades later, with the advent of pharmacologic treatments such as lithium, there was a greater sense of hope regarding the prognosis for persons suffering from bipolar disorder (Tondo et al., 1997). More recently, a range of evidenced-based psychosocial treatments—including cognitive behavioral therapy (CBT)— have shown promise in adding significantly to the overall treatment of bipolar disorder, emphasizing such skills as objective self-monitoring, behavioral moderation, regulation of sleep-wake patterns, improved communication and interpersonal collaboration, and metacognition, including rational responding and modifying maladaptive schemas (S. L. Johnson & Leahy, 2004; Reiser et al., 2017).1 Bipolar disorder consists of a wide spectrum of symptoms, and the course of the illness is highly variable. Though there are core principles of CBT that are applicable regardless of the condition in which a particular patient presents in a given session, an effective cognitive behavioral practitioner has to be able to assess changes (sometimes frequent and rapid) in a bipolar patient’s state of Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000219-007 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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mind and level of functioning, and to adapt the therapy agenda accordingly. Thus, the heterogeneity of bipolar disorder poses complexities in assessment and treatment planning (S. L. Johnson & Peckham, 2018). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) describes the many facets and subcategories of bipolar disorder. For example, the DSM-5 criteria for bipolar I disorder specifies the presence of at least one lifetime episode of mania, a term which is defined in such a way as to distinguish it from the less extreme but still problematic hypomania, which may also be present in bipolar I. However, if a patient is determined to have had a history of at least one major depressive episode and at least one hypomanic episode, but not a period of full-blown mania, this is designated as bipolar II. In spite of the lack of a full-blown mania, bipolar II should not be taken lightly, as it often confers serious symptoms on its sufferers, such as significant depressive episodes (with the potential for suicidality) and varying levels of functional impairment. Another variant is cyclothymic disorder, which comprises “chronic fluctuations between high and low moods that are not severe enough to qualify as episodes, yet persist for two years (or one year among children and adolescents)” (S. L. Johnson & Peckham, 2018, p. 253). Again, one should not be lulled into clinical complacency by the phrase “not severe enough to qualify as episodes.” For example, in a study of pediatric bipolar disorder, Freeman et al. (2009) reported that youth with cyclothymia have a lower quality of life and fewer days of quality functioning than their matched peers with serious medical illnesses. DSM-5 also describes “bipolar and related disorder due to another medical condition,” as well as “substance/medication-induced bipolar and related disorder” when sufficient mood symptoms have been triggered by the use of or withdrawal from substances. There is also a grab-bag category of “other specified bipolar and related disorders” (formerly called “bipolar disorder not otherwise specified”) that subsumes bipolar symptoms that do not meet full criteria for other sub-categories, such as short-duration hypomanic episodes (e.g., 2 to 3 days), as well as “unspecified bipolar and related disorders” when there is a probable but unverified history of manic symptoms. Add to all of these designations the myriad specifiers such as “with anxious distress,” “with mixed features,” “with rapid cycling,” “with psychotic features,” and others, and one can readily see the inherent difficulties in devising a treatment for bipolar disorder as if it were a single entity. For the sake of convenience, this chapter will choose the generic term bipolar disorder to refer to the entire bipolar spectrum, and will use subcategories when deliberately zeroing in on a specific type of bipolar disorder. Much of the literature on CBT for bipolar disorder is meant to refer to bipolar I (S. L. Johnson & Peckham, 2018), but this chapter describes interventions that may be used more broadly unless otherwise indicated. Another factor that potentially complicates the description of a given treatment for bipolar disorder is the fact that comorbidity is so prevalent (S. L. Johnson, 2004). Three top examples are anxiety disorders (as high as 60% to 75%; Goodwin & Hoven, 2002; Merikangas, & Kalaydjian, 2007), alcohol and other



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substance use disorders (up to 50%; Sherwood Brown et al., 2001; Zarate & Tohen, 2001), and personality disorders (ranging from 33% to 50%; e.g., Üçok et al., 1998). These additional diagnoses require more comprehensive treatment planning, with special attention paid to increased risk of medication nonadherence and suicidality (Üçok et al., 1998; Vieta et al., 2001). Bipolar disorder requires a longitudinal treatment plan given the disorder’s likely effects across the lifespan. Although CBT has a reputation for being time-effective, and for teaching patients durable coping skills that improve self-efficacy and help maintain gains over the long term, it is still often necessary to have repeated periods of CBT over the years, superimposed (ideally) on an ongoing regimen of pharmacotherapy (Newman et al., 2001; Reiser et al. 2017). Unless the cognitive behavioral practitioner is licensed to prescribe medications, the treatment will likely necessitate collaborative care between at least two mental health professionals. Such coordinated care requires good working relationships among the parties, including periodic communication, mutual support for and understanding of the respective treatment approaches, and skillful handling of situations in which the patient is dissatisfied with or rejecting of one of the treatments. It is helpful to think of CBT and pharmacotherapy as having points of overlap rather than as entirely separate treatments. For example, when pharmacotherapy is improving a patient’s stability of functioning, it facilitates the patient’s participation in CBT, including attendance, learning coping skills, and doing homework assignments. Similarly, when patients learn the CBT skills of self-monitoring and rational responding, they are in a better position to take their medications as prescribed and to identify and modify any excessively negative beliefs they may maintain about their medications (e.g., “I will lose my true self if I take medications”). Indeed, there can be a synergy between psychosocial and pharmacologic treatments (Basco, Ladd, et al., 2007; Sudak, 2011).

UNDERLYING THEORY Classic models of cognitive vulnerability in depression—including Beck’s (1967) model of negative self-schemas, Seligman’s (1975) learned helplessness model, and the hopelessness model (e.g., Abramson et al., 1989)—have been extended to bipolar spectrum disorders (e.g., Alloy et al., 2006). Alloy et al. (2018) reviewed the research indicating that the same cognitive styles hypothesized to be risk factors in unipolar depression may increase vulnerability to bipolar depressive episodes, stating, “Generally, many studies have indicated that individuals with BSD [bipolar spectrum disorder] in a depressive episode exhibit underlying cognitive styles at least as or more negative than those of unipolar depressed persons and more negative than those of healthy comparison individuals” (p. 111). The authors noted that bipolar sufferers in a depressed state also demonstrate negative cognitive biases on implicit tasks. Interestingly, Alloy et al. (2018) added that “hypomanic BSD individuals often present positive

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cognitive styles on explicit measures, but continue to exhibit evidence of underlying negative cognitive styles on implicit assessments” (p. 111). For example, a person in a manic state may experience a dramatic shift in mood valence such that they feel extremely attractive, with a desire to charm and seduce others, while still harboring self-doubts and a core belief of not being lovable, which is manifest in hiding away from others when depressed. Thus, the state of the person’s mood and belief may change with the phase of the illness, but the basic underlying vulnerability to feeling unlovable may remain. From a neurobehavioral perspective, there is evidence that persons with bipolar illness possess a hypersensitive behavioral approach system (BAS), a rewardfocused, motivational system involved in goal-striving and attainment of rewards (see S. L. Johnson et al., 2012). The BAS, which has been linked to a dopaminergic frontostriatal neural circuit activated by internal or external reward-relevant stimuli, is associated with increased motor activity, magnified focus on incentives (and less relative focus on risk), and heightened positive emotions associated with striving for goals (Gray, 1994; Haber & Knutson, 2010). Its corresponding cognitive styles include perfectionism, high valuing of autonomy, overambitious pursuit of goals, and marked self-criticism when these high goals are not met (Alloy et al., 2009). Data from recent studies are congruent with an integration of the cognitive models and BAS theories of bipolar disorder. For example, Lam et al. (2004) measured the cognitive styles of persons with unipolar depression and bipolar disorder via the Dysfunctional Attitudes Scale (Weissman & Beck, 1978) and found that the individuals with bipolar disorder scored higher than those with unipolar depression only on goal-attainment attitudes. Examples of such items included, “A person should be able to control what happens to him,” “I ought to be able to solve problems quickly,” and “If I try hard enough, I should be able to excel.” Similarly, Shapero et al. (2015) found that persons with bipolar disorder were more ambitious in their goal striving than depressed persons, but they were also more self-critical. Additional evidence for cognitive vulnerability to bipolar symptoms from a BAS perspective comes from Lozano and Johnson (2001), whose data indicated that cognitive styles involving the need for high achievement predicted increased manic symptoms over a period of 6 months. Rather dramatically, Alloy et al. (2012) studied adolescents with no prior history of bipolar disorder and (when controlling for initial mood symptoms and family history of bipolar disorder) found that ambitious goal-striving predicted first onset of bipolar disorder over a 13-month follow-up. Although BAS appears to be a feature that is particularly relevant to bipolar disorder, the preponderance of evidence seems to suggest that similar maladaptive cognitive styles may serve as vulnerabilities to both unipolar and bipolar mood disorders (Alloy et al., 2018). The dysfunctional attitudes, maladaptive self-schemas, and attributional styles described in hopelessness theories and Beckian cognitive theory appear to exhibit some independence from current mood state but predict onset and recurrence of symptom episodes in bipolar



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disorder, both spontaneously and in conjunction with life events that interact with the patient’s cognitive style. For example, the self-image of bipolar patients is composed of a complex combination of both positive and negative self-regard (e.g., Scott & Pope, 2003; Winters & Neale, 1985), though the “hyperpositive” aspects of self-image tend to emerge as a prodromal sign of hypomania (Goldberg et al., 2005; Lam, Wright, & Sham, 2005). These findings have direct therapeutic implications, in that cognitive-behavioral interventions need to help bipolar patients moderate their goal pursuits and self-image whilst taking care not to exacerbate the aspects of their thinking that are self-doubting and self-denigrating. Bipolar patients also demonstrate poor autobiographical recall (i.e., highly general and nonspecific) for both negative and positive life events, even exceeding the difficulties exhibited by persons with unipolar depression (Mansell & Lam, 2004; Scott et al., 2000). Cognitive behavioral practitioners can use guided imagery to help patients retrieve the specifics of important memories so that cognitive restructuring and problem solving can proceed effectively (Mansell & Lam, 2004). Alloy et al.’s (2018) summary of the above findings (and more) indicates that future research will continue to take into account the integration between cognitive and neurobiological models of bipolar disorder. Life events also play an important role in the development and expression of bipolar symptoms. S. L. Johnson et al. (2016) reported that childhood abuse is associated with greater severity of bipolar illness. Similarly, exposure to trauma at any age is related to chronic stress and greater reactivity to negative life events that worsen the course of the disorder. Further, family difficulties that include patterns of aversive interactions predict an increase in bipolar symptoms, particularly depression. Lack of social support in general is yet another exacerbating factor (S. L. Johnson et al., 1999). Similar to problems with patients’ problems with cognitive biases and dysfunctional behavioral habits, environmental hardships are important targets for intervention in CBT. The problems above can be targeted together in CBT, as there is evidence that stressful life events, cognitive vulnerabilities, and mood symptoms all influence each other (Calvete et al., 2013). In summary, the CBT model of bipolar disorder strives to find a conceptual bridge between biology, beliefs, and behaviors; between triggering life events and patients’ individual ways of making meaning out of these events; and between cognitive-emotional “states” and “traits.”

THE THERAPEUTIC RELATIONSHIP An important part of establishing a healthy, constructive therapeutic relationship lies in providing good psychoeducation about bipolar illness and its treatment in a way that invites the patient’s input. As noted by Colom and Murru (2011), psychoeducation with bipolar patients should sound like it is coming from a place of partnership, rather than from authority, and in a spirit of mutual

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education, rather than the mere unilateral delivery of information. In this manner, trust and teamwork can be established. Therapists need to be able to offer validation for patients’ sense of despondency and demoralization when they are in their down phases, and yet still offer sincere reasons to have hope and to keep trying. This has to be balanced with being truly happy for patients when they are bursting with good mood in their “up” phases, and yet still being able to give them caring, corrective feedback about their hypomanic or manic behaviors and thoughts. In a related vein, therapists should not prejudge that a hypomanic patient’s stated ambitious ideas and goals are necessarily unrealistic. Therapists can be generally supportive of patients’ endeavors while still walking them through the steps of advance problem solving, weighing of pros and cons, and seeking consultation from trusted others. Additionally, when patients express weary distress about the toll taken by the cyclical ups and downs of their functioning, and/or ongoing worries about future symptom episodes, therapists need to acknowledge that bipolar disorder is indeed a major life burden whilst still extolling the virtues of maximizing healthy functioning through serious commitment to treatment. It is sometimes difficult for patients to accept their diagnosis. Even those who are willing to acknowledge that their symptoms are consistent with a bipolar diagnosis may be loath to accept a goal of averting hypomania, reasoning that this phase of the illness helps them in a number of ways and provides some measure of “compensation” for the misery of the depressive phases. To be maximally effective, therapists must try to avoid getting into power struggles with patients who express these viewpoints. Instead, therapists need to take an approach that is akin to motivational interviewing (Miller & Rollnick, 2002)—a therapeutic stance that is congruent with good CBT in that it emphasizes collaboration, guided discovery, empathy, and a striving toward graded improvements in function (rather than taking an “all or none” position about complying with treatment). A sense of collaboration is fostered when therapists show an interest in and respect for the patient’s goals, even while characterizing some of those goals as being potentially problematic (e.g., wanting to accomplish as much as possible when one’s mood is good, even if it means overworking and losing sleep). The therapist can state that it is understandable that the patient may not want to seek a stabilized mood when what they really want is maximum functioning. However, therapists can use guided discovery questions to help patients examine their own past experiences for evidence for and against the advisability of their goals. For example, the therapist may say, “I remember that you said you were able to work on multiple projects when you were in a manic phase, and that you enjoyed this, but I also remember what you said about the unintended consequences, and how you couldn’t count on yourself to sustain working on your projects, so a lot of work got neglected before you were ever able to finish it. How might you be able to achieve more of your goals going forward? How might a more stable mood serve a useful purpose for you?”



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Therapists also realize that they cannot demand and dictate that patients automatically buy into the entirety of a “safe” treatment plan (e.g., taking appropriate medications, reducing excessive goal-directed behavior, getting feedback before acting on impulsive ideas), lest they risk straining the therapeutic relationship and perhaps losing the patient from treatment altogether. Instead, therapists find ways to engage the patients in pursuing goals where they show some agreement, reaching negotiated “compromises” in principle that are then evaluated in practice. For example, a patient who appeared to be exhibiting flights of thought, pressured speech, and grandiose ideation reported that he wanted to write a scientific textbook, and he explicitly asked the therapist for her opinion on this matter. The therapist recognized that the patient’s sense of self-efficacy was manically inflated, but she wanted to remain respectful of the patient even while trying to offer corrective feedback. Eschewing the all-or-none approach of telling her patient “flat out” that his thinking was manic (at one extreme) or risk positively reinforcing the patient’s grandiosity (at the other extreme), the therapist asked the patient if he would consider “running a pilot study.” The therapist explained that many major scientific projects start with a scaled-back version of a full study in order to collect data that will inform the larger project later on. She then suggested that the patient organize his hypotheses in the form of a short paper that could be submitted for publication as a feature piece in a popular scientific magazine. If this “pilot project” went well, then perhaps the patient could consider building on the paper to the point where it could become a book proposal. The therapist then added, “In the meantime, it is very important that you get enough sleep, and that you touch base with the psychiatrist, because having a strong desire to pursue demanding, time-consuming goals is one of those warning signs of mania we talked about, especially if you are tempted to work late hours.” In taking this “middle-ground” approach, the therapist was avoiding shaming or overcontrolling the patient while still advocating for limits and safeguards. An exchange of feedback is a key component of a well-run CBT session, as a means by which to clarify communication, to summarize key learning points, and to show mutual respect (J. S. Beck, 2011). In the case of bipolar disorder, cognitive behavioral practitioners make sure to ask patients their opinions about the session and about how they think they are being treated. They also give feedback to their patients, positively reinforcing the patients’ constructive efforts to engage with the treatment plan, and tactfully offering comments of concern if the patients appear to be off track or otherwise responding dysfunctionally. Toward this end, the following is a sample comment that therapists can make early in treatment: THERAPIST: We will work well as team if we can speak freely with each other

about important matters. I am depending on you to give me feedback about how you feel about our work together, and to let me know what seems helpful and what does not. On the flip side, I hope you will return the favor and allow me to give you

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feedback about how you’re doing in therapy. You can expect me to ask about your moods and thoughts every session, and to check on your between-session homework. If I see anything that concerns me, I won’t jump to conclusions about your state of mind until I point it out to you and ask you for your opinion. I hope that seems fair. I’m optimistic that we can give each other constructive feedback in a respectful way and make the most of this treatment. What do you think? It is in a spirit of teamwork that the specific interventions and related homework assignments will have their best impact. Patients will be more inclined to learn and practice psychological skills and therefore to maintain their gains, an outcome that is particularly important in the treatment of a disorder that requires long-term attention.

DESCRIPTION OF MAIN TREATMENT APPROACHES As noted, patients suffering from bipolar disorder may exhibit a wide range of symptoms, and the treatment landscape may change depending on the particular subtype(s) and/or phase of the illness that the patients demonstrate. As a reflection of this complex reality, the specific interventions described in this section represent a mixture of approaches, some more appropriate for patients in a depressive state, some more applicable to those who show signs of hypomania or mania, and some that may be utilized across the board. What the interventions have in common is an attempt to keep the patient’s functioning within normal limits and to provide compensatory coping strategies that include safeguards against overcompensating (such as when a person with bipolar depression engages in behavioral activation but takes care not to schedule too many activities that may interfere with sleep and risk potentially switching into hypomania). The first “intervention”—self-monitoring—also doubles as an assessment method. Self-Monitoring and Recognizing Prodromal Signs One of the most important skills that cognitive behavioral practitioners can introduce to their patients is to recognize early warning signs (i.e., “prodromes”) of symptom episodes, particularly hypomania or mania, in which patients may otherwise not think there is a potential problem. This intervention—which is an important subset of the overarching skill of self-monitoring—has solid empirical support (e.g., Lam et al., 2000; Lam, Hayward, et al., 2005; Perry et al., 1999). When patients are taught to self-monitor their moods, sleep patterns, behavioral activities, and feedback from others (as ongoing homework exercises), they gain valuable information as well as an increased sense of self-efficacy. Although there are some signs of impending symptom episodes



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that are common across patients, there is also individual variability. Thus, it is important for patients to identify their own “relapse signatures” as part of this process of spotting prodromes (Smith & Tarrier, 1992). Although it may not always be possible to fully prevent a symptom episode, early detection can help patients take prompt, active steps (in terms of cognitive-behavioral interventions and/or supervised pharmacologic adjustments) that may reduce the intensity and duration of the symptoms along with their potential consequences. For example, a young man in CBT for bipolar disorder called his psychiatrist when he noticed that he was “happy to stay up all night,” which resulted in his being instructed to increase the dosage of one of his medications ahead of his appointment. Further, the patient also contacted his cognitive behavioral practitioner to schedule an impromptu session, during which they devised an updated treatment plan that included focusing on sleep hygiene, agreeing on a temporary moratorium on important life decisions, and enlisting the help of a friend and a sibling to spend more time with the patient (thus providing supervision during a critical time). The patient also diligently practiced his controlled breathing and relaxation skills (for homework, twice per day) so as to reduce excessive physiological arousal. The skill of self-monitoring, in addition to being a central feature of recognizing prodromes, helps patients to identify patterns of functioning that, if altered therapeutically, may improve the patients’ quality of life and reduce the likelihood of provoking symptom episodes. Several mood monitoring tools exist and are readily available for patients to use as part of their regular homework (see Basco & Rush, 2007; Reiser et al., 2017; Sachs & Cosgrove, 1998). Reiser et al. (2017) astutely noted that bipolar patients may view any fluctuations in their mood with undue alarm and, therefore, that patients should be counseled to recognize the normality of mood variability for anyone. To that end, Reiser et al. provided a monitoring chart that incorporates a range of normal mood that they dub the “comfort zone.” At the same time, it is a good idea for bipolar patients to use their mood charting to flag signs that they associate with straying from the comfort zone so that they can implement self-help skills and enlist the assistance of professionals and people in their personal life in a prompt, preventative fashion. Although it is important to be vigilant for prodromal signs of hypomania and mania to be able to enact CBT and/or pharmacologic interventions promptly, it is also important for people to be able to enjoy an improved state of mind without necessarily being in an ever-present state of high alert, the likes of which can be excessively stressful and can reduce quality of life (Mansell et al., 2007). Toward the goal of allowing a respite from this sort of hypervigilant selfmonitoring, it is useful for patients to take stock of the differences between signs of “normal good mood” and prodromal signs of being too high. This inventory can be taken in session with the therapist assisting the process and/ or can be done or completed for homework. The following are examples of some responses about this matter from bipolar patients, including some of their ideas about how to reassure concerned others:

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• “When my mood is good, but normal, I can sit and read. I feel contented, and I don’t have to get up every couple of minutes to do something, and I don’t get distracted from what I’m reading. I don’t mind the quiet time, and I don’t get bored (if what I’m reading is interesting). I have noticed that my wife likes it when I sit and read for a stretch of time. She thinks it’s a signal that I’m doing well.” • “I know that my mood is in a good zone when I want to be social, but I don’t feel pressure to talk all the time, and I can focus on what other people are saying without feeling the need to interrupt or talk about myself. In fact, I make it a point to be a good listener. This tells me I am okay. Also, other people don’t get annoyed with me.” • “Sleep is important. If I am getting hypomanic, I can’t sleep or I don’t want to sleep. When I’m in a good mood but I can get a full night’s sleep, then I know I’m in a safe range, and I can trust myself to function properly.” • “If somebody tells me they think I’m getting manic I sometimes feel a little annoyed, but if I can reply calmly and not get angry, then this is a good sign that tells me that my mood is normal because I’m not overreacting to someone showing concern for me.” • “Sometimes if I joke around too much, or if I’m busy doing too many things at all hours, it worries my parents, and it can make we wonder about my mood as well. However, if I can hold a calm, serious conversation, and if I’m willing to slow down and take a break from my activities to get some rest, this usually shows me (and my parents) that I’m still in the ‘normal zone.’” Through self-monitoring, patients can determine from a position of strength (i.e., on their own volition and via their own observations) that they may be becoming hypomanic or manic, rather than always being on the receiving end of corrective feedback, which can be disconcerting.

Behavioral Activation and Behavioral Moderation The typical symptoms of unipolar depression—dysphoria, anhedonia, lethargy, sleep disruptions, difficulties with concentration, feelings of guilt and worthlessness, thoughts about suicide, and others—are difficult enough to manage when the “war on mood disorder” is only on one front. In the case of bipolar depression, there is the added challenge of helping the patients boost their mood and activity level without adding undue risk of overshooting the mark and inadvertently potentiating a hypomanic or manic episode. An important intervention for depression is behavioral activation (e.g., Dimidjian et al., 2011). Motivating depressed patients to take part in more of the activities of everyday life is a worthy goal, as success leads to greater self-efficacy, better maintenance of life tasks (which potentially prevents problems), and improved chances of experiencing naturally occurring positive reinforcement.



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However, in the case of bipolar disorder, patients who increase their levels of activity may run the risk of becoming overly involved in the pursuit of goals (perhaps staying up late at night in the process), a factor that has been linked to hypomania and mania (S. L. Johnson et al., 2012). Thus, therapists try to engage their patients in a collaborative effort to plan and take part in constructive and/or rewarding tasks in a careful, gradual, and methodical fashion. For example, more than simply scheduling things to do for the coming week, patients also must commit to adhering to a healthy sleep-wake cycle. A college student with bipolar disorder who had been missing classes, avoiding spending time with peers, not working on academic assignments, and not getting exercise would certainly be making progress if they started to do all of these things— but not if they began staying up until all hours of the night in the process, as this would increase the risk of “switching” to a high phase. Behavioral activation remains a central part of helping those with bipolar depression be more effective in the tasks of living, connecting with others, feeling a sense of healthy self-confidence, and experiencing enjoyment. However, therapists must provide the patients with psychoeducation about the importance of moderation and maintenance of sleep hygiene. This may be a “hard sell” to patients who are concerned about the productive time they have lost while depressed and who reason to themselves that they need to “make up for lost time” by going into hyperdrive when they are feeling good. The starting point for therapists is to express understanding of these patients’ position. Empathy is important under any circumstance, but especially so when therapists are setting limits or otherwise suggesting a course of action that is not exactly the patients’ top preference. The following represents the sort of comment that can set the right the tone to elicit the most therapeutic collaboration: THERAPIST: I’m glad that your mood is up and that your energy is up too.

It’s good to see. I want you to be able to sustain a healthy positive feeling and productivity level. I don’t blame you for wanting to do as much as you can as soon as you can. I would probably have the same impulse if I were you. But can we talk about how to pace yourself so that you stay in a safe, healthy zone? With your help and with a good plan, I think we can find a way to prevent going too far and incurring risk. It is okay to try to compensate for lost time, but it would be really wise not to overcompensate. What can be done when the bipolar patient is depressed and is underactive? An initial step is to identify the activities the patient has previously favored (or would like to incorporate) that create a sense of accomplishment or enjoyment (also described as “mastery” and “pleasure”). Patients who are currently depressed may not be optimistic about their ability to summon up the energy to do things for accomplishment, and they may not expect to feel a sense of enjoyment, but they may be willing to begin the process by describing their past interests. Compiling such a list can lead to the therapist encouraging the

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patient to choose a starting point, as a behavioral experiment to see if the chosen activity creates an incrementally positive effect. A related method is to help patients plan to “chain” behaviors together so that they can get themselves to start their day one action at a time, starting with basic self-care activities such as eating something, getting washed and dressed, and going outside (for exercise, a chore, or going to school or work). At times, patients will be unimpressed, downplaying the significance of such seemingly mundane aspects of functioning. Again, the therapist expresses empathy, emphasizing that quality of life clearly involves more than just getting “up and out” in the morning but also noting that it takes a great deal of fortitude to do this when depressive symptoms dominate. Therapists encourage any good-faith attempts patients make to increase their activity level. Even when the patients have difficulty in starting, the fact that a list has been generated provides ideas for what to do if the patients begin to feel a little better. On the other hand, when patients are in an “up” phase, therapists help patients moderate their participation in the activities for accomplishment and enjoyment. Therapists can present the idea that sometimes showing “mastery” means being the “master of one’s impulses.” This refers to knowing when to refrain from going too far in such activities as shopping, exercising, partying, engaging in hobbies and projects at the expense of sleep, and other potential excesses. The Daily Activity Schedule (DAS; see J. S. Beck, 2011) is a form that patients can use to chart how they use their time (hour-by-hour, day-by-day). The DAS can be used retroactively (i.e., writing what they have already done) or prospectively (i.e., planning how to use their upcoming time). When used retroactively, the DAS can provide clues about how the patients can make better use of their time going forward. When a patient is becoming hyperactive and the DAS indicates that the patient is overbooked to the point of risk, the therapist can ask the patient to choose “10% of the activities that are the lowest priority” and to experiment with replacing those activities with more relaxation and sleep (Newman et al., 2001). Aside from reducing the quantity of activities in which a potentially hypomanic patient may be engaging, another way to safeguard against extremity is to emphasize the importance of the “simple pleasures” of life. Rather than going for high-stimulation activities that pose risks (e.g., drinking at a party, going to a casino, making a major purchase), therapists can help patients consider activities that create a sense of quiet satisfaction and peacefulness. Such activities may include reading, speaking with friends, watching a movie, taking a walk (perhaps with their dog or with an important person), playing music, working on an uncomplicated household project, engaging in a hobby—anything that can be done without too much effort and that brings about a pleasant feeling. Understanding the Consequences of Hypomanic and Manic Behavior As Jamison (1995) noted in her classic memoir, An Unquiet Mind, feeling the high of hypomania and mania is very seductive. Jamison reflected on the days



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when she felt on top of the world, able to use her mind and her charms to their maximum power. What brought her back to stark reality was the downside: the inevitable depressive crash and the negative consequences wrought by risky and otherwise extreme behaviors enacted while “high.” Jamison noted that this hard-earned experience can be valuable in terms of preventing future consequences. When patients give indications that they are not being suitably vigilant in guarding against hypomania and mania, such as by skimping on hours of sleep, being a bit laissez-faire about taking their medications, and speaking fondly about being euphoric and energetic, therapists can empathize first, but then ask some important questions (adapted from Newman et al., 2001): 1. How would you describe yourself when you were in a hypomanic or manic episode? What are some things you did during those times that you would choose not to do now? 2. In your experience, how much does your excessively high mood convince you that everything is fine, even when everything is not fine? 3. Knowing what you know now, what sorts of precautions would you be willing to take to limit the risks of being high from this point forward? What are some of the valuable lessons you have learned from your personal experiences with hypomania and mania, and how can you apply those lessons now? When asking such questions, it is important to have a respectful tone because the topic can potentially be shaming. It is also helpful to acknowledge that the experiences of hypomania and mania can be very difficult to resist; therefore, it is important to focus ahead of time on the downsides of these phenomena (e.g., negative consequences) to serve as a motivating force for adhering to limits and striving for moderation in all things. Testing the Functionality of Hyperpositive Thoughts There is an extensive literature on the application of the methods of cognitive restructuring to modify negative thoughts and beliefs (including schemas) that contribute to excessive emotional distress (e.g., J. S. Beck, 2011; Newman, 2015). These same methods can be applied to hyperpositive thoughts (see Lam, Wright, & Sham, 2005; Newman et al., 2001) with the goals being to maximize the skill of “reality testing” and to prevent the sorts of impulsive actions associated with unrealistic optimism and exuberance. The goal is not to discourage, restrict, control, doubt, or demean the patients, though some patients may construe the intervention this way. Again, therapists should be very collaborative and respectful, emphasizing that supporting the patient’s autonomy is a priority, in the context of developing well-practiced skills for keeping themselves in check.

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What are some of the signs that a patient’s thoughts are dysfunctionally positive? The following is a brief list of some informal categories of such thoughts, each with an accompanying example: 1. Overestimating one’s capabilities. A tip-off is when patients describe goals that blatantly exceed their credentials, training, experience, and/or aptitude, but they lack the insight to see the implausibility of the outcomes they seek. For example, a young man who had just begun a martial arts class for beginners enthusiastically predicted that he could become the “sensei of [his] own dojo” in a couple of years. 2. Overreliance on luck. This hyperpositive distortion is often manifested by the patient who is neglecting to actively solve problems and/or meet responsibilities, but maintains an attitude that “it will all work out somehow.” Such patients demonstrate insufficient concern about consequences and are more focused on having a good time in the moment than on taking care of important matters that need attention. The people in this patient’s life often get the sense that they are “in denial.” For example, a patient was convinced that he could continue an illicit affair without being discovered, without having to make difficult choices, and without any emotional drama. Thus, he was disinclined to make any changes in his behavior, as he was content with the status quo, believing that it could continue indefinitely, entirely in his control. 3. Overvaluing of immediate gratification. This characteristic of thinking is associated with impulsivity, low frustration tolerance, and an exaggerated sense of urgency in doing something for pleasure. One patient enacted this in the therapy session itself, as she wanted to talk about the Academy Awards (which she had watched on television the night before) rather than focus on a therapeutic agenda. She felt strongly that she should obey her feelings on the matter (i.e., to not discuss appropriate clinical topics) and that she would be “untrue to [herself]” if she had to talk about “something less interesting.” Therapists who detect such hyperpositive thinking in their patients must find a way to address this cognitive problem while still communicating a willingness to understand the patient’s points of view. Therapists have to point out inconvenient truths in a respectful, caring way, without sounding judgmental or authoritarian. One therapist appealed to her patient’s better judgment by saying, “It’s great to be confident, but it’s risky to be overconfident. Knowing where the line between confidence and overconfidence lies requires great wisdom, patience, and humility. I have faith in you that you will exercise wisdom, patience, and humility right now, which means resisting acting on impulse and being willing to get feedback from others.” In terms of helping patients with bipolar depression rationally respond to their excessively hopeless and self-reproachful thoughts, the general literature on CBT interventions for unipolar depression is applicable (e.g., A. T. Beck et



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al., 1979; Moore & Garland, 2003). What may be added is a special emphasis on patients’ pessimistic thoughts about ever being able to manage and/or overcome the bipolar illness itself, as well as the patients’ self-condemning or shameinducing beliefs about having the illness in the first place. The sections in this chapter on suicide risk and stigma will touch upon these issues and offer suggests for intervention. Consulting With Trusted Others When patients experience flights of ideas, high energy, and extreme optimism, they often believe that they can do as they wish without having to get feedback from others about the advisability of their plans. In some instances—especially those in which the patient’s family members are alarmed by the patient’s behavior and try to assert control—these patients will do all they can to reassert their autonomy by doing as they please, confident that they are right and that things will work out well. This often leads to a power struggle, thus adding relational discord into the mix, which is distressing for all parties. Therapists can play an important role by helping patients see the merits in communicating openly with trusted others, asking for their feedback, and trying to be collaborative. Toward that end, the therapist can introduce the concept of the two-person feedback principle (Newman et al., 2001). During times when the patient is euthymic, the therapist and patient identify the people in the patient’s life whose judgment and/or counsel are trusted the most. The therapist and patient reach an agreement to utilize these people’s opinions as a safeguard whenever there is reason to believe that the patient is heading toward hypomania or mania. If the patient is married, it is often a good idea to encourage the patient to include the spouse on this “short list,” provided that the spouse is well meaning and responsible. If the patient professes to being solitary most of the time, it is okay if the therapist suggests that they, themselves, should be on this list, provided that someone else is added as well (e.g., a cohort from a support group that the patient has been attending). The patient does not necessarily have to ask others the question “Do you think I’m becoming manic?” It will suffice if patients ask for feedback about their ideas, plans, or decision making. For example, a patient may suddenly wish to buy a new car. Rather than simply acting on their own impulse, the patient can ask at least two other trusted people if they think this sounds like a reasonable idea. An important aspect of this technique is to present it in such a way that it helps the patient “save face.” Therapists do not want to imply that the patients are incapable of making their own choices or that they need a “watchdog.” Instead, this method is presented as a way for patients to illustrate to the important people in their life that they are capable of being careful and thoughtful and as a way to honor others by soliciting their opinions on important matters. Therapists can note that people who are accomplished and influential often hire consultants precisely because it is smart to do so, given that an

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individual cannot know everything. It is best to surround oneself with people whose judgment is trustworthy. Another benefit of consulting with at least two people is that it takes some time to enact and, therefore, serves as an anti-impulsivity technique. Anything that puts some time and distance between an impulse and acting on that impulse can help prevent patients from making important mistakes in decision making. Sometimes patients take umbrage at the idea that they are not supposed to be “spontaneous” or “trust their own judgment.” Therapists should reframe the matter, noting that the most rewarding acts of spontaneity are typically free of potential negative consequences, and that mastering one’s own impulses represents a high level of well-functioning (e.g., “The highest form of control is self-control”). Improving Interpersonal Functioning Having a good social support system helps patients with serious mood disorders have a higher quality of life and to reduce the risk of suicide (Jamison, 1999; S. L. Johnson et al., 1999). In bipolar disorder, patients’ interpersonal relationships tend to suffer when they self-isolate during periods of dysphoria and/or when they act out during manic episodes in ways that alienate others. Thus, it is common for a CBT agenda with such patients to include interpersonal problem solving, in which patients learn to monitor and recognize the need for repairs, improve communication skills, reduce expressions of anger, and affiliate with others within normal limits (i.e., not too little; with appropriate boundaries). When patients are depressed and disinclined to initiate social interactions, they can still make it a point to be receptive to social invitations and to test their hypotheses that they are “horrible company” or that they will “have a miserable time anyway.” When they are feeling too high, patients can be encouraged to practice self-restraint in what they say and how they act toward others, with the goals of respecting others’ boundaries and being the “master of their impulses.” Therapists teach their patients that effective communication starts with listening, which makes one a better companion for conversation, reduces pressured speech, and improves empathy for the other person. One could argue that training in listening is naturally embedded in a therapy session that includes such fundamental CBT components as summary statements (e.g., when patients are asked to restate the main points that they are taking away from the session) and in giving and receiving feedback. To teach communication skills more broadly, therapists serve as role models for making comments that are thoughtful, tactful, and on topic. Therapists respectfully try to “shape” their patients into speaking in ways that others will find pleasant and congenial, such as steering clear of profanities, making requests instead of complaints, keeping one’s tone of voice moderated, and avoiding being verbose (see Newman, 2005). Of course, the therapeutic relationship itself is a testing ground for the patient’s interpersonal behavior, and the therapist has to be a tactful pur-



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veyor of feedback and humble suggestions when patients are acting overly gregarious or familiar toward the therapist or expressing excessive negativity (e.g., insults or sarcastic comments directed at the therapist).

SPECIAL CONSIDERATIONS WITH BIPOLAR SPECTRUM ILLNESS Bipolar illness often poses special challenges for patients as well as their families and practitioners. Some of these challenges include (but are not limited to) the following: (a) difficulties with adherence to pharmacotherapy, (b) risk of suicide, (c) family stressors (both as a triggering factor and as a consequence of the patient’s psychological problems), (d) proper diagnosis and treatment of bipolar disorder in very young patients, and (e) stigma, all of which are described in more detail below. Difficulties With Adherence to Pharmacotherapy Although there is great promise in the use of CBT to improve the functioning and quality of life in bipolar sufferers, the standard of care still customarily necessitates pharmacotherapy. Those cognitive behavioral therapists who are not licensed prescribers themselves generally have to work in tandem with the practitioners who are in charge of their shared bipolar patients’ medication regimens. Although the use of CBT may seem to run parallel to the pharmacotherapy part of treatment, there are important points of overlap. These include the therapist’s need to be aware of the patient’s medication-taking habits (especially if these habits are inconsistent or otherwise maladaptive), the importance of the therapist being empathic about the patient’s fears and misgivings about their medications, and the therapist helping their patient to identify and modify their negative beliefs about medication that may be impeding their adherence to a pharmacotherapy plan. A number of studies have provided evidence that bipolar patients who receive CBT tend to adhere to their medication regimen significantly more than those who do not (e.g., Cochran, 1984; Lam et al., 2000; Scott et al., 2001). Even when patients with bipolar disorder take their medications faithfully, they may still experience low-level symptoms or symptom breakthrough (Solomon et al., 1995). This can be quite discouraging and even demoralizing for patients, and cognitive behavioral therapists have to be able to communicate empathic understanding. Similarly, pharmacotherapy typically comes with side effects, and although the hope is that side effects gradually subside as therapeutic benefits take effect, the reality is not always this straightforward. Further, patients may be on medications that interact in complex ways, such as when a patient needs to be on a diuretic, which can potentially have a problematic impact on the blood levels of the bipolar medication(s). Some patients react to these complications by wanting to abandon their use of the medication(s) for their bipolar illness. This is where therapists have to be able to demonstrate

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empathy and support while still taking a problem-solving approach that supports the pharmacotherapy in an improved way (in collaboration with whomever is prescribing). CBT has a particularly important role to play with regard to patients’ beliefs about medications, some of which contradict objective findings and/or unnecessarily discourage patients. In order to address such beliefs—the likes of which many patients spontaneously articulate—therapists must try to facilitate a mutually respectful dialogue. This starts with the therapist empathically summarizing the patient’s position as a prelude to offering their own. Let us look at how a therapist might address a number of such problematic beliefs by offering support, validation, reframing, and psychoeducation:

BELIEF: “Medications will turn me into someone I am not. I will lose my true self.”

THERAPIST: It may be true that when you take medications you feel a little

different, especially at the start. It may even feel quite disorienting if your side effects are prominent. On the other hand, if the medication helps prevent extremes in your mood, you may be able to function in the way you normally would, or how you naturally would have functioned if you didn’t have the burden of the bipolar symptoms in the first place. Maybe it is the bipolar illness itself that is robbing you of your true self. Maybe the right medications can help you be the person you were always meant to be if you didn’t have the illness. BELIEF: “Medications will take away my energy and my creative ideas.”

THERAPIST: I believe you when you say that your best creative work is done

with the burst of energy you get when you’re hypomanic, and that you value this. I agree that it is important for you to be able to be productive and imaginative in your work, and I think this is a strength of yours. I can understand why you might be reluctant to take any medications that might stabilize your mood, especially if you equate “stable” with “average,” which you most certainly are not. What I’m thinking about is all the valuable time you’ve lost to your depressive episodes, and how you almost completed a suicide last year, which would have ended all your creative ideas once and for all. I would like to work with you to find a way to minimize risk—and that means doing both CBT and pharmacotherapy—while still supporting your creative



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work in any safe way we can. Kay Redfield Jamison is a great role model for this. Remember her book An Unquiet Mind? She admits that when she’s on her medication she doesn’t read as fast, but her books are beautifully written and quite compelling nonetheless. Similarly, I think it is possible for you to take medication and still have great ideas and do great work. Are you willing to see for yourself? BELIEF: “Medications are only needed when I’m sick. I feel fine, so I don’t need them.”

THERAPIST: You’ve been great about taking your medications while you

were so depressed, and you’ve been very patient about waiting until your mood lifted. Now that you’re feeling somewhat better, you’re hoping to get off the medication and move on with your life. I get it, and I wish you could do that. You’ve worked so hard in therapy to get to this point. It would be a terrible thing if you suffered a setback, and I’m concerned that going off your medication would invite this outcome. You’re feeling fine now, and that’s great. You’ve reached a sort of “cruising altitude,” and staying the course seems like the safest thing to do. I’m worried about what might happen if you change the flight plan right now. Can we talk more about this? BELIEF: “Being told to take my medications is inherently demeaning and disrespectful.”

THERAPIST: I agree with you that some people sarcastically use the phrase

“You need to go take your pills” as a gratuitous insult. I know it’s used that way, and it’s wrong. It shows incivility and ignorance on the part of the person saying it. So if that’s the way you perceive being instructed to partake in pharmacotherapy by me, or your psychiatrist, or by somebody in your family, I can understand why you feel indignant. I would too if I were you. However, can we consider the possibility that sometimes being advised to take medication is part of a well-meaning, respectful recommendation, and that it comes from a place of good intentions combined with experience and knowledge?

BELIEF: “I could become addicted to my medications. Thus, I should avoid them.”

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THERAPIST: The issue of inadvertent addiction to a prescribed medication is

important and timely, and I’m glad you’re aware enough to inquire about it. You’re partially correct that your body adapts gradually to the sorts of medications you are taking and that you can’t just “get off” the medications when you want to make a change. You have to wean off carefully, under supervision. That looks suspiciously like an “addiction,” but actually it’s not. The medications you’re taking are not fast-acting, they don’t give you a “buzz,” and you’ll never develop cravings for them. Yes, there are medications that fit this description of “potentially addictive,” but the medications you’re being prescribed do not. But I appreciate your awareness of this matter, and it’s good that you brought up your concern. You’re asking good questions and being a good advocate for yourself, and I respect that. When patients express concerns, fears, and antipathy toward pharmacotherapy—whether based on maladaptive beliefs or hard experience or a combination of the two—it is imperative that therapists offer compassion and respect. Though pharmacotherapy is customarily an essential part of best practices for the most hopeful outcomes, it can bring side effects and long-term worries that would be daunting for anyone. If practitioners find themselves growing a bit exasperated by their patients who are inconsistent in (or downright avoidant of) taking their medication, they would do well to consider the following hypothetical questions to ask of themselves: “Would I ever volunteer to take the medications my patients are taking?,” “How would I feel about taking such medications for years and decades?” A sober answer to these questions may raise our level of understanding. Similarly, clinicians would do well to understand the appeal of hypomanic and manic states, as some patients with bipolar illness state that the feelings of energy, euphoria, and personal empowerment— however fleeting—are the most redeeming aspects of having the disorder. Thus, they are loath to volunteer to give up these extremely positive feelings through treatment. Therapists do respond by pointing out the negative consequences, including the crushing depressive states that typically follow soon enough, but they must also acknowledge that it is difficult to walk away from peak experiences. Ultimately, one of the idealistic goals of therapy is to help patients find joy and meaning in their lives amid the stability. Risk of Suicide The risk of suicide in the population of sufferers of bipolar disorder is substantial, with an estimated 15% to 19% ultimately completing suicide (Goodwin & Jamison, 2007; Simpson & Jamison, 1999; Strakowski, 2014). Clinicians need to be alert for this risk, assessing their bipolar patients’ thoughts about life and death as a routine part of treatment. The field of CBT has developed robust, brief interventions and safety-planning methods for suicidal patients and thus



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is well-positioned to provide care that offers safeguards for those with bipolar disorder (e.g., Brown et al., 2005; Stanley & Brown, 2012; Wenzel et al., 2009). It is good practice to utilize self-report measures (e.g., Beck Depression Inventory-II; A. T. Beck et al., 1996) on a routine basis so that negative changes in the patient’s mood and ideation can be monitored. The issue of hopelessness often is central to a patient’s risk for suicide (A. T. Beck et al., 1990, 1993, 1985), such as when patients maintain the belief that no matter what they do they are always going to suffer (so they might as well end things now). A similar cognitive concept related to the risk of suicide in bipolar patients has to do with feeling defeated and entrapped by an immutable illness (Owen et al., 2018). In such cases, therapists have to navigate a dialectic of validating the patient’s feelings and opinions about having a chronic disorder, while promoting the idea that adhering to treatment and learning self-help skills can in fact lead to significant improvements in one’s life (Newman, 2005). Patients sometimes lament that they are afraid to be hopeful, lest they set themselves up for having their hopes dashed yet again by another virulent symptom episode. They may view suicide as a way to “cut their losses.” The therapist’s task is to cite the current moment as a potential positive turning point if the patient can invest in and commit to treatment. The therapist can add that far from cutting their losses, patients who die prematurely by their own hand may in fact be forfeiting future improvements. The therapist must communicate empathy for the patient’s fears about being hopeful and acknowledge that it is unwise to have blind optimism. However, it is also a set-up for a self-fulfilling prophecy of misery if one only thinks about the downside of life and does not consider the possibility that working collaboratively in treatment can lead to a higher quality of life—one that is worth living. Cognitive behavioral therapists help their deeply depressed and suicidal patients with bipolar disorder construct rational responses to their “suicidogenic beliefs” (Newman, 2018). Three of such beliefs are outlined below, each followed by a sample rational response in brackets: 1. Suicide is the solution to end all problems. [Actually, suicide is the problem to end all solutions, and the problems will only be passed down to others I care about. If I stay alive, I can possibly work to solve some of my problems.] 2. I am a burden to others, and they would be better off if I killed myself. [Actually, the biggest burden to others would be if I killed myself, and that could never be fixed. If I want to be less of a “burden,” I can show that I care about others by working hard in therapy so I can bring something more positive to their lives. And who says I’m a “burden”? That may be my own self-criticism talking. There is plenty of evidence that others care and that I can do some good things.] 3. The pain of bipolar disorder is too much to bear, and the only way to end the pain is to die. [This feels so true, but I also remember what it’s like to feel joyful and enthusiastic, and I want that experience again, but first I have to live.]

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A sense of social isolation exacerbates the patient’s depression, and, therefore, therapists try to help their patients to seek social support. In fact, this is a standard part of safety planning in CBT (see Stanley & Brown, 2012). When friends are in short supply, and/or the patient’s family members are feeling depleted, therapists can assist their patients in finding and attending support groups via their local chapters of the National Alliance on Mental Illness (NAMI, https://www.nami.org) or the Depression and Bipolar Support Alliance (DBSA, https://www.dballiance.org), among other organizations. Bipolar Disorder and the Family “Bipolar disorder and its treatment frequently are family affairs” (Newman et al., 2001, p. 137). Fundamentally, there is a significant hereditary component to bipolar disorder, and, thus, it is quite common for bipolar patients to have family members who are also on the bipolar spectrum (Algorta et al., 2015). Individuals who suffer bouts of mood swings and other extreme symptoms also affect the lives of their family members, especially those with whom they reside. In like fashion, the individual’s treatment can be influenced (for better or worse) by the actions of their loved ones. The ways in which individuals with bipolar disorder and their close relations interact in characteristic patterns of communication and interpersonal control can exert an influence on the individuals’ episodes of relapse and recovery (S. L. Johnson et al., 2016; Miklowitz, 2008; Miklowitz et al., 1996). A thorough assessment necessarily involves inquiring about the role of the family relationships in the patient’s life, and the treatment plan can include family members in one or more of the patient’s therapy sessions. Cognitive behavioral practitioners are mindful of the hardships that bipolar patients and their families suffer, and they come ready to be explicitly empathic to all parties. For example, a bipolar patient may feel criticized, blamed, stigmatized, patronized, overcontrolled, and perhaps rejected by one or more family members. For their part, the family members may experience the stress of worrying about their loved one with bipolar illness being at risk for engaging in destructively impulsive behavior, including suicide. Family members often report that they have had to contend with such significant problems as the patient’s unwise monetary expenditures, risky behaviors (including those that put the household and its inhabitants in harm’s way), infidelities, neglect of responsibilities, legal involvements (e.g., stemming from illicit drug use and/or traffic mishaps), and at times abusive behavior, to name a few problems. In a conjoint couple or family session, therapists often must manage one or more parties’ anger, extreme worries, and/or hopelessness, and they must do so in a way that keeps order and structure in the session whilst still offering support and concrete suggestions for intervention. Families that are high in “expressed emotion” (EE; see S. L. Johnson et al., 2016; Miklowitz et al., 1996) are most often those who present in the manner described above. EE is a term that was originally coined in research on families



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of persons diagnosed with schizophrenia (see Kavanagh, 1992), but it has been appropriated for use in the study of the families of bipolar disorder. It refers to high levels of negativity and criticism, both emanating from and coming toward the identified patient in typically vicious cycles. Low-EE families have their tensions as well, but their interactions tend not to be characterized by attacks and counterattacks. In any event, assessment of the family’s communication style and intervening therein is central to doing family work with bipolar patients. Expressions of blame and shame need to be identified and modified. Similarly, malevolent interpretations of intent must become targets for intervention (e.g., when both the bipolar patient and their family members believe the other is deliberately trying to ruin their lives, when in fact they are all scrambling to survive the best way they know how). Communication skills training and modification of attributions are central components in working effectively with families, but these interventions are further assisted when the clinician takes the time to listen to and understand the unique hardships facing the patients and their families. To borrow from Leo Tolstoy, unhappy families are unhappy in their own way. Bipolar Disorder in Very Young Patients There is evidence that the first signs of bipolar disorder often occur in childhood and adolescence, and that early detection and early intervention are of key importance in outcome for sufferers and their families (Youngstrom & Algorta, 2014). The occurrence of a manic episode is required for the diagnosis of bipolar I disorder; however, there are challenges in identifying mania in children and adolescents, where factors surrounding cognitive and emotional development can cloud the assessment (e.g., when is “grandiosity” simply a matter of inexperience or immaturity rather than frank dysfunction?). Though it is difficult to apply the strict definition of mania as noted in adults to the assessment of children and adolescents, it is possible to flag symptoms such as chronic mood lability, agitation, and irritability as potential signs of a developing bipolar illness. Coincidentally, these are also signs of attention-deficit/hyperactivity disorder (ADHD) and pediatric depression (Strakowski, 2014). Therefore, differential diagnosis poses difficulties, made more complicated by the fact that ADHD and bipolar disorder can co-occur in children and adolescents (Pavuluri & May, 2014). Unfortunately, there are significant risks involved in providing pharmacotherapy for the “wrong” clinical problem. For the child or adolescent with bipolar illness who is inadvertently identified as having ADHD, a prescribed stimulant can induce manic symptoms. Conversely, the child or adolescent with ADHD who is given a bipolar diagnosis may needlessly take mood stabilizing medication(s) that are not ideal for neurodevelopment (i.e., cannot be taken under the age of 10), to be taken only when not taking them would lead to more unfavorable outcomes. To minimize errors, it is advised to look for distinguishing features of mania (e.g., decreased need for sleep, episodic presentation) combined with a family history of bipolar disorder (Strakowski, 2014; Youngstrom et al., 2010).

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Given that children and adolescents are very sensitive to side effects from medications that are approved for the treatment of bipolar disorder (e.g., weight gain, sedation, cognitive impairment), the use of psychosocial treatments that involve the family and that teach the skills of mood charting and self-reflecting before taking action are of critical importance. A prime example is the RAINBOW program (West et al., 2017), a 12-session child-and-family-focused CBT intervention (CFF-CBT) for children on the bipolar spectrum that involves intensive work with the parents in parallel to the work with the children. This treatment program fits the interventions to the developmental level of the child and the unique needs of the family, offers psychoeducation and communication skills training, and identifies itself as a combination of CBT and interpersonal therapy. Combating Shame and Stigma Manic episodes, in particular, can induce people to engage in behaviors that they would ordinarily exercise discretion to avoid if they were in a more stable state of mood and mind. Looking back over negative consequences incurred as a result of impulsive, risky, and otherwise undercontrolled behavior can cause shame and regret. As Jamison (1995) noted, even when it is difficult to remember what one has done while in manic states, the inevitable depressions that follow include the challenge of dealing with the consequences, which may include damaged relationships, work projects that have been started and abandoned, bills that have accumulated, and other results that exacerbate selfreproach. One of the delicate balances that therapists must maintain is the ability to support patients in their efforts to take ownership of their decisions and actions, while dissuading them from punishing and no longer caring about themselves owing to their earlier problematic decisions and actions. In addition to self-blame, persons with bipolar illness may face the prospect of discrimination in terms of housing and employment (Corrigan, 1998), as well as medical advice about their fitness to become parents (Jamison, 1995). Of course, in our present time, the looming threat of bipolar disorder as a “preexisting condition” that may impede access to health insurance is also a matter of great concern. In recent times, we have also seen more people in the public eye (e.g., actors, musicians) come forward with their stories about dealing with bipolar illness, and this development has served an important educational and potentially destigmatizing function in society. However, much remains to be done in order to overcome the stigmatization that still exists. Perhaps the area in which patients and their therapists have the best chance of making a positive impact on stigma is in overcoming self-stigma. Bipolar sufferers sometimes blame themselves for their illness, an internal attribution that serves as a counterproductive self-condemnation. Therapists can help their patients to modify this view by taking a more constructive stance. This is typified by endorsing the belief that while the bipolar illness itself is not directly in the patient’s control, the positive steps that can be taken to effectively manage



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the bipolar illness are at least partly in the patient’s control. Therapists give their patients much positive reinforcement for their active participation in treatment, including adhering to their pharmacotherapy as best they can, doing their CBT homework, maintaining stability in their personal schedules and sleep-wake cycles, and self-monitoring their depressive and/or hyperpositive thought processes for prompt modification, among others. Therapists need to keep their antennae up for patients’ self-stigmatizing statements such as “I’m just weird and crazy,” “I’m hopeless and useless,” and “I’m a burden to everyone.” These self-stigmatic beliefs immediately become targets for intervention in session and for homework. In summary, although it may be a difficult, long haul to change societal attitudes toward mental illness (though still a most worthy goal), we see that it is perhaps more doable to work on reducing stigma from the inside out (Newman et al., 2001). CBT inherently helps with this goal by focusing on objective assessment and skills acquisition, rather than on labeling and blaming (Lam et al., 1999). Additionally, CBT helps patients build on their personal strengths, including their talents, social support systems, and examples of successful coping. When patients are proud of their writing or artistic skills, therapists can encourage them to make use of these abilities in the service of therapy homework (provided that the patients do not keep themselves up too late at night working on it). Patients have been known to want to show their therapists examples of their creative output, including poetry, articles they have written, artwork and photography, and online links to their performances (e.g., singing in a band, doing stand-up comedy), and it is important for therapists to take an interest. Aside from demonstrating good will, therapists can also work with their patients to derive joy from their creative activities while striving toward improved self-management in areas of their life that require self-regulation and routinization (e.g., reliably getting up in the morning with enough time to get to work without being late; being tactful even when they have an urge to be sarcastic).

EFFICACY Although CBT for bipolar disorder is not necessarily a short-term treatment, most of the relevant studies have utilized a limited number of sessions for practical purposes. In one of the earliest studies, just six sessions of CBT were found to significantly improve patients’ adherence to lithium (21% discontinuing as compared with 57% discontinuing) and to reduce hospitalization rates when compared with pharmacotherapy alone (Cochran, 1984). Another brief CBT intervention (up to 12 sessions) called “relapse prevention” focused heavily on teaching patients to self-assess prodromal signs of bipolar mood episodes. Compared with treatment as usual (TAU), the CBT group had significantly fewer manic relapses (27% vs. 57%), and fewer, shorter hospital stays (Perry et al., 1999). The CBT group also showed higher levels of social functioning and work

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performance. In a study of 25 bipolar patients who were experiencing relapses in spite of being on mood stabilizers (Lam et al., 2000), 6 months of CBT was superior to TAU in terms of better adherence to medication, fewer symptom episodes, and improved hopefulness and social functioning. In a CBT trial that also emphasized activity regulation and sleep intervention, 42 patients were randomly assigned to CBT or a 6-month wait-list condition followed by CBT (Scott et al., 2001). Data collected at the 6-month mark and 18-month mark showed that CBT was associated with significant improvements in depressive symptoms, depressive relapse rates, and global adaptational functioning compared with the wait-list control, but manic symptoms showed no significant difference. Scott and colleagues later conducted a multicenter randomized controlled trial (RCT) involving 253 patients with bipolar disorder (Scott et al., 2006), in which 22 sessions of CBT were compared with TAU. Follow-ups were conducted approximately every 8 weeks for 18 months posttermination. Results were mixed in that adjunctive CBT was significantly better than TAU for patients who had relatively fewer previous episodes, but less efficacious in those with higher numbers of prior episodes, leading the authors to posit that CBT may be better viewed as an early treatment option for bipolar disorder. In another significant RCT, CBT with pharmacotherapy was compared with pharmacotherapy alone (Lam et al., 2003). Patients in the CBT condition had access to 12 to 18 sessions within the initial 6-month period and two booster sessions within the next 6-month period. During the first year of follow-up, patients who received CBT had significantly lower relapse rates (44% vs. 75%), fewer days in episode, higher social functioning, and less depression and mania than those receiving pharmacotherapy alone. At the 2-year follow-up mark, the gains made in reducing depressive symptoms held, but reductions in manic symptoms were not maintained (Lam, Hayward, et al., 2005). One interpretation of this finding is that maintenance of therapeutic gains in combatting mania may require more frequent sessions over a longer period of time, and another is that current CBT approaches may be more powerful for depression than for mania (S. L. Johnson & Peckham, 2018). The data from an earlier study also recommended more sessions of CBT even for depressive episodes, with an emphasis on modifying dysfunctional beliefs (Zaretsky et al., 1999). In an open trial, Reilly-Harrington et al. (2007) designed and tested a 20-session CBT protocol (50 minutes per session) designed to tackle one of the most virulent forms of bipolar disorder—rapid-cycling. Using the Newman et al. (2001) text and the Otto et al. (2011) manual, Reilly-Harrington and colleagues adapted the treatment to place emphasis on coping with frequent shifts in mood, as well as managing comorbid conditions (e.g., anxiety disorders). They reported that 6 out of 10 patients completed the program, with the four who dropped out doing so because of practical reasons unrelated to their satisfaction with the treatment. Completers showed improvements in depression, which remained stable through 2 months of follow-up. However, the tendency toward hypomania and mania did not change, and patients’ irregular sleep patterns frequently contributed to difficulties.



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Some studies have provided evidence that CBT and other active psychosocial treatment approaches (when used as adjuncts to pharmacotherapy) may achieve comparable results. In a study involving 204 patients, CBT did not differ from a group psychoeducation approach in terms of relapse rates and symptom severity across an 18-month follow-up (Parikh et al., 2012). In another clinical trial involving 120 adults with bipolar I disorder, structured psychoeducation sessions were found to be more efficacious when compared with an unstructured support group or medication alone, resulting in fewer symptom episodes and fewer and shorter inpatient stays, even at a 5-year follow-up (Colom et al., 2009). In yet another study of 76 patients randomly assigned either to CBT or a combination of psychoeducation, supportive therapy, and mood monitoring, relative relapse rates showed no difference (Meyer & Hautzinger, 2012). In a major, multisite, longitudinal RCT called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), Miklowitz et al. (2007) reviewed the data from 15 clinics, in which the active psychosocial treatments consisted of 50-minute sessions. A group of 163 patients diagnosed with either bipolar I or bipolar II disorder received either CBT, family-focused therapy (FFT; Miklowitz, 2008), or interpersonal social rhythm therapy (IPSRT; Frank et al., 2005); up to 30 sessions over 9 months. Another group of 130 patients received three sessions of “collaborative care” (involving psychoeducational videotapes and instructions), and all 293 patients received pharmacotherapy. Rates of attrition from treatment did not differ significantly across conditions (about a third of the patients left treatment early), and patients receiving CBT, FFT, and IPSRT had significantly higher year-end recovery rates and shorter times to recovery compared with collaborative care. There were no statistically significant differences between CBT, FFT, and IPSRT regarding outcome. Miklowitz et al. (2007) made some important observations about the results of the STEP-BD project, including the assertion that the overall attrition rate was unacceptably high and needed more attention as a target for assessment and intervention in its own right. He added that CBT, FFT, and IPSRT have many shared components in their protocols and that “future studies will combine the most effective components of the modalities and evaluate hybrid models of psychotherapy” (p. 425). Additional findings from the STEP-BD project are noteworthy. Having an extreme attributional cognitive style predicted lower likelihood of recovery (Stange et al., 2013), highlighting the importance of cognitive interventions. Also, subsyndromal depressive symptoms had a significant negative impact on patients (Marangell et al., 2009), suggesting that patients need support even when they are not technically in a symptom episode. Lower total time of sleep and increased sleep variability were associated with greater mood severity (Gruber et al., 2011), emphasizing the role of sleep disruption in the disorder and the utility of improved sleep hygiene. A recent meta-analysis (Chiang et al., 2017) reviewed the data from 19 rigorously conducted RCTs (from the years 2000 to 2015, including some of those mentioned above) in which CBT with pharmacotherapy was compared with “standard care” (often pharmacotherapy alone) in the treatment of both bipolar

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I and II disorders. The efficacy of CBT in lowering the relapse rate was evaluated from the overall odds ratio (pooled OR = 0.506), on the basis of which the authors concluded that CBT significantly reduced relapse (more so for those with bipolar I rather than bipolar II). Using Hedges’s g to determine the effect sizes of continuous outcomes, the authors concluded that CBT improved depressive symptoms (g = –0.494), lowered the degree of mania severity (g = –0.581), and aided the patients’ psychosocial functioning (g = 0.457), representing mild-to-moderate effect sizes. This outcome was particularly noteworthy in that the meta-analysis included the Scott et al. (2006) study that reported an overall null effect owing to its inclusion of patients with longstanding, refractory bipolar illness. Chiang et al. (2017) also found that the contributory benefits of CBT were enhanced when the sessions were lengthy (90 minutes or more), and they hypothesized that this may be due to the extra attention to the therapeutic relationship that is required in any given session with such patients. One may also hypothesize that getting patients in the depressive phase activated to take part in the session and helping patients in the hypomanic phase to be more focused and on track also requires more time in session. It should be noted that (in general) the treatment studies cited in this chapter indicate that 90-minute sessions are more common in group- and family-based sessions than in individual CBT. In addition to the studies that have found additive effects of CBT on improving functioning and reducing morbidity in patients with bipolar disorder, there have been recent studies (not included in the Chiang et al., 2017 meta-analysis) on CBT and related psychosocial interventions (e.g., mindfulness) aiming for broader goals. The “recovery-oriented” model of treatment seeks to improve patients’ quality of life even as they accept the difficulties that phasic mood instability and cognitive alterations pose over the long term (Jones et al., 2015; Murray et al., 2017). Jones et al. (2015) described the recovery-oriented model as being more flexible than customary CBT manuals for bipolar illness. The recovery-oriented model is based in part on the findings of the STEP-BD multisite study (Miklowitz et al., 2007), suggesting that the major psychosocial models for bipolar treatment (e.g., CBT, IPSRT, FFT) were all found to be superior to TAU, that there was an absence of significant differences in outcomes among them, and that each of them had something of value to offer, perhaps in a complementary fashion. Jones et al. (2015) stated that the goals of treatment are set collaboratively with the patients, the course of treatment is guided by an individualized case conceptualization (e.g., taking into account such factors as comorbid conditions and self-stigmatizing beliefs), and quality of life (e.g., improvement in social functioning) is given relatively more emphasis than a focus on reducing symptoms per se. The patients are free to draw from methods across psychosocial models as they see fit (e.g., going beyond CBT to include interventions from FFT and IPSRT). The Jones et al. (2015) study randomized 67 patients to 18 sessions of recovery-focused CBT or TAU. Although there was no significant difference between the groups with respect to medication adherence, the recovery-focused



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CBT group showed significantly increased time to any mood relapse up to 15 months of follow-up. The authors also reported that quality of life and social functioning were improved compared with TAU. There is acknowledgment that bipolar illness—as a longitudinal disorder— presents varying challenges across time. Patients who have suffered the illness through numerous cycles and many years respond differently to treatment than those who present for treatment earlier in the course of the illness (see Scott et al., 2006). In response, the recovery-oriented approach recommends a staging approach to treatment. For example, more time is allowed at the start of treatment to deal explicitly with what it means to the patient to receive the diagnosis of bipolar disorder. Taking time to engage the patient in this manner is not only empathic, it also facilitates patients’ acceptance of the treatment. Another example of a staging approach is the recovery-oriented model’s emphasis on the importance of subsyndromal symptoms (particularly depressive symptoms). This is particularly important in that patients with bipolar illness may feel worn down and demoralized with what they feel to be an ongoing battle with symptoms, even when clinicians might otherwise deem them to be in-between episodes (Samalin et al., 2014). At such times, focusing on maintaining hope and striving to continue to be invested in positive activities are of utmost importance. Additionally, there is evidence that mindfulness-based interventions may have a positive role to play across all stages of bipolar illness (Deckersbach et al., 2014; Miklowitz et al., 2009). Aside from facilitating a general sense of calm, mindfulness methods may also reduce anxiety and improve sleep, adding to quality of life and reducing the risk of provoking hypomania. The recoveryoriented CBT approach above (Jones et al., 2015; Murray et al., 2017) also included mindfulness among its interventions. Another application of a CBT treatment model aimed at reducing comorbid anxiety problems in bipolar disorder is the Unified Protocol (UP; Barlow et al., 2011). In a pilot feasibility and acceptability trial, Ellard et al. (2017) hypothesized that the UP’s focus on common core processes that underlie the full range of anxiety and mood disorders would be advantageous in helping anxious bipolar patients develop general emotional regulation skills. Their results were promising for the reduction of anxiety on the Hamilton-Anxiety Rating Scale (Hamilton, 1959; Cohen’s d = 0.88) and the attenuation of depressive symptoms on the Hamilton-Depression Rating Scale (Hamilton, 1960; Cohen’s d = 0.82), thus meriting further studies. The authors also suggested improvements to the protocol to bolster responsivity in those patients who showed greater difficulties with treatment compliance. As early intervention for bipolar disorder is ideal (Youngstrom & Algorta, 2014), treatment for children and adolescents with the illness takes on added significance. In terms of individual treatment, a manualized cognitive behavioral intervention was tested on a small sample of adolescents with bipolar disorder, half of whom received CBT in addition to pharmacotherapy (Feeny et al., 2006). The authors concluded that the results supported the feasibility and efficacy of the CBT approach as an adjunct to pharmacotherapy. Looking at treatment for

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children that also includes the family (the RAINBOW program; West et al., 2017), CFF-CBT was found in a randomized trial to result in reductions in patient-reported mania at posttreatment, reductions in patient-reported depression at both posttreatment and follow-up, and improvements in global functioning at follow-up (West et al., 2014). Later, this program was tested in Sweden in a case-series design involving patients from ages 8 to 18 and their families, where multiple families would meet together (Knutsson et al., 2017). The authors stated that this format of CFF-CBT was feasible to deliver in an outpatient setting and that there was evidence that it increased parents’ skills and knowledge for coping, improved the interactions of the family members, and enhanced the psychosocial functioning of the children and adolescents with bipolar disorder. CBT-based approaches in a group format for adults with bipolar disorder also seems to hold promise. In an early study, an open trial in the UK on a small group of four patients with bipolar disorder showed the potential benefits of this format (Palmer et al., 1995). Shortly thereafter, a randomized, controlled study in the United States using group CBT for bipolar disorder supported these findings (Hirshfeld et al., 1998), with longer periods of euthymia in the CBT group maintained at follow-up as well. More recently, in a RCT utilizing 14 sessions of group CBT for bipolar patients (CBT vs. TAU, with all participants receiving pharmacotherapy), those receiving CBT indicated significantly higher quality of life on self-report measures, significantly lower scores on depression, and reduced frequency and duration of symptom episodes (Costa et al., 2012). There have been recent developments in applying and adapting the dialectical behavioral therapy (DBT) group format for use with bipolar populations, based on the idea that patients with bipolar disorder are similar to those with borderline personality disorder in potentially benefiting from emotional selfregulation, mindfulness, and psychological skills training in a supportive, validating environment. For example, van Dijk et al. (2013) conducted a RCT with 26 adults with bipolar I or bipolar II disorder assigned to a DBT-based psychoeducational group, comparing them to patients in a wait-list control group. Those who took part in the DBT group evinced greater mindfulness skills, lower fear of and increased sense of control over emotional states, and fewer emergency department visits and mental health admissions over a 6-month period. Eisner et al. (2017) ran an open trial in which 37 participants with bipolar disorder engaged in a 12-week DBT skills group. Repeated measures for mixed models revealed improved emotional self-regulation, distress tolerance, and improved sense of well-being. Although there is an ever-growing body of literature on the efficacy of psychosocial approaches to the individual treatment of persons with bipolar disorder, the data on family and group approaches to psychological care show that there is indeed strength in numbers.

CONCLUSION AND FUTURE DIRECTIONS Overall, findings for the efficacy of CBT for bipolar disorder have been moderately promising, especially with regard to increasing adherence to pharmaco-



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therapy and in the amelioration of depressive symptoms. However, results have been mixed in that there is evidence that patients in later stages of bipolar disorder are less responsive to CBT (Scott et al., 2006), and questions remain about whether CBT is beneficial compared with other active psychosocial treatments (S. L. Johnson & Peckham, 2018). A more hopeful way of looking at the data is that there are several evidence-based psychosocial models of treatment for bipolar disorder that overlap in their approaches but also bring unique strengths that may work well in synergy (see Miklowitz et al., 2007). Treatment manuals, such as Reiser et al. (2017), bring together interventions from CBT, FFT, and IPSRT, and there is evidence that adding mindfulness training can also boost the efficacy of psychosocial approaches to the treatment of bipolar disorder (Deckersbach et al., 2014; Miklowitz et al., 2009). The intent of the recovery-oriented model of CBT (as a whole) is to place more emphasis on tailor-making the treatment to fit the bipolar patient’s stage of illness, to better address the patient’s comorbid problems and individually conceptualize the case, and to go beyond simple reduction of symptoms to improving the patient’s quality of life as the patient defines it. Further developments of psychosocial treatments for bipolar disorder will prioritize this humanistic approach (Murray et al., 2017). It is conceivable that, going forward, this hybridization of psychosocial interventions will be more the norm rather than the exception. Bipolar patients need to learn a plethora of self-help skills for combating dysregulation, which makes them potential candidates for the DBT model in terms of utilizing modules of skills training (e.g., social and circadian rhythm monitoring and routinization; behavioral activation and moderation; pursuit of personally meaningful goals within healthy limits; emotional self-regulation with relaxation and mindfulness; rational responding against hopelessness as well as hyperpositive thinking; making peace with pharmacotherapy; family sessions with communication training). As noted, promising work has been reported in applying DBT to bipolar sufferers (Eisner et al., 2017; van Dijk et al., 2013), and further research and development in this area is highly likely. Self-monitoring takes on added significance in bipolar disorder, as patients reflect on and measure their moods, thought processes, behavioral activities, and sleep-wake cycles. Handy, helpful tools such as phone apps to track and measure these (and other) areas of functioning will become more widely utilized and hopefully standardized (see https://www.healthline.com/health/ bipolar-disorder/top-iphone-android-apps for an up-to-date sampling of digital mood journals, diary cards, skills coaches, medication reminders, etc.). In the near future, one could imagine the further development of personal tracking devices that people wear (e.g., successive generations of Fitbit) that will go beyond monitoring activity levels and sleep patterns to actually provide warning messages, as well as positive reinforcement comments, all of which may be tied (with the patient’s consent) into the electronic records managed by the patient’s healthcare providers. The popularity of apps and personal devices will assist in the dissemination of CBT and other psychosocial treatments for bipolar

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disorder that emphasize self-monitoring, perhaps ultimately serving as an incentive for persons to seek treatment with mental health professionals when they otherwise may not have done so without the consciousness-raising assist from the apps. A more low-tech (yet high-benefit) method of dissemination of evidencebased treatments for bipolar disorder comes in the form of self-help books based on the treatment methods described in this chapter (e.g., Basco, 2015; Bauer et al., 2009; Miklowitz, 2011; Pavuluri, 2008; Otto et al., 2011; Roberts et al., 2014; van Dijk, 2009), which may be assigned by therapists as part of patients’ homework, and/or recommended to persons whose family members with bipolar illness may be reluctant to commence treatment but who may be willing to read on the subject of self-help. Cross-cultural issues increasingly have been recognized as playing important roles in understanding psychopathology and in crafting treatments to fit the sensibilities of the patients of differing backgrounds (Hays & Iwamasa, 2006). In the case of bipolar disorder, family approaches such as FFT (as well as CBT and IPSRT sessions that include family members) need to adapt communication exercises in a way that is sensitive to the cultural norms of the families. For example, the Western family communication model of making direct eye contact and using “I” statements may be construed as disrespectful if being directed from a younger to an older generation member in a non-Western culture (Ozerdem et al., 2015). Patients and their families from non-Western cultures may be more receptive to acceptance and mindfulness methods as compared with their Western counterparts, who may be more open to rational responding and other active change processes (Miklowitz, 2015). When studying bipolar disorder more broadly in terms of cross-national prevalence, there is evidence that cultures that value and reward individual empowerment and goal pursuit, and that provide rich opportunities for personal achievement, are somewhat “maniatrophic” (see K. R. Johnson & Johnson, 2014) when compared with societies that place more value on collectivism. Understanding such differences will shape future research on bipolar disorder and its treatment on a global level.

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Stange, J. P., Sylvia, L. G., da Silva Magalhães, P. V., Miklowitz, D. J., Otto, M. W., Frank, E., Berk, M., Nierenberg, A. A., & Deckersbach, T. (2013). Extreme attributions predict the course of bipolar depression: Results from the STEP-BD randomized controlled trial of psychosocial treatment. Journal of Clinical Psychiatry, 74(3), 249–255. https://doi.org/10.4088/JCP.12m08019 Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi. org/10.1016/j.cbpra.2011.01.001 Strakowski, S. M. (2014). Bipolar disorder. Oxford University Press. Sudak, D. (2011). Combining CBT and medication: An evidence-based approach. Wiley. https://doi.org/10.1002/9781118093368 Tondo, L., Jamison, K. R., & Baldessarini, R. J. (1997). Effect of lithium maintenance on suicidal behavior in major mood disorders. Annals of the New York Academy of Sciences, 836(1), 339–351. https://doi.org/10.1111/j.1749-6632.1997.tb52369.x Üçok, A., Karaveli, D., Kundakçi, T., & Yazici, O. (1998). Comorbidity of personality disorders with bipolar mood disorders. Comprehensive Psychiatry, 39(2), 72–74. https://doi.org/10.1016/S0010-440X(98)90081-5 van Dijk, S. (2009). The dialectical behavior therapy skills workbook for bipolar disorder: A comprehensive workbook for managing your symptoms and achieving your life goals. New Harbinger Publications. van Dijk, S., Jeffrey, J., & Katz, M. R. (2013). A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders, 145(3), 386–393. https://doi.org/10. 1016/j.jad.2012.05.054 Vieta, E., Colom, F., Corbella, B., Martínez-Arán, A., Reinares, M., Benabarre, A., & Gastó, C. (2001). Clinical correlates of psychiatric comorbidity in bipolar I patients. Bipolar Disorders, 3(5), 253–258. https://doi.org/10.1034/j.1399-5618.2001.30504.x Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional Attitudes Scale: A preliminary investigation [Paper presentation]. Annual meeting of the American Educational Research Association, Toronto, Canada. Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal clients: Scientific and clinical applications. American Psychological Association. https://doi.org/ 10.1037/11862-000 West, A., Weinstein, S. M., & Pavuluri, M. N. (2017). RAINBOW: A child- and family-focused cognitive-behavioral treatment for pediatric bipolar disorder: Clinician guide. Oxford University Press. https://doi.org/10.1093/med-psych/9780190609139.001.0001 West, A. E., Weinstein, S. M., Peters, A. T., Katz, A. C., Henry, D. B., Cruz, R. A., & Pavuluri, M. N. (2014). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(11), 1168–1178, 1178.e1. https://doi.org/10. 1016/j.jaac.2014.08.013 Winters, K. C., & Neale, J. M. (1985). Mania and low self-esteem. Journal of Abnormal Psychology, 94(3), 282–290. https://doi.org/10.1037/0021-843X.94.3.282 Youngstrom, E. A., & Algorta, G. P. (2014). Pediatric bipolar disorder. In R. A. Barkley (Ed.), Child psychopathology (3rd ed., pp. 264–316). Guilford Press. Youngstrom, E. A., Arnold, L. E., & Frazier, T. W. (2010). Bipolar and ADHD comorbidity: Both artifact and outgrowth of shared mechanisms. Clinical Psychology: Science and Practice, 17(4), 350–359. https://doi.org/10.1111/j.1468-2850.2010.01226.x Zarate, C. A., Jr., & Tohen, M. F. (2001). Bipolar disorder and comorbid substance use disorders. In J. R. Hubbard & P. R. Martin (Eds.), Substance abuse in the mentally and physically disabled (pp. 59–75). Dekker. https://doi.org/10.1201/b14027-5 Zaretsky, A. E., Segal, Z. V., & Gemar, M. (1999). Cognitive therapy for bipolar depression: A pilot study. Canadian Journal of Psychiatry, 44(5), 491–494. https://doi. org/10.1177/070674379904400511

8 Psychosis Neal Stolar and Rebecca M. Wolfe

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n medical school, one of us (NS) was advised by attending psychiatrists to ignore the content of voices and delusions, except to classify the latter as paranoid, grandiose, and so on. Beyond that, it was considered unnecessary to delve into what voices said or what material was contained in the delusions. To do so was a waste of time, as once the presence of hallucinations and/or delusions was established, it was only necessary to determine the presence of other symptoms that would clarify which diagnosis—containing psychosis as a symptom—was correct and, from there, which medications to order. It did not take this author long to question this approach. It was difficult to believe that someone reporting voices telling him to commit suicide was not also experiencing that same urge to do so. Likewise, it seemed that someone with a delusion of being married and having children and a career would also have those same desires.1 A number of years from then, in the mid-1990s, a book called CognitiveBehavioral Therapy for Schizophrenia was published (Kingdon, & Turkington, 1994). British authors David Kingdon and Douglas Turkington (cf., Kingdon & Turkington, 2002) described how the content of voices and delusions are important and are used to facilitate treatment efforts. Cognitive behavioral therapy for psychosis (CBTp) helps clients examine the beliefs associated with their voices and delusions by testing their veracity. Other British clinical research groups and clinicians (Chadwick et al., 1996; Fowler et al., 1995; Morrison, 2002; Morrison et al., 2004; Nelson, 1997; Wykes et al., 1998) were Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-008 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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also developing and testing the use of CBTp. This effort eventually spread throughout the world so that now CBTp is practiced and researched in most nations where CBT for other psychological conditions is utilized. The importance of the content of hallucinations and delusions has become a more acceptable outlook.

CONDITIONS AMENABLE TO CBT FOR PSYCHOSIS Psychosis consists of hallucinations and/or delusions. Some definitions add the positive symptoms of formal thought disorder (FTD) and bizarre behavior, and some even add the negative symptoms (i.e., lack of: motivation [avolition], interest [apathy], socialization [asociality], affect [blunted affect], speech [alogia], and pleasure [anhedonia]). Although commonly viewed as a loss of touch with reality, it is more an addition to reality (hence the term positive symptoms) of nonexistent entities (i.e., voices, images) and/or situations (i.e., being followed or listened to, or being able to read minds). Mostly associated with schizophrenia, psychosis presents in other mental health conditions including brief psychotic disorder, delusional disorder, schizoaffective disorder, major depressive disorder, bipolar disorder, and psychosis due to substance use or medical conditions. CBTp is used for these conditions (though the latter two are better managed by addressing the underlying causes—substance use and medical condition). Research posits that psychosis exists on a continuum from less frequent self-reported attenuated positive symptoms in the general population, to schizotypal traits, to schizotypal personality disorder, and ultimately to fullblown psychosis, which results in the diagnosis of a psychotic disorder (Esterberg & Compton, 2009). Not all instances of psychosis need treatment, but CBTp represents an important part of the collection of treatments available when the person is distressed or functioning suboptimally. CBTp is used in an expanded manner for people with schizophrenia— addressed as well are FTD, bizarre behavior, and negative symptoms. In addition, general CBT can be used when psychosis is in the context of other conditions typically treated using CBT (e.g., major depressive disorder with psychotic features is treated with both CBT for depression and CBTp). For brevity, we use the terms “psychosis” and “CBTp” to mean the conditions and CBT treatments of both psychosis and schizophrenia, keeping in mind that schizophrenia can also include FTD, bizarre behavior, and negative symptoms as well as cognitive deficits (e.g., difficulties with attention, memory, sequencing, etc.). We often refer to treatment of schizophrenia with the understanding that aspects involving psychosis also apply to other psychotic disorders. Although the emphasis here will be on cognitive therapy, we use the acronym CBTp as opposed to CTp, as some techniques presented here use predominantly behavioral approaches. However, behavioral approaches are most beneficial when the cognitive components are considered as well.



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A BRIEF HISTORY OF THE TREATMENT OF PSYCHOSIS Treatment of psychosis has drastically changed over the centuries (de Chávez, 2009; Colp, 1995). Ancient and medieval treatments, such as blood-letting, trepanation (i.e., drilling holes in the skull to release demons), and exorcisms, were “modernized” by the early 1800s with the use of fever therapy (sometimes induced by purposeful infection), freezing water, sensory deprivation, vomiting therapy, and forms of terror induction (e.g., immobilization, swinging). In the early 1900s, various (often dangerous) treatments such as hydrotherapy, insulin coma therapy, and lobotomies were utilized. Starting in the 1930s, electroconvulsive therapy was added. Medicinal treatment began in 1952 with the introduction of Thorazine. Institutionalization, started in medieval times, continues to this day, but with changes in its detailed nature. Psychotherapy for psychosis can be traced back to ancient Greece with the use of rhetoric and dialogue by philosophers to alter the thinking of those with psychosis (de Chávez, 2009). Formal psychotherapeutic approaches for schizophrenia started in the early 1900s with psychoanalysis, having limited success. Efforts to deinstitutionalize this population began in the 1960s with John F. Kennedy’s Mental Health Act. Psychosocial methods were needed (in addition to the prominent use of medications) in the rehabilitation into society of people with psychosis. The 1960s and 1970s were characterized by social skills training, token economy, and supportive therapy. This was followed, beginning in the late 1980s, by cognitive therapy and cognitive remediation/rehabilitation (which address cognitive deficits). Just as cognitive therapy expanded to include behavioral therapy, CBTp has more recently been expanded to include other modalities of treatment including acceptance and change therapy, compassionfocused therapy, and mindfulness approaches (Wright et al., 2014).

THE USES OF CBTp CBTp is used in the treatment of persons with psychosis in a number of ways. In a modified form (described below in the negative symptoms section), CBT helps with their depression, anxiety, anger, and other emotional distress, much as with any other client. Often, those with psychosis have not been provided with individual therapy addressing their basic concerns related to common emotional reactions. To this day, medication continues to be the mainstay of treatment for those with psychosis, partly due to them being less likely to request therapy than those with primarily emotional issues. This is also due, in part, to providers not being aware of psychotherapeutic treatments for psychosis such as CBTp. When therapy is provided, it is often supportive therapy that does not delve into ways to help them resolve these problems. Psychotherapeutic intervention, especially that of CBT, had not been recognized for decades as a modality for use with persons with psychosis. Once the British groups started

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using CBT to treat psychotic symptoms, the door was opened to use it for emotional problems as well. CBTp can address these issues using a structured, directive approach that is often needed by those with psychosis. CBTp is also used to improve insight about illness by increasing understanding of how symptoms could result from physiological alterations amenable to improvement with the use of medication and therapy. Examining, correcting, and modifying beliefs about one’s condition can be beneficial in many ways, but caution is needed, as it can be detrimental (as elaborated below). Finally, and most prominently, CBTp is useful in treating the individual positive and negative symptoms, as much of this chapter will describe. Together, these uses of CBTp for psychosis improve general, social, and occupational functioning, thus enhancing quality of life.

THE LIMITATIONS OF CBTp CBTp is beneficial to many people with psychosis, but there are limitations in its use and effects. Some persons have symptoms that are too severe to allow meaningful utilization of CBTp (or any psychotherapy, for that matter). If comprehension, attention, memory, language, and/or motivation are severely impaired (due to cognitive deficits, FTD, negative symptoms, and/or distraction by hallucinations), the interchange necessary for therapy to proceed does not occur. Likewise, if paranoia (especially involving the therapist) is severe, there can be reluctance to attend sessions or engage in the process in a sincere manner. Furthermore, lack of insight into illness can deter engagement in therapy by not seeing a purpose. Despite attempts to reduce these barriers (using medication, cognitive remediation, initial trials of CBTp, etc.), some persons are still not candidates for CBTp. It is difficult to know, however, if the hurdles are too high to surmount. The persistence and patience of the client, therapist, and family often determine how much effort needs to be exerted (and for how long) before reaching this conclusion. Importantly, “progress” is not only improvement, but also the prevention of relapse (including reduced hospitalization). In a given person, it cannot be known if inpatient treatment would have been more likely had CBTp not been used. There are also limitations for those who are able to benefit from CBTp, in that treatment might not completely eliminate symptoms or change quality of life dramatically. Although some persons relinquish their delusions or rid themselves of hallucinations, many retain the symptoms, but in a diminished and more manageable level. The transition from viewing situations as facts to viewing them as one’s own beliefs and finally as internal feelings or “a sense that . . .” shows progress. The feelings can persist without becoming troublesome or leading to bizarre acts or avoidance maneuvers. Complete elimination of the symptoms is often not the end result, but quality of life improves. Likewise, as mentioned above, hospitalization can be reduced with CBTp. Similarly, nega-



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tive symptoms can be reduced as a person becomes more involved in activities such as household chores or hobbies, even if they are still unable to hold a paid job. Improvement in insight into illness can also be limited. Insight into illness is treated as a type of belief. CBTp methods are used to examine evidence of those beliefs. As stated above, to avoid depression and possible suicide, care must be taken to assess the consequences of relinquishing these beliefs in a given individual. In many, lack of insight persists despite efforts to address and modify those beliefs. Lack of insight does not preclude continuation and usefulness of CBTp for the other symptoms. A person can work on and diminish, if not eliminate, paranoid delusions or voices even as they continue to be unaware of or disbelieving of the symptoms as internal symptoms of a mental health condition. Insight of illness is not necessarily required for one to benefit from CBTp treatment, as problematic symptoms can still be mitigated and quality of life increased. As stated above, another limitation in the effectiveness of CBTp is that medication is nearly always necessary as ongoing treatment for certain conditions with psychosis. CBTp can be used to treat the full psychosis spectrum—from prevention/early intervention with high-risk, prodromal, and first episode populations, to those experiencing mild, moderate, or severe psychosis in the clinical population, either exclusively or as part of other disorders. With some of these populations (e.g., early intervention, prodromal), it would be unethical to administer medication when psychotic symptoms are not present. In use with clinical populations (e.g., schizophrenia, schizoaffective disorder, bipolar disorder with psychosis), it is important to offer medications and explain the benefits and risks of using them, as well as the risk of not taking them, because not taking medication can severely limit the ability of CBTp to have its full effect. General CBT is a short-term therapy that often requires 12 to 16 weeks; however, with schizophrenia and schizoaffective disorder, therapy is typically longer and tends to be most useful as an ongoing treatment. In many cases, frequency of sessions can be reduced in time, but termination of therapy is likely to lead to recurrence or persistence of some symptoms. From another perspective, there are often residual symptoms (commonly negative symptoms) that can still be addressed by continuation of therapy. Although a person might improve by being able to do volunteer work, they may require further therapy if paid employment is desired as the next step. In one author’s (NS) clinical experience, delusions that persisted at first resolved years later as therapy continued. In contrast to schizophrenia and schizoaffective disorder, psychosis as part of mood disorders resolves as the current mood episode ends. Mood episodes may resolve with the use of CBT for depression or mania, so duration of treatment with CBT would follow the norms of those conditions. Other conditions, such as delusional disorder, have variable lengths of therapy. Booster sessions can help in cases when regularly scheduled sessions (even as infrequent as trimonthly) are no longer necessary but symptoms arise after some time, and relearning of certain useful skills can be quick but effective in returning to health.

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PSYCHOSIS AND THE COGNITIVE MODEL In the general cognitive model (Beck, 1976), an event activates an automatic thought (AT) or belief (AB), often influenced by a core belief about oneself, others (the world), and the future. This belief leads to an emotional reaction (including a physiological response) that can have behavioral consequences as well. The individual symptoms of psychosis and schizophrenia can be viewed in terms of this general model. Which components of the model fit each positive and negative symptom can be debated, but one characterization is as such: Hallucinations Hallucinations can be viewed as events and/or as beliefs (when voices are involved). Hallucinations are events partly since the person views the internal stimulus as an external event. The person’s interpretation of the event (ATs/ ABs) are examined in an effort to reduce the severity of the emotional and behavioral responses. Much of the work in CBTp for voices (the most common type of hallucination in schizophrenia) focuses on beliefs about voices (e.g., “who” they are, their power) and the emotions and behaviors (including avoidance) that result. When viewed as beliefs, the content of voices is determined (as best possible) as to whether it reflects the actual beliefs of the person. A voice saying, “The medication is poison,” might reflect a belief that can then be addressed as such using the cognitive model. Delusions Delusions (i.e., firm, fixed beliefs) fit neatly into the model as ATs/ABs. They can be in reaction to specific situations (e.g., “That person on the bus is coughing because they are angry at me”) or be ongoing beliefs (e.g., “The CIA is following me,” or “I have been selected for a divine mission”). Much of the work in CBTp for delusions focuses on examining these beliefs in terms of gathering evidence for and against them and considering alternative explanations. Cognitive components of delusions include a data-gathering bias of jumping to conclusions (Garety & Freeman, 1999), wherein persons with delusions reach decisions utilizing less information (Garety et al., 1991). Further, these persons frequently have an externalizing attributional bias (Garety & Freeman, 1999), which effects are attributed to external causes. Hence, there may be hypervigilance and safety behaviors with paranoid delusions in particular, which serve to alert persons to potential “dangers” while preventing exposure to safe situations (that could potentially dispel the belief of lurking danger). Bizarre Behaviors Bizarre behaviors are behavioral responses that are approached by determining what led to the behaviors—beliefs (e.g., wearing an aluminum foil hat due to a



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belief that it prevents the government from reading one’s mind), voices (e.g., yelling in public due to hearing and opposing what the voices are saying), or disorganization (e.g., wearing two pairs of pants, a shirt inside out, and a pair of glasses on an angle due to difficulty in organized dressing). Some bizarre behaviors can be more neurological (e.g., catatonic behavior) and therefore not subject to cognitive analysis. CBTp for bizarre behavior focuses on working on the ATs/ABs or voices (as described above) or disorganization (as described below) that might be responsible for the bizarre behavior. Formal Thought Disorder FTD, or disorganized speech, can be considered a physiological response, similar to stuttering. It results from beliefs about situations, leading to anxiety and hence a stress response. Disorganized behavior can be viewed in a similar manner. (This can be distinguished from more purposeful bizarre behavior as described above.) Work with FTD focuses on discerning what events are associated with its onset or worsening, and what ATs/ABs elicited by these events lead to the anxiety. The other symptoms of schizophrenia can be viewed in a similar way, in that stress has the ability to make symptoms such as hallucinations and delusions worse or more frequent (Kingdon & Turkington, 1994). Viewed in this way, work can be done to address situations (and their resultant ATs/ABs and emotions) associated with the symptoms when stress seems to affect their onset and/or severity. Negative Symptoms Negative symptoms can be viewed as behavior or the lack thereof. These diminished behaviors include emotional expression, socialization, motivated behavior, and speech. This halting of behavior may be the result of beliefs that it is useless to even try (e.g., to make friends, to get a job) after years of demoralizing failures (Grant & Beck, 2009). Work in CBTp for negative symptoms aims at dispelling these dysfunctional beliefs (e.g., negative expectancies, negative self-appraisals, defeatist beliefs) mainly by conducting behavioral experiments to show that steps toward desired goals can be achieved. Thus, each symptom can be characterized in terms of the cognitive model. This provides a framework for the symptoms and allows for therapeutic approaches based on this model.

STAGES OF TREATMENT Treatment is divided into stages, including establishing rapport, assessment, goal setting, coping skills, normalization, cognitive/behavioral approaches, case conceptualization, relapse management, and termination (Fowler et al., 1995; Kingdon & Turkington, 1994). Each session consists of symptom ratings, setting

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an agenda, using active problem-solving methods, assigning homework, and eliciting an evaluation. Establishing Rapport CBTp begins with the potentially long process of establishing rapport. It involves the pillars of therapy—listening, empathizing, reflecting, providing a positive regard without judgment, and demonstrating intention to assist the person in progressing. Establishing rapport begins at first contact—in person, by telephone, electronically, or by way of a third party (e.g., parent, spouse, adult child, mental health professional). It takes many sessions to develop. Maintenance continues as long as the person is in treatment. Rapport is especially difficult to establish and maintain with persons with psychosis in that they can develop paranoid delusions about the therapist, making trust a distant endeavor. In these cases, rapport must be reestablished repeatedly. In addition, poor insight into the need for help limits the desire of clients to engage in therapy, hampering the building of rapport by keeping objectives disparate. Assessment As with establishing rapport, assessment is a stage that can start before meeting a client—when one learns why the person is seeking or being sent for treatment—and continues throughout treatment until one assesses readiness for termination and referral. Depending on the cooperation of the person treated, full assessment may need to be delayed until enough rapport is established. Although many treatment facilities require a complete evaluation in the initial session (as guided by specific clinical procedure codes), it may be more clinically practical to spread the initial assessment questions over a number of sessions. Formal assessment uses standard psychiatric/psychological evaluations. Specific items include determining for each symptom the severity, frequency, duration, pervasiveness (i.e., how much it affects the person’s life), preoccupation (i.e., how much attention is paid to it), distress induced, personal explanation, precipitants, aggravating/ameliorating factors, nature of onset (i.e., age, circumstances, reaction), and development. Additional information is obtained for auditory hallucinations of voices (e.g., number of voices, familiarity, gender, intervoice communication, and content of what the voices say) and for delusions (e.g., content and conviction—to what extent the person believes each to be true). Often, information from the person in therapy about current symptoms is limited due to poor insight or distrust of the assessor (including fears of being hospitalized or further medicated). Reports might come from family, friends, hospital records, or others. Care is needed in how this information is presented to the person in therapy, but it can be an opening to further elaboration of the descriptions of the symptoms.



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Assessment is also an integral part of each session. CBT focuses on specific situations as a way to learn from them and generalize to similar situations and on the cognitive, affective, and behavioral reactions to them. The initial step in working with a specific situation is to assess it by gathering information about it—the thoughts/beliefs it elicited, the emotions resulting from the cognitions, and the behaviors and physiological reactions produced by the emotions. The person’s reaction to and interpretation of the symptoms, as well as how they may have been exacerbated or diminished by reactions of the person (such as isolating), are also important. The assessment of individual situations begins with whatever the person presents first as prominent. It could be the event, emotions, behaviors, physiological reactions, or the thoughts/beliefs themselves. However, it can help to conduct the assessment with the symptom as the starting point. Depending on the person’s perspective, the symptoms can be considered as various parts of the cognitive model. If viewing hallucinations as events, they need to be assessed in terms of the beliefs about them, leading to physiological responses and possibly behavior. Alternatively, if hallucinations are presented in terms of their content, assessment of the preceding step (situation) and resulting steps (emotions, physiological reaction, and behavior) fill out the story. Goal Setting Goal setting can be particularly difficult with people with psychosis because often there is little insight regarding having anything problematic on which to work. People with this condition are often persuaded by family or ordered by the legal system to engage in treatment. Eliciting goals on which to work from the people with the condition may be considered fruitless to some. However, CBTp is most effective when working towards an individual’s self-identified goals (Chadwick, 2006), regardless of how unrealistic they might seem (Riggs, 2019). Discussing the reasons as to why the individual would want to reach their identified goal, and what accomplishing that goal would mean to them, can aide in understanding the purpose that their identified goal would serve. With that information, one can break the goal down into smaller, achievable steps to focus on throughout treatment (Riggs, 2019). Family members serve as an additional source for information on an individual’s goals, but relying completely on goals generated from others deviates from the tenet of CBT to focus therapy on the goals of the person coming to therapy. A good starting point is asking the person what changes they would like to have happen in their life. When this is frequently followed by replies similar to “Nothing,” a more focused second approach is how they would like things such as voices, disturbing beliefs, difficulties in communication, socialization, employment, and so on to change. Sometimes, goals are indirectly related to symptoms. For example, getting a job could be a stated goal with voices being a barrier which can then be worked on directly. Another approach is when the

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person in therapy says they do not know why they are there, the goal for therapy can be addressing the issue of others wanting them to go to therapy when they do not know why (D. Foster, personal communication, 2004).

Coping Skills Therapy first addresses aspects of the condition that can interfere with the interpersonal, interactive, communicative requirements of the core therapy process. Some of these barriers are overcome as rapport is established, but others involve levels of symptoms too severe to allow formal therapy to proceed. The latter can be addressed using coping skills, often behavioral in form (Fowler et al., 1995), that can also be used at any stage of therapy when needed. Once symptoms are reduced enough, cognitive techniques can be applied. Coping skills, as with any treatment, need to be individualized. What works for one person might not work for another—or might even be deleterious. Therefore, it is best to begin with having clients list and rank order by effectiveness any coping skills they are already using or have used in the past, including ones that did not work or made things worse (Riggs, 2017). Second is identifying factors that exacerbate or ameliorate symptoms, and respectively reducing or promoting these precipitants. For instance, if voices worsen in social settings, the behavioral strategy of temporary solitude can be used to reverse this. Again, individualization of treatment is important, as some have voices that worsen in isolation, so for these, promoting social settings is the direction to proceed instead. In many cases, specific social supports can help in alleviating symptoms. Any factor that increases or reduces stress is a candidate for use as a coping skill (by eliminating or introducing that factor, respectively). Delusions and/ or voices can worsen in the presence of strangers or of familiar others. If symptoms become severe, moving away from such people helps keep those symptoms in check. These types of coping skills are often temporary fixes, as maintaining them can be unfeasible and/or countertherapeutic. A person becoming visibly agitated due to voices exacerbated by the presence of Uncle Charles at Thanksgiving might need to retreat to a bedroom for much of the evening, but this strategy is best supplanted by others that do not disrupt family events. Third is utilizing physiological strategies, which include relaxation methods such as deep breathing, progressive muscle relaxation, or meditation. Other coping skills specific for auditory hallucinations include attentional strategies in which alternative auditory processing tasks interfere with the hallucinations. These include listening to music (Breier & Strauss, 1983), reading (silently or aloud), humming, or repeating what voices are saying. Attentional strategies using distraction are another way to provide competition with the symptoms of hallucinations and delusions. For example, look, point, name is a way to ground a client in attending to external stimuli as a way to reduce the attention to internal stimuli. The individual is instructed to look around, point to objects one at a time, and name each in turn.



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Normalization Once coping skills have reduced the severity of symptoms, the verbal interactions of therapy sessions can proceed. An important component of CBTp, which applies to all symptoms, is normalization (Kingdon & Turkington, 1994). It can be used at any time in the course of therapy, and its repetition can be instructive. Normalization can be viewed as a type of acceptance (as prominent in Acceptance and Commitment Therapy [Hayes et al., 1999] and Dialectic Behavioral Therapy [Linehan, 1993]) in which a person learns to accept their condition while paradoxically making efforts to improve. Normalization goes beyond acceptance, showing how symptoms of psychosis can occur in any of us. Evidence is presented to diffuse the belief that one is odd or strange for having these symptoms. In this approach, the primary target for therapy is the distress, not the content of the beliefs. For one, certain conditions—ingestion of certain drugs, extreme lack of sleep, extreme stress, sensory deprivation—can induce true psychosis in anybody. Other, more common, situations can produce reactions similar to psychotic symptoms. Loss of a loved one can lead to hearing that person’s voice. Hearing one’s name called when no one appears to be doing so can happen to many without a mental health condition. Many of us have beliefs that can be considered as somewhat paranoid, referential, or grandiose. How many of us, hearing a police siren some distance behind us on the highway, suddenly check our speedometer and try to recall if our car is in good order, thinking the police siren is likely meant for us? When a car turns around in our driveway, we wonder what they are up to. Once the situation passes (the police go past us after someone else; the car that turned around goes off without event), we are relieved. Someone with psychosis might think there is still something afoot— the police made note of their license plate; the car now knows where they live. The initial assumption of something being wrong (paranoia), was made, nevertheless, by both groups. As for grandiosity, many people buying lottery tickets or supporters of a sports team watching a game have a strong belief that this time they are going to win. We make many assumptions and generalizations that protect us by assuming potential threats to, and possible greatness for, ourselves. Much of general CBT addresses these kinds of assumptions. To illustrate further, a person watches a horror movie. That night in bed, they notice out of the corner of their eye something that scares them, or they feel there is a presence in the room. Although this belief is similar to a paranoid delusion, the conviction is much less. The person who watched the horror movie, upon having this belief may say, “I am scared because I watched a horror movie. This is my mind playing a trick on me,” whereas a person with a paranoid delusion will have a stronger feeling that the belief is real and not attribute it to their imagination. The content of delusions can be normalized. Although many delusions seem bizarre, the content is often like that found in science fiction novels, dreams, and song lyrics. Although people without psychosis can create these same

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ideas, the strength of the beliefs differ. Furthermore, beliefs that are considered delusional in psychiatric populations cannot be distinguished, based on content alone, from new religious movements (Peters et al., 1999). Psychosis can be regarded as one end of a spectrum, not as a distinct, unusual anomalous condition. For instance, approximately 10% to 25% of the general population has heard voices at least once in their life (Slade & Bentall, 1988), and 60% to 80% percent of the population has heard a voice (Romme & Escher, 2000). There are many people who hear voices but lead otherwise normal lives. Many of these voice-hearers, as they call themselves, learn to merge the voices into their daily lives and do not require treatment (Romme & Escher, 1989). Paranoid beliefs are widespread and exist on a continuum, occurring throughout the general population. They are believed to be associated with the same mechanisms occurring in anxiety disorder (e.g., interpretation bias, hypervigilance, safety behaviors; Freeman et al., 2005, 2008). Moreover, such safety behaviors influence maintenance of the underlying threat belief (Freeman et al., 2016). The process of normalization can help reduce the stigma of “mental illness” and view it as a condition that one can learn to manage in order to live to one’s own potential. This in itself can reduce distress associated with the symptoms of psychosis. Cognitive/Behavioral Approaches The core of CBTp is a verbal, collaborative interchange between client and therapist in which beliefs of the former are evaluated by examination of evidence supporting or opposing these beliefs, while considering alternative explanations. This process is guided discovery, in which the therapist, through the use of Socratic questioning (i.e., probing questioning meant to stimulate critical thinking and to elicit ideas), gently leads the client to challenge their beliefs. Behavioral experiments, such as trying out a behavior to see if feared outcomes actually occur, enhance the cognitive approach by modifying beliefs on the basis of in vivo data. The techniques involved in these essential aspects of CBTp are presented in more detail in sections relating to the various symptoms of psychosis, as well as to the negative symptoms. Case Conceptualization Although specific therapeutic techniques are very useful in the treatment of psychosis, an overlying assessment and characterization of a person’s condition and reaction tendencies allows for a broader view and thought-out strategies over the mere use of one technique after another. The development of a case conceptualization (Morrison et al., 2004) and its presentation to the client provides a means to illustrate this overview, develop a hypothesis of how symptoms and problems formed and are maintained, and suggest treatment options.



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Although CBT focuses primarily on the here-and-now, case conceptualization begins with precedents for the current situation. The first are genetic and prenatal/perinatal factors (Beck et al., 2009), pertinent for schizophrenia and many other conditions with psychosis. For a given individual, the degree to which these factors are relevant in the etiology of the condition is not typically known; however, it can be informative to clients to see that these factors are part of how their conditions came to be. Sometimes this leads to relief that the condition is not their fault. Other clients could take this to mean that they are serving a life sentence with this condition. Care needs to be taken when providing this general information. Developmental influences, such as traumas or events at home, school, work, or with friends, can contribute to how vulnerable to symptoms someone is (Kingdon & Turkington, 1994). Genetic and developmental aspects are predisposing factors. The degree to which each category contributes (nature vs. nurture) is an ongoing focus of exploration. More proximal factors leading to the onset of symptoms are determined by gathering a detailed history—when they first occurred; what was happening at the time (especially stressors present); and thoughts, beliefs, emotions, behaviors at the time. Sometimes the content of voices and paranoid delusions reflect actual incidents in the person’s earlier life, implying that the incidents may have contributed to the onset. These incidents can be examined using CBTp techniques because they could still be influencing the person’s current emotions, thoughts, and behaviors. The next step in developing a case conceptualization involves compiling three to four samples of thought/belief records that represent common themes for the person. The records include events, ATs/ABs, and meanings of the beliefs, emotions, and behaviors. These are used to determine key symptoms, problems, core beliefs (i.e., unconditional assumptions about self, others, and the future), and conditional assumptions/beliefs/rules of how to cope with the core beliefs (e.g., “If I am being followed by the CIA, I am an important person,” as a way to cope with a core belief of “I am an insignificant person”). Next, precipitating, perpetuating and protective factors are listed. These are, respectively, (a) current triggers for symptoms; (b) thoughts and behaviors maintaining the symptoms; and (c) strengths, social supports, and positive patterns of behavior protecting against the symptoms. Coping or compensatory strategies (such as social isolation or vigilance) can be helpful in dealing with symptoms, or at times they can become problems themselves (Leahy et al., 2005). The case conceptualization serves to illustrate the origins of the problems and a working hypothesis of how the various factors and reactions above might be linked sequentially, suggesting a plan of treatment and a prediction of what obstacles to treatment might arise and how to overcome them (Persons & Tompkins, 1997). The case conceptualization guides the therapist and is presented to the client to increase understanding of one’s condition. However, insight gained from a

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formulation can have various effects (including depression and suicidality), so, again, care must be taken in the presentation, and in some cases, it might be best to limit it and introduce it gradually. Treatment Completion The ending of treatment is not always indicated, as many with psychosis require ongoing therapy. Progress in CBTp can be slower than that with nonpsychotic conditions. If symptoms remit, or at least improve, they often do so sequentially. Positive symptoms tend to improve before negative ones. Ego-dystonic (i.e., incongruent with one’s desires) delusions might be rejected before ego-syntonic (i.e., congruent with one’s desires) ones. Auditory hallucinations may continue to be present but less intrusive, whereas other symptoms persist. When indicated, the ending of treatment is a critical part of the process. It enables the person to continue treatment by treating oneself independent of the clinician, and to evaluate when return to formal therapy is needed. Relapse Management Part of the process of therapy is maintaining gains made and addressing relapse prevention, which consists in part of reviewing techniques that helped bring about remission. Frequently, skills learned in therapy to manage, diminish, or resolve symptoms need to be practiced on an ongoing basis. Another aspect of relapse prevention is identifying and acting upon early signs of relapse. The constellation of early signs varies among persons and conditions. For bipolar disorder (and schizoaffective disorder, bipolar type), less need for sleep and increased goal-directed activity can be the first signs of relapse. With schizophrenia, social isolation and talking to oneself could be early signs for some and have little clinical significance for others. Early signs signal clients, family members, and agency staff that a person might need to return to therapy or increase the frequency of therapy sessions. Medications might need to be adjusted and CBTp skills reminded, prompted, relearned, and/or resumed. As with initial therapy, coping strategies (such as listening to music when voices get worse) may be all that is needed.

ESSENTIAL COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS Formal CBTp proceeds virtually in the same manner as that for other conditions (Beck et al., 2009), with some minor adjustments (described below in the negative symptoms section). The basic focus is on identifying ATs/ABs and examining them for supporting or refuting evidence. Especially if there is only weak support for the beliefs, alternative explanations for the observed event(s) are determined and possibly tested. There is an emphasis on the person’s subjective experience and personal meanings given to events. These meanings are elicited and examined, but they may only be revealed after many sessions.



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The types of beliefs examined differ for the various symptoms. For hallucinations, it is beliefs about the hallucinations, including the source of the hallucinations (e.g., demons, deities, aliens), their power, and so on. It might also involve the content of voices, for example, when they say derogatory comments. For delusions, the beliefs are the content of the delusions themselves. These include grandiose, paranoid/persecutory, somatic, religious, and so on. For FTD, the beliefs could relate to what the person believes others might think of them or to whether they are capable of social interaction. Other beliefs are possible contributors to the stress leading to FTD. For negative symptoms, the beliefs tend to center around an inability to accomplish anything successfully or to be valuable or worthwhile (Beck et al., 2009). Cognitive Behavioral Therapy for Delusions Often, beliefs that are delusional are firmly held but isolated from their context. There are several CBTp approaches to delusions, including general normalization of delusions, first-generation reasoning experiments, and more recent interventionist causal approaches. The first-generation CBTp approach focuses on whittling down the beliefs by examining the context (context elaboration) in terms of logical conditions and logical outcomes. If the event had actually happened, what must likely have preceded and followed it, and is there evidence for these contextual items? To illustrate, a person believes that a man from her day program is in her bedroom in a house she shares with her aunt. One can ask how he got into the house. By the time she reports the event to a therapist, she should be able to say her aunt let him in, he got in via an open door/window, or it was a break-in. These are logical conditions to the man being in her bedroom; however, delusions are often single concepts (“The man is in my bedroom”) without the logical context. Next, the therapist could ask if she yelled for her aunt, called the police, or asked the man why he was there and told him to leave. These are logical outcomes. Also, because she sees him at least weekly, one can ask what she said when she next saw him. One author (NS) has a client with a similar scenario who did not have answers to any of these questions. This delusion was brought up by the client many times, with the therapist asking these questions each time it “occurred.” Eventually, the client changed her presentation of the story from the man being in the room to her feeling as if he was in the room. Without a context of logical conditions and outcomes, the delusion weakened from a belief to a felt sense. Sometimes, rather than the absence of a logical condition or outcome, there is an absence of logical arrangement of the immediate context of the delusional material. For example, a person stated a staff member who shared her living space was touching her inappropriately. When asked where she and the staff member were when this happened, she said that the staff member was at her bedroom door while she was lying in bed (some distance from the door). She had difficulty explaining how the staff member touched her from that distance. This exploratory questioning provides insights into delusions that can prove

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useful in other ways to understand particular delusions. In another example, one person had delusions of knowing famous people. Once, the therapist asked where the famous person was physically located at the time. The person responded that they were in her room on the television. This helped in determining how her delusions started with seeing celebrities on television and then grew into believing she knew them personally. Examining the evidence for beliefs is conducted in various ways using (a) guided discovery (with the therapist adapting a pseudoinnocent wondering, called the Columbo method, after the 1970s TV detective), (b) Socratic questioning (i.e., probing questioning to stimulate critical thinking), (c) behavioral experiments (i.e., testing beliefs using action, such as testing “Others will ignore me at parties” by going to a party and seeing how many people say “Hello”), (d) evidence for and against charts, (e) externalization of voices (i.e., use of a different term is more appropriate with this population), (f) pie charts, and (g)  spectrum lines (Beck, 1976; Burns, 1980; Greenberger & Padesky, 1995; Morrison & Barratt, 2010). Other creative methods are used to help people test the validity of their beliefs. For example, one person believed people from cars pulling up to his apartment building would invade his apartment. This client was asked to tally the times during the month he heard a car park outside his building and (a) people from the car invaded his apartment or (b) nobody invaded it. He brought back the paper with many checks indicating no invasion of his apartment and none indicating an invasion. When asked what he thought of his experiment, he said that he guessed people from the cars parking outside were not necessarily going to invade his apartment. Another person thought others could read his mind. His therapist asked if he would be okay if the receptionist (whom the client knew well) could join them to test his belief, and if he would believe the receptionist’s response. He agreed to both. Note that it is important in these experiments to establish, in advance, the client’s acceptance of the results. The receptionist was asked what the client was thinking. She said she did not know and was excused. When asked by the therapist, the client said he guessed people could not read his mind. Although these examples may seem like simplistic ways to disprove delusional beliefs, sometimes delusions rest on weak foundations that can be easily shattered by testing the beliefs directly, as these examples show. As another example, a person used a recording to test her belief that she said inappropriate things in front of her family. With the built-in recorder on her cellphone, she monitored what she said when she thought this event was occurring. Listening to the recordings revealed the absence of the believed event—she did not hear herself saying anything inappropriate to her family. Particularly when it is hard to prove a belief to be false or true, looking for alternative explanations is another way to loosen the tenacious grip of delusional beliefs. Even if the initial belief remains the primary belief, the presence of plausible alternative explanations can weaken its strength. For example, a person believed a blimp after a sports event was following him as he walked to



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his car. He rated this belief as 100% certain. When asked for other explanations for the blimp’s apparent movements, he denied any. He was then asked to give alternative explanations even if he did not believe them. He came up with the following: (a) the blimp happened to have turned the direction he had; (b) the blimp only appeared to have changed directions; and (c) the blimp changed directions first, but he thought he had turned first. After offering these explanations, when asked again about the strength of his belief that the blimp was following his movements, he lowered it to 95%. Although this may seem small, it was “a foot in the door.” What had originally been a fixed, firm belief became open to questioning once alternative beliefs were considered. In another example, where it might be difficult to determine if a belief is true or not, a person had the delusion that strangers he would see in such places as convenience stores were angry at him. This would lead many times to the person hitting the strangers. The therapist showed the client a paper (found in many therapy offices) containing cartoon drawings of labeled emotional facial expressions. The therapist covered the emotion labels and asked the client to identify each emotion. The client considered the smiling face as “happy” but all the others (including neutral, surprised, sad) as “angry.” It was difficult for the client to question his delusion by examining the evidence. Although the client did not have much evidence that strangers were angry with him (except for questionably angry faces), the absence of evidence did not convince him of the likely falseness of his delusion. For more direct evidence, he would have had to approach strangers and ask if they were angry with him. It was more fruitful for the therapist to address the client’s delusion with two sets of alternative explanations relating to the strangers’ emotions and their connection to the client—namely to consider the possibilities that the strangers were experiencing emotions other than anger, and if they were angry, they might be angry at something unrelated to the client. With these considerations in mind, the client was able to question and then ultimately reject his habitual delusional belief. This, in turn, resolved his aggressive behavior toward others. A form of examining the evidence is considering the belief to be due to the mental health condition itself. This approach is a delicate one. Increased insight into one’s condition can have various effects. For some persons, it will be a relief that they are not to blame for their situation (e.g., of not having a career, family, or housing of one’s own). Others may see it as devastating to think that one’s beliefs, possibly decades-long, have been due to some deficit in one’s thinking ability—and that one is forever limited by this condition. Depression and suicidality are potential consequences of this type of epiphany. It is important to individualize this topic. Each person’s reaction to this realization must be assessed before embarking on this discussion. One way to do this is to present the possibility of a delusion being false as a hypothetical, asking the person how they might feel if this was the case. Much progress can be made even without insight into one’s illness, but it can be helpful to approach the topic if a person appears ready.

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One way to venture gently toward the idea is to make the connection between stress preceding symptoms and the occurrence of the symptoms themselves. As a person comes to notice that voices and beliefs worsen during stressful situations, they might realize that these symptoms are dependent on their state of mind. It is usually a small step from this to statements such as, “It must be my mind playing tricks on me,” or “It’s all in my head.” In rare cases, attaching medical labels such as schizophrenia and delusional disorder may be useful, but more often, they are not necessary once the person considers the alternative explanation that some of their beliefs (and the presence of voices) are produced internally as opposed to being actual, external phenomena. At times there is a diminishing belief progression seen in the development of a person’s view of their delusions. Initially, delusions are considered to be facts. As the delusions are questioned over time, and as they discover that others do not share the same view of the “facts,” the delusions start to be viewed as personal beliefs. With more time, some persons who have challenged their own beliefs with repeated use of examining the evidence and considering alternative explanations begin to rephrase their beliefs as feelings (see Garrett, 2019; Nelson, 1997). The person who said a staff member of an agency she attended was in her house behind her when she was in bed came to rephrase it as “It feels as if he is right here behind me when I am at home in my bed.” This was arrived at after many instances of her reporting the recurring event as a fact and of being asked about logical conditions and outcomes (to which she was unable to provide answers). It is not necessary (and potentially detrimental) to challenge a person’s felt sense. It is best to validate the presence of the feelings and then educate the person that feeling (or “sensing”) something is occurring does not mean that it is. Examining the evidence and considering alternative explanations (the cornerstones of good science) are the steps that follow these feelings. Another way that progress in therapy might be partial, yet beneficial, is when clients no longer talk about delusions or allow them to influence their behavior or emotions, thus appearing to have relinquished them. Only when questioned about them is it known that they have not been completely abandoned, yet it might only be when probed that they think about them. Challenging beliefs is a delicate process better termed “guided discovery” and “Socratic questioning.” People with psychosis have endured years of others challenging their beliefs, yet they continue to cling to them. Facilitating the processes of examining the evidence and considering alternative explanations rather than directly confronting delusions more often leads to gradual rejection, alteration, or dampening of the importance of these beliefs. Therapists can facilitate these processes by first encouraging clients to provide examples of evidence for or against the beliefs and to consider alternative explanations for the events that led to assuming the delusional beliefs. If someone has difficulty producing their own examples, the therapist may suggest other possibilities. However, this should be done sparingly and in a collaborative, exploratory manner. Direct confrontation of delusions can lead to a more entrenched belief as well as confabulation (i.e., elaboration of the delusion to address logical



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challenges of it). An example of confabulation is adding to the delusion of an implanted listening device to say that it is microscopic, after being told it should appear on an x-ray. Confabulations can be incorporated into the delusion such that next time it is presented as if it was always part of the belief. At times, delusions serve a helpful purpose for the person. Most grandiose delusions have desirable qualities, but nongrandiose delusions, such as being married with children and having a regular job, can also be satisfying. Even paranoid delusions can have positive meanings if one’s importance feels enhanced by having important others (e.g., CIA, devil) follow and threaten them. Examining the evidence, considering alternative explanations, and other logical arguments have limited effect when desirable personal meanings are emotional anchors keeping the delusion in place despite utilization of cognitive techniques. The first step to dislodge emotional anchors is to identify the meaning behind the delusion(s), or what purpose it serves. A way to determine this is to ask the person what it would mean if the belief were true, or if it were not true. For example, if a person believes that they are a celebrity, the practitioner asks, “What’s good about being that person?” The person replies that it means they are talented, important, and liked by others, thus reflecting the possible purposes the belief is serving (to feel talented, important, and well-liked). Once the meaning is identified (which may not always be completely determined), the person can brainstorm (facilitated by the therapist) other means by which these meanings can be accomplished. In another case, an unemployed, unmarried college graduate with the delusion of being employed by the CIA was encouraged by her mother to read novels as opposed to passively watching television (and not being able to report what shows she had been watching). Therapy consisted in part of “quizzing” the person about the content of novels she was reading to ensure that she was doing so and to help her exercise her cognitive functioning through recall and summarization. Her delusion about being employed by CIA eventually subsided, potentially in response to the enrichment of her life with her return to reading. The concept of emotional anchors holding delusions in place is a specific example of a more recent approach to change in delusions that incorporates an interventionist-causal model (Kendler & Campbell, 2009). This model addresses delusions by specifically focusing on and targeting hypothetical factors that are involved in the formation and maintenance of delusions (Freeman, 2007; Freeman & Garety, 2014; Garety et al., 2007) without challenging the delusion itself (Mehl et al., 2015). Studies using the interventionist-causal model approach have focused on cognitive or emotional factors involved in the formation and maintenance of persecutory delusions such as reasoning biases (Waller et al., 2015), negative self-evaluations (Freeman et al., 2014), and worrying (Foster et al., 2010; Freeman et al., 2015). In their worry-intervention study, Freeman et al. (2015) used CBT to target and reduce worry in persons experiencing persecutory delusions and found, via mediation analysis, the change in worry may have accounted for 66% of the change in delusion, with reductions maintaining at a 24-week follow-up (Freeman et al., 2015). A meta-analysis on the effect

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of CBTp on delusions (Mehl et al., 2015) found first generation CBTp techniques to be superior to treatment as usual (TAU) with regard to delusion modification, which is maintained through the course of a follow-up period. However, they did not find the first generation CBTp methods superior to other effective interventions, such as those using the interventionist-causal model approach to delusion modification, at end of therapy nor at follow-up. It is important to recognize that delusions can also often be misinterpretations of real situations. Asking for evidence can expose real events leading to the production of the delusion. One elderly woman living in a residential facility reported that people in the building next to hers would come into her room at night and deliver, then steal, her newborn child. When finally asked what led her to this belief, she stated that she would wake with her bed wet. It turned out that, unbeknownst to the staff, she had urinary incontinence and changed the linen herself. This delusion informed the staff of this frequent occurrence. Later, she developed a heart condition, which was being treated when she started having a delusion that she was being stabbed in the back. When asked for evidence, she reported that she could feel the point of the knife “right here,” as she pointed to the left side of her chest. Had the heart condition not been previously identified, this delusion could have been the first indication that she was experiencing chest pain. Cognitive Behavioral Therapy for Hallucinations Cognitive behavioral treatment for hallucinations focuses partly on the beliefs about the origin and power of the hallucinations (Chadwick et al., 1996; Fowler et al., 1995), which tend to be auditory and mainly voices. Persons often believe voices to be from deities, aliens, demons, or other powerful sources. They often believe threatening voices are powerful enough to fulfill their threats. This leads to fear that if commands are not followed, the threat will be carried out. As with other delusions, examining the evidence and considering alternative explanations are the mainstay of treatment. Specifically, persons are queried about evidence for the belief that their voices have external sources. It is hard for persons to prove this—at best, the voices seem to be coming from outside oneself. Supporting evidence would include others hearing the voices, but these persons usually have experience of others saying they do not hear them. This has not swayed their belief in the voices. A method of testing the existence of voices is through the use of audio recording equipment; voices caught on the recording provide proof of existence, and their absence provides evidence that they do not exist. An illustration of utilization of tape recorders (or built-in recorders on cellphones or other electronic devices) is a person asked to record when she believes she hears neighbors or her mother (away at work) talking to her. The recording is played back to reveal the absence of the believed event— she did not hear neighbors or her mother talking to her. Prior to this experiment, the person would call her mother at work (or waking her, late at night), asking if she was home and talking to her. This method to gather evidence



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became disruptive for the mother, so the recording technique helped alleviate the disruption. With regard to the voices being powerful enough to fulfill threats, evidence against this includes that the person often has not obeyed the commands (ones such as hurting oneself or others) for many years and yet the alleged source of the voices has not fulfilled the threats. Although this conclusion may seem obvious, persons in this situation often overlook it. Consideration of alternative explanations includes that the voices are produced internally. As previously stated, as persons notice the connection of the presence or worsening of the voices in the context of stress, the conclusion that these voices must be produced by themselves arises. This eliminates the belief that the voices have any power or threat. Persons also discover they can at will initiate, terminate, and raise or lower the volume of auditory hallucinations (Fowler & Morley, 1989). This is best initiated with practitioners who coach the person on how to do these maneuvers. This technique helps persons realize the voices are produced internally since they can be internally manipulated. As with other symptoms, the belief that the phenomenon is produced internally can lead to recognizing it as something that can be treated. A second method to address voices is to consider the content of what the voices are saying. Sometimes voices reflect a person’s beliefs. For instance, a client in an initial psychiatric evaluation said her voices told her that the new agency was trying to poison her with medication. When asked if she believed what the voices said, she replied she did. This opened up discussion of the risks and benefits of the medication, that it was her right to refuse to take the medication at any time, and the strategy of starting at a low dose to see how she handled the medication. This consequently led to her agreeing to take the medication, which she continued to do long term. Assessing if voices reflect a person’s thoughts/beliefs consists of simply asking whether what the voices are saying is also what the person believes. If so, discussion can then shift to the person’s belief itself, sometimes no longer needing to examine the beliefs about what the voices are. Care must be taken not to assume that the content of voices reflects the person’s own beliefs. They can alternately reflect what others have said to that person (such as derogatory comments). Asking the person if they share the belief of the voice can provide clarification. Cognitive Behavioral Therapy for Other Positive Symptoms Additional positive symptoms include bizarre behavior and FTD. Bizarre behavior results from delusions, hallucinations, or disorganization. If someone wears a hat of aluminum foil because of the belief that aliens are reading their mind, then this behavior is best addressed by working on the delusion using CBTp methods. If a person shouts at unseen entities in public, gently determining if this is in response to auditory or visual hallucinations, followed by working on corresponding phenomena as described above, is the preferred approach. If nothing else, these approaches demonstrate understanding of the person by

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tuning in to the perceptions and beliefs behind the bizarre behavior rather than viewing the behavior from a bewildered stance. Many appreciate this attempt at greater empathy. At times, bizarre behavior is not associated with delusions or hallucinations, but rather is due to disorganization, one of three factor-analyzed subcategories of schizophrenia (the others being delusions/hallucinations and negative symptoms). Bizarre behavior of this type includes repetitive, meaningless movements (perseveration) and erratic behavior. Although using an aluminum hat is considered bizarre, it is a fairly organized behavior. Treatment of disorganized bizarre behavior is similar to that of disorganized thought/speech (FTD—also in the subcategory of disorganization). Although mostly handled with the use of medication, disorganization can be indicative of a stress reaction. Conceptualized in this manner, it can be reduced (although possibly not completely eliminated since other factors may be involved) by determining the ATs/ABs behind the emotions (especially anxiety) leading to the stress reaction that includes bizarre behavior. This can be difficult, as disorganized behavior is often accompanied by disorganized speech. One can use behavioral coping skills first, such as removing suspected stressors (e.g., certain people, places) and seeing if disorganization diminishes. A person could learn relaxation methods and be encouraged to use them when disorganization ensues. Examining and modifying irrational beliefs about the avoided people and places leads to further diminishing of anxiety (and the accompanying disorganization and bizarre behavior) and eventual reduction in the avoidance of these people and places. FTD itself contains verbal content—confusing content, however. Sometimes the content is meaningful, but these meanings take effort and exploration to determine since many have personal, obscure meanings. Additionally, explanations persons give frequently are disorganized themselves. An example of searching for personal meanings of seemingly meaningless speech is a client with bipolar disorder with psychotic features seen by the treatment team on rounds. A respiratory consult had determined the need to initiate treatment with an inhaler. The client, with FTD evident throughout her hospital stay, answered “Model.” The treatment team was confused by this response until one member (NS) asked if she was concerned about the recent, publicized death (from using an inhaler) of the sister of a famous model. The client responded affirmatively, so the team gave a detailed explanation about the inhaler and its benefits and risks. The client agreed to use the inhaler. Although this example presents the method in its simplest form, other attempts to decipher thought-disordered content in a collaborative manner can also lead to understanding what a person is communicating. Through the process, a person may feel understood in ways they have not with most others, as the more typical approach is to politely nod as if what is said is understood when it really is not. This feeling of being understood can reduce a person’s stress and thus turn a vicious cycle of stress to worsening speech to worsening stress into a virtuous cycle of feeling understood to less stress to improved speech to being more understood.



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Another approach to FTD is to have clients listen to tapes of themselves. This leads to reduction of its severity, which leads to improvement in quality of life. While in session, one client listened to tapes from the previous session and remarked, “That was me rambling,” when examples of FTD occurred on the tape. His thought-disordered speech improved markedly, and he was subsequently able to secure a managerial position at a food delivery establishment. Cognitive Behavioral Therapy for Negative Symptoms Much of CBTp research and treatment initially focused on the positive symptoms of delusions, hallucinations, and FTD. The negative symptoms of amotivation, apathy, affective flattening, asociality, and alogia were less amenable to the basic techniques of CBT. Negative symptoms seemed biologically based, as did neurocognitive deficits of diminished attention, memory, and executive functions. These did not seem to derive from beliefs. However, some studies showed positive changes in the negative symptoms when positive symptoms were mainly addressed (Rector et al., 2003). Later, work focusing more directly on negative symptoms showed significant results (Grant et al., 2012). Beck and associates (Rector, 2004; Rector et al., 2005; Grant & Beck, 2009) conceptualized negative symptoms as based on years of persons not succeeding in typical life functions—career, relationships, forming a family, and so on. These shortcomings led to the demoralized belief that it was not worth trying to do much of anything—certainly not to try anymore to get a job, a relationship, or have children. A vicious cycle of not doing well in the world leading to defeatist beliefs, then to retreat, and eventually to diminished ability to do well in the world characterizes the fate of those with negative symptoms. Reversing this cycle requires changing the belief one will not succeed into one of potential achievement. The first step is to identify a client’s personally meaningful goals. Next, the essence of these goals is elicited, such that accomplishable goals that meet the essence of the original goals can be formulated. For example, if a goal is to become the U.S. president, the essence might be being a leader, and an accomplishable goal might be to become a client coleader in a day program. Small steps are plotted out in that direction. The client is then assisted in achieving the first step. The belief that they cannot do the step (if present) is addressed and tested with a behavioral experiment. An example from Beck’s group (Grant et al., 2014) is an elderly woman who frequently called hospitals asking if they needed her help. Though seemingly benign, the frequency of calls was disruptive to hospitals. The therapist started with identifying the client’s personal goals. She stated she wanted to make coffee for people at her program. She did not know how to make coffee, so the therapist helped her learn during their sessions to make it and deliver it to persons at the therapist’s office. After discovering that she could make and deliver coffee, the client eventually achieved her goal of making it for her program. This accomplishment led to cessation of her calling the hospitals. The experience of making coffee for her program and the thanks she received appeared to

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give meaning to her life so that the pleas to the hospitals to help were no longer necessary (Grant et al., 2014). Along the lines of Viktor Frankl, Carl Rogers, Martin Seligman, and others, addressing meaning in one’s life is an important part of mental well-being. An accompaniment to addressing negative symptoms by examining validity of beliefs of inability to accomplish certain tasks, work on neurocognitive deficits helps not only the process of therapy, but also the ability to accomplish specific goals. Cognitive remediation/rehabilitation therapy (CRT; also confusingly referred to as cognitive therapy) utilizes computer “games” to provide systematic practice of neurocognitive skills (Wykes & Reeder, 2005). Whereas CBT focuses on higher levels of cognition (i.e., thoughts, beliefs, assumptions), CRT works on the building blocks of cognition, including neurocognitive skills such as attention, memory, decision-making, and planning. CRT works similarly to physical rehabilitation, enhancing basic skills through repetitive exercising of those skills in a gradual, progressive manner. CRT is outside the domain of this chapter; nevertheless, it is used to enhance the work of CBTp by improving basic cognitive functioning, leading to better participation in therapy. To accommodate for cognitive deficits in attention, memory, comprehension, and planning, techniques to facilitate clearer communication and remembrance of therapy items are used (Morrison et al., 2004), consisting of simplification, emphasis, repetition, and feedback. Simplification involves using words and phrases familiar to a given person. If new terms are introduced, they are defined using familiar words. Homework exercises are spelled out in simple steps. Any explanation is broken down into understandable units. Important points are emphasized by getting the client’s attention with good eye contact, using their name, pausing (but not too long), and writing down what has been said. The writing is another form of repetition, which emphasizes important points. Writing occurs in session with whiteboards or paper. At the close of a session, assignments, summaries, and take-home points are written (or typed and printed) and given to the client to take home for easy referral. Clients comfortable with electronic technology can make notes on their devices for easy reference (i.e., alternative rational beliefs used on coping cards for situations eliciting common ATs/ABs). Client feedback is also a key ingredient to accommodate for cognitive deficits. Having clients repeat important information during a session, summarizations of sessions, and homework assignments at the end of a session help to reinforce information via repetition (and emphasis), while allowing the therapist to confirm comprehension of material. Overall, improvement in understanding and retention can increase their confidence in their own ability to engage in therapy. This leads to a decrease in demoralization and an increase in motivation.

CBTp AND MEDICATION Although CBTp reduces psychiatric symptoms in some people with psychosis choosing not to take medication (Morrison et al., 2014), medications often



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provide relief and freedom from long-term hospitalization. Furthermore, many conditions with psychosis (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, and in many cases, major depressive disorder) require ongoing medication to prevent relapse. Clients and their families may believe CBTp leads to no need for medication, but this is generally not the case. Although doses might be safely reduced, rarely can medication be stopped completely. On the other hand, in persons at high risk for psychosis, medication use is not justified because symptoms are not yet present. Studies have shown that the use of CBTp in high-risk populations prevents the onset of psychosis in many—thus eliminating the need for antipsychotic medication (Stafford et al., 2013). Nevertheless, this is different from treating those who have had “full-blown” symptoms. The use of medication is resisted for various reasons including (a) believing medication is only needed temporarily as with antibiotics; (b) noting symptoms do not return after medications are discontinued (until they finally do); (c) not being comfortable with needing medication—due to side effects, cost, stigma, and having to accept the presence of a persistent disease; and (d) poor insight (e.g., believing one has no problem, and therefore, one needs no medication). CBTp approaches are useful in examining the evidence for and against these beliefs as well as in aiding the decision-making process related to the risks and benefits of taking or foregoing medication. Persons may develop the belief that once symptoms resolve, medication is no longer needed, especially when symptoms do not recur for weeks after stopping medications. Because the beneficial effects of psychotropic medications tend to linger for at least a month after stopping them, symptoms later recur. Resumption of medication does not work quickly enough to avert problems from the symptoms. Moreover, insight into the recurrence of symptoms is limited, such that the person does not recognize the need to resume medication, which in turn further perpetuates the symptoms. Hence, hospitalization is often needed to bring about remission. CBTp approaches can increase insight into one’s condition, potentially leading to increased adherence. Insight is not always required for clients to want medication. For example, one person with the delusion of being possessed by demons believed medication helped to dispel them. Side effects and costs of medications can be serious deterrents to continuation of their use. The beliefs associated with these factors are valid. Physicians can discuss with clients the potential major side effects, presenting available options so choices can be made based on individual preferences (e.g., persons more sensitive to weight gain choosing a medication less likely to have that side effect) and being aware of and addressing socioeconomic obstacles. Physicians can address socioeconomic obstacles by informing persons of government-offered and pharmaceutical-sponsored assistance programs, or by providing coupons for and samples of medication. There are barriers to inexpensive access to medications, but feeling embarrassed to ask for help can be the first, toughest barrier. Finally, life-altering illness (especially involving mental health) and the devastation as well as the stigma involved can be a serious setback to self-esteem, especially with the tendency for these conditions to have their onset when one

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is beginning to start one’s independent life. It can take considerable time to decide that taking medication as a way to maximize one’s potential is preferable to being medication-free but burdened with significant, life-draining symptoms.

FAMILY INVOLVEMENT It is often difficult to conduct CBTp without involvement of family members (or agency staff if a person lives in a residential facility). Family members provide useful information that the client is not able to (or only with inaccuracies) regarding history, symptoms, progress, and treatment adherence (therapy as well as medication). This can go both ways for delusions. A person might state something as true that family members refute (e.g., having graduated from college). Alternatively, a claim that seems delusional may be confirmed by a family member. Families often need education about the nature (including prognosis) of the condition. Misinterpretations exist, a common one being mistaking negative symptoms for laziness (Pelton, 2002). Given that schizophrenia often starts with years of prodromal symptoms (e.g., declining cognition and motivation) and progresses past an active positive symptom phase to a residual phase with mainly negative symptoms, the chronic aspects of low motivation can be viewed by families as laziness when unaccompanied by the more pathognomonic positive symptoms. Families can aid therapy by assisting with completion of homework exercises. They may need education in the thin line between useful encouragement to engage in certain activities (including household chores) and “nagging” about lack of involvement. There is another thin line between refuting a person’s delusion and refusing to collude with it. A gentle admission that one does not share the person’s belief but respects that they do can go a long way. Families may find it confusing and frustrating to wonder how their years of refuting delusions is any different from a therapist appearing to do the same thing with CBTp. As above, differences of therapy include not being a family member (with emotional associations involved), the gradual nature of guided discovery, involvement of the client in looking for evidence and alternative explanations via the “Columbo” and other collaborative methods, the individualization of treatment with a focus on the client’s needs and goals, and the use of positive acceptance and regard. Teaching these to families help improve symptoms, quality of life, and the client’s sense of being heard.

EFFICACY As noted previously, beginning in 1978, a number of research groups in the United Kingdom initiated the formal use and investigations of CBTp, and continue to lead the endeavor (Wykes et al., 2008), which has spread from the United Kingdom to several countries, including but not limited to the United



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States, Germany, Netherlands, Australia, Israel, Canada, and Italy. CBTp has been shown to be efficacious in treating the positive and negative symptoms of psychosis, mood, hopelessness, and overall functioning. More recently, CBTp has been used in the treatment of persons at clinical high risk (CHR) for psychosis (e.g., due to having first-degree relatives with schizophrenia) and has been found to be more effective in preventing transition to psychosis than TAU (van der Gaag et al., 2012), with results sustaining at a 4-year follow-up (Ising et al., 2016). Not only does the evidence show CBTp’s efficacy in CHR, prodromal phase (prior to onset of full symptomatology), first episode psychosis, and stable chronic symptoms (Birchwood, 2014), but also it has recently been found to lower ratings of positive and negative symptoms scores in those that are unmedicated (Morrison et al., 2014). Although more research is required on the predictive client characteristics and number of sessions required, it has been recommended as an adjunctive treatment to medication management by several entities including the Patient Outcomes Research Team (Kreyenbuhl et al., 2010), and the National Institute for Health and Care Excellence (NICE) guidelines—Psychosis and Schizophrenia in Children and Young People (Kendall et al., 2013), and Psychosis and Schizophrenia in Adults (National Collaborating Centre for Mental Health, 2014). Notwithstanding the above, reports of the efficacy of CBTp vary widely, especially considering differences among studies in the use of randomization of subjects, blind assessment of results, and therapy controls (e.g., supportive counseling) versus TAU. Initial summaries of CBTp studies reported results of individual studies (e.g., Haddock et al., 1998); later investigations used metaanalytic techniques (Burns et al., 2014; Jauhar et al., 2014; Jones et al., 2012; Lynch et al., 2010; Lutgens et al., 2017; National Collaborating Centre for Mental Health, 2009; Sarin et al., 2011; Tarrier et al., 2004; van der Gaag et al., 2014; Wykes et al., 2008; Zimmermann et al., 2005; see review Sivec & Montesano, 2012), mostly with small-to-moderate effect sizes (ESs; 0.20, 0.50 and 0.80 being small, medium, and large, respectively [Cohen, 1988], for positive, negative, and overall symptoms). In a comprehensive analysis of selected meta-analyses, Sivec and Montesano (2012) reported ESs for use of CBTp for positive symptoms ranging from 0.08 (for comparison to therapy controls at a 24-month follow-up; National Collaborating Centre for Mental Health, 2009) to around 0.30 (for studies with blind assessments; Zimmermann et al., 2005; Wykes et al., 2008). Regarding negative symptoms in studies in which blind assessments were used, ESs ranged from 0.04 (Jauhar et al., 2014) to 0.34 (standard mean difference; Lutgens et al., 2017). Again, limiting studies to those with blind assessments, ESs for overall symptoms ranged from 0.00 (Lynch et al., 2010) to 0.307 (Wykes et al., 2008). Possible reasons for the relatively low ESs include variability of experience using CBTp, small sample sizes (Lutgens et al., 2017), and variability in the treatment parameters (Wykes, 2014). What effects are pertinent can vary. Symptom severity, level of functioning, and quality of life are all reasonable foci of treatment. Client-defined goals may be viewed as an optimal category of measurement for effectiveness (Wykes, 2014).

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MECHANISMS OF CHANGE Researchers have begun to examine what specific changes occur that account for the positive effects of CBTp. While proposed mechanisms driving change in CBTp have included reasoning processes (Garety et al., 2015), use of case formulation and homework (Flach et al., 2015), and alteration of negative asocial and defeatist self-beliefs (Beck et al., 2019) as mechanisms driving change in CBTp, the evidence remains unclear. For example, a study that directly measured mechanisms of change using mediation analysis (Mehl et al., 2018) to assess amelioration of delusions using CBTp found that neither changes in reasoning biases (i.e., jumping to conclusions, theory of mind, attributional biases) nor in self-schemas accounted for the effect on delusions. In a study using imaging to determine brain region changes associated with improvement with CBTp, Mason et al. (2016) found that reduction of positive symptoms correlated with increased connectivity between regions associated with higher order cognitive processes (potentially including cognitive appraisal) and a network involved with threat perception and salience (i.e., the importance of stimuli). This study suggests that cognitive reappraisal may be a mechanism of change for CBTp.

DISSEMINATION AND APPLICATION TO DIVERSE POPULATIONS Despite being recommended in the United States as treatment, adjunctive to medication, for individuals with both psychosis (Dixon et al., 2010; National Collaborating Centre for Mental Health, 2014) and early psychosis (Bertolote & McGorry, 2005), CBTp continues to be poorly disseminated, and training is limited (Kimhy et al., 2013). Kimhy et al. (2013) examined dissemination by surveying training directors in psychiatry residency and clinical psychology doctoral programs, finding limited knowledge of CBTp’s efficacy and little to no training opportunities within the programs. Given the present state of inadequate training opportunities and minimal dissemination in the United States, delivery of effective CBTp services to mitigate psychoses is very limited. A collection of CBTp experts across North America has existed for approximately 2 years. This group formally launched as the NA-CBTp Network in October 2018, opening up membership more broadly (K. Hardy, personal communication, September 10, 2018). Hardy et al. (2011) successfully developed a sustainable community early psychosis program in a nonuniversity health care setting in San Francisco County, California, called the Prevention and Recovery from Early Psychosis (PREP) program (Hardy et al., 2011). PREP clinicians received extensive training in evidence-based approaches and treated 30 clients and their families within the first year of operation. Implementation of this community-academic partnership program included extensive partnering with agencies acquainted with the local resources and helped bridge the gap between research and prac-



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tice via successful integration of fidelity practice at the community level. More recently, Hardy et al. (2014) focused on the development of a sustainable “train the trainer” CBTp training and supervision model that could be implemented within a community-based service setting with predominantly master’s-level clinicians. This model included a 20-hour didactic training package, followed by weekly group supervision and monthly tape review. Persons trained to competence in the model became CBTp trainers and consultants. Community clinicians were trained to competence in CBTp utilizing this sustainable model. However, they encountered many obstacles throughout the development and implementation of the program, including staff turnover, resistance to implementation, recruitment of clinicians without basic background in CBT, language barriers, and delay in implementing skills in vivo due to gaps in establishing caseload (Hardy et al., 2014). Riggs et al. (2016), utilizing a pilot implementation project, demonstrated that staff in a high-demand, busy, real-world, public mental health system can learn and effectively implement CBTp achieving positive clinical effects. Moreover, Granholm et al. (2010) considered the feasibility of implementing CBTp in Assertive Community Treatment (ACT) teams and found that, whereas case managers can be trained to deliver CBTp with adequate fidelity, along with effective delivery from front-line workers, implementation barriers hindered the delivery of a sufficient amount of therapy (Granholm et al., 2010). Despite achievement of adequate fidelity ratings, key CBT skills were low in therapists with less than postgraduate education (this was with minimal, low-intensity training). Moreover, only 60% of therapists achieved adequate fidelity ratings, and only in at least one rated session. In reference to availability of CBTp services and trainings in the United States, there are some outlets that currently offer workshops and agency trainings, although they vary in applicability to outpatient and inpatient settings, milieu staff, and ACT teams. Yulia Landa is the program director for CBT for the Prevention and Treatment of Psychosis, a group- and family-based CBTp program for early psychosis (Landa et al., 2016). Landa also provides training in CBTp for mental health professionals working with psychotic disorders within the VA system (Landa, 2017). Aside from developing national strategies to increase dissemination of early psychosis models, with the aim of bringing these cutting-edge treatments to a broader population, Hardy also offers trainings and consultation in CBTp to a wide range of professionals. Riggs of NYC CBTp offers training workshops and consultations/supervision for both full individual and group therapy. Additionally, Riggs offers full CBTp trainings for agencies as well as CBTp-informed interventions for milieu working with psychosis. University of Washington’s Department of Psychiatric and Behavioral Sciences offers evidence-based trainings, including CBTp, for mental health providers working with persons with serious mental illness. In contrast to the United States, CBTp has been widely implemented and disseminated in Europe, especially within the United Kingdom, where it serves not only as a front line of therapy offered to persons experiencing psychosis

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(Wykes et al., 2008; Birchwood et al., 2014), but also in first episode psychosis (Bird et al., 2010) and as an early intervention service (van der Gaag et al., 2012; Ising et al., 2016). In South London and Maudsley, a clinical psychosis demonstration site used an approach from the U.K. National Health Service—Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI; Jolley et al., 2015). IAPT-SMI led to an almost three-fold increase in access to CBTp. Moreover, the protocol was found to be feasible and acceptable to service users, while boasting high completion rates and clinical improvement. Despite the success of such initiatives in Europe, implementation, training, and dissemination of CBTp in this country remain insufficient. A systematic review of 26 articles conducted by Ince et al. (2016) examined the implementation of recommended psychological interventions for schizophrenia, addressing rates, barriers, and improvement strategies. They found the estimated implementation range for CBTp from National Audits and Surveys in addition to local audits of services in different settings to be between 4% and 100%. Further, only one of the studies (Haddock et al., 2014) addressed quality assessment by using a design to minimize risk of bias to internal and external validity. Inequality in the provision of evidence-based therapies for persons with schizophrenia appears to continue notwithstanding our knowledge gains in this area. More recently, studies have examined feasibility, methodology, and cultural adaptability (Rathod et al., 2010, 2013) of CBTp trainings in countries such as Tanzania (Stone & Warren, 2011), Japan (Kikuchi, 2013), China (Li et al., 2017), India (Kumar, 2018), and Pakistan (Naeem et al., 2015, 2016).

CLINICAL EXAMPLE This example illustrates some CBTp techniques discussed in this chapter, including goal setting, normalization, voice content assessment, cognitive restructuring, coping tools for addressing auditory hallucinations, context elaboration (examining the context for logical conditions and outcomes), interventionist-causal approach to mitigating delusions and related distress, and guided discovery using the Socratic method. “Martha” is a 40-year-old woman who in her late 20s, while working as a clerk at an investment company after she graduated from college, began hearing voices and experiencing paranoia. Her symptoms worsened, interfering with her overall functioning and leading to the loss of her job. Her voices told her that people around her were saying negative things about her. Martha’s symptoms caused her significant distress whenever she was in public, which led to her avoiding crowded places and social interactions. Eventually, Martha’s decreased overall functioning and social isolation led her mother to move her back home and bring her to a CBTp therapist. Early in treatment, Martha and her therapist collaboratively outlined her treatment goals by breaking down her personal goals into achievable steps they could address together.



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THERAPIST: Now that we’ve spent some time discussing what brought you

here, let’s talk about some of your goals and dreams. Imagine you aren’t experiencing any of the symptoms we’ve discussed and there are no obstacles present; what would you want to be doing with your life? MARTHA:

Well, if I could do anything in the world, I would want to be a famous movie star.

THERAPIST: What would you like the most about being a famous movie star? MARTHA:

If I was a famous movie star, I’d be really popular. I would be an important person and lots of people would look up to me. I would have a lot of friends. Being a celebrity, I could get into any restaurant I wanted to, and all of the guests would compliment my beauty.

THERAPIST: If you were a famous movie star, you’d be very well-known and

well-liked. People would look up to you, say nice things about you, and you’d have a lot of friends. Can you describe what being well-liked looks like for you? MARTHA:

If I were well-liked, then I would have a lot of friends. People would want to hang out with me, and we could do fun things together.

THERAPIST:

What would it mean about you if others are complimenting you?

MARTHA:

It would mean that I’m not disgusting and that I’m good at doing things.

THERAPIST: What would “being good at doing things” say about you? MARTHA:

Being good at doing things would mean I’m useful and can contribute in some way.

THERAPIST: That makes a lot of sense. How do you feel about yourself

right now? MARTHA:

I feel like I can’t do anything right anymore. I’m not useful or helpful in any way. I’m probably just an added burden to my mother and the people around me. I’m also really gross, so people don’t want to be around me because they think I am disgusting.

THERAPIST: Those sound like really hurtful feelings. How about we work

together to come up with treatment goals that get you closer to things you identified as wanting to experience such as being well-liked, having friends, going out to places you like, and feeling useful.

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The therapist and Martha spent the rest of the session discussing her experience being around other people and some of the beliefs that arise during those times. They also spent some time reviewing the CBT triangle and breaking down some of Martha’s thoughts into core beliefs. Martha had scheduled another session the following week. The following conversation took place during the bridge from the previous session: THERAPIST: Last week we spent some time discussing what it feels like to be

out in public around other people. I remember you were telling me about some of the things the voices say to you when you’re out in public. You said they tell you what people around you are thinking. MARTHA:

That’s right. The voices get really loud when I’m out around other people. Especially when there are big crowds. They say very mean things that other people are thinking about me.

THERAPIST: That would make going out to places very uncomfortable. MARTHA:

It is really stressful going out places where other people are since the voices get really loud and everyone is really mean to me. It makes me feel very uncomfortable.

THERAPIST: You try to avoid going out to places where others are unless you

absolutely have to. MARTHA:

Yeah. Sometimes my mom makes me go places with her and I feel so anxious the whole time. The voices start talking more and much louder when we are out in public. They even say nasty things to me when I am on my way to our appointments.

THERAPIST: Would it be helpful to be able to control the voices? Like being

able to turn the volume down on a stereo so you don’t have to hear a song? MARTHA:

It would be nice to be able to control them. Is that possible? How can you do that?

THERAPIST: It is possible, and we can work together on building skills that

can help you control the voices. The technique we are going to work on today is called “look, point, name.” What I want you to do is to look at an object in the room, point to it with your finger, and then say the name of the object out loud. I am going to go first and then I want you to try.

[THE THERAPIST LOOKS AT THE WINDOW IN THE OFFICE, POINTS TO IT, AND SAYS “WINDOW” OUT LOUD.]

THERAPIST: Okay, now it’s your turn.

[MARTHA LOOKS AT THE AIR CONDITIONER, POINTS TO IT, AND SAYS “AIR CONDITIONER” OUT LOUD.]



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THERAPIST: Excellent! What were you thinking about when you were

engaging in this activity? MARTHA:

I wasn’t thinking about anything else besides the object I was looking at, pointing to, and naming in the moment.

THERAPIST: That’s how this technique can be helpful. This activity engages

different areas of your brain, which makes it hard to think about other things while you are doing it. When you look at something it is activating your visual system. Your motor system is activated when you point at the object, and then you use your memory recall and other parts of your brain when you name the object. Activating all of these different areas of your brain will help to turn down the volume and give you more control over the voices. It is much harder to concentrate on the voices when you are using your brain for all of the different types of activities involved in doing look, point, name. So, for your homework this week, I want you to practice using look, point, name, when the voices come up. Do it for as many rounds as it takes for them to quiet down, and record your experience with this coping technique to bring with you to our next session. Does that sound like something that would be helpful in getting closer to your goals? MARTHA:

I think having more control over the voices would be helpful. It would definitely make it easier to go places and be around other people since the voices wouldn’t be talking so loudly.

THERAPIST: It seems having control over your voices might make it easier to

go to places and be around other people since you won’t be hearing mean things other people might think about you. Martha continued to see her therapist for sessions regularly. In another session, Martha brought up an event that frightened her, MARTHA:

I was in bed and Steve Barnett from Community Clubhouse was there.

THERAPIST: He was in your room? MARTHA:

Yes. I didn’t see him, but I knew he was there.

THERAPIST: That must have been scary. MARTHA:

It was.

THERAPIST: Did you scream? MARTHA:

Oh, no. I did not.

THERAPIST: How did he leave? MARTHA:

I don’t know. He was gone.

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THERAPIST: And then you called the police? MARTHA:

No, I did not.

THERAPIST: You called for your mother? MARTHA:

I did not.

THERAPIST: You saw her at breakfast the next morning like you usually do,

correct? MARTHA:

Yes.

THERAPIST: What did you say to her about Steve? MARTHA:

Oh, nothing.

THERAPIST: You didn’t tell her that he got into your room? MARTHA:

No.

THERAPIST: That seems a bit unusual to not bring it up. MARTHA:

I suppose so.

Other times Martha brought up this type of delusion, the therapist would ask a few more questions examining logical conditions and outcomes. The therapist would ask only a few questions at a time to avoid interrogation as opposed to collaborative examination of the situation’s context. Other areas of inquiry included how Steve got into the house and Martha’s interaction with Steve the next day at the Clubhouse activities. The delusion was not questioned directly in terms of examining the evidence, and the therapist did not directly challenge any beliefs of Martha. Instead, questions concerning the context surrounding the delusional content were asked in an effort to elaborate the belief expressed in terms of logical conditions (e.g., Steve would have had to get in through an open door, someone letting him in, or by breaking in) and logical outcomes (e.g., Martha would likely have reacted to a real intruder by yelling, calling for her mother, calling the police, or at least letting her mother know about it). Martha’s belief in the delusion diminished as the logic behind it was gradually whittled away over the course of sessions. After some time, she started describing it in a subtly but significantly different manner: MARTHA:

Last night, it felt like Steve Barnett was in my bed again.

THERAPIST: Do you think he was really there or that it just felt like he

was there? MARTHA:

I just know that it felt that way—as if he was right there.

THERAPIST: Well, your feeling itself is real. You felt a sense as if he were

there. But you seem to recognize that just because someone has a feeling about something, does not mean it is true. The feeling



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is true. You had that feeling. But, again, that does not mean that what you feel or sense is actually happening. Many can have a feeling that someone is angry at them, but that does not necessarily mean it is true. People often feel as if someone in a group of people is looking at them, but when they look around, they do not see anyone looking at them. MARTHA:

Yes, I had the feeling about it, but I did not find any evidence that he was there.

Eventually, the Martha did not bring up this delusion anymore. Throughout the course of treatment, it became evident that Martha’s negative self-beliefs and fear of negative evaluation had been perpetuating her experience of paranoia, voices, social avoidance, anhedonia, lack of motivation, and loneliness. Martha and her therapist broke down her goal of being a “famous movie star” into smaller, achievable treatment goals that hit on some of her personal values. This included Martha having control over her voices and other distressing symptoms, making friends, engaging in more activities at the places she wanted to go to, building skills that would make her feel “more useful,” helping others, and feeling better about herself (e.g., not feeling “disgusting”). Through discussing the content of her voices and fears of negative evaluation from others, Martha and her therapist were able to identify some of her pervasive negative beliefs about herself (e.g., “I am disgusting,” “I am useless,” “I am unlikable,” “I am a failure”) and then subsequently use the CBT techniques of cognitive restructuring to replace them with more accurate and adaptive beliefs (e.g., “I am competent,” “I am likeable”). On the basis of the information Martha provided throughout their sessions, the therapist identified negative self-concept, low self-esteem, fear of negative evaluation, and worry to be primary issues impacting Martha’s symptomatology. As such, the therapist used the interventionist causal approach to CBTp (focusing on and targeting factors involved in the formation and maintenance of delusions) to address Martha’s paranoia and suspiciousness via engaging Martha in interventions and activities that targeted her negative self-evaluation and worry. That is, as Martha’s self-concept became more positive, fear of negative evaluation and worry decreased, and her experience of paranoia and suspiciousness began to dissipate.

CONCLUSION CBT expanded from its original use for treating depression to encompass a vast array of mental health conditions, including the challenging state of psychosis, found in a number of conditions, most notably schizophrenia. The basic tenets of examining the evidence and alternative explanations for events, interpreted by these persons in ways that stretch logic beyond what most of us would

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consider veritable, are viable methods even in these extreme cases. The definition of delusions as “firm, fixed beliefs” breaks down as this approach continues to help people question these beliefs and, at times, abandon them. In addition to addressing delusions, CBTp is used to alter beliefs about the power, nature, and content of voices; beliefs leading to bizarre behavior; beliefs that lead to stress exacerbating (or producing) disorganization of behavior and speech (the latter manifesting as FTD); and dysfunctional beliefs leading to negative symptoms. The effectiveness of CBTp has been called into question by rigorous analyses that require treatment controls (such as supportive counseling) and blind assessments when conducting meta-analyses. Although this evidence-based view is scientifically sound and helps prevent claims of treatment effectiveness that are not justified, there are limits to how well the evidence-based approach mirrors the clinical values of a given therapeutic method—specifically in three areas. First, by requiring CBTp outcome studies to have therapy controls, CBTp has to not just be shown to be effective, but it has to be statistically significantly more effective than other forms of therapy. This would be optimal, but is it fully necessary? CBTp was shown in Lynch et al. (2010) to usually be better than therapy controls, but not with a statistically significant difference. This would be important if it was significantly more expensive than other forms of therapy, but other than the initial cost of training a therapist in CBTp, there is usually no ongoing substantial cost difference. If parents are told that CBTp is better than other forms of therapy, but not statistically significantly better, and has a similar cost, they are likely to request it. Secondly, statistical analyses rely on means. With medications, maximum doses are sometimes determined by studies showing that, on average, people taking a medication will not do any better above the maximum dosage. However, there are a good number who do better, if needed, at the higher dose, so many physicians base their practices on experience and will prescribe the higher doses. This is an illustration of the principle of individualized treatment. Again, with most studies showing better outcomes for CBTp in the Lynch et al. (2010) analyses (but not statistically significant better), most individuals likely did benefit from the treatment beyond what other forms of therapy would do. A lesser number would have done no better, and an even lesser amount might have done worse than if they had another form of therapy. A better approach than dismissing CBTp as not effective enough is to determine which individuals are the ones who would benefit from CBTp—much as genetic analyses are being used more frequently to determine which medications work best for which clients, as often a client has to try many of them before finding one that works well enough. Finally, and perhaps most importantly, is how outcome studies depend on what measures of effectiveness are chosen. Usually symptom reduction and functioning are measured. Quality of life is sometimes used. These are important yardsticks, but when a parent says that no one else has connected as well



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with their adult child; when the person comes back to therapy again and again after leaving other attempts at treatment; when a person can have their beliefs addressed instead of merely medicated, listened to, and examined; and when the emotional anchors holding those beliefs in place are addressed, then perhaps additional measures need to be considered—ones that demonstrate the value of seeking to objectively learn another’s reality.

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Peters, E., Day, S., McKenna, J., & Orbach, G. (1999). Delusional ideation in religious and psychotic populations. British Journal of Clinical Psychology, 38(1), 83–96. https:// doi.org/10.1348/014466599162683 Rathod, S., Kingdon, D., Phiri, P., & Gobbi, M. (2010). Developing culturally sensitive cognitive behaviour therapy for psychosis for ethnic minority patients by exploration and incorporation of service users’ and health professionals’ views and opinions. Behavioural and Cognitive Psychotherapy, 38(5), 511–533. https://doi.org/ 10.1017/S1352465810000378 Rathod, S., Phiri, P., Harris, S., Underwood, C., Thagadur, M., Padmanabi, U., & Kingdon, D. (2013). Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: A randomised controlled trial. Schizophrenia Research, 143(2–3), 319–326. https://doi.org/10.1016/j.schres.2012.11.007 Rector, N. A. (2004). Dysfunctional attitudes and symptom expression in schizophrenia: Differential associations with paranoid delusions and negative symptoms. Journal of Cognitive Psychotherapy, 18(2), 163–173. https://doi.org/10.1891/jcop.18. 2.163.65959 Rector, N. A., Beck, A. T., & Stolar, N. (2005). The negative symptoms of schizophrenia: A cognitive perspective. Canadian Journal of Psychiatry, 50(5), 247–257. https://doi. org/10.1177/070674370505000503 Rector, N. A., Seeman, M. V., & Segal, Z. V. (2003). Cognitive therapy for schizophrenia: A preliminary randomized controlled trial. Schizophrenia Research, 63, 1–11. https://doi.org/10.1016/S0920-9964(02)00308-0 Riggs, S. (2017). Proceedings from CBT for Psychosis Training Workshop. Manhattan, NY: NYC CBTp. Riggs, S. E. (2019). Cognitive behavioral therapy for psychosis on the inpatient unit: The role of the clinical psychologist. In M. Turel, M. Siglag & A. Grinshpoon (Eds.), Clinical psychology in the mental health inpatient setting: International perspectives. Routledge. Riggs, S. E., Garrett, M., Arnold, K., Colon, E., Feldman, E. N., Huangthaisong, P., Hyacinthe, B., Indelicato, H. A., & Lee, E. (2016). Can frontline clinicians in public psychiatry settings provide effective psychotherapy for psychosis? American Journal of Psychotherapy, 70(3), 301–328. https://doi.org/10.1176/appi.psychotherapy.2016. 70.3.301 Romme, M., & Escher, S. (2000). Making sense of voices: A guide for mental health professionals working with voice-hearers. Mind Publications. Romme, M. A., & Escher, A. D. (1989). Hearing voices. Schizophrenia Bulletin, 15(2), 209– 216. https://doi.org/10.1093/schbul/15.2.209 Sarin, F., Wallin, L., & Widerlöv, B. (2011). Cognitive behavior therapy for schizophrenia: A meta-analytical review of randomized controlled trials. Nordic Journal of Psychiatry, 65, 162–174. https://doi.org/10.3109/08039488.2011.577188 Sivec, H. J., & Montesano, V. L. (2012). Cognitive behavioral therapy for psychosis in clinical practice. Psychotherapy, 49(2), 258–270. https://doi.org/10.1037/a0028256 Slade, P. D., & Bentall, R. P. (1988). Sensory deception: A scientific analysis of hallucination. Johns Hopkins University Press. Stafford, M. R., Jackson, H., Mayo-Wilson, E., Morrison, A. P., & Kendall, T. (2013). Early interventions to prevent psychosis: Systematic review and meta-analysis. British Medical Journal, 346, f185. https://doi.org/10.1136/bmj.f185 Stone, L., & Warren, F. (2011). Cognitive behaviour therapy training in a developing country: A pilot study in Tanzania. Cognitive Behaviour Therapist, 4(4), 139–151. https://doi.org/10.1017/S1754470X11000080 Tarrier, N., Lewis, S., Haddock, G., Bentall, R., Drake, R., Kinderman, P., Kingdon, D., Siddle, R., Everitt, J., Leadley, K., Benn, A., Grazebrook, K., Haley, C., Akhtar, S., Davies, L., Palmer, S., & Dunn, G. (2004). Cognitive-behavioural therapy in



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first-episode and early schizophrenia: 18-month follow-up of a randomised controlled trial. British Journal of Psychiatry, 184(3), 231–239. https://doi.org/10. 1192/bjp.184.3.231 van der Gaag, M., Nieman, D. H., Rietdijk, J., Dragt, S., Ising, H. K., Klaassen, R. M., Koeter, M., Cuijpers, P., Wunderink, L., & Linszen, D. H. (2012). Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: A randomized controlled clinical trial. Schizophrenia Bulletin, 38(6), 1180–1188. https://doi.org/10. 1093/schbul/sbs105 van der Gaag, M., Valmaggia, L. R., & Smit, F. (2014). The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis. Schizophrenia Research, 156(1), 30–37. https://doi. org/10.1016/j.schres.2014.03.016 Waller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., Hardy, A., Kuipers, E., & Garety, P. (2015). Thinking well: A randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. Journal of Behavior Therapy and Experimental Psychiatry, 48, 82–89. https://doi.org/10.1016/j.jbtep.2015.02.007 Wright, N. P., Turkington, D., Kelly, O. P., Davies, D., Jacobs, A. M., & Hopton, J. (2014). Treating psychosis: A clinician’s guide to integrating acceptance and commitment therapy, compassion-focused therapy, and mindfulness approaches within the cognitive behavioral therapy tradition. New Harbinger Publications. Wykes, T. (2014). Cognitive-behaviour therapy and schizophrenia. Evidence-Based Mental Health, 17, 67–68. https://doi.org/10.1136/eb-2014-101887 Wykes, T., & Reeder, C. (2005). Cognitive remediation therapy for schizophrenia; Theory and practice. Routledge. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34(3), 523–537. https://doi.org/10.1093/schbul/sbm114 Wykes, T. E., Tarrier, N. E., & Lewis, S. E. (1998). Outcome and innovation in psychological treatment of schizophrenia. Wiley. Zimmermann, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: A meta-analysis. Schizophrenia Research, 77(1), 1–9. https://doi.org/10.1016/j. schres.2005.02.018

9 Insomnia Jason G. Ellis, Michael L. Perlis, and Donn Posner

B

efore outlining cognitive behavioral therapy for insomnia (CBT-I) and the evidence surrounding its efficacy and effectiveness, it is important to provide, albeit briefly, a working definition of insomnia. This not only provides a context from which we can examine CBT-I and its central components, but it also gives an insight into what outcomes, in terms of its symptom profile, CBT-I is aiming to address.1,2,3 Insomnia has been conceptualized in many different ways since its inclusion in the ninth edition of the International Classification of Diseases (ICD) in 1977. Since that time, iterations of what determines a case of insomnia have changed between, and within, three main nosologies: the ICD, the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the International Classification of Sleep Disorders (ICSD). There are, however, some core features that have Throughout this chapter, cognitive behavioral therapy for insomnia will be referred to as CBT-I. This is partly because it is a standard acronym by which to refer to the treatment. As or more important, the acronym suggests that this is one form of CBT-I (one protocol), where there are many others (e.g., CBT-D for depression, CBT-A for anxiety, etc.). Although this kind of “naming” runs countercurrent to the “transdiagnostics” movement, it has the advantage of identifying the treatment protocols that are specific to the particular brand of CBT. Because the term “insomnia” has both formal and informal denotations, problems falling and staying sleep will also be referred to as “sleep continuity disturbance.”

1

Clinical examples are disguised to protect patient confidentiality. Conflict of Interest: The Economic and Social Research Council (RES-061-25-0120-A) in part funded this chapter. The funders had no role in any aspect of the production of the manuscript. https://doi.org/10.1037/0000219-009 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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both united these nosologies and stood the test of time. Predominately the principle complaint—of a self-reported difficulty in initiating and/or maintaining sleep—has remained constant. Additionally, albeit qualitatively and quantitatively different at times, the inclusion of minimum frequency, duration, and an impact criterion have also united these nosologies. Insomnia disorder, at least within the ICSD-3 and DSM-5, is predicated on the basis of a principle complaint of a difficulty getting off to sleep (initial insomnia), difficulty staying asleep (middle insomnia), and/or waking up earlier than required or desired (late insomnia) and should exist despite having adequate opportunity to sleep. Interestingly, there are no formal criteria for severity. That is, there is no definition for what “difficulty” initiating and maintaining sleep means. In other words, how much time needs to pass for it to be considered a problem? Although there are no formal definitions, there seems to be clinical consensus that suggests any amount of time greater than 30 minutes starts to frame the problem. Further, the difficulty should occur for at least three nights per week, have been present for at least three months, and cause—again within the context of self-report—significant distress and/or impairment to daytime functioning. One of the most significant advances in the area of defining insomnia, however, has been the reconceptualization of insomnia as a disorder, outlined in the fifth edition of the DSM (American Psychiatric Association, 2013) and the third edition of the ICSD (American Academy of Sleep Medicine [AASM], 2014). Previously, if insomnia was observed alongside another illness, disease, or disorder it was classified as secondary insomnia, with the assumption that if the other illness were managed the insomnia would resolve naturally. This change to a primary insomnia (where only insomnia is present) versus a secondary insomnia classification system continues to challenge the traditional viewpoint of insomnia and, indeed, all general forms of sleep disruption. Insomnia should no longer automatically be considered a symptom of another illness, disease, or disorder but instead a disorder in its own right, regardless of what comorbid disorders occur alongside the insomnia (unless a compelling case can be made for contingency—termed “adequately explained” in the DSM-5). This not only has ramifications for how insomnia is regarded by the healthcare profession but also mandates that chronic insomnia (i.e., insomnia disorder) be targeted for independent treatment and opens up the possibility that such treatment may have positive clinical effects on other disorders. The determination of whether a comorbid condition adequately explains the insomnia, however, is largely in the eye of the beholder. It remains easy for any clinician to assume that the insomnia is explained simply by the presence of the other illness. This is what continues to be the problem, which will not be solved until it becomes clear to the clinician that once perpetuating factors take hold the insomnia has taken on a life of its own and will not likely remit with targeted treatment for the “other” condition. Although definition is paramount, it is important, at least for our later understanding of why CBT-I may be considered a suitable candidate treatment for



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insomnia disorder, to understand how and why insomnia develops. Arguably the most influential framework for understanding the development of insomnia came from Spielman and colleagues (Spielman, 1986; Spielman, Caruso, & Glovinsky, 1987). According to Spielman, the course of insomnia is comprised of three factors: predisposing factors, precipitating events, and perpetuating factors (see Figure 9.1—the 3P model of insomnia). Whereas predisposing factors include anything underlying that may increase the likelihood of insomnia occurring when the individual is under challenge or threat, the actual stressor or trigger itself is considered the precipitant event, responsible for initial insomnia, otherwise known as acute insomnia. As can be seen in Figure 9.1, over time the impact of the stressor dissipates. That is not to say that the stressor, which Spielman conceptualized as a significant life event (e.g., bereavement, divorce, an illness)—although this viewpoint has been challenged more recently (see Ellis et al., 2012; Morin et al., 2003)—has been overcome, per se, but the stress response, largely biological in nature, fueling the initial period of insomnia has reduced. Most importantly, it is the perpetuating factors, which develop during the acute phase and grow in strength and importance over the course of insomnia, that are considered to be the drivers of the insomnia through its acute to chronic phase (Spielman, Caruso, & Glovinsky, 1987). These perpetuating factors, according to Spielman and others around the same time, such as Bootzin (1972), focused largely on the behaviors by which the individual attempts to cope or compensate for this initial period of insomnia and its resultant impact on daytime functioning. Perpetuating factors include drinking caffeine or napping during the day to counteract daytime tiredness, drinking alcohol to get off to sleep at night, and/or engaging in behaviors in the bedroom, such as watching television or working, when unable to sleep. FIGURE 9.1. Spielman's 3P Model of Insomnia

Note. CBT-I = cognitive behavioral therapy for insomnia.

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Whereas caffeine has the potential to keep us alert when we should or would want to be sleeping, alcohol is likely to decrease the amount of time it takes to fall asleep but increase the likelihood of fragmented sleep and nocturnal awakenings. Both strategies are therefore incompatible with sleep. Further, activities in the bedroom, other than sleep or sex—which is good for sleep—are likely to condition the bedroom to be a place for wakefulness by blurring the lines between daytime and nighttime activity whilst increasing arousal at night. The perpetuating factor believed to have a substantive impact on the course of insomnia, however, is spending excessive time in bed, either by going to bed early, lying in bed in the morning, or napping in the daytime (Spielman, Saskin, & Thorpy, 1987). Here, the belief is that any of these behaviors can reduce the drive to sleep at night, desynchronize the circadian rhythm for sleep, and have the capacity to fragment sleep. Further, this excessive time in bed is likely to create a scenario in which sleep-related stimuli become conditioned stimuli for wakefulness (i.e., bedroom, bed, and bedtime elicit the physiology of wakefulness and potentially negative affective states). Although the later models of insomnia (e.g., Buysse et al., 2011; Espie, 2002; Harvey, 2002; Morin, 1993; Perlis et al., 1997) still acknowledge the central role of the aforementioned behavioral factors in the perpetuation of insomnia, they also began to stress the importance of neurocognitive and neurobiological factors. Based upon phenomenological studies on individuals with insomnia, concepts such as “the racing mind,” the inability to “switch off,” and sleep-related attentional and interpretative biases were found to be common features amongst individuals with insomnia (Barclay & Ellis, 2013; Ree & Harvey, 2006; Wicklow & Espie, 2000). Thus, factors such as sleep-related dysfunctional beliefs, catastrophic worries over the short- and long-term consequences of poor sleep, sleep effort, and sleep preoccupation were seen as additional factors that could also perpetuate insomnia and would need addressing within a treatment framework (Ellis et al., 2007; Lichstein & Rosenthal, 1980; Morin et al., 1993). More importantly, and in some cases more implicitly, the newer models began to suggest that insomnia should be seen as a 24-hour disorder whereby actions, thoughts, and feelings during the day can influence sleep at night. In essence, if these perpetuating factors (both behavioral and cognitive) are the main issues fueling the chronic version of insomnia, then it stands to reason that their removal or successful management is likely to resolve or significantly ameliorate the insomnia. This rationale fits with the premise of CBT-I as a multicomponent treatment strategy that addresses both sleep-related cognition and behavior.

CBT-I AND ITS COMPONENTS The first thing to note about CBT-I is that it currently has no formal standardization. The length, number of sessions, and even the guidance on each component, including the order of delivery, differs among manuals, research



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protocols, and clinicians. That said, in the majority of cases, each session will generally be around 45 to 60 minutes in duration and occur over the course of 6 to 8 consecutive weeks. The first step in the treatment sequence is a thorough assessment. This initial evaluation aims to (a) ensure the individual has a form of insomnia that is amendable to CBT-I (e.g., not the sleeplessness associated with circadian rhythm disorders) and (b) take into account complicating factors related to comorbidities, substance use, current medication regimens, and/or life circumstances. The initial evaluation should also include assessment directed at uncovering the presence and type of perpetuating factors that may be involved. Immediately following the assessment is a period of baseline monitoring of sleep for between 1 and 2 weeks. This monitoring entails the prospective continuous sampling of sleep continuity data via the completion of daily sleep diaries. Sleep diaries, it should be noted, are critical to the conduct of CBT-I and are required for the duration of therapy. Sleep Diaries The sleep diary collects information, via self-report, regarding the timing, quantity, and quality of sleep. To be completed every morning, shortly after awakening, the information gathered from the sleep diary is usually summarized over the course of a week. The core sleep diary queries include time in and out of bed (TTB and TOB), sleep latency (SL), number of awakenings (NWAK), and time spent awake after sleep onset (WASO). These variables allow for the calculation of several additional metrics including total sleep time (TST), time in bed (TIB), and sleep efficiency (SE), the latter variables being essential for the conduct of CBT-I, or at least the component referred to as sleep restriction therapy. Although there are many sleep diaries available (which vary in both content and format), there is a consensus sleep diary (Carney et al., 2012), and this particular format is the one that is recommended here (see Table 9.1). These dimensions map on to the core symptoms of insomnia and are used both to inform treatment recommendations, as will be seen later on, as well as to TABLE 9.1. Recorded Dimensions From a Sleep Diary (Self-Reported) Label

Definition

Sleep latency (SL or SOL)

How long it takes the individual, after intending to, to fall asleep

Number of awakenings (NoA or NWAK)

The number of awakenings over the course of the sleep duration

Wake after sleep onset (WASO)

How long the individual was awake over the sleep duration after initially falling asleep

Time in bed (TIB)

How much time the individual has spent in bed over the sleep duration

Total sleep time (TST)

How much time the individual has slept overall

Sleep efficiency (SE or SEI)

The percentage of the time spent in bed asleep (i.e., TST ÷ TIB × 100)

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provide an indicator of treatment success. Importantly, sleep diaries can also provide a gross measure of adherence to the behavioral components of CBT-I. More recently sleep/activity trackers have been suggested as an alternative to self-report sleep diaries. Although these devices are helpful in some circumstances (e.g., where there are practical limitations to completing a self-report sleep diary or potentially to detect a form of sleep continuity disturbance— problems initiating or maintaining sleep—known as paradoxical insomnia), questions remain about their validity when used in place of sleep diaries in patients with insomnia (Kang et al., 2017). One of the main issues usually raised by the individual with insomnia, in the context of sleep diaries, is clockwatching. It is important to advise the individual not to have a clock face visible in the bedroom, as this can lead to clockwatching (i.e., calculating how long individuals have been asleep and how long they have remaining before they need to get up) throughout the night, which can increase anxiety about the consequences of poor sleep on daytime functioning, thus further delaying sleep onset. So how are individuals with insomnia going to complete a sleep diary if they do not have a visible clock from which to work? This is an interesting question and one that various therapists probably approach differently. One suggested way forward is to discuss the relevance of the subjective complaint (i.e., the reason they have come for CBT-I) over the issue of objective sleep. It is also essential to emphasize with the patient that clinical experience has demonstrated that, in most cases, subjective impressions are reasonable “ballpark” estimates that will be close enough to guide appropriate treatment choices. Psychoeducation (Including Sleep Hygiene) The main premise of psychoeducation is to begin to address the individual’s preconceptions and expectations about sleep, such as how much sleep an individual needs (including intra-individual differences), some basic sleep architecture constructs, how sleep changes over the lifespan, what insomnia is, and why it occurs. Addressing these issues affords the individual an understanding that there is no nomothetic rule with regard to sleep need and that insomnia, in its initial presentation, is a normal biological reaction to stress. Further, this latter assertion affords a discussion of the role of perpetuating factors using Spielman’s model, how these can maintain insomnia, and consequently, why CBT-I is an appropriate treatment strategy. Within this session, the basics of sleep physiology are also likely to be discussed, usually with reference to Borbély’s two-process model of sleep, which defines sleep regulation in terms of circadian and homeostatic factors (see Borbély, 1982). According to Borbély’s model, the circadian rhythm is the internal biological clock that regulates the timing of sleep, largely evidenced through the production and suppression of melatonin and changes in body core temperature, whereas the sleep homeostat (i.e., drive) regulates the propensity to sleep through a biochemical system that starts on termination of the prior sleep



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episode and continues until the next sleep episode occurs. The relevant points to note in this discussion are that (a) the homeostatic drive to sleep will continue to build until sleep occurs and (b) the circadian timing for sleep remains relatively constant whether we sleep or not. The first point allows for a discussion regarding night to night variability in sleep, in that individuals with insomnia will have the “odd” reasonable night of sleep because the drive to sleep is so high, and the second point allows for a discussion of why people are likely to feel particularly drowsy at certain times of the day, irrespective of how much sleep they have obtained (Perlis et al., 2010, 2014; Vallières et al., 2005). Additionally, providing an overview of this model affords a discussion on the way in which behaviors such as napping and spending excessive amounts of time in bed can weaken the sleep drive, making it difficult to sleep at night, and the way in which both variability in sleep schedules and the timing of other activities, such as eating and exercising, also have the potential to desynchronize the circadian system. It is helpful to underscore that such disruptions help explain why the individual’s sleep problem remains relatively consistent despite the fact that the original stressors that brought about the insomnia initially have long since abated. The second aspect of psychoeducation is sleep hygiene, which refers to a set of guidelines regarding the optimal sleep environment and routine, as well as lifestyle factors and habits that can impact on sleep. As with CBT-I, there is no standard set of guidelines; however, common aspects include (a) limiting or avoiding alcohol, caffeine, and nicotine in the evening; (b) ensuring that the bedroom is conducive to sleep (i.e., cool, dark, and quiet; removal of electronics from the bedroom); (c) not going to bed hungry or thirsty, but also not full up; and (d) using exercise to promote sleep, although exercise is not advocated in the later part of the evening due to its capacity to desynchronize the circadian rhythm (Morin, Hauri, et al., 1999). When considering the AASM’s Practice Parameters for the treatment of insomnia (Morgenthaler et al., 2006; see Table 9.2), one will note that sleep hygiene is not endorsed as a standard or guideline treatment on its own, but instead as part of a multicomponent treatment. The rationale for this is that studies that have examined differences between individuals with insomnia and normal sleepers in terms of levels of sleep hygiene practices have been equivocal, at best (Jefferson et al., 2005). In fact, several studies have shown that individuals with insomnia demonstrate a better awareness and practice of sleep hygiene than normal sleepers (Lacks & Rotert, 1986; Gellis & Lichstein, 2009). The final aspect of this session is likely to revolve around what CBT-I is and the individuals’ expectations from it. Many individuals with insomnia expect to be sleeping longer by the time they have completed treatment, when TST does not tend to significantly increase during acute treatment. The central aim of CBT-I is to reduce the amount of time awake during the night while simultaneously increasing the quality of the individuals’ sleep. To clarify this point, it is helpful to ask the individual to think of nights where they have slept for a long time and not felt refreshed and, conversely, nights in which they have had

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TABLE 9.2. American Academy of Sleep Medicine Practice Parameters for the Psychological and Behavioral Treatment of Insomnia Intervention strategy

Standard

Guideline

Option

N/R

Psychological and behavioral interventions for: Primary insomnia

X

Secondary insomnia

X

CBT with or without relaxation

X

Multicomponent therapy with or without cognitive therapy Individual components Stimulus control

X

Relaxation training

X

Sleep restriction

X

Paradoxical intention

X

Biofeedback

X

Sleep hygiene

X

Imagery training

X

Cognitive therapy (as a single therapy)

X

Note. N/R = no recommendation due to insufficient evidence; CBT = cognitive behavioral therapy.

fewer hours of sleep but woken feeling refreshed and alert. That said, individuals can be assured that if they continue to practice what they have learned in therapy, they can expect to slowly increase TST to more optimal levels over time.

Sleep Restriction Therapy (Restriction and Titration) Restriction The term sleep restriction therapy is a misnomer, as it is not the intention, or practice, of this protocol to restrict or reduce the amount of sleep an individual is achieving, per se (Spielman, Saskin, & Thorpy, 1987). The aim is to match sleep opportunity (i.e., amount of time in bed) to sleep ability (i.e., the amount of sleep the individual can generate) while simultaneously adding pressure to the sleep drive. This is achieved by restricting the amount of time that is allowed in bed, using the pretreatment sleep diary as a guide. As noted previously, the sleep diary provides information on how much time individuals perceive they are sleeping (TST) and how much time they are spending in bed (TIB). The initial goal of sleep restriction is to reduce TIB so that it is in alignment with TST. It is important not to reduce TIB too far, so if an individual with insomnia reports sleeping less than 5 hours on average, then a 5-hour minimum TIB is usually set (Spielman, Saskin, & Thorpy, 1987). Setting the timing of this new sleep schedule with the individual can be challenging, but the discussion generally focuses on what time the individual needs to be up in the morning.



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Setting the new sleep schedule “prescription” based upon wake time (i.e., the anchor time) serves two purposes: (a) a regular morning routine strengthens the sleep drive and places it roughly in alignment with the circadian rhythm, and (b) it limits interference with the individual’s life circumstances (e.g., getting up for work, getting the children ready for school), increasing the likelihood of adherence. Once the anchor time is set, the time to bed can also be calculated and set by working backward (e.g., “If I am getting up at 7 a.m., and my TST is on average 6 hours, then I will go to bed at 1 a.m.”). This “prescription” is adhered to (both in terms of time to bed and time out of bed) for the next 7 days or until the next appointment. Serious session time must be devoted to helping individuals devise ways to deal with obstacles to adherence (e.g., difficulty staying awake until the prescribed bedtime, waking up and getting out of bed at the prescribed wake time) at this juncture. Titration At the next session and over the subsequent weeks of treatment, the initial prescribed sleep schedule is titrated on the basis of the individual’s SE, from the most recent 5 to 7 days of sleep diary data. As seen in Table 9.2, the sleep diary can be used to create an index of SE with the equation: TST/TIB*100. Based upon the average SE, the rules of titration in most cases are then introduced: (a) if SE is less than 85%, then the amount of time allowed in bed is reduced (usually in terms of going to bed later) by 15 minutes; (b) if SE is between 85% and 89% then, the prescription stays the same; and (c) if SE is 90% or above, then the amount of time allowed in bed is increased (usually in terms of going to bed earlier) by 15 minutes (although there are some therapists who increase time in bed based upon a SE of 85% to increase the chances of adherence). Importantly, the 5-hour minimum is still in effect, as it is throughout the entirety of CBT-I, so if the calculations suggest that titration should go below 5 hours, then the 5-hour minimum is still used. The rationale for the 5-hour minimum is that at least for the first week of treatment the individual may still have sleep initiation or maintenance difficulties, and a buffer of 5 hours is needed to ensure unmanageable levels of sleep deprivation are not induced. It is important to tell individuals being treated that they are likely to experience higher levels of sleepiness, albeit for a brief period; otherwise, they may interpret the increased sleepiness as treatment failure and discontinue treatment. Caution must be taken to discuss the possible exacerbation of short-term sleepiness, and work is needed to come up with strategies to stay safe during the day (e.g., taking safety naps, considering alternative modes of transportation to driving). Stimulus Control (Standard, Exceptions, and Managing Time Out of Bed) Standard Developed by Bootzin (1972), stimulus control aims to address the conditioned arousal that has developed over the course of insomnia. It is common for individuals with insomnia to state, for example, that they frequently “nod off” on the sofa in the evening, but that when they approach the bedroom or start their

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normal bedtime routine (e.g., brushing their teeth), they become fully awake and alert and, thus, are unable to sleep. Moreover, many people with insomnia, when asked about their bedroom, are likely to respond negatively, stating that the bedroom and bed are a source of worry, anxiety, frustration, or anger. Naturally, being alert, anxious, worried, frustrated, or angry in bed is going to be incompatible with sleep. In order to break the association between the bedtime routine and the bedroom and wakefulness, as well as reestablish the bedroom as a place for sleep, Bootzin outlined a series of instructions relating to the bedroom environment and managing periods of being awake during the night. As can be seen in Figure 9.2, put simply, the instructions ensure that any time awake is spent outside of the bedroom and any time sleeping is spent in the bedroom, with the bedroom being optimally conditionable for sleep. This latter presentation also starts to address another insidious perpetuating factor—sleep effort. Most good sleepers cannot explain what intentional actions they take to get to sleep. In other words, they do not attempt to empty their minds, change breathing patterns, or relax muscles, much less toss and turn in order to achieve the right position to achieve sleep. Individuals with insomnia often perform all of these “efforts” to obtain sleep. Being told to get out of bed as soon as one becomes aware of being awake and engaging in any of these actions begins the process of helping the individual to let go of sleep effort, wait for sleepiness, and to get back into bed when sleep is more likely to unfold naturally without effort.

FIGURE 9.2. Bootzin's Instructions

STIMULUS CONTROL INSTRUCTIONS 1. Lie down to go to sleep only when you are sleepy/sleep only in the bedroom. 2. Do not use your bed for anything except sleep and sex. 3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep. 4. If you still cannot fall asleep, repeat step (3). 5. Set your alarm and get up at the same time every morning irrespective of how much sleep you got during the night. 6. Do not nap during the day.



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Exceptions As can be imagined or foreseen, there are inevitably circumstances whereby it is impractical for an individual to leave the bedroom or, indeed, the bed. These factors include frailty and the risk of falls, physical disabilities, and/or the bedroom environment itself (e.g., a bedsit, prison), for example. In these instances, counter control may be employed as an alternative. In this case, the individual remains in the bed, but one side of the bed is designated as an “awake” zone, and the other side is the “sleep” zone. In the “awake” zone, the individual can engage in wake-like activities, but there should be no intention to sleep (i.e., no sleep effort). Although limited, the studies that have utilized counter control have shown good efficacy comparative to traditional stimulus control (Hoelscher & Edinger, 1988; Zwart & Lisman, 1979). Managing Time out of Bed One of the main issues raised following both sleep restriction therapy and stimulus control is what can the individual do during those times out of bed. Maintaining good sleep hygiene is advocated, and the individual is usually instructed to engage in activities that are not physically or psychologically arousing. However, if the individual is devoted to getting out of bed and just sitting in the dark and waiting anxiously to return to bed, this should be seen as another type of sleep effort and a misunderstanding of how stimulus control works. It is important from the outset that the individual understand that the reconditioning that is expected with stimulus control cannot be achieved in a single night and may take several weeks of consistent application to help change the bedroom and bedtime experience back into conditioned stimuli for sleepiness and sleep. Therefore, any given night is to be sacrificed for improvement in the long term. It is important to work with the individual to make a list of activities they can do out of bed aimed at enjoyment and relaxation. This is why, on any given night, individuals need not worry about whether they can get back to sleep that night and why they need not fear engaging enjoyable activities (e.g., watching movies, reading good books, doing favored hobbies or crafts) at night. Relaxation Therapy The most evidence for relaxation therapy, used within the framework of CBT-I, has been from studies employing either progressive muscle relaxation (PMR) or biofeedback (Chesson et al., 1999; Freedman & Papsdorf, 1976; Morgenthaler et al., 2006). In fact, both strategies are endorsed, as was seen earlier, by the AASM. Other forms of relaxation, such as meditation, autogenic training, and imagery training, have also been used, but there is at present limited evidence for their efficacy. Irrespective of the type of relaxation employed, the aim is to reduce somatic tension either prior to or in bed by having the individual focus on their state of physical arousal. That said, there is limited evidence that this is the mechanism by which they work. It could equally be suggested that they work through cognitive distraction, limiting the racing mind and catastrophic

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thinking. PMR instructions suggest the individual start at the head and tense the muscles in that region, hold that tension for a few seconds, then release, and then progressively move all the way down the body, whereas biofeedback involves monitoring objective physiologic signals and identifying and self-modulating any signs of tension. Whereas PMR is a simple technique that can be employed by the individual at their leisure, the main challenge with biofeedback is that it is a resource intensive, time-consuming, and expensive procedure. Thus, biofeedback is rarely used in clinical practice. Cognitive Therapy Probably the component that most speaks to the lack of standardization is cognitive therapy, with several techniques currently being employed and with some protocols not including any form of cognitive therapy at all. In fact, as we saw earlier (Table 9.2), a cognitive component is not necessarily required for CBT-I by the AASM. The four main types of cognitive therapy used within the context of CBT-I are outlined in Table 9.3 alongside their aims and brief instructions (for full instructions see Espie & Ellis, 2016). Although dysfunctional cognitions are thought to influence insomnia primarily through worry and anxiety (i.e., a hyperaroused state), they are also likely to influence sleep-incompatible behaviors. For example, the belief that the individual needs 8 hours of sleep to TABLE 9.3. Overview of Cognitive Therapies for Insomnia Cognitive therapy

Aim in the context of insomnia

Brief instruction(s)

Articulatory suppression + imagery training

To distract the individual While in bed, use nonaffecfrom agitated, unfotive visual images, word cused, intrusive thoughts lists, or numerically based and images techniques to distract from intrusive thoughts

Descatastrophizing

To address catastrophic thinking at night

Cognitive control + constructive worry time

Preempt rehearsal, planning Write down a to-do list for and self-reflective the following day and thoughts at night provide opportunity in early evening to constructively address worries and concerns

Cognitive Restructuring

Correcting intrusive and irrational negative thinking and appraisals

Identify the most catastrophic thoughts that occur at night, related to poor sleep, and check their validity against the likelihood of their actually happening

Identify sleep-related dysfunctional attitudes and beliefs and assess their validity against previous experiences



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function or that sleeping badly one night can significantly impact on next day’s performance are likely to result in excessive time being spent in bed and the use of stimulants throughout the day. Two additional cognitive strategies are setting a wind-down time and practicing worry time. A wind-down time involves simply setting a time after which the individual sets aside arousing activities such as work, emails, and planning for the next day and instead begins to engage in more relaxing activities leading up to bedtime. Worry time is utilized when the individual with insomnia regularly complains of mind racing, worries, and thoughts about planning for the next day interfering with sleep onset and/or maintenance. The technique involves instructing the individual to set aside a dedicated period of time during the day (perhaps as short as 15 minutes) to actively plan or address worries that are bothering them. The rationale is that such a strategy can help shift the need for such problem solving from the night to the day. Regular practice can help the individual to avoid efforts to suppress such thinking at night (another form of sleep effort) and postpone these thoughts to a more appropriate time of the day. A recent study by Harvey et al. (2007) used a cognitive intervention alone to see its impact on insomnia. The aim was to address the five cognitive factors that she proposed to maintain insomnia in her earlier model (Harvey, 2002). The intervention contained three elements: case formulation (i.e., identifying cognitive factors perpetuating the insomnia), personalized experiments with guided discovery (i.e., devising and instigating behavioral experiments to challenge dysfunctional cognitions with the help of the therapist), and relapse prevention in order to identify and manage (a) worry and rumination, (b) attentional biases toward sleep-related cues and sleep-related threat monitoring (e.g., monitoring for physical signs of wakefulness at night), (c) dysfunctional beliefs about sleep, (d) the use of safety behaviors (e.g., canceling engagements due to perceived tiredness), and (e) misperception of both sleep and daytime deficits (e.g., attributing “normal” variations in daytime sleepiness to the insomnia). Although preliminary, the results showed continued sustained treatment gains in terms of self-reported sleep and on the Insomnia Severity Index (ISI; Morin, 1993) posttreatment and up to a year later (i.e., moderate to large effects in terms of reductions on SL, WASO, and ISI scores and increases in SE). Paradoxical Intention Paradoxical intention is the only “cognitive” therapy that is endorsed by the AASM. Its application to the treatment of insomnia is based on the premise that trying to sleep is counterproductive, and the effort expended trying to sleep is likely to result in keeping the individual awake feeling angry, frustrated, and/or worried (Espie et al., 2006). The instructions for paradoxical intention involve the individual getting everything ready for bed, as normal, including getting into bed and switching off the lights. With their eyes open, individuals are then instructed to remain quietly awake, periodically congratulating themselves on being able to passively resist sleep. This should continue until sleep has been

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achieved. Although not well studied, the rationale for its success is believed to be through reductions in sleep effort and the resultant physical and psychological tension when sleep effort does not pay off and the individual tries harder to sleep. Mindfulness-Based Approaches Although not strictly a cognitive therapy, more recently the principles of mindfulness have been introduced into existing CBT-I, with some excellent results (Ong, Shapiro, & Manber, 2008; Ong et al., 2009, 2014). For example, Ong et al. (2014) demonstrated a 78.6% treatment response rate, significant reductions in the amount of time spent awake at night, and a long-term (12 months posttreatment) effect size of 2.56 on the ISI. Mindfulness, as applied to insomnia, differs from the other cognitive therapies in that instead of identifying and addressing dysfunctional cognitions, the individual acknowledges any thoughts or attributions related to sleep or thoughts of any nature over the sleep period. Several techniques are applied to how sleep and insomnia are viewed—nonjudging (i.e., understanding that being awake at night is not automatically a negative occurrence), beginner’s mind (i.e., treating each night as just that, a single night), nonstriving (i.e., not trying to sleep at night or hiding your feelings of sleepiness during the day), acceptance (i.e., accepting the present state of wakefulness), letting go (i.e., not trying to change the content of sleep-related thoughts), trust (i.e., believing one’s sleep system can and will eventually reset), and patience (i.e., acknowledging getting sleep back on track will not happen overnight; Ong et al., 2012). One of the drawbacks of this approach, however, is that it appears that a great deal of training and practice is required to master the approach. Relapse Prevention Rarely discussed in the literature is relapse prevention, despite the fact that many clinicians use the final session of CBT-I to address this. Going back to Spielman’s 3P model, although CBT-I does not really consider predisposing factors and precipitating events in its main formulation, addressing these issues could be considered helpful at this point. For example, identifying the ways in which the individual is vulnerable to insomnia and the kinds of precipitating events that triggered insomnia previously, as well as the types of coping strategies used that were unhelpful in the past, may provide useful insights to prevention or early management of a future episode (Drake et al., 2014). In addition, once the individual is sleeping well, the amount of sleep restriction is reduced, and stimulus control is rarely needed. However, the individual should be alerted to the fact that bouts of acute insomnia are inevitable, and that re-application of stimulus control and sleep restriction can help to avoid more chronic insomnia. One final consideration at this point is regarding increased vulnerability. Although there is evidence that suggests that having a prior episode of insomnia confers a significant risk for a future episode (Jarrin et al.,



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2014; Morin et al., 2009), it should be borne in mind that the initial phase of insomnia (i.e., from onset to 2 weeks) may in fact be a normal biological reaction to a stressor (Perlis et al., 2016). Thus, during this period no intervention is required beyond telling the individual not to engage in compensatory practices and sleep-related effort during that period.

CANDIDATES FOR CBT-I The main consideration for candidacy for CBT-I has been the sleep deprivation, albeit brief, created by sleep restriction therapy and stimulus control. Candidacy has primarily focused on two areas—occupational issues and illnesses, diseases, or disorders (including medications), which may be affected by sleep deprivation. In terms of the first area, there are a few occupations, predominately ones that require sustained attention and focus (e.g., air traffic controllers, surgeons, train drivers, pilots), whereby more safeguarding and monitoring is usually required during the early part of CBT-I. For the exceptions noted above, it may be necessary to take these individuals out of work for the first week or two of CBT-I until they begin to experience better sleep and less daytime sleepiness. However, for most other individuals, it should be noted that a recent study suggests sleep restriction therapy does not confer “risk of significant impairments in sleepiness and reaction times” following 1 and 2 weeks of treatment (Whittall et al., 2018). Therefore, it may be reasonable to simply monitor sleepiness by using a sleepiness scale, such as the Epworth Sleepiness Scale (ESS; Johns, 1991), to track levels of sleepiness at the initiation of treatment and at regular intervals. If the individual reports a high level of daytime sleepiness (i.e., a score of 10 or above on the ESS), then additional support and safeguarding is advised. For example, typically when titrating sleep back into the individual’s schedule, when the criterion of 90% SE is reached, 15 minutes of time in bed is added to the schedule. However, it may be that with significant sleepiness (e.g., ESS > 10), an increase in time allowed in bed of 30 minutes would be more judicious. When the ESS is reduced below 10, then return to a weekly titration of 15 minutes. Other than occupational issues, a useful algorithm for determining who is and who is not a candidate for CBT-I was advanced by Smith and Perlis (2006). Following confirmation that the problem is one of falling asleep or staying asleep (in this case using a 30-minute SL or WASO minimum criteria) with an accompanying daytime complaint, the next stage is to ensure that the sleep problem is not a circadian rhythm issue. Here, the question, “If you were allowed to sleep ad libitum, would the 30 or more minutes awake at night still occur?” is used. If the issue would be resolved by being able to sleep whenever the individual wanted, then the likelihood is that the problem is a delay or advance in the circadian rhythm, and CBT-I is not indicated. The next sections of the algorithm focus on comorbidities. First, it asks (a) whether there are there any undiagnosed or untreated illnesses that will

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need assessing and treating before treatment is initiated; (b) if the insomnia still remains following appropriate management, then whether the illness prevents the individual engaging with CBT-I; and (c) whether CBT-I would make the illness worse (both exit points). Finally, the algorithm asks whether the individual presents with signs of sleep-incompatible maladaptive behaviors (i.e., excessive time in bed) and/or conditioned hyperarousal. That said, and as we will see shortly, as long as the illness appears to be stable, CBT-I can and has been used in the context of virtually all types of illness.

EFFICACY Before discussing relative efficacy and effectiveness of CBT-I, it is worth noting the outcome measures used within the context of CBT-I. In addition to the data from sleep diaries (in terms of improvements in SL, WASO, and SE), the ISI (Morin, 1993) is commonly used. The ISI is a brief (seven item), valid, and reliable self-report scale that maps onto the main symptom profile of insomnia disorder (Bastien et al., 2001). Although some have used other outcome measures (e.g., Pittsburgh Sleep Quality Index [Buysse et al., 1989]; PROMIS [Buysse et al., 2010]), the ISI remains the most often used outcome measure. One reason for its continued, and likely future, endurance is recent research by Morin and others (Morin et al., 2011), which provides cutoff scores for insomnia in both clinical and community samples (≥ 11 and ≥ 10 respectively) in addition to the point reduction on the ISI, following CBT-I, that equate to a slight improvement (i.e., a reduction of 4.7 points), a moderate improvement (i.e., a reduction of 8.4 points), and a marked improvement (i.e., a reduction of 9.9 points). Beyond the AASM practice parameters, there are now at least 20 metaanalyses that demonstrate that CBT-I is effective and durable (see Table 9.4). As can be seen, these meta-analyses do not just cover insomnia disorder/primary insomnia, but they are also relevant to comorbid insomnia in a wide range of different populations, including several meta-analyses of older adults. The combined evidence suggests moderate to large effects (using the vernacular of Cohen) for CBT-I in terms of reductions in individual symptoms (SL, WASO, SE) and overall insomnia symptomology (e.g., ISI) as well as increases in perceived sleep quality. Moreover, CBT-I appears to be durable, with many of the studies demonstrating only minimal declines in efficacy and/or relapse 1-year postintervention, with one study demonstrating its durability 24 months posttherapy (Morin, Colecchi, et al., 1999). To date, there are only two meta-analyses that compare CBT-I to pharmacotherapy (Mitchell et al., 2012; Smith et al., 2002). The findings of both meta-analyses indicate broadly similar effects for both treatment modalities during acute treatment but reduced efficacy following the discontinuation of pharmacotherapy. Comparisons of long-term durability were difficult, as there have been very few longitudinal studies of the efficacy and effectiveness of pharmacotherapy within the context of insomnia.



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TABLE 9.4. Meta-Analyses of Cognitive Behavioral Therapy for Insomnia Authors

Population

End points

Outcome

Morin et al., 1994

Insomnia

Sleep diary

Good effects

Murtagh & Greenwood, 1995

Insomnia

Sleep diary

Good effects

Pallesen et al., 1998

Insomnia (> 50 years Sleep diary old)

Good effects

Montgomery & Dennis, 2003

Insomnia (> 60 years Sleep diary old)

Good effects

Irwin et al., 2006

Insomnia (> 55 vs. 300 min/week) maintained the largest weight losses at 24 months (~10.5% of initial weight), compared with individuals who engaged in 250–299 min/week (~7% loss), 150–249 min/week (~5.5% loss), and < 150 min/week (~3% loss; Jakicic et al., 2008). For this reason, physical activity goals are often increased to 225–300 min/week during the maintenance phase of lifestyle modification programs (Donnelly et al., 2009). Unfortunately, studies that have randomly assigned participants to high, moderate, or low physical activity recommendations have not found a consistent benefit for high activity prescriptions, likely due to poor adherence to the prescribed activity goals (Catenacci & Wyatt, 2007; Jakicic et al., 2008). Behavior Therapy Adherence to diet and physical activity goals is facilitated through techniques derived from behavior therapy. These techniques are given a more central role in behavioral treatments but are also incorporated into some CBT modules (e.g., barriers to weight loss) alongside cognitive techniques. Core components of behavior therapy include goal setting, self-monitoring, stimulus control, and problem solving.



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Goal Setting Participants are encouraged to set specific, measurable goals at each session, including targets for modifying diet and physical activity and for changing their environment and habits to facilitate adherence to diet and activity goals (e.g., removing high-calorie foods from home, bringing gym bag to work). Participants are taught both to identify the specific behavior that they wish to adopt and to specify when, where, how, and with whom they will engage in that behavior (Wadden, Crerand, & Brock, 2005). Progress with meeting identified goals is reviewed with the interventionist at the subsequent treatment session and is often shared with other participants during group treatment sessions to further increase accountability. If a goal has not been met, the interventionist (and group, where appropriate) can help the participant to address barriers by problem solving or to modify the goal to make it more likely to be achieved. Self-Monitoring The monitoring of key behaviors allows patients to determine whether their goals are being met and to assess the effect of these changes on body weight. Throughout treatment, participants are encouraged to keep daily records of their food intake and physical activity, and to record their weight at least once weekly. Typically, food records include the types, amounts, and caloric content of all foods and beverages consumed. Ongoing record-keeping throughout the day can help patients select foods for remaining meals to stay within their daily calorie goal. Activity records can include the type and duration of physical activity or pedometer step counts, if available. A number of applications (“apps”) and devices now exist to facilitate the monitoring of food intake and physical activity (Ainsworth et al., 2015; Pagoto et al., 2013). Self-monitoring records typically form the basis for reviewing the patient’s goal progress in treatment. This review can help the patient and interventionist to identify intervention targets (e.g., high-calorie foods that could be replaced or consumed in smaller portions) and behavioral patterns that impact eating and activity (Wadden & Foster, 2000). For example, patients might track additional information about their emotional state or the location of eating episodes to help them to identify cues associated with overeating. The interventionist can also help patients identify additional sources of caloric intake. Most individuals underestimate their calorie intake, and this problem may be most extreme for the minority of patients who report that they are meeting their calorie goals but have not lost weight (Lichtman et al., 1992). All participants are encouraged to weigh or measure foods, when possible, to improve recording accuracy. A high frequency of self-monitoring is associated with better long-term weight loss (e.g., Tronieri et al., 2020; Wadden, Berkowitz, et al., 2005), and frequency of monitoring itself is often discussed as a behavioral goal in treatment. Barriers to record-keeping can be addressed by problem solving, or the interventionist may prescribe a more flexible monitoring schedule, as appropriate.

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Stimulus Control As discussed previously, both internal (e.g., emotions) and external (e.g., sight or smell of food) cues can become associated with eating or (in)activity. Stimulus control seeks to modify or reduce exposure to problematic cues, and to increase cues for behavioral targets in order to facilitate adherence to diet and activity goals (Butryn et al., 2011; Wadden, Crerand, & Brock, 2005). For example, patients can be taught to modify their environment by avoiding storing large quantities of high-calorie foods in their home and by increasing the visibility of healthy, low-calorie options (such as by storing them at eye-level). Problem Solving Behavior analysis involves the examination of antecedents (i.e., precipitating factors), behaviors, and consequences (i.e., reinforcement value) as a means of understanding factors that may contribute to a given behavior pattern (Wadden, Crerand, & Brock, 2005). Participants are taught to identify the series of preceding factors that may have contributed to an episode of overeating or physical inactivity, including both situational factors and cognitive and emotional antecedents. Linking these events and their consequences to form a “behavior chain” (see Figure 14.1) can allow the participant to identify opportunities to “break the chain” in the future by intervening to alter the sequence of events (Brownell, 2004; Wadden, Crerand, & Brock, 2005). Participants are taught to brainstorm possible solutions, select the intervention with the greatest likelihood of success (early in the chain, if possible), and implement and evaluate the solution’s efficacy. For example, in Figure 14.1, the patient might prevent overeating by using assertiveness skills (e.g., talking to friend about health goals, suggesting an alternative activity), stimulus control (e.g., selecting a restaurant that promotes healthy options, eating a healthy snack to reduce hunger), cognitive restructuring (e.g., “My health goals are important even though I’ve had a hard day. I can treat myself to a relaxing activity instead of with food”), or skills to cope with negative emotions (e.g., listening to music or talking to a friend to reduce stress). Cognitive Behavioral Therapy As in many CBTs, cognitive restructuring is used in obesity treatments to identify, test, and correct distorted or irrational thoughts that may interfere with behavior change. In behavioral treatment, unhelpful thoughts in response to lapses (i.e., deviations from eating/activity plan) are a primary target for cognitive restructuring (Wadden & Foster, 2000; Wadden et al., 2003). Patients may respond to overeating episodes by either minimizing (e.g., “Eating a few more won’t matter”) or magnifying their impact (e.g., “I’ve already blown it; I might as well eat whatever I want”). Either pattern can delay or prevent attempts to respond to the lapse by resuming efforts to meet diet and activity goals. Patients are taught to identify and respond to unrealistic thoughts by characterizing the lapse as a temporary setback that they can learn from, and emphasizing the importance of getting back on track as soon as possible.



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FIGURE 14.1. A Behavior Chain

Note. Situations, feelings, and thoughts that lead to or result from a given behavior (i.e., antecedents and consequences) are linked to help a patient to identify opportunities for intervention. Additional behavior chain examples can be found in Brownell (2004).

As described previously, the primary target for cognitive change in CBT for obesity is to help patients correct unrealistic expectations about weight loss and to view weight maintenance as a distinct and worthwhile goal that requires active intervention (Cooper & Fairburn, 2001). According to the theory underlying the treatment, patients who have more realistic expectations for weight loss and maintenance from the outset of treatment will be less likely to become discouraged when weight loss slows, more likely to appreciate the benefits of the loss that has been achieved, and, therefore, more likely to engage in the behaviors necessary to maintain lost weight. Through guided argument, the therapist helps the patient recognize the arbitrariness of their weight goal and that weight loss of a large magnitude is likely to be unrealistic (based on the patient’s prior experience) because it requires the maintenance of dietary restriction for long periods (Cooper & Fairburn, 2002). Through this discussion, the therapist and patient form a model for how unrealistic weight goals have impacted the patient’s ability to maintain lost weight with past attempts. During the weight loss maintenance phase, patients are explicitly discouraged from seeking further weight loss and are taught strategies associated with long-term weight maintenance (e.g., monitoring weight, cognitive responses, physical activity, flexible healthy eating; Cooper & Fairburn, 2001). A related goal in CBT for obesity is to help patients correct beliefs about the degree to which their “primary goals” (i.e., the goals that the patient hopes to achieve through weight loss) are tied to losing weight. Some goals may be reached with less weight loss than anticipated (e.g., health or fitness goals), whereas others can be addressed independently of weight loss (e.g., relationship goals, improving self-esteem; Cooper & Fairburn, 2001). Treatment seeks

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to help patients to both recognize the benefits of the weight loss that they have achieved and to separate the pursuit of primary goals from their weight loss goals (Cooper & Fairburn, 2002). For example, the body image module helps patients to improve body image directly by testing assumptions that maintain excessive body checking and/or avoidance, correcting negative thoughts about body shape, and encouraging body acceptance (Cooper & Fairburn, 2002). Problem-solving strategies are incorporated to help patients to take steps toward achieving other primary goals.

OUTCOME DATA After 6–12 months of treatment, intensive lifestyle modification programs produce mean losses of 5%–10% of initial weight (approximately 5–10 kg) that are significantly larger than those produced by usual care (e.g., advice, psychoeducation; Jensen et al., 2014; Wadden et al., 2020). Moderate-intensity programs (i.e., 1–2 sessions per month) are associated with smaller mean losses (Jensen et al., 2014). Christian et al. (2010) combined categorical data from 14 studies to show that a substantial portion of participants achieve clinically meaningful weight loss after 12 months, particularly in intensive programs (see Figure 14.2). Sustained losses of as little as 3%–5% can produce clinically meaningful health benefits, including improvements in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing Type 2 diabetes (Jensen et al., 2014). Losses greater than 5% are associated with improvements in blood pressure, high- and low-density lipoprotein cholesterol, and lipids (Jensen et FIGURE 14.2. Percent of Participants Who Achieve Categorical Weight Loss

Note. Outcomes at 1 year in intensive and less-intensive behavioral treatment programs, as reviewed in Christian et al., 2010. Not enough intensive programs reported the percent of participants who achieved a 0.1-4.9% loss or no weight loss to allow those results to be included.



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al., 2014), as well as quality of life and depression (Wing & Hill, 2001). Across these health outcomes, larger losses are associated with greater improvements (Wing et al., 2011). Weight regain continues to temper the long-term benefits of lifestyle modification. On average, one third of lost weight is regained in the year following treatment, and nearly half of participants have returned to their starting weight at 5 years posttreatment (Butryn et al., 2011). However, 35%–60% of patients maintain losses greater than 5% at 2 or more years after treatment, and weight losses remain superior to usual care at long-term follow-up points (Jensen et al., 2014). Further, although many of the benefits to cardiometabolic risk factors are reversed or diminished by weight regain, some may outlast the initial weight loss. For example, in the DPP, the intensive lifestyle modification program produced a 5.6 kg weight loss after a mean of 2.8 years that was associated with a 58% lower incidence in the development of Type 2 diabetes, compared with placebo (Knowler et al., 2002). At 10 years posttreatment, weight loss no longer differed between the groups (–2 kg for lifestyle intervention and –1 kg for placebo), but the lifestyle intervention group maintained a 34% lower incidence of Type 2 diabetes (Knowler et al., 2009). On an individual basis, successful weight loss maintenance is associated with ongoing engagement in key weight-control behaviors, including the consumption of a low-calorie diet, high levels of physical activity, and regular monitoring of body weight (Klem et al., 1997; Wadden et al., 2011; Wing & Hill, 2001). Successful weight-loss maintainers report a lower caloric intake than individuals who have a similar current weight with no history of weight reduction (e.g., Shick et al., 1998). This difference may be attributable to metabolic adaptation that is disproportionate to the change in their body mass (e.g., Astrup et al., 1999; Fothergill et al., 2016); however, not all studies have identified such deficits (e.g., Wadden et al., 1990), and others suggest that there is high individual variability in the degree of metabolic adaptation (Fothergill et al., 2016; van Dale et al., 1990). High levels of physical activity may help patients overcome changes in resting metabolic rate that would otherwise produce weight regain (van Dale et al., 1990). Regular self-weighing may facilitate maintenance because it allows patients to detect small increases in weight and implement additional weight control strategies to prevent further regain from occurring (Butryn et al., 2007). Additional behaviors, such as eating regularly throughout the day (an average of 4.9 meals and snacks/day), eating breakfast on most days, limiting eating out, eating a low-fat diet, and limiting television watching, are also reported by successful weight maintainers (Klem et al., 1997) and likely support their consumption of a low-calorie diet and high activity levels. Two treatment approaches have been shown to improve the maintenance of lost weight, likely by facilitating adherence to behaviors associated with long-term weight control. The first is the provision of ongoing lifestyle modification sessions, which reduce weight regain for periods of up to 2.5 years after initial weight loss (Jensen et al., 2014; Perri & Corsica, 2002). In a review of 13 studies assessing the benefit of ongoing sessions for weight-loss maintenance

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(Perri & Corsica, 2002), extended treatment (for an average of 12.5 months) resulted in the maintenance of 96.3% of the initial mean 10.7 kg loss (equivalent to 10.3 kg). Comparison conditions with no extended contact maintained a lower 66.5% (6.6 kg) of the initial loss. In longer-term treatment (beyond 1 year), treatment attendance begins to decline and some regain occurs, resulting in an average maintenance of 65.8% at 22 months for patients who are provided with ongoing treatment, compared with 38.3% for those who are not (Perri & Corsica, 2002). The rate of weight regain appears to level off, such that patients still maintain about 50% of their initial weight loss after 3 or more years of extended treatment (Knowler et al., 2002; Wadden et al., 2014). The second treatment approach is the addition of medications approved by the U.S. Food and Drug Administration (FDA) for weight management. This approach has been likened to the treatment of other chronic health conditions that require long-term pharmacologic intervention (Butryn et al., 2011). Several trials have shown that the addition of obesity medication after weight loss induction aids in the maintenance of lost weight (Hill et al., 1999; Smith et al., 2010; Wadden et al., 2013). However, the benefit of some pharmacologic agents may be small when combined with ongoing weight loss maintenance counseling (Tronieri et al., 2018), and more research is needed to evaluate the long-term benefit of recent FDA-approved medications. The Effect of Treatment Components on Weight Loss In addition to treatment intensity and duration, treatment format may influence short- and long-term weight loss. Group treatment has been shown to produce larger weight losses than individually delivered treatment in some studies (e.g., Renjilian et al., 2001), but equivalent losses in others (e.g., Minniti et al., 2007). Small group size appears to produce superior losses compared with large groups (e.g., 12 participants vs. 30 participants; Dutton et al., 2014). The results of a Cochrane review found that the combination of behavior therapy, diet, and physical activity (i.e., behavioral treatment) produces larger weight losses than treatment with diet and activity recommendations alone (Shaw et al., 2005). Behavioral treatment is typically delivered as a package, and the degree to which most individual behavior therapy components improve weight loss has not been tested in an RCT. Of these strategies, more frequent self-monitoring of dietary intake and weight has been associated with greater weight loss in several studies (e.g., Butryn et al., 2011; Tronieri et al., 2020; Wadden, Berkowitz, et al., 2005). A number of studies have tested whether treatment packages that add or emphasize particular skills produce superior results compared with standard behavioral treatment. The addition of a self-efficacy intervention (Burke et al., 2015), problem-solving therapy (Perri et al., 2001), or acceptance-based strategies (Forman et al., 2016) may improve weight loss, but further study is needed to replicate these results. Interventions that have not significantly improved weight-loss outcomes include increased attention to modifying the home envi-



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ronment, motivation-focused treatments (that highlight benefits associated with different motivations for weight loss), and relapse prevention training (although training in weight stability maintenance prior to initiating weight loss may be beneficial; Perri & Ariel-Donges, 2018). Of note, CBT for obesity as described by Cooper and Fairburn was not found to produce weight losses superior to behavioral treatment in an RCT (Cooper et al., 2010). After 44 weeks, behavioral treatment produced a mean loss of 12.7% of initial weight, compared with 8.9% with CBT (and 5.4% with guided self-help; differences between the behavioral and CBT groups were not statistically significant p = .07). During the 3-year follow-up, rate of weight regain did not differ between the two intervention groups, such that behavioral treatment had total losses that were still 2.8 kg larger than CBT participants at the end of the follow-up period. CBT produced greater improvements in body shape acceptance than behavioral treatment, but the hypothesis that those improvements would facilitate weight loss maintenance was not supported (Cooper et al., 2010). Efficacy of Lifestyle Modification With Diverse Populations A number of studies have examined whether demographic characteristics or comorbid conditions predict weight loss with lifestyle modification. In most studies, sex, education, employment, and marital status are not associated with weight loss (Fabricatore et al., 2009; Gomez-Rubalcava et al., 2018). Some studies have found younger age to predict poorer weight loss (Delahanty et al., 2013; Gokee-LaRose, Gorin, Raynor, et al., 2009; Wadden et al., 2011), whereas others have not (Fabricatore et al., 2009; Gomez-Rubalcava et al., 2018). It may be that younger individuals are more likely to have competing demands on their time (e.g., childcare, early career status) that interfere with their ability to focus on weight-loss goals. One study found that young adults aged 21–35 years attended fewer sessions (52% vs. 74%) and were less likely to complete 6 months of treatment than older adults (Gokee-LaRose, Gorin, Raynor, et al., 2009). Modifying treatment by limiting enrollment to young adults and directly addressing behaviors and experiences that are relevant to that age group may improve their treatment outcomes (Gokee-LaRose, Gorin, & Wing, 2009). Similarly, some studies have found that racial/ethnic minorities, particularly Black women, lose less weight in behavioral programs than their White counterparts after 6–12 months (Delahanty et al., 2013; Fabricatore et al., 2009; Gomez-Rubalcava et al., 2018). However, the smaller losses of Black participants may be better maintained than the larger losses of the White participants, and several studies suggest that longer-term losses do not differ by race/ethnicity (Gomez-Rubalcava et al., 2018; Seo & Sa, 2008; Wadden, et al., 2011). Researchers have suggested that lifestyle modification programs should be tailored to address sociocultural and environmental factors relevant to minority groups. However, interventions adapted for Black participants have reported only modest initial mean weight losses, and treatment delivery by interventionists

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of the same race/ethnicity does not improve weight loss (Seo & Sa, 2008). In meta-analysis, individually delivered interventions and interventions that included a family component were associated with larger weight losses in minority groups (Seo & Sa, 2008), but studies that directly compare interventions with these components to standard behavioral treatment are needed. Obesity is associated with a higher prevalence of psychological problems, including binge-eating disorder, depressive disorders, and anxiety disorders (Puhl & Pearl, 2018). The presence of these comorbid conditions has been hypothesized to limit weight loss; however, most studies have not found baseline binge eating, depression, or anxiety to predict treatment outcome (Fabricatore et al., 2009; Gomez-Rubalcava et al., 2018; Tronieri & Wadden, 2018). Patients who continue to experience binge eating during treatment may lose less weight (Chao et al., 2017; Grilo et al., 2011). A study by Grilo et al. (2011) compared CBT for binge-eating disorder to behavioral weight-loss treatment and combined treatment (CBT followed by behavioral weight loss) for producing binge-eating remission and weight loss. The three groups had similar rates of binge-eating remission after 24 weeks of treatment (44%, 38%, and 49%, respectively) and at a 12-month follow-up (51%, 36%, and 40%, respectively). However, reductions in binge frequency, while similar at posttreatment, were better maintained at 12-month follow-up in CBT than in BWL. At posttreatment, weight loss was greater in the behavioral and combined groups when compared with CBT; however, these differences were not maintained at follow-up. Similarly, depressive symptoms tend to improve in behavioral weight-loss treatment, although these improvements may decline over long-term follow-up in association with weight regain (Tronieri & Wadden, 2018). Treatments that combine behavioral weight loss and CBT for depression may lead to greater improvements in mood than behavioral treatment alone, but do not improve weight-loss outcomes. In general, these findings suggest that the presence of comorbid psychological conditions is not a contraindication to weight loss treatment for most patients; however, it is best practice to provide appropriate mental health referrals for the treatment of the psychological symptoms (Tronieri & Wadden, 2018).

DISSEMINATION Research on the efficacy of lifestyle modification for obesity has typically been conducted in academic medical settings (e.g., DPP Research Group, 2002; Wadden et al., 2006). Such programs are not widely available and can involve substantial costs, both to the institution and to participants who incur costs to travel to the site, even if treatment is provided free of charge. Participants typically are screened for appropriateness, which may involve the exclusion of individuals with certain medical or psychological conditions. They typically attend several visits prior to beginning treatment and thus are likely to be more



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highly motivated than individuals who do not complete the screening process or who do not volunteer for long-term research studies. Further, the behaviors required for successful weight loss represent a substantial commitment of time and effort on the part of the participant, as does their long-term attendance of treatment sessions. Providing lifestyle modification programs in community, primary care, and workplace settings can improve patient access. Of these, studies of behavioral treatments delivered in community centers produce outcomes that are most similar to those conducted in academic medical centers and are associated with lower program and participant costs (Butryn et al., 2011). Most studies also have found that high-intensity lifestyle modification programs (that provide at least 12 sessions per year, as defined by the U.S. Preventative Services Task Force) produce clinically meaningful weight losses (4–7 kg) when delivered in person or by phone in primary care settings (Tronieri et al., 2019). However, intensive programs are difficult to integrate into clinical practices due to lack of provider time, training, and reimbursement. Low- to moderate-intensity counseling delivered in primary care may be somewhat more feasible but produces only modest weight losses of 1–2 kg. Worksite programs also typically produce small mean losses (e.g., 1–2 kg; Butryn et al., 2011). Delivering lifestyle interventions by telephone, internet, or smartphone app may also improve their accessibility and reduce cost and time burdens. Telephone delivery has been shown to be as effective as in-person delivery for both weight loss and weight maintenance and substantially reduces travel costs to the participant (but not clinic costs; Donnelly et al., 2013; Perri & Ariel-Donges, 2018). Internet- and app-based treatments may have the widest availability and lowest costs. For weight loss, internet-based treatment consistently produces smaller losses than in-person treatment but is superior to minimal treatment in some studies (Butryn et al., 2011; Sherrington et al., 2016). Online treatments that offer a structured program of diet, physical activity, and behavioral strategies (Butryn et al., 2011), and that provide interventionist feedback, produce the strongest results (a mean 2.1 kg loss in meta-analysis; Sherrington et al., 2016). Internet-based programs may be more effective for facilitating weight-loss maintenance, and two studies found no differences between online and in-person delivery methods (Butryn et al., 2011). However, two other studies found that online programs resulted in greater weight regain than in-person treatment (1.2 and 4.7 kg more, respectively; Harvey-Berino et al., 2002; Svetkey et al., 2008). As noted previously, smartphone apps are now frequently used by individuals who are enrolled in behavioral treatment to facilitate self-monitoring of eating, weight, and physical activity. These apps could also be used to provide stand-alone interventions. A recent systematic review found that 13 of 21 studies (62%) did not find that apps produce greater weight loss than a control condition (Covolo et al., 2017). However, this is a relatively recent area of research and many studies were of low quality. Additionally, research-based apps may be less user-friendly than commercially available apps, which may

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impact their use. On the other hand, most of the numerous commercial apps that claim to facilitate weight loss, healthy eating, calorie tracking, or physical activity have not been tested in an RCT. A review of 30 commercial apps for weight loss found that, on average, they included only 19% of the behavioral strategies used in a typical lifestyle modification program (Pagoto et al., 2013). It is likely that the average benefit of such apps is small, if present. However, because of their wide reach and low cost, it is worthwhile to continue to investigate whether their efficacy can be improved by developing apps that are both easy to use and incorporate evidence-based techniques and corrective feedback.

CONCLUSION A distinction has been drawn between behavioral and cognitive behavioral obesity treatments based on the theoretical primacy of behavioral versus cognitive change, respectively, for producing weight loss and long-term weight maintenance. However, in practice, these treatments share many core features, including prescriptions for dietary change and increased physical activity and the use of behavioral and cognitive strategies to facilitate adherence to those recommendations. Further, when compared in an RCT, the two treatments did not produce different amounts of initial weight loss or different rates of weight regain. Instead, lifestyle modification programs with either a cognitive or behavioral emphasis can be expected to produce mean losses of 5%–10% of initial body weight and related improvements in cardiometabolic and psychosocial outcomes. Weight regain after treatment continues to be common and is reduced, on average, by the provision of ongoing behavioral or pharmacologic treatment. Patients who continue to consume a low-calorie diet and engage in high levels of physical activity are most likely to maintain lost weight in the long term. Further research is needed to develop methods for increasing access to these interventions and reducing treatment burden without significantly diminishing the treatments’ efficacy.

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Harvey-Berino, J., Pintauro, S., Buzzell, P., DiGiulio, M., Casey Gold, B., Moldovan, C., & Ramirez, E. (2002). Does using the Internet facilitate the maintenance of weight loss? International Journal of Obesity, 26(9), 1254–1260. https://doi.org/10.1038/sj.ijo. 0802051 Heymsfield, S. B., van Mierlo, C. A. J., van der Knaap, H. C. M., Heo, M., & Frier, H. I. (2003). Weight management using a meal replacement strategy: Meta and pooling analysis from six studies. International Journal of Obesity, 27(5), 537–549. https://doi. org/10.1038/sj.ijo.0802258 Hill, J. O., Hauptman, J., Anderson, J. W., Fujioka, K., O’Neil, P. M., Smith, D. K., Zavoral, J. H., & Aronne, L. J. (1999). Orlistat, a lipase inhibitor, for weight maintenance after conventional dieting: A 1-y study. American Journal of Clinical Nutrition, 69(6), 1108–1116. https://doi.org/10.1093/ajcn/69.6.1108 Jakicic, J. M., Marcus, B. H., Lang, W., & Janney, C. (2008). Effect of exercise on 24-month weight loss maintenance in overweight women. Archives of Internal Medicine, 168(14), 1550–1559. https://doi.org/10.1001/archinte.168.14.1550 Jakicic, J. M., Wing, R. R., Butler, B. A., & Robertson, R. J. (1995). Prescribing exercise in multiple short bouts versus one continuous bout: Effects on adherence, cardiorespiratory fitness, and weight loss in overweight women. International Journal of Obesity, 19(12), 893–901. Jeffery, R. W., Wing, R. R., Thorson, C., Burton, L. R., Raether, C., Harvey, J., & Mullen, M. (1993). Strengthening behavioral interventions for weight loss: A randomized trial of food provision and monetary incentives. Journal of Consulting and Clinical Psychology, 61(6), 1038–1045. https://doi.org/10.1037/0022-006X.61.6.1038 Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, K. A., Hu, F. B., Hubbard, V. S., Jakicic, J. M., Kushner, R. F., Loria, C. M., Millen, B. E., Nonas, C. A., Pi-Sunyer, F. X., Stevens, J., Stevens, V. J., Wadden, T. A., Wolfe, B. M., & Yanovski, S. Z. (2014). 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/ American Heart Association task force on practice guidelines and The Obesity Society. Journal of the American College of Cardiology, 63(25 Pt. B), 2985–3023. https:// doi.org/10.1016/j.jacc.2013.11.004 Johns, D. J., Hartmann-Boyce, J., Jebb, S. A., Aveyard, P., & the Behavioural Weight Management Review Group. (2014). Diet or exercise interventions vs combined behavioral weight management programs: A systematic review and meta-analysis of direct comparisons. Journal of the Academy of Nutrition and Dietetics, 114(10), 1557– 1568. https://doi.org/10.1016/j.jand.2014.07.005 Klem, M. L., Wing, R. R., McGuire, M. T., Seagle, H. M., & Hill, J. O. (1997). A descriptive study of individuals successful at long-term maintenance of substantial weight loss. American Journal of Clinical Nutrition, 66(2), 239–246. https://doi.org/10. 1093/ajcn/66.2.239 Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A., Nathan, D. M., & the Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393–403. https://doi.org/10. 1056/NEJMoa012512 Knowler, W. C., Fowler, S. E., Hamman, R. F., Christophi, C. A., Hoffman, H. J., Brenneman, A. T., Brown-Friday, J. O., Goldberg, R., Venditti, E., Nathan, D. M., & the Diabetes Prevention Program Research Group. (2009). 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet, 374(9702), 1677–1686. https://doi.org/10.1016/S0140-6736(09)61457-4 Larsen, T. M., Dalskov, S. M., van Baak, M., Jebb, S. A., Papadaki, A., Pfeiffer, A. F., Martinez, J. A., Handjieva-Darlenska, T., Kunešová, M., Pihlsgård, M., Stender, S., Holst, C., Saris, W. H., Astrup, A., & the Diet, Obesity, and Genes (Diogenes) Project. (2010). Diets with high or low protein content and glycemic index for weight-loss

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maintenance. New England Journal of Medicine, 363(22), 2102–2113. https://doi.org/ 10.1056/NEJMoa1007137 Lichtman, S. W., Pisarska, K., Berman, E. R., Pestone, M., Dowling, H., Offenbacher, E., Weisel, H., Heshka, S., Matthews, D. E., & Heymsfield, S. B. (1992). Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. New England Journal of Medicine, 327(27), 1893–1898. https://doi.org/10.1056/ NEJM199212313272701 Minniti, A., Bissoli, L., Di Francesco, V., Fantin, F., Mandragona, R., Olivieri, M., Fontana, G., Rinaldi, C., Bosello, O., & Zamboni, M. (2007). Individual versus group therapy for obesity: Comparison of dropout rate and treatment outcome. Eating and Weight Disorders, 12(4), 161–167. https://doi.org/10.1007/BF03327593 Pagoto, S., Schneider, K., Jojic, M., DeBiasse, M., & Mann, D. (2013). Evidence-based strategies in weight-loss mobile apps. American Journal of Preventive Medicine, 45(5), 576–582. https://doi.org/10.1016/j.amepre.2013.04.025 Perri, M. G., & Ariel-Donges, A. H. (2018). Maintenance of weight lost in behavioral treatment of obesity. In T. A. Wadden & G. A. Bray (Eds.), Handbook of obesity treatment (2nd ed., pp. 393–410). Guilford Press. Perri, M. G., & Corsica, J. A. (2002). Improving the maintenance of weight lost in the behavioral treatment of obesity. In T. A. Wadden & A. J. Stunkard (Eds.), Handbook of obesity treatment (1st ed., pp. 465–479). Guilford Press. Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., & Viegener, B. J. (2001). Relapse prevention training and problem-solving therapy in the longterm management of obesity. Journal of Consulting and Clinical Psychology, 69(4), 722– 726. https://doi.org/10.1037/0022-006X.69.4.722 Puhl, R. M., & Pearl, R. L. (2018). Psychosocial contributors and consequences of obesity. In T. A. Wadden & G. A. Bray (Eds.), Handbook of obesity treatment (2nd ed., pp. 149–168). Guilford Press. Renjilian, D. A., Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., & Anton, S. D. (2001). Individual versus group therapy for obesity: Effects of matching participants to their treatment preferences. Journal of Consulting and Clinical Psychology, 69(4), 717–721. https://doi.org/10.1037/0022-006X.69.4.717 Sacks, F. M., Bray, G. A., Carey, V. J., Smith, S. R., Ryan, D. H., Anton, S. D., McManus, K., Champagne, C. M., Bishop, L. M., Laranjo, N., Leboff, M. S., Rood, J. C., de Jonge, L., Greenway, F. L., Loria, C. M., Obarzanek, E., & Williamson, D. A. (2009). Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. New England Journal of Medicine, 360(9), 859–873. https://doi.org/10. 1056/NEJMoa0804748 Seo, D. C., & Sa, J. (2008). A meta-analysis of psycho-behavioral obesity interventions among US multiethnic and minority adults. Preventive Medicine, 47(6), 573–582. https://doi.org/10.1016/j.ypmed.2007.12.010 Shai, I., Schwarzfuchs, D., Henkin, Y., Shahar, D. R., Witkow, S., Greenberg, I., Golan, R., Fraser, D., Bolotin, A., Vardi, H., Tangi-Rozental, O., Zuk-Ramot, R., Sarusi, B., Brickner, D., Schwartz, Z., Sheiner, E., Marko, R., Katorza, E., Thiery, J., . . . the Dietary Intervention Randomized Controlled Trial (DIRECT) Group. (2008). Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. New England Journal of Medicine, 359(3), 229–241. https://doi.org/10.1056/NEJMoa0708681 Shaw, K., O’Rourke, P., Del Mar, C., & Kenardy, J. (2005). Psychological interventions for overweight or obesity. Cochrane Database of Systematic Reviews, (2), CD003818. Sherrington, A., Newham, J. J., Bell, R., Adamson, A., McColl, E., & Araujo-Soares, V. (2016). Systematic review and meta-analysis of internet-delivered interventions providing personalized feedback for weight loss in overweight and obese adults. Obesity Reviews, 17(6), 541–551. https://doi.org/10.1111/obr.12396 Shick, S. M., Wing, R. R., Klem, M. L., McGuire, M. T., Hill, J. O., & Seagle, H. (1998). Persons successful at long-term weight loss and maintenance continue to consume



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a low-energy, low-fat diet. Journal of the American Dietetic Association, 98(4), 408–413. https://doi.org/10.1016/S0002-8223(98)00093-5 Smith, S. R., Weissman, N. J., Anderson, C. M., Sanchez, M., Chuang, E., Stubbe, S., Bays, H., Shanahan, W. R., & the Behavioral Modification and Lorcaserin for Overweight and Obesity Management (BLOOM) Study Group. (2010). Multicenter, placebo-controlled trial of lorcaserin for weight management. New England Journal of Medicine, 363(3), 245–256. https://doi.org/10.1056/NEJMoa0909809 Stuart, R. B. (1967). Behavioral control of overeating. Behaviour Research and Therapy, 5(4), 357–365. https://doi.org/10.1016/0005-7967(67)90027-7 Svetkey, L. P., Stevens, V. J., Brantley, P. J., Appel, L. J., Hollis, J. F., Loria, C. M., Vollmer, W. M., Gullion, C. M., Funk, K., Smith, P., Samuel-Hodge, C., Myers, V., Lien, L. F., Laferriere, D., Kennedy, B., Jerome, G. J., Heinith, F., Harsha, D. W., Evans, P., . . . Aicher, K., & the Weight Loss Maintenance Collaborative Research Group. (2008). Comparison of strategies for sustaining weight loss: The weight loss maintenance randomized controlled trial. Journal of the American Medical Association, 299(10), 1139–1148. https://doi.org/10.1001/jama.299.10.1139 Tronieri, J. S., & Wadden, T. A. (2018). Behavioral assessment of patients with obesity. In T. A. Wadden & G. A. Bray (Eds.), Handbook of obesity treatment (2nd ed., pp. 253– 280). Guilford Press. Tronieri, J. S., Wadden, T. A., Berkowitz, R. I., Chao, A. M., Pearl, R. L., Alamuddin, N., Leonard, S. M., Carvajal, R., Bakizada, Z. M., Pinkasavage, E., Gruber, K. A., Walsh, O. A., & Alfaris, N. (2018). A randomized trial of lorcaserin and lifestyle counseling for maintaining weight loss achieved with a low-calorie diet. Obesity, 26(2), 299– 309. https://doi.org/10.1002/oby.22081 Tronieri, J. S., Wadden, T. A, Chao, A. M., & Tsai, A. G. (2019). Primary care interventions for obesity: Review of the evidence. Current Obesity Reports, 8(2), 128–136. https://doi.org/10.1007/s13679-019-00341-5 Tronieri, J. S., Wadden, T. A., Walsh, O., Berkowitz, R. I., Alamuddin, N., & Chao, A. M. (2020). Measures of adherence as predictors of early and total weight loss with intensive behavioral therapy for obesity combined with liraglutide 3.0 mg. Behaviour Research and Therapy, 131, 103639. https://doi.org/10.1016/j.brat.2020. 103639 Tsai, A. G., & Wadden, T. A. (2006). The evolution of very-low-calorie diets: An update and meta-analysis. Obesity, 14(8), 1283–1293. https://doi.org/10.1038/oby.2006.146 van Dale, D., Saris, W. H., & ten Hoor, F. (1990). Weight maintenance and resting metabolic rate 18–40 months after a diet/exercise treatment. International Journal of Obesity, 14(4), 347–359. Wadden, T., Bantle, J., Blackburn, G., Bolin, P., Brancati, F., Bray, G., Clark, J. M., Coday, M., Dutton, G. R., Egan, C., Evans, M., Foreyt, J. P., Sengardi, S. G., Gregg, E. W., Hazuda, H. P., Hill, J. O., Horton, E. S., Hubbard, V. S., Jakicic, J. M., . . . the Look AHEAD Research Group. (2014). Eight-year weight losses with an intensive lifestyle intervention: The look AHEAD study. Obesity, 22(1), 5–13. https://doi.org/ 10.1002/oby.20662 Wadden, T. A., Berkowitz, R. I., Womble, L. G., Sarwer, D. B., Phelan, S., Cato, R. K., Hesson, L. A., Osei, S. Y., Kaplan, R., & Stunkard, A. J. (2005). Randomized trial of lifestyle modification and pharmacotherapy for obesity. New England Journal of Medicine, 353(20), 2111–2120. https://doi.org/10.1056/NEJMoa050156 Wadden, T. A., Crerand, C. E., & Brock, J. (2005). Behavioral treatment of obesity. Psychiatric Clinics of North America, 28(1), 151–170. https://doi.org/10.1016/j.psc. 2004.09.008 Wadden, T. A., & Foster, G. D. (2000). Behavioral treatment of obesity. Medical Clinics of North America, 84(2), 441–461, vii. https://doi.org/10.1016/S0025-7125(05)70230-3

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Wadden, T. A., Foster, G. D., Letizia, K. A., & Mullen, J. L. (1990). Long-term effects of dieting on resting metabolic rate in obese outpatients. Journal of the American Medical Association, 264(6), 707–711. https://doi.org/10.1001/jama.1990.03450060053028 Wadden, T. A., Hollander, P., Klein, S., Niswender, K., Woo, V., Hale, P. M., Aronne, L., & the NN8022-1923 Investigators. (2013). Weight maintenance and additional weight loss with liraglutide after low-calorie-diet-induced weight loss: The SCALE Maintenance randomized study. International Journal of Obesity, 37(11), 1443–1451. https://doi.org/10.1038/ijo.2013.120 Wadden, T. A., McGuckin, B. G., Rothman, R. A., & Sargent, S. L. (2003). Lifestyle modification in the management of obesity. Journal of Gastrointestinal Surgery, 7(4), 452–463. https://doi.org/10.1016/S1091-255X(03)00048-9 Wadden, T. A., Neiberg, R. H., Wing, R. R., Clark, J. M., Delahanty, L. M., Hill, J. O., Krakoff, J., Otto, A., Ryan, D. H., Vitolins, M. Z., & the Look AHEAD Research Group. (2011). Four-year weight losses in the Look AHEAD study: Factors associated with long-term success. Obesity, 19(10), 1987–1998. https://doi.org/10.1038/ oby.2011.230 Wadden, T. A., Tronieri, J. S., & Butryn, M. L. (2020). Lifestyle modification approaches for the treatment of obesity in adults. American Psychologist, 75(2), 235–251. https:// doi.org/10.1037/amp0000517 Wadden, T. A., West, D. S., Delahanty, L., Jakicic, J., Rejeski, J., Williamson, D., Berkowitz, R. I., Kelley, D. E., Tomchee, C., Hill, J. O., Kumanyika, S., & the Look AHEAD Research Group. (2006). The Look AHEAD study: A description of the lifestyle intervention and the evidence supporting it. Obesity, 14(5), 737–752. https:// doi.org/10.1038/oby.2006.84 Wing, R. R., & Hill, J. O. (2001). Successful weight loss maintenance. Annual Review of Nutrition, 21(1), 323–341. https://doi.org/10.1146/annurev.nutr.21.1.323 Wing, R. R., Jeffery, R. W., Burton, L. R., Thorson, C., Nissinoff, K. S., & Baxter, J. E. (1996). Food provision vs structured meal plans in the behavioral treatment of obesity. International Journal of Obesity, 20(1), 56–62. Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., Hill, J. O., Brancati, F. L., Peters, A., Wagenknecht, L., & the Look AHEAD Research Group. (2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with Type 2 diabetes. Diabetes Care, 34(7), 1481–1486. https://doi.org/10.2337/dc10-2415

II MODALITIES AND SETTINGS

15 Cognitive Behavioral Group Therapy Elizabeth J. Pawluk and Randi E. McCabe

C

ognitive behavioral therapy (CBT) is an overarching term for a diverse set of treatments for various mental health disorders and associated problems, which include cognitive strategies, behavioral strategies, or a combination of the two. Across different CBT approaches is a common conceptualization of emotional disorders and psychopathology that is rooted in cognitive (Beck, 1976; Ellis, 1969) and social learning theory (Bandura, 1986). According to cognitive theory, thoughts play a pivotal role in determining emotional and behavioral responses (Beck, 1976; Ellis, 1969); in contrast, social learning theory (Bandura, 1986) emphasizes the important interplay among cognitive, behavioral and environmental factors in psychosocial functioning. A principle tenet of both theories is that the interactions between thoughts, behaviors, and emotion play a significant role in the etiology and maintenance of psychopathology. Thus, CBT approaches are designed to target both symptoms and impaired functioning via changes in cognition (Dozois & Dobson, 2001) and behavior (Marks, 1979; Wolpe, 1958). With numerous clinical trials and meta-analyses supporting the efficacy and effectiveness of CBTs for reducing distress, improving functioning, and preventing symptom relapse (see Hofmann et al., 2012; Stewart & Chambless, 2009), CBTs have become well-established as first-line treatments for many mental disorders and related problems.1 Although CBT protocols were originally developed for individually delivered therapy, in the 1970s individual CBT protocols began to be adapted for Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000219-015 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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group-delivered therapy (Bieling et al., 2006). A primary reason for the shift toward group-based therapy was to meet the growing need for evidence-based therapies that were efficient in terms of time and cost, while still being effective—cognitive behavioral group therapy (CBGT) appeared to offer just that. Indeed, the formal structure and skills-based content of CBT is found to be well-suited for use in a group format (Burlingame et al., 2013). Given that the outcomes show that group-based CBT is as effective as when it is delivered individually, an advantage of CBGT is its efficiency. CBGT allows for a greater number of individuals to receive therapy using fewer resources, including therapist time (Morrison, 2001). Not only does this reduce the number of individuals waiting for therapy, but group-based therapy also makes a client cancellation or no-show less burdensome to therapists. That is, if an individual does not attend a group session or cancels on short notice, the group therapist is still able to use the time to provide services to the other group members who are able to attend the session. Along with being more efficient, the overall cost of CBGT is found to be substantially lower relative to alternative treatment modalities. Otto et al. (2000) compared the cost of treating panic disorder across three different treatment modalities and found that CBGT ($523 USD) was the least expensive relative to individual CBT ($1,357 USD) and pharmacotherapy (i.e., medication; $2,305 USD). Therefore, CBGT appears to be a cost-saving alternative to individual CBT and pharmacotherapy. In addition to the logistical and cost-saving advantages, the therapeutic environment of CBGT has unique characteristics that can be capitalized on by therapists to enhance CBT. For example, a concrete difference between individual and group-based therapy is the number and types of interpersonal relationships formed. That is, in addition to the relationship between the group leader (i.e., therapist) and group member (i.e., client), relationships are formed among group members, between coleaders, and between the leader(s) and the group as a whole. The multiple relationships result in a variety of interactions that can be used when teaching CBT content. The interactions can be highlighted as opportunities for interpersonal learning and corrective learning experiences. For example, individuals in the group can be encouraged to observe and reflect on how they affect other group members and how they are in turn affected by the other group members, which may promote increased self-awareness and provide new learning that can be used in cognitive restructuring (Burlingame, MacKenzie, & Strauss, 2004; Yalom, 1995). Finally, the group milieu can promote high rates of client engagement. That is, when the group atmosphere is positive and encouraging, group members have increased motivation to practice their CBT skills with each other, which in turn leads to greater use of CBT skills in daily life (Scott, 2011). Despite the noted benefits of the group environment, individuals can be reluctant to participate in group therapy, as they describe fears about sharing personal, and often private, details with a group of strangers. As a consequence, it is important to ensure that individuals are properly informed about the structure of the group, confidentiality, and the benefits of learning and sharing with



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individuals who are going through similar experiences. With adequate psychoeducation and corrections of misperceptions about group therapy, many people become amenable to participating in CBGT. At the completion of the group, members often reflect that they were glad that they chose to attend the group and identify that the support and validation they received from the other group members had a positive impact on their personal growth during therapy. In sum, CBGT offers clients the content of individual-based CBT plus the benefits that exist due to the nature of having a group of individuals working towards a common goal.

DESCRIPTION OF CBGT AND TREATMENT PROCEDURES When initiating CBGT, it is important to first determine the focus of the group, as this will inform which CBGT protocol to use and who are good candidates for the group. If the focus of the group is to treat a specific mental health disorder, all members of the group will have the same disorder, and the group therapists should select from available disorder-specific CBGT protocols. If there is no empirically supported CBGT protocol available for the specific disorder, an individual CBT protocol for that disorder may be translated for the group setting. Alternatively, if the group will include individuals with different mental health disorders (e.g., anxiety disorders and depressive disorders), then a transdiagnostic CBGT protocol may be considered. The use of transdiagnostic CBGT protocols is increasing in popularity, as they are designed to offer strategies that are equally effective for all group participants regardless of their specific diagnosis. For example, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Barlow et al., 2011) was designed for use in groups with heterogeneous anxiety disorders and comorbid depressive disorders. Once the protocol is selected, the next step is to determine the specific structure of the group, which will likely be influenced by setting-specific factors. CBGT typically includes six to 12 group members. In settings with long wait lists for treatment, it may be advantageous to run larger groups. However, clinicians should note that increasing the number of participants in a group reduces the amount of individualized attention and could lead to increased attrition. CBGT is typically scheduled once per week, and the duration of each group is often 1.5 to 2 hours. The number of group sessions will be consistent with the chosen protocol but typically range from four to 16. CBGTs are typically closed groups (i.e., no new members are enrolled once the group begins) because most protocols are structured so that material from each session builds on material covered in the previous session. Therefore, it is not possible for new members to begin the group halfway through the protocol. In some settings, it is necessary to use an open group format where members can enroll or drop in to the group at any time. For example, in inpatient and medical settings, it can be advantageous to structure the group as an open group because there is often variability in the duration of patients’ stays. Open groups typically do not

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follow a full protocol, and, instead, each group session is based on a self-contained module that focuses on a specific topic or skill (e.g., managing worry, targeting avoidance). CBGT is usually facilitated by two cotherapists or group leaders. The group leaders work as a team, helping each other in teaching the material and monitoring the group. Logistically, having two group leaders is helpful for a few reasons. If one of the facilitators needs to be absent from the group, there is always a cofacilitator to provide continuity. If there is a difficulty with one of the group members (e.g., a group member is distressed and leaves the room during session), there is one group leader to run the group while the second group leader can check on the client. Finally, two group leaders can provide support to each other and plan together how to balance CBT session material and group process factors. Some groups may be difficult (e.g., if there are challenging interpersonal styles), and, therefore, having two leaders working together relieves the management burden that would be greater if the group was run by just one leader. To maintain the structure of the group, it is important for the group leaders to establish and review CBGT group norms with group members either before the first group session in an orientation meeting, or during the first session. Common group norms that are helpful to establish include expectations regarding behavior such as keeping other group members’ information confidential, treating others with respect, group participation (e.g., sharing in the group), homework completion, attendance, and notifying group leaders about any suicidal symptoms.

Content of CBGT The content covered in a CBGT group will be dependent on the disorder or condition being targeted and the specific CBT protocol used. When selecting a group protocol, it is recommended that a validated CBGT protocol is followed. However, if there is no available group protocol for the presenting problem, an individual CBT protocol can be translated for use with a group. This adaptation is possible because the content of a CBGT protocol often overlaps very closely with the content of an individual CBT protocol for the same disorder, and it is in the delivery of the material where the two modalities differ the most. If no group protocol is available, Wilfley et al. (1998) identified five questions for clinicians to consider when converting an individual protocol to a group protocol that will assist in maintaining the integrity of the treatment: • What are the effective change processes of the individual treatment, and how will they be preserved in the group format? • How will a focus on each individual’s work be maintained in the group format? • How are the therapist and client roles characterized in the individual treatment, and how will they be maintained in the group format?



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• What are the techniques of the individual treatment, and how will they be delivered in the group format? • What group processes need to be considered to facilitate effective implementation of the individual treatment in a group setting? When adapting an individual protocol, it is common to modify or reorganize the structure of the material so that it is appropriate for use with a group. Therefore, the translation should also be done with a great deal of planning and attention to detail. In addition, to ensure that the core features of CBT are maintained during the translation, it should only be done by clinicians who are well-versed in CBT theory for the specific disorder or group of disorders to be treated. As CBT is a structured therapy, there are common elements across CBGTs and within each group session. In the first group session, psychoeducation on the mental health disorder or problem to be addressed by the group is often provided. Subsequent group sessions include a systematic introduction of different cognitive and/or behavioral strategies. There is also a characteristic structure to each CBGT group session across protocols. A typical agenda for a CBGT group session includes a review of homework, teaching of new information or a CBT strategy, time to practice a skill, and homework planning. Informed by the CBT model for the specific mental health disorder or problem to be addressed, different cognitive and behavioral strategies will be introduced during the group. Common cognitive and behavioral strategies introduced across CBGTs include the following. Cognitive Strategies Cognitive strategies include cognitive restructuring (identifying and modifying maladaptive thoughts), Socratic questioning (clinician-guided questioning to identify thought patterns, uncover assumptions, and analyze concepts), and guided discovery (clinician-guided questioning to encourage reflection of how information is being processed). To ensure traditional cognitive strategies are effective when used in a group setting, therapists should adjust their delivery of the skill to try to incorporate all members of the group in the teaching and discussion. This is particularly relevant for disorder-specific groups, as many group members will identify with similar automatic thoughts, interpretations, and beliefs (e.g., the fear of being incapacitated by a panic attack in a group for panic disorder), and thus the learning can be universal for all group members. If the therapist is engaged in Socratic questioning with one group member, they can further the discussion by opening it up to the larger group, as other group members will likely be able to identify similar thought patterns. It is beneficial for group members to hear the perspectives of other group members or to observe another member modify their own thinking and identify a more balanced perspective for an automatic thought or cognitive distortion they also hold. Moreover, if group members are challenged by their peers in the group to modify their thinking, this form of

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inquiry is often better received and has greater impact than if it had come from a group therapist. Sample dialogue of a CBGT session reviewing cognitive restructuring is as follows: COTHERAPIST: [to the group] Who would like to share an example from their

monitoring homework about a situation that caused you to feel anxious in the past week and the automatic thoughts that went through your mind? JEFF:

I’ll go. This week, I tried to eat in the cafeteria at work with colleagues, but I felt so anxious. The whole time I was thinking that my colleagues thought I was boring and didn’t have anything interesting to say.

COTHERAPIST: [to Jeff] Great job at identifying the automatic thought that is

contributing to your anxiety in this situation. Let’s use the examining the evidence strategy to challenge your automatic thought in this situation. What evidence do you have that your colleagues thought you were boring and didn’t have anything interesting to say? JEFF:

No evidence, I guess. It just felt that way.

COTHERAPIST: [to Jeff] Great job at remembering that feelings are different

from facts. Just because we feel like they think we’re boring, it doesn’t make it true. [turning toward the other group members] Can anyone identify a cognitive distortion, or unhelpful way of thinking, that Jeff could be using? SUSAN:

I think Jeff’s thought that he believes people think he is boring would be mind reading. You can’t know for sure what your colleagues are thinking unless they actually tell you.

COTHERAPIST: Thanks, Susan, that’s right. [to Jeff] Have any colleagues told

you they think that you’re boring? JEFF:

[laughs] No, no one has said this to me.

COTHERAPIST: [to Jeff] It sounds like you don’t have any concrete evidence

that your colleagues were thinking you were boring or uninteresting. Do you have any evidence that does not support your thought that your colleagues were thinking that you were boring or didn’t have anything interesting to say? JEFF:

I don’t know . . .

COTHERAPIST: [to the group] How might you know if someone was interested

in what you were talking about? CAROL:

I find when I’m interested in what someone is talking about, I might ask them a question about it. When you talk with colleagues, do they ever ask you follow-up questions?



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JEFF:

When I told Mike that I was going fishing on the weekend, he asked me some questions about how long I had been fishing for and where I liked to go. I guess he likes to fish, too.

CAROL:

It sounds like in that situation you have some evidence that Mike found what you were talking about interesting, especially given your common enjoyment of fishing.

JEFF:

Yeah, you’re right. I totally forgot about that part of the conversation.

Behavioral Strategies Behavioral strategies include exposure-based strategies (i.e., gradually approaching feared situations or objects to reduce fear), relaxation strategies (e.g., breathing and imagery-based exercises), self-monitoring (monitoring of one’s own behavioral patterns), role-playing, behavioral experiments (i.e., planned exercises to test beliefs and assumptions), behavioral activation (i.e., activity scheduling to reengage in activities), problem solving, and social skills training. Behavioral strategies also translate well into the group format and therefore can be readily utilized within the CBGT framework. The group environment itself can offer group members an opportunity to test out behavioral skills, including conducting group-based exposures or behavioral experiments. Moreover, attending the group itself may offer an opportunity to practice skills. To illustrate, for an individual with social anxiety, attending the group may be modified to be a therapeutic exposure where the group member uses the experience as an opportunity to gather evidence and modify maladaptive beliefs (e.g., “People are making negative judgements about me”). Alternatively, for an individual with depression, the group may offer a source of behavioral activation via social engagement. In addition, the group provides a venue for individuals to observe other group members modeling the use of skills, which may in turn reduce their apprehension and encourage skills use. Example group dialogue for setting up an exposure in a CBGT session is as follows: COTHERAPIST: [to Laura] What exposure do you have planned for this session? LAURA:

Last week I completed the exposure of ordering a drink from the cafeteria, and it went okay. This week I am going to try it again, but this time I’m going to take extra time when ordering my drink.

COTHERAPIST: [to Laura] Great idea. What is the automatic thought you are

challenging with this exposure? LAURA:

The belief that I should never inconvenience anyone.

COTHERAPIST: That sounds like a great exposure. Remember to write down

your predictions before you go and to keep track of your anxiety during the exposure, then we’ll check in on how it went.

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MICHELLE:

Wow Laura, good for you! I have a similar exposure on my hierarchy, but it is at the top of my list. I’ll be curious to hear how it goes for you.

COTHERAPIST: This is the nice part about being engaged in a group. It provides

an opportunity to learn from each other. Michelle, what do you have planned for your exposure today? Check in after exposure: COTHERAPIST: [to Laura] Take us through how the exposure went and what

the outcome was. LAURA:

There were about two people behind me in the line, and I purposely took time deciding between two options for about 1 minute. My anxiety began to increase about 10 seconds in, peaked, and then started to reduce when I looked around and noticed that the two people behind me didn’t seem to care. They were having a conversation with each other. The cashier also didn’t seem to mind either, she didn’t say anything.

COTHERAPIST: That’s great. It sounds like you got a lot of new information out

of this exposure to modify your anxious thoughts. What do you think you learned from this exposure? LAURA:

I learned that no one was inconvenienced by taking my time to order. Actually, it seemed like no one seemed to notice, even though I thought they would.

MICHELLE:

Thanks so much for sharing, I would never have predicted that outcome would have happened either. I would have thought that people would have told you to hurry up or have gotten irritated.

COTHERAPIST: Michelle, how does Laura’s experience affect how you think

about approaching your similar hierarchy item? MICHELLE:

It definitely makes me feel open to trying it a little sooner than I planned. I had rated it as a 90 level of anxiety, but hearing about Laura’s experience makes me feel more like an 80.

COTHERAPIST: That is good to hear Michelle. [to the group] Does anyone else

have similar situations on their hierarchy? In the second to last or final CBGT session, the topic of relapse prevention is introduced, and each group member develops an individualized relapse prevention plan. Following the completion of the group, some clinics offer drop-in booster groups. The aim of the booster group is to offer a continuity of



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care that provides individuals with an opportunity to continue working on specific problems or to receive a CBT skills refresher. There is some evidence to suggest that booster groups do not offer clients additional gains but that they assist in maintaining treatment gains made while completing CBGT (Wesner et al., 2015).

SPECIAL CHARACTERISTICS OF CBGT As highlighted throughout the chapter, a unique characteristic of CBGT is the group environment itself and the multiple relationships that form among its members. Thus, it is of utmost importance for group leaders to be aware that the way to bring the therapy to “life” is by facilitating engagement and sharing among group members rather than providing each member with individual therapy in a group setting. Berne (1966) argued that “knowledge of group dynamics for a group leader is as essential as knowledge of physiology for a physician” (Burlingame et al., 2013; p. 667), and we could not agree more. The group setting is only the vehicle of change, whereas the group process is the mechanism of change in CBGT (Burlingame et al., 2013). Group process is broadly defined as a “set of factors that arise from conducting therapy within a group setting” (Bieling et al., 2006, p. 25). Theories of group process in relation to psychotherapy were first developed by Yalom (see Yalom & Leszcz, 2005, for a full review) and further expanded on by Burlingame (see Burlingame, Fuhriman, & Johnson, 2004, for a full review). Informed by both psychotherapy and cognitive behavioral theory, Bieling et al. (2006) identified process factors particularly relevant to CBGT outcomes including the following: • Group mechanisms of change • The effects of group members’ symptoms on one another • The effects of group members’ personality styles on one another • The effects of improvement/worsening in one group member on the others • The way in which group members interact with one another • The therapeutic relationship between the therapist and the group • The therapeutic relationship among group members • The therapeutic relationship among cotherapists • Effect of dropout and absenteeism • The effect of individual variables on the group (e.g., client expectations, client satisfaction with treatment, client variables that predict outcome, client suitability for group treatment)

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Group Mechanisms of Change Yalom (1995) identified several mechanisms of change that were uniquely associated with group therapy. This list was narrowed down by Bieling et al. (2006) to those group process factors believed to be specific to CBGT, including optimism, inclusion, group-based learning, shifting self-focus, modification of maladaptive relational patterns, emotional processing in the group setting, and group cohesiveness. Table 15.1 identifies how each group mechanism of change is described and can be connected to CBGT therapeutic strategies. Characteristics of Group Leaders and Members In addition to the mechanisms of change identified, group process is also affected by the quality of the therapeutic relationships in the group, which are influenced by the characteristics of both group leaders and group members. Group Leaders Group leaders make a significant contribution to the success of the group, and, therefore, in addition to being competent in CBT, group leaders should possess certain qualities and characteristics that will enhance their practice as a group leader. Group therapists must be able to be sensitive to and balance several different group-related factors occurring simultaneously. First, they must be able to adhere to the fundamental characteristic of a CBT therapist, including emphasizing collaborative empiricism and fostering guided discovery through Socratic questioning. Second, they must balance the pace of the group to allow time to cover the necessary material and leave time for group discussion, while ensuring that the content is presented in a way that is accessible to all group members. Third, the therapist must bring the presentation of CBT strategies to “life” in a dynamic and engaged way to be able to connect with all group members. When the material is presented as a lecture, it does little for creating group cohesion and enhancing group process. Several leadership characteristics have been identified for effective group leaders (see Corey et al., 2018, for the full list of characteristics). Of the characteristics identified, we believe the following are especially relevant to CBGT therapists: • Facilitating: Facilitating is described as the ability to assist group members in expressing themselves and in reaching their goals by creating an environment that is accepting and nonjudgmental, and that involves other group members in this discussion. • Linking: The aim of linking is to encourage interactions among group members. The therapist works to identify connections and themes that are common to group members to facilitate this connection. • Blocking: Blocking is an important leadership skill, as it is the role of the therapist to address and stop behaviors of group members that would be

The group raises awareness of a shared problem and provides a sense of belonging and reduced isolation.

The group provides an opportunity for learning on several levels.

The group promotes helping other group members, shifting emphasis from the individual to the group.

The group provides a corrective learning experience for maladaptive interpersonal interactions.

The group provides a place for open expression and working through of emotions, thoughts, and behaviors, allowing for the identification of therapeutic targets for intervention.

The attractiveness of a group to its members facilitates cognitive and behavioral change.

Inclusion

Group learning

Shifting self-focus

Modifying maladaptive relational patterns

Emotional processing in the group setting

Group cohesiveness

Providing information on the efficacy of the therapeutic strategy Highlighting behavioral changes that group members make as achievements Fostering a culture of support Developing specific behavioral plans that are concrete and manageable

• Increasing homogeneity of the group so that members can relate to each other’s experience • Linking of group members common experiences to promote connectedness • Allowing time for engagement and interaction among group members • Managing difficult group members

• Ensuring a healthy balance of focus on CBT skills and attention to group process factors • Allowing time in the group for sharing and discussion of emotional, cognitive, and behavioral responses

• Attending to group process so that unhelpful behaviors are identified and feedback is given • Role playing scenarios to practice interpersonal skill development (e.g., assertiveness, small talk)

• Allowing space in the group so that group members can engage, share, and help each other • Promoting sharing and idea generation for homework to help others • Asking how other group members managed a situation to help another group member who may be struggling

• Providing information in an engaging manner that utilizes group members’ current symptoms to highlight themes • Engaging in group exercises such as cognitive restructuring, role plays, and behavioral exposures

• Linking group members shared experiences • Promoting group interaction on key themes

• • • •

Therapeutic strategy

Note. From Cognitive-Behavioral Therapy in Groups (pp. 33–34), by P. J. Bieling, R. E. McCabe, and M. M. Anthony, 2006, Guilford Press. Copyright 2006 by Guilford Press. Reprinted with permission.

The group provides an atmosphere that promotes an optimistic, hopeful outlook on overcoming the problem, as well as motivational activation.

Description

Optimism

Mechanism of change

TABLE 15.1. Proposed Mechanisms of Change in CBGT

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counterproductive to the group as a whole (e.g., one group member dominating group discussion). • Initiating: It is often the role of therapists to engage in greater initiating at the beginning of the group, as the therapists take an active and directive role regarding teaching material and suggesting homework exercises. Equally important is for the therapists to learn when to take a step back and let the group members learn to take a more active role in the therapy. • Evaluating: The group therapists should monitor symptom improvement and group process, including the dynamics of individuals and the group as a whole, and plan intervention accordingly (Corey et al., 2018). Group Members Characteristics of the group members are equally important to that of the group leaders in influencing the group environment and their own likelihood of symptom improvement. Indeed, Yalom and Leszcz (2005) argued that “clients will fail in group therapy if they are unable to participate in the primary task of the group be it for logistical, intellectual, psychological, or interpersonal reasons” (Yalom and Leszcz, 2005, p. 234). Although it is not always known how to best help people who are at risk of treatment failure, a first step is to identify these individuals prior to their start of group or in the early stages of treatment. Most people who do poorly in a group begin deteriorating following three group sessions (Hannan et al., 2005) and appear to be at the greatest risk of prematurely terminating within the first few sessions of the group. Accordingly, it is important for group leaders to watch for early warning signs in their group members. To assist clinicians with identifying those members of the group who are at high risk of dropout, the Clinical Practice Guidelines for Group Treatment (Bernard et al., 2008) describes a list of characteristics that are associated with premature termination from group therapy. The characteristics include poor psychological mindedness, limited self-reflection, low motivation, significant use of defensiveness and denial, and a personality style that elicits angry and negative reactions from others. If clinicians identify these characteristics in a group member, or potential group member, they should be proactive in assessing whether CBGT is the most appropriate course of treatment. There are also assessment tools to assist with selecting individuals for specific groups. For example, the Group Therapy Questionnaire (Burlingame et al., 2006) is a self-report questionnaire that assesses client variables that may affect group participation. On the basis of this questionnaire, specific characteristics have been identified as being correlated with poor outcomes, including extremes of anger and hostility, social inhibition, substance abuse, and a medicalization of psychological problems. In addition, if possible, screening for inappropriate expectations of group psychotherapy, identified reasons for why the person may be unlikely to succeed in the group, and an inadequate level of social skills, may be beneficial, as those characteristics may lead to greater challenges and obstacles to a successful



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group outcome. These characteristics will also likely have a negative impact on other group members. To illustrate, if one of the group members has misconceptions about group treatment and is not prepared to engage in CBT skills outside of the group setting, this individual may dominate the session with topics that are irrelevant to the material being discussed, leading to a derailment of the group agenda. Related to the suitability of a client for CBGT, two factors have been identified as particularly important: the individual’s “fit” within a CBT model and their interpersonal style (Bieling et al., 2006). That is, group members should connect with the rationale for CBT and express an interest in actively engaging with therapy to change cognitive and behavioral patterns. Moreover, they should exhibit the ability to develop adaptive therapeutic relationships with the group leader and other group members. It is difficult for group leaders to attend to every group member’s individual needs, and thus the group benefits when all group members possess attitudes and goals that are consistent with a CBT orientation. As with all therapies, failure to see symptom improvement can be detrimental to the individual and may also negatively affect the other group members (Söchting et al., 2010). As a result, when possible, it is beneficial to select specific members for the group given that fit and suitability affect group process. Many settings are unable to accommodate this type of selection, and the individuals placed in the group are determined by the group schedule and spots available. Therefore, when it is not possible to exclude a client from a specific therapy due to poor fit, it is important for the group leaders to identify and address potential challenging or difficult issues that may arise and could potentially impact the group.

CHALLENGES ASSOCIATED WITH CBGT As there are several benefits of conducting CBT in a group setting, CBGT also poses a unique set of challenges for group leaders who are not present when conducting individual CBT. Challenges inherent to CBGT that are highlighted below include working with a cotherapist, managing group dynamics, and group-specific ethical considerations. Unlike individual therapy, group therapy often involves two cotherapists who must work together to support each other’s interventions, manage difficult situations, and maintain the balance between formal teaching and group process. Therefore, it is important that the group leaders communicate effectively with each other and in a supportive manner about these topics. To facilitate communication, the cotherapists should meet for regular meetings prior to the start of group and weekly throughout the group. Before the start of the group, the group leaders should meet to organize the administration of the group, including coordinating who will be responsible for different components of the group agenda. Following the group session, the cotherapists should meet

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to discuss the outcome of the group and troubleshoot the management of any problems that need to be addressed prior to the next session. During the session, the therapists must work together as a team. For example, when one therapist is presenting material, the other should monitor group members for nonverbal feedback or engage members who appear to be disengaged or struggling with the material. The quality of the relationship between group leaders influences the group dynamic. If one group leader is consistently unprepared for the group, this puts added burden on the other group leader and may foster resentment. Therefore, the relationship should be monitored, and issues that arise between group leaders should be addressed as soon as possible. In addition to having knowledge of general cognitive behavioral theory and therapeutic techniques, conducting CBGT requires the group leaders to have an additional set of skills to manage group dynamics. A necessary skill for group leaders is the ability to balance time spent on teaching the content for the specific session while allowing for time for group members to describe their reactions and insights about the material covered. It is also important for the therapists to be vigilant of the time spent focusing on a specific individual relative to other group members or the group as a whole. For example, to prevent the group from taking the form of individual therapy with other group members observing, after engaging in an interaction with a single group member, the therapist should bring the content of the interaction back to the group for a general discussion about how the topic may also be relevant to other group members. Group conflict can result in significant cognitive and emotional demands for group leaders; therefore, training on managing group dynamics is particularly important. The therapist must acquire skills for managing difficult client situations and using group dynamics to make them learning experiences that benefit the whole group. For example, if one of the group members makes an offensive comment to another group member, the group leaders need to determine how they will address the situation. The strategy for managing this interaction will be influenced by the context of the situation and the frequency of this type of problematic behavior (e.g., recurrent versus single occurrence), and the aim should be to maintain rapport with both group members. One method for managing this behavior is to identify that the comment was not appropriate, remind the group member about the norms for the group that should have been discussed at the first session (one of which is respecting other group members), and then process the experience in the group by checking in with the group member whom the joke was made to and allowing others to share their feelings. If the group member continues to make inappropriate comments in subsequent sessions and is unable to follow group norms, the group leaders may consider removing the person from the group. Given that other individuals in the group can positively and negatively impact the therapy for other group members, it is important for group therapists to manage these situations in a timely manner with the goal of reducing the impact on the group as a whole. Not only do difficult interactions with group members pose a challenge for group leaders, but different communication styles among group members can



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also influence the group dynamic. Communication extremes, from the individual who dominates the group discussion to the individual who is quiet and does not share, can both negatively impact the group atmosphere (Söchting et al., 2010). It is the role of the group leaders to ensure that there is equal “air time” for and attention to each group member, as well as between the group leaders and the group members. Common prototypes of challenging group members include (a) the quiet and silent type, (b) the overbearing type, (c) the helper, (d) the disbeliever, (e) the drifter, and (f) the not appropriate for group member (Bieling et al., 2006). In their text on CBGT, Bieling et al. identified strategies for management and for teaching group members based on their communication type. Another factor that can affect group process is changes to the group membership, such as a group member dropping out from the group or when a group member misses a session. When a group member decides not to return to the group, this can often affect the other group members, particularly in highly cohesive groups. It can be beneficial to ask the group member who decided not to return to the group if some details related to their decision can be shared with the other group members about why they decided to leave the group, as this may reduce some of the uncertainty and questions from other group members. When a group member misses a session, it can have several negative impacts on a group. It affects the dynamic of the group on the day the individual misses the group, as there is one less group member to participate. The individual will also be behind on the material that is covered in the group, which is problematic for CBGT, as new content is discussed and taught during each group session, and the content from one session often builds on the previous session. Developing a policy for managing nonattendance by group members, including whether to offer individuals separate appointments or time before or after the group to be caught up on the missed material, is helpful to establish prior to the start of the group. It is also important to communicate the policy to group members at the start of the group. Thus, in addition to presenting the material from the CBGT protocol, the therapist must manage several process-related factors that can influence group outcomes. Finally, an important ethical consideration when conducting CBGT is related to confidentiality and privacy, given that there are multiple clients in the group. Group members are not legally and ethically bound to maintain each other’s confidentiality. Thus, establishing and communicating guidelines for group members (e.g., being cognizant to not share identifying information about group members with people outside of the group) may prevent ethical dilemmas and increase group members’ comfort with sharing personal examples during the group. In addition, sometimes a group member will know another member in the group from another setting (e.g., work or school) and this is discovered in the first group meeting. When this occurs, the group leaders can meet with each of the group members and determine their comfort level in continuing with the group. If they are not comfortable continuing, the group leaders need to make an accommodation plan, such as providing individual treatment options.

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OUTCOME DATA The first studies to examine the efficacy of group psychotherapy across different theoretical orientations began in the 1960s, and the findings from these reviews offered preliminary support for the benefits of group therapy (e.g., Anderson, 1968; Mann, 1966). Many of the first psychotherapy groups were eclectic, and it was not until the 1990s that there was an influx in group protocols written for specific patient populations and diagnoses, including several CBT groups (e.g., Fettes & Peters, 1992, as cited in Burlingame et al., 2003). Now, CBGT protocols exist for a range of mental health disorders and conditions such as anxiety disorders (e.g., Dugas et al., 2003; Heimberg & Becker, 2002), depression (e.g., Oei & Dingle, 2008), bipolar disorder (e.g., Gomes et al., 2011), psychosis (e.g., Lecomte et al., 2016), addictions (e.g., Wenzel et al., 2012), insomnia (e.g., Koffel et al., 2015), chronic pain (e.g., Lamb et al., 2010), and comorbid disorders via transdiagnostic CBGT protocols (e.g., Norton, 2012). Equivalence of CBGT to Individual CBT A meta-analysis was conducted by Burlingame et al. (2016) to compare identical treatments, patients, and doses of individual therapy to group therapy across different therapeutic orientations. The authors noted the importance of comparing identical treatments given the high degree of heterogeneity across group therapies and the allegiance effects that are found when comparing nonidentical treatments. Across the 67 studies reviewed, the authors found that individual and group therapies result in equivalent therapeutic outcomes. Eleven of the studies reported on posttreatment remission of a diagnosis as the primary outcome measure and found no significant differences across the therapy formats on remission of a diagnosis (OR  =  0.53, p  =  .09). Across the studies included, most of the therapists providing group therapy identified with a cognitive behavioral theoretical orientation (65.9% versus behavioral orientation = 6.8% and cognitive orientation = 12.5%). In addition, the authors found no significant difference between patients’ acceptance of individual compared with group therapy (OR = 0.80, p = .09). Finally, there was also no difference found between the rate of patients who prematurely terminated from group therapy (M  =  17.28%, SD  =  14.30) compared with individual therapy (M = 14.96%, SD = 14.29). Overall, the findings support the equivalent efficacy of individual and group-based therapies, including CBGT. When directly comparing individual and group-based CBTs, there also appears to be equivalence in outcomes between the two modalities. For example, comparing the use of CBGT to individual CBT for social anxiety disorder, McEvoy (2007) found no differences between the modalities. The author reported that following a community-based CBGT group, 50% of patients achieved reliable change, whereas one third had clinically significant change, which was equivalent to individual CBT. Likewise, comparing CBGT to individual CBT for depression, no significant differences in outcomes have been found (Scott, 2005).



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Moreover, when compared with other forms of group therapy, CBGT results in positive outcomes. The average effect size for CBGT when compared with control groups was 1.10 (range 0.1 to 2.87), and the average effect size examining pre- to posttreatment outcomes was 1.30 (range 0.3–3.72; Oei & Dingle, 2008). The authors argued that CBGT is an effective alternative to individual therapy and that it is found to be effective across various samples of individuals and diagnostic subgroups. Taken together, although there is often allegiance to individual-based CBT, from an empirical standpoint, both therapeutic modalities are equally effective. Strategies for Evaluating Treatment Outcomes of CBGT The Clinical Practice Guidelines for Group Psychotherapy (see Bernard et al., 2008, for a full listing) recommend a battery of treatment outcome questionnaires called the CORE-R to evaluate the effectiveness of group psychotherapy. The battery includes general symptom and outcome measures: the Outcome Questionnaire-45 (OQ-45; Lambert et al., 1996), Inventory of Interpersonal Problems (IIP-32; Horowitz, 1999), Target Complaint Scale (Battle et al., 1966), Rosenberg Self-Esteem Scale (Rosenberg, 1965), Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott et al., 1993), and Personal Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001). In addition to the inclusion of general symptom measures, the battery includes a specific measure to evaluate the group members’ feelings about the group: Group Evaluation Scale (Hess, 1996). As a whole, the questionnaires offer insight into symptom and functional improvements following the completion of the group. The CORE-R is a general battery and not specific to group therapy or CBT-related outcomes. As a result, Söchting (2014) recommended that when examining the outcome of CBGT programs it is helpful to also include a symptom-specific measure (e.g., Beck Depression Inventory-II; Beck et al., 1996); a measure of interpersonal functioning; a measure of life quality; and a measure of group cohesion such as the Group Evaluation Scale (Hess, 1996), the Group Climate Questionnaire (MacKenzie, 1983), or the Therapeutic Factors Inventory—Cohesion Subscale (Joyce et al., 2011). An evaluation of group cohesion makes it possible to examine the impact of the group environment on treatment outcomes.

MECHANISMS OF CHANGE Mechanisms of change are defined as the theoretical reason that accounts for how or why change occurs in therapy (Kazdin, 2007). Related to the study of outcomes for group psychotherapy, five factors have been identified as interacting to influence change: (a) formal change theory, (b) structural factors, (c) client characteristics, (d) leader characteristics, and (e) group process (Burlingame, MacKenzie, & Strauss, 2004; Burlingame et al., 2013). Each of these factors and its role in influencing change in CBGT is discussed below.

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Formal change theory is related to the effectiveness of the specific group treatment protocol utilized for the group (Burlingame et al., 2013). In CBGT, the formal change factor is cognitive behavioral theory and the specific treatment components that are derived from the theory and taught in the group. Burlingame et al. (2003) completed a meta-analysis of 111 experimental and quasi-experimental studies examining the effects of group psychotherapy across different theoretical orientations. Overall, the authors reported that regardless of therapeutic orientation, group therapy is found to be superior to untreated control groups (average effect size = 0.58). In this study, improvement was expressed as an effect size and calculated using Cohen’s (1977) method: ES = (M1 – M2) ÷ SDp, where M1 and M2 are the means of the two comparison conditions and SDp is the pooled standard deviation of the two conditions. Of the studies included in the meta-analysis, the majority of therapists identified having a cognitive behavioral theoretical orientation (51%), compared with behavioral (19%), psychodynamic (15%), or eclectic (15%). The authors reported that the orientation of the therapists did have an impact on the group outcome; that is, groups led by a therapist with a behavioral orientation were found to have better outcomes than those led by a therapist who identified with an eclectic orientation. In terms of formal change theory, the findings suggest that the theoretical orientation from which the therapy is derived appears to have a role in influencing clients’ change during the group. However, it is also important to note that it is not the only factor that influences treatment outcomes. The composition and structure of the group may also impact group outcomes (Burlingame et al., 2013). Groups that are disorder specific (i.e., all group members have the same diagnosis or problem) are found to be associated with better outcomes relative to heterogeneous groups (Burlingame et al., 2003). In contrast, the findings related to the role of gender composition on group outcomes are mixed. In general, heterogeneous gender composition has been found to be associated with better outcomes; however, for some conditions and specific problems gender-specific groups have seen better outcomes. For example, in the treatment of substance abuse, gender-specific groups are found to have better outcomes than mixed gender groups (e.g., Greenfield et al., 2008). Regarding the structure of the group, CBT groups would be considered to have a high level of structure. That is, the content of each session, such as the specific psychoeducation provided and the introduction of specific skills and strategies, is guided by a manual that is derived from cognitive behavioral theory. There is limited research comparing the outcomes of structured to unstructured groups for specific disorders and problems, and this is primarily due to the difficulty in studying unstructured therapy. As a result, it is not possible to definitively state that greater or less structure is associated with better treatment outcomes. A meta-analysis examining factors associated with improved group outcomes found that there was no significant difference between groups that had varying degrees of structure. The authors noted that majority of the groups included in the analyses were structured groups, and therefore the



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analysis was unbalanced and should be interpreted with caution (Burlingame et al., 2003). Despite the lack of empirical evidence, there are several advantages to the use of structured, manual-based treatments, including the ability to study and evaluate its efficacy, which is likely contributing to the disproportionate percentages of structured to unstructured groups in meta-analyses. In addition, the use of CBGT manuals makes it easier to train other clinicians to conduct the group and contributes to a degree of consistency across clinicians and groups (Wilson, 1998). As noted previously, characteristics of both the group leader and the group members can affect outcomes. If the group leader does not integrate group-process-related factors into their delivery of the group, this can be associated with poorer group outcomes (Burlingame et al., 2013). The severity of group participants’ symptoms can also impact their outcome. For example, severity of depression symptoms has been found to influence the effectiveness of the group treatment. That is, CBGT has been found to be more effective for clients with mild-to-moderate depression compared with those with greater severity of symptoms (Feng et al., 2012). Finally, there is a significant role of group process mechanisms, including optimism, inclusion, group-based learning, shifting self-focus, modification of maladaptive relational patterns, emotional processing in the group setting, and group cohesiveness on group outcomes (Bieling et al., 2006). Each of these factors is believed to have an influence on therapeutic process and may contribute to positive group outcomes for the individual and the group as a whole (Yalom & Leszcz, 2005). However, one process-related mechanism that has received specific attention is group cohesion, as it is argued to be one of the most important mechanisms of action for CBGT and may be necessary for other group process mechanisms to operate (Yalom, 1995). Group cohesion is best defined as a strong emotional bond among the group members (e.g., Piper et al., 1983) and a shared commitment to the task of the group (see Budman et al., 1989; Burlingame et al., 2011; Yalom & Leszcz, 2005). In CBGT, there are multiple forms of group cohesion given the multiple types and levels of relationships that are formed (i.e., relationships among group members and relationships with the cotherapists). The three types of cohesion identified in group therapy include intrapersonal, intragroup, and interpersonal cohesion (Bernard et al., 2008; Yalom & Leszcz, 2005). Intrapersonal cohesion is described as an individual group member’s sense of “belonging, acceptance, commitment, and allegiance to the group” (Bloch & Crouch, 1985; Yalom & Leszcz, 2005, as cited in Bernard et al., 2008, p. 467). Group members’ report of greater relatedness (i.e., feeling understood, protected, and comfortable within the group), acceptance, and support is found to directly relate to greater symptom improvement (e.g., MacKenzie & Tschuschke, 1993). Intragroup cohesion is described as the compatibility that is reported by the group as a whole, which includes factors such as liking/trust, support, caring, and commitment to work as a group (Bernard et al., 2008; Burlingame et al., 2001). Strong intragroup cohesion has been associated with lower rates of attrition

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from therapy (MacKenzie, 1987). Finally, interpersonal cohesion is identified as the positive and engaging behavioral exchanges between group members. Positive interactions between group members are found to be associated with greater symptom improvement (Budman et al., 1989). Most studies that have explored different facets of group cohesion have shown a positive association between group cohesion and treatment outcomes for CBGT. A meta-analysis of 40 studies was conducted to examine the relationship between group cohesion and treatment outcomes (Burlingame et al., 2011). Overall, the authors found a strong correlation between cohesion and treatment outcome (r = .25) when controlling for age, theoretical orientation, duration of the group, and size of group, as well as interventions to enhance cohesion. This finding reinforces the argument that group leaders should utilize different strategies to enhance group cohesion. It is also worth mentioning that the size and duration of the group was found to affect the association between group cohesion and treatment outcomes. In particular, for groups that had between five to nine participants and lasted at least 12 sessions, cohesion was a stronger predictor of treatment outcome compared with groups with more or fewer participants, and with fewer treatment sessions. The authors suggest that this finding may be because group cohesion takes time to develop and may be difficult to establish if there are too few or too many group members. Several benefits have been associated with greater group cohesion. Relative to members of groups with weak cohesion, members of groups with strong cohesion are more likely to disclose information to the group that is important and meaningful, which ultimately reinforces this type of disclosure in other group members (Tschuschke & Dies, 1994). In addition, group cohesion also appears to be important in aiding group members in their ability to weather the emotional storms that come with therapy. That is, in groups with greater cohesion, group members are better able to work through difficult phases of treatment and tolerate conflict that arises in the group (MacKenzie, 1994). Although greater cohesion is associated with stronger group outcomes, it is also important to remember that a group functions at its best when clients have a balance between connecting with other group members and maintaining their own autonomy (Bernard et al., 2008). Group cohesion may also be related to or interact with other process-related factors, such as group climate (i.e., atmosphere of the group that can be influenced by degree of engagement; avoidance and conflict in the group) and therapeutic alliance (i.e., member-therapist relationship), to influence treatment outcomes. For example, in a study examining the role of group cohesion and therapeutic alliance on anxiety symptoms reported by group members in a transdiagnostic CBGT for anxiety disorders, each factor had a different role dependent on the stage in therapy. In the earlier stages of treatment, greater therapeutic alliance was associated with lower anxiety symptoms, whereas greater group cohesion was associated with lower anxiety in later stages of the group (Norton & Kazantzis, 2016). The authors suggest that group cohesion may depend on other factors that may take a longer time to form, such as trust and engagement.



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Therapeutic alliance also appears to have an association with treatment expectations, which may influence symptom improvement at specific times during the course of therapy. For example, Vîslă et al. (2018) examined the relation between individuals’ outcome expectations and ratings of therapeutic alliance with treatment outcomes (i.e., symptoms of depression and anxiety) following a CBGT group for depression. The authors found an indirect effect of outcome expectation on symptom outcomes that was mediated by therapeutic alliance. When they modeled the factors across the course of the group, the authors found that when patients believed that the therapy was going to lead to reduced symptoms, they were better able to establish stronger therapeutic relationships. Moreover, it was found that patients who were able to establish stronger bonds early in treatment also reported the greatest symptom improvement. Thus, there appears to be a bidirectional relationship between expectations and therapeutic alliance influencing symptom improvement following CBGT for depression (Vîslă et al., 2018). Taken together, “there is much more to effective group treatment than simply applying an EST [empirically supported treatment] to a group of patients with the same ‘disorder’ ” (Burlingame et al., 2013, p. 673). Therefore, as group therapy treatments continue to be utilized, it is necessary to continue studying the mechanisms of change, including structural and process-related factors. With statistical advances, it is now also possible to track changes in process-related constructs over the course of therapy, which will further our understanding of these relationships.

DISSEMINATION Implementing a CBT Group To assist clinicians with establishing group therapy programs, the American Group Psychotherapy Association formed a Science to Service Task Force to develop the Clinical Practice Guidelines for Group Therapy. The task force, which included researchers, educators, and practitioners, was developed in response to members of the association recognizing the need to ensure that practitioners who are conducting group therapy offer evidence-based psychotherapy (Lambert & Ogles, 2004). The guidelines pay attention to group process, emphasizing that the group environment should be utilized as an “agent for change,” and that group therapists must pay attention to individual, interpersonal, and group-as-a-whole dynamics. Challenges for the Dissemination of CBGT A significant challenge for the dissemination of CBGT is that many clinicians are not adequately trained to be a group leader. Unfortunately, group therapy is not the treatment modality that is the focus of many clinical training programs, despite the demand for clinicians to be able to competently deliver group psychotherapy (Fuhriman & Burlingame, 2001; Markus & King, 2003).

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The disparity between training and treatment demands does not appear to be improving (Butler & Fuhriman, 1986; Carmody & Zohn, 1980). In a survey of accredited psychiatry, psychology, and social work programs, it was identified that less than 50% of students received training in short-term group psychotherapy (Fuhriman & Burlingame, 2001). Of the different training programs, counseling and school psychology were more likely to offer training in group therapy, whereas clinical psychology appears to be falling behind in training its students in this treatment modality. It is found that clinical psychology students do not receive adequate group psychotherapy training in their coursework and in their predoctoral clinical psychology internships (Markus & King, 2003). Of 177 predoctoral internship sites accredited by the American Psychological Association that were surveyed across the United States and Canada, 43% indicated that group psychotherapy was a part of a major rotation, 67.7% reported there was an opportunity for interns to colead a CBT group, and 62.6% reported having a didactic seminar on group psychotherapy (Markus & King, 2003). Although clinically there has been an increase in the use of group psychotherapy, training programs are not placing greater emphasis on training in this area, and therefore practitioners are unable to successfully respond to the market demands. Despite the empirical evidence supporting the efficacy of CBGT, there appears to be limited training in this treatment modality included in program curriculums. This discrepancy may be influenced by a bias towards individual therapy, such that individual therapy is rated as being more valuable than group psychotherapy (Fuhriman & Burlingame, 2001). This bias has the serious consequence of not adequately training future clinicians to be competent in providing group psychotherapy. As there is greater emphasis for clinics to offer group-based psychotherapy, it is necessary for training programs to better prepare clinicians to meet this demand by offering adequate training in the content and process-related factors of CBGT. Training in Group Psychotherapy In addition to receiving adequate training in CBT, clinicians offering CBGT must also become an expert in conducting group psychotherapy. Dies (1983) argued that to become an expert in group psychotherapy, practitioners must move through five stages of development, from initial interest in seeking training (Decisional-Anticipatory Stage) to expert (Achieving and Maintaining Expertise). To assist with gaining greater competency and proficiency in providing group psychotherapy, the American Group Psychotherapy Association developed practice guidelines (Bernard et al., 2008). The guidelines are not specific to CBGT, but they address topics that represent important knowledge areas, including group process and strategies to reduce adverse outcomes and ethical dilemmas in group psychotherapy, as well as important logistical considerations to make when developing a psychotherapy group. Beyond coursework, practical training opportunities are necessary, as they offer in vivo exposure to how



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a group is run and the opportunity to receive feedback from an expert therapist (Barlow, 2004; Weiss & Rutan, 2016).

APPLICATION TO DIVERSE POPULATIONS CBGTs can be designed, or existing group manuals can be adapted, to address the mental health needs of diverse patient populations and across different treatment settings. When adapting an existing CBGT protocol, changes can be made to how material is presented or to the content of the group discussion so that it is relevant to group members’ concerns without departing from the underlying theoretical model. In the section below, we highlight the use of CBGT protocols to provide effective and efficient care for diverse patient populations, including people from ethnic minority groups, people with chronic medical conditions, and people with severe mental illness, as well as highlighting the use of CBGT in an inpatient setting. CBGT for People From an Ethnic Minority Group Extant findings suggest that CBT protocols, in general, are effective for people from ethnic minority groups (albeit the literature is limited; Horrell, 2008) and can also be effectively culturally adapted (Griner & Smith, 2006; Huey et al., 2014). A CBGT protocol is considered to be “culturally adapted” if the content of the group is modified to incorporate discussions or introduces specific skills that are derived from cultural values or norms relevant to the minority group. In addition to including culturally specific content, when conducting CBGT with minority groups it is advantageous if the group leader has similarities to the group members (e.g., same race, ethnicity, or native language), if the group is delivered within the community where the clients reside, and if the therapy aligns with other support resources, including community, spiritual traditions, and extended family. Incorporating one or more of these factors is found to have a significant, positive impact on outcomes relative to treatments that do not incorporate any of these cultural adaptations (d = 0.45; Griner & Smith, 2006). Carter et al. (2003), for example, reported on the use of a culturally adapted CBGT for the treatment of panic disorder in African American women. The group leader (an African American man with training and expertise in cultural sensitivity) adapted Barlow and Cerny’s (1988) Panic Control Therapy manual by incorporating culturally relevant content, such as group discussions on challenging the cultural belief that showing emotion is a sign of weakness, identifying relevant situations for in vivo exposures, and discussions on how societal stereotypes may exacerbate stress and anxiety symptoms. The authors found the therapy to be effective overall (d = 0.85 to 0.97, compared with a wait-list control group). The authors argued that the changes made to the protocol were beneficial; however, a limitation of the study is that all group members received the culturally adapted content, and therefore the degree of change

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as a result of the cultural modifications is unknown. Future research on the use of culturally adapted group content would benefit from comparing culturally adapted CBGT to treatment as usual (i.e., CBGT protocol without cultural modifications). When developing or selecting a culturally adapted CBGT protocol, it is also important to not assume commonalities across all individuals from the same ethnic minority group because they likely do not all hold the same values, beliefs or have the same lived experiences. Indeed, differences within an ethnic minority group may be as large the differences between groups (Pantalone et al., 2018). Therefore, it is important to assess rather than assume which values or issues would be relevant to all group members or who will be appropriate group members. CBGT for People With a Medical Condition The recognition of the importance of psychological interventions to manage distress while a person is receiving care for their medical illnesses is growing and is evidenced in the number of CBGT protocols that have been developed for various medical patient groups. CBGT have been conducted with a range of medical patient populations, including but not limited to those with cancer (e.g., Edelman et al., 1999), chronic pain (e.g., Nicholas et al., 1992), respiratory diseases (e.g., chronic pulmonary obstructive disease; Stanley et al., 2005), Parkinson’s disease (e.g., Hadinia et al., 2017), and diabetes (e.g., Snoek et al., 2001). When conducting CBGT for a medical population, the groups are generally homogenous (i.e., all group members have the same medical illness). The groups are often time-limited and may occur while the person is receiving acute care or as a part of their rehabilitation plan. The focus of the group is often related to the management of distress related to their medical condition, and thus topics of the group will range from learning to cope with their illness to offering support and recommendations for lessening the functional impairments caused by their illness (Folkman & Greer, 2000). CBGTs for specific mental health disorders can also be modified for medical patient populations. For example, when providing CBGT for depression within a medically ill population, the protocol can be modified to incorporate cognitive themes or behavioral strategies that are specifically relevant for people with chronic medical illnesses. Consequently, when providing psychoeducation on behavioral activation to enhance mood, it would also be important to incorporate a discussion related to pacing behavior or suggestions about how best to adapt specific behaviors to meet their physical limitations. The added content is necessary to ensure that the strategy is accessible to all group members and modified to ensure that will not exacerbate symptoms of their health conditions. To illustrate the utility of a CBGT group for an outpatient medical population, we highlight a CBGT protocol for irritable bowel syndrome (IBS) developed by Tkachuk et al. (2003). The group covers a range of cognitive behavioral strategies that are oriented to reducing distress associated with symptoms of



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IBS and overall stress reduction. Specific topics include psychoeducation about the biopsychosocial model of IBS, goal setting for IBS self-management, relaxation training, cognitive therapy, assertion training (i.e., time management, activity pacing, and time urgency reduction), and relapse prevention strategies. The effectiveness of the group was compared with a control treatment of symptom monitoring with weekly telephone contact. At a 3-month follow-up, the individuals who received CBGT reported greater gastrointestinal symptom improvement, lower psychological distress, and greater improvements in health-related quality of life than patients who received the control treatment. The authors noted that there are likely positive, long-term consequences of gastrointestinal symptom improvement, including less behavioral avoidance and reduced health care use (Tkachuk et al., 2003). In addition to targeting distress, CBGT can be a useful avenue for promoting behavioral change in medical patient populations. Patients often acknowledge the importance of engaging in self-care and making lifestyle changes to best manage their illness but struggle to follow through on the changes or feel a lack of confidence in their ability to make the changes that their medical team is asking them to do (van der Ven et al., 2005). Therefore, to target behavioral change, motivational interviewing techniques may also be incorporated into a CBGT group. The opportunity to participate in a group with people who have similar conditions and concerns can offer people a normalizing experience as well as a chance to troubleshoot with and receive support from their peers. CBGT for People With Severe Mental Illness Another area that has seen an influx in the use of CBGT is in the treatment of severe mental illness, including bipolar disorder and schizophrenia. Several clinical trials support the use of CBGTs for individuals with severe mental illness. Given the success of CBGT in the treatment of psychosis, it is now recommended as a component of the acute treatment phase for psychosis (National Institute for Clinical Excellence, 2014; Royal Australian and New Zealand College of Psychiatrists, 2005). In a review of treatment outcomes for the use of CBGT in acute settings for people with psychosis, Owen et al. (2015) found that CBGT resulted in reduced distress, greater knowledge of symptoms, decreased affective symptoms, and fewer readmissions. It appears that the utility of CBGT for psychosis extends beyond acute settings, as similar findings have been found for individuals who are living in the community (Wykes et al. 2008). Although there has not been a thorough examination of the mechanisms of change in CBGT for psychotic disorder, Newton et al. (2007) argued that individuals with severe mental illness are likely to benefit from the peer support that is inherent to group therapy. CBGT in Inpatient Settings Although CBGT is a structured therapy, it can be effectively adapted for use across different settings. One setting where it is becoming more readily used is

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inpatient mental health units. It is common for inpatient mental health units to offer group programming; however, most of the groups are not CBGT based. Consequently, much of the programming is not standardized across inpatient settings and has not been empirically tested. To offer patients with an evidence-based therapy during an inpatient admission, Vendittelli et al. (2003) developed a CBGT protocol for individuals who present with a range of mental health conditions, such as schizophrenia and major depressive disorder. The CBGT protocol is rooted in the vulnerability-stress model and designed to provide patients with a multidimensional view of mental illness and to normalize patients’ experience while admitted, reduce their isolation, increase their compliance in the ward and after discharge, improve the patients’ ability to recognize their early warning signs, and improve self-control and self-esteem. In 2006, Veltro et al. examined the impact of their standardized CBGT protocol. Compared with patient outcomes prior to the implementation of the CBGT, after CBGT was introduced there were significantly lower rates of readmission, improved atmosphere on the ward, and greater patient satisfaction. This study highlights that an evidence-based CBGT protocol can be developed for and administered to patients during their inpatient admission. Unique to inpatient or day-treatment settings is the ability to integrate cognitive behavioral strategies throughout patients’ daily activities, rather than during a single group session that is offered once per week. Lynch et al. (2011) reported on findings from a women’s comprehensive CBT inpatient unit that examined the integration of multiple CBGT groups throughout the day. The typical treatment plan for the day included a morning goals group, skills and activity groups, daily CBT groups, self-help time, and an evening wrap-up group. At discharge from this unit, women with major depressive disorder, bipolar disorder, and psychotic disorders showed improved psychosocial functioning on the OC-45. The authors also found that the treatment gains were maintained 1 month following discharge. The authors noted that participation and engagement with CBT groups was associated with improved functioning at discharge. The findings further highlight how CBGT can be effectively adapted for various treatment settings and for diverse patient groups.

CONCLUSION AND FUTURE DIRECTIONS CBGT provides an efficient and cost-effective intervention that offers a unique therapeutic environment wherein individuals benefit from their interactions with coleaders but also with the other group members who offer shared motivation and support, as well as opportunities for interpersonal learning. In this chapter, we reviewed the structure and content of CBGT, CBGT therapeutic strategies, and how these strategies should be adapted from an individual to a group setting. We also discussed the special characteristics of CBGT, including group process factors as well as the unique challenges of conducting CBGT,



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including working with a cotherapist, managing group dynamics, and ethical considerations. Although individuals have an overall preference for one-to-one therapy, a substantial body of research has shown that CBGT has equivalent efficacy and is an effective intervention across various diagnostic subgroups. The importance of assessing treatment progress and outcomes was discussed, including general measures of symptom severity, impairment, and quality of life, as well as group-specific variables such as group cohesion. We also reviewed mechanisms of change related to CBGT outcome, including the theoretical foundation, structure, and group process factors. Finally, the importance of dissemination and training in conducting group therapy was highlighted as well as adapting CBGT to diverse populations and settings. The progress made in developing the empirical basis of CBGT is exciting, yet there is much work to be done. Future research is needed in several areas, including establishing the differential efficacy of CBGT for a wider range of disorders as well as in diverse samples and settings, furthering our understanding of the role of group process factors beyond group cohesion in treatment efficacy, and the development of assessment tools and methods of measuring various group process factors.

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Effectiveness of cognitive behavioural group therapy for social phobia in a community clinic: A benchmarking study. Behaviour Research and Therapy, 45(12), 3030– 3040. https://doi.org/10.1016/j.brat.2007.08.002 Morrison, N. (2001). Group cognitive therapy: Treatment of choice or sub-optimal option? Behavioural and Cognitive Psychotherapy, 29(3), 311–332. https://doi.org/10. 1017/S1352465801003058 National Institute for Clinical Excellence. (2014). Psychosis and schizophrenia in adults: Prevention and management. NICE. Newton, E., Larkin, M., Melhuish, R., & Wykes, T. (2007). More than just a place to talk: Young people’s experiences of group psychological therapy as an early intervention for auditory hallucinations. Psychology and Psychotherapy, 80(1), 127– 149. https://doi.org/10.1348/147608306X110148 Nicholas, M. K., Wilson, P. H., & Goyen, J. (1992). Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain, 48(3), 339–347. https://doi.org/10.1016/0304-3959(92)90082-M Norton, P. J. (2012). Group cognitive-behavioural therapy of anxiety: a transdiagnostic treatment manual. Guilford Press. Norton, P. J., & Kazantzis, N. (2016). Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group CBT for anxiety disorders. Journal of Consulting and Clinical Psychology, 84(2), 146–155. https://doi.org/10.1037/ ccp0000062 Oei, T. P., & Dingle, G. (2008). The effectiveness of group cognitive behaviour therapy for unipolar depressive disorders. Journal of Affective Disorders, 107(1–3), 5–21. https://doi.org/10.1016/j.jad.2007.07.018 Ogrodniczuk, J. S., Piper, W. E., & Joyce, A. S. (2006). Treatment compliance in different types of group psychotherapy: Exploring the effect of age. Journal of Nervous and Mental Disease, 194(4), 287–293. https://doi.org/10.1097/01.nmd. 0000207366.49820.85 Otto, M. W., Pollack, M. H., & Maki, K. M. (2000). Empirically supported treatments for panic disorder: Costs, benefits, and stepped care. Journal of Consulting and Clinical Psychology, 68(4), 556–563. https://doi.org/10.1037/0022-006X.68.4.556 Owen, M., Speight, T., Sarsam, M., & Sellwood, W. (2015). Group CBT for psychosis in acute care: A review of outcome studies. Cognitive Behaviour Therapist, 8(e2), 1–18. Pantalone, D. W., Iwamasa, G. Y., & Martell, C. R. (2018). Cognitive-behavioural therapy with diverse populations. In K. S. Dobson (Ed.), Handbook of cognitivebehavioural therapies (pp. 445–464). Guilford Press. Piper, W. E., Marrache, M., Lacroix, R., Richardsen, A. M., & Jones, B. D. (1983). Cohesion as a basic bond in groups. Human Relations, 36(2), 93–108. https://doi. org/10.1177/001872678303600201 Rosenberg, M. (1965). Rosenberg self-esteem scale (RSE). Acceptance and commitment therapy. Measures package, 61, 52. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for the Treatment of Schizophrenia and Related Disorders. (2005). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry, 39(1–2), 1–30. https://doi.org/10.1080/j.1440-1614.2005.01516.x Scott, M. J. (2011). Simply effective group cognitive behaviour therapy: A practitioner’s guide. Routledge. Scott, R. H. (2005). Effectiveness of group versus individual psychotherapy for depression in a community counselling setting using the “mind over mood” cognitive therapy manual. Dissertation Abstracts International: Section B: The Sciences and Engineering, 65(12-B), 6673. Snoek, F. J., van der Ven, N. C. W., Lubach, C. H. C., Chatrou, M., Adèr, H. J., Heine, R. J., & Jacobson, A. M. (2001). Effects of cognitive behavioural group training

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(CBGT) in adult patients with poorly controlled insulin-dependent (type 1) diabetes: A pilot study. Patient Education and Counseling, 45(2), 143–148. https://doi.org/10. 1016/S0738-3991(01)00113-6 Söchting, I. (2014). Cognitive behavioral group therapy: Challenges and opportunities. Wiley Blackwell. https://doi.org/10.1002/9781118510261 Söchting, I., Wilson, C., & De Gagné, T. (2010). Cognitive Behavioural Group Therapy (CBGT): Capitalizing on efficiency and humanity. In J. Bennett-Levy, D. Richards, P. Farrand, H. Christensen, K. Griffiths, D. Kavanagh, B. Klein, M. A. Lau, J. Proudfoot, L. Ritterband, J. White, & C. Williams (Eds.), Oxford guide to low intensity CBT interventions (pp. 323–330). Oxford University Press. Stanley, M. A., Veazey, C., Hopko, D., Diefenbach, G., & Kunik, M. E. (2005). Anxiety and depression in chronic obstructive pulmonary disease: A new intervention and case report. Cognitive and Behavioral Practice, 12(4), 424–436. https://doi.org/10.1016/ S1077-7229(05)80070-7 Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595–606. https://doi.org/10.1037/ a0016032 Tkachuk, G. A., Graff, L. A., Martin, G. L., & Bernstein, C. N. (2003). Randomized controlled trial of Cognitive–Behavioral group therapy for irritable bowel syndrome in a medical setting. Journal of Clinical Psychology in Medical Settings, 10, 57–69. https:// doi.org/10.1023/A:1022809914863 Tschuschke, V., & Dies, R. R. (1994). Intensive analysis of therapeutic factors and outcome in long-term inpatient groups. International Journal of Group Psychotherapy, 44(2), 185–208. https://doi.org/10.1080/00207284.1994.11490742 van der Ven, N. C. W., Lubach, C. H. C., Hogenelst, M. H. E., van Iperen, A., Tromp-Wever, A. M. E., Vriend, A., van der Ploeg, H. M., Heine, R. J., & Snoek, F. J. (2005). Cognitive behavioural group training (CBGT) for patients with Type 1 diabetes in persistent poor glycaemic control: Who do we reach? Patient Education and Counseling, 56(3), 313–322. https://doi.org/10.1016/j.pec.2004.03.005 Veltro, F., Falloon, I., Vendittelli, N., Oricchio, I., Scinto, A., Gigantesco, A., & Morosini, P. (2006). Effectiveness of cognitive-behavioural group therapy for inpatients. Clinical Practice and Epidemiology in Mental Health, 2, 16–21. https://doi.org/10.1186/ 1745-0179-2-16 Vendittelli, N., Veltro, F., & Oricchio, I. (2003). L’intervento cognitivo-comportamentale di gruppo nel servizio psichiatrico di diagnosi e cura. Centro Scientifico Editore. Vîslă, A., Constantino, M. J., Newkirk, K., Ogrodniczuk, J. S., & Söchting, I. (2018). The relation between outcome expectation, therapeutic alliance, and outcome among depressed patients in group cognitive-behavioral therapy. Psychotherapy Research, 28(3), 446–456. https://doi.org/10.1080/10503307.2016.1218089 Weiss, A. C., & Rutan, J. S. (2016). The benefits of group therapy observation for therapists-in-training. International Journal of Group Psychotherapy, 66(2), 246–260. https://doi.org/10.1080/00207284.2015.1111083 Wenzel, A., Liese, B. S., Beck, A. T., & Friedman-Wheeler, D. G. (2012). Group Cognitive Therapy for Addictions. Guilford Press. Wesner, A. C., Gomes, J. B., Detzel, T., Guimarães, L. S., & Heldt, E. (2015). Booster sessions after cognitive-behavioural group therapy for panic disorder: Impact on resilience, coping, and quality of life. Behavioural and Cognitive Psychotherapy, 43(5), 513–525. https://doi.org/10.1017/S1352465814000289 Wilfley, D., Frank, M., Welch, R., Spurrell, E., & Rounsaville, B. (1998). Adapting interpersonal psychotherapy to a group format (IPT-G) for binge eating disorder: Toward a model for adapting empirically supported treatments. Psychotherapy Research, 8(4), 379–391. https://doi.org/10.1093/ptr/8.4.379



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Wilson, G. T. (1998). Manual-based treatment and clinical practice. Clinical Psychology: Science and Practice, 5(3), 363–375. https://doi.org/10.1111/j.1468-2850.1998. tb00156.x Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523–537. https://doi.org/10.1093/schbul/sbm114 Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). Basic Books. Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). Basic Books.

16 Cognitive Behavioral Couple and Family Therapy Frank M. Dattilio and Norman B. Epstein

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orking with couples and families offers a number of unique characteristics and challenges that are quite different from those encountered with individual psychotherapy. Because the therapist is working with the interactions among multiple clients simultaneously, they must be attuned to complex processes (Dattilio, 2001, 2014). This is truly a case of the whole being greater than the sum of its parts. Getting to know the couple or family involves becoming familiar with each member and the manner in which all of them interact, as well as the members’ interactions with the therapist. The therapist must have expertise in understanding the dynamics among cognition, emotion, and behavioral responses within each member (where traditional psychological training and cognitive-behavioral theory are relevant), but also be skilled at assessing mutual effects among the members. Tracking the interpersonal process among family members during a therapy session, which often occurs at a rapid pace, is different from a therapist monitoring the interaction between oneself and a single client while focusing on that individual’s internal experiences. One of the exciting advantages of couple and family therapy is repeated opportunities to observe live interactions among the members and to intervene in the moment to alter dysfunctional patterns. However, developing a firm grasp of the complex dynamics occurring within the system requires a different mindset than understanding the characteristics of an individual. It also requires observing rapid family interaction processes in vivo and dealing with the strong emotional currents often flowing through a family. https://doi.org/10.1037/0000219-016 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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In addition, development of a positive therapeutic alliance with the clients takes on different dimensions with a couple or family than with an individual. Much research has been conducted on characteristics and behaviors of therapists that facilitate a strong therapeutic alliance in individual therapy (Sprenkle et al., 2009), such as therapist expressions of empathy, warmth, and presence. Although it might seem that those characteristics would bode well in any modality of therapy, literature on “common factors” that influence the outcome of couple and family therapy suggests otherwise (Sprenkle et al., 2009). For example, while a therapist is listening intently to one member of a couple describe their complaints about their relationship and expressing empathic understanding, the other member may be getting upset while thinking that the therapist is siding with the partner. Thus, couple and family therapists continuously need to create a delicate balance in relation to the members of the system. With such complex dynamics within a family, which become even more complex when a therapist enters the system, it is essential to consider how one integrates concepts and methods of cognitive behavioral therapy (CBT) with a family systems approach. Understanding a couple or family requires examining the interactions that occur among the members, the overarching characteristics of the unit (e.g., a family coping with a hereditary form of cancer affecting multiple members), and the characteristics of each member. Furthermore, broader contextual factors, such as community violence, societal economic upheaval, and cultural factors, impinging on family relationships need to be assessed (Epstein & Baucom, 2002). Balancing all of this can be quite challenging at times for the clinician. Although couple and family therapists commonly prefer to work with all members who appear to be involved in some way with a presenting problem (including family members who are affected by an individual’s depression, substance use, or other individual problem), at times that is not possible due to reluctance of some member to attend sessions. That does not preclude moving ahead with sessions for those who are willing to attend, but it creates challenges for the therapist. For example, when an oppositional adolescent refuses to attend therapy, the therapist can begin by meeting with the parents and focusing on how they interact with the child, including how they attempt to motivate them to attend sessions. In addition, joint family sessions limit the degree to which a therapist can use traditional cognitive behavioral interventions focusing an individual member’s psychopathology symptoms, problematic cognitions, and emotion regulation difficulties. In such cases, they may need to refer various members of a couple or family out for concurrent individual therapy. At times, a therapist might be tempted to hold individual sessions with one or more members of a couple or family, in order to address factors that are interfering with the work on relationships. Although an occasional individual session may be productive in preparing a family member to participate constructively in joint sessions, conducting what begins to constitute individual therapy while simultaneously continuing joint sessions creates the dangers of creating dual relationships and



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their associated ethical problems, which should be avoided (Kazantzis et al., 2017). In addition, whenever a therapist has separate communications with a member of a couple or family, there is a risk that the individual will share secrets with the therapist (e.g., regarding infidelity) that places the clinician in a complicated bind involving collusion with that individual via-á-vis the other member(s). Couple and family therapists need to present clear policies to couples and families regarding secrets (e.g., the therapist’s refusal to hold secrets) during the initial consent procedures. The focus of this chapter is on applying CBT principles and methods to work harmoniously with couples and families. It should be kept in mind, however, that oftentimes significant modifications must be made with the delivery of CBT methods that were developed for use in individual therapy in order to effectively utilize them in sessions that include two or more clients. Clinicians who are accustomed to conducting CBT with individuals need to approach couple and family therapy with a different perspective and with flexible applications of tried and true individual therapy techniques.

UNDERLYING THEORY Cognitive-behavioral couple and family therapy (CBCFT) has developed over the course of more than a half century. Ellis and Harper (1961) were the first to identify how cognition influences relationship distress, especially when spouses harbor unrealistic beliefs about characteristics their relationship should have, leading to extreme negative evaluations of their life together (Ellis, 1977; Ellis, et al., 1989). The core assumption of their rational-emotive therapy (RET) model was that members of a couple who held irrational beliefs about characteristics that their partner and relationship should have would respond with strong negative emotion and dysfunctional behavior toward the partner when daily life with the partner inevitably failed to match those standards. However, this early application of RET to relationship problems focused on assessment and intervention with the individual members to challenge the distressing beliefs. That certainly is one common component of relationship problems, but it does not capture the interpersonal processes that occur in couple and family relationships. Fortunately, during the 1960s through the 1970s, when cognitive therapies (A. T. Beck, 1976; A. T. Beck et al., 1979; Meichenbaum, 1977) were developing and being disseminated widely, behavioral theorists and therapists also were applying learning theory to treat problematic behaviors of adults and children in individual therapy. They subsequently began to apply them to couple and family relationship problems as well. In particular, they used social exchange theory, operant learning strategies, and social learning theory principles to understand and intervene with negative interactions in couple and family relationships. Social exchange theory (Thibaut & Kelley, 1959) proposes that a high ratio of negative behaviors to positive behaviors exchanged by members

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of a couple leads the partners to be distressed with their relationship. Consequently, behaviorally oriented couple therapists, such as Stuart (1969), Liberman (1970), Weiss et al. (1973), and Jacobson and Margolin (1979) engaged couples in using behavioral contracts to systematically exchange more positive behaviors in order to create more satisfying exchange ratios. They also used operant conditioning principles (Skinner, 1953, 1971) that focus on how reinforcing and punishing consequences that members of a couple or family provide for each other’s actions influence the frequencies with which the recipients engage in those actions. Consequently, when a couple devised a contract to exchange behaviors desired by each partner, they also agreed to provide reinforcement to each other for following through. Regarding family relationship problems, Patterson (1971, 1982) used operant conditioning and contingency contracting concepts and methods to help parents improve their abilities to control aggressive behavior of their children. Patterson and his colleagues studied the behavioral interaction patterns of families that had been referred for a child’s conduct problems and uncovered what they referred to as “coercive family systems,” in which parents and children mutually exchanged aversive behaviors. They designed interventions to reduce the coercive behaviors and substitute positive family interactions. Even though, initially, the families had sought assistance because of a child’s negative behavior, the treatments modified the parents’ behaviors as well. Behaviorally oriented clinicians also drew on observational learning processes, which constitute a much more efficient means for individuals to learn complex behaviors than operant conditioning procedures that rely on shaping of responses via repeated consequences. Bandura’s (1977; Bandura & Walters, 1963) social learning model focuses on processes in which an individual observes another person modeling a particular type of behavior and then imitates the model, especially if the observer sees that the model receives reinforcement for the action, or if the model has some form of social status. Using a combination of modeling and reinforcement procedures, therapists taught members of couples and families skills for constructive communication and problem solving to reduce conflict and build positive bonds (Falloon et al., 1984; Jacobson & Margolin, 1979; Stuart, 1980). Over time, behavioral interventions with couples and families shifted away from a major use of contracts and toward development of constructive skills (e.g., Baucom & Epstein, 1990; Eyberg et al., 2001; Mueser & Glynn, 1999; Robin & Foster, 1989). Research on couple communication identified patterns that predicted partners’ distress and relationship dissolution, such as the demand-withdraw cycle, contemptuous behavior, and escalating exchanges of aggressive behavior (Christensen, 1988; Gottman, 1994; Revenstorf et al., 1984), and couple therapists targeted such destructive forms of couple behavior in their interventions. Although many pioneers in couple and family therapy (e.g., Dicks, 1953; Haley & Hoffman, 1968; Satir, 1967) commented on the relevance of intervening with members’ cognitions in addition to their behavior, there were no systematic descriptions of assessment and intervention with cognition. Eventually,



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in the late 1970s, behavioral marital therapists recommended that clinicians include cognitions in their treatment (Margolin & Weiss, 1978) without describing any systematic methods for identifying problematic cognitions or modifying them. However, in the 1980s and 1990s, cognitive therapists began to apply individual therapy methods to identify and modify couples’ and family members’ distorted or inappropriate cognitions about each other (A. T. Beck, 1988; Bedrosian, 1983; Dattilio, 1989, 1993, 1997, 1998; Dattilio & Padesky, 1990; Ellis, 1982; Ellis et al., 1989; Epstein, 1982, 1992; Epstein & Schlesinger, 1996; Epstein et al., 1988; Teichman, 1992). The focus tended to be on cognitions within each member of a relationship and ways in which members’ cognitions influenced each other, more than on couple or family behavioral interaction patterns that elicited or were influenced by those cognitions. The cognitions addressed went beyond the traditional cognitive therapy distinction between automatic thoughts, cognitive distortions involved in information processing (e.g., overgeneralization, dichotomous thinking), and schemas, to address a typology of relational cognitions. Those include selective perceptions that members have about the events occurring in their relationship, attributions that members have about determinants of their own and each other’s actions, expectancies or predictions that members have about likely consequences of behaving toward other members in particular ways, assumptions or beliefs that members have about natural characteristics of people and their relationships, and standards or beliefs that individuals have about characteristics that partners and relationships should have (Baucom et al., 1989). Schwebel and Fine (1994) and Dattilio (1993, 2010) have described family schemas comprised of beliefs shared by family members (e.g., that they are “a bad luck family”; that a particular family member is weak and incompetent) that organize the family’s responses to life events and challenges. In contrast to stream-of-consciousness automatic thoughts, schemas are longstanding core concepts about characteristics of relationships that are developed through various life experiences (e.g., observations of one’s parents’ couple relationship) that influence how the individual processes information in new situations. For example, an individual who developed a schema that romantic couple relationships are unstable from observing turmoil in her parent’s marriage may selectively notice instances of conflict in others’ relationships, including her own current couple relationship. Although established schemas can be resistant to change, an individual’s new experiences with significant others potentially can modify them (Dattilio, 2010; Epstein & Baucom, 2002). A more integrated cognitive-behavioral model of couple and family therapy was developed that combined behavioral interventions from behaviorally oriented approaches (e.g., contracts, communication and problem-solving training) and cognitive interventions adapted from individual cognitive therapy (Baucom & Epstein, 1990; Baucom et al., 1990; Rathus & Sanderson, 1999). Therapists simultaneously assessed a couple’s or family’s behavioral patterns and the members’ cognitions and emotional responses that either led to particular behaviors

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or were responses to other members’ actions. Circular causal pathways among family members’ responses to each other were identified, and points for intervention that could alter the self-perpetuating nature of those cycles were designed. Because cognitions, emotions, and behaviors were viewed as influencing each other continuously, the model proposed that change in any one of the domains had potential to produce change in the others (Baucom & Epstein, 1990). The primary ways that emotions were addressed were through teaching couples skills for noticing and expressing their feelings and for empathic listening to each other’s expressions, increasing their awareness of links between their cognitions and emotional responses, and some emotion regulation strategies (Baucom & Epstein, 1990). Those interventions provided couples constructive ways of thinking and behaving toward each other when experiencing emotions such as anger, depression, anxiety, and jealousy. Epstein and Baucom (2002) expanded the CBCFT model to incorporate additional phenomena, with emphasis on intrapersonal, dyadic interpersonal, and environmental influences on relationship function. In the intrapersonal realm, greater focus has been placed on individuals’ emotional experiences that influence each person’s cognitive and behavioral responses to a partner than was the case in the original behavioral and cognitive-behavioral couple therapy approaches. The main foci on emotion in the earlier models were emotions as consequences from a partner’s behavior—especially as mediated by the meanings that the recipient attached to the actions—and improving couples’ skills for expressing their emotions and listening empathically to each other’s feelings. In the enhanced CBCFT model, emotions have a more prominent role in influencing individuals’ cognitions and behavior regarding their significant others, as when persistent anger contributes to a person’s selective focus on a partner’s negative behavior. In addition, the model examines individuals’ basic human needs and motives (e.g., intimacy, achievement) that each member of a couple brings to the relationship and that influence the individual’s satisfaction with experiences with the partner. Dyadic interpersonal factors can involve differences between partners’ needs (e.g., differences in the need for intimacy), preferred styles for coping with stressors, and communication styles. Environmental factors include demands or stressors impinging on the couple’s relationship from various ecological levels, such as children, extended family, friends, jobs, schools, community violence, lack of adequate local health care, societal economic stresses, and so forth (Epstein, 1992), and Epstein and Baucom’s (2002) “enhanced” model also differentiates between the traditional CBCFT emphasis on “micro” behaviors occurring between partners in specific situations (e.g., the couple often argues about one of the partners being late for the couple’s planned activities) and “macro” level behavioral patterns and themes, such as a couple’s persistent conflict about perceived differences in their levels of commitment to their relationship. Jacobson and Christensen (1996) developed another modification of traditional CBCFT that emphasizes helping members of a couple strike a balance between efforts to make changes in how they relate to each other and develop-



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ing acceptance of characteristics in each other that are unlikely to change. Traditional behavioral change procedures involving communication and problemsolving training are combined with acceptance-based strategies involving strategic techniques (e.g., reframing a partner’s distressing behavior as having positive intent) and humanistic techniques (e.g., encouraging empathy for each other’s personal sources of stress). The acceptance strategies are intended to reduce partners’ propensity to blame each other for relationship problems and reduce their attempts to pressure each other to make changes. These approaches to increasing partners’ and family members’ acceptance of each other differ from the traditional cognitive-behavioral approach of working to reduce cognitions that contribute to individuals’ intolerance of characteristics of their partners and other family members. For example, CBCFT (Baucom & Epstein, 1990; Dattilio, 1997, 1998; Epstein & Baucom, 2002; Rathus & Sanderson, 1999) identifies stringent and unrealistic standards that members of couples and families hold for each other’s behavior and temperament and guides the individuals in examining the advantages and disadvantages of trying to live with such standards. In addition, members are coached in considering alternative explanations for negative attributions they have made (and which they consider unacceptable) regarding causes of each other’s behavior. Thus, shifting from inferring that one’s partner is often late because they are not committed to the relationship to an alternative attribution that their behavior is due to attention-deficit/hyperactivity disorder (ADHD) and executive function problems may not dissolve all of one’s frustration, but it may increase one’s acceptance to the extent that one is calm enough to engage in problem-solving discussions with the partner about new strategies that they can use to be more punctual. Beginning with its roots in social exchange and social learning theories, CBCFT also has taken family systems theory concepts into account, attending to mutual influences that family members have on each other. Systems theory focuses on the interconnectedness of the elements of a system such as a family, such that understanding the functioning of any one member requires identifying influences that other members continuously have on the individual (White & Klein, 2015). For example, in contrast to psychological theories that focus on linear intrapsychic causes of psychopathology, family systems theory examines interpersonal processes within the family that influence each member’s functioning. Therapists track interaction patterns and sequences, such as the common circular demand-withdraw pattern in many distressed couples (Christensen, 1988) and the reciprocation of aversive actions in “coercive family systems” of adolescents with conduct problems (Patterson, 1982). However, the systems perspective does not hold members of a family responsible (or blameworthy) for others’ actions; for example, even though both members of a couple may engage in aggressive behavior toward each other, neither person is blamed for the other’s inappropriate behavior, and each individual is considered responsible for their own choices to behave aggressively (Epstein et al., 2015). As we describe next, the integration of systems theory concepts with the cognitive-

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behavioral model offers options for assessing and treating a variety of presenting problems involving individuals’ psychological and physical health within the family context. The systems theory aspects of CBCFT include family members’ cognitions and emotions that interact with behavioral responses. The simultaneous attention to all three domains makes CBCFT a highly integrative model that is compatible with a variety of other systems-focused couple and family therapy models (Dattilio, 2010). The systemic quality of CBCFT also has led increasingly to its application beyond a focus on simply improving general relationship distress to addressing couple and family processes associated with individuals’ presenting problems that were at one time treated only with individual therapy (e.g., alcohol abuse, depression, anxiety disorders, eating disorders). These relational interventions have tested empirically and found to be effective (Epstein, 2018; Fischer et al., 2016). Birchler et al. (2008) integrated behavioral couple therapy procedures (e.g., increasing exchanges of pleasing and caring behavior, increasing shared rewarding activities, improving communication and problem-solving skills, avoiding threats of separation, focusing on the present, avoiding physical aggression) with interventions focused on a partner’s substance use (e.g., self-help meetings, medication, behavioral contracts between spouses to promote abstinence). CBCFT approaches have been used to decrease negative couple interactions and enhance mutual emotional support, either in conjunction with individual therapy or as the primary intervention in the treatment of depression (Beach et al., 2008; Whisman & Beach, 2012). Family-focused treatment that involves using couple or family therapy with a CBT emphasis as an adjunctive intervention with standard individual or group CBT treatments has been found to be effective in the treatment of anxiety disorders (Chambless, 2012). Chambless (2012) suggested a couple therapeutic approach that includes psychoeducation about the individual partner or family member’s anxiety disorder and how its symptoms affect and can be affected by relationship patterns, communication skills training, problem-solving training, preparation for coping with the individual’s symptoms, and reduction of accommodation of their daily interactions to the individual’s anxiety. Monson and Fredman (2012) addressed posttraumatic stress disorder (PTSD) using psychoeducation regarding reciprocal effects between an individual’s symptoms and couple/family interactions, plus CBT interventions to reduce avoidance of anxiety-eliciting situations at both the couple level and by the individual with PTSD. The systemic interventions addressing interpersonal as well as individual avoidance provide therapeutic leverage at a different level than traditional PTSD treatments that only target intrapsychic processes. Bulik et al. (2011) developed a couple-based cognitive behavioral couple therapy (CBCT) program for anorexia nervosa that combines interventions specific to the eating disorder (e.g., the partner’s provision of emotional support to the individual, reinforcing appropriate eating and other healthy behaviors, avoiding punishment) with traditional CBCT procedures to enhance overall couple functioning (e.g., problem-solving and communication skill training,



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especially regarding the individual’s symptoms). Couples facing severe physical illness have also benefited from CBCT procedures. Baucom, Porter, et al. (2009) developed a CBT-based relationship enhancement program for women suffering from breast cancer and their partners. Couples are taught communication skills that are especially applied to cancer-related topics (e.g., fear of mortality, medical decisions, sexuality, body image). In addition, couples are taught problem-solving skills that they can apply to making medical treatment decisions and are provided psychoeducation regarding psychological and physical effects of treatment on partners’ sexual functioning. CBCFT also has been expanded beyond treatment of general relationship distress to specific severe relationship problems. Baucom, Snyder, and Gordon (2009) developed a CBT-based program to help couples who are dealing with infidelity to cope with its common traumatic effects, gain insight into the factors that led to an affair, and make constructive decisions about the future of their relationship. CBT procedures also have been used to treat couples experiencing psychological and mild-to-moderate physical partner aggression (but not cases of physical battering; Epstein et al., 2015). Studies have indicated that many couples engage in high rates of mild-to-moderate physical aggression and even more psychological aggression (e.g., demeaning verbal attacks) by both partners. Increasingly, couple interventions, the majority of which have been forms of CBCT, have been used to treat these forms of partner aggression by targeting not only each individual’s anger management skills and the cognitions that contribute to aggressive behavior (e.g., a belief that aggression teaches a partner to treat one better) but also dyadic interaction patterns that exacerbate couple conflict. These systemic couple interventions have been found to be safe and effective (LaTaillade et al., 2006; O’Leary et al., 1999; Stith et al., 2011).

MAIN TREATMENT PROCEDURES As we have described, the theoretical and methodological origins of CBCFT can be traced to a few key sources that have provided foundations for understanding influences of cognition, emotion, and behavior on the quality of intimate relationships. On the basis of concepts and methods from behavioral couple and family therapy, cognitive therapy, and family systems theory, a variety of interventions commonly are used to assess and intervene with behavioral interaction patterns, cognitions, and emotions that contribute to or maintain relationship problems. The following sections provide descriptions of the major CBT treatment procedures used with couples and families. Given the systemic framework used in CBCFT, therapists continually assess how behaviors, cognitions, and emotions influence each other both within each family member and among members. Thus, a choice to focus on encouraging a behavior change between members of a couple is based on the potential that the change in actions will influence how the partners perceive each other and the emotions

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they will experience toward each other. At the same time, the therapist considers the partners’ existing cognitions (e.g., a negative expectancy that one’s partner will not reciprocate positive efforts) and emotions (e.g., global negative sentiment regarding the partner) toward each other that may interfere with their carrying out the therapist’s suggested behavior changes. Although this chapter cannot describe in detail the strategies that therapists use to integrate interventions for behavior, cognition, and emotion in depth, we give some examples. Because CBCFT is a highly collaborative approach to therapy, therapists begin treatment by educating the clients about the treatment model so that they understand the principles and methods involved. This didactic introduction can be supplemented by asking the clients to read popular books such as A. T. Beck’s (1988) Love Is Never Enough and Markman et al.’s (2010) Fighting for Your Marriage. Therapists also can emphasize that clients’ participation in homework exercises is essential in order to create change in their interaction patterns in their daily lives (Dattilio, 2002; Dattilio et al., 2011). The therapist also describes their role as a consultant and source of feedback to the clients, who will be engaged actively with them during sessions but will emphasize not taking sides with individual members. As is typical in CBT in general, therapists structure assessment and treatment sessions in order to collaborate with the clients on using the time well toward achieving the goals that they have developed for their therapy (Epstein & Baucom, 2002; Dattilio, 1997, 2010). This includes the therapist and clients beginning each session by collaborating to set an agenda regarding the topics that will be discussed. It also is important for the therapist to set ground rules regarding appropriate behavior on the part of the clients as well as the therapist, both within the sessions and in the clients’ daily life; for example, members of a couple or family avoiding aggressive actions and refraining from using each other’s vulnerable self-disclosures during sessions as “ammunition” to criticize them. Before formulating a treatment plan for a couple or family, a CBCFT clinician conducts an assessment of the presenting problems, as well as historical and current events and conditions that have influenced the development and maintenance of the problems. Although some questionnaires have been developed to assess behavioral patterns, cognitions, and emotional responses in couple and family relationships, those instruments have been used primarily in research studies, whereas therapists typically base their clinical assessments on joint interviews with the couple or family, individual interviews with the members to gather individual developmental data, and in-session observations of couple or family behavioral interactions. An advantage of observing members of a family during a session is the therapist’s opportunity to notice when one member shows nonverbal cues of a reaction to another’s specific behavior and to briefly stop the interaction to inquire about the individual’s thoughts and emotions at that moment—the essence of tapping into automatic thoughts and associated affect (Dattilio, 2010; Epstein & Baucom, 2002).



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Interventions to Modify Problematic Behavioral Interactions Social exchange and learning theory principles, especially regarding ratios of positive and negative actions exchanged, shaping of individuals’ actions via operant conditioning, and the efficiency of observational learning, have been the foundations of behavioral couple and family therapy treatment programs, and they are a core component of CBCFT. Treatments typically begin with some systematic assessment of the presenting problems, their history, and a functional analysis of the behavioral patterns and members’ associated cognitions and emotions (Dattilio & Epstein, 2016; Epstein & Baucom, 2002). The functional analysis examines the stimuli preceding a particular cognitive, emotional, or behavioral response and the consequences following the response (e.g., a parent paying attention when a child engages in a tantrum), which influence when and how often the individual exhibits the response. Regarding presenting problems, the therapist’s focus is on collecting information about specific behaviors involved in clients’ complaints; such as when parents initially report that a child “is disrespectful,” the therapist inquires about particular child behaviors that they consider disrespectful, alternative behaviors that they would prefer, and detailed examples of situations in which the negative behaviors occur. In addition, the therapist observes how the family members interact with each other during sessions because as family issues are raised, the members commonly react to each other in a naturalistic way, even with the therapist present. Both through client self-reports and observations of the family, the therapist is looking for eliciting conditions and consequences, especially responses from other family members, that might exacerbate or reinforce the child’s undesirable actions. In addition, the therapist observes the broader family behavioral interaction environment, looking for possible sources of observational learning, such as negative verbal behavior by parents that serves as a model for the child. Furthermore, although parents commonly focus on reporting a child’s negative behavior and associated negative family interactions, it also is important to inquire about the child’s strengths, as well as specific instances of positive behavior and the conditions in which they occur. Similarly with couples, the therapist inquires about both partners’ behavioral definitions of the presenting problem(s), the history of the relationship and timeline when the problems seemed to emerge, and the conditions under which the problematic couple interactions tend to occur. The goal is to conduct a functional analysis in order to understand patterns and sequences in the couple’s distressing interactions, especially the partners’ mutual influences on each other. As with assessment of families, this systemic approach to mutual influences does not hold child or adult victims of abusive behavior responsible for negative ways that others treat them; individuals are held responsible for their own aggressive acts (Epstein et al., 2015). On the basis of the assessment of the behavioral components of a couple or family problem, the typical couple and family CBCFT treatment programs include interventions focused on (a) deficits in communication and problemsolving skills, (b) replacing particular negative interaction patterns (e.g.,

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demand-withdraw, reciprocal verbal aggression) with constructive behavior, and (c) shifting to a more favorable and pleasing ratio of positive to negative relational behaviors, which involves increasing positive actions as well as decreasing negative behavior. The following are brief overviews of these types of interventions, which can be considered in greater detail in texts devoted to them (Christensen & Jacobson, 1998; Epstein & Baucom, 1989, 2002; Jacobson & Margolin, 1979; Mueser & Glynn, 1999; Rathus & Sanderson, 1999; Robin & Foster, 1989). Interventions are conducted during therapy sessions, but family members’ active engagement in homework activities, such as practicing communication and problem-solving skills during daily life, also is an essential component of CBCFT (Dattilio, 1998, 2002; Schwebel & Fine, 1994). Research has indicated that homework exercises are important for change in couple and family therapy (Dattilio et al., 2011). They help maintain therapeutic gains between sessions and promote a transfer of changes achieved during sessions to daily living. Practice heightens family members’ awareness of specific goals for behavioral, cognitive, and emotional changes. Interventions for Deficits in Communication and Problem-Solving Skills Empirical studies have supported clinicians’ observations that couples and families that seek assistance for relationship problems commonly exhibit poor communication and problem-solving skills (Epstein & Baucom, 2002; Mueser & Glynn, 1999). CBCFT enhances members’ skills for expressing themselves clearly and constructively, listening to each other’s expressions carefully and empathically, and collaborating in resolving problems in their relationships. Although the core components of improving communication and problem solving involve teaching couples and families specific behavioral skills, clinicians also attend to members’ cognitions and emotional responses that may be interfering with their ability to engage in those constructive skills. For example, an individual’s tendency to “magnify” a partner’s mild complaints about their actions, viewing them as “rejection of me as a person,” is likely to interfere with the individual’s ability to listen empathically to the partner’s expressions of feelings about their relationship. Similarly, an individual who is clinically depressed may lack the motivation and energy that are needed to engage in problem solving discussions with other family members. Consequently, while coaching couples and families on developing more constructive communication and problem-solving skills, the CBCFT clinician monitors members’ associated cognitions and emotional responses and integrates interventions to address them as needed. The therapist introduces communication training by presenting a rationale for the importance of clear constructive communication, followed by guidelines regarding behaviors for effective expression of one’s thoughts and emotions, as well as guidelines for constructive listening (Baucom & Epstein, 1990; Epstein & Baucom, 2002). The therapist also facilitates the skill acquisition by modeling



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the skills for the couple or family. The guidelines for expressing oneself include using language that acknowledges the subjectivity of one’s point of view (e.g., “It seems to me that . . .”), describing one’s subjective thoughts and emotions, acknowledging positives when describing a problem with one’s partner or relationship, and using specific language (e.g., “I feel lonely when you come home and immediately turn on the television”) rather than global descriptions (e.g., “You have little interest in me”). Other guidelines include keeping one’s expressions fairly brief to avoid overloading the listener with too much information to remember and using tact (e.g., not interrupting family members while they are in the midst of their favorite activities in order to broach a relationship issue). The guidelines for empathic listening include intentionally exhibiting nonverbal behavior (e.g., eye contact) that conveys paying attention; demonstrating that one accepts the speaker’s right to have their personal feelings (e.g., not debating the speaker’s expressed ideas); and providing feedback to the speaker, paraphrasing the essence of their messages in a respectful manner regardless of whether or not one agrees. It is helpful to give each family member a handout describing the communication guidelines for reference as needed during sessions or at home. After the therapist models the skills, they coach the clients as they practice using them. Even though many clients are eager to discuss controversial topics that motivated them to seek therapy, the therapist guides them in restricting their initial practice to relatively benign topics so that the strong negative affect that tends to be triggered by high-conflict topics will not interfere with family members’ ability practice and mastery of the skills. As the family members exhibit progress in using positive skills, the therapist guides them in discussing more challenging topics and practicing the skills at home. In CBCFT, the work on communication also is expected to influence family members’ cognitions, as they learn more about each other’s needs and motives through empathic listening. This process may disconfirm some distorted cognitions about each other. Problem-solving training with couples and families also involves both verbal and written instructions as well as modeling and behavioral rehearsal. Consistent with a CBCFT emphasis on developing constructive skills, it includes a series of steps that emphasize collaboration among family members. The first step involves the family members identifying a problem that they would like to solve and defining it as specific behaviors that are either occurring or not occurring. Thus, a family may discuss how little time they spend together in mutually enjoyable activities and reach consensus that they would like to increase shared activities. The second problem-solving step involves the members creating a list of possible behavioral solutions to the problem. In order to maximize creativity and avoid conflict, the members avoid evaluating each other’s ideas at this point. Next, family members discuss the potential advantages and disadvantages of each solution on their list. They can select one solution that they agree is feasible and palatable to all of them or a combination of more than one solution from their list. Following the selection process, the family reaches an agreement to try the proposed solution as

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homework, identifying a specific time and who will do what. During the next therapy session, the family reports on the degree of success they had in implementing the solution and how satisfied each member was with the outcome. The therapist guides them in revising the solution if needed and scheduling another trial. As with teaching communication skills, the therapist has the couple or family begin practicing problem-solving skills with relatively low-conflict problems and progressing to addressing more severe problems as they demonstrate their capacity to work collaboratively. Replacing Negative Interaction Patterns With Constructive Behavior Behavioral interventions with distressed couples also focus on reducing particular negative behavior patterns that were found in research studies (e.g., Gottman, 1994; Revenstorf et al., 1984) to be destructive to relationship satisfaction and stability. For example, Epstein and Baucom (2002) described interventions tailored to reducing patterns of mutual attack, demand-withdraw, mutual withdrawal, and mutual disengagement. For example, with a couple engaged in mutual verbal attacks, the therapist points out the pattern to the couple, discusses negative reciprocity with them, emphasizes each person’s responsibility for reducing their role in the reciprocity, obtains each person’s verbal commitment to behavioral change, sets specific guidelines for constructive behavior, intervenes actively during sessions to interrupt or block negative actions, and coaches each individual in substituting positive behaviors toward the partner. These interventions often must be supplemented with probes for negative cognitions that contribute to the negative reciprocity, such as an individual’s belief that “I’m not going to let her get away with treating me that way! I’ll give her a dose of her own medicine!” Similarly, the therapist often needs to coach the partners in strategies for managing their anger that fuels their aggressive behavior. Epstein and Baucom (2002) also described behavioral interventions, integrated with strategies for reducing negative cognitions and emotions, for modifying demand-withdraw, mutual withdrawal, and mutual disengagement couple patterns. Behavioral family therapists have constructed programs to help parents develop constructive and effective parenting skills to replace both harsh/aggressive and lax forms of child management behaviors that are ineffective and contribute to emotional distress in both the parents and children. The programs have social learning principles and methods in common (Eyberg et al., 2001; Forgatch & Patterson, 2010; Kazdin, 2005; Patterson, 1971; Sanders et al., 2003; Webster-Stratton & Herbert, 1994). The interventions include psychoeducation for parents regarding normal childhood development and characteristics of effective child management and discipline techniques, transforming tracking of negative child behavior into a focus on positive behaviors to reinforce, and coaching in how to shape their children’s positive behavior constructively by using positive reinforcement combined with time-outs and selective nonaggressive punishment.



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It is important for therapists to look for a couple’s or family’s “macro-level” pattern that may reflect core relationship issues, such as a power struggle between parents and their adolescent child. For example, the therapist may observe that whenever the adolescent expresses a desire for some independence (e.g., going to the local shopping mall with friends), the parents resist giving their permission, and the adolescent and parents escalate an argument about it, with neither side using positive communication and problem solving, and the parents becoming increasingly controlling. The therapist may hypothesize that the parents and adolescent have reached a developmental point at which the adolescent’s relatively normal desire for increased independence makes the parents uncomfortable, and the family lacks skills for identifying, discussing, and resolving this developmental stressor. The therapist can share that hypothesis with the family and guide them in using communication and problem-solving skills to address the members’ feelings and needs. Improving the Ratio of Positive to Negative Behaviors Exchanged by Members of a Couple or Family As emphasized in social exchange theory, the degree to which members of a couple or family are satisfied with their relationship is significantly associated with their relative proportion of positive to negative experiences with other members. Some behaviors have an instrumental function (e.g., cooking meals), whereas others convey members’ emotions, especially level of affection and caring, toward each other (e.g., spontaneously contacting the person to say hello; Baucom & Epstein, 1990; Epstein & Baucom, 2002). Because research has indicated that negative behaviors affect members’ levels of relationship satisfaction more than positive behaviors do (Gottman, 1994; Weiss & Heyman. 1997), therapists commonly pay more attention to the negative interactions than to positive behavior. However, decreasing negatives may leave individuals less distressed but still wanting more rewarding interactions (Epstein & Baucom, 2002). CBCFT clinicians commonly use guided behavior change interventions (Epstein & Baucom, 2002) to shift the proportion of positive to negative behaviors exchanged in a couple or family. In contrast to skill training, guided behavior change procedures focus on identifying a particular need or core relationship issue (e.g., increasing intimacy and cohesion in a couple or family), specifying a variety of behaviors that reflect the need or issue, and coaching the couple or family in devising a plan to enact more of those behaviors. Contracts or agreements to exchange behaviors that each person desires are used commonly to provide structure for increasing pleasing interactions. It is important that the agreements do not make one member’s enactment of positive acts contingent on another member’s positive actions. Each person’s positive efforts are supposed to occur regardless of how other members behave. The therapist focuses on minimizing any tendencies family members might have to “stand on ceremony,” waiting for someone else to take the initiative to behave positively.

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Interventions to Modify Problematic Cognitions As described in the section on underlying theory, CBCFT addresses the streamof-consciousness automatic thoughts, cognitive distortions, and relatively stable longstanding underlying schemas that have been the core foci of traditional cognitive therapy (A. T. Beck et al., 1979; J. S. Beck, 2011; Dattilio, 2010; Leahy, 1996). The typology of relational cognitions identified by Baucom et al. (1989) includes three that involve automatic thoughts (i.e., selective perceptions, attributions, and expectancies) and two that are forms of schemas (assumptions and standards). The interventions used in CBCFT are similar to individual cognitive therapy, but they are tailored to the complexities of treating two or more members of a couple or family jointly. For example, family members often are less open to a therapist’s input that challenges their cognitions when other members are present, as this can result in a loss of face or can provide the other members with “ammunition” in family conflicts (e.g., “I’ve been telling you that you are irrational, and now the therapist has shown it’s true!”). Consequently, a therapist’s cognitive restructuring efforts must be tactful and simultaneously supportive of each family member. Cognitive interventions in conjoint therapy also must take into account cognitions that are shared by family members because the members continually validate each other’s views. For example, both parents and an older sibling may hold the same attribution that tantrums of a younger child in the family are caused by the child having an inborn trait of selfishness. The common intervention of guiding an individual in obtaining information that may contradict a negative attribution and support an alternative inference can be difficult to carry out when members of a family validate each other’s attribution. Similarly, Dattilio (2010) and Schwebel and Fine (1994) described family schemas or beliefs that are shared (e.g., “You can’t trust anyone outside our family”), with members validating each other’s view of the world or their family. The following are descriptions of interventions used in CBCFT to target cognitions that are contributing to conflict and distress in couple and family relationships. As we have noted, they are based on traditional cognitive restructuring methods, but couple and family therapists pay special attention to creating an environment in joint therapy sessions that helps members be open to examining their own and shared cognitions. Identifying Automatic Thoughts and Associated Emotions and Behavior Subsequent to introducing the concept of automatic thoughts, the therapist guides the clients in noticing their thoughts that occur in conjunction with negative emotional responses and behavioral reactions to each other. This skill of monitoring one’s subjective experiences is emphasized throughout CBCFT. Clients often are encouraged to keep a log (on their phone or a small paper notebook) of specific situations with their significant others that elicit negative emotions and conflict. Mobile phone applications that allow the individual to record their automatic thoughts, emotional responses, and any resulting behav-



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iors toward other family members are available online. The therapist can use the logs to help family members identify macro-level themes (e.g., perceived lack of respect) that cause conflict with their relationships. This procedure in itself does not necessarily alter the degree to which family members believe that their cognitions are accurate and valid; it mainly increases their awareness of their thought processes and their links with emotions and behavior—helping them conceptualize their experiences in a more systemic way. When family members report the links that they noticed among their cognitions, emotions, and behavioral responses during family interactions, it commonly helps them make more sense of their own responses and those of other family members. The CBCFT therapist uses these opportunities to coach members in considering alternative (more benign) ways of thinking about each other that could elicit less negative emotional and responses and behavior on their parts. For example, parents might report noticing that when their young child exhibits tantrum behavior they automatically attribute it to willful selfishness, which makes them angry and results in their yelling at the child. First, the therapist may draw their attention to the strong automatic link between their negative attribution regarding the cause of the child’s tantrums and their anger and yelling: “Just a few minutes earlier you were calm and beginning to think that dinner was almost ready and everyone needed to get to the table soon, but suddenly you became angry and started yelling at your child. It was associated with seeing him having a tantrum and interpreting it as due to selfishness.” The subsequent interventions build on the identified links among cognitions, emotions, and behavior, guiding the family members toward considering information about alternative cognitions regarding the upsetting events. Identifying Cognitive Distortions and Labeling Them A useful strategy for engaging family members in evaluating their cognitions is to show them a list of common cognitive distortions, with definitions and examples, and ask them to identify which distortions they can see in their own automatic thoughts (Dattilio, 2010). The therapist guides them in considering how the cognitive distortions seemed to contribute to their negative emotions and behavior toward other family members. At times, a therapist may form an impression that a member’s cognitive distortions are associated with individual psychopathology such as an anxiety disorder (e.g., extreme negative predictions associated with generalized anxiety disorder). In such cases, the therapist may request an individual session with that person to examine their personal psychological functioning and determine whether a referral for individual psychotherapy may be warranted. Testing and Modifying Automatic Thoughts The modification of automatic thoughts involves the client(s) considering alternative ways of thinking about situations in which they find themselves (e.g., a parent who attributes a young child’s failure to follow directions to clean their

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room as due to intentional opposition can consider an alternative cause such as the child becoming distracted by an attractive toy in their room). This can be accomplished by having each client examine any available evidence concerning the validity of their thought within the present family situation, including any cognitive distortions. The therapist guides the client in noticing whether questioning their negative automatic thoughts results in change in the associated emotions and behavioral responses to other family members. The following are examples of questions that a therapist can ask to engage family members in examining the validity or appropriateness of their cognitions: • What evidence is available that can help you decide how accurate your thought is? What other information would be helpful? • What might be another possible explanation for why your family member behaved that way? • (From a handout listing and defining common cognitive distortions such as all-or-nothing thinking, fortune telling, selective abstraction, and overgeneralization [e.g., Dobson et al., 2018]): Which of these cognitive distortions, if any, can you see in the upsetting thoughts you had about your family member? For example, a young adolescent believed that her parents were unfair in denying her dating privileges. When the therapist asked what automatic thoughts go through her mind when she is upset with her parents, she shared, “They treat me like a child! They don’t want me to grow up.” The therapist replied, “You may be correct about their reason for restricting your dating, and if you are, that would be an important topic for all of us to discuss here in family therapy. However, I’m wondering whether there may be some other reason for their restricting you that would be important to consider. Please take a couple minutes and think about other possible reasons why your parents have reacted that way to your interest in dating. What comes to mind?” The therapist also encouraged her to ask her parents to explain their reasons for restricting their daughter’s dating. When the daughter turned to them and inquired, both parents replied that they were proud of her and enjoyed watching her mature, but they feared for her safety, especially after seeing news stories about incidents of sexual assault among teens. The daughter was able to hear that her inference about her parents not wanting her to grow up may not be accurate, and the therapist guided her in recalling some other instances in which her parents treated her as a maturing person. As is common in CBCFT, the therapist also engaged the family in a problem-solving discussion about what types of socializing with boys could be appropriate for her, integrating the behavioral intervention with the focus on examining upsetting cognitions. Guiding family members in considering the appropriateness of their assumptions and standards regarding each other and their relationships involves the challenges of any efforts to modifying individuals’ longstanding and commonly entrenched schemas (Dattilio, 2010; Epstein & Baucom, 2002). Because these



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are core beliefs about the world, it commonly requires repeated exposure to disconfirming information to begin to weaken them. For example, a stepparent may hold a standard that his adolescent stepchildren should automatically accept him as an authority figure and obey his rules and instructions. When the stepchildren refuse to comply with his directions and may even state, “You are not my father!” he becomes angry and verbally aggressive toward them. A therapist could initiate a discussion with the family about the ways in which stepfamilies (or “blended families”) are similar to biological nuclear families and ways in which they differ, as well as common challenges that they experience in forming their new relationships (e.g., love and respect commonly are not automatic but develop over time based on positive experiences with each other; children often feel torn between feeling loyalty to a missing biological parent and developing a new relationship with a stepparent). The stepfather in this case could be praised for his desire to become a member of the family, but the therapist also would guide him in examining the advantages and disadvantages of attempting to relate to the children according to a standard that they should automatically obey him. In joint family therapy sessions, family members can provide each other valuable feedback for evaluating the validity or appropriateness of their perceptions, attributions, expectancies, assumptions, and standards. In order to make it as easy as possible to hear each other’s feedback, the therapist guides the members in using good communication skills for discussing each other’s cognitions. Testing Expectancies With Behavioral Experiments Firsthand evidence is usually most effective in helping clients test their expectancies or predictions about events in their relationships. A common CBCFT intervention for eliciting such evidence involves coaching family members in designing and carrying out behavioral experiments, in which they test their predictions that particular actions on their part will lead to certain cognitive, emotional, and behavioral responses from others (Dattilio, 2010; Epstein & Baucom, 2002). For example, a man may have developed an assumption that his teenage children have no interest in him and an expectancy that if he tries to suggest that they spend some leisure time doing something together, they will turn him down. During a family session, he states that on a few occasions, he proposed that he could teach the children how to play golf (his favorite pastime) with him, and they showed no interest. At that point, the children emphatically stated that they considered golf boring. The therapist noted that the man’s expectancy was based on that past experience and expressed curiosity that perhaps the children might show more interest if their father asked them to choose an activity they could share. When the man restated his negative expectancy that his children would resist doing things with him, the therapist suggested that he conduct an experiment in which he invited them to choose the activity. The therapist also asked the children if they would be likely to share an activity with their father if they were able to choose it, and they replied that they most

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likely would. The therapist noted that in an experiment, we try something and observe whether the outcome matches our prediction, and in this case the father and children had made different predictions that would be tested. Public commitments that family members make toward cooperation with the experiment often increase the likelihood of its success. Use of Recollections and Role-Playing to Enhance Insight When couples and families begin therapy, the members commonly describe memories of negative experiences with each other. In order to assess their relationships more broadly, and to reduce instances in which the members have developed skewed negative perceptions of their relationships, the therapist can encourage them to access visual images of early instances when they enjoyed each other’s company and felt intimacy and affection. Another technique that can broaden members’ perceptions of each other and increase mutual empathy is the use of role-reversal role plays. Family members are asked to take on each other’s roles (e.g., a parent and adolescent play each other while discussing how an appropriate curfew time for the adolescent should be decided). Immersing oneself into the other’s frame of reference can help to increase members’ empathy for each other’s experiences (Epstein & Baucom, 2002). Empathic understanding, especially of the other person’s vulnerable thoughts and emotions, can reduce members’ adversarial stances toward each other, a process also considered essential in emotionally focused therapy (Greenberg & Goldman, 2008; Johnson, 2015). The “Downward Arrow” Technique Members of couples and families commonly are surprised by the degree to which other members are upset by their actions, and individuals themselves sometimes report that they are unsure of the basis for their own strong reactions to other members’ behavior. In cognitive therapy (e.g., A. T. Beck et al., 1979; J. S. Beck, 2011), the downward arrow technique is used to uncover distressing underlying meanings that individuals attach to events such as significant others’ behavior, helping them make sense of events that they initially may have viewed as trivial. The therapist begins with the individual’s initial report of their automatic thoughts about another’s behavior and asks a series of “And if that was true, then what would that mean to you?” questions to reveal the person’s upsetting inferences. Thus, a child may report an automatic thought, “My dad will yell at me if I don’t get mostly ‘A’ grades in school,” that makes him feel very anxious. When the therapist uses downward arrow questions, such as, “And if that happened, what would it mean to you?” or “What might that lead to?” the child finally reveals the “bottom line” thought: “He’ll get so upset with me that he’ll think I’m a loser and will wish he had someone else as a son, and he won’t want anything to do with me.” In individual cognitive therapy as well as CBCFT, individual clients are guided in examining how likely it is that each expectancy in their chain of negative predictions actually would occur, and how severe the predicted consequences would be, based



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partly on logic and partly on evidence from the past. An advantage of CBCFT is that the other family members who are present also can provide crucial feedback to the upset member. For example, the father of the anxious boy was surprised to hear his son’s severe fear of rejection and was able to reassure him that although as a parent he wanted the son to work hard in school, he loved him deeply and would never reject him. However, the process may unearth a genuine family problem such as parents’ reliance on punitive discipline. Consideration of Relationship Histories to Evaluate Assumptions Standards As we have described, members of couples and families commonly developed their schemas about relationships through experiences over the course of their lives, beginning in their families of origin. In addition to guiding them to examine the appropriateness of their assumptions and standards by evaluating their advantages and disadvantages, therapists can ask members to provide detailed memories about their experiences in past relationships. The process of taking a family history can be facilitated by constructing a genogram depicting family relationships over generations (McGoldrick et al., 2008). Constructing the genogram and examining intergenerational family patterns with it not only serves as assessment; it can be used in CBCFT as the basis of discussion with a couple or family about the potential for breaking old patterns, motivating them to experiment with new ways of interacting. Interventions to Modify Problematic Emotional Responses CBCFT provides several types of interventions intended to enhance inhibited family members’ awareness and expression of their emotions, as well as methods to help regulate extreme emotional responses (Epstein & Baucom, 2002). When clients report that they are not aware of having emotional responses to others’ actions, the therapist can validate that people vary widely in the intensity of their emotional experiences, but that it is important to pay attention to cues of one’s emotional responses because emotions provide very useful information about issues that have personal meaning to each individual. The therapist can describe examples, such as mild irritation at another family member’s actions being a cue that the individual perceives that the other person was paying insufficient attention to their preferences. When it appears that family members may be avoiding attending to their emotions because they fear recrimination for expressing them, the therapist can set a guideline in which members are to avoid criticizing or otherwise punishing anyone within or outside sessions for expressing personal thoughts and emotions. Even when such guidelines for safe emotional expression have been established, some family members may continue to avoid disclosure based on residual anxiety about possible negative consequences. In such cases, the therapist can emphasize that it likely will take repeated positive experiences to desensitize family members to anxiety about self-disclosure and can encourage reticent members to

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experiment with low-level disclosures to “test the waters.” The therapist can state that they will be supportive of individuals’ levels of unease but will guide them in reducing their avoidance (e.g., by catching them at changing the subject of conversation). Once safe conditions have been established for expression of emotions, the therapist can use downward arrow questions to uncover individuals’ unstated emotions as well as their cognitions. Many individuals who are not experienced at differentiating among various emotions also can benefit from the therapist providing psychoeducation about diverse emotions and their subjective internal cues, supplemented by a chart with cartoon representations of facial expressions of various positive and negative emotions. Finally, the therapist can engage family members in role-plays about their conflict topics to elicit their emotions “in vivo” during therapy sessions. In contrast to problems with emotional inhibition, therapists often encounter clients who have difficulty regulating intense emotional experiences and expression within their family and perhaps in other settings as well. Although some couples, labeled “volatile” by Gottman (1994), frequently experience both positive and negative intense emotional exchanges but are able to maintain a stable bond, others with poor emotion regulation are at risk for partner aggression and need assistance in managing emotional responses (Epstein et al., 2015). CBCFT, as is true of individual cognitive therapy, includes several types of intervention to improve family members’ regulation of intense emotional responses. First, the therapist can encourage family members to compartmentalize their emotional responses, rather than allowing them to occur indiscriminately, by scheduling specific times to talk about conflict topics (e.g., not when any member of the couple or family is sick or preparing for sleep). Another intervention that in a sense is quite simple but can have profound effects on regulating members’ escalation of intense and destructive emotional expression involves teaching the couple or family to use a “time out,” in which one or more members announce that the tension level seems to be rising and suggests a break for everyone to “cool down” before regrouping to discuss issues constructively. In conjunction with the compartmentalization and “time out” interventions, the therapist can coach the individuals in self-soothing activities (e.g., relaxation techniques, exercising, talking with a supportive and calming person). In addition, members can be coached in increasing their tolerance for distressing emotions, using the principles and methods of cognitivebehavioral exposure methods used in the treatment of anxiety, as well as methods from dialectical behavior therapy (Linehan, 1993). Integration of interventions for emotions and cognitions occurs when the therapist focuses on improving family members’ ability to monitor and challenge their upsetting automatic thoughts and associated underlying schemas that contribute to intense emotional responses. For example, coaching members to reduce selective perceptions of each other’s negative behavior to the exclusion of noticing positive actions can reduce anger, as can helping members notice and challenge their negative attributions about each other’s motives. “Softening” members’ rigid standards for each other’s behavior also can reduce frustration and anger.



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Finally, training couples and families in constructive communication and problem-solving skills can create a more positive, collaborative atmosphere in their relationships. There is a wealth of relevant literature on interventions for improving emotion regulation abilities in couples and families (e.g., Epstein & Baucom, 2002; Fruzzetti & Iverson, 2006; Goldman & Greenberg, 2006; Kirby & Baucom, 2007a; Meichenbaum, 1977).

OUTCOME DATA A body of empirical evidence has accumulated that demonstrates the effectiveness of forms of CBCFT. However, to date, the large majority of the outcome studies have tested the behavioral components of CBCFT (i.e., communication and problem-solving training, behavioral contracts), and most studies have examined the efficacy of treatment in controlled settings with randomized assignment of couples to treatments, a set number of sessions to equalize exposure to alternative treatments, specific training of therapists in protocols, and so forth rather than their effectiveness in naturalistic clinical settings (Baucom et al., 1998; Epstein, 2001; Fischer et al., 2016; Halford & Snyder, 2012; Lebow et al., 2012). Meta-analyses that were conducted in the early 2000s regarding cognitive-behavioral couple therapy outcome studies (e.g., Shadish & Baldwin, 2003, 2005) indicated that, overall, protocols including interventions for cognitions and those protocols restricted to behavioral interventions have produced large effect sizes for improvement in relationship satisfaction. For example, a meta-analysis of 30 studies comparing behavioral couple therapy to notreatment control groups found an effect size of 0.59 favoring the therapy. Fischer et al.’s (2016) review of outcome studies showed that behaviorally based couple therapies, some of which included cognitive interventions, had an average effect size of 0.84, comparable to effects found for other couple therapy models. Those results should be considered in the context of Baucom et al.’s (2003) finding that marital distress tends not to improve without treatment. Fischer et al. (2016) noted that since the initial meta-analyses were published, only one randomized controlled clinical trial has been conducted on behaviorally based couple therapies—Christensen and colleagues’ comparison of integrative behavioral couple therapy (IBCT) that combines interventions to increase partners’ acceptance of each other with communication and problem-solving training to facilitate change and what they label traditional behavioral couple therapy (TBCT) that is the traditional behavioral model developed by Jacobson and Margolin (1979) and others. Although the two protocols showed somewhat different rates of improvement in relationship satisfaction, the outcomes were for the most part similar, with effect sizes of 0.90 for IBCT and 0.71 for TBCT at the end of treatment, which were not significantly different. Christensen et al. (2004) also computed the clinical significance of the improvements, using the Jacobson and Truax (1991) calculation and found that at posttreatment 71% of the IBCT couples and 59%

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of the TBCT couples showed reliable improvement or recovery. At a 5-year follow-up assessment (Christensen et al., 2010), the effect sizes for improvement in relationship satisfaction were 1.03 for IBCT and 0.92 for TBCT, with 50.0% of IBCT couples and 45.9% of TBCT couples reaching clinically significant improvement. Family-level interventions emphasizing psychoeducation and structured communication and problem-solving skills training also have received considerable empirical support in controlled outcome studies focused on intervention for major mental disorders including schizophrenia, schizoaffective disorder, and bipolar disorder (e.g., Falloon et al., 1984; Miklowitz et al., 2004; Mueser & Glynn, 1999). For example, Miklowitz et al. (2004) conducted an open trial efficacy study for families with adolescents diagnosed with bipolar disorder, involving psychoeducation (including relapse prevention training), communication training, and problem-solving skills training. The adolescents showed an improvement effect size of 0.65 in depression symptoms from baseline to a 12-month follow-up, as well as an improvement effect size of 0.79 in mania symptoms. Parent-rated adolescent internalizing symptoms (d = 1.30) and externalizing symptoms (d = 1.46) also improved markedly. Overall, efficacy studies show a relapse rate for clients diagnosed with schizophrenia who received family psychoeducation of approximately 15% per year, in contrast to a relapse rate of 30% to 40% for those receiving medication with or without individual therapy, and in the best controlled studies the average relapse rate for family psychoeducation was 27%, compared with 64% for control groups receiving standard treatment (Baucom et al., 1998). Rummel-Kluge and Kissling (2008) noted that such family psychoeducation interventions have comparable effects in real-world settings (i.e., evidence of effectiveness) to those found in experimental settings (efficacy studies). Behavioral interventions for families also are prevalent within the literature applying operant principles and skill training to parent-child interactive therapies for conduct problems and ADHD (Barkley, 1998; Chronis et al., 2004; Estrada & Pinsof, 1995; Eyberg et al., 2001; Forehand & McMahon, 1981; Forgatch & Patterson, 2010; Henggeler & Sheidow, 2012; Webster-Stratton & Hancock, 1998). Meta-analyses of efficacy studies on these programs have produced variable (0.31–0.86) but consistently good effect sizes regarding improvement in negative child behavior (Fabiano et al., 2009). Outcome studies also have demonstrated effectiveness of behavioral family therapy for child anxiety, depression, and eating disorders (Brent et al., 1997; Couturier et al., 2013; Howard & Kendall, 1996; Jewell et al., 2016; Wood et al. 2006). Only a handful of studies specifically compared cognitive restructuring procedures to behavioral interventions. Two efficacy studies conducted by Baucom and colleagues (Baucom & Lester, 1986; Baucom et al., 1990) investigated whether adding cognitive restructuring modules to the traditional behavioral components would enhance the outcomes, although in order to maintain the same total number of sessions, adding sessions of cognitive restructuring necessitated reducing the number of sessions of behavioral interventions. Results



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indicated that all of the conditions increased relationship satisfaction more than a wait-list control condition, and the cognitive and behavioral interventions were equally effective. There also was some evidence that interventions focused on cognition tended to result in greater cognitive change, whereas interventions focused on behavior tended to lead to greater behavioral changes. No effect sizes were reported for those outcomes, so the results are encouraging but must be considered preliminary. Huber and Milstein’s (1985) pilot efficacy study comparison of cognitive interventions that targeted unrealistic relationship beliefs (assumptions and standards) with a wait-list control condition found that the cognitive restructuring condition led to more positive cognitions and higher relationship satisfaction than did the control group. Halford et al.’s (1993) efficacy study compared effects on partners’ behavior and cognitions of 12 to 15, 1½-hour sessions of traditional behavioral marital therapy (BMT) and an enhanced BMT that included cognitive restructuring, exploration of affect associated with negative couple interactions, and treatment generalization enhancement. The cognitive restructuring component involved identifying partners’ maladaptive relationship beliefs and attributions and using cognitive therapy procedures for Socratic questioning, modifying cognitions, and self-instructional training. In general, both conditions were successful in decreasing negative behavior and cognition, although degrees of those changes were not correlated with improvement in relationship satisfaction. Whisman and Snyder (1997) noted that interpretation of the findings from the few existing studies that focused on modifying cognitions has been difficult because those studies did not assess all of the relevant types of cognition (selective attention, expectancies, attributions, assumptions, and standards). There has been a striking absence of dismantling studies examining relative effects of interventions for cognitions, emotional responses, and behaviors in couple and family therapy, perhaps due to the complexity and expense of such designs in a time when funding for couple and family therapy outcome studies is scarce. Instead, CBCFT protocols that include cognitive and affective as well as behavioral interventions have been tested for their overall effectiveness, which has been very promising even though they fail to identify the relative impacts of the treatment components. Some studies have focused on treatment of severe relationship problems, whereas others have addressed couple interventions for psychological and physical health problems of an individual member of a relationship. Cognitive-behavioral programs for treating couples experiencing psychological partner aggression and mild-to-moderate physical aggression that have received empirical support through initial efficacy studies (Epstein et al., 2015; Heyman & Neidig, 1997; LaTaillade et al., 2006) include psychoeducation and anger-management interventions with prominent cognitive components in addition to behavioral interventions focused on communication and problem solving. The efficacy of the protocol developed by Epstein and colleagues was tested in a randomized clinical trial, compared with treatment as usual in their

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university family therapy clinic, involving a variety of systems-based couple therapy models. Results indicated that both treatments increased relationship satisfaction, decreased psychological partner aggression, decreased males’ use of physical aggression and showed a trend toward a decrease in females’ physical aggression, reduced negative attributions about one’s partner, increased overall trust in the partner, decreased anxiety, and increased positive moods prior to engaging in a conflict resolution discussion with one’s partner (Hrapczynski et al., 2012; Kahn et al., 2014; LaTaillade et al., 2006). The cognitivebehavioral treatment produced significant decreases during the couple discussions in negative communication by both males and females, whereas treatment as usual produced no change. Baucom, Snyder, and Gordon’s (2009) largely CBT-based treatment for couples experiencing infidelity has major components focused on enhancing partners’ constructive construal of factors that led to an affair, roles that both partners can play if they wish to recover from the trauma, and decisions that partners need to make about the future of the relationship. Regarding empirically supported CBCFT programs that have addressed individuals’ psychological and physical health problems, couple protocols for obsessive-compulsive disorder (Abramowitz et al., 2013), depression (Beach et al., 2008), substance abuse (Birchler et al., 2008), posttraumatic stress disorder (Macdonald et al., 2016), cardiac problems (Sher et al., 2014), and cancer (Baucom, Porter, et al., 2009) have been found to be effective overall. For example, Schumm et al. (2014) conducted a randomized controlled trial comparing the efficacy of behavioral couple therapy (BCT) with individual treatment, with women diagnosed with alcohol use disorder. The BCT cases had significantly fewer substance-related problems compared with individual treatment during the last 9 months of a 2-month follow-up period, with the effect size increasing steadily from −0.224 to −0.505. It is unknown how much the cognitive interventions in the treatment packages for these disorders contributed to the positive outcomes. As we noted previously, empirically supported behavioral family therapy protocols for major mental disorders (e.g., Mueser & Glynn, 1999) commonly include components of psychoeducation (e.g., etiology, symptoms, risk factors for symptom exacerbation including family conflict, and effective treatments; communication and problem-solving training; and strategies to identify and manage relapses). These components include CBCFT principles and procedures that address family members’ cognitions (providing them a clear understanding of the causes and course of a disorder and fostering realistic attributions for causes of a family member’s symptoms as well as realistic expectancies for the individual’s current and future functioning). However, to date no research has isolated effects of the cognitive interventions. Consequently, existing research on outcomes of CBCFT have been encouraging, but the limitations of the studies have left unanswered questions, especially about the degree to which treatment components targeting the clients’ cognitions contribute to the positive therapy outcomes.



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MECHANISM OF CHANGE As we described in the section on underlying theory, the overall CBCFT model is based on assumptions that improvements in couple and family relationship functioning occur when the interventions (a) reduce negative behavioral interactions, (b) increase positive behavior exchanges, (c) substitute constructive cognitions (unbiased perceptions, accurate attributions and expectancies, realistic and appropriate assumptions and standards), and (d) produce regulated experiences and expression of emotions among the members. Outcome studies have indicated that CBCFT protocols indeed produce such changes (Baucom et al., 1990, 1998; Epstein et al., 2015; Fischer et al., 2016; Kirby & Baucom, 2007b), although dismantling studies that isolate specific effects of interventions for behavior, cognition and emotions have been rare. The study by Hrapczynski et al. (2012) indicated that not only a CBT protocol but also other major couple therapy models (e.g., solution-focused, emotion-focused), were successful in reducing partner aggression and increasing relationship satisfaction, and that reduction in partners’ negative attributions about each other was associated with the other positive outcomes. As we noted previously, outcome studies on CBCFT-based family interventions also have demonstrated improvements in behavioral interactions, cognitions, and emotional responses. The improvements commonly found in measures of behavior, cognition, and emotion in CBCFT outcome studies are consistent with Benson et al.’s (2012) summary of core principles of effective couple therapy: altering partners’ views of presenting problems to be more objective and dyadic, decreasing emotiondriven dysfunctional behaviors, uncovering emotion-based avoidance behavior, increasing constructive communication, and emphasizing relationship strengths. Thus, although there is a great need for more research on the active ingredients of CBCFT, especially studies examining mediators of effective impacts of CBCFT interventions on measures of family functioning, its overall emphasis on those common factors in effective couple and family therapy (Sprenkle et al., 2009) makes it a highly integrative model that can be applied by practitioners who focus on other therapy models.

DISSEMINATION Behavioral and cognitive-behavioral models for understanding, assessing, and treating problems in couple and family relationships are widely used among practicing clinicians (Northey, 2002), and they are routinely included in couple and family therapy textbooks and handbooks (e.g., Gurman et al., 2015; Nichols & Davis, 2016). The present authors and their professional colleagues who focus on CBCFT have presented hundreds of training workshops on the model in countries around the world and have presented empirical papers reporting the effectiveness of the interventions at major professional meetings (e.g., the Association for Behavioral and Cognitive Therapies, American Psychological

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Association, American Association for Marriage and Family Therapy, National Council on Family Relations). In addition, a cognitive behavioral couple therapy protocol has been adopted by the National Health Service in Great Britain as a standard treatment for depression and evaluated for its effectiveness (Baucom et al., 2015).

APPLICATION TO DIVERSE SUBSETS OF THIS POPULATION Outcome studies on CBCFT have been conducted primarily in Western countries, and in general their samples have consisted predominantly of White, middle-class couples. Consequently, the extent to which the interventions would be effective with clients from other cultural, racial, and socioeconomic groups remains unclear. An exception was the treatment using cognitivebehavioral interventions that was evaluated as part of the Couples Abuse Prevention Program (CAPP) conducted by Epstein and colleagues (Epstein et al., 2015; Hrapczynski et al., 2012; LaTaillade et al., 2006) in a racially and socioeconomically diverse community clinic sample recruited on the basis of their psychological and mild-to-moderate physical aggression. The cognitivebehavioral protocol that included psychoeducation regarding forms and consequences of partner aggression, anger management, cognitive restructuring (e.g., regarding negative attributions about one’s partner that elicit anger), communication training, and problem-solving training produced improvements in relationship satisfaction, negative attributions, trust, self-reported partner aggression, and coded negative communication behavior. In addition, research conducted in several countries (with both Western and Asian cultures) on CBCFT psychoeducation and skills training programs with families that include members with major mental disorders has demonstrated their efficacy in reducing family members’ stress levels and the incidence of relapse by the identified patient (Baucom et al., 1998; Lucksted et al., 2012). Couple and family therapists commonly treat clients who are diverse in race, ethnicity, income, education, age, sexual orientation, gender identification, and levels of physical/intellectual functioning. This cultural diversity requires therapists to be culturally sensitive by (a) being aware of their own cultural values, and of potential biases that are based on their own and their clients’ cultural backgrounds; (b) understanding their clients’ culturally based worldviews; and (c) applying interventions that are consistent and respectful of clients’ cultural beliefs and traditions (Epstein & Falconier, 2014). A culturally sensitive approach is necessary for successfully “exporting” to other cultures a therapy model such as CBCFT that was developed within Western culture and, thus, includes core concepts and methods that were shaped by a Western perspective. For example, Epstein et al. (2012) reviewed cultural values and traditions in mainland China, often associated with the country’s collectivist culture, that tend to differ from those in Western societies and that may require Western-trained CBCFT clinicians to modify their assessments and intervention methods. Thus, the common



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focus that CBCFT places on individual family members’ identification and expression of their thoughts and feelings can conflict with Chinese families’ prioritizing responsibility to family over individual self-actualization, maintenance of harmonious relationships, and avoidance of loss of face by oneself or others. Similarly, Western family therapists’ focus on empowering parents as the primary source for socializing children may conflict with the key roles that Chinese grandparents play in raising children. The same holds true with other cultures as well (Dattilio & Bahadur, 2005). It also is important to note that making generalizations about any cultural group can result in overgeneralizing and overlooking intragroup diversity. Thus, we offer these as examples of couple and family cultural diversity that CBCFT clinicians need to take into account in assessing clients’ needs and devising appropriate treatment plans. There is a great need for further empirical research that assesses the relative effects of traditional CBCFT treatment components with subsets of couples and families. With the current limited information about treatment implications of client diversity, we urge therapists to spend time learning about the cultures, core beliefs, values, and traditions of each couple and family, tailoring interventions to their needs.

CONCLUSION AND FUTURE DIRECTIONS CBCFT is a treatment model that is well-suited to the complexities of conceptualizing intrapsychic, interpersonal, and environmental factors contributing to problems in close relationships and planning multipronged interventions that address those factors. The integration of a traditional cognitive-behavioral framework with family systems theory concepts and interpersonal theories of emotion yields a treatment approach that maximizes the potential for change through multi-level interventions. From its early roots in approaches that focused primarily on reducing negative behavioral interactions and increasing positive exchanges, CBCFT now emphasizes family members’ subjective cognitions and emotional responses to each other, family-of-origin historical roots of dysfunctional patterns, developmental changes in relationships and their members, and the crucial role of individual and family coping with layered life stressors. Its integrative assessment and treatment methods increasingly have been applied to complex relationship issues such as partner aggression, infidelity, and sexual problems, as well as family-based interventions for diverse presenting problems of individual members (e.g., forms of psychopathology, coping with physical health concerns). The body of empirical support for those applications of CBCFT continues to grow at a steady pace; however, there is a great need for more efficacy and effectiveness studies, an imposing challenge for clinical researchers as external funding for relational treatments is limited. Given the substantial empirical evidence that the quality of couple and family relationships has major impacts on the psychological and physical well-being of children and adults, it is imperative that clinicians and researchers increasingly invest their efforts in this vital treatment paradigm.

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Sher, T., Braun, L., Domas, A., Bellg, A., Baucom, D. H., & Houle, T. T. (2014). The partners for life program: A couples approach to cardiac risk reduction. Family Process, 53(1), 131–149. https://doi.org/10.1111/famp.12061 Skinner, B. F. (1953). Science and human behavior. Macmillan. Skinner, B. F. (1971). Beyond freedom and dignity. Knopf. Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy. Guilford Press. Stith, S. M., McCollum, E. E., & Rosen, K. H. (2011). Couples therapy for domestic violence: Finding safe solutions. American Psychological Association. Stuart, R. B. (1969). Operant-interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33(6), 675–682. https://doi.org/10.1037/h0028475 Stuart, R. B. (1980). Helping couples change: A social learning approach to marital therapy. Guilford Press. Teichman, Y. (1992). Family treatment with an acting-out adolescent. In A. Freeman & F. M. Dattilio (Eds.), Comprehensive casebook of cognitive therapy (pp. 331–346). Plenum Press. https://doi.org/10.1007/978-1-4757-9777-0_34 Thibaut, J. W., & Kelley, H. H. (1959). The social psychology of groups. Wiley. Webster-Stratton, C., & Hancock, C.L. (1998). Training for parents of young children with conduct problems: Content, methods, and therapeutic processes. In J. M. Briesmeister & C. E. Schaefer (Eds.), Handbook of parent training: Parents as cotherapists for children’s behavior problems (2nd ed., pp. 98–152). Wiley. Webster-Stratton, C., & Herbert, M. (1994). Troubled families—Problem children: Working with parents: A collaborative process. Wiley. Weiss, R. L., & Heyman, R. E. (1997). A clinical-research overview of couples interactions. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples intervention (pp. 13–41). Wiley. Weiss, R. L., Hops, H., & Patterson, G. R. (1973). A framework for conceptualizing marital conflict, a technology for altering it, some data for evaluating it. In L. A. Hamerlynck, L. C. Handy, & E. J. Mash (Eds.), Behavior change: Methodology, concepts and practice (pp. 309–342). Research Press. Whisman, M. A., & Beach, S. R. H. (2012). Couple therapy for depression. Journal of Clinical Psychology, 68(5), 526–535. https://doi.org/10.1002/jclp.21857 Whisman, M. A., & Snyder, D. K. (1997). Evaluating and improving the efficacy of conjoint couple therapy. In W. K. Halford & H. J. Markman (Eds.), Clinical handbook of marriage and couples interventions (pp. 679–693). Wiley. White, J. M., & Klein, D. M. (2015). Family theories: An introduction. Sage. Wood, J. J., Piacentini, J. C., Southam-Gerow, M., Chu, B. C., & Sigman, M. (2006). Family cognitive behavioral therapy for child anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45(3), 314–321. https://doi.org/ 10.1097/01.chi.0000196425.88341.b0

17 Cognitive Behavioral Therapy in Primary Care Robert A. DiTomasso, Scott Glassman, Christina Berchock Shook, Anna Zacharcenko, and Michelle R. Lent

P

rimary care psychology refers to “the provision of health and mental health services that includes the prevention of disease and the promotion of healthy behaviors in individuals, families, and communities” (Bray et al., 2004) through the specific application of psychological theory, constructs, and principles to problems commonly encountered in primary care over the course of the life cycle (McDaniel et al., 2004). In an effort to comprehensively and effectively address the challenges of assessing and treating primary care patients, the American Psychological Association (Bray, 2009) has established initiatives designed to promote interprofessional collaboration, education, and multidisciplinary, team-based approaches to practice.1 In light of the integrated primary care (IPC) movement in psychology, the field is rapidly witnessing a significant increase in psychologists who practice in integrated care medical settings, working side-by-side with physicians and other health care personnel. Successful integration of psychology in primary care hinges on the adaptation of a novel model of psychological practice in response to a number of demands, idiosyncratic to the primary care setting. These demands include rapid-paced practice, a large volume of patients, navigation of an interdisciplinary team-oriented approach to care, consultation, a population-based focus, and reliance on brief interventions (DiTomasso et al., 2013; Phelps et al., 2017). McDaniel et al. (2004) addressed essential core knowledge areas of primary care psychologists related to the biological, cognitive, affective, behavioral, developmental, and social/cultural arenas. McDaniel Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000219-017 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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et al. (2014) have carefully elucidated key primary care psychology competency domains (and specific competencies within each cluster) based on science, systems, professionalism, relationships, application, and education. The history of the IPC movement is deeply rooted in several factors (Phelps & Reed, 2004). IPC refers to systematic coordination of behavioral health and primary care services to produce the best and most effective health outcomes. Today, there is little if any doubt that the traditional medical model, exclusively focused on the biological domain, cannot efficiently, let alone effectively, address the myriad problems confronting primary care practitioners. Primary care physicians (PCPs) are confronted with a virtual onslaught of patients on a daily basis, oftentimes presenting with undifferentiated, seemingly simple yet sometimes complex, problems across the lifespan with a variety of presenting characteristics in part dependent on the age of the patient. Given the number of patients and limited time available in the daily schedule of the busy PCP, the traditional model of practice simply does not attend to the important dimensions impacting the physical and mental health of patients. Primary care refers to the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Institute of Medicine Committee of the Future of Primary Care, 1994). The primary care environment is one in which mental health and behavioral lifestyle problems abound. In describing primary care, DiTomasso and Esposito (2005) noted the following: Physicians have begun to realize that a thorough understanding and treatment of the whole patient is critical in accurately conceptualizing patient problems and in developing effective interventions. Primary care patients present with a multitude of possible problems, many of which have central components that are behavioral in nature. Given the reciprocal and synergistic relationship that exists between mind and body phenomenon, there is little wonder why patients seeking care from primary care physicians may do so for a variety of mental and physical reasons. (p. 295)

Within recent years, the evolution of practice in primary care has become embedded within the Patient-Centered Medical Home (PCMH), a context in which primary care psychologists can thrive and make significant contributions. The PCMH model promotes continuity and coordination of patient care and fosters interprofessional cross-talk among team members, a professional environment in which cognitive-behaviorally oriented primary care psychologists may play a central role (DiTomasso, Golden, & Morris, 2010; McDaniel & Fogarty, 2009). An understanding of the primary care model using family medicine as an example underscores the potential utility of cognitive behavioral approaches in primary care. A major impetus for creating the specialty of family medicine was to address the fractionation of patient care, which was highly prevalent before the specialty emerged. The basic tenets of family medicine were designed to offset this fractionation and create a model of care that incorporated several key facets. These tenets include continuity of care, comprehen-



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siveness, a psychosocial focus, patient education, and evidence-based practice. A thorough appreciation of these constructs begs for an integrated model that embeds a cognitive behavioral perspective in primary care. A brief consideration of each tenet will suffice as an explanation. Continuity of care refers to a model through which a patient consistently receives their medical care from the same physician over the course of life (DiTomasso, Golden, Morris, & Chiumento, 2010). The value of having an ongoing, continuous relationship with the same practitioner offers a multitude of advantages. Repeated experiences with the same patient provides a unique perspective to a primary care practitioner, most often not available or available only in part to other physicians not continuously involved in the patient’s care. There is value added in understanding the patient’s medical history, family history, psychosocial and psychiatric history, lifestyle attitudes, beliefs and habits, and idiosyncratic presentation in fostering a unique understanding of a particular patient and how these facets unfold over the course of time. These factors are likely to elucidate and shape when a patient is ill and why a patient may be symptomatic at a given point in time, provide key information that explains how a patient typically reacts under specific sets of circumstances, and offer critical hypotheses to be addressed in assessment and treatment. In other words, continuity provides a multitude of repeated experiences that inform the treating physician of important information that affects assessment, diagnosis, and intervention, as well as impacts the time and effort expended on the part of the physician. The patient’s medical record provides a rich, chronological narrative that is replete with critical information that may be useful in explaining and predicting the patient’s behavior across a variety of health-related domains. The consistent nature of patients’ responses to their environment is often rooted in their beliefs, attitudes, assumptions, feelings, and behavioral repertoire based in large part on their unique learning histories. Primary care psychologists are in a unique position to inform the clinical decision-making processes of physicians and to plan treatments that attend to the nature of the patient’s problems over time. Comprehensive care (DiTomasso, Golden, Morris, & Chiumento, 2010) emphasizes the importance of understanding and treating the “whole” patient. This tenet underlies the basic consideration of biological, psychological, cognitive, behavioral, social, spiritual, and cultural factors. Factors within each of these domains are likely to be important in creating a fuller picture of the patient in the context of their presenting problems. Failure to address an important factor in any of these domains may make the difference between effective versus ineffective assessments and treatments in understanding the onset, exacerbation, maintenance, and ultimate resolution of a problem. The idiosyncratic meaning of a patient’s experiences may be a key factor in explaining and offering a comprehensive approach to addressing problems. Once again, primary care psychologists can expand the delivery care model by attending to the interactive nature of various factors likely to affect the patient and their care.

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The psychosocial arena is a ripe area for investigation in understanding the onset, development, exacerbation, and maintenance of patient problems. In the context of a primary care model, this domain emphasizes the mind-body phenomenon. The implicit assumption here is that it is impossible to separate the mind and body. Focusing on one area to the exclusion of the other may prove to be quite limiting if not dangerous in some instances. By thoroughly embracing the interplay of the two, primary care practitioners are in a better position to address the interaction of these areas in not only better understanding patient problems but engaging with them to collaboratively solve these problems (DiTomasso, Golden, Morris, & Chiumento, 2010). The primary care psychologist is attuned to the ways in which psychological distress manifests itself in physical symptoms, how physical problems may mimic psychological symptoms, and how behaviorally based components play a critical role in the development and maintenance of life-threatening conditions. As behavioral consultants (Cos et al., 2010; Robinson & Strosahl, 2009), primary care psychologists are available to focus attention on the identification and treatment of psychological disorders commonly seen in primary care. A patient’s engagement in their own care is a critical element of the primary care model. Over the past several years, with a focus on building on patient strengths and self-determination, strategies specifically designed to enhance motivation to change (Miller & Rollnick, 2013; Prochaska & DiClemente, 1983) and facilitate movement from przecontemplation to action and maintenance of change have flourished. This approach has replaced the traditional approach that emphasized the passive role of the patient through which the patient is told in a prescriptive manner why and how they need to change. Primary care psychologists empower patients to change for their own reasons and view their ambivalence as a normal process. Patient education is another key component of primary care. PCPs educate patients about their conditions. When done effectively, this provides important information that is necessary but oftentimes not sufficient to promote change (DiTomasso, Chiumento, Singer, & Bullock, 2010). Helping patients understand their conditions can provide valuable information that allows patients to see the connection between their condition and treatment plan (DiTomasso, Freeman, et al., 2010). Patient education may also help patients to learn how to engage in a specific behavior designed to foster health. Finally, it may help patients to fully appreciate the connection between their problems and elements of the treatment plan. Primary care psychologists often use education as a means to collaboratively develop a formulation of the patient’s problems with patient and physician input. The primary care medical environment is one where there is also a great emphasis on evidence-based approaches to care (DiTomasso, 2017; DiTomasso, Cahn, et al., 2010). Not surprisingly then, given the track record of cognitive behavioral therapy (CBT) as an efficacious treatment for many problems seen in primary care (DiTomasso, Golden, & Morris, 2010; Sperry, 2008), this therapeutic approach has become an important model in the primary care domain. Phelps et al. (2017) emphasized the application of CBTs specifically tested in



Cognitive Behavioral Therapy in Primary Care  553

primary care settings for a variety of problems (Cigrang et al., 2015; Jakupcak et al., 2010; Pigeon & Funderburk, 2014). The literature suggests that these short-term-oriented approaches are both applicable and effective. The relevance of cognitive behavioral approaches in the assessment, conceptualization, and treatment of primary care patients is then relatively indisputable. The applicability of CBT to primary care is underscored by the view of Sir William Osler who valued understanding the type of person with a given disease more than the type of disease a person has (Chehab & Fealy, 2008). In the mid-1700s, Gaub observed the following: “The reason why a sound body becomes ill or an ailing body recovers, often lies in the mind” (Lipowski, 1977, p. 234). These words predated the biopsychosocial model developed by George Engel (1977) that forms the foundation of practice in cognitive behavioral approaches in primary care (DiTomasso, Golden, & Morris, 2010). PCPs address mental health problems in their patients, especially anxiety and depressive disorders. Also, eight of the top 10 leading indexes of health are essentially behavioral in origin. Frequent presenting problems are often rooted in behavior in the form of poor eating habits, excessive substance use, tobacco use, sedentary lifestyles, violent acts, suicide, injuries, and unsafe sex practices (U.S. Department of Health and Human Services, 2000). Also, although psychological problems may present as somatic complaints, acute and chronic stressors often trigger physical symptoms and worsen existing psychophysiological disorders. Likewise, organically based problems may masquerade as psychological disorders, or patients may suffer from both simultaneously (DiTomasso & Esposito, 2005). The CBT model is useful for a number of reasons. First and foremost, there is a large database of problems typically seen in primary care. A comprehensive review of 269 meta-analyses provides evidence for the CBT approach (Hofmann et al., 2012), and reviews of common mental health problems including depression (Freeman et al., 2010), anxiety (Salas et al., 2010), suicide risk (Rudd & Bryan, 2010), substance abuse (Dolan & Nam, 2010), somatic disorders (Golden, Stankewiecz, & Kestel, 2010), and eating disorders (Cahn & McFillin, 2010) are available. Likewise, reviews of CBT for nonadherence (DiTomasso, Chiumento, Singer, & Bullock, 2010; DiTomasso et al., 2017), problematic lifestyle habits (Anton et al., 2010), essential hypertension (DiTomasso, Chiumento, & Morris, 2010), asthma (Kotay & Lehrer, 2010), diabetes (DiTomasso, Boyle, et al., 2010), obesity (Tsai et al., 2010), pain (Golden, Gatchel, & Glassman, 2010), headaches (Buse & Andrasik, 2010), IBS (Toner & Antony, 2010), insomnia (Rosenfield et al., 2010), and personality disorders (DiTomasso & Rosenfield, 2015) are also available. While there is an evidence base to support CBT approaches, adapting the CBT model to the primary care setting is critical.

DELIVERING CBT IN PRIMARY CARE Delivering effective CBT in IPC often requires adaptation to accommodate a population-based health approach. To optimize access to behavioral health

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services in busy, high-volume primary care practices, CBT protocols should fit well within a behavioral health consultation (BHC) model. Relative to traditional outpatient treatment, the BHC model involves shorter courses of treatment with as few as one or two contacts, briefer sessions that last between 10 to 30 minutes, and an emphasis on psychoeducation, targeted cognitive behavioral skills training, and self-management support (Rowan & Runyan, 2005). Condensing more extensive CBT protocols to make these interventions appropriate for IPC often means choosing a subset of active components to administer. In treating anxiety, for example, many versions of relaxation training can last between six and 15 sessions at 50 minutes each and include combinations of diaphragmatic breathing, guided imagery, mindfulness meditation, and progressive muscle relaxation (Klainin-Yobas et al., 2015; Manzoni et al., 2008; Volpato et al., 2015). In IPC, a patient and provider might collaboratively choose a single relaxation exercise from an intervention menu that can be taught through a short demonstration (Shepardson et al., 2016). Shepardson et al. (2016) suggested additional CBT adaptations for IPC: (a) providing psychoeducation as brief as 5 minutes, (b) selecting one “best-fit” cognitive restructuring exercise (e.g., an evidence-for/against worksheet for challenging a dysfunctional thought), (c) reviewing one or two pertinent cognitive distortions instead of providing a comprehensive list, (d) developing manageable sets of values-based goals (e.g., one to three) to guide behavioral activation (BA), and (e) shifting in-session practice (e.g., exposures for social anxiety) to homework. The competent implementation of CBT techniques in IPC settings depends on rapidly establishing a strong working alliance and devoting attention to patient motivation to engage in treatment, particularly early in the service delivery process. Strong relationships between health care providers and patients are associated with increased participation in health behavior change programs, greater utilization of preventive health services, improved health, and higher quality of life (Okunrintemi et al., 2017; Parchman & Burge, 2004; Sturgiss et al., 2016; Weeger & Farin, 2017). Similarly, successful outcomes in CBT are positively correlated with patient engagement (Glenn et al., 2013), which is linked to a more evocative, collaborative, and affirming style of communication used by the clinician (Huang et al., 2016; Kertes et al., 2011). Findings in both traditional therapy and health care settings related to the importance of empathy and partnership echo the factors Bordin (1979) proposed as essential to a positive working alliance: mutually agreed upon goals and tasks and a therapist–client bond characterized by unconditional positive regard. It is estimated that 30% of client improvement is attributable to these relationship variables (Asay & Lambert, 1999). In addition to establishing trust and a collaborative view of the presenting problem early in treatment, clinicians in IPC settings may also want to address the patient’s overall readiness to initiate CBT for targeted behaviors. The PCMH, an increasingly common model for integrating behavioral health and primary care, follows standards that require providers to assess for illness self-management



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barriers, which can include low readiness to adopt healthy lifestyle practices (NCQA, 2014). Many patients seen in primary care settings are likely to present with medical and psychiatric comorbidities but are hesitant about participating in behavioral health services. One sample indicates that nearly 20% of primary care patients had a comorbid anxiety disorder but that 40% were not currently receiving treatment (Kroenke et al., 2007). Engagement may be even more challenging among minority groups due to a variety of internal and external factors, including cost, cultural congruence, and beliefs about help-seeking (Bridges & Anastasia, 2016). Engagement in primary care-based CBT may present a challenge without added attention to motivational variables and relational factors, with a dropout rate that ranges from 17% (Binnie & Boden, 2016) to nearly 50% (McHugh et al., 2014). The results for those who do remain in treatment are promising. McHugh et al. (2014) studied a brief CBT protocol delivered in primary care and found that although only about half the participants completed all five sessions, those who completed showed significant clinical improvements in the areas of depression and overall psychosocial functioning, with moderate effect sizes of 0.64 and 0.45, respectively. In a study reporting a higher completion rate of 75%, primary care patients who attended 10 sessions of CBT for somatization were 4 times more likely to be rated as “much improved” or “very improved” in severity of somatic symptoms and depression relative to a control group (Escobar et al., 2007). Generally, brief CBT in primary care is more effective for anxiety disorders (d = 1.06) than for depression or mixed anxiety and depression (d = 0.32) relative to control groups (Cape et al., 2010). Some evidence points to the utility of computer or internet-based CBT interventions for depression and anxiety when symptoms fall in the mild-to-moderate range of severity, with effect sizes ranging from 0.3 to 1.4 (Høifødt et al., 2011). An ongoing obstacle to engagement is a widespread shortage of behavioral health integration in primary care, particularly outside larger health systems (Massa et al., 2012). A solution to the lack of behavioral health resources involves training PCPs and medical residents in CBT; however, the ease of implementation and efficacy of transferring a therapeutic skill set require further study. In one review of studies where medical professionals provided CBT, there was wide variability in the amount of training received (3.5 hours to 8 days) and mixed satisfaction with the content (Dorflinger et al., 2016). Patient outcomes with physician-provided CBT were also mixed, with one study showing no effect on depression, anxiety, and functional health, and two others showing positive effects, including significant improvements in global distress, high patient satisfaction with physician-provided CBT, and high adherence with the intervention. In summary, cognitive behavioral approaches are evidence-based assessments and interventions that are directly applicable in primary care settings and can be blended into the daily work of the primary care psychologist. It behooves primary care psychologists integrated in medical settings to consider

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using these approaches in collaboratively addressing the common mental health and medical problems frequently encountered by PCPs. While not the only available treatments that are evidence-based, the CBT approach is applicable in such settings for a number of reasons. CBT approaches are easy for physicians and patients to understand and apply and are practical in application. The overarching model is active, directive, psychoeducational, structured, goal-oriented, more short-term oriented, and outcomes focused. In the fastpaced and demanding primary care environment, this model is likely to be more easily adopted. In the present chapter, we outline the evidence base for four common problems/issues in primary care. These topics are (a) depression and anxiety, (b) substance abuse, (c) obesity, and (d) chronic pain.

DEPRESSION AND ANXIETY IN PRIMARY CARE Depression and anxiety, common problems in the primary care setting, are associated with medical comorbidity. In the 2001–2003 National Comorbidity Survey Replication (NCS-R), more than 68% of adults with a mental health disorder reported having at least one general medical disorder (Druss & Reisinger Walker, 2011). Co-occurring depression is predictive of poor adherence to positive health behaviors and greater disease progression, as well as compromised disease outcome and increased mortality (Rutledge et al., 2009). Moreover, depression is associated with an increased risk of developing heart disease and is common in cases of congestive heart failure (CHF; impacting approximately 24% to 42% of patients; Guck et al., 2003; Rutledge et al., 2009). Depression is also an independent risk factor for readmission to the hospital, functional decline, and mortality in patients with CHF (Guck et al., 2003), and depressed patients with cardiovascular disease display lower self-care ability in comparison with nondepressed patients (Kessing et al., 2017). In diabetes, depression may hinder an individual’s ability to manage diabetes successfully and may accelerate cognitive decline (Park & Reynolds, 2015). Given that 70% to 80% of all antidepressants prescribed are recommended through primary care practice, this setting appears ideal for early identification and treatment of depression. Depression screening, intervention, and follow-up, quality measures that are promoted by the Centers for Medicare & Medicaid Services (CMS), are being delivered in advanced primary care medical homes with the goals of improving the quality for patients and offsetting unnecessary medical costs. However, the challenges of identifying and treating depression in primary care include developing a systematized, efficient, and accurate screening process; delivering evidenced-based interventions with limited time and resources; and increasing patient engagement in and adherence to the treatment process.



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Screening and Diagnosis The administration of screening tools is embedded in a stepwise approach to depression and anxiety care, which also includes comprehensive evaluation, treatment planning, delivery of the intervention, and follow-up to monitor patient progress (Franx et al., 2012). The selection of a screening instrument may be shaped by efficiency, time constraints, and cost containment (Smithson & Pignone, 2017). Although several reliable and valid depression and anxiety screening instruments exist, we recommend the Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder-7 (GAD-7). An efficient screening process is highly desirable. The PHQ and GAD-7 screeners were created during the development of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool with modules on 12 different mental health disorders. The PHQ comprises the mood (PHQ-9), anxiety, alcohol, eating, and somatoform modules in the original PRIME-MD. The GAD-7 was developed as a brief scale for anxiety, and the PHQ-9 was developed to assess symptoms of depression. The PHQ and GAD-7 screeners are downloadable from the PHQ screener website (http:// www.phqscreeners.com) at no cost, making them easily accessible. Permission is not required to reproduce, translate, display, or distribute these screening instruments. The PHQ-9 has been identified as effective in screening patients for depression as well as monitoring patient progress (Sahni & Agius, 2017). The diagnostic validity of the PHQ-9 has been established through research involving eight primary care and seven obstetrical clinics. PHQ-9 scores > 10 had a sensitivity of 88% and a specificity of 88% for major depressive disorder (MDD; Kroenke et al., 2001). Reliability, validity, accessibility, and ease of administration are favorable characteristics of the PHQ-9, making it suitable for use within the primary care environment. As a self-report measure, the PHQ-9 can be completed by the patient followed by provider verification of responses. Scoring ranges indicate the level of symptom severity, and guidelines for treatment based upon symptom severity are provided. Last, the actual PHQ-9 screener can also be embedded within the patient’s electronic health record, increasing ease of administration, data collection, and symptom monitoring. Developed by Spitzer and his colleagues, the GAD-7 was initially intended to diagnose generalized anxiety disorder. The 7-item scale was validated in 2,740 primary care patients. The GAD-7 also proved to have good sensitivity and specificity as a screener for panic, social anxiety, and posttraumatic stress disorder. It has been found to have excellent internal consistency (Cronbach = 0.92) and good test-retest reliability (intraclass correlation = 0.83) as well as good criterion, construct, factorial, and procedural validity (Spitzer et al., 2006). With respect to symptom severity, cutpoints of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety. The same cutpoints apply to the PHQ-9 and PHQ-15 for depressive and somatic symptoms. Last, like the PHQ-9, the

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GAD-7 can be embedded within the patient’s electronic health record, increasing ease of administration, data collection and symptom monitoring. The diagnostic process can be influenced by physician and patient characteristics. Patients identified provider behaviors of asking about depression and showing concern as facilitators to identifying and treating mood disorders in primary care. Provider time constraints, however, were cited as an impediment to the disclosure of symptoms (Keller et al., 2016). Such results underscore the importance of provider training and the critical role of the primary care psychologist in educating primary care team in interviewing styles, assessment skills, and eliciting patient engagement. Additionally, the psychologist can also guide the development and implementation of depression and anxiety screening, as well as a stepped care intervention program grounded in the principles of CBT. Once a health care provider has diagnosed a patient with depression or anxiety, the practitioner is tasked with recommending a plan of care. Adopting a stepped care model allows a practitioner to develop interventions tailored to the patient’s symptom severity. Stepped care approaches for depression, for example, have been applied in primary care with diverse patient populations (Franx et al., 2012). The approach has shown promise for improving patient well-being and reducing health care costs. Utilizing this approach, low-intensity interventions are offered to patients who exhibit subthreshold and mild depression. Psychoeducation, self-help, counseling, physical exercise, problem-solving treatment, and watchful waiting are examples of appropriate interventions during this phase of treatment. More intensive treatment interventions are offered to patients who exhibit more significant symptoms. Antidepressants, psychotherapy, and self-management strategies are examples of interventions for severe and chronic cases of depression. A critical component of the stepped care approach is the monitoring of patient progress to recognize when it is necessary to transition to a more intensive treatment. This practice model, however, has not been achieved, as evidenced by high antidepressant prescription rates unrelated to symptom severity. In addition, cost-effective alternatives for patients with mild depression are still underutilized. CBT Outcomes Within a Stepped Care Approach Time, resources, and ease of delivery are factors that can shape the success of implementing intervention programs. CBT is congruent with a stepped care approach, as evidenced by various cognitive behavioral interventions that have been adapted for use in the primary care setting (Franx et al., 2012). These include guided self-help programs, telephone and internet-based interventions, activity scheduling interventions, psychoeducation, and brief one-to-one CBT protocols (Eriksson et al., 2017; Newby et al., 2017; A. D. Williams & Andrews, 2013). Multimodal CBT for symptoms of depression and anxiety have revealed a continuum of effect sizes, ranging from small to medium. A meta-analysis of cognitive behavioral focused randomized controlled trials (RCTs) delivered in



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primary care revealed that multimodal CBT was more effective than no primary care treatment and primary care treatment as usual (TAU) for anxiety and depression symptoms (Twomey et al., 2015). Furthermore, multimodal CBT in addition to primary care TAU was shown to be more effective than primary care TAU for depression symptoms. Specifically, when implementing multimodal CBT versus primary care TAU for anxiety in three RCTs, CBT was found to be more effective than primary care TAU, yielding an effect size of d = 0.46. With respect to depressive symptoms, CBT was compared with primary care TAU in 11 RCTs and was found to be more effective than primary care TAU, yielding an effect size of d = 0.47. In addition to short-term remission of symptoms, long-term stabilization and improvement in mood symptoms are other areas of concern. In a long-term follow-up of an RCT, Wiles et al. (2016) examined the clinical and costeffectiveness of CBT as an adjunct to usual care that included medication over 3 to 5 years in primary care patients with treatment-resistant depression. CBT as an adjunct to usual care that includes antidepressants was clinically effective and cost effective over the long term for individuals whose depression had not responded to pharmacotherapy. Utilizing data from 6-, 12-, and 46-month intervals, individuals in the intervention group had a mean Beck Depression Inventory-II (BDI-II; Beck et al., 1996) score approximately 4.7 points lower over 46 months compared with those individuals in the usual care group. This translated to an effect size of 0.45. A beneficial effect of the intervention was revealed for all secondary outcomes as individuals in the intervention group were more likely to experience remission (BDI-II score < 10), a reduction in anxiety (GAD-7), and greater improvement on the SF-12 mental health subscale over the 46 months compared with those in the usual care group. The above-described findings support the use of CBT to address depression and anxiety in the primary care setting. Consistent with a stepped care approach, the health care practitioner’s choice of interventions will rest upon symptom severity and the most suitable method of delivery. Telephone CBT for Depression If treatment is inadequate or delayed, mild-to-moderate depressive episodes may develop into chronic or more severe forms of depression (Trautmann & Beesdo-Baum, 2017). The identification and delivery of timely and adequate forms of treatment are then crucial (Trautmann & Beesdo-Baum, 2017). The landscape of treatment for mild-to-moderate depression has been changing with the emergence of telephone psychotherapy. Provided as an adjunct to antidepressant treatment for adults in primary care, it has demonstrated utility and efficacy. Telephone psychotherapy has and continues to be examined as an adjunct to TAU in primary care as well as a stand-alone treatment in specialty care. In one clinical trial, researchers enrolled 30 adults, with a majority of the participants reporting high satisfaction with the eight-session CBT telephone treatment and significant reduction in depression severity over 3 to 6 months. At termination, 42% of the participants were considered recovered. Components

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of the program included BA, cognitive restructuring, psychoeducation, and relapse prevention. Symptom monitoring was achieved through the administration of the PHQ-9 depression screen. This telephonic method of program delivery allows for increasing convenience if patients face challenges in attending face-to-face sessions. Behavioral Activation Optimal utilization of resources is a critical component in a primary care depression intervention program. At times, a primary care psychologist may be unavailable or simply unable to service large numbers of patients. As improvement in less severe forms of depression may be achieved with less complex protocols, the psychologist may consider educating other providers or trainees in interventions such as BA. If the practice is situated within an educational institution, the treatment team may consist of a variety of health care providers, including physicians, physician assistants, nurses, social workers, and trainees. A qualitative study that focused on participant views on the impact of BA delivered by junior mental health workers versus CBT delivered by professional psychotherapists revealed that participants perceived specific factors associated with BA and CBT as crucial. Behavioral change was considered important for participants receiving the BA intervention. Cognitive change and behavioral change were considered critical for those receiving the CBT intervention. Experiencing a positive impact on symptoms of depression and working on relapse prevention were also identified as critical elements of the program (Finning et al., 2017). Another RCT targeting late life depression consisted of eight weekly 30-minute BA sessions delivered by a trained mental health nurse. BA delivered by a variety of providers, such as nurses, social workers, and trainees could increase the availability and accessibility of nonpharmacological treatments for depression in primary care (Janssen et al., 2017). Care management programs as a method for delivering a BA intervention have also been examined. In an RCT, “collaborative care” BA was the principal treatment compared with TAU for older adults with subclinical depressive symptoms. The study found a small-to-medium effect size of collaborative care on depressive symptoms compared with TAU (Gilbody et al., 2017). Thus, although BA may be focused upon behavioral change versus cognitive change, it seems to hold promise as a stand-alone intervention that can target problem areas of depression, such as rumination and avoidance (Sudak et al., 2014). CBT and Mindfulness Group Intervention In addition to telephone and individual face-to-face CBT interventions, primary care group interventions allow for increased patient access to behavioral health services in a cost-effective manner. Group interventions may also provide patient accountability with respect to treatment adherence within the context of peer support, thus decreasing isolation. Craner et al. (2016) implemented and evaluated a 6-session cognitive behavioral and mindfulness group for patients with a variety of mood and anxiety concerns. Generalized anxiety dis-



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order and MDD were the most common prevalent behavioral health disorders represented in the sample of participants. The format consisted of two sessions focusing upon mindfulness-based interventions, two sessions focusing on cognitive reframing, and two sessions dedicated to behavioral strategies (i.e., BA and exposure therapy). Reinforcement and consolidation of skills were addressed through between-session exercises. When pretreatment and posttreatment self-report assessment measures were compared, significant improvements in depression and anxiety were reported by participants following engagement in the group intervention. The reported large effect sizes (d = 0.81) point to the possible benefits of increased access and cost effectiveness of evidence-based group interventions in the primary care setting. Poor Adherence, Severe Depression, and Transition to a Higher Level of Care Although primary health care providers shoulder the major responsibility for treating depression, research is needed to examine the continuity of pharmacological and psychosocial treatments offered and patient attitudes of and adherence to their treatment in this setting. Results from the Vantaa primary care depression study highlight the problems encountered with adherence (Vuorilehto et al., 2016). A total of 100 patients with MDD or partly remitted MDD were prospectively followed up to 18 months. Treatment contacts and the treatments provided were followed longitudinally. Antidepressant treatment was offered to 82% of patients, and only 50% initiated treatment and adhered to it as prescribed. Psychosocial support was offered to 49%, and 29% adhered to the interventions. Reasons for poor adherence included negative attitude, concern regarding side effects, practical obstacles, or no perceived need for treatment. A lack of systematic follow-up was also identified. Approximately 23% of patients were referred to specialized care at some time-point. As previously discussed, untreated or inadequately treated depression may develop into a chronic condition. Symptoms could progress into the moderately severe or severe range, thus requiring more intensive treatment. In addition, in the primary care setting, a subset of the patient population will represent those individuals with chronic psychiatric disorders and histories. Whereas some patients present with symptoms that can be addressed within the primary care setting, others will require a referral to more intensive behavioral health services. Regardless of the presenting symptom severity, the treatment team is tasked with engaging the patient in a collaborative treatment planning process. When nonadherence is a potential threat to the success of the treatment intervention, applying a cognitive behavioral case conceptualization can be useful for all providers involved in the patient’s care. Specifically, patients can be encouraged to examine their beliefs regarding behavioral health disorders and treatment options. In the process of examination, patients can be assisted in identifying cognitive distortions which prevent them from addressing their behavioral health issues. In the case of referral to a more intensive treatment modality, cognitive behavioral interventions may be utilized to help the patient

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move toward accessing and accepting a referral to a clinically indicated level of care. These treatment options may include referral to a psychiatrist, an outpatient behavioral health practice, an intensive outpatient program, or a partial hospitalization program. Special Populations In designing and implementing depression and anxiety intervention programs within primary care practice, the needs of special populations must be considered. This includes but is not limited to adapting materials, format, and content to individuals with sensory and cognitive impairments. Modifying materials for use by the visually and/or hearing impaired is critical to the delivery of effective intervention. In addition, as primary care providers encounter patients with acquired brain injuries, the primary care psychologist can assist in developing CBT protocols that address the potential cognitive challenges of such patients. Clinical Example Mary was a 55-year-old married woman employed as a project manager and residing with her spouse of 25 years. Mary’s PCP referred her for a psychology consultation after she screened positive for depression during an office visit. The patient complained of weight gain, depression, and fatigue. Her initial PHQ-9 depression screen score (12) suggested moderate symptoms of depression. In addition, over the past few years her body mass index (BMI) had climbed from 25 to 27, and her blood pressure readings indicated prehypertension. Mary was also entering menopause. As previously discussed, comorbid depression has been shown to be predictive of poor adherence to health behaviors and disease progression. In addition, if left untreated, mild-to-moderate depressive episodes may develop into a more severe form of a depressive disorder requiring more intensive treatment (Trautmann & Beesdo-Baum, 2017). The patient’s age, menopausal status, depression, weight gain, and prehypertension also placed her at an increased risk for an adverse cardiovascular event (Guck et al., 2003; Rutledge et al., 2009). Mary was offered the opportunity to participate in brief behavioral health services within the primary care practice. During the initial consultation, Mary explained that she observed herself withdrawing from activities since her younger brother had died of an aggressive form of cancer 3 years prior. Mary reported losing motivation for exercising and becoming less attentive to her eating habits. She identified wanting to address her prehypertension through lifestyle changes and her depression through “talk therapy.” She reported continuing to satisfactorily meet her work obligations, but with less enthusiasm. She commented, “I am waiting to feel motivated, but the motivation does not come.” The primary care psychologist informed Mary of the brief scope of behavioral health services within the primary care practice. In addition, psychoeducation regarding the cognitive behavioral model was shared, and Mary



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agreed to participate. Although BA can be used as a standalone intervention (Sudak et al., 2014), the primary care psychologist incorporated it as one element of a more comprehensive cognitive behavioral case conceptualization and protocol. During Mary’s 8-session course of treatment, the primary care psychologist introduced activity scheduling to address Mary’s depression and her health-related behaviors. An important dimension of BA strategies consists of the patient identifying activities that are meaningful and consistent with the patient’s values. The underlying rationale is that patients may be more likely to engage in meaningful activities of choice in comparison to those suggested by the clinician. The following vignette illustrates how the primary care psychologist guided Mary in clarifying her values and in identifying meaningful activities that reflected her values. PSYCHOLOGIST: You’ve been feeling disappointed in yourself. MARY:

Yes, I have. I thought that at this point in my life, with my son going off to college, I would have more time to do things I enjoy.

PSYCHOLOGIST: You pictured yourself doing more. MARY:

I did, but instead of doing more, I am doing less.

PSYCHOLOGIST: If you were more active and less depressed, what kinds of

things would you be doing? MARY:

Well, up until 3 years ago, I had been enjoying exercising. I loved singing as a member of the church choir. After my brother died, I thought of volunteering with the American Cancer Society. [sighs] Now, I come home from work, barely eat a meal, and sit in front of the television for most of the night. My husband has noticed the change in me.

PSYCHOLOGIST: You’re not doing the things you once enjoyed, and your hus-

band has noticed. I would like to help you sort this out. May I suggest something? MARY:

Yes. Please, I want to hear your suggestions.

PSYCHOLOGIST: We had talked about how waiting to be motivated doesn’t

help alleviate depression but that we need to first start the activity and that will help improve motivation. MARY:

I agree with you. But it’s hard for me to get started.

PSYCHOLOGIST: There are ways I can help you get started. Before planning

any activity, it’s important to have a clear idea of what you value the most. I would like to help you pinpoint which activities are most meaningful to you. MARY:

Okay.

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In completing a values rating sheet, Mary identified four important domains in her life. These domains included physical health, family, community volunteering, and spirituality. The next task was to construct an activities list corresponding with each value area. Mary identified that walking at least three times a week would improve her physical health. In the realm of community/civic involvement, she identified volunteering for the American Cancer Society and noted that by volunteering she would be honoring a family member, her departed brother. Last, she identified that her previous participation in a gospel choir and listening to gospel music enriched her spiritual life. As they reviewed an activity planning worksheet, Mary and her psychologist discussed the importance of planning an activity that she would complete. In the spirit of collaboration, Mary was encouraged to choose the activity and to describe the circumstances that would increase the likelihood that she would engage in the activity. PSYCHOLOGIST: So Mary, you’ve listed that attending a gospel concert is very

important to you. MARY:

I’ve wanted to hear this choir for a long time. They’re performing at our local theater in 2 weeks. My nephew works at the theater, and he can get me tickets.

PSYCHOLOGIST: You sound excited. MARY:

I’m excited but a little nervous. [sighs] My husband doesn’t like gospel music. So I may have to go alone. I can do that, but it just makes me a little nervous.

PSYCHOLOGIST: Okay. So you feel a little nervous and excited. Think of a time

when you were nervous and still looking forward to an activity. MARY:

[pauses] I remember my first time performing with the choir. I was so excited but really nervous, thinking I would mess up and my choir members would be mad at me.

PSYCHOLOGIST: What happened? MARY:

I had butterflies in my stomach, and I was shaking a little. [laughs nervously] When it was over I was so glad that I had performed. The music and singing just lifted my spirits. I can’t describe it. I just know it was a wonderful experience for me.

PSYCHOLOGIST: So you can be excited and nervous and still enjoy yourself.

Seems like it was worth it. MARY:

It was worth it. I made a few small mistakes but no one noticed.

PSYCHOLOGIST: What would help you follow through with attending this

concert?



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MARY:

[pauses] Today, when I get home, I’ll text my nephew and ask him to put aside a ticket for me. I’ll tell him I want to have lunch with him before the concert. If I make a date with him, I won’t stand him up. He is my brother’s son. It’s important that I spend time with him.

PSYCHOLOGIST: I’m glad you’ve decided upon something which has such a

special meaning for you. I’ll look forward to hearing about it. In a follow-up session, Mary reported having attended the gospel concert. In reviewing her activity planning worksheet, she identified the concert activity as completed and described her corresponding mood as “uplifted.” As she continued attending the remaining therapy sessions, Mary expressed increased interest in scheduling activities as well as episodes of ambivalence. The primary care psychologist introduced a pleasure predicting worksheet. This tool allowed the patient to identify and schedule activities with potential for pleasure and feelings of mastery in addition to rating predicted satisfaction compared with actual satisfaction upon completion. After attending 8 sessions, Mary endorsed fewer items on the PHQ-9 depression screen, resulting in a lower score suggesting mild depression. She requested periodic booster sessions and subsequently attended follow-up visits at 30, 60, and 90 days, respectively. During her last visit, Mary denied any symptoms of depression.

SUBSTANCE DISORDERS IN PRIMARY CARE Cognitive behavioral therapists have much to offer in the realm of substance disorders including tobacco, alcohol, and illicit drug use. Tobacco Use The Centers for Disease Control and Prevention (CDC, 2014) identified tobacco use as the preventable behavior most strongly associated with mortality in the United States, accounting for 480,000 deaths annually. In addition to causing cancer and lung disease, smokers are at higher risk of cardiovascular disease, strokes, and pregnancy complications that include low birth weight, stillbirth, and preterm delivery. The NCQA recommends tobacco use screening and cessation counseling for all primary care patients over the age of 18 (CMS, 2016). Some research, however, indicates that PCPs may provide less tobacco cessation than recommended given patient readiness level to quit (El-Shahawy et al., 2016), emphasizing the importance of psychologist-guided interventions. Evidence-based CBT approaches to tobacco cessation that can be implemented in primary care settings include motivational enhancement, anticipatory planning, environmental management strategies, social support, and behavioral contracting (Manske et al., 2004; Web Hooper et al., 2017; Wray et al., 2017). In a four- to eight-session CBT protocol, early sessions would

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build motivation by considering reasons for change, examine tobacco use history and previous quit attempts, offer health education related to nicotine addiction and withdrawal, and begin setting goals. Once motivation for cessation or reduction has been established, treatment would progress to coping skills training, stress management, and cognitive restructuring around irrational or maladaptive thoughts associated with quitting or withdrawal (e.g., “If I don’t smoke, I’ll go crazy”). In terms of coping skills acquisition, the therapist may offer in-session training for controlled breathing or other relaxation skills, review thought-stopping techniques related to intrusive thoughts about smoking, and develop pleasant event activity schedules to reduce depression or anxiety. In later sessions, the therapist would help patients develop a quit plan that identifies high-risk situations, relapse prevention strategies, and ways of responding to lapses. Treatment may include developing a plan for managing cravings and appetite changes while planning positive substitute behaviors, such as exercise and healthy food choices. Potentially most beneficial in middle to later sessions, behavioral contracts could involve mutually agreed-upon reductions in tobacco use as the patient moves toward a quit date. Some patients have experienced cessation success with CBT augmented by pharmacotherapy (e.g., nicotine patch, gum), including populations with high rates of psychiatric comorbidity (Loreto et al., 2017; Webb et al., 2010). Interventions that combine behavioral and pharmacotherapy increase cessation by 82% and are nearly twice as effective as minimal intervention or usual care (risk ratio = 1.82; Patnode et al., 2015). CBT has sometimes, but not always, outperformed health education (Mitali et al., 2014; Webb et al., 2010). CBT that incorporates motivational enhancement and attention to the stages of change in youth have led to moderate success in terms of 30-day and 6-month abstinence rates, with an estimated 1.5 times greater effectiveness than comparison groups (Stanton & Grimshaw, 2013). When presented in a group modality and with culturally sensitive adaptations, CBT has led to 7-day point prevalent abstinence at a rate of 50%, exceeding general health education in effect size by 2.5 times (OR = 2.57; Webb et al., 2010). The feasibility of implementing group formats in primary care requires further investigation; however, it is clear that relying on brief interventions delivered by psychologists in IPC for tobacco use presents a common, effective, and important target for CBT. Alcohol Use Unhealthy alcohol use represents another leading cause of death in the United States (Kochanek et al., 2016). Primary care is an optimal point for screening for alcohol disorders and risky drinking with the 10-question Alcohol Use Disorders Identification Test (AUDIT; Babor & Grant, 1989). Brief behavioral interventions with more than two contacts between 5 and 15 minutes show effectiveness in reducing episodes of heavy drinking, probability of drinkingrelated injury, and amount of drinking to recommended limits (Moyer, 2013). Health improvements from brief interventions delivered by PCPs have included



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improved blood pressure where moderate drinkers were 7 to 17 times more likely than controls to have their blood pressure controlled at 18 months following the intervention (OR = 7.1, 17.6; Chi et al., 2017). Common components amenable to delivery in IPC are education about risky drinking, motivational interviewing (MI), feedback on drinking behavior and effects, self-monitoring in the form of alcohol consumption diaries, self-help exercises, and problem solving (Jonas & Garbutt, 2017). Problem solving involves the identification of specific triggers (e.g., passing a bar, feeling depressed) related to the urge to drink. The therapist would work with the patient in developing strategies for avoiding triggers or managing negative emotions that can prompt drinking, which may include exercise or other positive activities. Combining technology, education, self-monitoring, and BA represents a promising, novel way to address problem drinking in IPC. As an example, participants in alcohol treatment who were provided digital fitness trackers reported that physical activity helped them successfully cope with urges to drink (Abrantes et al., 2017). Intervention delivery through mobile apps is also a promising direction for reducing excessive alcohol consumption (Gajecki et al., 2017). Structuring CBT alcohol use interventions in a stepped approach may prove efficient and cost-effective in IPC, fitting well within the rapid pace of practices. In one recent example of this approach developed by Coulton et al. (2017), all patients who screened positive with the AUDIT received 20 minutes of behavior change counseling based in MI (Step 1). If, after 4 weeks, the patient still engaged in risky drinking, they would receive a referral to three 40-minute sessions of motivational enhancement, which involved feedback on use delivered in an MI-consistent manner (Step 2). If hazardous drinking continued after Step 2, a referral to specialty alcohol treatment services was made (Step 3). Stepped approaches have shown small but significant effects in reducing drinking at 6 and 12 months postintervention and increasing motivation to change, with lower costs compared with other interventions (Drummond et al., 2009; Watson et al., 2013). Illicit Substance Use Only 10% of people who met the criteria for substance use disorder in 2016 received treatment, but 29% of those who did pursue treatment did so in nonspecialty settings, which include primary care (Park-Lee et al., 2017). The low rate of treatment engagement among those who met criteria and the significant number of diagnosed individuals who accessed care through nonspecialty settings suggests that primary care may serve as a valuable point of screening and intervention. MI-based counseling interventions are more common than CBT interventions in primary care (Shapiro et al., 2013) and exert a small effect size on outcomes (VanBuskirk & Wetherell, 2014). One multicomponent intervention for psychoactive drug use that combined CBT, MI, and health education was associated with fewer days of self-reported use relative to controls (Gelberg

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et al., 2015). Evidence is mixed as to whether CBT is effective in augmenting medical opioid dependence treatment in primary care. One study found that patients using opioids who attended a 12-session CBT protocol combined with physician management experienced twice as many weeks of abstinence on average as those who participated in physician management alone, with an effect size in the small-to-medium range (Moore et al., 2016). An earlier study with the same design showed no difference between conditions (Fiellin et al., 2013). The role of CBT in treating illicit drug abuse or dependence may be limited by the brief courses of treatment offered in primary care, resulting in a predominant reliance on motivational interventions to facilitate engagement in more intensive services. More research is needed to specify whether some of the CBT approaches that have been utilized for alcohol use treatment could generalize to other substances (e.g., marijuana, opioids, cocaine). Another common problem in primary care is obesity.

WEIGHT MANAGEMENT IN PRIMARY CARE Obesity (BMI ≥ 30 kg/m2) is one of the most common health issues seen in patients presenting to primary care settings (Stecker & Sparks, 2006). Obesity increases the risk of developing comorbid conditions, including hypertension and Type 2 diabetes, and obesity-related conditions comprise many of the leading causes of premature mortality, such as cardiovascular disease and certain cancers (Friedman & Andrus, 2012; Heron, 2013; Kahn et al., 2006). In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care providers screen all adults for obesity and provide or refer patients to intensive behavioral counseling (or as they are also referred, “comprehensive lifestyle” interventions; Moyer, 2012). These recommendations suggest that patients follow a reduced calorie diet (≥ 500 kcal/day), engage in physical activity, and adopt behavioral strategies to achieve these goals (LeBlanc et al., 2011; Moyer, 2012; Wadden et al., 2014). Additionally, in 2011, CMS began to reimburse primary care providers for delivering behavioral therapy for obesity (CMS, 2012), opening the door to greater access to this treatment within primary care. However, PCPs can encounter challenges administering behavioral treatment given the significant time required to treat this condition (Roberts et al., 2015). Psychologists and other mental health providers, however, are increasingly embedded in primary care and can address behavioral concerns, including obesity. The Society for Behavioral Medicine (SBM), a multidisciplinary organization dedicated to the science of behavior change, provides an evidence-based framework for delivering behavioral obesity treatment in adults seen in primary care, known as the “5 As” (Assess, Advise, Agree, Assist, Arrange; Fitzpatrick et al., 2016). The first step, “Assess,” includes screening for obesity, the identification of comorbidities that can impede weight loss efforts (i.e., binge



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eating, sleep disorders, depression, and chronic pain), and assessment of the patient’s readiness to begin behavior change (Fitzpatrick et al., 2016). During Step 2, “Advise,” providers counsel patients regarding the health risks associated with obesity and the improvements in health (i.e., cardiovascular, glycemic control) associated with even modest reductions in weight (Fitzpatrick et al., 2016; Look AHEAD Research Group & Wing, 2010). In Step 3, “Agree,” providers and patients collaboratively set SMART goals (Specific, Measurable, Attainable, Relevant, and Time-based). A weight loss goal of 5% to 10% (over 3 to 6 months) is recommended (Fitzpatrick et al., 2016). “Assist,” Step 4, collaboratively identifies barriers to goal attainment and employs problem solving to overcome these barriers. Finally, Step 5, “Arrange,” comprises regular follow-up visits to monitor progress and help patients to achieve their goals. Efficacy Generally, behavioral and cognitive behavioral interventions for adults with obesity result in weight losses of 5% to 10% of initial body weight over 3 to 6 months, as well as reductions in the risk for obesity-related conditions, including Type 2 diabetes and cardiovascular disease, and improvements in glucose control, cholesterol levels, and blood pressure (Fitzpatrick et al., 2016; Knowler et al., 2002; Look AHEAD Research Group & Wing, 2010; Wadden et al., 2007, 2003, 2012). A meta-analysis by Franz et al. (2007) of diet and exercise-based weight loss studies reported an average effect size of Hedges’s g = 0.82 at 12 months. However, even small reductions in weight (5%) can result in clinically meaningful improvements in health. Evidence-Based Interventions in Adults Behavioral treatment for obesity is founded on the principles of conditioning and learning theories. Specifically, eating behaviors are triggered by internal or external cues (antecedents) that become associated with eating or drinking (Foster et al., 2005). Treatment helps individuals to identify these cues and develop more adaptive responses, and to learn to positively reward the practice of healthier responses (Brownell & LEARN Education Center, 2000; Foster et al., 2005). Adults living with obesity are encouraged to achieve healthier weights using a multifaceted behavior change approach. Self-monitoring of dietary intake via food and beverage logs, caloric restriction and increases in physical activity to promote a negative energy balance, goal setting, and behavior change strategies (i.e., skill acquisition, cognitive restructuring, and problem solving) are common elements of behavioral weight loss programs (Butryn et al., 2011; Cooper et al., 2003; Foster et al., 2005). Calorie recommendations generally range from 1,200 to 1,500 kcal/day in adult women to 1,500 to 1,800 kcal/day in men but can vary depending on individual BMI and weight-loss goals. Several evidence-based, behavioral or cognitive behavioral treatments are available to manage obesity in adults. The LEARN® Program for Weight

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Management 2000 (Lifestyle, Education, Attitudes, Relationships, Nutrition), developed by Kelly D. Brownell, PhD, (Brownell & LEARN Education Center, 2000), comprises 16 weeks of modules designed to promote healthy lifestyles, weight reduction, and weight loss maintenance in the context of calorie counting and self-monitoring of intake through food logs. The LEARN program emphasizes goal setting, recognition of hunger and satiety signals, slow and mindful eating strategies, stimulus control, planning, estimation of portion sizes, problem solving, and regular weigh-ins. The expected mean weight reduction from the LEARN program at 6 months is approximately 3.0 kg, or 6.6 lb (Gardner et al., 2007), and this program has been implemented in primary care (Wadden et al., 2001; Wadden et al., 1997). Cooper et al.’s (2003) 9-module obesity treatment program, CognitiveBehavioral Treatment of Obesity focuses on setting weight and calorie goals, addressing overeating and barriers to weight change, and promoting healthy eating and physical activity. Detailed weight loss maintenance techniques, as well as cognitive strategies for body image concerns, are also included (Cooper et al., 2003). In an RCT, participants lost 10% of their initial body weight after 24 weeks of treatment (Cooper et al., 2010). It is recommended that the modules that are most relevant to the patient’s goals be selected for maximum efficacy and efficiency when this program is utilized within primary care. Two similar, effective, and evidence-based lifestyle interventions for obesity and comorbidity risk reduction are noteworthy. The Look AHEAD (Action for Health in Diabetes) and Diabetes Prevention Program (DPP) curricula have been widely studied in health care settings (DPP Research Group, 2002; Look AHEAD Research Group & Wing, 2010; Wadden et al., 2006). Look AHEAD’s “intensive lifestyle intervention” (diet and physical activity modification) was designed to generate at least 7% body weight loss at 1 year and demonstrates promising results for up to 4 years after treatment (Look AHEAD Research Group & Wing, 2010). DPP lifestyle intervention goals are similar (7% weight loss/weight maintenance and physical activity), and DPP guides and materials are available from the CDC. Several new approaches to obesity treatment demonstrate promising potential. Acceptance-based behavioral therapies for obesity incorporate elements of standard behavioral treatment as well as the development of goals derived from personal values (Forman et al., 2016). In an RCT, acceptance-based obesity therapy resulted in significantly greater weight loss after 1 year compared with standard behavioral treatment (13.3% vs. 9.8%, respectively; Forman et al., 2016). Further, the delivery of weight loss treatment via technology (i.e., internet, telephone) has the potential to increase patient access to treatment while reducing the time and cost burden associated with delivering behavioral treatment in primary care (Bennett et al., 2010; McDoniel et al., 2010) Assessment Patients will benefit from regular weight checks at every primary care visit and should be encouraged to weigh themselves at home at least weekly. For most



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patients, a 1 to 2 lb weight loss per week is a reasonable goal in behavioral treatment. Patients may also benefit from completing the Weight and Lifestyle Inventory (WALI) at treatment initiation (Wadden & Foster, 2006), a comprehensive questionnaire assessing weight and dieting history, mood, stressors, eating behaviors, and physical activity. Special Considerations Patients with obesity of lower socioeconomic status (SES), racial and ethnic minorities, and certain comorbidities such as sleep disturbances, pain, Type 2 diabetes, depression, and binge eating disorder may experience greater challenges achieving their goals during behavioral weight loss treatment (Fitzpatrick et al., 2016). Efforts to tailor treatment to the needs of these populations will help to maximize success. Additionally, patients with a history of eating disorders with restrictive or binge and purge features (i.e., anorexia, bulimia) may require referral to other treatment modalities for obesity. For patients with severe obesity, small changes to the primary care office, such as wider chairs, larger gowns, and scales that capture elevated weights, can help minimize patient discomfort during treatment. Finally, behavioral weight management in children and adolescents is typically family-based, with impressive efficacy up to 10 years posttreatment (Epstein et al., 2007, 1994). The American Academy of Pediatrics (AAP) recommends that PCPs treat obesity using an evidence-based, staged approach that begins with brief counseling, followed by incremental increases in intensity depending on the patient’s age and weight status (Barlow & the Expert Committee, 2007). Family-based behavioral treatments focus on self-monitoring, stimulus control, limiting high calorie foods and sugar-sweetened beverages, screen time, goal-setting, physical activity, sleep hygiene, and relapse management, with calorie intake targets dependent on the child’s weight and age. The American Academy of Family Physicians (AAFP, 2019) published guidelines for providers to utilize when working with obesity in children and adolescents (https://www.AAFP.org). In summary, empirically supported, effective cognitive behavioral interventions for obesity, in both children and adults, are available to clinicians based in primary care. A multidisciplinary approach to obesity treatment in primary care that includes cognitive behavioral treatments can help patients to lose clinically meaningful amounts of weight, as well as to improve their quality of life and overall health.

CHRONIC PAIN IN PRIMARY CARE PCPs manage the majority of acute and chronic pain conditions. Pain is not only the number one reason patients seek medical attention, but also 80% of all medical visits involve complaints of pain (Institute of Medicine Committee on Advancing Pain Research, Care, and Education, 2011). Chronic noncancer

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pain impacts over 100 million Americans, contributing to $560 billion to $635 billion annually in direct treatment costs and lost productivity (Institute of Medicine Committee on Advancing Pain Research, Care, and Education, 2011). More American adults experience chronic pain than those affected by heart disease, cancer, and diabetes combined (National Center for Health Statistics, 2006). Given its detrimental impact on quality of life, employment/ occupational functioning, and mental health, it is one of the most challenging chronic diseases to treat in the primary care setting. PCPs feel inadequately prepared to handle the needs of this population due to lack of knowledge and specialized competency in pain management and addiction, time limitations, and lack of resources (Arnstein & St. Marie, 2010). Behavioral health providers are uniquely qualified to assist PCPs given their training in the biopsychosocial approach, which is clinically and economically efficacious in the management of chronic pain. Despite increasing awareness of the biomedical model’s limitations for treating chronic pain, there continues to be a rapid rise in rates of opioid therapy, injections, implantable devices, and surgeries. For example, in the treatment of back and neck pain there was a 220% increase in spinal fusion rates from 1999 to 2001, a 307% increase in lumbar MRIs from 1994 to 2005, and a 629% increase in expenditures for epidural spinal injections (ESI) with no evidence of concurrent improvements in outcomes or disability rates (Deyo et al., 2009). Moreover, with increased calls of alarm regarding the opioid epidemic, there is increased pressure upon PCPs to address the problem of opioid prescribing. In the United States, prescriptions of opioids for noncancer pain increased dramatically over the past 15 years (CDC, 2011), with no comparable decline in the degree of pain reported. Although the United States accounts for 4.6% of the global population, it accounts for 81% and 99%, respectively, of global consumption of oxycodone and hydrocodone. For every 100 Americans, there are 82.5 opioid prescriptions made by health care professionals (Paulozzi et al., 2014). Echoing mounting evidence demonstrating limited substantiated benefit from the biomedical approach, the Institute of Medicine Committee on Advancing Pain Research, Care, and Education (2011) called for a paradigm shift, urging the American health care system toward cultivation of an interdisciplinary perspective on pain management. The biopsychosocial model of chronic pain (Gatchel et al., 2007) aligns nicely with the universally adopted definition of pain published by the International Association for the Study of Pain (IASP) in 2004, describing pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” and emphasizing two key points. First, demonstrable evidence of tissue damage is not a necessary criterion for pain. In fact, for many chronic pain conditions there is an absence or minimal amount of tissue damage present. Second, there is a particular emphasis on the salience of psychological determinants of pain. As Merskey and Bogduk (1994) noted, pain “is unquestionably a sensation in part or parts of the body, but it is always unpleasant and therefore also an emotional experience” (p. 210). This definition recognizes that the interaction of psychological factors such as emotional states, cognitions, memories, and



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behaviors play a larger role in the maintenance of chronic pain than sensory factors alone. A vast body of literature demonstrates that psychosocial variables contribute to pain perception as much, or more so, than tissue pathophysiology. For example, in an investigation of workers with low back pain, psychological variables including depression, fear avoidance, and fear of movement predicted 85% of the variability in outcomes at the 6-month mark of the study, whereas the degree of tissue damage was a poor predictor (George & Beneciuk, 2015). Efficacy When evaluating the efficacy of CBT for chronic pain (CBT-CP), reviews of the literature and meta-analyses find small-to-moderate effect sizes (d = 0.2–0.5; Morley, 2011). CBT-CP adequately reduces pain catastrophizing and pain while improving physical and psychological functioning during and immediately following treatment; however, long-term outcomes remain unknown (A. C. Williams et al., 2012; Morley, 2011; Ostelo et al., 2005). The A. C. Williams et al. Cochrane review found that although CBT had statistically significant effects on pain, disability, mood, and catastrophizing when compared with wait-list controls, the effects sizes were small to moderate (d = 0.2–0.5). CBT-CP shows promise for specific types of pain. Meta-analyses support its efficacy for chronic back pain when compared with active controls in the domains of pain intensity (d = 0.15), pain interference (d = 0.09), and disability-working (d = 0.36; Hoffman et al., 2007). It also shows potential for the alleviation of headache (Andrasik, 2007), chronic orofacial pain (Aggarwal et al., 2011), arthritis pain (Astin et al., 2002; Knittle et al., 2010), fibromyalgia (Glombiewski et al., 2010), and lupus (Greco et al., 2004). Given the established efficacy of CBT-CP, A. C. Williams et al. noted that no further trials of CBT versus other treatments are needed; instead, research is needed to better understand the effects of CBT through identification of which components of CBT work for which type of patient on which outcome(s). Although there are some theoretical differences related to the role of cognitions, for the most part mindfulness-based interventions and acceptance and commitment therapy (ACT) are extensions of traditional CBT approaches and are increasingly incorporated into CBT-CP. In recent years, an increasing number of reviews and RCTs support the effectiveness of mindfulness-based interventions (Cherkin et al., 2016; Grossman et al., 2004) and ACT (Veehof et al., 2011) for chronic pain. CBT-CP is among the most efficacious for the management of chronic pain; has few, if any, side effects or complications; and is regarded as particularly cost-effective when considered side-by-side with biomedical approaches, which in most cases provide no greater benefit than psychological therapies. Evidence-Based Interventions in Adults CBT-CP is a front-line approach for the treatment of chronic pain with widespread application alone or in conjunction with other rehabilitative approaches.

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CBT-CP uses well-established behavioral and cognitive techniques to target feelings, beliefs, expectations, catastrophizing, self-efficacy, coping skills, fear avoidance, pain behaviors, and acceptance, as well as the social, interpersonal, cultural, and environmental factors that impact the experience of a person with chronic pain. Several CBT-CP protocols and manuals (Murphy et al., 2014; Otis, 2007; Thorn, 2017) are considered gold-standard approaches. On average, CBT-CP is eight to 10 sessions, but there is variability in research and clinical practice as to the number of sessions and specific techniques included in a treatment “package.” Hence, CBT-CP can be adapted to 5 or 6 sessions for IPC. Additionally, CBT-CP is being adapted to include components of mindfulness and acceptance-based strategies (McCracken & Vowles, 2014; Veehof et al., 2011), physical activity goal setting, and behavioral sleep medicine.

Assessment At the start of treatment, patients benefit from a thorough assessment of medical, psychiatric, and substance abuse history; lab work/urine drug screens; assessment of compliance with medical care and current usage of pharmacotherapy; family/social history; pain description and ratings; observation of pain behaviors; pain treatment history; coping strategies for pain; gaining a thorough understanding of how pain impacts mood and physical functioning; assessment of degree of impairment in work/school, family, lifestyle (e.g., sleep, weight, exercise), and social/emotional functioning; and legal history/disability claims. Commonly used assessment measures include (a) the BDI-II and PHQ for depressive symptoms; (b) Pain Catastrophizing Scale (PCS; Sullivan et al., 1995) for rumination, helplessness, and magnification about pain; and (c) West Haven-Yale Multidimensional Pain Inventory-Interference Subscale (WHYMPI/ MPI-INT; Kerns et al., 1985), Brief Pain Inventory (BPI; Cleeland, 1991), and Pain Outcomes Questionnaire (Clark et al., 2003) for pain interference in psychosocial and physical activities. Weekly CBT sessions, structured at-home practice assignments, problem solving, and motivational enhancement are beneficial throughout the course of treatment.

Special Considerations Pain remains undertreated and underdiagnosed, especially in disadvantaged and underserved populations. CBT-CP has the potential to improve access and quality of pain care, given the relative ease with which this approach can be adapted to subsets/special populations. CBT-CP has been effectively tailored to treat children/adolescents, older adults, low-literacy adults in rural areas, and adults with neurological conditions (for review, see Ehde et al., 2014). Addressing the pain needs of diverse populations in a stepped care approach (primary care, secondary, and tertiary) is critical to effectively address the opioid crisis and subsequent costs associated with chronic pain and opioid use disorders. With increasing awareness and evidence that specific psychosocial factors (e.g.,



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depression, catastrophizing, and fear-avoidance) play a significant role in the risk of progression from acute pain to chronic pain, there is also increased interest in CBT as a secondary prevention strategy. Interventions are needed to better support perioperative pain management as well as the utilization of brief screening measures in the primary care setting to identify and target individuals at high risk for chronic pain and opioid misuse and to stratify treatment options and intensity based on risk.

CONCLUSION The state of affairs in primary care psychology and CBT is currently quite encouraging. The application of CBT approaches is likely to offer both efficient and effective models for assessing and treating patients experiencing a variety of problem in primary care. Although it is certainly not the only available evidence-based approach, it is one that offers a number of unique advantages to physicians, psychologist and patients. The primary care cognitive behavioral psychologist is likely to play a key role in shaping the delivery of services from an empirically based perspective. Yet there is need for further research in the primary care setting to establish the utility of this model in addressing what appear to be overwhelming demands made upon the PCP. The CBT model fits well within the prevailing paradigm of primary care by focusing on constructs that are most likely to inform our understanding of how thoughts, feeling, beliefs, assumptions, and behaviors are reflected in the presenting health problems of patients. The basic elements of the CBT model are deeply embedded within the tenets of primary care, including continuity of care, comprehensives of care, a psychosocial focus, patient education, and empiricism. We await further adaptations, testing, and validation of the basic CBT model in effecting change in the primary care setting and its patients.

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18 Cognitive Behavioral Therapy for Inpatient Wards Aaron P. Brinen

Michael wakes up in a room and starts reconstructing the previous evening’s events. He had been feeling unwell the night before and stayed in his room to protect his family. His mother became concerned, as this was a familiar pattern and had previously led to Michael acting unpredictably. As the crisis team arrived, Michael reacted to the violation of his home with frustration and threats. By the time he arrived in the emergency department, he was completely distraught and yelling about the situation. A doctor ordered medicine to “help” him feel better, and that is Michael’s last clear memory. Now he finds himself in a hospital gown, and his belongings are nowhere to be found. As he takes in the setting, he recognizes the hallway outside. He has been to this inpatient psychiatric ward before . . . many times before. Michael feels his chest sink with embarrassment. He knows that he will spend the next 3 to 14 days in “groups” and the doctor will meet with him for a few minutes each day to “fix” his medicines. The sinking feeling grows as he remembers this routine: medicine, group, and so-called recreation. A whisper in the back of his mind grows: “This isn’t going to help . . . it never helps.” He sits on the edge of the bed as the door opens.

M

ichael’s experience is not rare.1 Many individuals become stuck in a cycle of hospitalization, discharge, decompensation, and a return to hospitalization. They are greeted with comments like, “Oh Michael, back again? I thought last time was the last time.” Inpatient treatment has a long history, but instead of considering where the treatment occurs (i.e., acute inpatient hospital) one should focus on what the treatment entails (i.e., strategies, interventions). This chapter will define the objectives of inpatient treatment, review research of tailored cognitive behavioral therapy (CBT) programs and propose a new model of integration of CBT and inpatient treatment. Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000219-018 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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The National Mental Health Services Survey (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018) investigated what services were offered across inpatient hospitals and how individuals came to the treatment. They found that twice as many patients were hospitalized involuntarily (versus voluntarily), and three fifths of hospitals provided what was described as “individual therapy.” However, when examining what this therapy involved, the description contained a grouping of modalities, including groups, medicines, individual therapy, and CBT. A lack of definition and the current ubiquity of the term “CBT” makes this description of treatment difficult to understand. Clinically, observations of hospital programs claiming to “do CBT” often provided treatment that hardly resembled even a caricature of CBT. Even if CBT was offered with fidelity, the surveyors had no idea if the treatment addressed any real need of the individual, leaving cases like Michael floundering in the system. For example, providing Michael with 4 days of anger management because he was angry and out of control in the hospital misses the central problems leading to his becoming unwell. In this chapter, we consider a more focused application of CBT and consider innovative and intentional treatments. We discuss a future for CBT in inpatient treatment that is designed to reduce recidivism, start a trajectory of recovery, and, most importantly, lift up individuals like Michael, who are stuck in this demoralizing cycle.

GOAL OF ACUTE INPATIENT TREATMENT Before thinking about interventions, the provider should consider the purpose of inpatient treatment and develop a strategy to deliver individuals to that goal. As described previously, individuals can arrive at acute inpatient treatment involuntarily or voluntarily, with or without forensic involvement. The criteria for admission usually fall into three categories: danger to self, danger to others, and inability to care for self. Acute inpatient treatment is often described as being designed to be a short-term treatment, 3 to 14 days, although some patients stay much longer. The stated purpose of inpatient treatment is stabilization and safety. Let us return to Michael as an example: Michael was admitted to the hospital because he heard murmuring of agents who knew he was going to harm his family. The murmuring voices often sniggered at his attempts to avoid harming people and his isolation. In Michael’s frustration, he became hopeless and started contemplating whether the best way to protect those around him was to no longer be alive. He would stockpile the medicines he was given at the hospital as a means to accomplish that idea. His hopelessness related to having little strategy for stability besides “taking his medicines.” As the distress mounted, he felt more helpless, and the murmurs agreed with him that death would be the best solution for him. When his mother tried to help, he became distressed that she would get hurt by the murmuring people and interfere with his plans to protect others from the impending doom. Her questions of what he could do to feel better were met with desperate thoughts because the only solution, medicine, was no longer working.



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The case example of Michael is an illustration of how the therapeutic target of stabilization seems useful but, without a comprehensive strategy to realize that change, can quickly devolve into “fix the medicine,” and the intervention can accelerate a downward cycle of hospitalizations and demoralization. First, a comprehensive definition of stabilization must be developed to inform tasks and open opportunities for other interventions. Conceptually, the provider divides stabilization into specific tasks: 1. Stabilize of admission crisis: Identify the functional chain of thoughts, feelings, and behaviors that accelerated the crisis to the point of needing hospitalization. Halt the distress and change the pattern of behaving, thinking, and feeling that drove the individual to the hospital. 2. Increase mastery over symptoms: Use the immediate experiences from the stabilization to test the accuracy of the individual’s beliefs of being incompetent to handle the symptoms. Plan to continue these new routines and draw conclusions about the individual’s competence in relation to symptoms. 3. Develop plans for remaining in the community: Identify what will be the benefit of being in the community (aspirations) and then develop a plan to increase the likelihood of success maintaining in the community. 4. Identify methods for maintaining mastery of symptoms: Transfer specific learning developed in the hospital out into the world to increase a sense of mastery while out of the hospital. With the increased sense of mastery, the individual should feel less stress related to the symptoms. Through these separate, systematic tasks, the provider increases the likelihood of successful maintenance in the community and engagement in future treatment. The challenge with executing this strategy is that many inpatient providers limit the scope of treatment to stabilization as it relates to medication of symptoms. Without a comprehensive approach to stabilization, the individual can end up in a cycle of rehospitalization and demoralization. One solution is a comprehensive formulation and strategy of change based on a unifying treatment approach: CBT.

ROLE OF CBT CBT in the inpatient setting can serve an important role. At its core, CBT involves a comprehensive understanding of the presenting crisis and an intentional strategy for changing the underlying constellation of causal factors. CBT providers develop a structure for forward motion in recovery and maintenance of gains. However, to succeed, CBT must be focused on the core task of hospitalization versus broader attempts of more general clinical objectives. More importantly, the CBT provider can use the hospitalization experience as a learning opportunity to correct unhelpful or inaccurate beliefs and to problem solve previous obstacles.

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OVERVIEW OF CBT STRATEGY In CBT, the provider starts by identifying the thoughts, behaviors, and feelings through eliciting a specific situation when distress or a problem occurred. For hospitalized individuals, the starting point is the event that led to hospitalization. Many reports echo the same pattern: Stopped taking medicine—>Became unwell—>Decompensated—>Needed hospital

What these reports neglect is the precipitants, the areas of potential intervention, and the opportunities for prevention. A comprehensive understanding of the chain of events leading to hospitalization provides a menu of options for intervention that address the individual’s actual needs and develop new skills which reduce the likelihood of return. In Figure 18.1, many opportunities for intervention become obvious: isolation, worry, sleep. In relation to the perceived failure, the provider helps reframe the hospitalization as a learning opportunity and prevents a catastrophic interpretation. The principle strategy involves developing a new hypothesis about recovery being possible and systematic, rather than a game of luck or a miracle. This objective is accomplished through a behavioral testing of an individual’s beliefs that “nothing can help.” In lieu of complex, convoluted interventions, the provider uses simple interventions related to the events precipitating hospitalization to establish quick, palpable successes and an action plan to seek out other possibilities outside the hospital. Michael quickly fell into the normal routine of the unit, but something seemed different. He met with a clinician after breakfast on the first day. He had a kind demeanor and started to put Michael at ease. “Hey, Mike, it must be a bummer to be here again. I bet you’re ready for all those really annoying comments? Instead of a lecture about medicine and skills, what if we could figure this thing out a little? Maybe stack the deck so you’re less likely to end up in a place like this again?” Michael was interested. The provider continued, “Once you get out of here, what do you want to be doing? What do you want to get?” Michael was actually stumped for a moment and then explained what he was looking forward to: going to school, helping his mom, and dating. The provider asked some other questions about the aspirations (“Where would you go on a date?” and “What school?”) until Michael had a solid image of these hopes that had become unlikely, far-off memories versus goals. The provider asked if he could get on the team to start helping him to these new goals. Next, the provider said, “Can I get an idea of what happened? I want to see it the way you see it.” Michael tentatively told the story, but this clinician did not correct him; he asked questions, linked the evening’s events together, and seemed to understand. Then they extended the chain of events further back and started to make sense of how Michael became unwell. After summarizing the series of events, the clinician asked, “Do I have this right? I was wondering . . . if those murmurs didn’t bother you so much, would you have felt better or worse? Can we try some things to help with those murmurs?” Over the next week, they met and developed plans.

The provider aligns with Michael at first, and together they regroup after the crisis. Next, they refocus on Michael’s future and what would help. Finally, they plan to develop new routines and skills to retool Michael’s last approach.



Cognitive Behavioral Therapy for Inpatient Wards  593 FIGURE 18.1. Chain of Events Leading to Hospitalization Reduction of work shifts

Isolation in room

Reduced energy

Hear murmurs of voices

Worsening of voices

Increased frustration and hopelessness

Decreased sleep

Worry about dangers of voices

Increased isolation

Yelling at mother when she checks in

Increased voices

Crisis team called

INNOVATIVE COGNITIVE BEHAVIORAL TREATMENTS Some innovative treatments conducted in inpatient settings target mechanisms leading to hospitalization amongst various psychiatric presentations: suicidal behavior, psychosis, self-harm, and posttraumatic stress disorder (PTSD). CBT Programs Targeting Suicidal Behavior When someone is suicidal, their suicidal thoughts are interpreted catastrophically, and they start a process of overfocusing on the inevitability of suicide while neglecting other possible outcomes and solutions (Wenzel et al., 2009). Ghahramanlou-Holloway et al. (2020) adapted the cognitive therapy intervention for suicidal patients (Wenzel et al., 2009) into an inpatient application for service members with comorbid reactions to trauma—Post-Admission Cognitive Therapy (PACT). The protocol is currently undergoing a well-powered multisite trial to determine efficacy. In the pilot trial, they found reliable change in suicidal ideation (45% PACT, 33% enhanced usual care), even if the findings were not significant. Stanley and Brown (2011) developed a one-session intervention subsequently adapted to inpatient treatment that aims to modify the tunnel vision and neglect of other options, referred to as safety planning intervention (SPI). In SPI, the clinician and individual create a hierarchy of behaviors to occupy the individual’s attention in an attempt to wait out the suicidal urges. Additionally, they identify warning signs to alert when the plan is needed. The individual’s activities progress from those the individual might use alone (e.g., listening to music, coloring) to include others progressively, at first as distractions (e.g., calling family members to talk about movies) and, later, as helpers or supports to manage the suicidal crisis (e.g., informing about the crisis and applying skills together). During the SPI, the clinician and individual add new behaviors for distraction and concretely plan for the availability of these distractions (e.g., collecting a kit of the tools, alerting supports that they are included). Additionally, phone numbers and professional connections are collected to ensure successful accessing of supports when the individual is in a crisis and previous steps are unsuccessful. As the individual successfully uses the SPI and develops the plan, the impulsive and uncontrollable nature of suicidal ideation becomes suspect and therefore loses some of its power.

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CBT Programs for Psychosis CBTp Led by researchers and clinicians in the United Kingdom, cognitive behavioral therapy for psychosis (CBTp) has decades of research supporting its use. CBTp is an umbrella term that includes a range of protocols from broad, formulationdriven treatment to specific treatments that focus on a singular mechanism for action. CBTp approaches psychosis as an experience largely influenced by the individual’s thoughts, feelings, and behaviors. For example, hearing voices is not seen as problematic but rather the individual’s interpretation (or beliefs) of the voice as uncontrollable, of the resulting isolation, and of the subsequent increase in hallucinations (Beck et al., 2020). With this frame, any symptom returning an individual to the hospital is perceived as in their own control, versus an external locus of control, as is the case with medication. CBTp has been applied to inpatient treatment successfully and found to delay or prevent readmission in individuals with psychosis (Haddock et al., 1999; Lewis et al., 2002). Other studies applied a more targeted approach to CBTp, addressing self-esteem (Hall & Tarrier, 2003) and distressing voices (Mortan et al., 2011). Treatment was provided individually and in group format, but specifically adjusted to accomplish the task at hand in acute hospital settings. Recently, the work of Freeman et al. (2019) highlights easily targetable objectives (i.e., worry, sleep, self-esteem, avoidance) that can impact symptoms and increase functioning. These interventions can be easily adapted for application in the inpatient setting. Recovery-Oriented Cognitive Therapy Aaron T. Beck and colleagues at the University of Pennsylvania extended the application of CBTp to individuals least likely to engage in psychosocial treatments, those with negative symptoms (Beck et al., 2020). Recovery-oriented cognitive therapy (CT-R) was originally developed for outpatient treatment and found to have an effect on functioning, motivation, and positive symptoms. CT-R shifts the focus of treatment from remediation of problems to pursuit of an individual’s aspirations, as in the case example of Michael. Problems such as hallucinations, delusions, and self-injury are targeted as they obstruct progress toward the individual’s desired life. CT-R privileges the negative symptoms over positive symptoms and cognitive deficits due to them being a better predictor of an individual’s time spent in the community (Ahmed et al., 2016). Chang et al. (2014) implemented a CT-R training program on an inpatient ward and found effects on incidents of seclusions and restraints reduced by half during the 4-month training period, from 19 seclusions or restraints to seven. CT-R provides a unifying approach for all staff within the inpatient milieu, and the approach has been disseminated in long-term and short-term hospital settings. Acceptance and Commitment Therapy Bach and Hayes (2002) adapted acceptance and commitment therapy (ACT) for an inpatient application. They drew out two main components of ACT:



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(a) acceptance of distressing experiences and (b) taking action toward valued goals. This approach avoids any conflict over the reasons for the experiences and instead helps individuals note the distressing experiences and respond differently. In the place of discussions about symptoms and their management, the ACT provider identifies methods to take action toward valued goals. Individuals receiving ACT as opposed to treatment as usual were half as likely to be readmitted and were less distressed by experiences. This type of intervention goes directly to the core of stabilization, which is forward action posthospital and living a valued life. The intervention provides some guidance for more successful structuring of inpatient treatment. Mindfulness Interventions Mindfulness equips an individual to observe experiences instead of reacting to them. The distance from the experience allows for a flexibility in reaction, which can serve the individual after their hospital stay. Of note, mindfulness is a relatively nonstigmatizing and straightforward practice, easily accessed outside of the hospital. Mindfulness-based interventions in inpatient settings were delivered in group and individual formats. Jacobsen et al. (2020) found the intervention was feasible even considering the regular distractions and interruptions of the inpatient ward. They found individuals appreciated and enjoyed the intervention. In addition, they found lower readmission rates 12 months out from the very brief intervention (Mindfulness = 7, Control = 11). CBT for Self-Harm Self-injurious behavior can precipitate hospitalization and drive recidivism (Gibson et al., 2014). Dialectical behavior therapy (DBT) is a package intervention that shows good effects on borderline personality disorder and self-harm. As a proximal case for hospitalization, emotional reactivity to situations is a prime opportunity. Not only would this be helpful in relation to self-injury, but also in relation to most other presentations. Successful elements of DBT were adapted to target the immediate causes of self-harm, using the skills-training portion of DBT. Compared with treatment as usual (M = 14.44, SD = 18.75), they found this purposefully-designed program showed a greater reduction in frequency of self-harm (M = 9.41, SD = 28.48) and some improvement in emotional regulation. More importantly, these gains were maintained 3 months later. Programs like this one capitalize on the purpose of short-term hospitalization, on the stabilization of crisis, and on movement toward recovery in the community. CBT Programs for PTSD Since its codification in the DSM-III as an anxiety disorder, PTSD has expanded its evidence-based treatments, with many of the interventions based on CBT. Two gold-standard treatments, prolonged exposure therapy (PE; Foa et al.,

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2019) and cognitive processing therapy (CPT; Resick et al., 2016), have been applied to the inpatient setting (Tran et al., 2016). Some studies find that the massed provision of these treatments increases adherence and completion. Additionally, they find that communal living allows for support as the individuals are engaging in similar treatments. Homogenous treatment programs can capitalize on the benefits of CBT and unify the approach of the unit staff.

THEORY-DRIVEN APPROACH TO TREATMENT The reviewed innovative studies highlight two relevant points. First, intentional treatments can be implemented to facilitate meaningful and durable stabilization of crisis versus quick patching and discharge of individuals. Although some might question the limits of a 3-month follow-up, providers should view that follow-up length as the aim. By the 3rd month, outpatient treatment providers should establish and continue treatment. In place of treating labels and diagnoses, the clinicians in the above-mentioned studies provide interventions for specific mechanisms that maintain pathology and crisis. In conversation, some administrators and policy makers use emergency medical treatment as an analogy for acute psychiatric treatment, acknowledging that the scope of treatment for acute psychiatry is not long-term resolution of the psychiatric problem, but rather stabilization. However, no emergency medicine provider would give a critically ill patient some pain medicine to temporarily stop symptoms and then discharge the patient. Yet, the over reliance on medicine as the focal treatment of acute psychiatry runs that very risk. Second, even though acute inpatient is a long-standing treatment tradition, a poverty of research exists to inform meaningful treatment decisions for providers. What follows is a model for applying CBT in inpatient settings that supports a recovery focus, as was prioritized in the President’s New Freedom Commission on Mental Health report (2003), and ventures to accomplish the durable stabilization of an individual. Michael continues to meet with the clinician throughout his weeks on the unit. He expresses how badly everything goes in the “real world” and how he keeps getting stuck in the cycle. Others on the unit express their distress over ending up in a psychiatric ward and what it means about their worth as a person (e.g., “What will my family think?”). For some, this leads to a worsening of the very crisis of increased hopelessness and suicidality that brought them to the hospital. However, as Michael spends more time on the unit, he notices the change. Each provider starts by validating the patient’s concerns and reframes them as a chance to develop a new plan while learning from the crisis. In the regular meetings, the clinician and other providers on the unit talk less about the time on the unit and more about the next step for each patient. The problems on the unit and before coming to the hospital are treated as more of a nuisance or obstacle to achieving the “next steps” for life after the hospital. Michael finds that group, individual, and milieu meetings revolve around understanding what happened and developing little routines or habits that neutralize the obstacles to getting these exciting lives they keep discussing. Michael and his fellow patients become so focused on the



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next steps that they hardly mind the medicine meetings. Even the prescriber seems more interested in Michael’s apartment outside the hospital and the mindfulness practices he is learning; the medicine is like an afterthought.

CHALLENGES FOR INPATIENT TREATMENT PROVIDERS The case example of Michael highlights some specific challenges inpatient treatment providers face that need consideration while devising interventions. First, twice as many patients are hospitalized involuntarily, and half of these patients are hospitalized with a forensic involvement (SAMHSA, 2018). Anecdotally, even patients hospitalized voluntarily are, at times, participating in treatment under duress. Depriving a person of their basic freedoms as a result of a diagnosis can elicit defensiveness and even disagreement about the definition of the problem, often referred to as lack of insight. Additionally, the individual’s stay is often short, a matter of days, and the discharge date is unpredictable. The inpatient provider also faces a heterogeneous population that is constantly in fluctuation. Patients on one unit can range from chronic to acute psychotic disorders, from severe depression to active mania. The provider must attend to all of those patients’ needs. Defensiveness The first challenge facing the provider when starting treatment in an inpatient setting is reducing an individual’s defensiveness and starting the collaborative process. Although some providers educate patients about client roles and the provider’s intention to help, this approach might be received with mixed results. The provider needs to conceptualize the defensiveness as an understandable reaction and devise an approach to align with the individual. By no fault of the provider, the system sets the patient and hospital staff at odds and misaligned in objectives. Patients desire freedom, and hospitals desire treatment. These purposes are not inherently aligned. For example, Michael wants to solve the problem of his murmuring adversaries, and the doctors want to identify a medication profile that manages his symptoms. Similarly, a suicidal patient desires to end her life, and the hospital staff are dedicated to maintaining life. Any suggestion of medical treatment for the problem is met with defensiveness and questioning of the providers’ motives. Defensive behaviors such as refusing treatment, arguing with staff and providers, and avoiding groups and treatment teams are employed in response to thoughts that others are trying to control and reject the individual. These unhelpful thoughts are primed during the detention and hospitalization process. When considered empathically, reacting defensively when a person sees others as controlling them and labeling them is not completely irrational (see Figure 18.2). The provider needs to approach the inpatient treatment with the understanding that the patient is likely starting from a defensive position. The more the provider focuses on getting the problem fixed, the more the patient will be

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FIGURE 18.2. Defensive Thoughts, Feelings, and Behaviors as a Response to

Treatment Thought: I am hopeless; They don’t care; They are trapping me Situation: Provider starting therapy

Feeling: Anger; Shame Behavior: Rejection of treatment; Arguing; Avoidance

defensive about what happened and why they are fine. The individual yearns to disprove the belief of being defective. The more the provider aligns with the individual around future aspirations and post-hospital plans, the less the cognitions about being controlled are activated, and the resulting defensive behavior decreases. Any discussion of symptoms is in service of the individual’s desired life. Insight or Rejection of Diagnosis Patients’ connection of their problems with a definable mental disorder, or insight, is frequently considered an important first step in the pursuit of wellness. However, some research questions this singular entry point to recovery. Lincoln et al. (2007) found that insight in schizophrenia was not associated with long-term adherence to treatment and was associated with long-term development of depression in this population. This creates a conundrum because much psychiatric treatment involves the education of individuals about their illness, and lack of insight often causes providers to assert the presence of an illness even more. So providers need an alternate explanation for the experiences. Freeman et al. (2004) found that the reason individuals chose a delusional explanation for experiences over a biological one was because the delusional explanation just made more sense to them. Those findings match what might be expected from a purely cognitive behavioral formulation. The confirmation bias holds that individuals find evidence that supports the beliefs they hold and, without purposeful work, are unlikely to disconfirm those beliefs, which insight inherently involves. Further, promoting insight involves contradicting and challenging the individual’s worldview and would result in defensiveness against the association with illness. The provider increases the likelihood of finding success though a functional and pragmatic approach to treatment. Freeman et al. (2019) found that individuals were eager to treat certain targets such as sleep, worry, self-esteem, and others. These treatment objectives are established to have an impact on the broader pathology. By treating targets, the clinician avoids the power struggle over labels and diagnosis. Instead, the clinician partners with the individual on



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a treatment target that matters to the individual. In the case of Michael, the clinician started by engaging him around aspirations to reduce his defensiveness and then developed a functional understanding of the thoughts, feelings, and behaviors leading up to the hospitalization. With that understanding, they identified potential areas for improvement (e.g., Michael’s isolation and worry) to reduce the likelihood of distress in the future and, by extension, reduce the chance for hospitalization. In this way, the discussion of diagnosis is irrelevant to the collaboration. Short Stay The next challenge relates to planning a treatment that fits within the length of stay at the hospital. This challenge presents a real concern for providers. The stay in the hospital is often impacted by issues of stabilization, availability of aftercare, and financial constraints. Additionally, providers often have multiple, competing demands on time (e.g., patient admissions paperwork, crisis sessions, discharge planning) and can lose time dedicated for direct treatment. That being said, the provider has little control over the length of treatment, and plans should be made accordingly. Providers should attempt to encapsulate each meeting as though it were the final session. Treatment episodes should build on each other; however, no session should be planned with the expectation of another session or two. For example, the provider working with Michael might have a session where they experiment with ways to stop the murmuring and then use that experience in the next session to evaluate Michael’s hopelessness. Conversely, the provider should avoid an intervention for evaluating hopelessness that extends across multiple sessions without intermediate lessons because Michael might be discharged and never finish that intervention. At the beginning of the hospital stay, the provider and individual should outline the most promising treatment targets and move through them systematically. Upon discharge, the individual will have a catalog of new skills and a list of obstacles and their functional relationship to unwellness to continue using outside the hospital. In Michael’s case, he and his provider work on the murmuring noises for a few meetings and the pros/cons of isolating when Michael feels unwell. Upon discharge, he has a longer list of treatment targets that include the frustration when communicating with his mother and ways to be assertive to remain in control when dealing with others. Michael takes this to a clinician after discharge and looks up other resources. And yet, providers should not aim to make the sessions so discrete that they are not useful for the individual’s recovery. In this way, agendas can consist of meaningless skills absent of any context. To inoculate against this concern, the provider can follow a protocol when setting the session agenda that ensures a constant reference to the larger recovery plan: 1. Activating the aspiration: The provider elicits a vivid image of the aspiration and the most exciting aspects. The provider requests to partner in pursuit of the aspiration.

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2. Functional connection of agenda item and aspiration: The provider and individual consider the current agenda and how success in executing it will make pursuit of the aspiration easier or harder. 3. Work on agenda item: The agenda item is pursued by developing a new skill, evaluating and correcting cognition, increasing activity, or another actionoriented plan. 4. Evaluate and plan to apply/practice new learning: Evaluate the benefits of the new learning, imagine how its use might impact the individual’s current life and desired life, and plan for remembering and/or practicing. This type of protocol can increase the session as a stand-alone. Should the individual suddenly get discharged, they will be set to apply the previous session’s work in the world outside of the hospital.

REGROUP, REFOCUS, RETOOL With the previously mentioned concerns in mind, the provider can consider the scope of inpatient treatment. Administrators are correct that the hospital is not the place for long-term treatment or even for the full course of most cognitive behavioral treatment protocols, unless adapted as in the PTSD protocols. The objective of the acute hospital treatment involves setting a trajectory toward recovery. If the trajectory of treatment aims at stabilization, the individual will stay at stabilization. If the trajectory is aimed at employment or school, the individual might not end up there, but at least they will land along the path of recovery. The way the individual interprets the hospitalization has rippling effects on the future of the individual’s treatment. Experiences we have in life can act as behavioral experiments to change our beliefs, and new beliefs change our cognitive and behavioral patterns. The attentional focus of the individual will direct where they end up. Finally, the time available should be used efficiently. If the provider attempts to teach the individual everything, they will accomplish nothing. The tools need to be specific and purposefully chosen. The tasks of hospitalization follow three nonexclusive phases: regrouping from the crisis, refocusing on the future and clearing the pathway, and retooling the recovery efforts with some new skills. Regroup The first phase is regrouping after the crisis. Regrouping involves coming together, validating negative emotions, and reframing negative reactions to the events. Whether the individual was hospitalized voluntarily or involuntarily, the events that led to acute hospitalization can be at best upsetting and at worst traumatic. Mueser et al. (2010) found that the process of hospitalization can act as an index trauma for PTSD. With this consideration, the individual needs to



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experience connection with the providers and be embraced by the treatment team, with an eye toward the future. The guiding principle is that this event is a learning experience, and the team is going to make the most of the episode to increase the odds of this being the final hospitalization. The team takes time with the individual to validate the individual’s various negative emotions, which might include reactions like • shame for not being able to control their experiences; • guilt associated with conflicts during the hospitalization, inconveniences for family and friends, and letting the staff down; • anger for being hospitalized; • hopelessness related to stigma or failed previous hospitalizations; • fear of psychiatric symptoms; or • other understandable and unhelpful reactions. Finally, the regrouping involves reframing the experience with discussions like, “Let’s use this as an opportunity to refocus on your path and figure out how to get back to life for good. We are here for a reason. Many people end up in a hospital, and some return more than once, but the plan is to use this as an opportunity to learn and come up with a new trajectory.” Regrouping is about decatastrophizing the hospital stay and starting a collaboration. In relation to the original description of stabilization in this chapter, regrouping directly aims to address to the first two theoretical dimensions of stabilization: stabilizing the crisis that led to admission and increasing mastery over the symptoms. The collaborative and warm interpersonal quality of the CBT intervention will halt the continued escalation of the crisis. The empirical approach to the crisis turns the tables on the normal reaction to the hospital treatment. Whereas the usual intervention is about trying to lock the symptoms down long enough to be discharged, the empirical approach of learning from the crisis turns the symptoms and situations into a subject for the providers and individual to study together. The individual is the master, and the symptoms are their subject. Refocus Before the provider initiates the second phase of hospitalization, they must deescalate the reactions to the crisis and increase the sense of collaboration with the provider. Once these steps are initiated, the objective is to refocus the discussion toward the future and what needs to be fixed in order to clear the path toward that future. As with the case of Michael, the provider needs to get a clear understanding of what led to the hospitalization. This functional chain highlights the potential intervention points to plan for development of immediate plans following the hospitalization. The functional understanding goes further to increase the individual’s sense of mastery over the symptoms since they can

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be described and charted. Before the functional plan, the provider refocuses on the individual’s desired life after leaving the hospital. The provider looks toward the big picture as a source of motivation, focusing on what the individual wants to be doing or getting. With a motivating aspiration, the provider and individual align, and power struggles around treatments are reduced. Additionally, the aspiration provides a blueprint for remaining and thriving in the community. Any skills and routines are planned in the context of pursuit of the aspiration. Retool This final phase of hospitalization might seem the most familiar to the providers. However, the objective of retooling is to develop a small collection of new routines and skills. Those skills are meant to help the individual remain in the community and start building a more robust repertoire of behaviors. The routines or skills should target proximal causes of crises and should be kept simple. These are bridges to treatment providers or support systems outside the hospital. If the provider targets irrelevant and distal causes, the individual will either be at a loss to choose the correct strategy or become overwhelmed and use no strategy. Worse, if in the few days available the provider attempts to teach a litany of skills and routines, the individual is not getting a particularly substantive training. The following are examples of good targets for routines or skills: • Activity scheduling: Systematic monitoring, planning, increasing, and evaluating daily activities • Worry management: Skills to reduce worry • Assertiveness: Communication skills to reduce passivity and aggressiveness, leading to greater control • Targeted cognitive interventions: Identifying and training the individual in cognitive skills specific to the presentation, practicing on the hospital unit • Mindfulness: Life-practice to take an observer stance on experiences to reduce reactivity • Sleep hygiene: Sleep scheduling and habits to increase quality and quantity of sleep, a well-established causal factor in psychopathology During the retooling phase, the provider draws the individual’s attention to the increased mastery resulting from the ongoing increase in skill attainment.

AFTER TREATMENT Many individuals desire to put treatment behind them after discharge. They leave and express, “I am done, this was a big mistake, and I need to just get back



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to my life.” Some of these individuals run directly into the very pathology they are trying to escape. From the beginning of the treatment, the provider frames this experience with metaphors, like a pulled muscle: “In the hospital you are going to start the treatment, but the more the you follow up after the hospital, the better you will heal and the less likely you will be to reinjure the same muscle.” Together, the provider and patient develop a plan to follow up and set specific objectives for the treatment after the hospital. Furthermore, the provider empowers the individual to find a new provider if the first one does not meet the individual’s needs. Finally, the provider discusses what it will mean if the individual does need to return to the hospital, framing it as another opportunity for learning rather than a failure.

DISSEMINATION Acute inpatient hospitals pose some unique challenges in considering dissemination. Hospitals are staffed 24 hours per day with providers ranging in training and education levels. For successful implementation, all members of the staff need to be operating with the same clinical focus adjusted for the providers duties. In the implementation of CT-R (Chang et al., 2014), staff were trained throughout the course of the day to capture the staff on each shift. Further, new hire orientations can be used as powerful training opportunities for communicating basic understandings of CBT for all staff.

CONCLUSION The acute inpatient ward has traditionally been the site of stabilization, with the common definition being stabilization of medicine. This biological focus can inadvertently elicit defensiveness and power struggles, while failing at the primary goal of stabilization. Recent research has demonstrated that an intentional and adjusted treatment approach can have significant effects on the outcome of individuals. Future directions for inpatient CBT should expand the evidence base and dissemination of CBT on inpatient wards. With a more focused, formulation-driven approach to inpatient treatment, researchers can better identify what works and what is irrelevant in treatment. Further, more options for treatment can be offered to individuals, increasing engagement and reducing recidivism. Expanding on these findings, CBT can be leveraged to provide the type of durable and meaningful stabilization that establishes a trajectory for recovery and places the individual in the control position.

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REFERENCES Ahmed, A. O., Murphy, C. F., Latoussakis, V., McGovern, K. E., English, J., Bloch, A., Anthony, D. T., & Savitz, A. J. (2016). An examination of neurocognition and symptoms as predictors of post-hospital community tenure in treatment resistant schizophrenia. Psychiatry Research, 236, 47–52. Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129–1139. https://doi.org/10. 1037/0022-006X.70.5.1129 Beck, A. T., Grant, P. M., Inverso, E., Brinen, A. P., & Perivoliotis, D. (2020). Recoveryoriented cognitive therapy for serious mental health conditions. Guilford Press. Chang, N. A., Grant, P. M., Luther, L., & Beck, A. T . (2014). Effects of a recoveryoriented cognitive therapy training program on inpatient staff attitudes and incidents of seclusion and restraint. Community Mental Health Journal, 50(4), 415– 421.https://doi.org/10.1007/s10597-013-9675-6 Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press. Freeman, D., Garety, P. A., Fowler, D., Kuipers, E., Bebbington, P. E., & Dunn, G. (2004). Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. Journal of Consulting and Clinical Psychology, 72(4), 671–680. https://doi.org/10.1037/0022-006X.72.4.671 Freeman, D., Taylor, K. M., Molodynski, A., & Waite, F. (2019). Treatable clinical intervention targets for patients with schizophrenia. Schizophrenia Research, 211, 44– 50. https://doi.org/10.1016/j.schres.2019.07.016 Gibson, J., Booth, R., Davenport, J., Keogh, K., & Owens, T. (2014). Dialectical behaviour therapy-informed skills training for deliberate self-harm: A controlled trial with 3-month follow-up data. Behaviour Research and Therapy, 60, 8–14. https:// doi.org/10.1016/j.brat.2014.06.007 Haddock, G., Tarrier, N., Morrison, A. P., Hopkins, R., Drake, R., & Lewis, S. (1999). A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 34(5), 254– 258. https://doi.org/10.1007/s001270050141 Hall, P. L., & Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behaviour Research and Therapy, 41(3), 317–332. https://doi.org/10.1016/s0005-7967(02)00013-x Jacobsen, P., Peters, E., Robinson, E. J., & Chadwick, P. (2020). Mindfulness-based crisis interventions (MBCI) for psychosis within acute inpatient psychiatric settings; A feasibility randomised controlled trial. BMC Psychiatry, 20, 193. https://doi.org/10. 1186/s12888-020-02608-x Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D., Siddel, R., Drake, R., Everitt, J., Leadley, K., Benn, A., Grazebrook, K., Haley, C., Akhtar, S., Davies, L., Palmer, S., Faragher, B., & Dunn, G. (2002). Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: Acute-phase outcomes. British Journal of Psychiatry, 181(S43) S91–S97. https://doi.org/10.1192/bjp.181.43. s91 Lincoln, T. M., Lüllmann, E., Rief, W. (2007). Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophrenia Bulletin, 33(6), 1324–1342. https://doi.org/10.1093/schbul/sbm002 Ghahramanlou-Holloway, M., LaCroix, J. M., Perera, K. U., Neely, L., Grammer, G., Weaver, J., Novak, L. A., Colborn, V., & Lee-Tauler, S. Y. (2020). Inpatient psychiatric care following a suicide-related hospitalization: A pilot trial of Post-Admission



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Cognitive Therapy in a military medical center. General Hospital Psychiatry, 63, 46–53. https://doi.org/10.1016/j.genhosppsych.2018.11.006 Mortan, O., Tekinsav Sütcü, S., & German Köse, G. (2011). İşitsel Halüsinasyonlarla Başa Çıkmaya Yönelik Bilişsel-Davranışçı Bir Grup Müdahalesinin Etkililiği: Bir Pilot Çalışma [A pilot study on the effectiveness of a group-based cognitive-behavioral therapy program for coping with auditory hallucinations]. Turk Psikiyatri Dergisi, 22(1), 26–34. Mueser, K. T., Lu, W., Rosenberg, S. D., Wolfe, R. (2010). The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis. Schizophrenia Research, 116(2–3), 217–227. https://doi.org/10.1016/j.schres.2009.10.025 President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. https://govinfo.library.unt.edu/ mentalhealthcommission/reports/FinalReport/toc.html Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press. Stanley, B., & Brown, G. K. (2011). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi. org/10.1016/j.cbpra.2011.01.001 Substance Abuse and Mental Health Services Administration. (2019). National Mental Health Services Survey (N-MHSS): 2018. Data on Mental Health Treatment Facilities. https://www.samhsa.gov/data/report/national-mental-health-services-survey-n-mhss2018-data-mental-health-treatment-facilities Tran, K., Moulton, K., Santesso, N., & Rabb, D. (2016) Cognitive processing therapy for post-traumatic stress disorder: A systematic review and meta-analysis [internet]. Canadian Agency for Drugs and Technologies in Health. https://www.ncbi.nlm.nih.gov/books/ NBK362325/ Wenzel, A., Brown, G. K., Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. American Psychological Association.

19 Cognitive Behavioral Therapy Delivered Using the Internet Gerhard Andersson and Per Carlbring

T

he internet is no longer something new. It has existed now for a long time and has been part of many peoples’ lives for at least 20 years. The internet increasingly informs many aspects of our lives, including the economy, health care, and delivery of psychological treatments.1 There are many areas in which the internet has had an impact on cognitive behavioral therapy (CBT; G. Andersson, 2015b). First, clients often seek information about their conditions/problems, treatment, and even their therapist. The quality of information on the internet is a field of its own (Khazaal et al., 2008), and not only clients, but also their significant others, tend to seek information either before or after a consultation. Moreover, not only do clinicians in private practice often market their services on the internet, but hospitals, universities, and government-funded facilities (with countries in Europe often having tax-funded health care like the National Health Service in the United Kingdom) do so as well. Second, the world has changed dramatically with the introduction of social media and smartphones, with access to the internet not only being increased but also becoming more personalized and filtered. There is literature on the effects of getting support via discussion forums on the internet, with results being mixed. For example, one controlled study found negative effects of being part of a discussion forum for breast cancer (Salzer et al., 2010). However, social We thank our coworkers and students and in particular our webmaster George Vlaescu. Additionally, this work was sponsored in part by a grant to Dr. Andersson from Linköping University. The authors have no conflict of interest but do receive royalties for books based on some of the self-help material used in ICBT studies.

1

https://doi.org/10.1037/0000219-019 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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media (e.g., Facebook) has a major influence, and closed Facebook groups are being created for various professional and lay purposes. As a cognitive behavioral therapist, it is not uncommon to be part of a professional social media network, and at the same time, clients may be part of groups related to their problem (e.g., obsessive-compulsive disorder [OCD]). Third, health care, including the provision of CBT, is increasingly digitalized, with booking systems and medical files being online, albeit in closed networks. In some places, like Sweden, patients can access their own medical files from home and also seek health care directly via the internet. This has facilitated the spread of internet-supported CBT, which is the topic of this chapter. The aims of this chapter are to (a) describe challenges when delivering CBT via the internet; (b) comment on assumptions behind treatment programs; and (c) describe the main approaches, outcomes, and potential mechanisms of change. Further, we comment on the dissemination of internet-delivered CBT (ICBT), as well as applications for diverse target groups, and possible future developments. Although ICBT may appear as something new, it is almost as old as the internet itself, and the research field is very large, with more than 200 controlled trials. It will not be possible to cover all studies, aspects, and forms of ICBT, but the main findings are outlined, along with details on how ICBT can be practiced.

ADDITIONAL BACKGROUND AND CHALLENGES WHEN DELIVERING ICBT As a starting point, we must highlight the fact that terminology in this field is scattered and inconsistent, which has been referred to as “terminology chaos” (Barak, 2013). Various terms are endorsed to describe the use of the internet in the delivery of CBT, including the rather overinclusive digital therapy, internet interventions, and computerized psychotherapy. Other terms, such as webbased psychotherapy and online psychotherapy, are also commonly used. ICBT is specific in that it refers to the use of the internet and CBT. It is the term used in this chapter bearing in mind that other terms are in use. One way to describe the characteristics of ICBT is to refer to the historical background. The most important characteristics is that it is a form of self-help in the sense that it almost always involves text, even if pictures, games, videos, and various interactive features can be included as well. Indeed, in many early (and some current) publications on ICBT, the treatment is called “guided self-help” (G. Andersson, Bergström et al., 2008). It could be argued that ICBT is just another way to deliver bibliotherapy, with the text being online and guidance being text-based rather than over the phone or in session. In earlier versions of ICBT, it was a requirement that clients could print out the self-help texts, and this is often still recommended even if it is easier to read on screen now. Internet access is not time restricted, as it often was in the late 1990s, when many clients had to dial-up using their phone connection. A long-standing challenge in ICBT is transferring good self-help texts into shorter formats and



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making self-help materials more interactive and attractive. It is not clear from the literature, however, that this improves outcomes, as most trials comparing ICBT against guided bibliotherapy yield equivalent outcomes, as observed in a trial on bulimia nervosa (Wagner et al., 2013). However, there are still advantages of ICBT in terms of access, including smartphone delivery. It is a continual challenge for research to show that ICBT can be better than the more traditional guided self-help bibliotherapy treatment format. A second background is computerized CBT, which has a history on its own with programs like Eliza and stand-alone CD-ROMs that were investigated in the early 1990s and later (Marks et al., 2007). Computers are still widely used in testing and in exploring novel approaches using virtual reality, but most research on self-help has moved to the internet, even if there are examples of computer-assisted therapies that are being investigated (Roy-Byrne et al., 2010). One challenge when doing research and clinical management using technology is the combination of rapid development and constant changes. For example, security issues, access, platforms, and various aspects influence how we interact with technology. It is, for example, interesting to note that it took a long time for computerized CBT programs (like Beating the Blues®) to become available on the internet. A third challenge relates to the way in which society changes. What sometimes has been referred to as a "digital divide" is still relevant (Latulippe et al., 2017), even if many countries and a majority of the world’s population have at least some access to the internet (https://internetworldstats.com). Other challenges will be dealt with when describing the treatment format.

MAIN APPROACHES AND TREATMENT PROCEDURES The first issue to consider when using the internet for CBT is the treatment platform in which assessment instruments, treatment materials, and interactions between clinician and client take place (Vlaescu et al., 2016). Currently, most treatment platforms can present video and audio files, and there are also embedded possibilities for text and video chat. However, one crucial aspect is data security in the interaction between client and a therapist via text or video chat, as when collecting sensitive data such as symptom ratings. Technical solutions often resemble internet banking (e.g., when bills are payed online), including encryption of data traffic. In many countries, there are strict regulations, and it is not enough to access the system with a single password. Instead, systems are encrypted and use a double-authentication procedure at login. When it comes to collecting data using the internet, there are a large number of studies showing that psychometric properties and measurement characteristics tend to stay the same as in paper-and-pencil formats when question­naires are administered over the internet (van Ballegooijen et al., 2016), but it may be best to stick with the format and not change from paper-and-pencil to the internet in clinical trials (Carlbring et al., 2007). When it comes to computerized

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diagnostic procedures, our long-standing experience is that self-report procedures (i.e., questionnaires) need to be complemented with at least a telephone interview using a structured diagnostic interview in order to obtain reliable diagnoses (Carlbring et al., 2002). The second and crucial component of ICBT is consideration of the actual treatment manuals. A wide range of self-help manuals have been either transferred and/or inspired by previous self-help texts or developed with no previous self-help material existing. Further, ICBT modules can be influenced by previous face-to-face work, including manuals. Thus, one important aspect of ICBT is the language in the texts and addressing whether empathy is conveyed with the wish to create trust and even a therapeutic relationship with the program/text (Richardson et al., 2010). The length of the treatment programs varies from very short to as long as a full book, with the equivalent of 200 pages of text. As the presentation format can vary, one way to differentiate between programs is to consider how much time the client engages with the program and, perhaps most importantly, how much the client completes assignments in the form of “homework” between taking part of the treatment modules. In terms of duration, the programs vary as well, but an overall impression is that ICBT programs tend to be a little shorter in duration than face-to-face manuals. For example, in our trials on social anxiety disorder (SAD), the number of treatment weeks has been nine (G. Andersson et al., 2006), which is shorter than most face-to-face manuals for SAD (Clark et al., 2006). A screenshot from a depression program is presented in Figure 19.1. Although there are self-guided ICBT programs (Karyotaki et al., 2017), most of the applications and studies have involved at least some form of clinician guidance, which usually tends to generate larger treatment effects and better treatment completion than purely self-administered treatments (Baumeister et al., 2014). Therefore, a third component of ICBT is the role of the therapist. The amount of clinician-client interaction can vary from minimal support and encouragement via secure asynchronous email to more interactive support involving real-time online chat sessions and even face-to-face sessions. The latter is a separate treatment format, which has been named “blended treatment” (van der Vaart et al., 2014). The most common format is minimal text-based guidance. Interestingly, several studies have documented that a therapeutic alliance is formed in this treatment format (Berger, 2017). Research is inconsistent, however, with regard to the association between alliance ratings and outcomes, with several studies showing no correlation (Berger, 2017). When it comes to the actual interaction, there are studies showing that most of the interaction is in the form of support (Sánchez-Ortiz et al., 2011) and that there are small if any therapist effects (Almlöv et al., 2011). However, this does not mean that the writings of the clinician are irrelevant. For example, one study showed a negative association (r = –.37) between therapists expressing deadline flexibility and outcomes (Paxling et al., 2013). Given observations that telephone support and asynchronous email support generate similar outcomes and alliance ratings (Lindner et al., 2014), there is a need for further consider-



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FIGURE 19.1. Screenshot From the “Robin” Study on Tailored ICBT for Depression

ation of both client (Svartvatten et al., 2015) and clinician behaviors (Schneider et al., 2016), as well as differences between face-to-face and email contact. For example, researchers and clinicians must consider the possibility that support may not need to be provided during the treatment but can be provided both before and after, and also that support can be in the form of “on-demand” when the client needs guidance. Perhaps just knowing that there is someone who will respond and help may be sufficient for many clients. Studies indicate that any support is better than no contact at all, and in one review on depression and amount of therapist contact in four categories (0, no therapist contact either before or during treatment; 1, contact before treatment only; 2, contact during treatment only; and 3, contact both before and during treatment), a Spearman correlation of ρ = 0.64 was found between amount of contact and

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outcome (Johansson & G. Andersson, 2012). Recent studies show that support on demand may be as effective as scheduled support, but in one study lower completion rates were found for optional support (56.6%) versus scheduled support (82.4%; Hadjistavropoulos et al., 2017). Both approaches to support were, however, effective in reducing anxiety and depression.

UNDERLYING THEORY In many ways, ICBT is just a format, and the theoretical assumptions behind the treatments are the same as in face-to-face CBT. For example, in internet treatments for depression, Beck’s cognitive theory (G. Andersson et al., 2005), behavioral activation theory (Nyström et al., 2017), theory associated with acceptance and commitment therapy (Lappalainen et al., 2014), and indeed even psychodynamic (Johansson et al., 2012) and interpersonal theory (Donker et al., 2013) have informed treatment programs. Internet interventions involving attention training for SAD rely on cognitive processing theory (Boettcher et al., 2012b), just to give a few examples. However, a treatment based on a theory cannot be seen as a test of the theory in and of itself; when it comes to ICBT, there is a need for theories to help us understand the treatment format and how and why it works (G. Andersson, Carlbring, et al., 2009). There are some initiatives to develop theories specific for internet interventions (Ritterband et al., 2009), but they are mostly aimed at explaining the more technical and human-computer interaction side of internet interventions. In our group, we have started to elaborate on the possibility of viewing ICBT as a form of online education, inspired by new thinking in CBT when it comes to improving learning and memory of treatment (Harvey et al., 2014). We have started to investigate whether ICBT influences knowledge acquisition (G. Andersson et al., 2012), with trials suggesting that improvements in this domain occur (Strandskov et al., 2017), even if the concept of knowledge and confidence in knowledge is still developing. The main idea, however, is to view ICBT as a form of patient education, which is an inherent part of CBT (e.g., in the form of psychoeducation), but it has not been well-examined using experimental procedures to enhance learning and memory of the intervention. It should be acknowledged that theoretical assumptions behind ICBT are still poorly developed and are heavily dependent on existing theories in CBT (e.g., in relation to exposure to fears, stages of change in drug treatments).

OUTCOME DATA As mentioned, there are numerous trials on internet interventions and, in particular, guided ICBT. In Table 19.1, we present an overview of conditions and whether there are effectiveness studies in addition to efficacy studies (the former



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TABLE 19.1. Summary of Research Studying Internet-Delivered Cognitive Behavioral Therapy for Different Conditions

Condition

Efficacy

Compared with Effectiveface-toness face Replicated

Psychiatric Major depression

√

√

√

√

Panic disorder

√

√

√

√

√

Social anxiety disorder

√

√

Generalized anxiety disorder

√

√

√ √

Specific phobia

√

√

√

√

Posttraumatic stress disorder

√

√

√

√

√

√

√

√

√

√

Obsessive-compulsive disorder

√

Eating disorders

√

Body dysmorphic disorder

√

Health anxiety

√

Mixed anxiety/depression

√

Pathological gambling

√

Alcohol/drug addictions

√

Attention-deficit/hyperactivity disorder

√

√

√ √ √

√ √

Other problems Couples therapy

√

Parent training

√

Nightmares

√

Procrastination

√

Interpersonal violence

√

Perfectionism

√

Loneliness

√

Grief

√

√ √

Health problems Headache

√

√

Tinnitus

√

√

Stress

√

√

√

√ √

Insomnia

√

√

√

√

Chronic pain

√

√

√

√

Cancer

√

√

Cardiac problems

√

√

Erectile dysfunction

√

√

Hearing loss

√

√

Irritable bowel syndrome

√

√

Diabetes

√

Dizziness

√

√ √

√

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being conducted under clinically representative conditions). Moreover, if there are studies directly comparing ICBT to face-to-face CBT, and if the efficacy studies have been independently replicated by at least two research groups, it is stated. Starting with the short-term studies, there is now enough research to motivate separate systematic reviews/meta-analyses for different conditions as attested by many reviews being published. One Cochrane review on anxiety disorders showed promising outcomes, with a standardized mean difference of 1.06 (equivalent to Cohen’s d) for disorder-specific symptoms at posttreatment (28 studies, 2,147 participants), but they also identified research issues (Olthuis, Watt, et al., 2016), such as heterogeneity among studies. However, as summarized in Table 19.1, there are controlled trials on most anxiety disorders, and, in a majority of studies, effects have been moderate to large and in line with previous face-to-face CBT results. Although there are numerous studies, the number of trials and independent replications vary, with SAD carrying the strongest evidence base. Following our first controlled trial (G. Andersson et al., 2006), in which a between-group effect size of Cohen’s d = 0.77 was found against a wait-list condition, studies have been conducted in Australia (Titov et al., 2008), Spain (Botella et al., 2010), Switzerland (Berger et al., 2009), and more recently, the United Kingdom (not yet published). Moreover, the Swedish program was translated and tested in Romania showing a large between-group effect (Cohen´s d = 1.19) against a wait-list control (Tulbure et al., 2015). In terms of effects, results have been remarkably similar, with large between-group effects for ICBT in more than 20 controlled trials (Kampmann et al., 2016), with a controlled effect size of g = 0.84 for ICBT relative to passive control conditions at posttreatment. There are also controlled studies on specific phobias (G. Andersson, Waara, et al., 2009), generalized anxiety disorder (Paxling et al., 2011), panic disorder (Carlbring et al., 2006), posttraumatic stress disorder (PTSD; Olthuis, Wozney, et al., 2016), and OCD (Dèttore et al., 2015)—all conditions for which face-to-face CBT has substantial empirical support. The same is the case for major depression and depressive symptoms, for which there are several systematic reviews (Arnberg et al., 2014), often confounding ICBT and computerized interventions in general (Andrews et al., 2018) and more recently with mobile phone interventions (Josephine et al., 2017). As with the anxiety disorders effects, the results of many studies mimic face-to-face results, with one review on direct comparisons showing a minor difference of Hedges’s g = 0.12 favoring guided ICBT over face-to-face, based on five studies including 429 participants (G. Andersson et al., 2016). However, it is important to note that there are fewer studies on other mood disorders like bipolar disorder (Barnes et al., 2015) and dysthymia. It is also the case that unguided treatments may be less effective than guided treatments when it comes to depression, even if there are exceptions (Berger et al., 2011). Several controlled studies exist on ICBT for various health problems like chronic pain and headache (Buhrman et al., 2016), with an average Hedges’s of g = –0.49 against control for measures of catastrophizing; tinnitus (G. Anders-



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son, 2015a), with an average Hedges’s g = 0.58 against control; and several other conditions like irritable bowel syndrome (Ljótsson et al., 2011), cancer (Abrahams et al., 2017), and heart failure (Lundgren et al., 2016), just to give a few examples as listed in Table 19.1. In addition to these there are several controlled studies on ICBT for insomnia (Seyffert et al., 2016), with sleep efficiency significantly improved 7.22% when compared against wait list across 9 trials, and stress-related problems (Heber et al., 2017), in which the mean effect size for stress at posttest was Cohen d = 0.43 across 26 comparisons. Researchers have also published trials on transdiagnostic problems that are not necessarily diagnoses on their own, with examples including trials on perfectionism (Arpin-Cribbie et al., 2012), procrastination (Rozental et al., 2015), and behavioral couples therapy (Doss et al., 2016). One of the first and most crucial questions raised when the initial promising findings on ICBT appeared almost 20 years back was whether this treatment format—clinician-guided ICBT—could be as effective as face-to-face CBT. We began doing such trials in 1998, and there are now systematic reviews on the controlled trials that have directly compared the treatment formats with randomized participants. We recently published an updated meta-analysis in which we included 20 studies with a total of 1,418 participants who had received either guided ICBT for psychiatric and somatic conditions or face-toface CBT within the same trial (Carlbring et al., 2018). The pooled effect size at posttreatment was Hedges’s g = 0.05, which means that ICBT and face-to-face treatment produce equivalent overall effects. Long-term effects of internet interventions have been investigated with, for example, one depression trial in which we found no differences between guided ICBT and group face-to-face treatment at a 3-year follow-up (G. Andersson et al., 2013). Whereas there are many studies including those with 6-month and 1-year follow-ups, there are at least 14 trials in which data have been collected for follow-up 2 years or longer after completed treatment. When we recently reviewed this literature, we located 14 studies involving 902 participants, with an average follow-up period of 3 years (G. Andersson et al., 2018). There were long-term outcome studies on panic disorder, SAD, generalized anxiety disorder, depression, mixed anxiety and depression, OCD, pathological gambling, stress, and chronic fatigue. The prestudy to follow-up effect size was Hedges’s g = 1.52. In most studies, there was no control group and no systematic, longitudinal investigation of treatments received during the follow-up period, but as the response rate across studies was as high as 70%, we can at least have some confidence in the results. Although not in the focus of this review, it should be mentioned that there are many studies investigating the cost-effectiveness of ICBT, with clear indications that it is a cost-effective treatment format (Donker et al., 2015). Donker et al. (2015) reviewed 16 studies in which 9 studies featured a societal perspective (i.e., not only intervention costs but overall costs for society). The authors reported that guided ICBT for depression, anxiety, smoking cessation, and alcohol consumption had favorable probabilities of being more cost-effective when

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compared with wait list, treatment as usual, group CBT, attention control, telephone counselling, or unguided internet CBT.

MECHANISM OF CHANGE Along with the many trials on ICBT there exists literature on mechanisms of change (G. Andersson, 2016) and what makes ICBT work. A narrative review based on clinical impressions was published almost a decade ago (G. Andersson, Carlbring, et al., 2009), but there are also several predictor, moderator, and mediator studies based on data mostly collected in association with controlled trials. In the narrative review, we noted our observations that ICBT works well when (a) a proper diagnosis and/or clinical evaluation is made before the treatment starts, (b) a comprehensive treatment is provided, (c) the treatment is user-friendly and not overly technical, and (d) support and a clear deadline are provided for the duration of the treatment (G. Andersson, Carlbring, et al., 2009). The empirical support for these notions is mixed with, for example, one study suggesting that an interview before the treatment did not matter much for the primary outcome in that study (Boettcher et al., 2012a). Separately, in a review on the role of support in ICBT for depression, we found that some clinician contact (not necessarily during treatment) was better than no contact at all (Johansson & Andersson, 2012). The second statement is grounded in the observation that brief treatments tend to generate smaller effects than more comprehensive treatments, but to our knowledge there are few controlled comparisons. Some clients want and prefer just a short treatment, and if that leads to smaller treatment effects, it can be due to having fewer problems and thus less room for improvement than persons who need longer treatments (Kaldo et al., 2013). In particular, it may be that this needs to be tested with “real” clients and not media-recruited participants in research trials. The third observation is also not robustly researched, but it is our strong belief that a client is more disturbed when a system does not work (or crashes) than if the website has a color the clients do not like. However, when it comes to prevention and less motivated clients, there is definitely a role for so-called persuasive design features (Kelders et al., 2012), and in any case, the looks of an internet treatment should not stand out as outdated and ugly even if it is not clear how important looks are for treatment gains. Other interactive features, such as automated messages when submitting homework, may also increase the effects (Titov, Andrews, Schwencke, et al., 2010), even if all features of an ICBT program tend to be presented in packages, making it hard to disentangle the relative merits of each component. The fourth assertion, that support and a clear deadline for treatment completion influence outcomes, is to date fairly clear when it comes to support (see previous section on main approaches and procedures). Whether a deadline makes a difference has not been investigated in full, even though we have done small unpublished pilot studies and, as mentioned previously, being flexible with deadlines as a therapist tends to be associated with worse outcomes (Paxling et al., 2013).



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Several predictor studies have been published with scattered findings. One example is cognitive function, and in one study based on data from 3 samples, perseverative error scores on the Wisconsin Card Sorting Test at baseline were unrelated to treatment outcomes (Lindner et al., 2016). However, in a later study on older adults with anxiety, we indeed found a correlation suggesting that worse cognitive function (perseverative errors) was related to poorer treatment outcomes (Silfvernagel et al., 2018). In an early study on panic disorder, we assessed the verbal fluency test at baseline but failed to find any associations with outcomes (G. Andersson, Carlbring, & Grimlund, 2008). Clearly, this is a field in need of more research, but clients with poor cognitive function are most likely excluded from both trials and clinical practice, as computer and reading skills are necessary in order to even initiate treatment. On a more promising note, there are a few studies using brain imaging techniques in order to predict outcomes. One study showed that long-term treatment outcomes for SAD were possible to predict using a support vector machine learning approach with responses in anterior cingulate and the amygdala being predictive (Månsson et al., 2015). Another study found that anterior cingulate cortex morphology predicted treatment response in depression (Webb et al., 2018). Additionally, changes in brain function have been found following ICBT (Månsson et al., 2013), including structural changes (Månsson et al., 2016), and it is possible that this field of investigation will grow. Genetics is another area being investigated, but to date, findings have not been promising in terms of predicting treatment outcomes, such as with the 5-HTTLPR, COMT Val158Met, and TPH2 G-703T genes (E. Andersson et al., 2013). Several studies have investigated demographic characteristics (e.g., gender) and symptom severity as predictors of outcomes. There is no systematic review of this literature, and it is also likely that predictors vary depending on target condition (e.g., depression) and client characteristics (e.g., primary care, adolescents). There are also differences between predictors of treatment uptake (Hadjistavropoulos et al., 2016) versus treatment outcomes; for example, in a trial involving children with anxiety, it was suspected that autism spectrum disorder was associated with less change in symptom severity (Vigerland et al., 2017). It is fairly common to find that demographic variables such as age, gender, marital status, computer skills, educational level, and having children have no significant predictive value (Hedman et al., 2015). As with cognitive function, it is often the case that clients who are unsuitable or unable to complete ICBT are less likely to be included in trials, which has consequences for outcomes predictions. Moderator studies are fewer, but the same conclusion applies that there are few consistent moderators of outcomes, even if statistically significant results have been reported in some studies (El Alaoui et al., 2013). From a scientific point of view, mediator studies are important to investigate mechanisms of change (Kazdin, 2007). Here, ICBT trials can benefit from the relative ease of collecting weekly process measures. One good example of this was a trial on irritable bowel syndrome, in which two mediators (i.e., symptomspecific anxiety and stress reactivity) were investigated, and the former was

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found to mediate treatment effects in the exposure treatment versus the stress management treatment (Ljótsson et al., 2013). There are a few other examples of mediational studies using weekly measures, such as one study on tinnitus (Hesser et al., 2014), in which tinnitus suppression mediated changes in tinnitus severity in internet-delivered ACT but not in ICBT. In another study, mindful nonreactivity in exposure-based ICBT for severe health anxiety was found to mediate outcome (Hedman et al., 2017). Overall, it is not yet possible to draw any conclusions regarding consistent robust mediators of change in ICBT. In sum, much work needs to be done on the mechanisms of change, including predictors of outcomes and mediators. One possible future direction is to focus less on variables derived from traditional face-to-face research (e.g., the therapeutic alliance) and more on domain-specific factors (such as activitymonitoring data collected via smartphone).

DISSEMINATION As stated in Table 19.1, several effectiveness studies have been published for a number of disorders and conditions. This literature has also been reviewed (G. Andersson & Hedman, 2013), but several additional effectiveness studies have been published since that review. The definition of what counts as “effectiveness” is not obvious, but at least a requirement is that the intervention is part of regular practice and not just a research project (Hunsley & Lee, 2007). Two contemporary examples of effectiveness reports come from the MindSpot clinic in Australia (Titov et al., 2017) and the internet psychiatry unit in Sweden (El Alaoui et al., 2015; Hedman et al., 2014). Both groups have published data from their regular clinical practice indicating that ICBT works when delivered as regular practice with ordinary clients. One of the first applications in general health care was the tinnitus clinic in Uppsala, Sweden, which began delivering CBT for tinnitus via the internet by the end of 1999, and published effectiveness data early on (Kaldo-Sandström et al., 2004). Those early studies clearly supported that ICBT works, but perhaps not as well as in the efficacy studies. On the more commercial side, the Interapy program from the Netherlands started in the 1990s and subsequently published effectiveness data (Ruwaard et al., 2012). In addition to these, the publicly available MoodGYM from Australia is another early example with subsequent real world data being published (Christensen et al., 2006), albeit not based on a regular clinic but rather community users. A more recent study described implementation of ICBT in five countries (Australia, Canada, Norway, Sweden, and Denmark; Titov et al., 2018). They also included references to published effectiveness studies of outcomes that all demonstrated large clinical improvement, low rates of deterioration, and high levels of patient satisfaction. While still being at an early stage, the published data clearly suggest that ICBT can work in regular settings, but in most cases, the implementation has been handled by specialist and centralized clinics, rather than wide scale dissemination across a whole country with several clinics involved.



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A possible hurdle when implementing new treatments is negative attitudes among clients, clinicians, and other stakeholders (e.g., as insurance companies). There are some attitude surveys (Donovan et al., 2015) that again show mixed findings and are most likely also rapidly outdated, given the spread of information technology in society. One stakeholder survey was conducted in eight European countries with 175 organizations participating in a survey (Topooco et al., 2017). Results showed greater acceptability toward blended treatment (the integration of face-to-face and internet sessions within the same treatment protocol) compared with stand alone internet treatments. For example, for mild depression, 46.5% would recommend ICBT only and 69.8% blended treatment. But for moderate depression, the corresponding figures were 15.7% and 57.2%—in other words, a marked difference. The same discrepancy was found for severe depression, with 1.9% recommending ICBT and 27% recommending blended treatments. Another study was conducted with clinicians in child and adolescent psychiatry (Vigerland et al., 2014), and it showed a relatively low knowledge of ICBT (including computerized treatments overall). In fact, they found that a large majority of 86% reported having no prior experience of ICBT and that only 19% reported that they had “quite a lot” or “a lot” of knowledge about ICBT content, how ICBT is used, or research supporting ICBT (again the actual questions concerned the broader concept on computerized treatments overall). Whereas the majority of clinicians were positive to ICBT for prevention and for mild-to-moderate problems (75%), they were more cautious with regard to more severe mental health problems. Another study from Norway reported positive attitudes among clinicians (Wangberg et al., 2007), with a total of 1,040 members of a psychologist association reporting that as many as 45% had used e-media in interaction with clients. Only 3% stated that use of e-media between client and therapist was unacceptable. However, a study from the United States conducted in a primary care setting showed that patients were less interested in taking part in ICBT than face-to-face treatment (Mohr et al., 2010). Overall, this body of literature is evolving, and there are likely differences both between and within countries and settings. Given the observation that clinicians may not know what ICBT is, there is a role for education in order to facilitate dissemination (Hadjistavropoulos et al., 2012).

APPLICATION TO DIVERSE POPULATIONS Most of the programs, studies, and clinical applications of ICBT have been for adults, often reflecting demographic characteristics of how problems are represented in the general population. In fact, one study found that participants in an ICBT clinic were more representative of the general population than patients seen in regular practice (Titov, Andrews, Kemp, & Robinson, 2010). Moreover, in that same study, the internet sample had disorders as severe as those attending an outpatient clinic. In line with many research trials in psychotherapy,

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research participants tend to be better educated than people in the general population, and in the case of the early internet trials, access to a computer and the internet were also factors that made these participants less representative of the general population. Now, internet access is less of a factor, at least in Europe with a vast majority having regular access (https://www.internetworldstats.com). In addition to the large body of literature focused on adults, there is a growing interest in studies and clinical applications for children and adolescents. Here, the evidence base for ICBT is less extensive, and as with the literature on adults, the terminology is inconsistent. One systematic review and meta-analysis included 25 studies on 11 disorders (including somatic disorders). Calculations based on 24 of these studies showed a between-group effect size of Hedges’s g = 0.62 when compared against wait-list control conditions (Vigerland et al., 2016). Another earlier meta-analysis focusing on depression and anxiety included fewer trials (N = 13) but found a similar effect size of Hedges’s g = 0.72 (Ebert et al., 2015). For older adults (ages 60 years and older), there is emerging literature with controlled trials, but much less than for adults below age 60. In many trials and clinical audits, older adults have been included, and in one study on depression, comparable outcomes were observed for adults 65 and older (n = 69) as in the younger cohorts (Hobbs et al., 2018). Similar results were found in a related study focusing on anxiety (Hobbs et al., 2017). Overall, the evidence for older adults is in line with the findings on adults in general. Another interesting development is the translation and adaptation of programs for different languages and cultures, such as those being developed to treat immigrants. Controlled studies have been conducted in Arabic (Knaevelsrud et al., 2015) as well as Chinese (Choi et al., 2012), among others. One project aimed at disseminating treatment across languages and cultures involved translation of a Swedish ICBT program for SAD into Romanian, which resulted in a control trial showing a large treatment effect (Tulbure et al., 2015). This is a rapidly growing field, and a possible future development will be global trials with participants being able to select their preferred language. A final target population is the clinicians. The internet can be used for investigating therapists but also for training in CBT. Work has been done on training in CBT for eating disorders and depression (Fairburn & Patel, 2017), but there are also examples of experimental studies using the internet (Weingardt et al., 2009), and finally experiences of doing supervision online (Rakovshik et al., 2016). However, this work is in its early stages, and more studies are needed as education in general and also supervision increasingly take advantage of modern information technology.

NEGATIVE EFFECTS AND FAILED TRIALS While being hardly noticed (and perhaps even dismissed for a long time), the possibility of unwanted negative effects following CBT has more recently been



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investigated in relation to ICBT. First, negative effects are increasingly documented in controlled trials of ICBT, but there are also separate reports of negative effects. One example is a patient-level meta-analysis (Rozental et al., 2017), that included 2,866 patients from 29 clinical trials. The authors found deterioration rates of 5.8% in the treatment conditions and 17.4% in the control conditions using a definition of deterioration based on reliable change index. Overall, negative effects do occur and should be documented in ICBT as well as in all other forms of CBT (Rozental et al., 2014). Another important contemporary task in contemporary research is to prevent publication bias and the file-drawer problem (with negative results remaining unpublished). We have made an effort and published both trials with negative findings (Carlbring et al., 2012) and failed trials (Lindh-Åstrand et al., 2015). The latter was a trial in which we did not manage to recruit and deliver treatment effectively. Although there are reasons not to publish poor research, it is important to communicate negative findings and failed trials to other researchers. This leads to discussion of the ethical aspects of ICBT. There is a small body of literature on this that is highly dependent on the setting, as policies differ between countries and the practice of ICBT has been around longer in some places (Dever Fitzgerald et al., 2010). For example, there is probably less research and clinical experience in the United States than in Australia and Sweden (Webb et al., 2017), to give an example that could be related to legal issues (e.g., different licenses to practice across states, higher risks of costly litigation). Good practice guidelines need to be developed both for research and practice, and are already in place in some settings (G. Andersson, 2015b).

CONCLUSION AND FUTURE DIRECTIONS A number of developments are possible in this field, bearing in mind that both technology and clinical knowledge change, as well as clients and their preferences. First, given the increased computer power of machine learning, using large data sets might become a topic of research for ICBT data, both for machine learning (Lenhard et al., in press), but also for doing process studies on change mechanisms with sufficient statistical power. In line with this research, sensor monitoring and data collected using smartphones may continue to attract scholarly attention (Mohr et al., 2017). Second, as technology advances and become less costly, we believe that virtual reality techniques will be used more frequently in research as they become more easily available and delivered via the internet (Lindner et al., 2017). Third, we foresee an expansion in research on blended treatments, in which components of ICBT and face-to-face CBT are combined (van der Vaart et al., 2014). This would be in line with stakeholder preferences and also with clinicians in general who want to complement rather than replace their clinical services with technology. Finally, given the speed of developing and testing new ICBT programs, we expect more research on

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transdiagnostic problems like procrastination (Rozental et al., 2015). This research will have the potential to inform regular CBT practice in cases where there are no manuals or clinical practice standards. In sum, ICBT is now a large and rapidly growing field that shows no signs of slowing down. Given the evidence base from controlled efficacy trials and an increasing number of effectiveness trials, we believe that ICBT is now ready for dissemination as a way to deliver CBT and reach more people in need.

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Silfvernagel, K., Westlinder, A., Andersson, S., Bergman, K., Diaz Hernandez, R., Fallhagen, L., Lundqvist, I., Masri, N., Viberg, L., Forsberg, M.-L., Lind, M., Berger, T., Carlbring, P., & Andersson, G. (2018). Individually tailored internet-based cognitive behaviour therapy for older adults with anxiety and depression: A randomised controlled trial. Cognitive Behaviour Therapy, 47(4), 286–300. https://doi. org/10.1080/16506073.2017.1388276 Strandskov, S. W., Ghaderi, A., Andersson, H., Parmskog, N., Hjort, E., Wärn, A. S., Jannert, M., & Andersson, G. (2017). Effects of tailored and ACT-Influenced internetbased CBT for eating disorders and the relation between knowledge acquisition and outcome: A randomized controlled trial. Behavior Therapy, 48(5), 624–637. https:// doi.org/10.1016/j.beth.2017.02.002 Svartvatten, N., Segerlund, M., Dennhag, I., Andersson, G., & Carlbring, P. (2015). A content analysis of client e-mails in guided internet-based cognitive behavior therapy for depression. Internet Interventions, 2(2), 121–127. https://doi.org/10.1016/ j.invent.2015.02.004 Titov, N., Andrews, G., Kemp, A., & Robinson, E. (2010). Characteristics of adults with anxiety or depression treated at an internet clinic: Comparison with a national survey and an outpatient clinic. PLOS ONE, 5(5), e10885. https://doi.org/10.1371/ journal.pone.0010885 Titov, N., Andrews, G., Schwencke, G., Drobny, J., & Einstein, D. (2008). Shyness 1: Distance treatment of social phobia over the internet. Australian and New Zealand Journal of Psychiatry, 42(7), 585–594. https://doi.org/10.1080/00048670802119762 Titov, N., Andrews, G., Schwencke, G., Robinson, E., Peters, L., & Spence, J. (2010). Randomized controlled trial of internet cognitive behavioural treatment for social phobia with and without motivational enhancement strategies. Australian and New Zealand Journal of Psychiatry, 44(10), 938–945. https://doi.org/10.3109/00048674. 2010.493859 Titov, N., Dear, B., Nielssen, O., Staples, L., Hadjistavropoulos, H., Nugent, M., Adlam, K., Nordgreen, T., Bruvik, K. H., Hovland, A., Repål, A., Mathiasen, K., Kraepelien, M., Blom, K., Svanborg, C., Lindefors, N., & Kaldo, V. (2018). ICBT in routine care: A descriptive analysis of successful clinics in five countries. Internet Interventions, 13, 108–115. https://doi.org/10.1016/j.invent.2018.07.006 Titov, N., Dear, B. F., Staples, L. G., Bennett-Levy, J., Klein, B., Rapee, R. M., Andersson, G., Purtell, C., Bezuidenhout, G., & Nielssen, O. B. (2017). The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives. Australian and New Zealand Journal of Psychiatry, 51(12), 1227– 1239. https://doi.org/10.1177/0004867416671598 Topooco, N., Riper, H., Araya, R., Berking, M., Brunn, M., Chevreul, K., Cieslak, R., Ebert, D. D., Etchmendy, E., Herrero, R., Kleiboer, A., Krieger, T., García-Palacios, A., Cerga-Pashoja, A., Smoktunowicz, E., Urech, A., Vis, C., Andersson, G., & the E-COMPARED consortium. (2017). Attitudes towards digital treatment for depression: A European stakeholder survey. Internet Interventions, 8, 1–9. https://doi.org/10. 1016/j.invent.2017.01.001 Tulbure, B. T., Szentagotai, A., David, O., Stefan, S., Månsson, K. N. T., David, D., & Andersson, G. (2015). Internet-delivered cognitive-behavioral therapy for social anxiety disorder in Romania: A randomized controlled trial. PLOS ONE, 10(5), e0123997. https://doi.org/10.1371/journal.pone.0123997 van Ballegooijen, W., Riper, H., Cuijpers, P., van Oppen, P., & Smit, J. H. (2016). Validation of online psychometric instruments for common mental health disorders: A systematic review. BMC Psychiatry, 16, 45. https://doi.org/10.1186/s12888-0160735-7 van der Vaart, R., Witting, M., Riper, H., Kooistra, L., Bohlmeijer, E. T., & van Gemert-Pijnen, L. J. (2014). Blending online therapy into regular face-to-face



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therapy for depression: Content, ratio and preconditions according to patients and therapists using a Delphi study. BMC Psychiatry, 14, 355. https://doi.org/10.1186/ s12888-014-0355-z Vigerland, S., Lenhard, F., Bonnert, M., Lalouni, M., Hedman, E., Ahlen, J., Olén, O., Serlachius, E., & Ljótsson, B. (2016). Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clinical Psychology Review, 50, 1–10. https://doi.org/10.1016/j.cpr.2016.09.005 Vigerland, S., Ljótsson, B., Bergdahl, F., Hagert, S., Thulin, U., Andersson, G., & Serlachius, E. (2014). Attitudes towards the use of computerized cognitive behavior therapy (cCBT) with children and adolescents: A survey among Swedish mental health professionals. Internet Interventions, 1(3), 111–117. https://doi.org/10.1016/j. invent.2014.06.002 Vigerland, S., Serlachius, E., Thulin, U., Andersson, G., Larsson, J.-O., & Ljótsson, B. (2017). Long-term outcomes and predictors of internet-delivered cognitive behavioral therapy for childhood anxiety disorders. Behaviour Research and Therapy, 90, 67–75. https://doi.org/10.1016/j.brat.2016.12.008 Vlaescu, G., Alasjö, A., Miloff, A., Carlbring, P., & Andersson, G. (2016). Features and functionality of the Iterapi platform for internet-based psychological treatment. Internet Interventions, 6, 107–114. https://doi.org/10.1016/j.invent.2016.09.006 Wagner, G., Penelo, E., Wanner, C., Gwinner, P., Trofaier, M. L., Imgart, H., Waldherr, K., Wöber-Bingöl, C., & Karwautz, A. F. (2013). Internet-delivered cognitivebehavioural therapy v. conventional guided self-help for bulimia nervosa: Longterm evaluation of a randomised controlled trial. British Journal of Psychiatry, 202(2), 135–141. https://doi.org/10.1192/bjp.bp.111.098582 Wangberg, S. C., Gammon, D., & Spitznogle, K. (2007). In the eyes of the beholder: Exploring psychologists’ attitudes towards and use of e-therapy in Norway. Cyberpsychology & Behavior, 10(3), 418–423. https://doi.org/10.1089/cpb.2006.9937 Webb, C. A., Olson, E. A., Killgore, W. D. S., Pizzagalli, D. A., Rauch, S. L., & Rosso, I. M. (2018). Rostral anterior cingulate cortex morphology predicts treatment response to internet-based cognitive behavioral therapy for depression. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3(3), 255–262. https://doi.org/10. 1016/j.bpsc.2017.08.005 Webb, C. A., Rosso, I. M., & Rauch, S. L. (2017). Internet-based cognitive-behavioral therapy for depression: Current progress and future directions. Harvard Review of Psychiatry, 25(3), 114–122. https://doi.org/10.1097/HRP.0000000000000139 Weingardt, K. R., Cucciare, M. A., Bellotti, C., & Lai, W. P. (2009). A randomized trial comparing two models of web-based training in cognitive-behavioral therapy for substance abuse counselors. Journal of Substance Abuse Treatment, 37(3), 219–227. https://doi.org/10.1016/j.jsat.2009.01.002

20 Combined Cognitive Behavioral Therapy and Pharmacotherapy Jesse H. Wright, Stephen S. O’Connor, Jessica Reis, and Michael E. Thase

C

ognitive behavioral therapy (CBT) and pharmacotherapy are the two most heavily researched treatments used for mental disorders. Developed from disparate theoretical models and research bases, the methods usually have been presumed to have different mechanisms of action—either psychological (CBT) or biological (pharmacotherapy). Thus, primary targets of CBT may be maladaptive patterns of thinking and behavior, whereas primary targets of pharmacotherapy may be brain functions involved in psychiatric illnesses.1,2 Despite these differences, the two forms of treatment have several common features. The therapies are (a) empirically grounded, (b) pragmatic and action oriented, (c) used for a broad range of psychiatric conditions, and (d) recognized as effective in treatment recommendations and guidelines from organizations such as the National Institute of Clinical Excellence (NICE), the American Psychiatric Association, and the American Psychological Association (Wright, 2007). Also, as we detail later in this chapter, there is growing evidence that CBT is a biologically active treatment influencing some of the same central nervous system pathways as medications and that pharmacotherapy can reduce dysfunctional thinking and behavior. Because research designs have typically pitted CBT against pharmacotherapy or combined treatment in attempts to determine relative efficacy, potential

The authors wish to thank Carol Wahl, who assisted with manuscript preparation, and Leslie Pancratz and Deborah Dobiesz, librarians at Norton Health Care in Louisville, Kentucky, who helped with literature searches. 2 Clinical examples are disguised to protect patient confidentiality. 1

https://doi.org/10.1037/0000219-020 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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mechanisms of interaction have received less attention by investigators. Nevertheless, theories of ways the treatments could influence one another were proposed from the time that effective antidepressants and other drugs were introduced (Group for the Advancement of Psychiatry 1975; Uhlenhuth et al., 1969; Wright, 1987, 2004). More recently, imaging studies have been producing clues on central pathways for treatment interactions (Furmark et al., 2002; Goldapple et al., 2004), and investigations with drugs such as d-cycloserine are examining medication effects on learning in psychotherapy (Charney et al., 2016; Otto, McHugh, & Kantak, 2010; Pull & Pull, 2014; Szuhany et al., 2014). We begin this chapter with a theoretical rationale for using an integrated treatment method, including a synthesis of key points from studies on biological effects of CBT. After providing a rationale for combined treatment, a succinct review is given of the extensive research on monotherapy versus CBT plus medication. Then we turn to a consideration of pragmatic clinical issues in using an integrated cognitive-behavioral-biological treatment, include a clinical example, and end the chapter with a discussion of future directions for research and clinical practice.3

THEORETICAL PERSPECTIVES ON COMBINED TREATMENT Four types of interaction between pharmacotherapy and psychotherapy were proposed almost 50 years ago (Uhlenhuth et al., 1969). These possible outcomes are: “(1) addition—the effect of the combined treatment is equal to the sum of the individual contributions; (2) potentiation—combined effects are greater than the sum of the individual components; (3) inhibition—results of combined therapy are less than the contributions from each individual treatment; or (4) reciprocation—the result of the two therapies combined is equal to the influence of the most potent treatment” (Wright & Schrodt, 1989). As we detail later in the chapter, randomized controlled trials (RCTs) have found Dr. Jesse Wright is an author of the Good Days Ahead computer program used in studies of computer-assisted CBT for depression (not discussed in this chapter) and has an equity interest in Empower Interactive and Mindstreet, developers and distributors of Good Days Ahead. He receives no royalties or other payments from sales of this program. His conflict of interest is managed with an agreement with the University of Louisville. He receives book royalties from American Psychiatric Publishing, Inc., Guilford Press, and Simon and Schuster. Dr. Wright receives grant support from the National Institute of Health (Agency for Health Care Research and Quality) and the Oticon Foundation. Dr. Michael Thase reports the following relationships. He is an advisory/consultant to Acadia, Alkermes, Allergan (Forest, Naurex), AstraZeneca, Cerecor, Eli Lilly, Johnson & Johnson (Janssen, Ortho-McNeil), Lundbeck, MedAvante, Merck, Mocksha8, Nestlé (PamLab), Neuronetics, Novartis, Otsuka, Pfizer, Shire, Sunovion, and Takeda. In addition to the National Institute of Mental Health, he received grant support from the Acadia, Agency for Healthcare Research and Quality, Alkermes, Assurex, Avanir, Axome, Forest Pharmaceuticals, Johnson & Johnson, Otsuka Pharmaceuticals, and Takeda. Dr. Thase received royalties from the American Psychiatric Press, Guilford Publications, Herald House and W.W. Norton & Company, Inc. Dr. Thase’s spouse, Dr. Diane Sloan, works for Peloton Advantage, which did business with Pfizer and AstraZeneca. Drs. Stephen O’Connor and Jessica Reis have no disclosures.

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evidence for additive effects for many disorders (e.g., 2 + 2 = more than 2 [perhaps 2.5]), but no potentiation (2 + 2 = more than 4), and little or no evidence of deleterious interactions (2 + 2 = less than 2). A number of more specific potential interactions have been theorized (see Tables 20.1 and 20.2), but most have not been investigated fully in empirical studies (Charney et al., 2016; Group for the Advancement of Psychiatry, 1975; Wright, 2007, 2014; Wright & Schrodt, 1989). We describe each of these suggested interactions here, starting with possible negative influences, and then examine them further in the section on combined CBT and pharmacotherapy in clinical practice. Our overall perspective is that there is a greater opportunity for salutatory effects than deleterious effects when CBT and pharmacotherapy are used together. Possible Negative Interactions Between Treatments From the time when effective antidepressants and anxiolytics were introduced and entered widespread use, concerns have been raised that medications might undercut motivation for psychotherapy by removing symptoms that cause enough emotional distress to make patients want to undergo a psychologically based treatment (Group for the Advancement of Psychiatry, 1975; Wright & Schrodt, 1989). In our clinical experience, we do see patients who decide to reduce the frequency of psychotherapy sessions or stop them entirely when they enter remission or have other substantive responses to treatment (often combined therapy). Moreover, as first asserted by Rounsaville et al. (1981) nearly 40 years ago, there is no evidence that the addition of medication to psychotherapy reduces motivation for behavior change or leads to an inappropriately early termination of psychotherapy. The addition of pharmacotherapy to psychotherapy does convey some greater risk of attrition due to side effects, which was estimated to be about 1.2-fold (i.e., 24% vs. 20% risk of attrition) compared with psychotherapy alone in the meta-analysis of Swift et al. (2017). However, despite this modest difference in attrition, meta-analyses of studies comparing combined treatment with psychotherapy alone showed a significantly greater symptom reduction (i.e., effect sizes ranging from 0.25 to 0.35) and a significantly higher probability of response/remission with combined therapy (i.e., Number Needed to Treat to benefit ranging from 7 to 10, which reflect an advantage of 10 to 15% in response/remission rates (Cuijpers et al., 2009, 2010, 2014). Possible negative interactions between pharmacotherapy and psychotherapy are listed in Table 20.1. The greatest concern has been that benzodiazepines might impair exposure-based treatments for anxiety disorders by interfering with extinction learning (Charney et al., 2016; Wright & Schrodt, 1989). However, the limited number of research studies that have examined this question have had inconsistent results. One early study (Marks et al., 1993) found that alprazolam may reduce the effectiveness of CBT for panic disorder. However, Rosen and coworkers (2013) observed that benzodiazepines did not lower the effectiveness of exposure therapy for posttraumatic stress disorder (PTSD).

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TABLE 20.1. Pharmacotherapy and Psychotherapy: Possible Negative Interactions Medication effects on psychotherapy • Decreased motivation for psychotherapy • Impaired learning and skill acquisition • Medication becomes a safety behavior • Dependency on medication makes psychotherapy more difficult

Psychotherapy effects on pharmacotherapy • Disruptive effect that impairs medication response • Devalues pharmacotherapy • Delays or otherwise interferes with patients receiving needed biological treatments

Another investigation (Westra et al., 2002) reported that regularly scheduled use of benzodiazepines had no negative effects on CBT for panic disorder, but “as needed” use led to a small decrement in effectiveness. Another issue in the treatment of anxiety disorders or other psychiatric conditions is potential for benzodiazepines to impair memory (Curran, 1986; Lister et al., 1988). A meta-analysis performed by Barker et al. (2004) found mediumto-large negative effect sizes (range –0.42 to –1.30) for benzodiazepines on a variety of cognitive functions, although a link between such laboratory assessments and a deleterious effect on therapy outcomes is tenuous. Moreover, Bierman et al. (2007) found a very small negative effect of benzodiazepines on cognition in the elderly. Glucocorticoid and amygdala-mediated learning has been proposed as a mechanism whereby benzodiazepines may impair skill acquisition (Otto, McHugh, Simon, et al., 2010). There also are the well-known risks of problematic use and drug dependence associated with benzodiazepines. However, from a public health perspective, the risk of dependence resulting from therapeutic prescription of benzodiazepines is relatively small: only about 10% of patients who begin treatment with a benzodiazepine will take the medication for 6 months or longer and only about one third of such “long-term users” will experience difficulties stopping treatment (Lader, 2014). The risks are minimized by not prescribing benzodiazepines to patients who have had prior problems with drugs or alcohol and, from the outset, conceptualizing therapy as a time-limited strategy. When problematic benzodiazepine use is recognized during ongoing treatment, a CBT approach can be used to taper patients off the benzodiazepine when it is having a negative impact on functioning and/or treatment outcome (Otto, McHugh, Simon, et al., 2010). Despite these concerns, we do not believe that it is justified to completely eschew prescription of benzodiazepines for patients receiving CBT. We have found that benzodiazepines are not always problematic for patients with severe anxiety disorders and—in the hands of judicious and collaborative prescribers—some patients who might not otherwise be helped can benefit greatly from targeted benzodiazepine therapy. Although pharmacotherapy often can have side effects that may cause distress, psychotherapy is not free of adverse reactions (Linden, 2013; Rheker et al., 2017; Rozental et al., 2016). Could CBT sometimes have a disruptive effect, thereby undermining the effectiveness of pharmacotherapy? Could cognitive



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behavioral therapists who hold strong opinions about the value of psychotherapy as opposed to medication be overzealous in encouraging patients to stop medication? Could therapists devalue pharmacotherapy, thus reducing the chances that patients will accept appropriate medications and/or take them reliably? All of these concerns may have validity in some cases and should not be ignored. We recommend persistent vigilance for possible negative effects of psychotherapy when combined treatment is selected and/or medication may have significant value in promoting positive treatment outcomes. Possible Positive Interactions Between Treatments Table 20.2 displays potential positive interactions between pharmacotherapy and psychotherapy. The placebo effect could possibly account for positive interactions by heightening expectancies for favorable outcomes, activating biological pathways involved in symptom relief, or other hypothesized mechanisms for the placebo response (Peciña et al., 2015; Rutherford & Roose, 2013). Although placebo responses are most often linked to treatment with medication, such effects are also possible with psychotherapy (Wright & Schrodt, 1989). Among the other ways that medication could positively influence psychotherapy, the suggestion that improved concentration or relief of other symptoms could make psychotherapy more tenable or effective has considerable appeal. For example, a patient with acute mania who is agitated, sleeping only a few hours a night, and has grandiose delusions would likely be a poor candidate for CBT until pharmacotherapy could begin to ameliorate symptoms. A subtler illustration is the use of antidepressants to improve concentration, energy, and interest—functions that might promote better uptake of cognitive restructuring and involvement in behavioral activation exercises in treatment of major depressive disorder. Cognitive behavioral therapists may consider psychotherapeutic interventions the prime, or perhaps only, route to reduce negative thinking. However, TABLE 20.2. Pharmacotherapy and Psychotherapy: Possible Positive Interactions Medication effects on psychotherapy

Psychotherapy effects on pharmacotherapy

• Positive placebo effect • Improved concentration, thus enhancing the impact of psychotherapy • Reduction of other symptoms (e.g., agitation, insomnia, psychotic thinking, mania, fatigue, intense anxiety, chronic pain) that could interfere with ability to benefit from psychotherapy • Decrease negative automatic thoughts, thus adding to the cognitive restructuring actions of CBT • Enhanced learning and skill acquisition

• Positive placebo effect • Increased medication adherence • Assists with medication discontinuation • Psychotherapy can help patients understand, accept, and have increased hope for pharmacotherapy • Psychotherapy has biological effects that can be additive or synergistic with CNS effects of medicationst

Note. CBT = cognitive behavioral therapy; CNS = central nervous system.

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studies of pharmacotherapy for depression have discovered that antidepressants also can reduce negative thinking (Fava et al., 1994; Kovacs et al., 1981; Lorenzo-Luaces et al., 2015). If properly dosed and implemented, could pharmacotherapy and CBT work in concert to promote more rational thinking? Clinicians who often use medication and CBT together may consider the two treatments to be partners in restoring a balanced, adaptive thinking style. In addition to possible facilitating effects of standard medications used in treatment of depression, anxiety, and other disorders, there has been a growing interest in research on alternative drugs that may have cognitive enhancing actions. One recent line of research has studied the effects of d-cycloserine—a partial N-methyl-D-aspartate (NMDA) agonist conceptualized as improving extinction learning through stimulation of NMDA glutamate synapses (McGuire et al., 2017) when combined with exposure-based treatment. Early metaanalyses demonstrated large-to-moderate effect sizes at posttreatment (d = 0.60) and at follow-up (d = 0.47; Norberg et al., 2008), whereas more recent metaanalyses have reported less impact in improving treatment outcomes (Ori et al., 2015). The current literature on d-cycloserine offers mixed findings on the drug’s utility as a treatment enhancer for individuals receiving exposure-based treatment. One recent meta-analysis by McGuire et al. (2017), which included 20 separate RCTs, found small (g = 0.33) effects for treatment efficacy of CBT + cycloserine versus CBT + placebo for anxiety disorders, with nonsignificant findings for PTSD and obsessive-compulsive disorder (OCD). In contrast, Mataix-Cols et al. (2017) completed a systematic review and meta-analysis of 21 RCTs of d-cycloserine for patients with anxiety disorders, PTSD, and OCD, and observed significant improvement at both posttreatment and follow-up. After controlling for the effect of antidepressants, they found significantly greater posttreatment improvement for those patients receiving d-cycloserine (vs. placebo) who were also engaged in exposure-based treatment, although the effect size was small (d = 0.25). Taking these two recent meta-analyses into account, it appears that d-cycloserine offers a small but potentially meaningful benefit to individuals receiving exposure-based treatment. Other drugs that have been studied as potential cognitive enhancers include 3,4-methyl­enedioxy­methamphetamine (MDMA), yohimbine, oxytocin, and modafinil (Charney et al., 2016; Mithoefer et al., 2011, 2013; Oehen et al., 2013; Szuhany et al., 2014; Thal & Lommen, 2018). The MDMA research has been somewhat controversial because this compound is used as a drug of abuse. Research on MDMA has found it can be safe to administer if in a pure, unadulterated form, and it has been shown to enhance treatment with psychotherapy in some but not all studies (Mithoefer et al., 2011, 2013; Oehen et al., 2013; Thal & Lommen, 2018). Several mechanisms other than the placebo effect may account for positive influences of CBT on pharmacotherapy (see Table 20.2). For example, improved adherence to medication regimens could be an important goal of combined treatment. Medication nonadherence is a major reason why pharmacotherapy may not be effective, and studies have typically found that 50% or more of



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patients do not take medications for mood disorders and other conditions reliably (Akincigil et al., 2007; Gilmer et al., 2004; Keck et al., 1997; Offord et al., 2013). Results of research on the influence of CBT on medication taking have supported the theory that CBT can promote improved medication adherence (Cochran, 1984; Kemp et al., 1996; Lecompte, 1995; Perris & Skagerlind, 1994). When medication discontinuation is the treatment goal, CBT may offer considerable help in weaning off drugs, such as benzodiazepines, that have dependency effects (Otto, McHugh, Simon, et al., 2010). CBT also could be used to help patients understand and manage discontinuation symptoms encountered when antidepressants are tapered and stopped for conditions such as major depressive disorder and panic disorder. Another possible way for CBT to facilitate pharmacotherapy is to apply the educational and cognitive restructuring components of psychotherapy to enhance patients’ understanding and acceptance of treatment with medication. If an integrated model is used, there can be a rational, fact-based discussion of the benefits and risks of medications, and the cognitive behavioral therapist (either alone if a prescribing clinician that is trained in CBT, or as a team of nonprescribing therapists and prescribing clinicians) can strive for a fully collaborative approach to medication taking that promotes realistic hope for a positive treatment response. Last, there is the burgeoning area of research investigating the hypothesis that CBT and other forms of psychotherapy have additive treatment effects for people with mood or anxiety disorders because these treatments address distinctly different, and potentially complementary, brain mechanisms (Barsaglini et al., 2014; Kalsi et al., 2017; Quidé et al., 2012). It also seems likely that different pretreatment profiles may differentially moderate response to CBT or pharmacotherapy (Goldapple et al., 2004; McGrath et al., 2013; Siegle et al., 2012). For example, in the recent study of Dunlop et al. (2017), a measure of the strength of resting connectivity among prefrontal cortical regions was associated with a higher likelihood of remission with CBT and a lower probability of remission with treatment using escitalopram (a selective serotonin reuptake inhibitor). Although it borders on cliché to say that, with respect to targeted brain mechanisms, CBT acts “from above” (i.e., via functions mediated by regions such as the dorsolateral prefrontal cortex) and antidepressants act “from below” (i.e., via direct and indirect effects on monoaminergic tracts ascending from brainstem nuclei), this indeed remains the most parsimonious explanation of differential treatment effects (DeRubeis et al., 2008; Dunlop & Mayberg, 2014). Moreover, in cases in which the severity of state-dependent brain dysfunction—as might be reflected by marked changes in sleep electrophysiology, alterations in brain neurocircuitry, or perturbations in stress hormone secretion—adversely affect response to pharmacotherapy or psycho­therapy alone, a combined or staged/sequential approach may have particular benefits. Consistent with this hypothesis, the findings of a meta-analysis of individual patient data suggested that the advantage of combined treatment over psychotherapy alone was primarily observed among more severely depressed patients with more highly recurrent depressive episodes (Thase et al., 1997).

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RATIONALE FOR COMBINED TREATMENT Research studies have made major contributions to understanding the relative efficacy of CBT, medication, and combined treatment (see meta-analyses by Bandelow et al., 2015; Canton et al., 2012; Cuijpers et al., 2013, 2015; Dugosh et al., 2016; Grilo et al., 2016; Hofmann et al., 2009; Manber et al., 2008; Romanelli et al., 2014; Skapinakis et al., 2016; and Watanabe et al., 2009). As detailed in the section on outcome studies later in this chapter, meta-analyses have found an advantage for combined treatment for depression, bipolar disorder, eating disorders, and psychosis, whereas overall results for treatment of anxiety disorders have been mixed. However, there are many problems in extrapolating results of RCTs to clinical practice (Friedman et al., 2006; Wright, 2004, 2007, 2014; Wright & Schrodt, 1989). We briefly discuss these issues here to provide context for our rationale for combined treatment, which rests as much on clinical experience and need as on empirical research. Our main conclusion from reviewing RCTs is they may have undervalued combined treatment and may not provide information that can be directly extrapolated into clinical decision making. Some of the limitations of RCTs on monotherapy versus combined treatment are listed in Table 20.3. Foremost among the issues that confound the interpretation of results of RCTs are the strictures placed on the treatments in order to make them replicable in experimental protocols (Friedman et al., 2006; Wright, 2004, 2007, 2014). For example, pharmacotherapy usually is conducted with fixed dose regimens that lack the customization commonly used in clinical practice. A typical protocol for depression might continue a patient on the same antidepressant for 12 to 16 weeks. However, most pharmacotherapists would usually modify the dose, switch medications, and/or use various adjuncts if the patient is not responding adequately to treatment within 4 to 8 weeks. Likewise, the probability of dropping out because of medication side effects is magnified in RCTs because it is usually not possible to switch patients to dissimilar (and hopefully better tolerated) alternatives. In a similar manner, CBT may follow a manual that helps ensure standardization of treatment delivery but puts constraints on therapists that would not be present in TABLE 20.3. Limitations of Randomized Controlled Trials of Combined CBT and Pharmacotherapy • Treatments not flexible or customized as in clinical practice • Inclusion criteria may yield more homogeneous patient populations than are seen in clinical practice • Severity and phase of illness not considered in treatment selection • Treatments not delivered with integrated model and method • Inadequate sample sizes • Studies may have features that bias against one or more therapy methods • Analysis of mean responses may obscure positive or negative interactions in individual patients • Patient preferences for treatment typically are not considered • Studies not focused on potential mechanisms of interaction



Combined Cognitive Behavioral Therapy and Pharmacotherapy  641

nonresearch settings. Also, therapy sessions usually are recorded, and therapists receive weekly supervision to improve fidelity of treatment. These procedures could either enhance the effects of CBT, as compared with delivery in clinical practice, or perhaps impair efficacy. Another typical requirement of RCTs designed to test efficacy is the use of restrictive inclusion/exclusion criteria to provide a study population that does not have comorbidities commonly encountered in clinical practice. When tight inclusion/exclusion criteria are used, the patients studied may not have problems that could be treated best with a combined approach (e.g., bipolar disorder, major depression with psychotic features, attention-deficit disorder). A related problem is lack of attention to the severity or phase of illness. As Thase (2014) has argued, monotherapies might be sufficient for uncomplicated, milder forms of illness, but severe or chronic conditions could respond better to more aggressive treatment with combined therapies. Although meta-analyses counter the problem of inadequate sample sizes to some extent, the majority of RCTs of combined treatment have been underpowered to find advantages of one form of therapy (Friedman et al., 2006). Because adequately powered outcome studies are expensive and difficult to conduct, and current research funding has been focused primarily on areas other than comparisons of monotherapies versus combined pharmacotherapy and psychotherapy, it is unlikely that enough large-scale, head-to-head comparisons of monotherapies versus combined treatment will be conducted (at least in the near future) to fully answer questions of the relative value of therapies. Because RCTs parcel out CBT to therapists who do not prescribe medication and to pharmacotherapists who presumably are only prescribing medication and providing clinical management, the research design explicitly endorses a split method of treatment delivery as opposed to an integrated method in which both therapies are delivered by the same clinician who is skilled in CBT and pharmacotherapy or teams of clinicians who use a comprehensive model and communicate regularly. We are not aware of a study that examined the effects of fully integrated treatment delivery. Among the design issues that could influence or bias results is the use of “clinical management” along with medication prescription in pharmacotherapy. The three authors of this chapter (JHW, JR, MET) who are psychiatrists and routinely prescribe medication along with therapy in brief sessions (approximately 20 minutes) know that such sessions typically contain many useful functions of psychotherapy, including “nonspecific” elements of all therapies (e.g., collaboration, support, empathy, active listening) in addition to methods drawn from CBT (e.g., behavioral activation, development of coping strategies, cognitive restructuring; Wright et al., 2010). Typical protocols for pharmacotherapy in RCTs involve four to eight visits with a psychiatrist for “clinical management” lasting about 25 minutes. Usually, the activities of the clinician in these sessions is not monitored or controlled. Although little is known about the possible psychotherapeutic elements in clinical management, we think that the only true monotherapy in RCTs of combined treatment is CBT. The single

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study we have found that specifically forbade psychotherapeutic activities was reported by Murphy et al. (1995). Interestingly, CBT performed better than pharmacotherapy for depression in this investigation—a result that stands in contrast to a large body of research on CBT and medication for depression (Wright, 2014). Two other design elements that have received little attention stand out as factors that could influence interpretation of results of RCTs. First, statistical methods that compare mean responses may obscure positive or negative interactions between treatments, particularly amongst relatively small subsets of patients. To illustrate, one patient might have a robust improvement in symptoms of depression (including concentration) that could have a favorable effect on participation in CBT; whereas another patient could have side effects such as excessive sedation or sleep disruption that would impair ability to utilize psychotherapy. A conclusion that there are no interactions between pharmacotherapy and CBT would be erroneous in such a scenario. Lack of consideration of patient preference for treatment is another design question that typically has not been addressed. Most studies that have examined effects of treatment preference have been on psychotherapy versus pharmacotherapy, not combined treatment (Gelhorn et al., 2011; Lindhiem et al., 2014). However, a large study of treatment with the cognitive behavioral analysis system of psychotherapy (CBASP), supportive therapy, antidepressant medication, or combined treatment found a large preference for combined therapy (Steidtmann et al., 2012). Finally, RCTs of monotherapies versus combined therapy usually have not been designed to look at the interface between treatments to search for potential mechanisms of action, such as those listed in Tables 20.1 and 20.2. Because there are indications from other research that positive interactions do exist and could be facilitated with an integrated treatment delivery model, and there are potential negative interactions that might be avoided if considered in treatment plans, we conclude that attempts to better understand and implement combined treatment are warranted. We propose that the rationale for selecting and using monotherapies or combined treatment include more than the findings of RCTS that have studied treatment outcome. Other factors to be considered include (a) the need for customization of treatment; (b) consideration of severity, comorbidities, and phase of illness; (c) patient preference; (d) the potential for enhancing outcome by promoting positive interactions (e.g., adherence, improved concentration, reduction in symptom burden, learning enhancement); and (e) possible biological effects of CBT.

EMPIRICAL RESEARCH ON MONOTHERAPY VERSUS COMBINED TREATMENT Depression Monotherapy with CBT or medication has been compared with combined treatment for depression in a large number of RCTs. Although individual stud-



Combined Cognitive Behavioral Therapy and Pharmacotherapy  643

ies often have not reported a statistically significant advantage for combined treatment, meta-analyses have consistently found that combined CBT and pharmacotherapy offers greater benefit than either treatment alone (Cuijpers et al., 2013, 2015; Friedman et al., 2006; Manber et al., 2008). Despite problems with sample size in research on treatments for depression (Thase, 2014), there is solid evidence that combined therapy gives the best chance for symptomatic improvement. In a meta-analysis of 115 studies of CBT, pharmacotherapy, or combined treatment for the acute phase of depression, Cuijpers et al. (2013) found no evidence that CBT was more effective than monotherapy with antidepressants or with other therapies. However, CBT plus medication had significantly greater efficacy. The Hedges’s g effect size for this comparison was 0.49, indicating a moderate effect for combined therapy over treatments administered alone. In a subsequent meta-analysis that included all psychotherapies compared with pharmacotherapy, pill placebo, or combined treatment, Cuijpers et al. (2015) reported similar results. Overall, combined treatment had a significant effect on depression compared with pill placebo (g = 0.46), pharmacotherapy alone (g = 0.38), or psychotherapy alone (g = 0.34). There was no difference in effectiveness of the various psychotherapies, except for a somewhat lower effect size for interpersonal therapy in the combined comparison (g = 0.14), compared with CBT (g = 0.47) and other psychotherapies (g = 0.41). The reasons for the advantage for combined treatment for depression remain unknown. However, Thase (2014) and Craighead and Dunlop (2014) have suggested that different forms of depression (e.g., “anxious” depression, chronic depression, social deprivation-influenced depression) may respond differentially to CBT and medication, thus yielding an additive effect for using more than one therapy. With growing evidence that this cluster of problems should be conceptualized as “depressions” instead of a unitary “depression,” it may be useful to examine differential response in future research (Craighead & Dunlop, 2014). Other possible mechanisms for positive interactions between CBT and pharmacotherapy are discussed in the section of this chapter on theoretical perspectives. Bipolar Disorder The standard treatment for bipolar disorder continues to be pharmacotherapy with mood stabilizers (e.g., lithium, valproate, carbamazepine, and lamotrigine) and atypical antipsychotic medications (e.g., quetiapine, aripiprazole, risperidone, and lurasidone). Although such medications have been shown to be effective for acute mania and depression and to reduce the risk of relapse (Ostacher et al., 2016), treatment responses vary. Some patients have excellent results, and some show treatment resistance, partial responses, and return of symptoms. Thus, CBT methods have been developed for bipolar disorder (Basco & Rush, 2005; Newman et al., 2002; Wright et al., 2010), and adjunctive psychotherapy has been investigated as a possible way to enhance the effectiveness of treatment.

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Studies of CBT added to pharmacotherapy have had varied results (Ball et al., 2006; González Isasi et al., 2014; Lam et al., 2003; Miklowitz et al., 2007; Parikh et al., 2012; Scott et al., 2006). An initial study by Lam et al. (2003) provided encouraging findings on the potential for combined treatment of bipolar disorder. In this trial, adjunctive CBT had a strong impact on reducing relapse/recurrence, in addition to improving adherence with pharmacotherapy and enhancing coping skills (Lam et al., 2003). However, studies by Scott et al. (2006) and Parikh et al. (2012) failed to confirm these positive results. In the Scott et al. (2006) investigation, patients with a history of fewer episodes of bipolar illness did have a better response to combined treatment than monotherapy. Other investigations by Ball et al. (2006) and Miklowitz et al. (2007) found an advantage for adding CBT to medication for bipolar disorder. The Miklowitz et al. (2007) report came from a large and influential multicenter study (Systematic Treatment Enhancement Program for Bipolar Disorder [STEP-BD]). Three forms of psychotherapy (CBT, family-focused therapy, and interpersonal-social rhythms therapy) were added to treatment with a mood stabilizer or an atypical antipsychotic medication. After a year, patients who received any psychotherapy were 15% more likely to remit/ recover than those who did not receive psychotherapy (Miklowitz et al., 2007). Although there has been a limited amount of research on adjunctive CBT in treatment of bipolar disorder, a recent meta-analysis (Chiang et al., 2017) concluded that adding CBT to pharmacotherapy has significant effects on improving depressive (g = 0.494) and manic symptoms (g = 0.581), enhancing psychosocial functioning (g = 0.497), and reducing the risk for relapse (OR + 0.506). Another meta-analysis found that CBT plus psychoeducation reduced medication nonadherence, reduced manic symptoms, and improved Global Assessment of Functioning (Chatterton et al., 2017). As clinicians who treat many patients with bipolar disorder, we believe there are advantages for combining CBT with medication for patients who have these life-long disorders. Thus, we typically recommend that comprehensive long-term treatment plans include both treatments. Frequent targets for treatment with CBT include psychoeducation about the disorder and its treatments, learning to spot and respond to early signs of cycling into depression or mania, building coping skills, and treatment adherence (Wright et al., 2010) Anxiety Disorders Panic disorder, generalized anxiety disorder (GAD), and social anxiety disorder (SAD) are included under the broad rubric of anxiety disorders in the classification system of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) and are associated with a significant decline in overall quality of life functioning (Barrera & Norton, 2009). Findings from a recent meta-analysis examining the efficacy of psychotherapy, medications, and combined treatment for the treatment of anxiety disorders demonstrated a larger pre-post effect size for medications (Cohen’s d = 2.02) compared with psychotherapy (Cohen’s d = 1.22), with a large effect size for combined therapy that involved both medication and psychotherapy



Combined Cognitive Behavioral Therapy and Pharmacotherapy  645

(Cohen’s d = 2.12; Bandelow et al., 2015). Individual CBT comprised 52% of the therapies included in the meta-analysis and had a large effect size (Cohen’s d = 1.30). When examining these disorders individually and over a longer period of time, the research literature reflects a more complicated picture regarding the individual and combined impact of CBT and medications. Panic Disorder There is a well-developed body of research that supports the efficacy of monotherapy with CBT, medication, or the combination of the two treatments for individuals with panic disorder (Mitte, 2005; Szuhany et al., 2014; van Balkom et al., 1997). Serotonin reuptake inhibitors (SRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended before benzodiazepines, which introduce concerns about physiological dependence and heightened side effects (Ballenger et al., 1998). A previous meta-analysis indicated that combining psychotherapy (typically behavior therapy or CBT) and antidepressants resulted in the greatest therapeutic gains in the acute period compared with standalone antidepressant (relative risk [RR] = 1.24, 95% confidence interval [CI] [1.02, 1.52]) and psychotherapy (RR = 1.17, CI [1.05, 1.31]). Combined treatment remained superior to antidepressants alone over longer periods (RR = 1.61, 95% CI [1.23, 2.11]) but was no more effective than psychotherapy alone (RR = 0.96, 95% CI [0.79, 1.16]; Furukawa et al., 2007). Another meta-analysis found that benzodiazepines plus behavior therapy is no more effective than behavior therapy alone (RR = 1.25, 95% CI [0.78, 2.03]; Watanabe et al., 2009), whereas a separate study demonstrated that behavior therapy alone may lead to greater response and maintenance of treatment gains over time compared with combination treatment or benzodiazepine monotherapy (Marks et al., 1993). Generalized Anxiety Disorder Both CBT and medications have demonstrated efficacy in treating patients with GAD as compared with medication placebo, attention controls, or wait-list control groups; however, there is generally a dearth of research investigating the added benefits of a combination approach (Baldwin et al., 2011; Crits-Christoph et al., 2011; Cuijpers et al., 2014). Research providing the strongest support for combination treatment has been found in studies involving older adults or children. For older adults, a four-arm CBT/escitalopram study of older adults with GAD demonstrated the greatest reductions on worry symptoms for individuals who received the combination treatment, with each monotherapy also preventing relapse at a higher rate than pill placebo (Wetherell et al., 2013). Similarly, in a large, multisite study of children with anxiety disorders (79% were diagnosed with GAD), combination therapy that included CBT and sertraline resulted in the greatest amount of clinical improvement compared with either monotherapy or pill placebo (Walkup et al., 2008). More specifically, 80.7% receiving combination therapy were classified as much or very much improved on a global rating scale, compared with 59.7% for CBT and 54.9% for sertraline. Each monotherapy was significantly more effective in improving clinical symptoms as compared with pill placebo.

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Social Anxiety Disorder Research on SAD indicates support for combined and monotherapy treatment (Mayo-Wilson et al., 2014), although results for combined treatment have been inconsistent in adult samples. In one multisite study of adults with SAD, Blanco et al. (2010) found that a combination of group CBT and phenelzine sulfate resulted in the greatest reductions in anxiety symptoms, as well as overall clinical improvements at 12 and 24 weeks as compared with either monotherapy or pill placebo. Each of the monotherapies outperformed the placebo group. In comparison, a multisite study of adults with social phobia comparing fluoxetine, CBT group therapy, placebo, and combined treatment found that whereas each treatment condition was more effective in reducing associated symptoms in comparison with placebo, no added benefit was found for the combined treatment group (Davidson et al., 2004). With regard to youth, 82% of the of the children included in Walkup et al. (2008) also met criteria for the DSM-IV diagnosis of social phobia, indicating that combined treatment was the most effective approach at improving clinical functioning compared with monotherapy or pill placebo. Posttraumatic Stress Disorder There are several trauma-focused treatments that utilize aspects of CBT that are efficacious in the treatment of PTSD, including prolonged exposure (Foa et al., 2005), cognitive processing therapy (Resick et al., 2012), and eye-movement-desensitization and reprocessing (Chen et al., 2014). First line medication therapy involves SRIs and SNRIs (Lee et al., 2016). Although the literature on combined treatment is underdeveloped (Hetrick et al., 2010; Pull & Pull, 2014), some research has demonstrated the utility of combining or augmenting treatment through a combined approach. In a study of adult patients with PTSD following the World Trade Center attack, combined paroxetine and prolonged exposure was shown to be significantly more effective in reducing posttraumatic stress symptoms compared with prolonged exposure plus placebo (Schneier et al., 2012). In an augmentation study design, Rothbaum et al. (2006) demonstrated a significant reduction in PTSD symptoms in patients who had a partial response to sertraline by adding 10 weeks of prolonged exposure compared with patients who continued on sertraline monotherapy. In comparison, Simon et al. (2008) found that although prolonged exposure was efficacious in treating patients with PTSD, there was no observed benefit to adding paroxetine for those patients who remained symptomatic after eight therapy sessions of psychotherapy. Obsessive-Compulsive Disorder CBT-informed treatment (i.e., behavior therapy and cognitive therapy) and SRIs are both supported as effective treatments for OCD (Skapinakis et al., 2016). In a recent network meta-analysis, larger mean differences were observed



Combined Cognitive Behavioral Therapy and Pharmacotherapy  647

for behavioral (–6.79, 95% CI [10.44, 3.11]) and cognitive (–5.83, 95% CI [10.17, 1.51]) therapies in reducing obsessive compulsive symptoms compared with a reference class of SRIs, but many of the patients included in these trials were also taking SRIs. Recent research has demonstrated that among patients stabilized on an SRI, those receiving exposure and response prevention had significantly greater improvements as compared with patients who were prescribed risperidone (Simpson et al., 2013). Follow-up moderator analyses revealed that although exposure and response prevention worked equally well for all levels of OCD severity, risperidone was less effective for individuals with more severe OCD, strengthening the assertion that exposure and response prevention is a preferable augmentation strategy to SRIs (Wheaton et al., 2015). Binge-Eating Disorder Critical reviews and meta-analyses of the treatment literature support CBT as the best-established treatment for binge-eating disorder (Iacovino et al., 2012; Wilson et al., 2007). The NICE guidelines identify CBT as the treatment of choice for patients with binge-eating disorder (NICE, 2004). CBT has demonstrated continued benefit at 24-month follow-up (Grilo et al., 2016). Pharmacotherapy for binge-eating disorder is a more controversial topic in the literature. One medication, lisdexamfetamine, is FDA-approved for binge-eating disorder after 3 RCTs demonstrated its superiority over placebo for binge-eating abstinence after 11 weeks. However, there has not been longer-term follow-up or direct comparison with CBT (Grilo et al., 2016). The addition of various classes of medications to CBT have been evaluated, and, in certain cases, superior outcomes have been demonstrated. Two anticonvulsant medications (i.e., topiramate and zonisamide) when combined with CBT have shown greater efficacy compared with CBT alone in the reduction of eating disorder pathology and weight (Claudino et al., 2007; Ricca et al., 2009). There is some limited support for adding anti-obesity medication (i.e., orlistat) to CBT to enhance treatment outcomes, particularly weight loss (Grilo et al., 2016). Novel medications approved for the treatment of obesity have not been studied alone or in combination with CBT for binge-eating disorder. There is currently a lack of evidence for the use of antidepressant monotherapy or in combination with CBT for binge-eating disorder (Grilo et al., 2016). Substance Use Disorders Alcohol Use Disorder Several psychosocial interventions and pharmacotherapy with FDA-approved medications are used for the treatment of alcohol use disorder. Despite these well-established interventions, relapse to heavy drinking is common in alcohol dependence. Low rates of sustained sobriety have led researchers to investigate whether combined treatments and matched patient-treatment interventions may be more efficacious than monotherapy with psychotherapy or pharmacotherapy alone.

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Results from an influential National Institute on Alcohol Abuse and Alcoholism (NIAAA) sponsored study were published in 1997 (NIAAA, 1997). The outcomes suggested that CBT, motivational enhancement therapy, and 12-step facilitation counseling are equally efficacious in treating alcohol use disorders. There was no benefit from matching patients with specific therapies (NIAAA, 1997). These three modalities continue to be mainstay psychosocial interventions for alcohol use disorder. In addition to psychotherapy, there are four FDA approved medications for alcohol use disorder (i.e., oral naltrexone, monthly injectable naltrexone, oral acamprosate, and oral disulfiram), as well as a number of medications that are widely used to facilitate safe withdrawal from alcohol and/or promote early abstinence and the transition to sobriety (e.g., diazepam, gabapentin, phenobarbital, topiramate). The COMBINE study (Anton et al., 2006), which followed Project MATCH, sought to determine if improvements in treatment outcome for alcohol use disorders could be achieved by combining pharmacotherapy and behavioral interventions. The efficacy of naltrexone and acamprosate, singly and combined, was assessed when used with or without behavioral therapies in an attempt to assess the advantage of adding psychotherapy to medication. The behavioral therapy tested, combined behavioral intervention (CBI), was derived from previously proven treatments including CBT and motivational enhancement therapy. All groups in the COMBINE study showed a reduction in drinking, measured as percent days abstinent from alcohol and time to first heavy drinking day. The groups receiving naltrexone alone, CBI + placebo, and naltrexone + CBI had the highest percentages of days abstinent (80.6, 79.2, and 77.1, respectively) compared with those receiving placebo and medical management alone (75.1; Anton et al., 2006). A meta-analysis of six studies did not show significant benefit in adding CBT to naltrexone treatment (Agosti et al., 2012). Alternatively, several studies have demonstrated a synergistic effect when pharmacotherapy is added to CBT, with better outcomes than CBT alone (Anton et al., 1999; Feeney et al., 2006). Thus, results of investigations on combined CBT and medication for alcohol use disorder are mixed but seem to suggest that adding pharmacotherapy to CBT is most likely to improve outcomes. In contrast, there is not clear evidence at this point to support adding CBT to pharmacotherapy. Opioid Use Disorder There are currently three FDA-approved medications to treat opioid use disorder in the United States. These include methadone, buprenorphine, and naltrexone (American Society of Addiction Medicine, 2015). There is evidence that when utilized as indicated and as part of a comprehensive treatment program including medical, social, and psychological intervention, these medications are effective in reducing opioid use and public health and safety problems related to opioid use (American Society of Addiction Medicine, 2013). A variety of psychosocial interventions are commonly utilized in conjunction with these medications and include supportive counseling, motivational interviewing, contingency manage-



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ment, CBT, and family training. The delivery of these interventions may occur in detoxification, intensive outpatient, or outpatient settings. Individual, group, telephone, and web-based therapies have all been employed for the treatment of opioid use disorders (Carroll & Onken, 2005). Despite the variety of interventions and delivery models, there is scarcity of empirical evidence to guide clinicians when they are making treatment decisions for patients with opioid use disorders. A systematic review of the literature on the combination of psychosocial interventions and medication found support for efficacy of combined pharmacotherapy and psychotherapy although some studies have not shown benefit over pharmacotherapy alone (Dugosh et al., 2016). In addition, there is little evidence to support a specific psychosocial approach as the most efficacious in combination treatment because few studies compare the differential effectiveness of psychosocial therapies (Dugosh et al., 2016). However, the most widely studied psychosocial interventions have been contingency management and CBT. One large review demonstrated improved outcomes when CBT was used as an adjunct to methadone maintenance therapy (Dugosh et al., 2016). In general, studies have failed to examine the influence that comorbid psychiatric disorders, including other substance use disorders, may have had on outcomes. Psychosis There is now solid evidence that the addition of CBT to antipsychotic medication can improve outcomes. A meta-analysis of a large number of studies found moderate effect sizes (g = 0.47 for positive symptoms, g = 0.52 for general symptoms) for the combination of CBT and medication compared with medication alone (Burns et al., 2014), and the NICE in the United Kingdom has strongly recommended that all patients with schizophrenia have CBT added to medication. Although one study has shown positive effects of CBT alone in patients who refuse medication (Morrison et al., 2014), little is known about the potential for monotherapy with CBT. Summary The overall results of outcome studies comparing CBT, pharmacotherapy, and combined treatment are summarized in Table 20.4.

COMBINED CBT AND PHARMACOTHERAPY IN CLINICAL PRACTICE When CBT and pharmacotherapy are delivered together, we recommend that an integrated, comprehensive model be used to guide treatment (Wright, 2004; Wright et al., 2010; Wright & Thase, 1992). Key principles of this model include these assumptions: • Cognitive processes modulate the effects of the external environment (e.g., stressful life events, interpersonal relationships, social forces) on the central

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TABLE 20.4. Combined CBT and Pharmacotherapy: Summary of Results of Outcome Research Condition

Additive effects

Subtractive effects

Major depression

++

0

Bipolar disorder

+

0

Anxiety disorders (benzodiazepines)

0

0/+

Anxiety disorders (antidepressant therapy)

+

0

Posttraumatic stress disorder

+

0

Obsessive-compulsive disorder

+

0

Bulimia nervosa

+

0

Substance use disorders

+

0

Psychosis

++

0

Note. 0 = No consistent evidence for interaction, + = Small to moderate evidence of additive effects, ++ = Strong evidence with 2 or more meta-analyses showing additive effects, 0/+ = Little evidence of subtractive effects.

nervous system (CNS) substrate (e.g., activation of CNS pathways, neurotransmitter function, autonomic and neuroendocrine responses) for emotion and behavior. • Dysfunctional cognitions can be produced by both psychological and biological influences. • Biological treatments can alter cognitions. • Cognitive and behavioral interventions effect biological processes. • Environmental, cognitive, biological, emotional, and behavioral processes should be conceptualized as part of the same system. • It is valuable to search for ways of integrating or combining cognitive and biological interventions to enhance treatment outcome. (Wright, 2004, p. 346) There are a variety of ways to deliver an integrated course of CBT plus medication following the general principles of the cognitive-biological model. If a psychiatrist or psychiatric nurse practitioner is trained in CBT and can arrange their practice to provide both treatments, there will be an ease of integration that is difficult to match when treatment is managed by two or more clinicians. Since the adoption of a mandate for CBT education in psychiatric residency programs in the United States and increased emphasis on CBT training for psychiatrists in other countries, there are a growing number of prescribing clinicians who are capable of providing combined treatment. However, this singular mode of delivery is less common than a dual approach in which a psychiatrist, primary care doctor, nurse practitioner, or other prescribing clinician has responsibility for pharmacotherapy while a psychologist, social worker, or other therapist performs CBT. Several possible ways of delivering combined treatment are outlined in Table 20.5 (Wright et al., 2010).



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The second format in Table 20.5 can achieve a highly integrated approach, even when two clinicians are involved. They work in the same practice, see one another frequently, share the same electronic healthcare record, develop a collaborative treatment plan, and can have “curbside consults” to work together closely in delivering comprehensive therapy. If the psychiatrist is experienced in CBT, brief sessions with the patient often may contain more than “medication management.” For example, the psychiatrist may ask about and reinforce homework exercises from the therapist and implement (in coordination with the therapist) brief CBT interventions (e.g., behavioral activation, safety plans, coping cards, thought records). This method of delivering CBT and pharmacotherapy has been detailed in the book High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Wright et al., 2010). Format 3 in Table 20.5 describes treatments in which the clinicians may not work in the same practice, but they still attempt to communicate and forge a shared treatment plan, whereas Format 4 outlines situations where the prescribing and nonprescribing clinicians have little or no communication and work largely in parallel. We think that when there are dual clinicians, the ideal environment for combined treatment should include communication between the providers, valuing and supporting the “other” therapy methods, and collaboration in developing the treatment plan. Some additional suggestions for integrating treatments include the following: 1. Use the structure of therapy to promote integration. Because structuring is a fundamental element of CBT and pharmacotherapy, it can be used to bring the therapies together. Goal- and agenda-setting, feedback, and artful pacing are TABLE 20.5. Formats for Combined CBT and Pharmacotherapy

Provider(s)

Work in same practice

1. Psychiatrist/nurse practitionera

NA

NA

NA

Yes

2. Psychiatrist/nurse practitioner and cognitive-behavioral therapist

Yes

Yes

Yes

Yes

3. Psychiatrist/nurse practitioner/primary care doctor and cognitive-behavioral therapist

Yes/No

Yes

Yes

Yes/No

4. Psychiatrist/nurse practitioner/primary care doctor and cognitive-behavioral therapist

No

No

No

Yes/No

Note. CBT = cognitive behavioral therapy. NA = not applicable.

a

Prescribing Collaborative clinician Communicate treatment provides CBT or regularly plan assists with CBT

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used to keep CBT sessions on target and productive. In pharmacotherapy, sessions are typically organized around symptom checks, side-effect assessment, and medication prescription. Both treatments are pragmatic and try to use time wisely. When one therapist is providing both treatments, the agenda can include items from both approaches, collected and addressed as a unitary method of working toward goals. When there are dual clinicians, the cognitive behavioral therapist can solicit concerns about symptoms and medication effects for agendas, whereas the pharmacotherapist can make room on the agenda for discussions of responses to CBT, questions about homework assignments, or other CBT-related topics. 2. Educate on a comprehensive treatment model. Psychoeducation is another shared element of CBT and pharmacotherapy that can be used to promote an integrated therapy approach (Wright, 2004). Both treatments may use minididactic sessions, readings, internet searches, or other methods to help patients understand and use treatment to their benefit. Conventional pharmacotherapy, managed by a clinician not experienced in CBT, may use less Socratic questioning (i.e., asking questions that help the patient search for the answer) as a teaching method than CBT. Yet we think that effective pharmacotherapists often employ a collaborative style that draws the patient into the learning process. When a single clinician or tightly knitted teams of clinicians are delivering combined therapy, educational methods can underscore the potential value of comprehensive treatment, and educational materials can be selected to give the patient a message that is consistent with the cognitive-biological model. For example, shared opinions could be given that alprazolam has a risk for impairing the effectiveness of exposure therapy or that behavioral activation is a key element in recovery from severe depression. Another example could be educating patients with anxiety disorders on neuroimaging findings that show psychotherapy can decrease hyperactive amygdala functioning and improve other limbic system functioning (Cervenka et al., 2012; Klumpp et al., 2014). A fundamental tenet of psychoeducation for combined treatment is to provide the most accurate, up-to-date information available. Clinicians can recommend self-help books such as Breaking Free from Depression: Pathways to Wellness (Wright & McCray, 2011) that equally value and represent CBT and pharmacotherapy. Examples of other self-help books that give a balanced view of therapy options and can be used in support of combined treatment are Mastery of Your Anxiety and Worry (Barlow & Craske, 2006), The Anti-Anxiety Workbook (Antony & Norton, 2009), and Feeling Good: The New Mood Therapy (Burns, 2008). 3. Address adherence issues in pharmacotherapy and CBT. Adherence to treatment recommendations is an important key to success in both pharmacotherapy and CBT. Although lack of consistency of medication taking is the most obvious reason why treatment may not be working, problems in adherence to



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CBT also can reduce effectiveness. For example, patients who frequently miss appointments, do not follow through with action plans, or veer off topic in sessions may have difficulties benefiting from treatment. In combined treatment, attention can be paid to overall adherence in an attempt to amplify treatment responses. A collaborative therapeutic relationship can encourage open, shared discussions about developing treatment plans, identifying obstacles to following them, and troubleshooting difficulties that may arise. Motivational interviewing methods can be employed to increase chances of adherence, and standard CBT interventions can target problems that might interfere with adherence. One of the helpful CBT methods for promoting adherence is modification of negative automatic thoughts or maladaptive core beliefs about medication or other elements of treatment. Several themes of cognitions have been identified that could interfere with pharmacotherapy (Wright & Schrodt, 1989). They include cognitions about personal weakness (e.g., “If I have to take a medication, it means I’m weak”; “I should be able to do this on my own”; “Medications are a crutch”), fear of medication effects (e.g., “I’m always the one to get side effects”; “I’ll get dependent on the drug”; “It will make me worse”; “I’ll lose control”), fear of others’ opinions (e.g., “If my boss finds out, I could suffer”; “My wife wants me to stay off medication”; “If I get better, my family will credit the medication, not me”), problems with the therapeutic alliance (e.g., “I’m just a guinea pig”; “Drug companies control the doctors—I can’t trust them”; “Doctors are only interested in pushing pills—they don’t listen”), and misunderstandings about the illness or treatment (e.g., “If I take the medicine for a few days and it doesn’t work, it will never help me”; “Depression is a choice—I need willpower instead of medication”; “How can medication help when I have a real-life problem?”). As with other applications of CBT, work on negative thoughts about medication should involve a rational examination of the evidence. Perhaps some of the fears are well-founded and alterations in the treatment plan or coping strategies for side effects might be needed. However, opportunities for modification of treatment-interfering thoughts may be present. Behavioral strategies also can be employed to promote treatment adherence. Examples are pairing medication taking with behaviors that are done routinely every day (e.g., brushing teeth before bed, shaving each morning), using 7-day pill containers, developing reminder systems, and logging pill taking on activity schedules or other records. Also, smartphone apps are available to remind people to take medication. When medication adherence is a major concern, it may be helpful to write out a specific plan that includes both cognitive and behavioral methods. 4. Be flexible—adjust methods to meet patients’ unique history, needs, and opportunities. From the pharmacotherapy perspective, it can be valuable to perform a detailed assessment of responses or lack of responses to other treatments, family history of medication trials, medical illnesses that could contribute to symptoms or complicate treatment, dietary habits, possible vitamin

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deficiencies, sleep apnea, and a variety of other influences on psychiatric illnesses and treatment outcomes. Also, genomic testing may be useful in choosing and dosing medications (Rosenblat et al., 2017). With these considerations in mind, the prescribing clinician can customize a plan that may have a better chance of being well-tolerated and effective than a “one-size-fits-all” approach. In a similar manner, CBT can be tailored to fit the patient’s symptoms, temperament, personality traits, weaknesses, and strengths. As treatment proceeds, the patient’s responses to therapy initiatives can help shape an evolving plan that emphasizes flexible and effective use of the resources of both CBT and pharmacotherapy.

CLINICAL EXAMPLE Rhonda was a 60-year-old woman who was referred to one of us (JHW) after a full course of electroconvulsive therapy (ECT) had been unsuccessful in relieving symptoms of depression. During the first visit, Rhonda scored 25 out of 27 points on the Patient Health Questionnaire-9 (PHQ-9) and reported that she had almost canceled the appointment because “the doctors gave up on me. . . . If shock treatment didn’t work, nothing will.” She had been treated with many courses of antidepressants plus augmenters such as aripiprazole and quetiapine prior to receiving ECT. Genomic testing to guide pharmacotherapy had been done prior to ECT and had not improved outcome. Psychotherapy with three different therapists had been supportive in nature. But Rhonda had not tried CBT. She had never been suicidal and said that she would never kill herself because of her husband, daughters, grandchildren, and strong religious beliefs. Although JHW recognized the difficulties in working with this severe form of treatment-resistant depression, he tried to avoid being swept up in Rhonda’s profound hopelessness. Instead he offered a structured, systematic, and encouraging approach. RHONDA:

Seeing you is probably a waste of time. My doctors have tried everything.

PSYCHIATRIST: I’ve had other patients like you. Shock treatment didn’t help,

but we took the time to find a combination of treatments that did work. Could I explain how we can do it? RHONDA:

Okay. But I’ve had psychotherapy. It was useless. My doctors told me you do this CBT stuff. I’ve read about it. Too simplistic for me. I have a chemical imbalance—talking won’t help.

PSYCHIATRIST: I can understand your skepticism. It must have been very hard

to keep going to doctors when you were so depressed. What do you think of psychiatrists and psychologists?



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RHONDA:

They try.

PSYCHIATRIST: Will you let me try? I want to “look under every stone” to find

out why you haven’t gotten better and figure out how to get you back to normal. CBT could be a part of our plan. I don’t know yet if it might be good for you, but I do know that it has the strongest proof of any psychotherapy for depression and it works really well when it’s combined with medications. RHONDA:

Go ahead. I don’t have anything to lose.

Although Rhonda was very hesitant in the beginning, a methodical, empathic, and cautiously optimistic approach swayed her by the end of the first session. JHW conducted a thorough initial evaluation that included a full assessment of risk factors for depression, medical history, in-depth review of her experiences with other treatments including medications and supportive therapy, and psychoeducation on how a combined approach of CBT and biological treatments might be beneficial. He also helped Rhonda set realistic treatment goals during this first session. Her goals were to (a) be able to spend at least half a day out of bed and being productive with chores or seeing family, (b) find medicines that help with depression but don’t cause weight gain, and (c) return to part-time work at a coffee shop. Collaborative-empirical methods were used to engage Rhonda and promote efforts to try out different treatments until a mix could be found that would relieve depression. By the end of the first session, she agreed to three initial steps: (a) accept referral for obstructive sleep apnea testing (JHW had found symptoms suggestive of possible sleep apnea which can be a contributor to treatment-resistant depression), (b) use a weekly pill container to help ensure full use of the medication prescribed by her previous doctor (Rhonda noted that she missed about a quarter of doses of medication because she forgot or “just gave up on it helping”), and (c) log her activities with mastery and pleasure ratings on two mornings during the next week (JHW explained the basics of behavioral activation and assessed barriers to completion of the action plan). Sessions were planned weekly for about 20 minutes each. At the second session the agenda focused on her action plan to begin behavioral activation and on discussion of options for pharmacotherapy. To her surprise, Rhonda found a few glimmers of pleasure in the hours she had logged. At the first session she had reported, “I don’t do anything but sit in front of the TV or go back to bed. I don’t want to do anything. I don’t enjoy anything.” However an activity schedule entry showed a pleasure rating of 6 for a Zoom call from a daughter and grandson. We leveraged this positive report to discuss some possible additions to her daily activities and the potential value of spending less time in front of the TV and more time attempting to connect with family and friends. Her action plan for the next week included scheduling at least three Zoom calls with family and friends and spending 2 hours going through recent emails she had been ignoring to look for messages

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from people she knew. She also agreed to try short walks of 10 to 15 minutes every other day. JHW framed the behavioral activation plans as a way to counter the deconditioning that goes along with chronic depression. Even though Rhonda was pessimistic about psychotherapy, she could see the logic behind a rehabilitation conceptualization and tried to follow through with most of the plans. The pharmacotherapy part of the agenda at Session 2 focused on looking for treatments or combinations of treatments that hadn’t been tried and offered promise. Rhonda had completed courses of three SRIs, two SNRIs, and augmentation with aripiprazole, quetiapine, and buspirone. However, she had not been treated with two of the newer antidepressants, vortioxetine and vilazodone; an atypical antipsychotic, lurasidone, which is unlikely to cause weight gain; or some of the more advanced medication options such as pramipexole, lithium or thyroid augmentation, ketamine, or monoamine oxidase inhibitors. Because Rhonda noted that she could not afford medications that were not generic yet (e.g., vortioxetine, vilazodone, lurasidone), she accepted JHW’s recommendation of a trial of adding pramipexole to the escitalopram she was currently taking. JHW explained the dopamine-stimulating effects of this medication that might give her a boost in completing activities, and he discussed potential side effects. Rhonda asked a few questions and consented to this treatment. Then JHW encouraged her to use the secure email service in their electronic medical record to send him reports of progress or side effects. By Session 5, Rhonda was using activity scheduling on a daily basis and was following a regular routine of sleep and wake times, meals, and pleasurable activities. Some of the positive changes were walks with a neighbor at least three times a week, resuming a previous hobby of painting with watercolors, planning and cooking meals for herself most days, and hosting a dinner for her daughter and her family. Pramipexole had been gradually increased to a dose of 2 mgm daily at bedtime. She had experienced some nausea when the dose was increased to 2.5 mgm daily, so she and JHW decided to reduce the dose to a tolerable level. The PHQ-9 score at this session was reduced to 15, a solid improvement but still showing significant depression. A brief excerpt from this session shows improved collaboration compared with Session 1. PSYCHIATRIST: [looking at the schedule she brought to the session] Great job

with the activity schedule this week. I’m seeing a lot more ratings of seven or higher. What do you think of your progress? RHONDA:

Yeah. It was a better week. I never thought I’d be doing those things again.

PSYCHIATRIST: As you look at the schedule, what ideas do you have for this

next week?



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RHONDA:

My daughter wants us all to go to a state park and rent some kayaks. I never did that sort of thing, but I think I’ll go along. Give it a try.

PSYCHIATRIST: Sounds like fun. I hope you’ll do it. What other ideas do you

have for next week? They then sketched out several modifications to the activity schedule that build on the success of recent weeks before moving on to discuss pharmacotherapy.

PSYCHIATRIST: When we started, you told me you were missing doses of med-

ication because you forgot or got discouraged about it. How is going now with taking the medication? RHONDA:

Pretty close to not missing a dose. I couldn’t get to the drug store in time last week and ran out of the pramipexole for one night. I just skipped it that night and didn’t double up. Is that what I should do?

PSYCHIATRIST: That was fine. Next time, you could send me a secure email so

we could talk about it. With pramipexole, a double dose might give you side effects. RHONDA:

I thought that was what you would say.

PSYCHIATRIST: You had some negative thoughts about taking meds when

we started. Any changes in the way you think about taking medication? RHONDA:

I like to be able to talk with you about what we do. And the pramipexole really helps my energy.

By the end of Session 5, they decided to keep the medication part of the treatment plan unchanged while it had more time to work and they continued with reactivation. After 10 sessions at the same dose of pramipexole and escitalopram plus CBT, Rhonda’s PHQ-9 score had fallen to 7 (minimal depression), and she had achieved her goal of returning to part-time work. She had completed sleep studies and had been using CPAP treatment for a month. Full remission was achieved after about 6 months of combined CBT and pharmacotherapy.

CONCLUSION CBT and pharmacotherapy have been developed from theoretical perspectives and research bases that are largely separate. Yet they are predominant methods

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in contemporary mental health treatment and may offer assistance to one another in achieving improved outcomes. The overall results of outcome research on monotherapies compared with combined treatment favors use of both CBT and pharmacotherapy for many disorders (especially major depressive disorder, bipolar disorder, and psychosis). However, designs of RCTs have not settled the question of whether to use one or more treatments in clinical practice. When combined therapy is chosen, we recommend a comprehensive, integrated model that considers the full biopsychosocial spectrum of influences and opportunities in planning and implementing treatment.

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van Balkom, A. J., Bakker, A., Spinhoven, P., Blaauw, B. M., Smeenk, S., & Ruesink, B. (1997). A meta-analysis of the treatment of panic disorder with or without agoraphobia: A comparison of psychopharmacological, cognitive-behavioral, and combination treatments. Journal of Nervous and Mental Disease, 185(8), 510–516. https://doi.org/10.1097/00005053-199708000-00006 Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753–2766. https://doi. org/10.1056/NEJMoa0804633 Watanabe, N., Churchill, R., & Furukawa, T. A. (2009). Combined psychotherapy plus benzodiazepines for panic disorder. Cochrane Database of Systematic Reviews, (1), CD005335. https://doi.org/10.1002/14651858.CD005335.pub2 Westra, H. A., Stewart, S. H., & Conrad, B. E. (2002). Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia. Journal of Anxiety Disorders, 16(3), 233–246. https://doi.org/10.1016/ S0887-6185(02)00091-9 Wetherell, J. L., Petkus, A. J., White, K. S., Nguyen, H., Kornblith, S., Andreescu, C., Zisook, S., & Lenze, E. J. (2013). Antidepressant medication augmented with cognitivebehavioral therapy for generalized anxiety disorder in older adults. American Journal of Psychiatry, 170(7), 782–789. https://doi.org/10.1176/appi.ajp.2013.12081104 Wheaton, M. G., Rosenfield, D., Foa, E. B., & Simpson, H. B. (2015). Augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: What moderates improvement? Journal of Consulting and Clinical Psychology, 83(5), 926–937. https:// doi.org/10.1037/ccp0000025 Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199–216. https://doi.org/10.1037/0003-066X. 62.3.199 Wright, J. H. (1987). Cognitive therapy and medication as combined treatment. In A. Freeman & V. Greenwood (Eds.), Cognitive therapy (pp. 36–50). Human Sciences Press. Wright, J. H. (2004). Combined cognitive therapy and pharmacotherapy. In R. L. Leahy (Ed.), Contemporary cognitive therapy (pp. 341–366). Guilford Press. Wright, J. H. (2007). Introduction: Combined cognitive-behavior therapy and pharmacotherapy. Journal of Cognitive Psychotherapy, 21(1), 3–6. https://doi.org/10.1891/ 088983907780493331 Wright, J. H. (2014). Combined CBT and pharmacotherapy: Introduction to the special section. International Journal of Cognitive Therapy, 7(2), 103–107. https://doi.org/10. 1521/ijct.2014.7.2.103 Wright, J. H., & McCray, L. W. (2011). Breaking free from depression: Pathways to wellness. Guilford Press. Wright, J. H., & Schrodt, G. R. (1989). Combined cognitive therapy and pharmacotherapy. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Handbook of cognitive therapy (pp. 267–282). Springer Publishing. https://doi.org/10.1007/978-1-4757-97794_14 Wright, J. H., Sudak, D., Turkington, D., & Thase, M. E. (2010). High-yield cognitive-behavior therapy for brief sessions: An illustrated guide. American Psychiatric Publishing, Inc. Wright, J. H., & Thase, M. E. (1992). Cognitive and biological therapies: A synthesis. Psychiatric Annals, 22(9), 451–458. https://doi.org/10.3928/0048-5713-19920901-05

21 Cognitive Behavioral Therapy Supervision Donna M. Sudak and Robert P. Reiser

C

linical supervision is rightly regarded as the “signature pedagogy” (Goodyear, 2014) in training psychotherapists. Wherever state or national standards exist for the licensure of mental health practitioners, a substantial requirement for supervised practice is embedded in rules and regulations. In the past decade, multiple sets of supervision competency frameworks and standards for proficiency in supervisory training have been set forth across varied disciplines subsuming cognitive behavioral therapy (CBT) supervision (American Association for Marriage and Family Therapy, 2014; American Psychological Association [APA], 2015; Borders et al., 2011; Falender et al., 2004; Roth & Pilling, 2008). So what can be added to the plethora of current standards and guidelines to enhance CBT supervision? Although it is true that standards and competency frameworks for clinical supervision have burgeoned over the past decade, they represent enabling aspirations and guidelines, antecedents that are necessary but insufficient for the faithful implementation of CBT supervision. High-fidelity CBT supervision requires evidence-based training in supervision, supervision-of-supervision (including careful observation, corrective feedback, and regular training updates), and linkage to consequences such as the credentialing and accreditation of clinical supervisors—conditions that have not kept pace (Milne & Reiser, 2017). For example, compared with the credentialing model for cognitive behavioral therapists, which entails direct observation and evaluation on standardized competency measures such as the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980) or the revised cognitive therapy scale (CTS-R;

https://doi.org/10.1037/0000219-021 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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Blackburn et al., 2001), similar efforts to install standards for certifying supervisors have fallen short. To illustrate, there are still only the most nominal of requirements for accrediting supervisors in most jurisdictions. For example, in the state of California, the only requirement for psychologists to become supervisors is to complete a 6-hour continuing education class, which may be internet-based, every 2 years (with little attention paid to the quality of the coursework). In summary, a consistent lack of commitment to evidence-based supervisor training and a lack of systematic observation of supervision (due in part to the scarcity of valid and reliable measures of supervision quality) have hampered efforts to improve the overall quality of CBT supervision (Milne & Reiser, 2017). The result is a kind of incomplete development, a “failure to thrive” in terms of achieving the full potential for CBT supervision. This failure to develop CBT supervision is indicated by systematic reviews of the outcomes of supervision that have yielded disappointing results in terms of identifying benefits for patients or improvements in the treatments being delivered (Alfonsson et al., 2017; Ellis & Ladany, 1997; Milne & James, 2000; Watkins, 2011; Wheeler & Richards, 2007). A recent review noted an extreme gap between the hypothesized value of clinical supervision and its demonstrated benefits to patients in terms of reduction of symptoms or improved outcomes in any domain and concluded, “No study could show benefits from supervision for patients” (Alfonsson et al., 2017, p. 206). This results in a rather puzzling picture (“something does not compute”; Watkins, 1997), in that clinical supervision is universally acknowledged as having vital gatekeeping and normative functions, but the training of supervisors and research into the effectiveness of supervision has lagged. Highlighting these limitations, Falender (2014) has concluded, “Increasingly, however, supervision is akin to the Emperor’s New Clothes, scaffolding of a profession without adequate attention to how effective or essential supervision is as a distinct professional practice” (p. 143). In contrast to this dismal assessment, Milne and Reiser (2017) developed a clearer and better validated procedural account of CBT supervision in the form of a manual that employed a strategy for enhancing the evidence base from specific research on CBT supervision. This was accomplished by adopting a more inclusive notion of “evidence,” incorporating major findings from neighboring literatures (especially industrialorganizational psychology, psychotherapy/CBT research, staff training, education), reviewing expert consensus statements (including competence frameworks), and assimilating relevant, well-established clinical supervision theory (e.g., experiential learning; the zone of proximal development [ZPD]).

HISTORY Continuing the “failure to thrive” reasoning, we categorize at least three distinct stages in the development of CBT supervision, leading up to the current evidence-informed approach. In the first stage, reports of supervision were primarily narrative and qualitative, practitioner-focused accounts outlining basic



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procedures and concepts closely linked to how CBT itself was to be delivered. Milne (2008) referred to this as the “reflexive model” of supervision in that it closely parallels the practice of CBT. In the second stage, CBT supervision was informed by the development of a competency-based model, as illustrated in the framework for an empirically based set of competencies for CBT supervision (Roth & Pilling, 2008). In the final stage, CBT supervision is derived from key empirical evidence as the basis for effective practice. This latter stage is in an early phase of development and has yet to be fully adopted within supervision practice (or embodied within common national guidelines and standards). Probably the most robust model for empirically supported CBT supervision training is linked to the Improving Access to Psychological Therapies (IAPT) program in the United Kingdom (IAPT, 2011). A recent survey of 110 highly trained and experienced CBT supervisors and supervision leaders in the United Kingdom, many of whom were IAPT supervisors, suggested a broadening of the empirical base informing supervision. Many of these supervisors indicated that they take an empirically informed approach to CBT supervision, with almost 50% citing a research-informed or evidence-based model of supervision (Reiser & Milne, 2016). We next describe these three developmental stages of CBT supervision in some detail. Early Development: Reflexive CBT Supervision Two of the first comprehensive accounts of CBT supervision (Liese & Beck, 1997; Padesky, 1996) were published almost 20 years after the original CBT manual for depression (Beck, 1979). Ludgate (2015) noted, “Although supervision was a recommended part of the training for cognitive therapists, no systematic descriptions of CBT supervision practice appeared in the literature until the mid- to late-1990s” (p. 5). A slightly more recent update (Beck et al., 2008) provided a similar picture of CBT supervision. These largely descriptive, qualitative, and narrative accounts nonetheless provide a distinctive picture of early approaches to CBT supervision. In effect, CBT supervision directly parallels the structure and process of CBT by maintaining an agenda-driven, structured approach, emphasizing collaboration, relying on cognitive case formulation, prizing direct observation and use of standardized measures of competency, and utilizing common CBT methods to enhance learning (e.g., Socratic questioning, guided discovery, demonstrations, role-play, and behavioral rehearsal; see Exhibit 21.1). These texts continued to be regarded as authoritative and seminal at least over the next 10 years, as evidenced in later surveys of CBT supervisors (Townend et al., 2002, 2007) and in recent book length treatments of CBT training and supervision (Sudak et al., 2015). Middle Development: Empirically Derived Supervision Frameworks A watershed event in CBT supervision was the development of a comprehensive empirically derived framework for supervision competencies by Roth and

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EXHIBIT 21.1

Original and Updated Elements of CBT Supervision 1. Has structured session elements in common with cognitive therapy (check-in, bridge to past session, setting the agenda, using capsule summaries, setting homework, getting feedback, summarizing session) 2. Is collaborative 3. Makes primary use of cognitive case conceptualization to formulate assessment and treatment plans 4. Uses cognitive therapy techniques to teach (especially Socratic questioning and guided discovery) 5. Teaches evidence-based CBT procedures 6. Makes use of direct observation to assesses competence, using standardized measures (e.g., the CTRS) 7. Utilizes empirically supported methods of teaching and training, including active learnings strategies, direct observation, modeling, educational role-play and behavioral rehearsal with corrective feedbacka 8. Monitors the supervisee’s clinical effectiveness using clinical outcomes measuresa (e.g. The Patient Health Questionnaire [PHQ-9; Kroenke & Spitzer, 2002]; The Generalized Anxiety Disorder Scale [GAD-7; Spitzer et al., 2006]; The Beck Depression Inventory-II [BDI-II; Beck et al., 1996]) Note. Data from Liese & Beck (1997), Padesky (1996), and Reiser (2014). a Updated elements of CBT supervision are consistent with current research evidence and expert consensus (Milne & Reiser, 2017).

Pilling (2007). This set of specific competencies, derived from training practices identified in successful CBT clinical trials, provided the first clearly evidencebased set of standards for evaluating the competence of CBT supervisors. Roth and Pilling (2008) discussed their approach as follows: “The approach taken here was to constrain competencies to those that form part of treatment packages that have shown evidence of efficacy in clinical trials” (p. 131). In a later paper, Roth et al. (2010) expanded on their methodology where they extracted details of training and supervision from 27 selected exemplar CBT trials for depression and anxiety to develop competency statements. However, a major shortcoming in this framework is the lack of specificity required to provide detailed procedural guidance. The third stage of development of CBT supervision requires a level of procedural detail to enable evidencebased supervisor training, and a specificity that allows systematic evaluation of the supervisor’s adherence to standards through a reliable method of competency evaluation. Current Status of CBT Supervision The findings of Weck et al. (2017) in a recent survey comparing CBT and psychodynamic supervisors highlight a second challenge facing CBT supervision: a lack of actual observation of supervisee work in supervision. This surprising and disappointing conclusion parallels the earlier survey of 170 CBT supervisors in the United Kingdom by Townend et al. (2002), which determined that a majority of time in supervision was spent on case discussion, whereas direct



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observation, role-play, and feedback (i.e., active, experiential methods known to improve transfer and generalizability of skills) were utilized a minority of the time. Findings in a recent survey of 79 workplace supervisors (Dorsey et al., 2018) support these conclusions—supervisor self-report indicated a low frequency of active methods of clinical supervision including direct observation, behavioral rehearsal, and modeling. The uptake of effective practices in CBT supervision appears to continue to lag behind the evidence base. Unfortunately, this conclusion simply recapitulates a much earlier review by Armstrong and Freeston (2006) and others. In summary, CBT supervision and clinical supervision in general has suffered the equivalent of a developmental delay; it has languished in a theoretical and empirical backwater. Supervision has fallen behind in terms of the robust theory development, empirical research, and procedural training that characterize the scientific heritage of CBT. This is a striking paradox in that clinical supervision is widely recognized as the signature pedagogy for training psychotherapists. Plan for This Chapter Having summarized the historical context for developments in CBT supervision, our chapter introduces a procedural account of CBT supervision. We aim to address gaps in the design, development, and dissemination of CBT supervision by providing an account of evidence-based methods and procedures for CBT supervision with sufficient support to constitute best practices. Because clinical research on CBT supervision is so limited, we include research from clinical, industrial-organizational, and educational literatures (see, especially, Milne & Reiser, 2017). We summarize “gold standards” for training supervisors and methods of evaluating competence in supervision that can be utilized to provide the impetus to better design, develop, and disseminate CBT supervision. Finally, we address problems with broader dissemination and uptake of these concepts. We describe general principles and major considerations in the design of effective CBT supervision based upon our review of the empirically supported elements of CBT supervision (Milne & Reiser, 2017; Roth & Pilling, 2008). Moreover, we illustrate the practical implementation of these approaches with our combined experience.

ESTABLISHING A COLLABORATIVE AND ACTIVE LEARNING ENVIRONMENT Our approach to facilitating learning within CBT supervision posits an adult learning model in which trainees collaborate in setting and working on learning goals. This is consistent with the learning model inherent to CBT and the use of Socratic questioning and guided discovery; that is to say, by engaging in a process of guiding the learner to draw conclusions with questions that stimulate reflecting upon prior knowledge and experience. Systematic reviews (e.g., Prince, 2004) summarizing evidence from the educational literature support

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the use of active learning. Furthermore, inductive learning methods which Prince and Felder (2006) described as “inquiry-based learning, problem-based learning, case-based teaching, discovery learning, and just-in-time learning” were found to be especially effective in developing “deep conceptual understanding” and “the ability to apply appropriate metacognitive and reasoning strategies,” capabilities especially applicable to developing therapy skills. Finally, recent reviews of the supervisory alliance (Milne & Reiser, 2017) emphasized development of collaborative and participatory leaning as a key variable in successful supervision. The concept of a supervisory working alliance, first posited by Bordin (1983), includes an explicit learning agreement between supervisor and supervisee, with clear tasks and learning goals and the development of a collaborative bond. Empirical research including psychometric work on measures of the supervisory alliance (Cliffe et al., 2016) conceptualize it as a complex, multifactorial set of qualities that include providing a role model—a “reflective educator”—using formative feedback, and providing a safe base for trainees. The supervisory alliance is facilitated by obtaining information about the supervisee’s background and professional goals, taking genuine interest in their growth and development, and making supervision emotionally engaging. The alliance is furthered by setting well-defined and specific goals and establishing a supervision framework, including describing tasks to be performed. Milne (2009), as summarized in Milne and Reiser (2017), has suggested other practical ways of enhancing the bond in CBT supervision, including strategic self-disclosing to address typical difficulties (e.g., anxiety, shame, perfectionism), sharing clinical work, engaging and connecting emotionally, and engaging in mutual feedback. Supervisors who model openness and honesty by disclosing their own struggles and who praise courage in supervisees who disclose challenges or problems are likely to be more effective and promote an open, honest approach to the challenge of mastering CBT. Another challenge in CBT supervision is the optimal facilitation of relevant emotions (Lombardo et al., 2009). Clinical supervision is unanimously regarded as a process that nearly always entails supervisee anxiety, so supervisors must attend carefully to such performance-related anxiety and provide sufficient recognition, validation, and support. This is accomplished by appropriately balancing support and challenge within the supervisory relationship based upon the developmental training needs and current skill level of the trainee. The theoretical construct of the ZPD (Vygotsky, 1978) illustrates such a process where appropriate scaffolding assists the learner in developing the capabilities necessary for independent practice. The ZPD is described as “an interaction between a more competent person and a less competent person on a task, such that the less competent person becomes independently proficient at what was initially a jointly-accomplished task” (Chaiklin, 2003). The validity of the ZPD is indicated by most supervision guidelines, which emphasize the need for tailoring challenges in supervision so that they are developmentally appropriate (APA, 2015; Roth & Pilling, 2008).



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Decreased anxiety is also essential for supervisees to feel rewarded by the process of learning and therefore help them be more likely to form the habit of self-evaluation and lifelong learning critical for optimal patient care. Supervisee anxiety may be further engendered by the gatekeeping and evaluative function of supervision where problematic performance could have serious adverse career consequences. When performance monitoring is required, the supervisor must very carefully review with the supervisee the required methods of evaluation. This review is best accomplished at the outset and embedded in a supervisory contract, that outlines evaluation methods, specific measures utilized to assess competencies, and key expectations. A major consideration in addressing anxiety in supervision is to help the supervisee feel sufficiently empowered to be truthful about interactions with patients. In a survey of supervisees, Ladany et al. (1996) reported that 44% of trainees admitted to failing to disclose “clinical mistakes” to their supervisor. They noted that 50% of trainees indicated that a “poor alliance with the supervisor” was a factor and that 51% of trainees indicated that “negative feelings such as shame, embarrassment, or discomfort” were important factors in nondisclosure. Nondisclosure of important or even critical clinical problems may be associated with poor supervisory alliances, in which trainees do not trust their supervisor and feel ashamed about making mistakes. We recommend an explicit conversation at the start of supervision indicating that supervision is a learning process, that trainees are likely to make mistakes, and that no mistake is regarded as a critical problem with the exception of not disclosing issues in supervision. Milne (2009) suggested, in addition to a clear, consistent structure for supervision sessions (agenda setting, duration, shared goals) and careful regulation of challenge versus support in supervision, that supervisors may decrease anxiety by knowing when to intervene, as in issues of client safety. Having outlined the context that should enable supervisee development, we next concentrate on specific, evidence-based supervisory techniques, offering our best-practice recommendations.

NEEDS ASSESSMENT AND GOAL SETTING Perform an Educational Needs Assessment According to the ZPD, logic, and the evidence and the reasoning provided in Milne and Reiser (2017), training should begin with an educational needs assessment designed to establish the trainee’s baseline competencies. Several major guidelines and competency frameworks emphasize the role of competence assessments in supervision to establish a baseline and develop a shared understanding of the trajectory of supervision (APA, 2015; British Association for Behavioural and Cognitive Psychotherapies [BABCP], 2018; Milne & Reiser, 2017; Roth & Pilling, 2008). Such assessment can be accomplished by selfassessment on a measure of baseline CBT competencies, such as a standardized measure like the CTRS (Young & Beck, 1980) or the CTS-R (Blackburn et al.,

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2001). Another key technique is direct observation of patient care, typically accomplished using recordings, with or without the use of rating instruments. The supervisor and supervisee actively consider the supervisee’s prior learning, current work situation, and learning goals. Supervisors elicit problem areas and strengths in therapeutic skills, including skills that are not solely CBT based, with questions that stimulate reflection. The needs assessment activates prior knowledge and models the type of self-inventory that kindles excitement about learning. This is very consistent with the Socratic method and guided discovery central to CBT; “guided empiricism” is a fundamental method for engaging patients in active learning. As noted earlier, active learning and inductive learning methods, including problem or case-based learning, are particularly suited for acquiring complex and deep conceptual understanding (Prince & Felder, 2006). The needs assessment logically leads to collaborative goal setting. Set Clear and Specific Goals for Supervision Without clear, collaborative, and explicit objectives, CBT supervision lacks focus and is likely to be less effective. There is powerful evidence from industrial organizational psychology (Locke & Latham, 2002) that setting challenging and clearly defined goals typically improves performance. Especially complex goals, typical in psychotherapy training, are best “chunked” into smaller, more discrete learning tasks. This delineation is best accomplished by “setting the table”; by structuring supervision based upon explicit learning goals and objectives, typically framed in terms of desired competencies. Furthermore, collaborative goal setting accompanied by routine formative feedback on progress toward goals in supervision facilitates the supervisory relationship (Lehrman-Waterman & Ladany, 2001). Collaborative learning goals enhance supervisory efficacy and move the supervisee toward targeted, defined, measurable new skills, which lead to positive changes in attitudes towards evidence-based practices. Goals are delineated by the strengths and learning needs of the supervisee. For example, it may be necessary to teach basic psychotherapeutic skills if the supervisee has not mastered these, prior to teaching more specific CBT skills. Other basic skills that frequently need reinforcement include how to distinguish making a diagnosis from making a problem list, how to formulate or diagnose a patient, and how to plan treatment. As therapists become more sophisticated, more complex CBT skills come to the fore. Typically, the most complex skills, including case formulation and the use of guided discovery, are acquired later in the training process. Goal setting in supervision enables the assessment of both skill and capability as well as potential performance deficits related to problematic attitudes in the supervisee. A common example is the reluctance to employ exposure because of faulty beliefs by the therapist, such as exposure procedures could be harmful to the therapeutic relationship. Another common problem occurs when trainees are reluctant to structure therapy sessions, set an agenda, or



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redirect patients who are off track because they believe that patients will become angry or feel invalidated. In such instances, it can be useful to identify the problematic belief and help the trainee explicitly test it through active experimentation (e.g., “How do you think your patient will react if you try to set a more structured agenda for your next therapy session? Let’s test that out and see if it’s accurate”). This represents reflexive CBT supervision and builds self-practice/self-reflection, known to enhance the development of competence (Bennett-Levy et al., 2001). In being “needs-led,” goal setting in supervision often involves incorporating goals related to the supervisor, employer, or educational program or organization goals that are not necessarily held by the supervisee. For example, psychiatry residency training programs require trainees to attain a level of competence in CBT as determined by individual program standards. Some psychiatry residents may have no interest in being competent in CBT, despite the requirement for graduation. In such circumstances, increasing the motivation of the trainee will be necessary for full engagement. Use of Supervision Contracts Multiple competency frameworks and guidelines advocate the use of written supervision contracts (APA, 2015; Milne & Reiser, 2017; Roth & Pilling, 2008); yet in practice, these types of written agreements specifying roles and expectations are often overlooked. Supervision contracts should operationalize the learning needs assessment and constitute a formal agreement that specifies the framework of the relationship, clarifies expectations of both parties, increases transparency, and addresses patient welfare and safety. It makes explicit each party’s contribution to the learning that is about to occur. Policies regarding attendance, communication, methods of evaluation, expectations about recording sessions and written documentation, emergency contact protocols, duration, fees, and methods of disclosure of supervision to patients are included in the contract. The supervisor’s training philosophy, credentials and scope of practice, methods of instruction, and malpractice insurance information may also be included. Structuring Supervision The structure of CBT supervision is generally quite similar to the structure of therapy, and significant attention is paid to the supervisory relationship as central to the process of change (Liese & Beck, 1997; Padesky, 1996). CBT is agenda-driven in order to enhance learning and efficiency; a similar approach makes sense in supervision. In an initial supervision session, explaining the elements of the session and setting an agenda and discussing its purpose decreases supervisee anxiety by creating shared expectations and a collaborative sense of what to expect. The structure keeps supervision on track and the supervisor oriented to the specific goal set for each session. The elements of a supervision session typically include checking in with the supervisee, setting an

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agenda, reviewing homework assignments, working on agenda items, summarizing, giving feedback, and developing homework (see Exhibit 21.2; see also Liese & Beck, 1997; Milne & Reiser, 2017; Padesky, 1996). Each item on the agenda should be accorded due priority and related time, so that the agenda can be targeted systematically and allow the most pressing concerns of the supervisee to be addressed. Consistent work toward attaining learning goals should underpin the process. Periodic summaries emphasize the important points learned within the session, and action plans and feedback reinforce learning to occur between supervision sessions. Bidirectional feedback informs the dyad about issues in the relationship that could impair honest disclosure and collaboration and enables greater focus on the supervisee’s needs.

TRAINING METHODS IN CBT SUPERVISION Surveys of CBT supervision in actual practice indicate that supervisors prioritize didactic instructional approaches and case discussion over more active experiential techniques (Accurso et al., 2011; Dorsey et al., 2018; Milne, 2008; Reiser et al., 2018; Townend et al., 2002). Formative accounts of CBT supervision (Liese & Beck, 1997; Padesky, 1996) and more recent supervision competency frameworks (Roth & Pilling, 2008) provide an even more balanced picture, including an emphasis on direct observation and utilizing educational role-play. Bearman et al. (2013) determined that use of specific supervision strategies, including supervisor modeling and therapist-enacted role-play, were associated with increased frequency of therapists attempting new practices with patients. However, discussion of practices alone did not result in any increased use. Gold standard methods for CBT supervision, as defined by Dorsey et al. (2018), include experiential and interactive methods such as direct observation, modeling, and behavioral rehearsal. These active supervision techniques have been linked to improved training outcomes (Bearman et al., 2013; Miller et al., 2004; Roth et al., 2010; see Exhibit 21.2). The experiential learning model as set forth in Kolb (1984) is useful heuristically for evaluating the content and effectiveness of CBT supervision sessions in terms of maintaining more active experiential methods. Within this model, new learning is acquired in an active transactional process through planning, experiencing, reflecting, conceptualizing, and experimenting. Milne and Reiser (2011; Reiser, 2014; Reiser et al., 2018) have developed an instrument to systematically evaluate and measure different methods and processes in supervision related to experiential learning. This observational tool, SAGE (Supervision: Adherence and Guidance Evaluation), which was empirically derived utilizing a systematic review of the supervision literature to identify elements of effective supervision (see Milne et al., 2010, 2011; Milne & James, 2000) and based on Kolb’s experiential learning model (Kolb, 1984), captures key content areas of supervision including “Demonstrating,”



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EXHIBIT 21.2

Gold Standard Elements of CBT Supervision Fidelity monitoring: The Cognitive Therapy Rating Scale and/or other fidelity measures are used to assess the degree to which therapy procedures are being implemented as intended. Skill building/behavioral rehearsal: Supervisor models key skills and asks trainee to rehearse these skills with coaching and feedback. Review of practice (live observation, or audio-video): Supervisor routinely reviews recordings of therapy sessions in part and entire sessions that are rated on the Cognitive Therapy Rating Scale. Outcome monitoring: Well validated and reliable instruments are used to routinely monitor client progress, and this informs the supervision. Note. Data from Dorsey et al. (2018).

“Training/Experimenting,” and providing “Feedback,” as well as “Reflecting” and “Experiencing.” The use of SAGE for routine self-assessment of supervision sessions, objective feedback on supervision, and as a formative learning tool is detailed later in this chapter. Although the content of supervision sessions may vary, the supervisor should aim to use a variety of teaching methods. These should include didactic or declarative methods (i.e., teaching, conceptualizing, reflecting), direct observation, demonstration, and behavioral rehearsal (i.e., experiencing, experimenting) with feedback. A short version of SAGE (Reiser et al., 2018) may be used as a self-observation rating tool to assist supervisors to evaluate the content and process of their supervision sessions and to promote empirically supported practices. Consistent with the seminal thinking of educationalist Dewey (1933), subsequent interpretations by Kolb (1984), and Bennett-Levy’s (2006) declarative, procedural, and reflective model of learning, Milne (2006; Milne & Reiser, 2017) has suggested that optimal learning involves utilizing a blend of major learning modes responsively. The blend should include symbolic methods (i.e., teaching, case presentation, discussion), iconic methods (i.e., modeling and demonstration, whiteboard case formulation diagram), and enactive methods (i.e., role-play and behavioral rehearsal), as well as adjusting teaching strategies depending on the supervisee’s reaction. Research is lacking regarding the optimal blend of methods, but a number of studies highlight the importance of active experiential supervision strategies (i.e., modeling, role-play, direct observation) relative to achieving training outcomes (Beidas & Kendall, 2010; Muse & McManus, 2013; Roth et al., 2010; and summarized in Dorsey et al., 2018). For example, in a systematic review of training in evidence-based practices, Beidas and Kendall (2010) concluded that active learning strategies must be utilized in order to change therapist behaviors in the realms of adherence, competence, and skill, as well as improving client outcomes.

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Supervisors typically employ too much declarative (didactic) training and provide too little in the way of active experiential methods. Experiential methods may be more challenging for supervisors and trainees, being “outside the comfort zone” for most supervisors accustomed to primarily didactic, declarative teaching. As a pragmatic benchmark, at least 25% of the session should be spent directly observing the supervisee’s work and 25% in activities related to modeling or demonstration of techniques with behavioral rehearsal by the trainee and feedback. A good rule-of-thumb based on Anders Ericsson (2008) suggests that repeated performance of a task, with opportunities for multiple cycles of iterative development based on feedback, results in significant improvements over time. The balance of the session is likely to be allocated to case formulation, discussion of specific evidence-based techniques, and standard features of every supervision session, such as agenda setting, summarizing key learning points, reflection, feedback, and homework/action planning (see Exhibit 21.3). In short, telling a supervisee “how to” do it is far less effective than demonstrating and having them practice the skill in vivo (see Exhibits 21.4 and 21.5). Typical barriers to effective time management in supervision include high caseloads, crisis-oriented case discussions where safety and risk management considerations must prevail over optimal teaching strategies or focusing on case management, and administrative or policy issues to the detriment of clinically focused discussions. Finally, discomfort and anxiety provoked by more active methods (especially role-play, modeling, and observation) may limit use of these highly effective strategies. Supervisors may overestimate the value of teaching and case discussion in imparting procedural knowledge or “how to, when to” rules required to develop expertise. Also likely, given the all too common absence of proper training in supervision, supervisors may fall back on supervising as they were supervised. EXHIBIT 21.3

Training Elements Within an Effective CBT Supervision Session Develop a collaborative learning agenda consistent with training goals. Routinely monitor and review clinical outcomes using standardized measures. Use a range of learning strategies including declarative, procedural, and reflective (Bennett-Levy, 2006). Use a range of learning methods including symbolic, iconic, and enactive (Milne, 2006). Incorporate modeling and behavioral rehearsal. Provide direct observation and specific feedback to the trainee, linked to a standardized fidelity measure (CTRS, CTS-R) or to empirically supported competence frameworks (Roth & Pilling, 2007). Utilize active learning methods and allow time for reflection on what has been learned. Solicit feedback on how to improve supervision and training. Prescribe homework and provide other memory supports (notes, email tips, 3 by 5 cards) to enhance/extend learning in the session and recall of information (Harvey et al., 2014).



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EXHIBIT 21.4

Barriers to Effective Use of Supervision Time constraints Time spent on nonclinical, policy, or administrative issues Focus on nonclinical case management issues High caseloads High risk cases or crisis situations requiring more intensive supervision Didactic teaching methods may be more “comfortable.” Active experiential methods may provoke anxiety and be less familiar. Active supervision methods may require more effort.

FEEDBACK AND EVALUATION Provide Routine Feedback on the Gap Between Current Proficiency and Level of Desired Competency Feedback is perhaps the most universally recognized effective teaching and training strategy and is naturally a key process in effective CBT supervision. A requirement for effective feedback is that it pinpoint the gap between current proficiency (the baseline) and the level of desired competency based upon supervision goals (Hattie & Timperley, 2007). In a correlational study, providing clear feedback and evaluation was associated somewhat unexpectedly with positive improvements in the supervisory relationship: “The overall proportion of variance in the three factors of the supervisory working alliance accounted for by goal setting and feedback was significant, Pillai’s trace  =  .83, £[6, 246] = 28.88, p < .001” (Lehrman-Waterman & Ladany, 2001, p. 173). Milne and Reiser (2017) summarized the considerable evidence base and provided a detailed guideline regarding timely, specific, and clear feedback as one of the central processes underpinning effective supervision (see Exhibit 21.6). Effective supervisors make clear and specific observations and provide ongoing feedback with coaching focused on the development of requisite knowledge, skills, and attitudes. Detailed and explicit directions about what is going well and what specifically can be improved is a critical part of the process of trainee development. Specific areas that must always be a focus of attention include the essentials of conceptualization, treatment planning, the therapeutic alliance with the patient, and attention to the effective deployment of CBT skills. Recorded material from the supervisees’ therapy sessions must be the primary data source to assess skill level. This is particularly important given that nondisclosure in supervision is known to be a significant problem (Ladany et al., 1996). Even if a trainee is totally open and honest, it is difficult when employing a new skill to accurately remember what has occurred. Novice trainees will be incapable of noticing or valuing the therapy process in the same way as the more expert supervisor. There is a major challenge in recognizing and

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EXHIBIT 21.5

Active Experiential and Didactic Methods of Supervision Didactic methods Case discussion Review of treatment manual Reading and summarizing EBT article Discuss case formulation Teach about an EBT Review a written case formulation Supervisor provides relevant examples from clinical experience Supervisor discusses how to use a specific technique Trainee is asked to review or summarize their current knowledge of working with “X” disorder Trainee is asked to plan future interventions based on a case formulation or case discussion Active experiential methods Direct live or audio/video observation with trainee Model or demonstrate a specific skill Role-play or behavioral rehearsal “Live” feedback on role-play Discuss experiences/emotional reactions of trainee Codevelop a collaborative case conceptualization on the whiteboard Have trainee self-rate and reflect on therapy session using a version of the Cognitive Therapy Rating Scale or a fidelity checklist Stop audio/video and ask trainee to reflect on what is happening in the moment Stop audio/video and ask trainee to provide an “in role” intervention Have trainee review a therapy recording and identify instances of a skill that they performed well Have trainee review a therapy recording and identify instances of a skill that they need additional help with. Trainee is asked to experiment or test out a new treatment strategy based on their hypothesis or case formulation Trainee and supervisor watch a video with an expert role-playing a relevant intervention Supervisor plays their own recording of a therapy session illustrating Socratic questioning and asks for feedback using the relevant Cognitive Therapy Rating Scale item

addressing the supervisee’s inevitable biases in self-monitoring (Kruger & Dunning, 1999). For instance, when role-playing for practice, self-observations can often be inaccurate due to a self-serving bias, so it helps to record and watch role-plays together with the supervisee to raise awareness of bias and to reduce some of that bias. This provides a sound platform for performance feedback.



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EXHIBIT 21.6

Key Steps in Skill Training 1. 2. 3. 4. 5.

Provide a rationale for why the skill is important and how it fits into the learner’s goals. Demonstrate the skill through role-play. Ask the trainee to demonstrate the skill. Ask the trainee to evaluate their performance. Building on the trainee’s self-evaluation, give clear and specific positive (what you did well) and negative (what could be improved) feedback focused on performance of the skill utilizing a standardized measure such as the CTRS-R or CTRS, if possible. 6. If necessary, provide further demonstrations pinpointing areas for improvement and ask trainee to repeat. 7. Ask trainee for feedback about your feedback (What was helpful? Did anything not make sense? Did they feel criticized?). 8. Collaboratively agree to follow-up activity designed to strengthen acquisition of the skill. Note. Data from Milne and Reiser (2017) and James (2015).

Effective therapy entails deploying skills in situations with multiple variables and therefore supervision must involve monitoring skill use in real-world situations as well as role-play. If role-play is employed, it should practice scenarios that use skills at multiple levels of difficulty and in other respects aim to be realistic and transportable to clinical practice. Supervisors provide effective feedback by first decreasing trainee anxiety in order to make certain that the feedback is being received in good faith and without undue bias. As a fundamental principle, supervisors should first demonstrate and practice any new skills required within a supervision session to make certain the supervisee is capable of their competent execution. Once the trainee attempts the strategy, either in practice with the supervisor or with a patient, a common supervision strategy is to first give feedback about what the trainee executes successfully and then give feedback about necessary improvements (e.g., a strengths and weaknesses appraisal). However, we find that a good way to start is to elicit the supervisee’s perceptions of their own performance, consistent with an active collaborative learning model (see Exhibit 21.5) and modeling self-reflection as a fundamental therapy skill. This self-assessment reveals not only levels of proficiency, but negative and positive biases, and the capacity for insight and self-reflection can provide priceless glimpses into the supervisee’s world. This process empowers the supervisee, further builds collaboration, and fosters a respectful, professional alliance. Supervisors must allow sufficient time for feedback and target a small number of new learning skills so as to not overwhelm the trainee. Supervisees should also be encouraged to offer feedback about the supervisor to strengthen the relationship and to assess the level of challenge versus support perceived in the session. Finally, assigning a task to practice in the subsequent week helps promote the generalization of new behaviors and models a basic expectation in both learning theory and CBT.

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Use Fidelity Measures in Supervision Performance evaluation is a critical part of supervision. Rating scales (discussed later) that determine if a supervisee has employed CBT with fidelity and integrity must be used with regularity. Many CBT supervisors review and rate recorded work samples between sessions and review the ratings and the questions that the supervisee has about the session in supervision. As bias also affects the supervisor’s judgment, measurement instruments can offer an invaluable corrective. Measures of treatment fidelity and patient outcome assist the supervisor in providing feedback. Rating scales that measure treatment fidelity are essential to use to sharpen the focus of feedback, teach the critical elements of the treatment approach, and monitor the progress of the supervisee. Clinical outcome rating scales allow the supervisor to monitor the patient’s progress and to tailor interventions appropriately. Supervision must teach the supervisee to monitor patient progress and in turn provide feedback to the patient about the trajectory of therapy (especially valuable in relation to expected improvement; Lambert et al., 2001). Research demonstrates that therapists are not able to identify “not-on-track” cases without use of clinical outcome monitoring and tend to overestimate positive outcomes while underestimating treatment failures or deterioration in treatment (Lambert, 2007). The practice of routine monitoring and providing feedback has been demonstrated to decrease rates of nonresponse and deterioration to therapy by targeting patients that are not improving as expected (“not-on-track cases”; Lambert et al., 2005) and therefore is an essential principle to inculcate in supervision. Supervisee confidence may increase with the independent use of rating instruments. Trainees learn key components of the therapy approach by reviewing work samples either of their own or of experts; thus, the instruments reinforce both didactic and procedural knowledge. Trainees should also learn the importance of fidelity measurement over a practice lifetime to avoid drift in therapy implementation. Continual improvement and refinement of skills must occur to maintain therapy competence. Research on developing expertise suggests that without a commitment to deliberate practice of skills with accurate feedback (from clinical outcome and fidelity measures), therapists tend to plateau and not develop higher levels of expertise over time (Tracey et al., 2014). The most commonly used measures assessing CBT procedural skills are the CTRS (Young & Beck, 1990; for published revisions of the scale, see Blackburn et al., 2001) and the Assessment of Core Clinical Skills (ACCS), a new rating instrument specific to CBT (Muse & McManus, 2013; Muse et al., 2017). These scales measure skill deployment within a session and can focus the superviseesupervisor dyad on particular elements of the session critical to patient change, including agenda setting, focusing on key cognitions and behaviors, pacing, homework, and application of cognitive behavioral techniques (Strunk et al., 2010; for a discussion of reliability and validity issues connected with the CTRS and its revision, see Blackburn et al., 2001; Kazantzis et al., 2018; Vallis et al., 1986). Because homework compliance also has a positive effect on patient out-



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come (Kazantzis et al., 2000), the skillful assignment of homework by the therapist should be assessed with care. Unfortunately, the number of measures to evaluate CBT competence is quite limited. The CTRS and ACCS generally target broad skills rather than skills that relate to specific types of CBT for particular disorders (e.g., exposure). Several review articles about measures of therapist competence have discussed the limitations of existing measures (Muse & McManus, 2013; Simons et al., 2013) and their lack of adequate reliability and validity. Poor interrater reliability is a particular issue that poses impediments to standardizing feedback to trainees. Whenever possible, we recommend that supervisors attend a periodic reliability training on the CTRS or the CTS-R. This can be as simple as a small group of raters who independently rate a single recorded session against a gold standard and then compare ratings. If a workplace or educational institution requires summative feedback about the supervisee, supervisors should keep especially detailed records of sessions so that they have careful observations and a good sense of supervisee progress. The supervisee should be informed at the start about the evaluation format and process. Ideally, a full session should be set aside to thoughtfully review the supervisee’s progress. Following the principles of collaborative and active learning, supervisee self-assessment enhances this process. An environment of respect and the ability to make accurate, nonjudgmental observations is necessary, particularly when the supervisee has problematic performance. Goals that are still to be attained, strengths, areas for growth, and improvement should be balanced in a summative evaluation. An action plan should follow any summative feedback, along with assessing trainee motivation to implement the plan.

TRAINING CBT SUPERVISORS A cardinal principle in training CBT supervisors is to make certain that the supervisor is competent to deliver CBT before supervisor training. Many individuals who regard themselves as capable CBT practitioners are not trained with the rigor necessary to provide truly competent CBT, let alone CBT supervision. Therefore, the beginning phase of supervisor training should entail reviewing work samples and case conceptualizations from the supervisorcandidate. Because direct observation is a gold standard for competency assessments, supervisor-candidates should be trained in the use of rating scales. Generally, both the progress of the patient and the learning of the supervisee must be held as equally important goals in supervision. Therefore, it is imperative that supervisor-candidates have ongoing supervision-of-supervision, with review of recorded work samples of supervision sessions. Recorded work samples of supervision are assessed for structure, learning goals, employing varied methods of teaching within supervision, assuring monitoring of patient improvement and safe patient care, summarizing, assigning action plans to supervisees, and delivering feedback. Role-play and practice are used extensively,

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specifically enhanced by giving timely, accurate, and constructive feedback. Identification of what aspects of a trainee’s behavior must change and tactful delivery of feedback is a central task in training supervisors. Written feedback from the supervisor-candidate’s supervisees regarding methods of teaching, feedback, opportunities to reflect and solve problems on their own, personal issues that arose, and problems with the supervisor provides important data for initial and ongoing evaluation of supervisor-candidates. Once competence is assured, the next step is to discuss with the supervisorcandidate their philosophy regarding supervision to encourage alignment with the active, collaborative approach of CBT supervision. Because the objectives of super­vision include formative, normative, and restorative practices, and supervisory roles may range from social support and mentorship to providing a role model to evaluation and gatekeeping (Milne, 2006), supervisor-candidates should be asked their view of the supervisory relationship, about past experiences with personal supervision and supervising others, and their motivation for training. Unfortunately, supervision is not a consistently beneficial activity, and research on ineffective and harmful supervision (Ellis et al., 2017; Reiser & Milne, 2017) has demonstrated the long-term, highly aversive impact of problematic supervisors. Ellis (2001) noted the profound effects of harmful supervision: The effects of harmful supervision include symptoms of psychological trauma (e.g., prevailing sense of mistrust, debilitating fears, or excessive shame, guilt, and self-derogation); functional impairment in the supervisee’s professional or personal life; the supervisee’s conspicuous loss of self-confidence; and the supervisee’s debilitating general mental or physical health as a result of the supervisory incident or experience. (p. 402)

Harmful supervision often involves supervisors’ mishandling of power and influence issues; the innate power differential between supervisors and trainees may be exacerbated by racial and ethnic disparities (Reiser & Milne, 2017). Hence, supervisor-candidates should be assessed for their capacity to manage issues of cross-cultural diversity and overall sensitivity to interpersonal issues in supervision. Feedback provided to trainees that entails personal issues or focuses on the person of the therapist rather than the skills or tasks performed is likely to be less effective and possibly particularly unhelpful (Hattie & Timperley, 2007). Other characteristics that make supervisors more effective should be inculcated in training. These include the ability to identify and track the trainees’ most central issues and concerns and share clinically relevant struggles in managing difficult patients. Effective supervisors encourage autonomy, are sensitive to the nuances of the supervisory relationship, provide a positive role model and a strong emotional bond, engage actively with supervisees, and demonstrate knowledge and skills, as well as facilitate collaborative goal setting and open discussion (Ladany et al., 2013). Supervisor-candidates should be taught to structure supervision, plan and review assignments, set learning goals, and



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effectively manage nonadherence. They must model working with differences and apply educational principles that enhance learning. Above all, supervisors must be taught to use the Socratic method so as to not intervene immediately but allow the trainee to reflect and struggle with a clinical question to enhance learning. Addressing therapist drift in supervision is another challenge, especially when working with more advanced trainees. Supervision should target the fact that therapists frequently “fail to deliver the optimum evidence-based treatment” (Waller & Turner, 2016, p. 129) and that their skills erode over time, as is also the case in other professions. The problem of therapist drift offers an additional powerful rationale for supplementing self-assessment of skills with a standardized rating instrument, as therapists’ estimation of their own therapy skills (and presumably supervision skills) is inaccurate (Walfish et al., 2012). Chow et al. (2015) linked deliberate practice activities to superior therapy outcomes. One important observation was that therapists who spent time listening to recordings of patient sessions had improved outcomes. It logically follows that the supervisor’s mandated educational requirements (e.g., continuing education credits for maintaining licensure or board certification) should entail focused practice or measurement of supervisory skills. Expertise must be the goal. The work setting and other organizational requirements will also influence training requirements for supervisors. For example, many supervisors work with supervisees in groups and will need training regarding how to supervise CBT and simultaneously manage the needs of a group. Group supervision is complex and requires a nuanced approach so that it does not devolve into “individual supervision in a group setting,” which can be boring and unhelpful for group members. Optimal use of group supervision requires a number of specialized skills, including supporting group members and creating a safe learning environment, as well as maximizing learning by activating and engaging the group process, through consistent use of active experiential techniques such as video review accompanied by modeling and behavioral rehearsal with feedback from group members. Balancing appropriate levels of challenge and support can be particularly difficult when there is a great deal of variance in terms of skill level within the group. In addition, group supervision skills require managing group dynamics, efficiently managing time, and balancing training requirements with the need for risk management and assuring patient safety. A final critical aspect of training supervisors related to the restorative and supportive functions of supervisors includes focusing on emotional reactions and helping their trainees manage the negative consequences of being in a helping profession (e.g., burnout). Such emotional fallout may occur as stress and emotional upset about a particular patient through a full syndrome of burnout, including emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. Significant amounts of “compassion fatigue” can occur from treating severely traumatized patients. Unrecognized emotional

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distress produced by being a therapist may cause problems with personal well-being, poor productivity, and significant problems in patient care. Training supervisors in self-monitoring and self-reflection and teaching supervisees this skill, as well as prioritizing and focusing on self-management, is of paramount importance. Supervisors are encouraged to help trainees recognize and evaluate their own thoughts and beliefs about the clinical work, adopting the same tools that they use with their patients

EVALUATING CBT SUPERVISION Although competency frameworks and best practices consistently recommend direct observation of supervision as an essential component of supervisory training (APA, 2015; Roth & Pilling, 2008), few psychometrically sound instruments exist to evaluate supervision through observation (Milne & Reiser, 2011; Reiser et al., 2018). This is especially remarkable in that instruments for rating CBT sessions have been available for close to 40 years and their use (e.g., the CTRS and the CTS-R) is considered a gold standard for evaluating competence in CBT. In addition, a landmark review by Ellis and Ladany (1997) consolidated by follow-up reviews (e.g., Inman et al., 2014) noted the need for greater rigor in developing sound instruments to measure supervision. This lack of standardized instruments to observe and measure CBT supervision is the most visible evidence of the “failure to thrive” syndrome to which we have alluded. Although a toolkit to evaluate supervision with sound instruments has now been developed (Wheeler & Barkham, 2014), it does not include instruments that explicitly measure competence in supervision through direct observation. A review of 10 extant observational instruments to evaluate supervision highlighted the need for a well-validated objective measure (Milne & Reiser, 2011). In order to address this gap, Milne et al. (2011) have developed SAGE, an empirically derived 23-item instrument designed to evaluate and measure supervisory competence through direct observation. SAGE is intended to assist in developing supervisory competence, hence it has an important formative purpose as well as potentially serving to evaluate supervision (normative and gatekeeping functions). Preliminary psychometric work has been conducted on SAGE (Milne et al., 2011), suggesting adequate levels of reliability (Cohen’s kappa coefficient was 0.54, indicating moderate agreement) and validity (SAGE was able to detect differences between methods of supervision and discriminate between different theoretical approaches) as well as acceptability from a user perspective. A recent principal components factor analysis of SAGE (Reiser et al., 2018) provides a shortened 14-item measure, further enhancing user friendliness and acceptability. Although dissemination in the United States has been limited to date, SAGE is currently being used in multiple IAPT programs in the United Kingdom mainly for formative and training purposes. The original 23-item version of SAGE was empirically derived based upon research evaluating factors found to contribute to effective supervision (Milne



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et al., 2011) and consisted of three groups of items termed the “Common Factors” (akin to the common factors in psychotherapy), “The Supervision Cycle” (including the supervisor’s technical skills or methods), and “The Supervisee’s Learning” (summarizing the supervisee’s experiential learning) patterned after the work of David Kolb (1984) that set forth a cycle of experiential learning involving action, reflection, conceptualization, and experiencing. The 14-item shortened version of SAGE includes only the last two of these factors, as a two-factor solution proved to fit best with the updated factor analysis. SAGE is intended to be used to evaluate supervision through direct observation of a full session of supervision. SAGE items are defined within a user manual, and each item is rated on a seven-point scale ranging from “incompetent” to “expert” (Dreyfus & Dreyfus, 1986). Quantitative ratings are accompanied by detailed notes of observed supervision and suggestions for improvement. SAGE is primarily used to provide detailed, specific, qualitative corrective feedback to supervisors with a primarily formative purpose. Alternatively, SAGE can be used in a self-evaluative mode to prompt supervisors to reflect on their use of supervision methods, the supervisory relationship, and the process of supervision. The complete SAGE manual, including the record sheet, is available by request from the first or second authors of SAGE (Derek Milne or Robert Reiser).

DISSEMINATION Dissemination of CBT supervision has relied on early formative work (Liese & Beck, 1997; Padesky, 1996), still cited by CBT supervisors as an important influence (Milne & Reiser, 2015). Increasingly, other frameworks such as the Roth and Pilling (2008) supervision competency framework have become influential for practitioners and supervisor trainers. The literature on developing expertise and “deliberate practice” suggests that iterative cycles of practice, expert observation, and valid corrective feedback are required to develop expertise (Tracey et al., 2014). Recent surveys of supervisory practice (Dorsey et al., 2018) suggest that routine supervision is practiced with low levels of fidelity to these competency frameworks, suggesting significant barriers remain to effective dissemination efforts: “Three gold standard supervision techniques were infrequently used and/or used mostly at low intensity. These included reviewing actual practice, clinician behavioural rehearsal in supervision, and supervisor modeling” (p. 9). This finding is consistent with previous surveys (Townend et al., 2002), suggesting minimal change in the prevalence of didactic methods in supervision such as case discussion and reformulation. A rare exception was a purposive sample of CBT supervision leaders (trainers, supervisors-of-supervisors, program directors, etc.), who did report utilizing the active experiential methods (i.e., modeling, behavioral rehearsal, feedback; Milne & Reiser, 2015). Even for this select sample, direct observation of therapy occurred at the lowest mean

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frequency of all methods (Milne & Reiser, 2015). On a more encouraging note, in this same survey, a great majority of respondents indicated that evidence-based supervision guidelines were an “essential” or “high priority” need in terms of supervisor training resources. We conclude that progress has been made in disseminating evidence-based CBT supervision, but that we still have work to do in order to catch up with the highly effective dissemination of CBT. What, then, is the way forward in terms of improving the dissemination of CBT supervision? As noted in an earlier review of CBT supervision (Reiser, 2014) and summarized here, dissemination efforts will require further operationalizing of CBT competency frameworks (see Milne & Reiser, 2017, for an example) combined with empirically supported teaching methods to help make supervisors more effective. There are also substantial challenges in respect to the burden and cost of training, especially training on a national scale as exemplified in the IAPT program in the United Kingdom. Although there have been efforts to assess new technologies and innovative methods for training (Karlin et al., 2012; McHugh & Barlow, 2010), it is likely that training supervisors will still require a labor intensive, hands-on component. Dissemination of CBT supervision can clearly be improved. A platform for additional development will depend on the availability of specific, operationalized, and empirically derived supervision guidelines in combination with standardized training for supervisors and an emphasis on direct observation and valid instruments for observing and providing corrective feedback to supervisors.

CONCLUSION AND FUTURE DIRECTIONS Patel et al. (2006) noted the lack of infrastructure for assuring the delivery of high-quality, evidence-based treatments. Similar concerns apply to the infrastructure and systems required to train and certify supervisors, which lack a coherent regional or national umbrella with few exceptions: the Academy of Cognitive Therapy (ACT) certification of consultants and trainers (http://www. academyofct.org/page/TrainCertification) and the IAPT program for training supervisors (Turpin & Wheeler, 2011). While significant progress has been made, there are still substantial problems with standardizing training and supervision in CBT so that high-quality training can be systematically provided utilizing evidence-based methods. Culloty et al. (2010) noted that high-quality, systematic evaluations of supervisory training are rare. Furthermore, training is quite expensive and requires significant organizational support and commitment to providing supportive resources, there is a lack of qualified supervisors available, and many of these are untrained as educators. While technology must be deployed to more effectively train supervisors—a web-based training system to train supervisors such as exists for training in certain therapies would be a welcome addition to the field—training is likely to still require a resource-intensive, expensive, hands-on component. Finally, as noted above, we need to improve the dissemination of



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measures of competence for therapy performance as well as for observing and evaluating supervisory competence.

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III APPLICATIONS TO DIVERSE POPULATIONS

22 Children and Adolescents With Externalizing Disorders R. Trent Codd III and Nathan Roth

E

xternalizing disorders include various acting out, delinquent, aggressive, or hyperactive behaviors and are distinct from internalizing disorders, which encompass anxiety, social withdrawal, or depression. According to Lahey et al. (2008) and Waschbusch (2002), there are two major categories of behavioral problems among externalizing disorders. These are problems associated with an attention-deficit/hyperactivity disorder (ADHD) diagnosis, which includes inattention, impulsivity, and hyperactivity, as well as problems associated with oppositional defiant disorder (ODD) or conduct disorder (CD), which includes conduct problems, asocial behavior, and aggressive behavior. Researchers commonly maintain separation between these two categories of externalizing behavior; however, there is considerable comorbidity, or overlap. This is particularly the case with children and adolescents, such that approximately 50% of children with ADHD also have a comorbid CD diagnosis, and nearly 90% of children with either an ODD or CD diagnosis also have ADHD (Abikoff & Klein, 1992; Waschbusch, 2002). Awareness of the high comorbidity of externalizing disorders is important in interpreting the research and applying the most effective treatment.1 Although the disorders mentioned above are considered childhood disorders, or disorders typically found in childhood or adolescence, the presence of externalizing disorders and comorbidity of these disorders are also found in late adolescence and adulthood. When considering adulthood, antisocial behavior and substance use disorders are also referred to as externalizing disorders. Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-022 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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Three major patterns have consistently emerged in the externalizing disorders literature: (a) substance use disorders have a high rate of comorbidity with antisocial behavior (Kessler et al., 1994); (b) men have higher rates of externalizing disorders than women (Newman et al., 1996); and (c) the prevalence of externalizing disorders increases from childhood to late adolescence o emerging adulthood, reaches its peak in early adulthood, and then declines throughout the rest of adulthood (Bachman et al., 1997; Chen & Kandel, 1995; Harford et al., 2005; Jackson et al., 2000; Moffitt et al., 2001). Hicks et al. (2009) found that as environmental stress increases, the genetic differences among individuals become more important in externalizing etiology. Furthermore, Reef et al. (2011) found that externalizing symptoms during childhood predict disruptive behaviors, along with anxiety, mood, and substance use disorders in adulthood. Thus, effective and timely treatments are essential. A meta-analysis assessing the impact of cognitive behavioral therapy (CBT) on externalizing problems and behaviors as well as their comorbid difficulties found that CBT shows a moderate decrease in externalizing symptomatology among inattention, ODD, and ADHD problems in addition to improved social competence and reduced parental distress (Battagliese et al., 2015). There are many component cognitive behavioral interventions, including psychoeducation; analyzing connections among an individual’s thoughts, feelings, and behavior; parenting skills or behavior management training; coping strategies; and therapeutic homework. Psychoeducation within CBT can include teaching the cognitive model of the disorder; teaching what symptoms are and how they are maintained; and teaching the theory behind the connectedness of thoughts, feelings, and behavior. Following the education components, thoughts can then begin to be elicited and evaluated appropriately. Very important to parents of children with externalizing behaviors, CBT offers skills training and behavior management that address antecedent and consequential interventions. Lastly, to be done in the session or as therapeutic homework, coping strategies are implemented, which can include breathing, relaxation, and coping statements.

SPECIAL CHARACTERISTICS AND CHALLENGES There are at least three primary considerations for the clinician treating externalizing disorders. The first involves the potential for iatrogenesis when treating ODD and CD clients in groups, and the second concerns parental emotional tolerance repertoires for delivering parent management-based interventions. The final consideration is the low rate of adherence to stimulant treatment in ADHD despite evidence of its considerable efficacy. These three concerns are discussed next. Peer Deviancy Training It is common to treat adolescents with antisocial behavior in groups and group settings (Dodge et al., 2006; Handwerk et al., 2000). However, iatrogenic effects



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of such grouping has been observed in several investigations (e.g., Dishion et al. 1995, 1997, 1999; Mahoney et al., 2004; Poulin et al., 2001), and whether treatment environments can be modified to attenuate these effects appears unlikely. Thus, the implications of this literature are that grouping these individuals together for treatment purposes is generally contraindicated. Interaction of Parental Distress and Treatment Delivery Most efficacious treatment interventions for externalizing disorders, especially for ODD and CD, rely heavily on the ability to influence parental behavior. When parents are able to reliably execute model-specific interventions, outcomes are optimized. However, parents frequently have difficulty executing interventions because of various emotional factors, such as difficulty tolerating distress elicited by the delivery of the trained interventions. For example, a child may respond to an intervention with anger or the magnitude of problem behavior may increase. This frequently elicits distress in parents, who commonly are already in distress and fatigued from the pretreatment existence of problem behavior. Parents may escape their distress by ceasing delivery of the intervention altogether or through inconsistent application. Most models do not guide the clinician to specifically assess for and address these psychological factors. However, our recommendation is that clinicians pay specific attention to these factors in every case because failure to do so may impede treatment compliance. Suboptimal Adherence to Stimulant Treatment The treatment of ADHD with stimulant medication has been studied extensively and found to be efficacious and safe (Conners, 2002; Jensen 2002; MTA Cooperative Group, 1999; Pliszka & the AACAP Work Group on Quality Issues, 2007). Notwithstanding the empirical evidence, adherence to stimulant treatment is low (Pappadopulos et al. 2009; Sanchez et al., 2005). Thus, treating clinicians should plan to thoroughly assess and intervene upon barriers to treatment adherence.

UNDERLYING THEORY Cognitive behavioral approaches to intervention are informed by basic models of human behavior. It is essential for the clinician to be fluent in these models so that their delivery of CBT is optimized and so they may “lean” on principles derived from these models when clinical presentations are atypical. In this section, we provide an introduction to the fundamentals associated with each theory, enough for the reader to comprehend the connection between the basic principles and the interventions built upon them. For readers who desire greater depth, we provide resources in the recommended reading section. We begin with operant learning and end with a discussion of cognitive models.

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Operant Learning Operant conditioning (Skinner, 1938) is a type of learning in which the rate of behavior is a function of its consequences. Two categories of consequences, each with two subtypes, are considered in operant learning. The two overarching categories are reinforcing and punishing consequences, each with different impact on rate of behavior. Reinforcing consequences lead to an increased probability of the behaviors they follow whereas punishers decelerate the probability of behaviors that precede them. The subtypes are designated positive and negative, as in positive and negative reinforcement and positive and negative punishment. Importantly, positive and negative are not evaluative terms, as in “good” and “bad.” Rather, they refer to the addition or subtraction of a stimulus. For example, positive reinforcement involves adding a stimulus immediately following a behavior and that consequence subsequently leading to an increased probability of that behavior. Consider a child who aggresses a sibling, and immediately following the aggressive behavior a parent intervenes and “distracts” the child with a preferred toy (e.g., “Johnny, here’s your truck to play with”). The parent’s intention in this example is to prevent further aggressive behavior by diverting the child’s attention with a toy known to capture the child’s focus. However, the parent may have just inadvertently positively reinforced the aggressive behavior by providing a valuable toy (i.e., adding a stimulus) immediately following the undesirable behavior. In contrast, negative reinforcement involves the removal of a stimulus, which similarly leads to an increased probability of that behavior. Consider a child who finds math boring, difficult, or otherwise aversive. During math instruction the teacher provides a math worksheet to the class, and shortly after receipt of this worksheet this student begins cursing. The teacher, quick to respond to the cursing behavior, sends the student to time out. The teacher intends to punish the cursing behavior, presuming time out will function as a punisher and subsequently decrease the occurrence of that behavior. However, in this circumstance, the teacher may have inadvertently reinforced the cursing behavior because sending the student to time out removes the aversive stimulus (i.e., the math worksheet). Thus, the probability of cursing behavior increases under similar conditions. Punishing consequences have the opposite impact on behavior than reinforcing consequences. Instead of increasing the probability of the behavior they follow, they decrease the probability of behavior. Similar to reinforcing consequences, they can usefully be categorized into positive and negative categories, again referring to the addition or removal of a stimulus. Negative and positive do not refer to an evaluation of punishing stimuli. Positive punishment, then, is the addition of a stimulus immediately following a behavior that leads to a subsequent decrease in the probability of that behavior. For example, an adolescent “mouths off” at their parents, and their parents respond by spanking them. If spanking functions as a punisher, then the probability of mouthing off in the future reduces. Negative punishment involves removal of a stimulus that results in the reduced probability of behavior. For example, time out, when



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delivered properly, is a negative punishment procedure. A child may be playing with preferred toys and playing with friends but then emit a problem behavior, triggering their parents to send them to time out. The time in condition, which is reinforcing, is removed, and this removal results in a reduction in the problem behavior. Negative reinforcement and punishment are frequently confused with one another. The important distinction is that any reinforcement procedure results in an increase in behavior whereas any punishment procedure, by definition, results in a decrease (i.e., negative reinforcement  =  increase; punishment = decrease). They have opposite effects on behavioral trajectory. Understanding these concepts and their impact on behavior is important for a couple of reasons. First, parents frequently presume their responses to problem behavior will produce certain effects, but, frequently, they do not and often have an effect opposite to what was intended. It is not uncommon for a parent of a child or adolescent with an externalizing disorder to say “punishment doesn’t work on my child,” or “my child doesn’t care about rewards.” There are some important considerations in relation to punishment, which we consider shortly, and by reward, they generally mean what we mean by reinforcer, but the important point for now is that their conclusions are not possible. If the child emits behavior, then that behavior is responsive to punishing and reinforcing consequences. In fact, by definition, behavior cannot be occurring unless it has been reinforced. Indeed, most scientifically supported models demonstrate that parents are often inadvertently strengthening the very behaviors they intend to eliminate. Second, the exact same problem behavior can be reinforced by a range of reinforcers. Frequently, when parents present for consultation, they simply describe the problem behavior without reference to antecedent and consequent events, with the presumption that knowing what the behavior is will inform the clinician as to appropriate intervention. However, although knowing the behavioral targets are important, they are insufficient for determining an intervention plan. One must identify relevant environmental events that surround the behavior. Understanding the effects of punishment is important. Although punishment can be quite effective at reducing behavior, it comes at a significant cost. A punishing consequence tells a child or adolescent what not to do, not what to do. Parents frequently assume that the individual knows what to do instead, but that is not always the case. Even more concerning is that a behavior that emerges instead of the punished behavior may be worse than the punished problem behavior. Another well-known side effect of punishment is that it tends to elicit anger and aggression, an unhelpful response when treating ODD or CD. Punishing behavior can be negatively reinforced. For example, a child is engaging in problem behavior, which a parent experiences as aversive. The parent delivers a punishing stimulus, and the problem behavior quickly stops, removing the aversive stimulation equally fast. Thus, the parent’s punishing behavior was reinforced, increasing the probability of its recurrence in the

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future. Indeed, most families with children and adolescents with problem behavior overrely on punishing consequences, and this is likely one of the primary reasons. Finally, children and adolescents can frequently habituate to punishing stimuli, necessitating an increase in the magnitude of punishing stimuli in the future to achieve similar effects. This can lead to punishing behavior at dangerous levels. For these reasons, punishment is highly undesirable as a consequence for problem behavior. Instead reinforcing consequences are preferred because they do not entail these side effects and lead to faster acquisition of desirable behavior. Extinction is another behavioral phenomenon important for clinicians to understand. Extinction occurs when a reinforcer that previously maintained a behavior is no longer delivered when that behavior occurs again in the future. For example, assume a child’s problem behavior is maintained by attention in the form of parental nagging and pleading. If this child’s parents later ignore the problem behavior (i.e., discontinue nagging, pleading, or providing other forms of attention) whenever a child emits the problem behavior, that behavior is now said to be on extinction. Extinction will predictably lead to an extinction burst, a phenomenon with important treatment implications. Extinction bursts involve several behavioral consequences once extinction occurs. Specifically, one may see an increase in the magnitude of the behavior that was previously reinforced and/or an increase in the variability of the topography of responses that are “tried.” Anger elicitation is also possible. For example, consider a vending machine that an individual visits frequently in order to retrieve their favorite candy bar. The behavior of “button pushing” is positively reinforced with the delivery of the selected candy bar. One day, however, this individual follows their typical routine except that their button pushing fails to result in the delivery of the candy bar (e.g., it gets hung up on the rack and does not fall into the tray where it is typically retrieved). In this circumstance, one might observe the individual pushing the button several additional times. The button pushing may further increase in frequency or in magnitude. They may use different body parts to push the button (e.g., elbow, foot). They may try non-button-pushing behaviors. They might punch, shake, and rock the machine. These various behavioral responses make up an extinction burst and demonstrate an increase in magnitude (i.e., more forceful button pushes, kicks) and increase in topography (i.e., non-button-pushing responses, new ways of button pushing) that frequently occur. However, it is important to note that an extinction burst will not last forever; it will run its course. An example in the context of oppositional defiance is useful. A parent describes a frequent interaction between her and her son shortly after arriving home from school each day. After providing the child with an afterschool snack, she prompts him to initiate homework. He refuses and says he will only do his homework after he watches television. After a bit of back and forth, the parent relents and allows the child to watch television. Eventually, the parent decides that she should not give in so easily and is determined to not allow him access to television until after he completes his homework. We might label the



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child’s common problem behavior in this context “pleading for television.” That behavior has been reinforced historically through the provision of access to television. However, when the mom decides to deny access, she is putting pleading for television behavior on extinction and is thus likely to observe an extinction burst. For example, the child may start pleading more loudly, using curse words, crying, and/or throwing things. Many parents, being unfamiliar with extinction bursts, presume that what they are doing (in this case withholding television access) is either ineffective or making the circumstance worse, so they revert back to more familiar ways of responding. This only makes matters worse because now a greater instance of the problem behavior has been reinforced. Because extinction bursts will always run their course, an important element of therapy with externalizing disorders is educating parents (and school personnel) about extinction bursts and teaching them the skill of learning to tolerate these behavioral episodes. Many factors converge to produce and maintain externalizing behaviors, but frequent observations, from a behavioral perspective, are that families with externalizing disordered children overrely on the use of punishment and underutilize positive reinforcement for desirable behavior. Consequently, parents lose much of their reinforcing value and instead become signals for punishment. Cognitive Theory Cognitive, emotional, and behavioral responding correspond with one another. For example, parents may have beliefs about how children and adolescents should behave or how behavior should be modified. They might maintain demanding beliefs such as “children should always be respectful.” One consequence of such an idea is that they attend to every instance of child problem behavior, regardless of how insignificant that behavior might be. Attention, even topographically negative attention, often functions as a positive reinforcer. Thus, the provision of such attention frequently increases the probability of the very behaviors they desire to eliminate. Indeed, many evidence-based approaches teach parents to ignore insignificant behaviors so that they are placed on extinction. However, parents are unlikely to follow through with such extinction procedures if they maintain rigid beliefs about the significance of minor, and often developmentally typical, behavior. Similarly, parents might endorse beliefs that “I shouldn’t have to reward my child for good behavior,” similarly interfering with their delivery of highly effective positive-reinforcement-based interventions. Parental distressing emotions, as noted previously, can also undermine their competent application of treatment procedures. For example, when angry or depressed they are more likely to be influenced by automatic thoughts such as “to hell with it!” or “there’s no hope.” Such ideas and their emotional consequences can lead to inconsistent application of treatment interventions or the use of punishment procedures.

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Child and adolescent cognition can also be important intervention targets. This may involve the modification of dysfunctional cognition or the development of cognition to assist with governing behavior when such cognition is absent or underdeveloped.

EMPIRICALLY SUPPORTED TREATMENTS FOR EXTERNALIZING DISORDERS The Society of Clinical Child and Adolescent Psychology (SCCAP), Division 53 of the American Psychological Association, maintains a list of psychological treatments with a favorable evidence base.2 It presents treatments, by clinical problem, in rank order based on level of evidence and should be consulted regularly as the research evolves. Currently, the SCCPA identifies that behavioral interventions maintain the most evidence for the treatment of ADHD.3 The American Academy of Pediatrics Practice Guidelines (American Academy of Pediatrics [AAP], 2011) similarly recommends behavior therapy and also stimulant or related medication in isolation or in combination with behavior therapy. Notable is the list of interventions that have been previously evaluated and found lacking in efficacy in the treatment of ADHD (see AAP, 2011; Waschbusch & Hill, 2001). Various combined behavioral, cognitive behavioral, and family therapy approaches contain the most evidence for disruptive behavior disorders (Society of Clinical Child & Adolescent Psychology, 2019). Applied behavior analysis also has demonstrated efficacy with many behaviors exhibited by those diagnosed with an externalizing disorder.4 It is beyond the scope of this chapter to review the empirical literature on specific cognitive behavioral interventions and intervention packages for externalizing disorders (see recommended reading for comprehensive reviews of this literature). However, the field is moving toward process-driven care and away from treatment packages (Hayes & Hofmann, 2018); thus, we discuss core empirically supported principles in the treatment of externalizing disorders. Unsurprisingly the approaches with the most evidence share many features. For example, they recruit parents into treatment, seek to undermine the use of punishment, alter the unintended reinforcement of problem behavior, and emphasize attending to and reinforcing desirable behavior.

CLINICAL STRATEGY Externalizing disorders are defined by disruptive behaviors that directly impact functionality, resulting in negative interpersonal experiences and outcomes. It https://effectivechildtherapy.org/ Being a psychological organization, they are silent on the efficacy of medication for disorders. 4 See https://www.bacb.com/ for more information. 2 3



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is not surprising that this population can be difficult for clinicians to work with. They can be rude, unapologetic, distrusting, argumentative, and deceitful. They may choose to hurt others, engage in animal cruelty, or destroy property. They can be overactive, loud, disorganized, or easily distracted. Regardless of their presentation, engagement in mental health services can be problematic. Children and adolescents who exhibit behaviors associated with ADHD, ODD, and CD are far too often defined by their actions, something even evident in our introduction to this section. The label of “problem” or “disruptive” is already attached. Additionally, comorbidity and overlapping symptomatology with substance use, anxiety, depression, trauma, and delinquency is common, making treatment complex. Maladaptive, dysfunctional behavior naturally results in judgment from peers, family, and authority figures. Similarly, their behavioral responses to others around them can feel personal to the recipient of their behavior, including the clinicians charged with treating them. This can make working with this population even more difficult. It is neither the goal nor within the scope of this chapter to outline the diversity of individuals that clinicians might encounter. Each client is unique, bringing different strengths and weaknesses, temperament, personality traits, environmental factors, and aptitudes to the table. Understanding the interaction of biological, psychological, and social factors is essential when working with children and adolescents. Biological, behavioral, and socioemotional milestones provide a framework to better identify and maintain appropriate expectations. Clinicians should have a well-developed understanding of these contributing factors and the complexities of the systems involved. Children and adolescents with externalizing presentations can exhibit deficits in many domains, including affect regulation, cognitive processes, academic aptitude, interpersonal skills, and self-awareness. Each of these areas can have a profound impact on their functioning across settings. Assessment is vital and should guide treatment. Taking time to examine all factors that have contributed to a child’s current problematic behavior is critical in developing individualized treatment goals. Information should be obtained through structured and semistructured interviews, rating scales, and observations. Specific attention should be given to familial relationships and family functionality. Gathering an accurate history of symptomatology and events is also important in the determination of onset, which plays a pivotal role in the progression of symptoms and future presentations. Although assessment will primarily focus on specific areas of concern, problematic behavior, and dysfunctional interpersonal relationships, it is important to consider individual strengths and interests. Finally, monitoring symptoms and reevaluation of short- and long-term treatment goals can assist in continued treatment effectiveness and modification. Early in treatment, goals may be more behaviordriven. As treatment progresses, goals may shift focus to examination of underlying motives, beliefs, and future aspirations that were not initially distinguishable or well formulated. In most cases, children and adolescents receiving mental health services are not self-referred. Youth diagnosed with externalizing disorders are no exception.

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They are often referred by those who are trying to help, whether it be their parents, family members, a physician, a teacher, or the court system. High acuity, low motivation, passivity, and a low frustration tolerance can be expected early in treatment. Change is difficult for everyone. It is often scary, involves uncertainty, requires hefty response effort, and can be perceived as insurmountable, unnecessary, or unattainable. Furthermore, although a behavior has produced negative outcomes, even those of high magnitude, it is always sensible when considering the contingencies of reinforcement maintaining it. It can be useful for clinicians to remember this, as it can be facilitative of empathy toward their clients. There are additional obstacles to treatment. A child’s environment, family dynamics, dysfunctional social relationships, conflicting experiences, and past trauma should all be considered. These, along with other factors, have a direct impact on one’s motivation to trust and engage in self-exploration and change. Age, and more specifically cognitive development, should be a primary consideration when implementing evidence-based treatment (EBT). It should be expected that younger children will think in concrete, black-and-white terms when engaging in therapeutic interventions. Conversely, adolescents will demonstrate abstract thinking, venturing “outside of the box,” and finding exceptions to the rules. Each client is unique. Attention should be given to individual differences in order to set realistic, attainable goals for treatment. As previously noted, children and adolescents are rarely self-referred, which has significant implications for treatment. Establishing a strong therapeutic relationship with the client is paramount to positive treatment outcomes. Therapeutic rapport is a universally accepted component of all treatment styles and interventions. Generally, clinicians work to identify problematic behavior and set treatment goals to address specific areas of concern. This is assumed with self-referred clients. However, without rapport, motivation for change can be nonexistent, making the fundamental purpose of treatment unattainable. Thus, treatment with children, especially those who struggle to initiate and maintain healthy relationships, can take time. Therapeutic alliance is a collaborative effort with the purpose of developing trust and respect between both parties in order to attain one’s goals. This relationship is fostered through a safe environment, one that develops over time. Treatment should be engaging, flexible, and dare we say, fun! It should be action-oriented and pragmatic. Too often, treatment goals reflect the wants and needs of the caregiver or school personnel who initiated the referral. The problem behaviors are often complex and impact different systems. These are valid concerns for those trying to help the child or adolescent, but clinicians must be diligent in helping their clients and their families develop realistic goals with individual, family, and community engagement in mind. Another important component of treatment is the perception of hope. Hope, generally defined, refers to one’s feeling, want, or desire for something to happen. Hope, in the context of therapeutic intervention first presented by Snyder



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et al. (1991), is fundamentally different and closely aligns with alliance and the therapeutic process. Hope is not simply the expectation or desire for something to happen, but the development of thought processes that stimulate the identification of pathways and agencies to attain one’s future goals and ambitions. Oftentimes, youth do not possess these specific cognitive abilities and skillsets entering treatment. Academic performance, psychological adjustment, overall physical health, and specific therapeutic outcomes have all been found to be positively related to one’s perception of hope (Snyder, 2002). By creating a positive sense of self, working with youth to identify new ways of thinking in the here-and-now, clinicians can introduce new skills necessary for success. It is then that we become more able to motivate our clients to make changes in the present to enhance their lives and outlook for their future. Hope, at its core, represents a positive motivational state that can assist in overcoming obstacles in treatment. It promotes a sense of control and eventually resilience for children and adolescents. It is our opinion that without instilling a mutual sense of alliance and hope, a clinician’s ability to effectively implement EBT and overcome the inherent barriers with this population, as well as treatment effectiveness and fidelity, can and will be undermined, resulting in transient outcomes at best. Clinicians are encouraged to spend time getting to know their client and be vocal about this primary treatment goal. It is important to examine the whole child and to appreciate their experiences, values, preferences, and interests. Many times, pressure from families and outside parties facilitate an expectation to “get to work” teaching age-appropriate social skills, self-regulation, and coping strategies in conjunction with practical family interventions. Friedberg and McClure (2015) presented a continuum of collaboration that embodies this need for understanding of the therapeutic process with youth. Clinicians are encouraged to consider the importance of the initial stage of therapy for non-self-referred clients and its impact on future treatment sessions. In doing so, we are less likely to overlook the functionality of the initial sessions and more likely to foster a therapeutic relationship that promotes trust, vulnerability, self-disclosure, and ultimately motivation to actively pursue change. Communication plays a central role in the development and maintenance of therapeutic alliance and engagement in treatment. Communication with children and adolescents should be nonjudgmental. By the time a child or adolescent diagnosed with an externalizing disorder steps into the clinician’s office, they have likely experienced judgment and exclusion more than most. It is recommended that clinicians strive to develop a communication style that fosters interest and curiosity rather than forgone conclusions and predetermined solutions. Balance between direct intervention and guided discovery is important. High levels of reactivity are often elicited and/or expected from others. Therapeutic work should focus on the situations and later themes rather than their reactivity. Clinicians may find that they become defensive, explaining their methods and reasoning in an attempt to align with their client. By maintaining an explorative and proactive approach, children are less likely to be

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successful in engaging in power struggles and blame, two maladaptive strategies that are common with this population. Here are some questions that may promote a more productive dialogue: • What were your choices? (With this question, encourage cognitive flexibility by exploring all choices: good, bad, positive, negative, helpful, and unhelpful.) • How did that work for you? • Is that what you wanted/expected to happen? • Did they respond how you wanted? • Did you react how you wanted? • What would you do differently now that you know the outcome? • What got in the way? Clinicians are also encouraged to take time to gather all the details as they begin to examine events and possible change. Many times, this is overlooked, and critical information, whether perceived or factual, goes unrecognized. Taking time to gather information with curiosity and interest reduces the likelihood that clinicians will be perceived as passing judgment and instead gives youth the benefit of the doubt—something they are often not afforded. Clinicians who lose sight of the utility of dysfunctional behavior as well as the importance of collaboration and unconditional positive regard may ultimately lose the trust of their client, resulting in minimal engagement and early termination of services. Up to this point, we have considered universal strategies and considerations to effectively work with children and adolescents diagnosed with an externalizing disorder. We now shift focus and discuss strategies within the cognitive behavioral framework. In many ways, the treatment structure for children and adolescents diagnosed with an externalizing disorder will parallel application with other populations. Consistency and routine are vital to this process. Some of the most problematic behaviors stem from inconsistency. By introducing and maintaining structure from the outset, treatment becomes more predictable and can potentially reduce low engagement often associated with initial sessions. In order to attain this goal, we suggest collaboratively setting an agenda with the child or adolescent, offering choices and the opportunity to add activities, topics, or problem areas to the list. Additionally, providing time to talk about interests, personal strengths, and successes is paramount. Flexibility and consistency can coexist and together can promote a sense of control that is often not afforded to youth. Another staple of the CBT model is gathering feedback from clients. Feedback is essential to the treatment of externalizing disorders. Children and adolescents need to feel heard. Asking what they enjoyed about the session, what they did not like, and what was boring or uncomfortable is instrumental to



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future sessions. More often than one would expect, the client will share a different interpretation of their experience that might have gone unnoticed had the clinician not asked. This also provides a sense of flexibility and control that the client is not accustomed to in everyday settings. Clinicians should also exhibit transparency affording time to introduce and explore new concepts. Psychoeducation is necessary; however, we strongly recommend treading lightly until rapport has been developed. Psychoeducation provides children and adolescents with an opportunity to obtain accurate information in order to better understand themselves, others, and the world. Normalization is an effective tool within this component. Often, youth struggling with an externalizing disorder feel alone and ostracized by their peers. The information they have gathered from experience is commonly negative and, at best, inconsistent. Psychoeducation provides another resource for information and the opportunity to observe problematic behavior through another lens. Far too often, the expectation of parents, school personnel, and physicians is for therapy to help a child or adolescent develop healthy coping strategies. Although this most certainly falls within the scope of the CBT model, this conceptualization of coping is far too simplistic. It assumes coping as a strategy can exist in isolation as a set of tools one can pull from their tool belt when needed. When this happens, children and adolescents often will misidentify, misinterpret, and/or misuse their learned coping strategies, leading to more negative outcomes, which in turn reduces the likelihood that they will use it in the future. In reality, most children and adolescents struggle to first accurately identify their emotional experiences, which can be complex and/or conflicting. This makes it difficult for the child to articulate to others what they need and reduces the probability of an appropriate response of support. By oversimplifying the use of coping skills, we reduce the likelihood that they will be able to implement their newly acquired tool at the appropriate time, inadvertently setting them up for failure. Only by linking these skills together do we provide youth with the tools necessary for success. Children and adolescents with externalizing presentations have had a plethora of experiences, mostly negative, before coming to a clinician’s office. Children learn through experience. Some have insight and are direct in their motives, whereas others may be oblivious to how their behavior impacts those around them. Modeling, practice, rehearsal, and role-play provide youth with the opportunity to try something new or apply a specific skill in a new way. Children and adolescents are more likely to respond to clinicians who are excited, engaging, curious, and flexible, but also realistic. It is not enough to introduce a new strategy and develop a skill in session. Clinicians should work diligently to help the client identify situations and environments that are conducive to successful application. Familial and community supports must also be involved in this process, learning similar tools and assisting with implementation when feasible. Through between-session homework and increased positive social engagement, youth are given the opportunity to test new skills and explore new thought processes that ultimately lead to change.

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Taking the model further, clinicians are encouraged to explore situations, themes, and problematic behavior, noting all options and outcomes. Children and adolescents rarely have a sense of control. Therapy is the perfect platform to support this basic need. More often than not, youth are expected to act like adults but are treated as children. This mentality is problematic on many levels and becomes more pronounced as children enter adolescence and seek autonomy and independence. Cognitive distortions of blame, labeling, and black-andwhite thinking contribute to a negative mental filter that develops. Education without denoting right and wrong or good and bad can stimulate the development of cognitive flexibility. Cognitive flexibility is a primary component of treatment and functions as a means to decision making, adaptation, and change. It is our opinion that the development and nurturing of cognitive flexibility is paramount to therapeutic progress and adaptive learning. No child should be in treatment alone. In our supervision with graduate students and mental health professionals, it can be disconcerting to review an evaluation that only recommends individual outpatient therapy. Externalizing disorders imply behavioral dysfunction perpetuated by environmental influences. Children do not live in a vacuum. In order to create long-term systemic change, clinicians must work with the child’s family and supports. Thus, family involvement is a critical component of the therapeutic process and therapeutic gains. Similarly, parent buy-in matters. When meeting parents for the first time, we often use two analogies. The first is the mechanic. We let parents know, in no uncertain terms, that clinicians are not mechanics, and their child is not a car. They cannot expect to simply drop off their child for a short period of time and return to a problem “fixed” or “repaired.” The second analogy is the mobile. We explain to parents that each family is like a mobile that hangs over an infant’s crib. Each member represents one of the objects that dangle from the strings above. As we ask one to change, pushing it up or pulling it further down, the other pieces naturally shift. Change is difficult and affects the entire family unit. Family dynamics, roles, responsibilities, and expectations already exist. Everyone must be ready and prepared for this transition, accepting their new placement (i.e., roles, responsibilities). One cannot expect lasting change without this acceptance. Parents also need to be equipped with the appropriate skills and strategies to respond to their child’s needs, behaviors, and emotions. Helping parents acquire a new lens in which to see their child or adolescent’s behavior can resonate in treatment. Parenting is not about control, but teaching. It is not one-size-fits-all. By understanding how to respond to the underlying purpose or function of a behavior, parents can learn to respond with empathy and support rather than frustration. Psychoeducation is a useful tool in family therapy, providing the opportunity to develop more realistic expectations. We often ask parents one simple question when they begin parent sessions: “Do you respond the right way every time?” The answer is, unquestionably, “No.” No one is perfect, and this cannot be the expectation for children and adolescents. As parents begin to



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understand the importance of goodness-of-fit and effective communication, children and adolescent’s dysfunctional behavior becomes more manageable and malleable. When consistency, follow through, and patience are appropriately implemented, parents and supports can begin to create an environment conducive for healing and long-term change. The therapeutic environment also matters. The treatment setting should be inviting but also promote engagement. It is important not to expect adolescents and especially children to enter a calm, soothing office to talk out their problems. The room should reflect the age of the clients. Children and adolescents learn through experience. Without understating biological and psychological influences, social and experiential learning is essential. The expectation that a child will want to engage with their clinician, especially early in treatment, through witty and challenging dialogue is not realistic. Movement and active engagement are necessities. Simply throwing a ball to one another can stimulate a back-and-forth connection or nonverbal cue that can elicit collaboration and investigation. Therapy need not always take place in the office. When feasible and appropriate, children and adolescents need to practice and experience new skillsets in a natural environment. Although this may not always be realistic, the closer we can be to an event or situation, the more likely we can elicit real emotion and responses, helping to modify dysfunctional behavior. Acuity and specific symptomatology should always be taken into consideration, especially with regard to safety. This is true for every session. Although clinicians should be perceived as inviting and compassionate, safety for themselves and the client should always remain deliberate. Finally, prior to beginning work with this population, it is recommended that clinicians take time to explore and know themselves. Most graduate and training programs successfully work with their students on self-exploration and professional growth. However, it is important for clinicians to consider their background and experiences, realizing that they have their own lens through which they view the world. It is important for clinicians to be aware of their beliefs, values, and biases, becoming comfortable identifying and accepting personal strengths and weaknesses. Lastly, clinicians should be cognizant of their own issues and “hot topics” and work to become comfortable with the uncomfortable.

DISSEMINATION Treatment developers of specific treatment packages often offer training and certification in those packages. However, the nature of training and certification differ. For example, many certifications attest to number of training hours completed but do not speak to competence. One notable exception is the Academy of Cognitive Therapy. Among the certification requirements is the requirement to submit a work sample (i.e., a video recording of a session) to be scored by an independent rater using an instrument high in reliability and validity.

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The interested clinician is encouraged to investigate the nature of certifications, if any, specific to a treatment intervention or package.

CLINICAL EXAMPLE Harry is a bright, social 14-year-old male in the eighth grade. Harry enjoys playing video games, hanging out with friends, all things sports, and being outdoors. He has a younger brother (11) and sister (9). His relationship with his younger siblings is described as a “typical” love-hate relationship; however, conflict between Harry and his younger brother has increased in recent years. Harry’s father and mother are both employed and work long hours. His relationship with his parents has declined over the past year, and he rarely wants to spend time with his family members. Harry’s current diagnoses include ADHD, combined presentation, and ODD. He has exhibited symptoms associated with inattention and hyperactivity/impulsivity from an early age. Recently, he has become more defiant both at school and at home. Harry has had difficulty managing his anger since he transitioned to middle school. Harry makes friends easily but struggles to maintain close peer relationships due to impulsivity and a low frustration tolerance of others. Harry was referred to a therapist by his parents after concerns with poor academic engagement, disrespect toward authority figures, and recent peer conflict were shared by his teachers at school. Select samples of therapeutic conversations with Harry, interspersed with brief clinical commentary, are presented below: THERAPIST: Hey, Harry. How are you doing today? HARRY:

I’m alright. Just got out of gym. We got to play basketball today. Me and my two buddies were on the same team. We crushed the other kids. It was like three on seven!

THERAPIST: Wow. Sounds like you had a really fun time in gym today.

The clinician should be curious when children and youth share their experiences, continuing to gather information and considering strengths and interests. This helps to facilitate and maintain rapport, promoting a sense genuine interest and collaboration. HARRY:

Yeah. We have been playing basketball all week. There are about 15 kids who usually pick basketball.

THERAPIST: Do you always get to pick what you want to do in gym? HARRY:

Yeah, this week we can. Mrs. Aberman is out, so the sub, Mrs. Conway, lets us pick what we want to do when we finish our drills.



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THERAPIST: What kind of drills do you have to do? HARRY:

Run 10 laps, 20 sit-ups, 20 push-ups, and 50 jumping jacks.

THERAPIST: Wow, that’s impressive. I am not sure I could do that! HARRY:

It’s not that bad. It usually only takes 10 minutes, and then we have the rest of the time to play basketball.

THERAPIST: Sounds like fun. I bet you wish gym class was always like that. HARRY:

Yeah, it usually is. Yesterday wasn’t so great.

THERAPIST: What happened? Fill me in. HARRY:

I got sent to the office and spent all yesterday in in-school suspension. I didn’t even do anything.

THERAPIST: Oh, man. I am sorry to hear that. Is that something you would

want to talk about today? HARRY:

Yeah. Definitely.

THERAPIST: Okay. Is there anything else that has been going on or that is on

your mind that you want to add to our agenda? HARRY:

Yeah. I was supposed to go to my friend’s house this weekend, but now my parents say I can’t go and that I am grounded until they decide I have learned my lesson. Whatever that means . . .

THERAPIST: Oh, no. I’m sorry to hear that. HARRY:

Yeah. It’s B.S.

THERAPIST: I can tell you are upset and this is important to you. Is there

anything else that is on you mind or that you have been dealing with this week that you want to add to our agenda? HARRY:

Not that I can think of.

THERAPIST: It sounds like we have two important things to discuss: what

happened yesterday and missing out on going to your friend’s this weekend. Is that right? HARRY:

Yes.

THERAPIST: If anything else comes to mind, just let me know and we can

always add it to the agenda. HARRY:

Okay. I will.

THERAPIST: Which makes sense to you to talk about first? HARRY:

I guess we can talk about gym class and getting ISS since that is why my parents are freaking out.

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THERAPIST:

That makes a lot of sense. And then we can talk about this weekend and things at home with your parents.

HARRY:

Yeah. That works for me.

THERAPIST: Okay. Before we dive into what happened yesterday, let’s do our

regular check-in. On a scale of 1 to 10 with 1 being really low, a really tough day, and 10 being really great, like your trip to the beach this past summer, where would you say today falls? HARRY:

Well today, I am a 6 or 7. But yesterday I was a 2.

THERAPIST: So what are some things that come to your mind when you

think about today and this week that played into your ratings? In instances where other underlying emotional concerns are present, the clinician should work to delineate between specific features in addition to an overall mood check using multiple scales if necessary to assess symptomatology. In situations in which youth provide a neutral score of 5 on a scale of 1 to 10, the following response may assist with further exploration: THERAPIST: On a scale of 1 to 10, with 10 being a great day and one being a

terrible day, how would you rate your overall mood? HARRY:

A 5 I guess.

THERAPIST: 5 is a pretty neutral number. It sounds like there are both good

and bad things about today. HARRY:

Yeah. You could say that.

THERAPIST: Do you think you could pick a direction, maybe 5.1 or 4.9 even? HARRY:

I would say 5.1.

THERAPIST: Okay. That helps a lot. How about we talk about some of the

things contributing to your mood? HARRY:

Sure.

THERAPIST: Now that I have a better sense of how your day and week have

been going, why don’t we go ahead and dive right in and see what we can figure out. Do you think you could walk me through what happened yesterday? HARRY:

I was having a great day when we got to gym class. We finished our drills in like 5 minutes and starting picking teams. Jack didn’t like that me and Thomas were on the same team. He started accusing us of cheating, and when he tried to take the ball out of my hands he hit me in the face. So I turned around and hit him with the basketball and told him I was going to knock him out.



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He started crying, and Mrs. Conway blew the whistle and just started yelling at me in front of everyone. THERAPIST: How did that make you feel?

The clinician should spend as much time as needed examining the event and assisting the client with identifying their thoughts, feelings, beliefs, and important contextual variables associated with the specific event. THERAPIST: I notice how tense you are as you tell me this story again, even

after a day has passed. Your face is a little red and your voice sounds agitated. Did you notice that? HARRY:

Yes.

THERAPIST: Do you notice anything else? HARRY:

Yeah. He makes me so angry. I just want to knock him out. [clenches his fists]

THERAPIST: I can see how you might come to that conclusion. You know a

lot of times in everyday situations people often say they felt one way or another. Our brain does a really good job of trying to simplify the situation so we can respond right then and there. So in these moments, we notice a specific feeling, like anger. But oftentimes, we experience other feelings or emotions. We just don’t always recognize them because anger jumps to the front of the line. When you think back to that situation again, do you notice anything else other than just being angry? HARRY:

I mean, yeah. He is annoying. He thinks he can tell me what to do.

THERAPIST: I can see that. Do you notice anything else? HARRY:

Just thinking about it makes me mad. I feel hot and my heart is racing. I just want to knock him out. And Mrs. Conway doesn’t care.

THERAPIST: What makes you say she doesn’t care? HARRY:

She just stands there and doesn’t say anything. But as soon as I do something . . . she calls me out.

THERAPIST: What happens when she calls you out? HARRY:

Everyone looks at me.

THERAPIST: What happens when everyone looks at you? HARRY:

I don’t know. Class stops and everyone is looking at me like I started it. It’s embarrassing. She doesn’t respect me.

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THERAPIST: I can see based on your evidence so far why you see it that way.

So how did you respond? HARRY:

I told her it was B.S. and that she always calls me out. Then she sent me to the office.

It is important that clinicians take the time to fully consider the specifics of the situation. Youth are not always forthcoming, especially about their behavior. By taking time to completely examine the context, reactions, and evidence, the clinician will likely gather additional information to help the client connect their interpretation with their emotional and behavioral responses. Open-ended questions provide the client with the opportunity to share their perspective and reduce the likelihood of fixed, one-word responses. Patience and validation of emotions can assist in exploration and collaboration around choice behavior moving forward. THERAPIST: This information is very helpful. Now I can see how this all

played out. Let me see if I have this right. At the beginning of gym class, you were excited to play basketball with your friends, knocking out your drills in 5 minutes so you and your friends could pick up where you left off the day before. But you quickly became annoyed by Jack, who called you a cheater and got in your space. He tried to take the ball away and hit you in the face in the process. That is when you became angry, threw the ball at Jack, and threatened him. To make matters worse, Mrs. Conway stopped class and called you out in front of everyone which was embarrassing and you felt disrespected. Do I have that right? Please let me know if I missed anything important. HARRY:

Yes. You got it. Every day I go into gym knowing he is going to follow me around and bug me until I do something. He makes me so mad. Someone should knock him out. Then he would learn.

THERAPIST: That is one way to respond. I wonder what would happen if you

went with that choice. HARRY:

I would get suspended or even expelled for fighting.

THERAPIST: Hmm. While that may satisfy your anger in the moment, do you

think this would be the best option for you or Jack? HARRY:

Probably not.

THERAPIST: I wonder if we could come up with a list of other ways you could

respond next time. What do you think? HARRY:

I don’t know.



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THERAPIST: Would you be willing to make a list with me? How many differ-

ent choices do you think we can come up with? HARRY:

I don’t know. Like five.

THERAPIST: That would be a good start. Let’s see what we can come up with

together. Just start naming off anything you can think of. Let’s not worry about labels or if it’s good or bad. You start naming options, and I will write them down. HARRY:

I could punch him, kick him, or call him names when the teacher isn’t looking.

THERAPIST: Okay. What else? HARRY:

I could refuse to play or get everyone to ignore him and leave him out, but he will just tell on us.

THERAPIST: So far we already have five ways to respond. Do you notice any-

thing about these choices? Any you want to try? HARRY:

I mean, I really want to hit him, but I will just end up in ISS again or worse.

THERAPIST: What about the others? HARRY:

Of these five? I will probably end up getting blamed and get in more trouble with my parents.

THERAPIST: Okay. So let’s see if we can come up with some more. HARRY:

That’s all I can come up with.

THERAPIST: Remember, we often think we only have a few choices, but

really we can do anything. Can I give you an example of what I mean? HARRY:

Sure.

THERAPIST: Right now, you are sitting here brainstorming with me. You are

doing great, but really you could do anything. You could stand up on the couch. You could jump up and down singing your favorite song. You could even laugh like your favorite villain. Do you get it? HARRY:

I think so.

THERAPIST: For fun, let’s keep going with the example right now. What else

could you do right now while you are meeting with me? In this situation, collaboration and cognitive flexibility for both the client and clinician will help to generate a long list of potential responses that can provide an avenue for problem solving and future decision making. The process

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of generating alternative solutions can be translated to future exploration promoting openness and creativity in addition to increased self-awareness of how one’s behaviors are related to specific thoughts, perceptions, and emotions. Once a list has been generated, it is important to take time to explore each option. As multiple options are identified, specific skills, resources, and supports may also be explored to assist the client with appropriate implementation. Specific responses selected by the client should be modeled, practiced, and rehearsed in session to develop necessary skillsets that increase the likelihood of follow-through and potential effectiveness. The clinician can also help guide this process by considering others’ responses, and the client may be encouraged to identify supports that may be able to provide additional solutions. The goal is to reduce black-and-white thinking that accompanies adolescent decision making and increase cognitive flexibility. Example questions for assisting youth with the examination of specific events include the following: • Can you walk me through what happened, step by step? • What happened next? • How would you like them to respond? What were you hoping would happen? • What thoughts or images ran through your mind? What about right now as you think about this happening again? • What was going on right before this all started? • What do you notice? • What was going on around you? Example follow-up questions when considering options include the following: • What have you tried so far? • What skills could you use to help you handle this situation? • How do others you know respond when this happens to them? • When have you seen someone else try that response? • How did that work out? • How has this worked for you in the past? • What parts of the situation do you control? • Where/how can we apply this moving forward? • Is there anyone who could help you accomplish this? Example questions for engaging a client in skill development and role-plays include the following:



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• So which strategy do you want to try out? • Why don’t we go ahead and have a trial run? • Why don’t we see how it plays out? • Would you rather be you or your classmate? I can be the other. Reversing roles can be very effective in engaging this population in role-plays and skill development.

CONCLUSION AND FUTURE DIRECTIONS In this chapter, the key characteristics, natural course, and common comorbidities among externalizing disorders were introduced. Important theoretical underpinnings of clinical interventions, including operant and cognitive theory, were presented. This presentation included discussion of how theoretical elements operate in the development and maintenance of these disorders. Finally, unique and important considerations pertaining to the treatment of these disorders, as well as general clinical strategy, were detailed. Several directions for future research and practice patterns are evident. First, the literature is clear that the treatment of children and adolescents with externalizing disorders should not solely involve individual therapy, but rather must incorporate the family. It is unclear how many community clinicians treating externalizing disorders incorporate the family, or other important systemic elements, into treatment to the exclusion of solely relying on the provision of individual therapy. It is similarly unclear how knowledgeable clinicians are of the peer deviancy training literature and whether the implications of this research have impacted their clinical behavior. Future research should assess clinician practice behavior in these regards. Finally, more research attention should be given to increasing adherence to stimulant medication treatment in the treatment of ADHD.

RECOMMENDED READING There is a large literature on the cognitive-behavioral treatment of externalizing disorders. The following titles are highly recommended. Cipani, E., & Schock, K. M. (2010). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. Springer Publishing. Dishion, T. J., & Kavanagh, K. (2003). Intervening in adolescent problem behavior: A familycentered approach. Guilford Press. Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 43(4), 527–551. https://doi. org/10.1080/15374416.2013.850700

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Kaminski, J. W., & Claussen, A. H. (2017). Evidence base update for psychosocial treatments for disruptive behaviors in children. Journal of Clinical Child and Adolescent Psychology, 46(4), 477–499. https://doi.org/10.1080/15374416.2017.1310044 Kazdin, A. E. (2008). Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. Oxford University Press. https://doi.org/ fhm7 Latham, G. I. (1990). The power of positive parenting. P&T Ink. McCart, M. R., & Sheidow, A. J. (2016). Evidence-based psychosocial treatments for adolescents with disruptive behavior. Journal of Clinical Child and Adolescent Psychology, 45(5), 529–563. https://doi.org/10.1080/15374416.2016.1146990 Wolraich, M., Brown, L., Brown, R. T., DuPaul, G., Earls, M., Feldman, H. M., Ganiats, T. G., Kaplanek, B., Meyer, B., Perrin, J., Pierce, K., Reiff, M., Stein, M. T., Visser, S., the Subcommittee on Attention-Deficit/Hyperactivity Disorder, & the Steering Committee on Quality Improvement and Management. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/ hyperactivity disorder in children and adolescents. Pediatrics, 128(5), 1007–1022. https://doi.org/10.1542/peds.2011-2654

REFERENCES Abikoff, H., & Klein, R. G. (1992). Attention-deficit hyperactivity and conduct disorder: Comorbidity and implications for treatment. Journal of Consulting and Clinical Psychology, 60(6), 881–892. https://doi.org/10.1037/0022-006X.60.6.881 American Academy of Pediatrics. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128(5), 1007–1022. https://doi.org/10.1542/ peds.2011-2654 Bachman, J. G., Wadsworth, K., O’Malley, P., Johnston, L., & Schulenberg, J. (1997). Smoking, drinking, and drug use in young adulthood: The impact of new freedoms and new responsibilities. Erlbaum. Battagliese, G., Caccetta, M., Luppino, O. I., Baglioni, C., Cardi, V., Mancini, F., & Buonanno, C. (2015). Cognitive-behavioral therapy for externalizing disorders: A meta-analysis of treatment effectiveness. Behaviour Research and Therapy, 75, 60–71. https://doi.org/10.1016/j.brat.2015.10.008 Chen, K., & Kandel, D. B. (1995). The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of Public Health, 85 (1), 41–47. https://doi.org/10.2105/AJPH.85.1.41 Conners, C. K. (2002). Forty years of methylphenidate treatment in Attention-Deficit/ Hyperactivity Disorder. Journal of Attention Disorders, 6(Suppl. 1), 17–30. https://doi. org/10.1177/070674370200601S04 Dishion, T. J., Capaldi, D., Spracklen, K. M., & Li, F. (1995). Peer ecology of male adolescent drug use. Development and Psychopathology, 7(4), 803–824. https://doi.org/ 10.1017/S0954579400006854 Dishion, T. J., Eddy, J. M., Haas, E., Li, F., & Spracklen, K. (1997). Friendships and violent behavior during adolescence. Social Development, 6(2), 207–223. https://doi. org/dhdd5p Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54(9), 755–764. https://doi.org/b9rff6 Dodge, K. A., Dishion, T. J., & Lansford, J. E. (2006). Deviant peer influences in intervention and public policy for youth. Social Policy Report, 20(1), 1–20. https://doi. org/ggkj78



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Friedberg, R. D., & McClure, J. M. (2015). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts (2nd ed.). Guilford Press. Handwerk, M. L., Field, C. E., & Friman, P. C. (2000). The iatrogenic effects of group intervention for antisocial youth: Premature extrapolations? Journal of Behavioral Education, 10(4), 223–238. https://doi.org/10.1023/A:1012299716053 Harford, T. C., Grant, B. F., Yi, H. Y., & Chen, C. M. (2005). Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: Results from the 2001 National Household Survey on Drug Abuse. Alcoholism: Clinical and Experimental Research, 29(5), 810–828. https://doi.org/10.1097/01.ALC.0000164381.67723.76 Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. New Harbinger. Hicks, B. M., South, S. C., Dirago, A. C., Iacono, W. G., & McGue, M. (2009). Environmental adversity and increasing genetic risk for externalizing disorders. Archives of General Psychiatry, 66(6), 640–648. https://doi.org/10.1001/archgenpsychiatry.2008. 554 Jackson, K. M., Sher, K. J., & Wood, P. K. (2000). Trajectories of concurrent substance use disorders: A developmental, typological approach to comorbidity. Alcoholism: Clinical and Experimental Research, 24(6), 902–913. https://doi.org/10.1111/j.15300277.2000.tb02072.x Jensen, P. (2002). Longer term effects of stimulant treatments for attention-deficit/ hyperactivity disorder. Journal of Attention Disorders, 6(Suppl. 1), 45–56. https://doi. org/10.1177/070674370200601S06 Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51(1), 8–19. https://doi.org/10. 1001/archpsyc.1994.03950010008002 Lahey, B. B., Rathouz, P. J., Van Hulle, C., Urbano, R. C., Krueger, R. F., Applegate, B., Garriock, H. A., Chapman, D. A., & Waldman, I. D. (2008). Testing structural models of DSM-IV symptoms of common forms of child and adolescent psychopathology. Journal of Abnormal Child Psychology, 36, 187–206. https://doi.org/10.1007/ s10802-007-9169-5 Mahoney, J. L., Stattin, H., & Lord, H. (2004). Unstructured youth recreation centre participation and antisocial behaviour development: Selection influences and the moderating role of antisocial peers. International Journal of Behavioral Development, 28(6), 553–560. https://doi.org/10.1080/01650250444000270 Moffitt, T. E., Caspi, A., Rutter, M., & Silva, P. A. (2001). Sex differences in antisocial behavior: Conduct disorder, delinquency, and violence in the Dunedin longitudinal study. Cambridge University Press. https://doi.org/10.1017/CBO9780511490057 MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56(12), 1073–1086. https://doi.org/10.1001/archpsyc.56.12.1073 Newman, D. L., Moffitt, T. E., Caspi, A., Magdol, L., Silva, P. A., & Stanton, W. R. (1996). Psychiatric disorder in a birth cohort of young adults: Prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21. Journal of Consulting and Clinical Psychology, 64(3), 552–562. https://doi.org/10.1037/0022006X.64.3.552 Pappadopulos, E., Jensen, P. S., Chait, A. R., Arnold, L. E., Swanson, J. M., Greenhill, L. L., Hechtman, L., Chuang, S., Wells, K. C., Pelham, W., Cooper, T., Elliott, G., & Newcorn, J. H. (2009). Medication adherence in the MTA: Saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 48(5), 501– 510. https://doi.org/10.1097/CHI.0b013e31819c23ed

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Pliszka, S., & the AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/ hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 894–921. https://doi.org/10.1097/chi.0b013e318054e724 Poulin, F., Dishion, T. J., & Burraston, B. (2001). 3-year iatrogenic effects associated with aggregating high-risk adolescents in cognitive-behavioral preventive interventions. Applied Developmental Science, 5(4), 214–224. https://doi.org/10.1207/ S1532480XADS0504_03 Reef, J., Diamantopoulou, S., van Meurs, I., Verhulst, F. C., & van der Ende, J. (2011). Developmental trajectories of child to adolescent externalizing behavior and adult DSM-IV disorder: Results of a 24-year longitudinal study. Social Psychiatry and Psychiatric Epidemiology, 46(12), 1233–1241. https://doi.org/10.1007/s00127-0100297-9 Sanchez, R. J., Crismon, M. L., Barner, J. C., Bettinger, T., & Wilson, J. P. (2005). Assessment of adherence measures with different stimulants among children and adolescents. Pharmacotherapy, 25(7), 909–917. https://doi.org/10.1592/phco.2005. 25.7.909 Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. AppletonCentury. Snyder, C. R. (2002). Hope theory: Rainbows in the mind. Psychological Inquiry, 13(4), 249–275. https://doi.org/10.1207/S15327965PLI1304_01 Snyder, C. R., Irving, L. M., & Anderson, J. R. (1991). Hope and health. In C. R. Snyder & D. R. Forsyth (Eds.), Pergamon general psychology series: Vol. 162. Handbook of social and clinical psychology: The health perspective (pp. 285–305). Pergamon Press. Society of Clinical Child & Adolescent Psychology. (2020, July 23). Rule breaking, defiance & acting out. Effective Child Therapy. https://effectivechildtherapy.org/ concerns-symptoms-disorders/disorders/rule-breaking-defiance-and-acting-out/ Waschbusch, D. A. (2002). A meta-analytic examination of comorbid hyperactiveimpulsive-attention problems and conduct problems. Psychological Bulletin, 128, 118–150. https://doi.org/10.1037/0033-2909.128.1.118 Waschbusch, D. A., & Hill, G. P. (2001). Alternative treatments for children with attention-deficit/hyperactivity disorder: What does the research say? Behavior Therapist, 24(8), 161–171.

23 Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders Amber Calloway, Nicole Fleischer, and Torrey A. Creed

T

he term internalizing disorders refers to a broad grouping of behavioral, emotional, and social problems. Internalizing disorders are usually associated with high levels of effortful control or overcontrol (Eisenberg et al., 2001) and consist of problems related to worry, fear, guilt, irritability, sadness, and somatic complaints (Achenbach et al., 2016; Ollendick et al., 2005). Overall, the central feature of internalizing problems is disordered mood or emotion. Thus, internalizing disorders in childhood include anxiety and depressive disorders. The symptoms of these disorders may be expressed differently among children and adolescents as compared with adults. In addition to the standard criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for a depressive episode, children and adolescents often report symptoms of irritability, thinking issues (e.g., derealization or depersonalization), and physical complaints (e.g., abdominal pain, headaches; American Psychiatric Association, 2013).1 Internalizing disorders are often more difficult to detect and are viewed as less problematic by caregivers and teachers than externalizing disorders due to their self-directed nature (Tandon et al., 2009). Although they are characterized by quiet, internal distress that may be quite impairing to the person experiencing them, internalizing symptoms are often less disruptive to the environment around the child or adolescent, so they may be overlooked in favor of adults attending to externalizing behaviors. They may also be more difficult to detect in younger children who may not possess the verbal skills or Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-023 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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capacity to describe their emotional state, relative to adults. Although internalizing disorders may be harder to detect than externalizing disorders, prevalence rates indicate that approximately 5% to 25% of children under 12 years of age experience symptoms that would merit diagnoses (Boyd et al., 2000), and these rates only increase from early childhood to adolescence (Avenevoli et al., 2015; Hankin, 2016). Also, younger and younger children are receiving diagnoses of internalizing disorders (Liu et al., 2011). Children with these diagnoses often have multiple problems, such as school failure, problems with peers, and increased psychopathology (Albano et al., 2003) and often live with caregivers that experience psychiatric symptoms themselves (Kovacs & Devlin, 1998). Given the deleterious effects on childhood functioning and the potential for these disorders to persistent into adulthood, considerable efforts have been made to identify effective treatments for childhood internalizing disorders. Cognitive behavioral therapy (CBT) has been studied more than any other mode of psychotherapy in the treatment of depressed and anxious children and adolescents and is therefore the focus of this chapter.

UNDERLYING THEORY Cognitive behavioral theory holds the fundamental assumptions that thoughts, emotions, and behaviors are interconnected, and that psychological distress is maintained by cognitive factors and learned behavioral responses. In internalizing disorders specifically, distress may be maintained by unhelpful behavioral responses, such as avoidance or overall behavioral constriction (i.e., disengagement from activity) in conjunction with inaccurate or unhelpful cognitions. These cognitions include automatic thoughts, which are just below the surface of consciousness, to underlying beliefs (i.e., intermediate and core beliefs) that are at the heart of how children or adolescents see themselves, others, the world, and the future. Core beliefs are the foundational beliefs that a child develops early in life and set the stage for later beliefs and thoughts. Core beliefs about the self generally fall into two categories: beliefs about helplessness and beliefs about unlovability (Beck, 2005). For example, a child who is repeatedly exposed to developmentally inappropriate tasks that are too difficult for them may develop the belief that they are helpless or incompetent. Based on the underlying beliefs that youths have about others, the world, the future, and themselves, they develop a set of compensatory strategies, or behaviors that they use to cope with their underlying beliefs and then live according to the “rules” of their world. The function of most clinically relevant behaviors in internalizing disorders is negative reinforcement. Children with internalizing disorders will often engage in behaviors that reduce or remove their distressing feelings or thoughts, which in turn negatively reinforces the behavior and increases the likelihood that they will engage in the behavior in the future. For example, a child with social anxiety may believe that they are unlikable and therefore avoid engaging in social activities. The avoidance



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provides relief of their distress in the short term, which reinforces their avoidance of anxious situations in the future. In the long term, however, they miss out on the opportunity to experience counterevidence to their belief. The maladaptive behavioral response of avoidance precludes the opportunity for extinction, inhibitory learning, or the development of fear tolerance. In other words, they never get a chance to test out their belief and learn that, perhaps, others will like them more than they expect or that they are more able to tolerate the distress of the unknown (e.g., “Will anyone like me?”) than they expected. The next time they encounter a situation that activates their belief about being unlikable, they are therefore even more likely to avoid the situation, further reinforcing the behavior and beliefs. Similarly, a child with depression may believe that they will always feel down and that any attempts to improve their mood are hopeless. They then disengage from activities that they once found enjoyable, expecting that they will also fail to lift their mood. As the child constrains their behavior, they reduce their likelihood of receiving naturally occurring rewards, such as experiences of pleasure, mastery, or social interactions. As the child experiences fewer and fewer positive events, their beliefs about the hopelessness of feeling better may be reinforced, creating a self-fulfilling prophecy. Ferster (1973) suggested that individuals with depression might engage in behaviors that are motivated by attempts to escape from aversive feelings that “prevent positively reinforced behavior” (p. 859). This parallels the avoidant behavior in anxiety disorders, in which individuals engage in behaviors (or fail to engage in behaviors) to escape from negatively appraised internal experiences. Diminished engagement in activities may partially explain the high comorbidity rate across internalizing disorders. An overarching goal in CBT for internalizing problems, and CBT more broadly, is the promotion of new learning. This approach assumes that identifying and changing one’s unhelpful or inaccurate beliefs will consequently change one’s emotions and behaviors. The majority of CBT protocols for children and adolescents have been adapted from protocols originally developed for adults. Although specific interventions are adapted to be developmentally appropriate and account for considerations specific to youth like school or family contexts, many of the core components are similar.

MAIN PROCEDURES Youth with anxiety and depression tend to experience more frequent negative cognitions than those who do not have an internalizing disorder (McNally Keehn et al., 2013). According to the cognitive model (Beck, 2011), these inaccurate or unhelpful thoughts may then lead to undesirable emotional or behavioral reactions, and this cycle can ultimately reinforce the initial negative cognition. Cognitive restructuring can provide an opportunity for children and adolescents to check and change their automatic thoughts, leading to thoughts

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and reactions that are more adaptive (Creed et al., 2011). A simple way of teaching this process to youth is based on the three “C”s (Granholm et al., 2004). Clients first learn to catch their automatic thoughts, or notice that a quick, evaluative, situation-specific thought has gone through their mind, leading to a shift in emotion or behavior. Next, they check the thought. Using Socratic questioning or other methods, they evaluate whether the thought is as true as it first seemed, and whether that thought is helping them to get closer to their goals. Finally, based on their evaluation in the checking step, clients change their original automatic thought to one that is more realistic or helpful (Creed et al., 2011). For example, an adolescent might notice that they often react to social situations by thinking, “I’m the worst! No one likes me!” Having caught that thought, a cognitive behavior therapist might help the adolescent evaluate how true the thought is, using Socratic questions like, “What are the clues that tell you that thought might be true?” (e.g., I sat alone at lunch because I couldn’t find a friend to sit with), “Are there any clues you may have missed that would suggest it not as true as it first seemed?” (e.g., I didn’t really ask anyone if I could sit with them. I also didn’t really sit alone—there were other people, but we spent the whole time looking at our phones), “What would you tell your sibling if they were in that situation?” (e.g., Maybe put down your phone and try talking to someone? That’s the only way to find someone to talk to!). Alternatively, the therapist may help the adolescent evaluate the helpfulness of the thought: “When you say that to yourself, how does it make you feel?” (e.g., More upset and sad), “Does it make it easier or harder for you to achieve your goals of being comfortable around other kids?” (e.g., Harder, because I feel even worse). Finally, the therapist might ask the adolescent if there is a new thought that feels more helpful and truer than the original distressing thought (e.g., I shouldn’t just assume no one wants to talk to me, especially if I’m not talking to them either. I would have loved to have someone talk to me! Next time, I’ll try being the brave one and see what happens). Behavioral activation (Lewinsohn, 1974) has been used in CBT with an emphasis on scheduling pleasant and mastery activities to shift inaccurate or unhelpful thinking (McCauley et al., 2016). During an episode of depression, youth tend to experience less of a reward from engaging in pleasurable activities or those where they experience mastery (Forbes, 2009). As activities become increasingly less rewarding, youth tend to do fewer things. Doing fewer things, in turn, can lead to increased anhedonia and depression (McMakin et al., 2012). Behavioral activation is an intervention that aims to reverse that cycle by identifying and introducing activities that increase mastery and pleasure, leading to a mood lift, which in turn can be helpful in the treatment of depression. To begin activity monitoring, the child or adolescent may be asked to track their activities over the course of a week, noting how much pride (mastery) and fun (pleasure) they experienced in relation to each activity. Ideally, “proud” and “fun” ratings are gathered temporally close to the activities to decrease any biased recall that may otherwise deflate ratings. The information gathered from this type of activity monitoring is reviewed in session to identify any themes in activities that are already a part of the child’s routine and might



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be increased or amplified to bring additional experiences of pride or fun (Dimidjian et al., 2014). Next, the therapist and client work collaboratively to choose a few activities to try in the upcoming week. Fewer activities that may be accomplished realistically are preferable to choosing a long list of activities that may be experienced as overwhelming or unrealistic. Social activities may be particularly rewarding, so activities that involve family or friends can provide a strong boost. The client is asked to continue monitoring their experiences of pride and fun, including the scheduled activities. Over time, the therapist and client track changes in overall mood in relation to the activities of the day. Typically, adding rewarding activities leads to an overall improvement in mood, in addition to the immediate bursts of mastery or pleasure. In turn, these experiences and changes in mood can be used as evidence to “check” beliefs related to internalizing symptoms like “Nothing will ever get better,” “There’s nothing that can help me, “I don’t enjoy anything,” and “If I’m anxious then I can’t have fun” (Creed et al., 2011). The use of exposure to treat anxiety disorders among youth has wide empirical support for its use (Whiteside et al., 2015). In brief, the therapist and child begin by identifying a single area of distress or anxiety. For example, treatment may focus on speaking in public, dogs, dental procedures, or any other specific area of anxiety. Although children often present to treatment with multiple domains of anxiety, focusing on a single area for exposure has a number of benefits. Successful completion of exposure tasks for a single domain of fear often leads to benefits in other areas, so focusing in one area is an efficient manner of intervening. Any areas of fear that have not resolved with the first course of exposure may be treated in a subsequent course, and given the skill-building nature of CBT, children and their families may be able to either conduct the additional exposure exercises on their own or complete them more quickly by applying their new skills to the additional domain. On a practical note, the nature of an exposure hierarchy also requires a single area of focus. Once the focal fear is identified, a hierarchy is developed, in which each step increases the child’s anticipated experience of fear. Mastery of a lower step then lends itself to increased confidence in facing the next step on the “ladder” of fears. If the hierarchy consisted of fears in different domains, mastery of one (e.g., sitting in a dentist’s chair) may contribute less to confidence in facing a more intense but unrelated fear (e.g., giving a speech in front of a crowded room). While completing the exposure, children are asked to rate the intensity of their distress using a 1-to-100 rating scale known as the Subjective Units of Distress (SUDS). Clients should remain in the feared situation until their SUDS have reduced by at least 50%. A goal of these exposure activities is for children to learn that facing the situations may be less distressing than they expected when they were avoiding them, and that they are more able to cope with distress than they may have believed (Craske et al., 2014; Guzick et al., 2018). Exposures should be conducted both during therapy sessions and between visits to encourage generalization of the child’s learning. Family members and others in the child’s environment, therefore, become particularly important to

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take into consideration. Accommodation, or changes in others’ behavior in an attempt to prevent or reduce a child’s distress, may often be observed among the people in an anxious child’s environment (Thompson-Hollands et al., 2014). For example, a parent who observes their child preparing to complete a between-session exposure may provide suggestions to make the exposure “easier,” like accompanying their child, suggesting they put off the exposure until they feel less anxious, or other well-intentioned behavior. However, these suggestions are actually antithetical with exposure given the premise of having children face their fears, and they may even increase a child’s anxiety by communicating that the parent believes that the exposure is too dangerous or scary for the child. Psychoeducation around the role of exposure and accommodation in the treatment of anxiety disorders can be very helpful when these dynamics arise. If needed, family members may also be referred for treatment to strengthen their own skills for distress tolerance. Relaxation and distraction skills are related sets of strategies that can strengthen coping with anxiety and managing distress (Nassau, 2007). Relaxation may be most helpful when a child is experiencing anxiety and needs to be able to reduce their distress while staying connected to the anxiety-provoking situation. For example, exposures are most effective when clients are experiencing anxiety in the situation (so that they can learn that they can cope with their fear) but not so overwhelmed that they are unable to stay in the situation. Relaxation can help children learn to modulate their anxiety rather than experiencing it as overwhelming. Square breathing is simple to learn and use in anxious situations. Clients breathe slowly for a count of four, hold their breath for a count of four, breathe slowly out for a count of four, and hold their breath for a final count of four (see Figure 23.1). Other relaxation techniques include diaphragmatic breathing, progressive muscle relaxation, and yoga, among others. FIGURE 23.1. Square Breathing



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Distraction techniques, as a contrast, can help children move their thinking away from their worries or anxiety by shifting their focus elsewhere. Distraction is not recommended during an exposure, when the goal is for the child to learn from facing their fear. However, distraction can be helpful when a child needs to detach from rumination, which is a pattern of responding to distress by passively and persistently thinking about the causes, consequences, and experiences of their distress without the active problem solving or coping that might change the cause of that distress. Distraction techniques should be tailored to the interests and abilities of each child, but guided imagery, playing video games, engaging in high-energy physical activity or sports, listening to audio books, and other activities that occupy the mind can all be helpful. Problem solving is particularly helpful when faced with a situation in which (a) thinking differently seems less likely to help than identifying an active response to a problematic situation, (b) when the situation places the youth at risk of harm, or (c) when the child’s thoughts appear to be accurate and appropriate (Creed et al., 2011). Note that problem solving as a CBT strategy is different than simply having a therapist offer the client a solution, or even working collaboratively to identify a solution. Rather, CBT problem solving involves the therapist using a current problem as content to teach a client problem-solving skills. As additional problems arise, the therapist encourages the child or adolescent to practice problem-solving skills in the new situations. In this way, in-the-moment problems are solved, and problem-solving skills are strengthened for facing future dilemmas. Ideally, problem solving is taught using a step-by-step process to help with learning. The problem-solving process typically begins with identifying one specific problem to solve, rather than multiple or general problems. Next, the child brainstorms all possible solutions. If needed, the therapist can add other prosocial options after the child’s brainstorming ends. Third, the client selects a solution that seems most likely to help and least likely to cause additional problems. After choosing, the therapist ensures that the child has all the necessary skills to execute the solution or builds those skills through role-play and other methods. A plan is developed for the child to try out the solution to the problem. Finally, therapist and child evaluate how well the solution worked. If it was successful, then they can celebrate a job well done and build on this success the next time a problem arises. If things did not end as planned, the therapist and child can evaluate what went well and what could be strengthened for the next time (Creed et al., 2011; Muñoz et al., 2000).

SPECIAL CONSIDERATIONS WITH CHILDREN AND ADOLESCENTS WITH INTERNALIZING DISORDERS For any child or adolescent entering into psychotherapy, motivation is a key factor to consider. Whereas most adults enter into treatment because they have chosen to do so (with exceptions for those legally stipulated to treatment or

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participating in response to a partner’s insistence), many youth are not self-referred. More commonly, children and adolescents enter therapy because an adult has suggested or decided they should do so. Family members, school staff, coaches, religious leaders, or other authority figures are often the impetus for children to enter treatment. The referral may be focused on factors that the child does not see as a problem or solvable, or where the child may not see psychotherapy as a solution for any concerns they have. For example, an adolescent with chronic depression may think, “I’m not depressed—this is just who I am!” A child with generalized anxiety disorder may believe, “No one can help me to worry less. The world is genuinely full of problems, and there isn’t any sort of treatment for me that will change that!” Beginning by talking with a new young client about why they have presented for treatment, who suggested that therapy might be beneficial, and what their thoughts are about therapy can be a great starting place. This not only provides important clinical information, but it also communicates that the therapist is there to listen to the child and values their viewpoint. Goal setting can be leveraged to help build buy-in and treatment motivation. Rather than beginning CBT by talking extensively about the child’s challenges, deficits, and the referral problem, therapists may consider asking the child about the things that matter most to them. What lights this child up inside? What are their interests and goals? How do they want their life to look several months from now? Once the child and therapist have identified goals that are important and personally meaningful, discussion moves to challenges or barriers that may be in the way of reaching those goals right now. Are there problematic behaviors that are interfering with the child’s functioning? Are there inaccurate or unhelpful beliefs that are causing distress or blocking momentum? Do any skill deficits, practical barriers, or interpersonal barriers exist? These challenges are traditional treatment targets like avoidance and rumination, related beliefs (e.g., “The future is hopeless,” “I’m weak and vulnerable”), or other areas of concern (e.g., being bullied at school, poor distress tolerance). When those challenges are posed as interfering with the ambitions and wishes of the child, motivation to make changes can shift to more internal motivation rather than external, adult-driven participation. Finally, the therapist and child can work together to build specific CBT strategies and skills to help reduce the barriers and move the child toward their goals. Given that the environment around children (and to a slightly lesser extent, adolescents) is strongly influenced by family members, the inclusion of primary caregivers and other family members can be key to treatment success (Kingery et al., 2006). Caregivers can have a positive effect on motivating youth to engage in their CBT practices outside of the session, which in turn can increase generalization of the child’s skills outside of the therapy context and speed overall recovery. As noted in the previous section of this chapter, family members may engage in behavior with an intention to avoid or alleviate distress related to their child’s internalizing disorder. For example, a parent who observes their child preparing to complete a between-session exposure may



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provide suggestions to make the exposure “easier,” like accompanying their child, suggesting they put off the exposure until they feel less anxious, or other well-intentioned behavior. Another parent whose child has separation anxiety disorder may go to extreme lengths to ensure that their child is with them at all times. Paradoxically, these strategies may actually increase the child’s anxiety by communicating that the family believes that the child’s fears are accurate, and that the avoided situations are either dangerous or unmanageable for the child (Storch et al., 2015). Reducing accommodation has been shown to be associated with decreases in anxiety (Salloum et al., 2018), especially when children are reluctant to participate in therapy (Lebowitz et al., 2014). Psychoeducation around the role of accommodation can be very helpful when these dynamics arise, and role-play can assist family members in developing alternative responses when they see their child in distress. If needed, family members may also be referred for treatment to strengthen their own skills for distress tolerance.

TREATMENT OUTCOME The efficacy of cognitive behavioral approaches for adult anxiety and depression has been well established (Hofmann et al., 2012; McMain et al., 2015). In fact, CBT is the first-line approach to treating anxiety disorders (National Institute for Clinical Excellence, 2004). Research has also shown that CBT is efficacious for children and adolescents with internalizing problems such as depression (Butler et al., 2006; Chambless & Ollendick 2001). CBT is listed as an evidence-based psychotherapy for childhood depression by the Society of Clinical Child and Adolescent Psychology of the American Psychological Association. CBT is also efficacious for youth anxiety (see Hollon & Beck, 1994; Kendall et al., 2008; Wood et al., 2006), including separation anxiety (Kendall et al., 2008) and specific phobia (Chambless & Ollendick, 2001). The literature suggests that CBT for anxiety remains efficacious even in the presence of comorbid externalizing disorders (Berman et al., 2000; Flannery-Schroeder et al., 2004; Southam-Gerow et al., 2001). Less is known about the effects of CBT for anxiety when comorbid depressive disorders are present, perhaps because depression is usually the principal diagnosis in youths with depressive disorders and anxiety. Among the manualized CBTs developed for youth anxiety or depression, Coping Cat (Kendall & Hedtke, 2006) is an exemplar with strong empirical support. The Coping Cat was designed to provide CBT in an individual format for children aged 7 to 13 years with a variety of anxiety disorders and has been translated into five languages. The core components of the program are psychoeducation/skill building and exposure to fear situations. The Coping Cat has also been adapted for adolescents aged 13 to 17, known as C.A.T. Project, and a computer-assisted version has been developed (Khanna & Kendall, 2008). Both versions of the treatments have demonstrated efficacy in multiple

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randomized controlled trials (RCTs; Khanna & Kendall, 2008). One-Session Treatment (OST), a specific variant of CBT, has also demonstrated efficacy in treating youth anxiety (Ollendick et al., 2009). This treatment for specific phobia involves gradual exposures, participant modeling, and identifying and modifying automatic thoughts. In this way, it shares many similarities with traditional CBT; however, as the name implies, OST is conducted in a single 3-hour session. In addition to individual CBT, there are several efficacious treatments utilizing a family or group-based intervention. For example, cognitive behavioral group therapy for adolescents (CBGT-A) was developed for adolescents with social anxiety. Like Coping Cat, CBGT-A is a 16- to 20-session protocol that includes social skill building and exposure phases of treatment (Albano & DiBartolo, 2007). Protocols for depressive disorders have also received empirical support. For example, Adolescent Behavioral Activation Program (A-BAP), a 12-session protocol designed to help adolescents overcome barriers to experiencing rewards and achieving goals (McCauley et al., 2016), and the Treatment for Adolescents with Depression Study (TADS) protocol (TADS Team, 2009), a multiphasic, multistage approach, have been shown to reduce depressive symptoms in adolescents. A meta-analysis examining the effect of transdiagnostic CBT, or CBT designed to be applicable to people who have a range of DSM-5 diagnoses, revealed medium pre-to-posttreatment effect sizes on anxiety (g = 0.45) and depression (g = 0.50; García-Escalera et al., 2016). A more recent review of meta-analyses, which found medium-to-large effect sizes (0.42 to 1.54) for treatment reduction when CBT was compared with a nonactive control, also concluded that CBT should be considered an effective treatment approach for childhood anxiety and depression (Crowe & McKay, 2017).

MECHANISMS OF CHANGE Although the efficacy of CBT has been repeatedly demonstrated across a variety of internalizing problems, the factors that contribute to desired psychotherapy outcomes are less understood. However, efforts have been made in the past decade toward gaining a clearer understanding of mechanisms of change in CBT. Most of the published investigations of mechanisms of change have examined the role of cognitive change in the reduction of symptoms and prevention of relapse (McMain et al., 2015). This makes sense because many specific CBTs were developed in accordance with cognitive behavioral theory, which posits that maladaptive cognitions contribute to the maintenance of emotional distress and behavioral problems. It follows that therapeutic strategies to change these maladaptive cognitions would lead to changes in emotional distress and problematic behaviors. In fact, there is growing evidence that supports that cognitive changes mediate the relation between CBT for anxiety specifically and symptom reduction in adults (Hofmann, 2004; Hofmann et al., 2007; Smits et al., 2006). The exact nature of these cognitive changes is not well understood



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but may include belief changes, schema changes, and changes in cost and probability biases. Threat reappraisal is one specific type of cognitive change that has been shown to mediate the relation between treatment and outcome in adults (Smits et al., 2012). However, it is important to note that many studies have failed to find evidence supporting this mediation model (e.g., Lemmens et al., 2017; Vittengl et al., 2014; Warmerdam et al., 2010). Fewer studies have examined mechanisms in child and adolescent populations, and many studies that attempted to identify mechanisms did not include formal tests of mediation. Of those that did, many examined continued the trend from the adult literature and examined cognitive factors as potential mechanisms of change. For example, Kendall and Treadwell (2007) found that changes in both anxious and negative self-talk mediated treatment outcome in the Coping Cat program. Kendall et al. (2016) followed with another study examining anxious self-talk and coping efficacy as potential mediators. They hypothesized that reductions in anxious self-talk would mediate treatment gains because the presence of anxiety-related cognitions is a foundational component of the CBT model of anxiety and children, which is supported by the evidence that anxious children report more anxious self-talk than nonanxious children. Coping efficacy, the ability to manage anxiety-provoking situations, was selected as a potential mediator because a child with greater coping efficacy is presumably less likely to avoid an anxiety-provoking situation than a child with lesser coping efficacy and therefore can further develop coping skills. Moreover, coping efficacy had been examined as a mediator in previous studies of child anxiety that did not statistically test for mediation (Lau et al., 2010). Surprisingly, negative self-talk did not emerge as a significant mediator of treatment gains. This is contrary to the relatively extensive adult anxiety literature that suggests cognitive factors mediate treatment gains, as well as previous empirical work in youths (e.g., Kendall & Treadwell, 2007; Muris et al., 2009). Coping efficacy, on the other hand, was a significant mediator. Although not a mediator in a statistical sense, parental involvement has also received a considerable amount of attention in the internalizing disorder treatment literature. Cognitive behavioral therapists working with children and adolescents in an outpatient setting traditionally strive to involve the parents or caregivers in therapy. The beliefs that parents hold often greatly influence the way a family system functions. Belief and behavior patterns can be passed on across generations as children learn their core beliefs and rules about the world from their family. Parents’ beliefs are often communicated to their children both directly and indirectly. For example, a father with a belief of, “If someone gets angry with me, then it means that the person really doesn’t love me” may withdraw whenever his son gets angry at him. Even if he never directly voices this belief, his son may observe his father’s withdrawal and indirectly develop his own beliefs from there. For example, he may come to believe, “I should never show my anger, because it makes people pull away from me. It must be wrong to show anger.” When parents are not involved in therapy with their children, the child faces the additional challenge of learning to manage the role

736  Calloway, Fleischer, and Creed

of the family’s beliefs in their own belief system. Making change in the whole family system can be more effective than making a change in only one member of the family. Therefore, theoretically an ideal situation would include parents in treatment. The empirical support for the involvement of parents in CBT with children and adolescents, however, is less compelling. In their recent review of meta-analyses of CBT for childhood anxiety and depression, Crowe and McKay (2017) found small or insignificant effects sizes in studies comparing CBT for anxiety with parental involvement to child-only CBT (average weighted effect size of d = 0.02). This suggests a minimal difference between the two formats of treatment. A review of dismantling studies also concluded that children receiving CBT with parental involvement do not derive significant benefit relative to those who receive CBT without parental involvement (Spielmans et al., 2007). The observed lack of benefit of parental involvement in CBT for children with anxiety, specifically (Nauta et al., 2003), may be related to changes in parental behaviors intended to help a child avoid anxiety-related distress. This kind of family accommodation, while well-intentioned, can lead to more severe child anxiety, greater functional impairment, and ultimately poorer response to CBT (Norman et al., 2015; Salloum et al., 2018). Overall, additional research is needed to understand mechanisms of change in CBT for internalizing disorders for children and adolescents. Understanding why treatment works can serve as a basis for maximizing treatment effects and ensuring that critical features are generalized. The childhood internalizing disorder literature may benefit from examining mechanisms identified in the adult literature such as anxiety sensitivity (Gallagher et al., 2013) and decentering (Hayes-Skelton & Lee, 2018) as well as other predictors of symptom change, such as expectancy violation during extinction training (Brown et al., 2017).

DISSEMINATION As outlined in this chapter, CBT for childhood internalizing disorders has received considerable empirical support. Unfortunately, however, interventions with the most empirical support are often not the treatments received in routine clinical practice. Both patient-level factors (e.g., access to affordable health care, mental health stigma, limited mental health literacy) and organizational factors (e.g., implementation climate, inadequate staffing, support from administration) may account for the low rate of CBT received by children and adolescents. Improvements in the transportability of CBT are needed in order to benefit a wider range of children with mental health needs (Elkins et al., 2011). Such improvements may require modifications to the format or setting in which CBT is delivered. For example, computerized CBT (Dewis et al., 2001; Nelissen et al., 1995), camp-based CBT (Chronis et al., 2004; Pelham et al., 2000), and school-based CBT (Lyon & Bruns, 2019) have been employed to increase access and utiliza-



Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders  737

tion of treatment for childhood internalizing disorders. Of these modifications, school-based CBT in has received the most empirical support. The presentfocused, goal-oriented, and structured nature of CBT may make this treatment approach a particularly good fit for a school setting. CBT has a distinct session structure that can help clinicians and youth to accomplish more work in less time than they might in a less structured therapy. Implementing CBT in a school setting may also have unique advantages to CBT delivered in an outpatient setting. For example, clinicians in a school setting have access to information about a child or adolescent’s academic and social functioning that they might not have in any other situation. School clinicians can also obtain valuable information about school performance and classroom behavior by observing a student’s interactions with peers and staff. In addition, clinicians have regular access to the students who attend school consistently. Therefore, a clinician may see a student two or three times per week for 30 minutes each. Schools also offer a team environment in which the clinician is working with other professionals, all focused on supporting the same group of students. Schools present the opportunity for the clinician to work together with other school staff-support interventions so that the student receives support beyond the session. Certain school-based CBTs have demonstrated efficacy in the treatment of childhood internalizing disorders, particularly those for anxiety disorders (Bernstein et al., 2008; Ginsburg and Drake, 2002; Masia-Warner et al., 2005; McLoone et al., 2006; Schoenfield and Morris, 2009). For example, the Skills for Social and Academic Success (SSAS) program, a cognitive behavioral, school-based intervention for adolescents with social anxiety disorder, has been shown to reduce anxiety symptomatology (Fisher et al., 2004; Masia-Warner et al., 2007, 2005). Similar to other CBTs for social anxiety, this program consists of twelve 40-minute group sessions that emphasize social skills and in vivo exposure. Although there has been success in adapting CBT for use in school settings, the majority of mental health services provided in schools continue to not be evidence-based psychotherapies (Owens et al., 2014). This may be a result of the unique challenges to using CBT in this setting. For example, counseling services within schools typically have large caseloads with very limited staff. The staff must find a way to fit metal health services into a busy academic day, which can result in sessions that are much shorter than the typical “50-minute hour, once per week” therapy. Clinicians also have limited access to students’ families and other home-based collateral. Children also may risk missing academic instruction, recess, and other important activities when services are provided during the school day. However, coordination with other school staff can often mitigate the impact of integrated mental health care services. Given these challenges, school-based clinicians may feel challenged to provide effective CBT to their students. In addition, a substantial and sustainable financial commitment is needed to implement CBT in a school setting. Unsurprisingly, of the various obstacles to successful implementation and sustainability of school-based interventions, financial concerns are the most often cited (Forman et al., 2009).

738  Calloway, Fleischer, and Creed

APPLICATION TO DIVERSE GROUPS As is the case for CBT for other presenting problems, CBT for childhood internalizing disorders should not take a one-size-fits-all approach. Treatments should be delivered in a way that is responsive to the lived experiences and cultural context of the client. Evidence from the adult literature suggests that better treatment outcomes are obtained when clinicians take a culturally responsive approach to psychotherapy (Hofmann, 2006; Pantalone et al., 2009; Sue, 2001). Therefore, utilizing multicultural principles to effectively tailor therapies may better serve the mental health needs of diverse populations. Culturally responsive practice involves having an understanding that culture can and does influence the manifestation, course, and expression of mental health diagnoses. Although this approach does necessitate an understanding of the modal experience of groups of people (e.g., depressed Chinese American youth also seem to have more somatic complaints; Sue, 1994), it also requires clinicians to recognize and appreciate individual variability that exists within groups. Therefore, cultural responsiveness requires flexibility and humility, whereas “cultural competence” may imply mastery or suggest that one can arrive at an end-state of knowing everything there is to know about doing therapy with a certain cultural group. A number of CBT’s qualities have the potential to lend themselves to culturally responsive clinical practice. For example, CBT emphasizes understanding the way in which contextual factors (e.g., rewards and punishers) shape and maintain behaviors. Some of those contextual factors will be cultural in nature and related to the client’s social identities given that social identity itself is a context for behavior. Consider a student of color in a mostly White classroom, who may feel depressed and begin to withdraw because they have the experience of being ostracized whenever they attempt to socialize with classmates. The rejection that they experience may lead them to withdraw further, thus exacerbating their depressive symptoms. Having an understanding of this context may allow a clinician to select and tailor a more effective intervention. The collaborative nature of CBT can also be used in a way to help clinicians practice in a culturally responsive way. For instance, clinicians can work with clients to collaboratively define goals that are consistent with the life experiences, contexts, and cultural values of client. Specific interventions can also be implemented in ways that are responsive to the client’s context. Exposure exercises, for example, should be tailored to align closely with the client’s life context. Thus, exposures should involve culturally congruent situations. If the client holds a marginalized identity, discrimination may be a regular occurrence in that client’s context and could be an important contextual factor that may be exacerbating or interacting with the client’s distress. Race may be a salient aspect of identity for an Afro Latino child with social anxiety, for example. If this child experiences anxiety when interacting with teachers, but only White teachers, a clinician should tailor exposure exercises to include racially salient cues. An exposure could involve seeking out and asking a question of one of



Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders  739

their White teachers. While collaboratively designing this exposure, it is important to bear in mind that, given the pervasiveness and insidious nature of racism, it is possible that the student’s teacher does in fact hold biases against people of color. The goal of an exposure of this nature is never to prove that racism does not exist or that a particular person does not hold racist attitudes or to habituate to discrimination. Rather, the goal is to tolerate the emotional response to the possibility that a negative outcome like discrimination could occur.

CLINICAL EXAMPLE James is an 8-year-old Caucasian boy presenting with comorbid generalized anxiety disorder and persistent depressive disorder. His mother reports that he has been anxious for the past 2 years, but his depression is more recent, worsening in the past year. James and his mother report that he is often anxious in new situations and is worried about the well-being of his family. James voices frequent “what if” worries about his future and his family, including “What if my mom loses her job?” “What if I fail 3rd grade?” and “What if we lose our home in a fire?” These thoughts keep him up at night and are difficult for him to turn off. James’s mother reported no trauma history and no significant adverse events aside from his parents’ divorce when he was 4 years old. As his anxiety worsened, James began experiencing increased depression. His mother reports he no longer enjoys playing baseball or soccer and is often tearful and irritable throughout the day. James states he has a hard time enjoying activities because of his worry, and as a result, he often feels down about withdrawing from friends and family. His mother reports he will often say things like “I’m a loser” or “I’m not good at anything.” The therapist begins the initial sessions with rapport building and developing a sense of James’s preferences and strengths. James talks about his love for playing baseball and soccer, watching baseball, and playing with the neighborhood kids. In subsequent sessions, the therapist provides the rationale and process of CBT for anxiety and depression. James and his mother are encouraged to collaborate with the therapist on goals for treatment. THERAPIST: While I understand Mom wants you to come here to work on

your worries and sadness, I want to find out what it is that you want to get out of coming here every week. JAMES:

Well, I don’t feel like I have fun anymore. I don’t hang out with my friends as much anymore.

THERAPIST: So having fun with your friends is an important goal for you.

Anything else? JAMES:

I really liked playing baseball and soccer, but now they’re just not as fun for me. I’m always scared I’m not going to do well or that I’ll mess up. It’s not fun anymore.

740  Calloway, Fleischer, and Creed

THERAPIST: Okay. So by working on your worries and sadness in here, we

will work toward increasing your fun with friends and having fun playing sports. How will we know you’re having fun? JAMES:

Well, after we win a game, I can go celebrate with my friends instead of going home and thinking about how I can play better.

To address James’s anxiety and depression, the therapist encourages him to engage in cognitive restructuring. His mother is included in these sessions to develop skills that can be transferred at home. After providing psychoeducation on cognitive restructuring, the therapist engages James in being a “thought detective” to modify his thoughts and integrates his interests to develop a replacement thought. THERAPIST: So you and your mom have told me that when you lose a game,

you will often say to yourself “I’m no good at hitting the ball.” When you say that to yourself, what happens inside you? How do you feel? JAMES:

I start to feel really down and worried about it. It actually makes me not want to play anymore.

THERAPIST: So it sounds like this is one of those thoughts we talked about

that might not be working so well for you, if it’s adding to your sadness and worry. I wonder if we could be thought detectives and check the clues that tell you more about how true that thought is. What are the clues that tell you that thought is true? JAMES:

Well, I sometimes strike out when I’m at bat.

THERAPIST: Okay. Anything else? JAMES:

No, just that. I miss the ball or strike out, and it reminds me that I’m no good at hitting.

THERAPIST: Good job. And are there any clues that this thought may not

be true? JAMES:

I’ve hit the ball more than once. I actually got a home run last game!

THERAPIST: Awesome. So sometimes you strike out, but sometimes you hit a

home run. What happens most of the time? JAMES:

I usually get a couple of hits in the game and at least get to a base. But most people can do that.

THERAPIST: Wow! JAMES:

Yeah, but then I think I should be better than that. I should be hitting the ball every time.



Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders  741

THERAPIST: So now we need the thought detective to investigate how help-

ful that thought is. I remember that you told me that your favorite baseball player is Mike Trout. Does he hit the ball every time? JAMES:

Well, no. He hits the ball a lot, but he still strikes out or pops it up.

THERAPIST: So what can the thought detective conclude with this information? JAMES:

Just because I don’t hit the ball every time doesn’t mean I’m not good?

THERAPIST: Great! So what can you say to yourself instead of “I’m no good

at hitting the ball”? JAMES:

It’s okay. I’m trying my best.

THERAPIST: Great! Anything else? JAMES:

Even the best ball players strike out sometimes!

THERAPIST: Good job. And when you say those things to yourself, how do

you feel? JAMES:

I actually feel less pressure. I feel more comfortable and like it might be a little more fun to play than it has been.

THERAPIST: I’m so glad to hear that! Now how can we help you to remember

those thoughts before your next baseball game? JAMES:

I bet I could put a note in my baseball bag. I’d see it before warm-ups. But Mom, can you help me remember to do that when I get home?

MOM:

Yes!

James experiences some relief related to his baseball performance worries, but as James and his mother continue working with the therapist, it becomes clear that James has a broader sense of worry related to perfectionism and making mistakes. He frequently seeks reassurance from his mother prior to anything where he might make a mistake and after anything where he judges that he made a mistake. That reassurance-seeking behavior has become disruptive to the family’s functioning, as times before and after school become more and more full of reassurance seeking and as James texts his mother repeatedly during the school day. If he cannot reach his mother, he becomes very agitated or distracted, cries, and spends time in the nurse’s office. The therapist collaborates with James and his mother to construct a fear hierarchy to prepare for exposures. His hierarchy can be seen in Table 23.1. This hierarchy will be used throughout the second half of treatment to engage James in facing anxiety-provoking situations, learn that the situations might not have been as bad as he feared, and learn that he is able to cope with no more than one reassurance-seeking request when he does make mistakes. His mother will be

742  Calloway, Fleischer, and Creed

TABLE 23.1. James’s Fear Hierarchy Situation

SUDs rating

Play baseball in front of a crowd and strike out

10

Drop his tray in the cafeteria

9

Give a wrong answer aloud in class

8

Intentionally make an error on a test

7

Intentionally make an error on a quiz

6

Raise his hand in class and say that he doesn’t understand the lesson

5

Buy a snack in a store and not have enough cash to pay for it

4

Buy a snack in the store and give the wrong amount of cash before correctly paying

3

Ask someone for directions and then walk off in the wrong direction

2

Pretend to trip while walking in the school hallway

1

Note. SUDs = Subjective Units of Distress.

present during in-session exposures so the therapist can model effective exposure therapy procedures with limited reassurance provided. Prior to beginning exposures, the therapist meets with James’s mother to discuss potential parental accommodation of anxious behaviors. His mother identified reassurance seeking as a common behavior that James engages in when anxious. She will often answer his questions and provide reassurance, though this process has become time consuming and distressing for her as well. THERAPIST: So can you give me an example of James seeking reassurance

and what you do in response? MOM:

Well he’ll often ask me what would happen if he failed an upcoming social studies test. I’ll reassure him that he won’t because he’s very smart and studied very hard. This doesn’t seem to help though, and he’ll start coming up with more scenarios. He’ll ask things like what if he forgets everything, or what if he missed something while studying. I’ll try to answer the questions the best I can but then more just seem to pop up. He never runs out of what-ifs!

THERAPIST:

I see. This definitely sounds like an exhausting cycle for both you and James.

MOM:

It is.

THERAPIST: From what you have told me, James has been seeking reassur-

ance from you for a while now. I can totally understand that when we see our children in distress, we want to help them to



Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders  743

feel better as quickly as possible, and that can easily be by reassuring them that things will be fine. Unfortunately, as you’re seeing, that doesn’t always work as planned. Offering a lot of reassurance actually means that James depends on you to help him feel better, while his brain is busy focusing on all of the what-ifs that could still happen. That means that James doesn’t get the opportunity to face his anxiety, learn whether his what-ifs are realistic or helping him to reach his goals, or develop ways tolerate distress for himself. Today I was hoping we could talk about a tool or two that you could try when James is looking for reassurance. MOM:

That sounds great.

THERAPIST:

So when a child is seeking reassurance for their anxious thoughts, we can try a few different things instead of jumping to reassure him. First, you could label and reflect his anxiety. So, for example, when James is anxious you can say something like “It sounds like your worry brain is acting up right now.”

MOM:

Okay. I think I can do that. I kind of like it because it still gives me something to say that shows that I’m listening and I care, but it’s not just short-cutting his sorting it out for himself.

THERAPIST: Exactly! Next, you can give a small reminder to James to use

some of the tools he’s learned so far. For example, you might say, “Are there any therapy skills you’ve learned that might help?” If he’s having a hard time refocusing on a skill, you could even suggest one, like being a thought detective, practicing some of the deep breathing techniques, or using one of his distraction plans to help switch his brain away from the what-ifs. The key here is for you to find a balance where you’re able to give him a nudge to use skills if he needs it, but you’re not the one in charge of remembering and orchestrating his use of skills. That would just be trading the reassuring for a different job where you’re in charge of making it all better. MOM:

That makes sense. I think I can help him do that.

THERAPIST: Great. Let’s give it a try. First, I’ll trying being you and you can

be James, and then we’ll switch. Okay? MOM:

Okay. Mom, what if I don’t get a good grade on my science project? I tried my best but I don’t know if that’s good enough. What if my teacher doesn’t like it?

THERAPIST: James, it sounds like your worry brain is acting up right now.

Are there any things you’ve learned in therapy that could help?

744  Calloway, Fleischer, and Creed

MOM:

Well, if I try the thought detective, I’d start by checking clues that tell me that my teacher won’t like it. It’s possible he won’t like it, and I did get a B– on my first science project. On the other hand, my teacher did say he was excited about my project, and most of the time, I get pretty good grades. Even a B– isn’t terrible, and I found a way to handle it when that did happen. So if I try my best then I should do fine, and even if things aren’t perfect, I can handle that?

THERAPIST: Good job, James! I’m so proud of you for being a thought detec-

tive. Great job. . . . Now let’s switch roles so you can try. During the course of treatment, techniques such as cognitive restructuring, relaxation, and distraction gave James the tools to later face exposures of uncertainty and failure. By incorporating his mother into sessions, she was able to support his use of skills and reduce her reassurances, and James’s progress was furthered due to generalizing his progress in therapy to real-life situations. James showed improvement in facing anxiety-provoking situations with more confidence and with expressing more pleasure and mastery with regard to sports and school.

CONCLUSION AND FUTURE DIRECTIONS This chapter examines the key characteristics of internalizing disorders in children and youth, exploring the underlying cognitive behavioral theory that informs treatment for these disorders in youth. Key empirically based interventions were discussed, including cognitive restructuring, behavioral activation, problem solving, and exposure therapy, and the outcome data regarding these techniques were reviewed. Finally, mechanisms and cultural implications for treatment were discussed in context of internalizing disorders for youth. This chapter also details several areas of future research and practice for the treatment of youth with internalizing disorders. Future research should focus on family involvement in the cognitive behavioral treatment of children and youth with anxiety and depression. Although this chapter outlines some research on parent involvement in the treatment for youth internalizing disorders, more research is needed to replicate findings and further research on increased parent involvement. Additionally, although there is sufficient research to demonstrate the efficacy of CBT for youth with internalizing disorders, few youth are able to access high-quality CBT in their communities. Further research should focus on effective strategies to broaden access to CBT and other evidence-based practices, including implementation strategies to increase uptake and sustainability in practice settings, and policies that require and incentivize these practices.



Cognitive Behavioral Therapy for Children and Adolescents With Internalizing Disorders  745

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24 Cognitive Behavioral Therapy With Older People Kenneth Laidlaw

C

ognitive behavioral therapy (CBT) is particularly appropriate as an intervention with older people as it is a pragmatic, jargon-free approach that empowers people to manage their problems more effectively through the transmission of coping skills, while adopting a “here and now” problem-solving orientation. CBT is attractive to older people because it presents straightforward rationales to redress problems in practical and effective ways. CBT empowers older people to believe that change is possible at any age, and while not always easy, change can occur through cognitive and behavioral methods of problem solving. Psychoeducation about the nature of maintenance cycles for depression and the anxiety disorders provides helpful coping strategies that can be adopted immediately. The simple, but not simplistic, explanations of how to identify and challenge cognitions and strategies for behavioral change provide older people with tools they can use positively for themselves and pass on to younger generations in their extended families.1 Depression and anxiety disorders in later life are often misunderstood as occurring as a “natural” consequence of challenges and losses associated with aging. Depression is therefore often underrecognized, underdiagnosed and undertreated in older people, with poorly treated depression associated with higher mortality rates and higher health care utilization costs (Pocklington, 2017). Nevertheless, depression is not an outcome of old age, and it is treatable, with rates of major depressive disorder lower than those in working-age adults (Fiske et al., 2009). CBT with older people has established itself as a mainstream Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000219-024 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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option for the treatment of depression and the anxiety disorders (see Kropf & Cummings, 2017). Evidence also suggests that CBT is efficacious in achieving symptom reduction in depression in dementia caregivers. The evidence base continues to advance with exciting developments taking place in psychological treatments for people with dementia and for reducing morbidity in people with long-term chronic conditions. Contemporary research findings from gerontology (the science of aging) may augment efficacious outcomes for CBT with older people, and more specifically, understanding normal aspects of aging may act as a counterbalance to negative age stereotypical beliefs about working with older people (Bryant & Koder, 2015). Evidence from gerontological research debunks myths and negative stereotypes of older people and may encourage therapists to expect a good outcome treatment (Karel et al., 2012).

SPECIAL CHARACTERISTICS AND CHALLENGES OF CBT WITH OLDER PEOPLE The world is experiencing a profound and irreversible demographic shift, meaning that therapists are much more likely to come in contact with many more and much older people than ever before. It is becoming more urgent that therapists consider how best to work with the oldest-old client group (those aged 80+ years), as this client group may present some challenges to therapists. Therapists often feel ill-prepared to meet the needs of this new cohort of older people (Karel et al., 2102; Laidlaw, 2015). Evidence also suggests that if older people are able to self-refer, rather than be referred by their primary physician, a larger range of older people would seek therapy (Burch et al., 2017). Like many other countries across the developed and developing world, the United States is not immune to the aging of its population. By 2030 in the United States, there will be 73 million people aged 65 years and over, amounting to one in five of the population (Vespa et al., 2018). In common with most demographic projections, it is the oldest-old section of the population that shows largest relative increase, with the numbers of older people aged 85 years plus almost doubling from 6.4 million currently to 11.4 million by 2035. This increase is not temporary, as the numbers of those aged 85 years and above are set to triple (19 million) by 2060 (Vespa et al., 2018). Life expectation at birth for males is currently 76.1 years, and for females it is 81.1 years. Life expectancy at age 65 for men and women in the U.S. is 18.1 and 20.67 years, respectively (Murphy et al., 2018). Older people may have many years of life left, and this may be longer than previous generations and often beyond the individual’s own expectation of years left. Recent research in the United Kingdom suggests that while life expectancy will increase, up to one quarter of life expectancy for people aged 65 years plus will be lived with disability (Guzman-Castillo, 2017). Thus, when therapists do work with older people, there may be a number of long-term conditions (LTCs) or noncommunicable diseases (NCDs) to be con-



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sidered. Clinicians experienced in working with older clients understand that comorbid LTCs develop gradually and one should not assume these all have negative impacts on quality of life or affective status. NCDs (i.e., nontransmissible and noninfectious diseases) are the main reasons for death, with the CDC reporting that the 10 most common causes of death in the United States accounting for 74% of all deaths (Murphy et al., 2018) are cardiovascular disease, cancer, chronic respiratory diseases, and diabetes. Age-adjusted deaths due to Alzheimer’s disease in the United States rose by 2.3% between 2016 and 2017 (Murphy et al., 2018). NCDs may be factors when working with our oldest clients; therefore, following a careful historytaking, one should consider the meaning attributed to the presence or consequence of comorbid conditions. For instance, a client developing heart disease may consider this to be “an old’s man’s disease,” and a negative attribution about the future aging experience may engender a sense of hopelessness. This can be transferred into therapy sessions as passivity on the client as they see the nature of their problems as part of an inevitable decline in which they are unable to intervene. CBT, however, provides clients strategies to develop new problem-solving skills to meet their challenges. Multimorbidity may also be a consideration for a therapist developing a formulation and treatment plan. Therapists working with older people should not necessarily be overwhelmed when a client has a number of NCDs. As NCDs typically have a slow developmental trajectory, many older clients will live with chronic health conditions for a long time and are likely to develop ways (good and bad) of accommodating to these in their daily lives. Nevertheless, therapists working with older people should expect to update their knowledge and skills in order to address longevity, chronicity, comorbidity, and continuity of problems (see Sadavoy, 2009). CBT can be differentiated from other forms of psychotherapy by considering the following fundamental principles: • Session targets and treatment focus are structured according to an explicit, agreed agenda at the start of each session. • Collaborative empiricism, where clients are encouraged to use behavioral experiments to test out new ideas, is emphasized throughout treatment. • CBT is based on the simple premise that “talk is cheap” and that meaningful change comes through people trying something different in response to the existence of their problems. • Change often occurs outside of the treatment session, and therefore CBT is an active treatment that requires behavioral as well as cognitive actions to occur. Homework tasks are often the vehicle for people to generalize learning outside of the session and to promote an enhanced sense of agency. • Negative (cognitive) interpretations to events and situations are idiosyncratic and do not represent the only way to think and act in a situation. Therefore cognitions (thoughts and images) are open to empirical testing (disputation).

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• The primary means of exploration is Socratic questioning, • CBT assumes that behavior change will also bring about cognitive change. • Interventions are linked to individualized case conceptualizations, also known as formulation. • CBT is an evidence-based, time-limited treatment approach whose primary aim is symptom reduction. The above description of the fundamental aspects of CBT outlines both structural and procedural elements that are essential to the success of any package of CBT treatment, and these are equally likely to predict successful treatment outcome with older people. CBT with older people very often does not require any specific adaptations or modifications to bring about beneficial change (Chand & Grossberg, 2013). Of note will be whether a client possesses a negative age stereotype where they expect old age to be characterized by frailty and degeneration. While aging does present challenges, for many aging is no more challenging than any stage of life. Understanding normal aging is essential for CBT therapists, as it may not be possible to differentiate a factual representation of a problem from that of a catastrophic misinterpretation. For example, if a client says, “At my age I am depressed, but that is to be expected as old age is a depressing time of life,” how does one proceed in evaluating this and in formulating a response? Having a means of educating oneself about a contemporary understanding of the normative course of aging and prevalence of depression and anxiety disorders in later life is a minimum requirement for those interested in applying CBT with elders.

NORMAL AGING AND CBT Evidence suggests that as people age their emotional well-being improves, and older people report better emotional stability in comparison with working-age adults (Scheibe & Carstensen, 2010; Urry & Gross, 2010). As older people generally possess enhanced emotion regulation competences (Sims et al., 2015), it may be possible that this confers an enhanced ability to down-regulate negative emotions when faced with losses (Reed et al., 2014). In terms of CBT, it is also understood that whatever problem is facing an individual, if one approaches it with a negative mindset, one is less able to optimally manage problems. This simple premise is captured in the wisdom of the stoic Epictetus, who said, “People are not disturbed by things, but by the views they take of them.” Thus, older people who are more adept at emotional regulation and have a lifetime of experience of dealing with problems may make especially good candidates for CBT, and therapists working with older people are encouraged to maintain an optimistic expectation for change. There are a number of “how to” guides for applying CBT with older people, and interested readers are recommended to consult texts by Thompson et al. (2010) and Laidlaw (2015).



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Rather than being a natural outcome of the challenges associated with aging, depression appears to be less common in older people and especially so when compared with working-age adults: “Happiness is approximately U-shaped throughout the life-course; mental distress tends to reach a maximum in middle age” (Blanchflower & Oswald, 2008). A recent paper by Hutnik et al. (2016) suggests that CBT with centenarians helped older people positively reframe their perspective of previous life events. These data are consistent with the observation of a positive bias in recall for memories in nondepressed older people (Mather & Carstensen, 2005), with evidence of a preferential recall for emotionally positive memories and the opposite for negative emotional events. Thus, if an older client demonstrates an absence of positive bias and a predominance to dwell on negative emotional recall of past events, this is most likely indicative of depressive affect rather than a normal recall of one’s life. It was previously an accepted tenet that older people would not want “talking cures.” However, as with many previously accepted beliefs, the facts seem to suggest otherwise; older people view psychological therapy as effective and acceptable as medication but with far fewer unwanted side effects, and if given a choice, many prefer psychotherapeutic treatments rather than psychotropic medications (Gum et al., 2008; McKenzie et al., 2008). Neither are older people too rigid and inflexible to benefit from psychological therapy. Data from large-scale longitudinal studies from gerontology testify that emotional change occurs across our entire lifespan, and as one ages emotional regulation improves with better emotional stability experienced (Carstensen et al., 2011). When asked, older people often report higher levels of life satisfaction than working-age adults (Lohani & Isaacowitz, 2014). As Knight (2006) notes, age teaches people to be more open, flexible, and less dogmatic with an increased understanding of the relative nature of life, and thus older people may make very good candidates for psychological therapies. Isaacowitz et al. (2017) capture this as follows: “Older adults have the benefits of experience and motivation to promote emotional well-being.” Thus, when working with older people, therapists should expect their older clients to make good candidates for therapy, and therapists should expect their clients to benefit from treatment and achieve symptom resolution.

CBT EFFICACY FOR DEPRESSION AND LATE-LIFE ANXIETY DISORDERS Over many years, CBT has established itself as an efficacious psychological treatment for use with older people. A series of systematic reviews and meta-analyses have demonstrated that CBT is efficacious with older people in comparison with other therapeutic approaches. Cuijpers et al. (2014), in their comprehensive review of psychological interventions for late-life depression, reported a medium effect size of 0.45 for CBT. A recent meta-analysis by Hall et al. (2016) focused on the efficacy of CBT for older people with generalized

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anxiety disorder (GAD), with end-of-treatment medium effect sizes of 0.7 when compared with any control condition (including wait list) and effect sizes of 0.4 when compared with active treatment conditions (Hall et al., 2016). Holvast et al. (2017) conducted a meta-analysis to look at the efficacy of nonpharmacological treatments for depression in older people in primary care settings. Only five randomized controlled trials (RCTs) of CBT were identified, and most of these compared individual CBT versus care as usual. At a 6–9 month follow-up, the overall effect size was small (0.21) but nevertheless favored CBT. This is a good result, as comparing CBT to usual care provides clinicians with a good indication of the potential efficacy of interventions outside of university research settings. While much evidence has accumulated from RCTs, systematic reviews, and meta-analyses, evidence from Britain in terms of the improving access to psychological therapies (IAPT) public dataset provides intriguing findings with regard to more naturalistic outcomes for CBT with older people. IAPT started in England in 2008, providing free access to evidence-based psychological treatments for depression and anxiety disorders. Since that time, more than 900,000 people have accessed treatment. A key feature of IAPT is that all services measure outcome using the same minimum dataset. Older people can also access treatment using IAPT, although the number accessing this are lower than population estimates may suggest. Nevertheless, the public dataset is based on very large numbers of older individuals who report outcome data for CBT. The data suggest that, at the very least, CBT is as efficacious with older people as with working-age adults. Moreover, national level outcome data from IAPT demonstrate that older people report better treatment outcome (i.e., more are recovered at end of treatment; 59% vs. 46%) and better treatment completion rates (60% vs. 49%) in comparison with adults of working age (Chaplin et al., 2015). Unfortunately, despite good results achieved by older people in these services, they still experience barriers accessing therapy. In a study examining inequity of access for psychological services, Pettit et al. (2017) note, “Once referred, adherence to and recovery resulting from treatment increases with age, and higher proportions of older adults are accessing and engaging with treatment than the 20- to 24-year-olds, who are being referred more frequently” (p. e457). In data from the United States, Karlin et al. (2015) reported equivalence in CBT treatment outcome between combat veterans aged 18 to 64 and those aged 65 years plus, with both groups achieving good reduction in depression using the BDI-II at end of treatment (39% vs. 38%, respectively). Cuijpers et al. (2009) examined the differential effectiveness of psychological therapies with older people and adults of working age in 112 individual RCT studies, with 20 of those papers evaluating treatment outcomes with older people. When examining the effect sizes between participants in working age and older people treatment trials, there is no significant difference in outcome. Older people studies report an overall effect size of 0.74, whereas working age adult studies report an overall effect size of 0.67. By usual convention, effect sizes of 0.2 are considered small, 0.5 moderate, and above 0.8 large. According



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to Cuijper et al. (2009), there is a comparable effect size of 0.62 overall; thus about 73% of participants in these studies improved. Cuijpers et al. (2014) examined the efficacy of psychotherapy (mainly CBT) for GAD and included a number of studies that examined CBT with older people. This finding was in contradiction to recent meta-analyses by Covin et al. (2008) and by Gould et al. (2012), suggesting that CBT was less efficacious with older people. Kishita and Laidlaw (2017) explicitly addressed the question of CBT efficacy for GAD when subgroups of older people and working-age adults are compared using the same metrics in a single integrative meta-analysis. In this innovative study, Kishita and Laidlaw (2017) reported no statistically significant treatment differences between older people and working-age adults. Overall, however, effect sizes were moderate for older people (0.6) and large for workingage adults (0.9). Kishita and Laidlaw suggested differential outcome may be related to poor adaptation of treatment protocols for use with older people that enable the CBT therapist to provide a treatment that is more properly age and developmentally appropriate. While the majority of studies adopted standard CBT protocols with simplified procedural modifications such as the use of mnemonic aids or simplifying homework forms, these modifications, added little to improving treatment outcome, suggesting a more robust approach to age-appropriate CBT may be necessary. Thus, evidence from a range of sources supports the assertion that CBT is an efficacious treatment for common mental health problems on par with data reported for working-age adults. While these figures may seem unimportant, this belies the fact that for many years it has been assumed differential treatment outcome favored working-age adults over older people in CBT. This belief could potentially and inadvertently justify a lower provision of evidence-based psychological treatment. In summary, a contemporary review of the outcome literature for CBT for late-life depression suggests the following: • Evidence for efficacy of CBT in late-life depression is stronger than for other forms of therapy, but there remain insufficient studies of optimal quality to definitively conclude CBT is superior to other forms of psychological therapy in older people. Treatment outcomes are larger when compared with waiting list or no treatment controls than with other forms of psychological therapies. • There appears to be equivalent treatment outcome for CBT with older people in comparison with working-age adults, but this remains largely underexplored. Nevertheless, CBT treatment outcome with the oldest-old (mean age 75 years plus) is insufficient (only two RCTs published), as many of the earlier CBT older adult outcome studies tended to recruit “young-old” participants. • CBT appears comparable in efficacy to medication in terms of both treatment outcome and dropout. However, this comparison is underexplored,

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with limited data examining the effect of combination treatments (i.e., CBT plus medication versus medication or CBT alone) in late-life depression. • Many of the earlier psychotherapy and CBT outcome studies tended to report data on completer samples rather than use intention to treat (ITT) designs, and hence results may require some judgement on the part of the reader. Recent CBT outcome studies have reported efficacious outcomes when using ITT designs. CBT for late-life anxiety disorders is receiving increasing attention as more studies provide clarity on the efficacy of treatment outcome for very common distressing conditions experienced in later life. More recent studies have started to demonstrate grounds for optimism that CBT can be efficacious with older people with anxiety disorders. In summary, a contemporary review of the outcome literature for CBT for late-life anxiety disorders suggests the following: • Many earlier RCTs for CBT for anxiety disorders recruited younger, relatively healthy, well-educated older adults; were conducted in university medical lab/clinics; and appear to report completer data. • There is a need to develop clinical trials with oldest-old participants, and RCTs need to examine specific treatment protocols with specific anxiety disorders with older people (e.g., CBT for GAD, CBT for panic disorder). • Many early RCTs have focused on mixed presentations of anxiety disorders in group format. • Case study reports rarely report schematic and age-appropriate conceptualizations. • A recent meta-analysis suggests CBT for late-life anxiety disorders is as efficacious with older people as compared with adults of working age. • Recent RCTs for specific anxiety disorders in later life report promising outcomes. Recent research evaluating CBT treatment of anxiety disorders appear to be redressing initial concerns about efficacy and attrition. Wuthrich and Rapee (2013) carried out a well-designed RCT of CBT versus wait-list condition for comorbid anxiety disorders and depression. Previously, outcome for comorbid psychological distress was considered to result in poorer outcome. In this study, those randomized to receive CBT (27 out of 62 participants) reported better outcome, with 73% reporting a reliable change index (where reduction in scores on standardized measures are considered to achieve clinically significant change, usually where individuals achieve reductions on scores taking them outside of diagnostic scores) as opposed to 23% on clinician-reported severity of problems. When considering client-reported severity of their main problems, participants in the CBT group reported reliable change scores of 52% versus 11% for those in the wait-list condition (Wuthrich & Rapee, 2013). In a later



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study, Wuthrich et al. (2016) extended their research into efficacy of CBT for comorbid anxiety disorders and depression by comparing CBT to an active treatment control condition (discussion) in a larger trial with 133 participants. In this study, Wuthrich et al. again reported better outcome for the CBT group in that 54% of participants no longer met diagnostic criteria for their primary disorder compared with just 24% of those in the discussion group. Overall, the data for CBT for depression and the anxiety disorders demonstrate a substantial effort has been dedicated over the years to prove that CBT is an efficacious format of psychotherapy. While there is much to celebrate about the data here and the fact that CBT has established itself as a mainstream treatment for late-life affective disorders, there remains much to be done. CBT needs to establish an evidence-base for treatment with the oldest-old and with people with comorbid life limiting conditions, as well as providing more substantive evidence for CBT with people with dementias and affective disorders.

CBT WITH DEMENTIA CAREGIVERS The Office of National Statistics (2019) published national data suggesting that as the numbers of older people living longer increases so does the likelihood that people will care for family members with dementia. Identifying and managing depression in dementia caregivers is important as it is associated with increased risk of breakdown of care and unhelpful caregiver behavior (Cooper et al., 2010). Kwon et al. (2017) conducted a recent meta-analysis of 12 RCTs from seven different countries and concluded that CBT for depression in dementia caregivers is very strongly efficacious with a beneficial outcome for depression, anxiety and both general and caregiver-related stress. When comparing a subsample of the studies for outcome reported for depression using the CES-D at baseline and end of treatment, there was an overall effect size of 5.02. This suggests CBT is an efficacious treatment for depression in caregivers. What appears to be the effective ingredients of this format of CBT is a pragmatic emphasis on enhancing coping skills, maintaining and engaging in informal social support networks, pleasant event scheduling, and modification of dysfunctional cognitions, as well as targeted psychoeducation. In effect, CBT for dementia caregivers works because it focuses on the active elements of standard CBT and that should give good cause for optimism in therapists interested in working with older people. CBT has also been compared with a third-wave therapy in RCT to acceptance and commitment therapy (ACT) for dementia caregiver depression with interesting findings. Losada et al. (2015) reported that at the end of treatment 27% of participants in the CBT group compared with 24% of those in the ACT group reported clinically significant change on measures of depression. These promising results suggest ACT could be a very viable alternative psychological intervention to reduce distress in caregivers. Overall, the evidence for dementia caregiving suggests active interventions are more effective than interventions that are passive. CBT is most beneficial

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when targeting specific symptoms of depression and anxiety. While psychoeducation improves subjective well-being, it is effective in reducing distress only if it is active. Two comprehensive reports have confirmed the efficacy of CBT for caregivers. Goy et al. (2010) was funded by the U.S. Veterans Administration and provides a very up-to-date systematic review of the evidence base of interventions aimed at nonprofessional carers (informal caregivers). In the United Kingdom, Elvish et al. (2012) produced a report examining the evidence for psychosocial interventions with caregivers and makes a series of sound recommendations when working with caregivers.

CBT FOR PEOPLE WITH DEMENTIA Depression in dementia is complex to treat, and currently evidence for the efficacy of antidepressants remains inconclusive, with Dudas et al. (2018) reporting no difference in outcome between antidepressants and placebo at 12 weeks. Thus, there is an urgent need to consider whether CBT may have a role to play in treatment options for people with dementia and their caregivers. Evidence for the efficacy of CBT in anxiety and depression in dementia is a developing research field with a number of intriguing clinical trials and case studies suggesting that in the mild-to-moderate stages of dementia, CBT may be efficacious in promoting symptomatic relief in depression and the anxiety disorders. Orgeta et al. (2014) report mixed results in a Cochrane review of psychological treatments versus usual care for depression and anxiety in older people with cognitive impairment. For clinician-reported improvement in depression scores for people with dementia, there were small effects of 0.22 and a larger effect for clinician-rated improvement in anxiety disorders with effect sizes of 4.57. This review is small as it only incorporates six studies and there were no gains reported on any secondary measures. Thus the data are inconclusive, but characterize these results as reported by Dudas et al., and there remains grounds for optimism. In the United States, a recent modification of problem adaptation therapy (PATH) by Kiosses et al. (2015) for use with older people with depression and cognitive impairment has shown promising results. PATH is a 12-session, home-delivered intervention based on problem-solving therapy (a derivation of CBT) that recruits caregivers as cotherapists with a primary aim to enhance emotional functioning and reduce behavioral limitations in people with dementia. Kiosses et al. recruited 74 participants who all met criteria for major depressive disorder and moderate levels of cognitive impairment (more than half had dementia). Participants were randomized to receive either PATH or supportive therapy, which focuses upon nonspecific therapeutic factors. Participants in the PATH intervention reported statistically significant reduction in depression in comparison with those receiving supportive therapy. As PATH teaches people with dementia and their caregivers problem-solving and to implement strategies, including environmental adaptations and manipulations to meet the chal-



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lenges of living with dementia, it should not be that surprising to see superior outcome in comparison with a control condition (38% remission rate for PATH compared with 14% for SC) that validates emotional responses but does not help people develop pragmatic ideas to overcome difficulties. PATH is still at an early stage of development and awaits further and larger evaluation, but this is a very promising intervention. Given there are limited efficacious interventions for depression in dementia, any new developments in CBT for people with dementia create an exciting evidence-based new frontier for enhancing emotional well-being and quality of life.

HOW IS CBT DIFFERENT WITH OLDER PEOPLE? The question as to how and whether CBT is different with older people is a nuanced one. In many respects, data shows (see above) standard CBT treatment protocols examined in RCTs are as efficacious with older people as with working-age adults. However, there can be a disconnect between the clients who enter RCTs and those seen by clinicians outside of research settings. Many older clients seen in clinics would be excluded on the basis of complexity, such as multimorbidity, frailty, and so on. Thus, our evidence base is a better fit for therapists working with the youngest-old, or those closest in identity with working-age adults in terms of vitality, attitude, and physical status. Many therapists inexperienced in working with older people can be intimidated with the great age of clients (as well as a substantial age gap between therapist and client) and the often extensive list of comorbid conditions. Clients may be referred because other physical treatments have not completely resolved affective distress, and age-stereotypes implicit in the therapist and client can often deflate expectation for change. For these reasons and many others, older people do not always receive the treatment that is indicated. The population identified as older people (i.e., aged 65 years and above) is a very heterogeneous group containing up to four different generations. It may be useful for therapists less experienced in working with older people to consider the potentially different needs of young-old (65–79 years) and that of the oldest-old (80 years and above). One should not become too focused on chronological age as an indicator of need. In reality there are as many individual experiences of aging as there are individual older people, but nevertheless the oldest-old may often present with higher levels of physical comorbidity. Beyond chronological age, the advanced life-years of older clients may provide an opportunity for the therapist to understand the potential psychological resources of the individual (e.g., resilience) and their ability to overcome challenges as they have aged (e.g., onset of chronic limiting conditions, bereavement and loss). While CBT for late-life depression in later life is the most systematically researched psychological treatment approach for use with older people, in many cases the question for clinicians is how does one reconcile an evidence-based,

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protocol-driven approach to treatment in the clinic when there is limited literature addressing process issues in the application of CBT with older people. Space precludes a full description of all elements of an age-appropriate approach to CBT; therefore, the following contains an account of a new technique within CBT with older people to identify and use lifeskills to augment CBT efficacy.

THE LIFESKILLS APPROACH The oldest-old age group may be more intimidating for younger, less experienced clinicians to work, as the age gap can be five or more decades. Sometimes therapists worry that their older clients will not find them credible because they are young, and that the client may adopt a protective stance fearing that sharing their emotional distress with someone young may overwhelm them. Sometimes when there is a large age difference between client and therapist, there can be challenges in reconciling different values and attitudes. Cohort beliefs, that is, those beliefs endorsed by groups of individuals born at similar times periods (e.g., people born in the war years 1939–1945 are often known as the “make-do and mend” generation), suggest that in some cases the therapist’s values may not entirely align with older clients being born and lived in different social milieu. To help develop a stronger therapeutic alliance, the therapist may find it useful to learn something of the social history of the country or culture of the population they work with, as often the past can be a different country. A scientific approach to developing an age-appropriate CBT is to look to gerontology for inspiration and guidance. Contemporary research findings from gerontology provide a theoretical perspective to enhance treatment outcome. This may simply be to provide data about normative aspects of aging to dispel negative expectations and to act as a counterbalance to negative age stereotype beliefs implicitly endorsed by therapists unused to working with older people. By doing so, therapists appreciate and understand that depression, anxiety disorders, and dementia are not outcomes of aging, with a consequential change in expectation of outcome for older clients (Bryant & Koder, 2015). Much more powerfully, data from gerontology can suggest new treatment interventions to enhance and augment treatment outcome in CBT with older people. One such approach is the development of the use of timelines in CBT with a specific unique focus upon helping the client use their past to better manage challenges facing them in the present time. Lifeskills cultivate an appreciation of the psychological and emotional resources developed and enhanced by older people over a lifetime. By this means, an age-appropriate version of CBT focused upon wisdom enhancement is fostered. Lifeskills in CBT use timelines and encourage older clients to focus on the past in order to gain new insights into their psychological resources and adopt a more compassionate approach to themselves as they work to overcome current difficulties.



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Lifeskills in CBT find scientific validation from wisdom research (Bangen et al., 2013). While wisdom is one of the few positive attributes accorded to the aging process, paradoxically it is not an outcome of aging. One can be wise at any age, but in reality, wisdom is not easily acquired. In CBT, personal theories of wisdom (Bluck & Glück, 2005) may offer more value to the CBT therapist in making use of the past in order to overcome difficulties in the here and now. Research suggests wisdom may be more likely to develop after one has overcome adversity, and as such it reflects competence in the fundamental pragmatics of human life (Staudinger & Glück, 2011). Contemporary theories of wisdom suggest this may be more likely to develop after one has engaged in a challenging and honest process of review and reflection (see Weststrate & Glück, 2017, for review). Wisdom-fostering forms of self-reflection require that individuals explore their own role in the occurrence of negative life events, confront and examine negative feelings, and do the effortful work of finding meaning in the difficult experience: “This type of self-reflection is rare, probably because it is less pleasant than other processing modes” (Weststrate & Glück, 2017, p. 810). Lifeskills are emotional and psychological resources that clients possess. As CBT has traditionally emphasized a “here and now” perspective, CBT therapists have mainly either ignored or undervalued the additional life years older clients possess (Laidlaw, 2015; Laidlaw & Kishita, 2015). As people are living longer than ever before and as it increasingly becomes likely that therapists will see many more nonagenarian clients (people in their 90s) the time has come to consider whether to make use of the age gap between client and therapist to promote more change and better outcome after treatment. A client who has lived longer than the therapist will likely have faced and overcome many adversities over their lifetime (e.g., loss of spouse, changes to physical health and independence, role change) that the therapist may not yet have faced. Therapists may reflect on how their client has navigated these significant life events and ponder as to how they would cope were similar circumstances to occur in their own experience. Research suggests that as people age, emotional development continues, and additionally life teaches one to be resilient (Bluck & Glück, 2005). Thus, older people have the ability to benefit from experience and the sagacity to put that experience to good use in the here and now. A timeline can be created very simply using a pen and paper where the date of birth of an individual is placed at the top of the page and the current date of session work is placed at the bottom. The timeline is a summation of an individual biographical account of a life story from an idiosyncratic perspective. When completing the account, the client is encouraged to note down their most significant life events (good and bad) and the therapist encourages the client to do so as openly as feels comfortable. When asking the client to complete the timeline as homework, the therapists should say, “All that we live through helps make us the person we are today.” Figure 24.1 gives an example of a timeline worksheet that can be used as a homework task for the client to complete at the end of the third session.

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FIGURE 24.1. Timeline Worksheet (Complete With Your Therapist)

Timelines afford a targeted and specific review of past experiences, consistent with the strengths-based approach to CBT advocated by Padesky and Mooney (2012). Timelines are best viewed as an augmentation to standard CBT techniques, such as cognitive restructuring and reappraisal and behavioral



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experiments, and are not used as a standalone technique. Events from an individual’s timeline are idiosyncratically reviewed using Socratic questions. Table 24.1 outlines the types of Socratic questions that may be used with the client to explore events. Discussions are more effective if they are followed up with behavioral experiments testing out this new realization (see Laidlaw & Kishita, 2015). Memory biases in depression influence how a person perceives events, frequency of negative recall, and even what aspects of situations are attended to (Joormann & Tanovic, 2015; Williams et al., 2007). Thus, an even-handed fair review and reappraisal of past events is almost impossible for depressed clients to do on their own, as they habitually are drawn to a negative focus, which in turn can lead to rumination. Thus, therapists take an active directive stance as they help the client review how they have overcome adversity in the past. As a starting point, therapists may review how clients perceive their ability to deal with difficulties. A good question to ask when looking at a timeline with a client is, “Looking back at this timeline, what do you learn from dealing with setbacks? What does that tell you?” The aim here is to help the client explore personal evidence that they have resources for coping with challenges, and this opens the possibility that they have resources to better manage their here and now challenges. Timelines allow CBT therapists to simultaneously reduce negative affect and increase positive affect. Research suggests that being more compassionate to oneself is associated with better psychological well-being (Phillips & Ferguson, 2012). Once the timeline is used to Socratically explore ways to challenge the negative self-view the client possesses, the therapist can start to examine more challenging life events from the timeline. For example, Jennifer (see Laidlaw, TABLE 24.1. Socratic Questions to Be Used With Timelines in CBT Task

Timeline Socratic question

Factual reappraisal of event

Looking back on that event now, what does it tell you about yourself when you think about how you managed?

Enhancing sense of internal resources

If you could somehow go back in time as you are now and talk to your younger self, what would you say to your younger self about how you coped?

Learning from the past

Have you been in a similar position in the past? If so, how did that turn out? How might this help you manage your current problems?

Challenging negative narrative of self

Pick an event from the timeline. If someone would have told you that was about to happen, how would you have predicted how you would cope? . . . Looking at that event now, what did you actually do?

Self-acceptance

In the past in times of crisis, how, and in what way, has being self-critical in the midst of a crisis been helpful to you?

Reappraisal of self as a survivor

Looking back at this timeline, what do you learn from dealing with setbacks? What does that tell you?

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2013, for a fuller account) experienced the sudden and unexpected death of her husband in midlife. This necessitated her subsequently having to return to work for the first time during her married life because she had two children to care for. In reviewing this event in the timeline, the therapist inquired as to how Jennifer coped. She replied she did not cope at all during this time despite holding down a job and caring for her children. It would not have been helpful for the therapist to reassure her that she had in fact coped. Jennifer herself needs to be able to challenge this idea in order to manage her current difficulties, and the timeline affords the therapist with an opportunity to help the client challenge their beliefs using evidence from across their lifetime. As this reappraisal occurs after the fact of events, the therapist is able to help the client compare their emotional beliefs with the facts as events have turned. This is a variation on the well-known approach in CBT of helping clients to recognize that feelings aren’t facts. Using one of the Socratic questions from Table 24.1, the therapist asked Jennifer, “If someone would have told you that your husband would die suddenly how would you have predicted you would cope?” At first, Jennifer was taken aback by the question, and said, “I wouldn’t have coped.” The therapist gently helped Jennifer to reappraise this by asking, “Looking at that event now, what did you actually do? How do you consider how you did back then?” Jennifer was able to see for herself, using her own experience, that she had coped, survived, and looked after the needs of her children. She had carried on. Jennifer was encouraged to reappraise events more factually, and although she habitually described herself as a “fall apart person,” on the episode of her husband’s death (and many more) Jennifer was able to challenge her belief that she couldn’t cope. Additionally, she was able to detect a difference from how she felt about a situation and what she did in the aftermath of a crisis. This is a far more powerful intervention than the therapist disputing a client’s belief about weakness. Sometimes timelines, while retaining strong utility within CBT with clients facing adversity and uncertainty about the future, can also be useful for clients to remind themselves that change is possible, as they are resilient individuals who have overcome multiple challenges across their life. Geraldine was 89 years old and living alone with no close relative nearby and whose friends had died or were frail. She was therefore isolated. She originally made good progress in treatment managing her panic symptoms. Unfortunately, within a few sessions she fell inside her home when engaging in some housework and fractured her pelvis, necessitating a prolonged stay in the hospital. On her discharge she was housebound and temporarily immobile. She stated her belief that life was no longer worth living, and she was very hopeless about any possibility for change and improvement in her circumstance. In this case, the timeline presented a picture of an individual who had overcome many challenges and adversity over her lifetime (see Figure 24.2). The timeline was used with the client to raise the possibility of her overcoming this challenging episode in her life when reviewing her current difficulties. Using the timeline, the therapist asked, “Have you been in a similar position in the past? If so, how did that



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turn out? How might this help you manage your current problems?” Importantly, the timeline also helped the therapist expect change in the here and now. Geraldine was discharged at the end of treatment and was able to say that she was “more in control of myself now than when you first came to see me . . . was as low as it was possible to get. . . . Convinced I am better in myself.” Timelines can be challenging to fill out as people reappraise important life events. People can only learn and grow after adversity if they can reflect on FIGURE 24.2. Geraldine's Timeline

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lessons learned, but this is not a natural tendency. In CBT, timelines allow people to learn from and profit from past experience and to reach a new appraisal of themselves that is more compassionate and accepting. J. S. Beck (2011) has emphasized that CBT aims to help clients become their own their own therapist, and the timeline provides therapists with the tools to enable this process.

SUMMARY AND FINAL COMMENTS CBT with older people is an efficacious treatment approach for common mental health disorders, and older people make very good candidates in CBT. In part, the possibility for change after psychological treatment is due to the emotional development of older people and life having helped people become more relativistic in their views, making them more open to options and possibilities. In reality, therapists working with older people will do well to remember that later life is just another phase of life, each phase in life is likely to be challenging, and chronological age is the least useful piece of information we collect about an individual. The apparent complexity of case presentations of older people (e.g., multimorbidity) may put therapists off, but it shouldn’t, as change is possible at any age and in any circumstance. One should remember a situation does not cause distress; it is one’s view of that situation. New insights about normal aging from gerontology can be very useful to help therapists maintain an action-oriented perspective and an expectation for positive outcome. New models of age-appropriate CBT are promising, especially with the promise of new techniques designed to augment treatment outcome, but new interventions such as timelines are not intended to be used as a standalone technique and work best embedded in guided exploration supported by Socratic dialogue.

REFERENCES Baltes. P. B., & Staudinger, U. M. (2000). Wisdom: A metaheuristic (pragmatic) to orchestrate mind and virtue towards excellence. American Psychologist, 55(1), 122–36. https://doi.org/10.1037/0003-066X.55.1.122 Bangen, K. J., Meeks, T. W., & Jeste, D. V. (2013). Defining and assessing wisdom: A review of the literature. American Journal of Geriatric Psychiatry, 21(12), 1254–1266. https://doi.org/10.1016/j.jagp.2012.11.020 Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Blanchflower, D. G., & Oswald, A. J. (2008). Is well-being U-shaped over the life cycle? Social Science & Medicine, 66(8), 1733–1749. https://doi.org/10.1016/j.socscimed.2008. 01.030 Bluck, S., & Glück, J. (2005). From the inside out: People’s implicit theories of wisdom. In R. J. Sternberg & J. Jordan (Eds.), A handbook of wisdom: Psychological perspectives (pp. 84–109). Cambridge University Press. https://doi.org/10.1017/CBO9780511610486.005 Bryant, C., & Koder, D. (2015). Why psychologists do not want to work with older adults—And why they should [Editorial]. International Psychogeriatrics, 27(3), 351– 354. https://doi.org/10.1017/S1041610214002208



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Burch, S., Preston, C., Bateup, S., & Hina, F. (2017) The use of internet-enabled cognitive behavioral therapy in the treatment of depression and anxiety amongst older people. Aging & Society, 8(1), 1–11. Carstensen, L. L., Turan, B., Scheibe, S., Ram, N., Ersner-Hershfield, H., SamanezLarkin, G. R., Brooks, K. P., & Nesselroade, J. R. (2011). Emotional experience improves with age: Evidence based on over 10 years of experience sampling. Psychology and Aging, 26(1), 21–33. https://doi.org/10.1037/a0021285 Chand, S. P., & Grossberg, G. T. (2013). How to adapt cognitive behavioral therapy for older adults. Current Psychiatry, 12(3), 10–15. Chaplin, R., Farquharson, L., Clapp, M., & Crawford, M. (2015). Comparison of access, outcomes and experiences of older adults and working age adults in psychological therapy. International Journal of Geriatric Psychiatry, 30(2), 178–184. Cooper, C., Selwood, A., Blanchard, M., Walker, Z., Blizard, R., & Livingston, G. (2010). The determinants of family carers’ abusive behaviour to people with dementia: Results of the CARD study. Journal of Affective Disorders, 121(1–2), 136–142. https:// doi.org/10.1016/j.jad.2009.05.001 Covin, R., Ouimet, A. J., Seeds, P. M., & Dozois, D. J. (2008). A meta-analysis of CBT for pathological worry among clients with GAD. Journal of Anxiety Disorders, 22(1), 108–116. https://doi.org/10.1016/j.janxdis.2007.01.002 Cuijpers, P., Karyotaki, E., Pot, A. M., Park, M., & Reynolds, C. F. (2014). Managing depression in older age: Psychological interventions. Maturitas, 79(2), 160–169. https://doi.org/10.1016/j.maturitas.2014.05.027 Cuijpers, P., van Straten, A., Smit, F., & Andersson, G. (2009). Is psychotherapy for depression equally effective in younger and older adults? A meta-regression analysis. International Psychogeriatrics, 21(1), 16–24. https://doi.org/10.1017/ S1041610208008089 Dudas, R., Malouf, R., McCleery, J., & Dening, T. (2018). Antidepressants for treating depression in dementia. Cochrane Database of Systematic Reviews, 8(8), CD003944. https://doi.org/10.1002/14651858.CD003944.pub2 Elvish, R., Lever, S. J., Johnstone, J., Cawley, R., & Keady, J. (2013). Psychological interventions for carers of people with dementia: A systematic review of quantitative and qualitative evidence. Counselling and Psychotherapy Research, 13(2), 106–125. https://doi.org/10.1080/14733145.2012.739632 Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual Review of Clinical Psychology, 5, 363–389. https://doi.org/10.1146/annurev.clinpsy.032408. 153621 Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Efficacy of cognitive behavioral therapy for anxiety disorders in older people: A meta-analysis and meta-regression of randomized controlled trials. Journal of the American Geriatrics Society, 60(2), 218– 229. https://doi.org/10.1111/j.1532-5415.2011.03824.x Goy, E., Freeman, M., Kansagara, D. (2010). A systematic evidence review of interventions for nonprofessional caregivers of individuals with dementia. VA-ESP Project #05-225. Guzman-Castillo, M., Ahmadi-Abhari, S., Bandosz, P., Capewell, S., Steptoe, A., SinghManoux, A., Kivimaki, M., Shipley, M. J., Brunner, E. J., & O’Flaherty, M. (2017). Forecasted trends in disability and life expectancy in England and Wales up to 2025: A modelling study. The Lancet Public Health, 2(7), e307–e313. https://doi.org/10. 1016/S2468-2667(17)30091–9 Hall, J., Kellett, S. M., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of cognitive behavioral therapy for generalized anxiety disorder in older adults: Systematic, metaanalysis, and meta-regression. American Journal of Geriatric Psychiatry, 24(11), 1063– 1073. Holvast, F., Massoudi, B., Oude Voshaar, R. C., & Verhaak, P. F. M. (2017). Nonpharmacological treatment for depressed older patients in primary care: A

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systematic review and meta-analysis. PLOS ONE, 12(9), e01846666. https://doi.org/ 10.1371/journal.pone.0184666 Hutnik, N., Smith, P., & Koch, T. (2016). Using cognitive behaviour therapy to explore resilience in the life-stories of 16 UK centenarians. Nursing Open, 3(2), 110–118. https://doi.org/10.1002/nop2.44 Isaacowitz, D. M., Livingstone, K. M., & Castro, V. L. (2017). Aging and emotions: Experience, regulation, and perception. Current Opinion in Psychology, 17, 79–83. https://doi.org/10.1016/j.copsyc.2017.06.013 Joormann, J., & Tanovic, E. (2015). Cognitive vulnerability to depression: Examining cognitive control and emotion regulation. Current Opinion in Psychology, 4, 86–92. Karlin, B. E., Trockel, M., Brown, G. K., Gordienko, M., Yesavage, J., & Taylor, C. B., (2015). Comparison of the effectiveness of cognitive behavioural therapy for depression among older versus younger veterans: Results of a national evaluation. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 70(1), 3–12. Karel, M. J., Gatz, M., & Smyer, M. A. (2012). Aging and mental health in the decade ahead: What psychologists need to know. American Psychologist, 67(3), 184–198. https://doi.org/10.1037/a0025393 Kiosses, D. N., Ravdin, L. D., Gross, J. J., Raue, P., Kotbi, N., & Alexopoulos, G. S. (2015). Problem adaptation therapy (PATH) for older adults with major depression and cognitive impairment: A randomized clinical trial. JAMA Psychiatry, 72(1), 22– 30. https://doi.org/10.1001/jamapsychiatry.2014.1305 Kishita, N., & Laidlaw, K. (2017). Cognitive behavior therapy for generalized anxiety disorder: Is CBT equally effective in adults of working age and older adults? Clinical Psychology Review, 52, 124–136. https://doi.org/10.1016/j.cpr.2017.01.003 Knight, B. G. (2006). Psychotherapy with older adults (3rd ed.). Sage Publications. Kropf, N. P., & Cummings, S. M. (2017). Evidence-based treatment with older adults: Theory, practice, and research. Oxford University Press. Kwon, O.-Y., Hyeong, S. A., Kim, H. J., & Park, K.-W. (2017). Effectiveness of cognitive behavioral therapy for caregivers of people with dementia: A systematic review and meta-analysis. Journal of Clinical Neurology, 13(4), 394–404. Laidlaw, K. (2015). CBT for older people: An introduction. SAGE Publications. Laidlaw, K., & Kishita, N. (2015). Age-appropriate augmented cognitive behavior therapy to enhance treatment outcome for late-life depression and anxiety disorders. GeroPsych: The Journals of Gerontopsychology and Geriatric Psychiatry, 28(2), 57–66. https://doi.org/10.1024/1662-9647/a000128 Laidlaw, K. (2013). Self-acceptance and aging: Using self-acceptance as a mediator of change in CBT with depressed and anxious older people. In M. E. Bernard (Ed.), The strength of self-acceptance. Springer Publishing. Lohani, M., & Isaacowitz, D. M. (2014). Age differences in managing response to sadness elicitors using attentional deployment, positive reappraisal and suppression. Cognition & Emotion, 28(4), 678–697. https://doi.org/10.1080/02699931.2013.853648 Losada, A., Márquez-González, M., Romero-Moreno, R., Mausbach, B. T., López, J., Fernández-Fernández, V., & Nogales-González, C. (2015). Cognitive-behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for dementia family caregivers with significant depressive symptoms: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 83(4), 760–772. https://doi. org/10.1037/ccp0000028 Mather, M., & Carstensen, L. L (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences, 9(10), 496–502. https:// doi.org/10.1016/j.tics.2005.08.005 Murphy, S. L., Xu, J., Kochanek, K.D., & Aria, A. (2018). Mortality in the United States. NCHS brief, 328. Office of National Statistics. (2019). Living longer: Caring in later working life. Examinining the interplay between caring and working in later life in the UK. https://www.ons.gov.uk/



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peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/articles/ livinglongerhowourpopulationischangingandwhyitmatters/2019-03-15 Orgeta, V., Qazi, A., Spector, A. E., & Orrell, M. (2014). Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database of Systematic Reviews, 1, CD009125. https://doi.org/10.1002/14651858. CD009125.pub2 Padesky, C. A., & Mooney, K. A. (2012). Strengths-based cognitive-behavioural therapy: A four-step model to build resilience. Clinical Psychology & Psychotherapy, 19(4), 283–290. https://doi.org/10.1002/cpp.1795 Pettit, S. M, Qureshi, A., Lee, W., Stirzaker, A., Gibson, A., Henley, W., & Byng, R. (2017). Variation in referral and access to new psychological therapy services by age: An empirical quantitative study. British Journal of General Practice, 67(660), e453– e459. https://doi.org/10.3399/bjgp17X691361 Phillips, W. J., & Ferguson, S. J. (2012). Self-compassion: A resource for positive aging. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 68(4), 529–539. https://doi.org/10.1093/geronb/gbs091 Pocklington, C. (2017). Depression in older adults. British Journal of Medical Practitioners, 10(1), a1007. Reed, A. E., Chan, L., & Mikels, J. A. (2014). Meta-analysis of the age-related positivity effect: Age differences in preferences for positive over negative information. Psychology and Aging, 29(1), 1–15. https://doi.org/10.1037/a0035194 Sadavoy J. (2009). An integrated model for defining the scope of psychogeriatrics: The five Cs. International Psychogeriatrics, 21(5), 805–812. https://doi.org/10.1017/ S104161020999010X Scheibe, S., & Carstensen, L. L. (2010). Emotional aging: Recent findings and future trends. Journal of Gerontology, Series B: Psychological Sciences and Social Sciences, 65B(2), 135–144. Sims, T., Hogan, C. L., & Carstensen, L. L. (2015). Selectivity as an emotion regulation strategy: Lessons from older adults. Current Opinion in Psychology, 3, 80–84. https:// doi.org/10.1016/j.copsyc.2015.02.012 Staudinger, U. M., & Glück, J. (2011). Psychological wisdom research: Commonalities and differences in a growing field. Annual Review of Psychology, 62, 215–241. Thompson, L. W., Dick-Siskin, L., Coon, D. W., Powers, D., & Gallagher-Thompson, D. (2010). Effective treatment for late-life depression: A client workbook. Oxford University Press. Urry, H. L., & Gross, J. J. (2010) Emotion regulation and older age. Current Directions in Psychological Science, 19(6), 352–357. https://doi.org/10.1177/0963721410388395 Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic turning points for the United States: Population projections for 2020 to 2050. Current Population Reports, P25-1144. US Census Bureau. Weststrate, N., & Glück, J. (2017). Hard earned wisdom: Exploratory processing of difficult life experience is positively associated with wisdom. Developmental Psychology, 53(4), 800–814. Williams, J. M., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E., & Dalgleish, T. (2007). Autobiographical memory specificity and emotional disorder. Psychological Bulletin, 133(1), 122–148. https://doi.org/10.1037/0033-2909.133.1.122 Wuthrich, V. M., & Rapee, R. M. (2013). Randomised controlled trial of group cognitive behavioural therapy for comorbid anxiety and depression in older adults. Behaviour Research and Therapy, 51(12), 779–786. https://doi.org/10.1016/j.brat.2013.09.002 Wuthrich, V. M., Rapee, R. M., Kangas, M., & Perini, S. (2016). Randomized controlled trial of group cognitive behavioral therapy compared to a discussion group for co-morbid anxiety and depression in older adults. Psychological Medicine, 46(4), 785– 795. https://doi.org/10.1017/S0033291715002251

25 Veterans and Military Service Members Maegan M. Paxton Willing, Larissa L. Tate, and David S. Riggs

D

ue to the large number of active duty and former service members in the United States, there is a growing need for mental health clinicians to provide competency-based care. The most recent conflicts in Afghanistan and Iraq deployed over 2.8 million service members (Meadows et al., 2016). In 2016, the National Center for Veterans Analysis and Statistics (2018) estimated the United States was home to 18.6 million living veterans from past and current wars. Consequently, there is a high likelihood that mental health care providers will encounter a patient with a military background at some point in their careers. Both the culture and the structure of the military pose challenges for mental health care including, but not limited to, service members’ fear of negative career implications, difficulty taking time off work, and specific mandated reporting circumstances. These challenges require consideration when determining treatment options but offer an opportunity to further develop competency. Other characteristics, including the mobility of the population and an emphasis on a swift return to duty, necessitate a brief and efficient treatment modality with a problem-focused and evidence-based approach. The military’s unique characteristics and their implications for mental health treatment may make cognitive behavioral therapy (CBT) an excellent fit in the treatment of service members. CBT is typically short term with targeted, problem-focused approaches. This overlaps well with the military’s Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Uniformed Services University, Department of Defense, or U.S. Government. Additionally, the authors have no conflicts of interest to report. https://doi.org/10.1037/0000219-025 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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emphasis on a swift return to duty. Additionally, both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) emphasize the use of evidence-based treatments in the care of active duty service members and veterans. CBT has a long tradition of empirically validated treatment approaches and has been well studied and shown to be effective in treating a number of disorders in many populations, including the military and veteran communities. Further, this tradition has contributed to the development of manualized therapy protocols that may be (relatively) easily disseminated across the large, widely dispersed health systems that care for military personnel, veterans, and their families.

MILITARY CULTURE The military is a unique culture often unfamiliar to those outside of it, including clinicians. Stereotypical beliefs about the military and military personnel have the potential to influence the delivery and implementation of psychotherapy. For example, there is a common belief that psychological problems among military personnel only result from combat experiences. Although it is certainly true that mental health issues can be a consequence of combat, service members may also experience psychological distress from other noncombat events and deployments, such as involvement in humanitarian or disaster relief, boot camp or basic training, unexpected temporary duties, or simply the stress and strain of the military lifestyle. These stressors may include repeated moves and separation from family and loved ones, long work hours, high work demands, and high disciplinary standards (Domenici et al., 2016). Finally, they are susceptible to the same mental health concerns as civilians. As a result, a significant minority of military personnel do experience problems adjusting, which may develop into psychological illnesses (Domenici et al., 2016). Military service members and veterans are also often labeled “emotionally broken” (Domenici et al., 2016). This perception may be due to the fact they are more likely than civilians to experience physical injuries or traumatic events (e.g., rigor of deployment, death of close buddies, and moral injury). However, we have encountered numerous therapists and other health care professionals who seem to presume the presence of an emotional injury if a service member has deployed or, even more strikingly, just because someone has served in the military. Notably, many service members returning from deployment actually demonstrate high resilience and readjust to home, work, and civilian life without many complications, possibly due to individual resilience or to protective factors unique to military service. These protective factors may be seen in the shared philosophy of those who serve. At the most basic level, the military outlook encompasses the idea that survival depends on sustaining the viability and readiness of the unit (Engel, 2014). The military, therefore, emphasizes a sense of camaraderie and structure while offering a sense of purpose, meaning, and security. Certain philosophies are stressed throughout, including those of



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strength, teamwork, discipline, loyalty, self-sacrifice, self-reliance, and emotional control (Domenici et al., 2016). However, some of these values may also interfere with mental health help-seeking. From the perspective of a mental health professional, it is important to keep this disconnect in mind. As Domenici et al. (2016) noted, “Recognizing that a warrior mindset may conflict with help-seeking is valuable when serving military patients” (p. 2). Service members may believe revealing any psychological problems will result in dismissal from the military. They may also be concerned that their duties will be limited or that they will appear weak to themselves and to their subordinates, peers, and superiors. These views may complicate mental health treatment because symptoms may be underreported or concealed (Domenici et al., 2016). The military is a distinct culture with expectations, rules, and traditions that at times may conflict with the culture and traditions of psychotherapy. Indeed, aspects of the military culture and the warrior mindset may be incongruent with typical psychotherapy. Traditional therapy typically involves viewing the patient in individualistic terms; however, this approach may not work well with a service member. Military patients may have a deep-seated belief toward viewing themselves as part of a larger cohesive unit and may not resonate well with a sole focus on themselves (Domenici et al., 2016). Therapists may also find it challenging to get military patients to permit themselves to be emotionally vulnerable in therapy. Given the focus on the success of their unit or team and the potential consequences of being the “weak link” on the battlefield, interpersonal vulnerability can be seen as quite risky. Clearly, therapists’ understanding and respect for the system in which the service member operates is crucial to the effective delivery of psychotherapy. The military system or culture may also impact on the beliefs or expectations that military personnel have of mental health clinicians. For example, some service members may believe that civilian providers will be unable to help them because the providers are unfamiliar with military values and experiences. More significantly, military-connected individuals may believe that civilian providers hold negative opinions about the military or the actions required of service members. These beliefs, whether accurate or not, can lead service members and veterans to avoid seeking care from civilian providers and instead seek care from a mental health professional who has served. In contrast, other service members may prefer a therapist outside the military health system because they believe that there is less threat of commanders or unit members learning that they are receiving mental health care. Providers, whether they be military or civilian, should be aware that military patients may be more guarded during sessions because of concerns of confidentiality or fear the information could reach their command (Domenici et al., 2016). As always, mental health professionals should clearly define the limits of confidentiality and be open to discussing any concerns. In addition to the cultural differences that can interfere with the delivery of mental health care, there are logistical barriers to providing care to military

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personnel. Units and individuals are frequently required to spend time away from their home stations for training or temporary duty assignments. In combination with requirements to work long hours and the frequent need to complete sudden, short-suspense tasks (Domenici et al., 2016), it is often necessary to conduct time-limited therapy that can withstand breaks in continuity. The military’s unique characteristics and their implications for mental health treatment may make CBT an excellent fit in the treatment of service members. The time-limited, problem-focused approach reflected in many CBT protocols is quite consistent with the values of the military and the logistics of treating these individuals. From the perspective of the military services, much of the value of these interventions is in their ability to effectively return troops to a full active duty status as quickly and as efficiently as possible. In fact, the DoD medical retention regulations state that “behavioral health patients must be treatable within a year, and thereafter must be fully capable of performing military duties to include deployment” (Domenici et al., 2016, p. 3). For service members who will not be returning to duty, treatment is typically problem-focused with an emphasis on regaining functionality with the possibility of transition to longer care in the VA system where CBT approaches are common. Thus, whether the goal is to return to full duty status, regain functionality, or transition to VA care, a CBT model tends to resonate well with military patients. In the following pages, we describe a number of CBT treatment protocols shown to be effective when working with active duty personnel and/or veterans. We have chosen to focus on several behavioral health issues that are particularly salient to the military-connected patient: posttraumatic stress disorder (PTSD), depression, sleep, and suicide. Our intention is not to provide a comprehensive review of all of the CBT protocols that may be used to address these issues. Nor will we provide a systematic review of the literature that supports the efficacy of these particular treatments. Rather we have selected these examples to serve as illustrations of CBT approaches that have been found to be effective in treating service members and veterans to encourage the reader to consider CBT approaches when working with these populations.

SPECIFIC APPLICATIONS OF CBT PTSD PTSD, one of the most common psychological disorders after exposure to a traumatic event, is often comorbid with other psychiatric illnesses and can lead to decreased quality of life (Kar, 2011). Individuals with PTSD may experience symptoms such as intrusive memories, trauma-related nightmares, difficulty sleeping, hypervigilance, concentration problems, irritability, increased startle response, and avoidance of memories or reminders of the event. Fortunately, therapies have been developed to successfully treat PTSD. Among these treatments, CBT is one of the most highly recommended and empirically supported



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(Foa et al., 1999; Kar, 2011). Several specific CBT protocols were given the highest level of recommendation in the most recent VA/DoD guidelines for the treatment of PTSD (VA & DoD, 2017). The broader literature demonstrates strong support for CBT as a safe and effective intervention for individuals across a wide age range, from a variety of different cultures, and with exposure to a multitude of different traumatic events (Kar, 2011). The recent conflicts in the Middle East have exposed a significant number of service members to an assortment of combat stressors and potentially traumatic experiences (Chard et al., 2010). Compared with the general population, service members are particularly at risk of being exposed to direct contact with combat situations (Forbes et al., 2012). Additionally, military personnel may also face events during nondeployment phases still related to their military service, including physical and sexual assault, training accidents, and mortuary affairs after disasters (Ikin et al., 2005). PTSD among military personnel is pervasive, affecting 5% to 20% of returning service members (Han et al., 2014; Tanielian & Jaycox, 2008), translating to approximately 110,000 to 400,000 individuals. International clinical practice guidelines cite trauma-focused CBT (TF-CBT) as the “gold standard” treatment for PTSD (Foa et al., 2008; VA & DoD, 2017). Cognitive processing therapy (CPT) and prolonged exposure (PE) are specific types of TF-CBT that have shown to be effective among military personnel with PTSD and are strongly recommended by the VA and DoD as a first-line treatment (Powers et al., 2010; VA & DoD, 2017). The results from multiple studies support the efficacy of these treatments for PTSD. For example, a meta-analysis of 13 studies (Powers et al., 2010) assessed the effectiveness of PE for PTSD and demonstrated large effect sizes for PE versus wait-list or placebo-control conditions on both primary (Hedges’s g = 1.08) and secondary (Hedges’s g = 0.77) outcome measures at the end of treatment; medium-to-large effect sizes were maintained at follow-up on primary and secondary measures (Hedges’s g = 0.68 and 0.41, respectively). Overall, individuals who received PE had better outcomes than 86% of the individuals in the control conditions posttreatment (Powers et al., 2010). Both CPT (e.g., Chard et al., 2010; Monson et al., 2006) and PE (e.g., Schnurr et al., 2007; Tuerk et al., 2011) have been found effective in treating PTSD among veterans. For example, in a sample of 60 veterans with chronic military-related PTSD (Monson et al., 2006), those who participated in CPT experienced significant improvements in PTSD symptoms compared with a wait-list condition. Specifically, the researchers found large effect sizes for CPT at posttreatment (Hedges’s g = 1.14). Similarly, Tuerk et al. (2011), in a study of the effectiveness of PE with a sample of OEF/OIF veterans, found large-sized effects (Cohen’s d = 1.19 and d = 2.07 for the intention-to-treat [ITT] and completer samples, respectively). Currently, research concludes that there are no significant differences between CPT and PE treatment outcomes (e.g. Bisson et al., 2007; Powers et al., 2010; Seidler & Wagner, 2006). Therefore, the VA and DoD clinical practice guidelines recommend patient preference as the deciding factor between these two treatment options (VA & DoD, 2017).

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CPT is a manualized treatment, typically administered over 12 sessions, that targets cognitive elements as a method of reducing PTSD symptoms (Cukor et al., 2010). CPT focuses on key themes of PTSD by methodically addressing thoughts related to intimacy, self-esteem, power, safety, trust, and control that appear altered by the traumatic experience. Studies have shown that CPT is “highly suitable for addressing the more complex psychiatric sequelae emerging from these recent military conflicts” (Forbes et al., 2012, p. 442). Specifically, CPT encourages patients to expose themselves to their traumatic memory by having them write and read their trauma account in session with the therapist. Then together, the patient and therapist can identify “stuck points,” or cognitive distortions that have stalled their recovery (e.g., “I should have been able to prevent my buddy’s death,” “What happened is my fault,” “I can’t trust anyone,” or “I’m weak and helpless”). These distortions are believed to be the result of the patient’s attempts to make sense of their trauma in relation to previously held beliefs about themselves, others, and the world. Ways in which their trauma may have altered these beliefs, especially as they relate to the aforementioned themes, are identified and explored over the course of therapy. Randomized controlled trials (RCTs) have indicated the efficacy of CPT in treating military-related PTSD (Forbes et al., 2012; Monson et al., 2006). Forbes et al. (2012) found that veterans who received CPT showed greater improvement in their symptoms than those who received treatment as usual. Specifically, veterans in the CPT condition demonstrated greater clinically significant improvement (greater than 12 units) in scores on the Clinician Administered PTSD Scale (CAPS) at posttreatment (66.7%) than those in a treatment-asusual condition (34.5%). Further, at the conclusion of treatment, 37.5% of veterans in the CPT group no longer met diagnostic criteria for PTSD, compared with 13.0% in the treatment-as-usual group. A study conducted by Resick et al. (2015) demonstrated a group format of CPT was significantly more effective than group present-centered therapy (PCT) in treating PTSD among active duty U.S. military personnel. At posttreatment, 49% of the service members in the CPT group attained a clinically meaningful reduction in posttraumatic stress symptom severity, compared with 34% of those in the PCT group. In contrast to CPT, PE places an emphasis on behavioral strategies and directly targets avoidance behaviors of PTSD through imaginal and in vivo exposure exercises. PE is a manualized protocol delivered in nine to twelve 90-minute sessions during which therapists work with patients to approach their trauma-related memories and cues. Over repeated exposure sessions, patients are able to process the traumatic memory and their intense emotional responses to reminders, and the traumatic memories are reduced. During imaginal exposure exercises, patients are instructed to close their eyes and repeatedly relate the memory of their trauma experience to the therapist. Repeatedly activating the memory of the event along with the associated thoughts and emotions in a safe setting allows the patient to process the trauma memory. Imaginal exposure exercises also encourage patients to recognize that they are able to cope with their distress. Following the exposure exercise, the patient



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and therapist engage in a discussion to encourage the processing of the memory. These processing discussions are typically reflective and informal, with the therapist taking a supportive approach. The particulars of these discussions vary from session to session, but they generally include reflection on the exercise and the associated cognitions and emotions. The discussion may also incorporate new perspectives or details that arise, as well as an exploration of the meaning of the trauma in the patient’s current life. As between-session homework, patients are asked to listen to recordings of their imaginal exposure sessions to allow for further processing of the memories and emotions. Patients also complete in vivo exposure exercises between sessions. These exercises progressively reintroduce patients to avoided activities, people, situations, and environments that have been associated with their traumatic memories. The therapist and patient collaboratively identify a range of possible stimuli connected to the traumatic fear and agree on which stimuli to confront as part of in vivo exposure. The patient is encouraged to challenge themselves, but to do so in a graduated fashion so as to experience some success in confronting feared stimuli and coping with the associated emotion. This process is meant to allow patients to assimilate corrective information regarding the safety of reengaging with these behaviors. Decades of research demonstrate the efficacy of PE for PTSD (e.g. Foa et al., 1999, 2005; Marks et al., 1998; Resick et al., 2002). For example, Foa et al. (1999) found PE was superior to both a wait-list control condition and to stress inoculation training (SIT). PE had larger effect sizes at posttreatment not only on PTSD symptom severity (Cohen’s d = 1.92) but on anxiety (Cohen’s d = 1.44) and depression symptoms (Cohen’s d = 1.47) as well. At the end of treatment, 65% of participants in the PE condition no longer met diagnostic criteria for PTSD at the conclusion of treatment, compared with 58% in the SIT condition and 0% for the wait-list condition. Studies have indicated efficacy for PE for both chronic PTSD (e.g., Foa et al., 1999, 2005; Resick et al., 2002) and for acute stress disorder (Bryant et al., 1999; Foa et al., 2006). Further, patients who undergo PE for PTSD typically continue to maintain decreased levels for up to a year or more (e.g., Foa et al., 2005; Resick et al., 2002). PE has been successful in treating PTSD across varied populations (Cahill et al., 2009), including military veterans (Eftekhari et al., 2013; Schnurr et al., 2007; Tuerk et al., 2011). In a large-scale evaluation (n > 1,900) of the effectiveness of a national PE implementation effort in the VA, Eftekhari et al. (2013) found PE to be effective at reducing posttraumatic stress symptom in veterans (d = 0.87 and d = 1.21 for ITT and completer samples, respectively). As in other studies, PE was found to reduce depression symptoms as well as PTSD (d = 0.66 and d = 0.95 for depression in ITT and completer samples, respectively). Additional research indicates that PE can be effective with individuals who carry a comorbid diagnosis of traumatic brain injury (TBI; Wolf et al., 2015), a commonly co-occurring condition for personnel deployed to Iraq and Afghanistan. Although studies of PE targeting active duty service members are limited, recent research has demonstrated promising results with this population (e.g.,

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Foa, McLean, et al., 2018; Peterson et al., 2018; Reger et al., 2016). In one large study of active duty personnel, PE was successful even when modified to be delivered in 10 daily sessions (Foa, McLean, et al., 2018). In this study, the within-group effect sizes were large for PE delivered weekly (d = 0.84) and for PE delivered in daily sessions (d = 1.04). Further analyses indicated that the weekly and daily PE groups did not differ from one another with regard to outcomes (Foa, McLean, et al., 2018). Additional trauma-focused CBT approaches have been found effective in treating PTSD (see VA & DoD, 2017), and some have evidence of their efficacy with military and veteran samples. For example, Trauma Management Therapy (TMT) is a multicomponent CBT that combines both exposure therapy and social emotional rehabilitation (Beidel et al., 2011). Research found TMT produced significant improvement in a group of Vietnam veterans with chronic combat-related PTSD, particularly as it related to improvement of social functioning (Beidel et al., 2011). Participants who received TMT showed significant and clinically meaningful reductions in posttraumatic stress symptomatology (average decrease of 15.9 points on the PTSD measure) and, additionally, engaged in social activities more frequently (average increase of 5 points) and spent a greater amount of time in social activities (average increase of 56.1 points). Insomnia Insomnia is a serious problem affecting a significant number of military service members and is characterized by poor sleep quality or quantity that negatively affects patient functioning (American Psychiatric Association, 2013). Many deployment-related factors contribute to the development of insomnia, including experiencing traumatic events, TBI, irregular sleep patterns, and stressors related to returning home (Bramoweth & Germain, 2013). In a 2011 survey of active duty personnel, approximately 60% of service members indicated receiving less than the recommended hours (7 to 8) of sleep each night, and about 11% reported receiving less than 4 hours of sleep each night during the preceding week (DoD, 2013). In this study, fewer than 20% of service members with high anxiety, depression, anger propensity, and posttraumatic stress symptoms received the recommended number of hours of sleep. A review of the Defense Medical Epidemiological Database (DMED) indicated that in 2014, for every 1,000 service members, there were 75 encounters with a medical provider for insomnia (Caldwell et al., 2017). Additionally, insomnia is a primary symptom remaining after successful treatment for PTSD, depression, and anxiety; thus, it is not surprising that sleep is the primary nonwound concern among returning service members (Center for Deployment Psychology, n.d.). CBT for insomnia (CBT-I) has been shown to be effective with service members and veterans (Talbot et al., 2014; Taylor et al., 2018), and it is recommended as a first step in the treatment of insomnia (Taylor & Pruiksma, 2014). CBT-I is a very versatile and flexible treatment, making it ideal for treating service



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members. The treatment incorporates a number of core elements including “stimulus control instructions and sleep restriction therapy, cognitive therapy, relaxation and other stress reduction techniques, and sleep hygiene education” (Siebern & Manber, 2011, pp. 22–23). It is effective in individual, group, and telephone-consultation formats (73%, 56%, and 64% of patients, respectively, reported clinically significant improvements in sleep; Bastien et al., 2004). Treatment has been successful in various delivery models, including a single session paired with a follow-up telephone call (87% reported improved sleep; Wagley et al., 2013), in 1-day community workshops (18% reduction in insomnia symptoms; Swift et al., 2012), and both in-person (41% reported complete remission of insomnia symptoms compared with none in the wait-list control group; Talbot et al., 2014) and online (d = –1.23; Lancee et al., 2015). It has also been implemented in deployed settings using combat medics (Amin & Wirtz, 2017). CBT-I has been shown to be as effective for initial treatment of insomnia as prescription medications, such as benzodiazepine and nonbenzodiazepine sleep medications, with better long-term effects (self-reported sleep quality as measured by the Pittsburgh Sleep Quality Index [PSQI; Buysse et al., 1991] improved by an average of 1.2 points in CBT-I compared with worsening an average of 0.8 points with temazepam; Mitchell et al., 2012). Although outcome research with active-duty participants is limited, one recent, wellconducted trial found that it effectively reduced insomnia and improved fatigue and mental health in active duty patients (Taylor et al., 2018). Insomnia is often comorbid with PTSD in military and veteran populations. One recent study of veterans with comorbid PTSD and insomnia suggested that CBT-I could be effective even in the context of co-occurring PTSD. In this study, CBT-I was associated with a decrease of insomnia symptoms that maintained over a 6-month follow-up (Talbot et al., 2014). Additionally, patients reported increased psychosocial functioning (e.g., relationships, activities, and work). Talbot et al. (2014) noted that CBT-I is “promising” for the treatment of nightmares, but more research is necessary. The VA has developed a group-based CBT-I protocol that includes stimulus control, sleep restriction, and cognitive restructuring (Koffel & Farrell-Carnahan, 2014). Over six sessions, the group learns about insomnia, the effect of sleep hygiene and stimulus control on sleep, and how anxiety and worry can exacerbate insomnia. The group also identifies dysfunctional cognitions related to insomnia while incorporating cognitive restructuring techniques and establishes relapse prevention techniques. The groups were well attended with low dropout rates (90.48% completed all sessions). Veterans rated the treatment highly and found the behavioral and sleep hygiene topics to be most beneficial. Participants reported improved sleep on the self-report insomnia questionnaire (31% reduction) and sleep efficiency (13% increase); gains persisted after the active treatment phase was completed with insomnia symptoms further decreasing by 16% (Koffel & Farrell-Carnahan, 2014). Brief Behavioral Treatment of Insomnia—Military Version (BBTI-MV) was adapted specifically for use with combat-exposed service members and veterans

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from a behavioral intervention for the treatment of insomnia in elderly patients (Germain et al., 2014). BBTI-MV is implemented over 4 weeks with patients seen in-person during Weeks 1 and 3 and telephone check-in sessions during Weeks 2 and 4. The first session consists of psychoeducation, including a discussion of military-specific factors that contribute to sleep dysfunction, and providing the patient a personalized “sleep prescription” that identifies specific times to go to and leave the bed. During Week 3, adherence is discussed, and the sleep prescription updated as needed. In Germain et al.’s (2014) study of 40 OIF, OEF, and Operation New Dawn (OND) veterans, the treatment was found to be effective at improving sleep quality (effect size  =  0.76) and insomnia (effect size = 0.72) with gains maintained over a 6-month follow-up period. Nightmares and Insomnia As mentioned previously, PTSD often co-occurs with sleep problems; nightmares may also be present as part of the symptom picture. Studies suggest that as many as 90% of those with PTSD experience sleep disturbances such as trauma-related nightmares (as cited in Creamer et al., 2018). CBT interventions have been developed to address the added problems of nightmares. For example, imagery rehearsal therapy (IRT) targets nightmares through the use of relaxation techniques, psychoeducation, and cognitive restructuring (Nappi et al., 2010). A retrospective analysis of medical records showed veterans who completed IRT showed decreased frequency (33% decrease) and intensity (36% decrease) of nightmares as well as improved insomnia (27% decrease) and posttraumatic stress symptoms (27% decrease; Nappi et al., 2010). This study included patients who had participated in four or five sessions of IRT in either individual or group format. The authors report that patients generally saw a significant decrease in insomnia symptoms, with patients receiving individual treatment showing the most benefit. Researchers also have combined IRT with CBT-I in an effort to efficiently treat insomnia and nightmares (Ulmer et al., 2011). Sleep intervention for PTSD (SIP) consists of six sessions: three sessions of CBT-I followed by three sessions of IRT. A pilot study suggested that this approach was effective in improving insomnia severity (d = –2.15), sleep quality (d = –1.60), and PTSD severity (d = –1.76; Ulmer et al., 2011). Depression Major depressive disorder (MDD) is a significant concern in active duty service members and veteran patients. MDD is characterized by persistent depressed mood and decreased interest and leads to significant negative effects on the patient’s functioning (American Psychiatric Association, 2013). In the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel, high levels of depression were present in 9.6% of service members (DoD, 2013). The VA/ DoD Clinical Practice Guideline for the Management of Major Depressive Disorder recommends several CBT-based approaches for treating depression. These include



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CBT for depression (CBT-D), behavioral activation, problem-solving therapy, mindfulness-based CBT, and acceptance and commitment therapy (ACT; VA & DoD, 2016). At this time, no studies have examined the use of CBT-D specifically in active duty military personnel (Hundt et al., 2014). In studies of CBT-D with veteran populations, results suggest it is an effective treatment approach for depression. However, a recent review (Hundt et al., 2014) cited smaller effect sizes in CBT-D treatment trials in veteran samples (d = –0.50 to 1.20) than in civilian samples (d = 0.71 to 1.00), suggesting CBT-D may not be as effective at treating depression in veteran populations. Hundt et al. (2014) proposed that this may be due to a more rigorous treatment as usual comparison conditions at VA sites than at civilian sites. Additionally, it is possible that the high rate of comorbidity seen in veteran populations may result in a more treatment-resistant depression. Symptoms of common co-occurring conditions such as PTSD and TBI may reduce treatment effects by affecting compliance and treatment alliance. Finally, demographic factors such as male gender, older age, lower health status, and unemployment may be associated with diminished CBT treatment effects (Hundt et al., 2014). Although the effects of CBT-D may be somewhat diminished in veterans, it has been found to be effective in reducing symptoms of depression and improving quality of life in both younger and older veterans. For example, one study specifically examined the effectiveness of CBT-D in younger and older veterans across the VA system. These researchers found a nearly 40% reduction in self-reported depressive symptoms for both age groups (Karlin et al., 2015). Improvements were also shown on nearly all subscales of the World Health Organization Quality of Life measure (e.g., physical, psychological, and social); however, physical quality of life did not improve in the older group. Researchers stated these effects are comparable to other RCTs of CBT in both older and younger populations (Karlin et al., 2015). These results suggest CBT-D can be an effective treatment for military-related populations and may provide support for its use with active duty populations as well. Depression and Suicide Some depression protocols have been shown to improve both depression and suicidal ideation in veteran populations. For example, an effectiveness study of CBT-D in the VA found that the treatment improved depression symptoms similarly in veterans with (38% decrease) and without suicidal ideation (40% decrease; Brown et al., 2016). Importantly, decreases in depressive symptoms were associated with a 64% reduction in odds of suicidal ideation. ACT has been adapted to treat depression in veteran populations. Patients who received ACT for depression (ACT-D) exhibited improved depression symptoms in cases with (32% reduction) and without suicidal ideation (40% reduction; Walser et al., 2015). Furthermore, patients treated with ACT-D were likely to have lower suicidal ideation, with patients reporting no suicidal ideation

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increasing more than 20% from baseline. Experiential acceptance was related to improved depression symptoms and reduced suicidal ideation, with mindfulness also contributing to reduced depression severity. Suicidal ideation may be improved by addressing experiential avoidance by decreasing dysfunctional attempts to avoid emotional pain through experiential acceptance and mindfulness (Walser et al., 2015). Suicide Prevention Suicidal ideation is a prevalent concern among military and veteran patients. Of active duty service members, 7.9% had experienced suicidal ideation during their military career (DoD, 2013). Further, 1.3% reported a suicide attempt, and 5.2% endorsed self-injurious behaviors during their career. Traditionally, care of suicidal patients has focused on ensuring safety and the use of psychotherapy or medication to address the presumed underlying causes (e.g., depression, PTSD) of the suicidal ideation (VA & DoD, 2013). Recently, a CBT protocol that focuses directly on treating suicidal behaviors has shown promise in both civilian (Brown et al., 2005) and military (Rudd et al., 2015) samples. The core elements of these treatment approaches use CBT techniques to identify and address patients’ thoughts, beliefs, and images that contribute to suicidal ideation and behavior. In addition, coping and emotion regulation skills are taught. Toward the end of treatment, a relapse prevention exercise is introduced. In this exercise, patients are asked to activate specific thoughts, feelings, and images associated with prior suicide crises and to generate adaptive strategies for coping in such situations (Brown et al., 2005; Rudd et al., 2015). Trials of this CBT approach to treating suicidal patients suggest that it is effective in reducing the risk of additional suicide attempts. In a civilian sample, the treatment reduced the risk by approximately 50% over the 18 months following treatment (Brown et al., 2005). In a study of military service members, CBT reduced the risk of additional suicide attempts by about 60% (Rudd et al., 2015). A follow-up analysis of the military sample suggested that the treatment had the greatest effect among those individuals initially deemed at highest risk of suicide (Bryan et al., 2018). Of potential interest, the groups treated with CBT focused on reducing suicide risk showed only minimal (Brown et al., 2005) or no greater reduction (Rudd et al., 2015) than those receiving usual treatment in presumed correlates of suicide such as depression and hopelessness, and suicidal ideation. The Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment (SAFE VET) Project (Knox et al., 2012) is a short-term behavioral protocol to reduce suicide risk among veterans obtaining treatment at a VA emergency department. The intervention incorporates a brief safety planning intervention with structured telephonic follow-up (Knox et al., 2012). There are four basic safety planning elements of SAFE VET including means restriction, psychoeducation regarding problem-solving and coping skills, work to improve social support and create an emergency contact list, and motivational



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interviewing to increase follow-up. An acute services coordinator begins working with the veteran upon admittance to create a safety plan and continues working via telephone contacts to update the safety plan and transition the veteran into outpatient care (Knox et al., 2012). There have been no formal tests of the SAFE VET program, but the initial demonstration project suggested that it was acceptable, and the participants generally found the program elements to be helpful (Stanley et al., 2016). In addition, the program appears to enhance engagement with treatment (Knox et al., 2012).

MODIFYING CBT DELIVERY IN MILITARY SETTINGS As noted previously, there are unique challenges of delivering mental health treatment to an active duty military population. Often, therapists may find themselves in a situation that requires treatment to be delivered in a constrained period of time (e.g., 3 weeks not 3 months) before the client moves or deploys or with limited time for sessions (e.g., 20-minute sessions rather than the traditional 50-minute hour). Clinicians may also find it necessary to deliver treatment in settings that are strikingly unlike the traditional therapeutic office. Imagine, for instance, conducting a session in a tent in Afghanistan. These challenges inherent in providing therapy within the Military Health System can also be seen as opportunities to examine the effectiveness of CBT protocols when they are “bent” to fit less than ideal circumstances. We generally lack controlled trials of these modifications (see Foa, Zandberg, et al., 2018, for an exception). At this point, though, we would argue that CBT approaches have proven quite flexible and robust in the face of such challenges. One example of such flexibility is the delivery of PE in daily, or massed, sessions. The first examples of such treatment delivery of which we are aware occurred when therapists were endeavoring to treat posttrauma symptoms while deployed to Iraq (Peterson et al., 2009). Faced with the challenge of service members struggling with posttrauma symptoms and a need to rapidly decide whether to return them to their unit or medevac them out of country, clinicians began delivering PE sessions over a short time, typically daily. Many of the service members treated in this manner were able to return to their units and complete their deployments. In the ensuing years, a large, randomized trial has supported the efficacy of PE delivered in 10 sessions across 2 weeks (Foa, McLean, et al., 2018). Although finding more efficient treatments may be valuable in many settings, it is notable that the initial attempts at delivering “massed PE” were driven by the realities of treating military personnel in a deployed setting with the goal of treating them effectively and returning them to their units as rapidly as possible. Even when treated in their home communities, active duty service members may experience a disruption in care because a deployment or change in duty station leaves limited time to compete treatment. Alternative, compact treatment delivery methods can prevent these interruptions of treatment and speed

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recovery (Beidel et al., 2017). For example, PE and TMT in combat-related PTSD have been effectively implemented as intensive outpatient (IOP) protocols. A case study documented the use of PE in an active duty female with PTSD (Blount et al., 2014). Over 10 days, the patient received morning sessions with her primary therapist along with afternoon sessions processing and reviewing the morning sessions with one of two cotherapists. Note that this approach required the client to share and discuss her trauma with multiple therapists, something not part of the standard PE protocol (Foa et al., 2005). As with standard PE, the client was asked to listen to recordings of her trauma narrative and work through a list of in vivo exposure activities daily (Blount et al., 2014). Significant decreases were reported for PTSD (25%), depression (90%), and anxiety (100%), and the patient reported improvements for insomnia symptoms and nightmares. Additionally, all symptom reports were in the minimal range at 6-month follow-up. TMT has also been used in intensive outpatient settings through a combination of individual exposure therapy with group therapy for anger, social isolation, depression, and guilt (Beidel et al., 2017). Closed cohorts of four to seven individuals underwent treatment in a 3-week IOP setting. Each veteran or service member received individual exposure therapy; completed unaided in vivo exposure assignments; and participated in a social and emotional rehabilitation group targeting social reintegration, anger management, and brief behavioral activation. Participants reported significant decreases in PTSD (55%), illness severity (41%), sleep disturbance (18%), anger (37%), guilt (62%), and depression (33%) and increases in social interaction (33%). Improvements were maintained at 6-month follow-up for most participants, with only a 1% relapse rate (Beidel et al., 2017). At the other end of the “intensity spectrum,” both the DoD and VA are working to shift some behavioral care into primary care settings. The Air Force’s Behavioral Health Optimization Program (BHOP) is an outgrowth of earlier smaller-scale programs (e.g., Runyan et al., 2003; Wilson, 2003). Similarly, the VA launched a broad program to integrate behavioral health care into primary care settings following successful smaller-scale rollouts (e.g., Funderburk et al., 2010; Rubenstein et al., 2010). These treatment models tend to emphasize a problem-focused, short-term treatment approach with brief (e.g., 20-minute) sessions. Given the fact that CBT treatments tend to be short-term and problem-focused, it is not surprising that CBT treatments have proven quite successful in primary care settings. For example, a protocol for brief CBT in primary care has been implemented within the VA to target depression and anxiety (Cully et al., 2012). Similarly, there is evidence that CBT treatments for insomnia can be delivered in the primary care setting (Goodie et al., 2009). Both the DoD and the VA are required to address the needs of a widely dispersed patient population. Whether it be due to deployments or to residing some distance from the care facility (e.g., rural settings), finding ways to get



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treatment to patients who are not able to attend regular appointments at the clinic represents a challenge. Additionally, it has been argued that telemental health care and other alternative treatment settings can help to reduce stigma as a barrier to care (Luxton et al., 2014). It will come as little surprise then, that the DoD and VA are among the leaders in the delivery of mental health care via telemedicine connections and in developing internet-based tools for delivering treatment. Again, CBT approaches for issues that commonly arise for service members and veterans appear robust to delivery at a distance. For example, both CPT (Morland et al., 2015) and PE (Yuen et al., 2015) for PTSD have been delivered via telehealth systems. Similarly, a home-based telemental health treatment for depression using modified behavioral activation has been implemented in a military treatment facility through the use of web cameras (Luxton et al., 2014). Recent meta-analyses conclude that CBT delivered at a distance can be effective for PTSD (Hedges’s g = 0.71; Sijbrandij et al., 2016), depression (standardized mean difference = 0.74; Sztein et al., 2018), and insomnia (the combined studies suggest total improvements of approximately 18 minutes in sleep onset latency, 22 minutes total time to sleep, and 10% increased sleep efficiency; Ye et al., 2016).

CONCLUSION AND FUTURE DIRECTIONS CBT provides a robust, evidence-based treatment approach that can be adapted to fit the complex cultural and lifestyle issues inherent in treating active duty service members and veterans. The DoD and VA health care systems offer substantial opportunities to examine and understand the effectiveness of CBT protocols in a variety of settings, some of which will require substantial modification of the standard protocols. Undoubtedly, there is need for additional research regarding the effectiveness of CBT protocols, in standard and modified formats, to address various behavioral health issues in the active duty population. However, research, particularly clinical trials with active duty samples, is complicated due to many of the logistical challenges involved in delivering care to this population. Therefore, it is important to approach the clinical care of service members and veterans systematically using established assessment tools as well as novel outcome indicators so as to better understand the effectiveness of CBT with this population. In addition, the field will benefit from an exchange of information such that the modifications made to treatment protocols by providers working in military settings can be shared with civilian researchers, who can then conduct controlled tests of such modified protocols. Through better understanding of the military’s unique organizational and social challenges and their implications for delivery of therapy, we would hope to improve the treatment received not only by military personnel but also the broader population.

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26 Cognitive Behavioral Therapy for Lesbian, Gay, Bisexual, and Transgender Populations Trevor A. Hart, Julia R. G. Vernon, and Tae L. Hart

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esbian, gay, bisexual, and transgender (LGBT) individuals are a diverse group encompassing multiple identities and behaviors. People who selfidentify their sexual orientation as other than heterosexual may identify as lesbian, bisexual, or gay, but other terms are used to describe nonheterosexual identities, including queer, a broad term suggesting nonidentification with heterosexual norms (APA, 2015); pansexual, a term used by individuals who do not choose sexual or romantic partners based upon their gender; and terms used more frequently by people outside of the White majority found in many Western countries, such as same-gender loving, a term used by some people predominantly in the African American community (Harris & Battle, 2013; Truong et al., 2016). Sexual orientation often suggests one’s sexual behavior but is somewhat independent of one’s actual sexual or romantic behavior. For example, a man may identify as gay but may choose to have sexual and romantic relationships with women to avoid the stigma of being gay. In addition, people who identify as queer may have sexual and romantic relationships with others who identify anywhere on the sexual orientation and gender identity spectra.1 Gender identities are also diverse, as discussed in detail in the American Psychological Association (APA) Guidelines for Psychology Practice With Transgender and Gender Nonconforming [TGNC] People (APA, 2015). These include (a) cisgender, which is an individual who identifies with the gender assigned at

This research was supported by an Applied HIV Research Chair Award (TH, #AHRC G937) from the Ontario HIV Treatment Network. 1 Clinical examples are disguised to protect patient confidentiality. https://doi.org/10.1037/0000219-026 Handbook of Cognitive Behavioral Therapy: Vol. 2. Applications, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Applications, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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birth by society; (b) transgender, an individual who identifies with a gender other than that assigned at birth, such as an individual identified as female at birth but who now identifies as male or as neither male nor female; and (c) gender nonconforming, genderqueer, or nonbinary—a person who does not identify as fitting into the dominant societal conceptualization of everyone needing to identify as either male or female (APA, 2015). Sexual orientation is differentiated from gender identity, which is defined as one’s identification with a gender such as male or female. For example, a transgender woman who was assigned male at birth but who now identifies as female may identify her sexual orientation as gay, bisexual, lesbian, queer, or another sexual orientation identity. Consistent with the APA Guidelines for Psychology Practice With Transgender and Gender Nonconforming People, this chapter will use the term TGNC when describing people who identify as transgender or gender nonconforming. Moreover, this chapter will use LGBT as an umbrella term to describe members of sexual and gender minorities as a whole to be consistent with terms used by several large institutions, including the National Institutes of Health (NIH, 2018), the Centers for Disease Control and Prevention (CDC, 2014), the Fenway Institute (Fenway Health, 2018), and the Williams Institute (2011). LGBT individuals face significant health inequities compared with the general population, including a higher prevalence of mood disorders and anxiety disorders (Mays & Cochran, 2001), posttraumatic stress disorder (PTSD; Roberts et al., 2010), body image disturbance (Austin et al., 2004; Russell & Keel, 2002), and substance use disorders (Gilman et al., 2001; Green & Feinstein, 2012; Sandfort et al., 2001). LGBT individuals may also experience other psychological problems such as higher loneliness and social isolation (e.g., Hatzenbuehler et al., 2001; Mereish & Poteat, 2015). According to a systematic review, bisexual women and men had higher rates of depression and attempted suicide rates compared with those who identified as lesbian or gay (Plöderl & Tremblay, 2015). Similarly, data from a large sample of LGB people from the National Health Interview Survey (NHIS) showed bisexual men had high rates of moderate or severe psychological distress (over 40%) compared with gay men (25.9%) and heterosexual men (16.9%; Gonzales et al., 2016). Moreover, bisexual men were more likely to report heavy drinking and heavy smoking than gay and heterosexual men. Bisexual women were found to report higher rates of psychological distress (46.4%) than lesbians (28.4%) and heterosexual women (21.9%), and they also were more likely to report heavy drinking. Subsets of the LGBT population, such as gay and bisexual men, are at higher risk for sexual health concerns such as human immunodeficiency virus (HIV; Stahlman et al., 2017) and sexually transmitted infections such as hepatitis C virus (HCV) and human papillomavirus (HPV; van de Laar & Richel, 2017) relative to their heterosexual peers. For example, in the United States, men who have sex with men (MSM) have a yearly rate of new HIV infections that ranges from 522 to 989 per 100,000 MSM, compared with 12 per 100,000 in the general adult male population (CDC, 2017a). In addition, transgender women have high rates of HIV, estimated at 21.7% in the United States (Baral



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et al., 2013); African American transgender women disproportionately account for more than half of these infections (CDC, 2017b). Higher rates of HIV among this subset of individuals has been attributed to violence, history of childhood abuse, and concurrent substance abuse (CDC, 2017b). Approximately 0.6% of people identify as TGNC in the United States (Flores et al., 2016). As identified in the APA Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (APA, 2015), many psychologists are unfamiliar with how to work with this population. Compared with non-TGNC people, TGNC people face disproportionate rates of sexual and physical violence; discrimination in health care, housing, employment, and educational settings; as well as serious harassment and discrimination in quotidian life, such as significant barriers in using binary choice bathrooms (for a review, see APA, 2015). A growing body of research documents the mental health concerns of TGNC people. For example, in a large sample of TGNC men and women, over 60% reported scores consistent with depression on the Center for Epidemiologic Studies—Depression Scale (Radloff, 1977; Rotondi, Bauer, Scanlon, et al., 2012; Rotondi, Bauer, Travers, et al., 2012). Moreover, over 35% of this same sample reported suicidal ideation, and 11.2% had attempted suicide in the prior year. TGNC people have been shown to report five to six times more cocaine and amphetamines use than cisgender people, which is associated with prior transphobic violence, being homeless, and engaging in sex work (Scheim et al., 2017). TGNC women of color, in particular, confront high rates of violence, stigma, physical illness, and mental health problems (e.g., Herbst et al., 2008; Nemoto et al., 2011). The multiple health inequities faced by LGBT people can be explained by the empirically supported Minority Stress Model (Meyer, 2003), which posits that the higher prevalence of psychological problems among LGBT individuals compared with heterosexuals can be explained by the presence of minority-specific stressors not experienced in the general, non-LGBT population, such as antiLGBT harassment, discrimination, bullying, and violence (e.g., HightowWeidman et al., 2011; Mereish & Poteat, 2015; Pachankis, 2014; Perry et al., 2017). An extension of the Minority Stress Model, the Psychological Mediation Framework (Hatzenbuehler, 2009; Schwartz et al., 2016) suggests that minorityspecific stressors may lead to poor mental health outcomes as mediated by cognitive variables such as low self-esteem, affective variables such as difficulties with emotion regulation, and social variables such as low social support. Addressing sexual- and gender-minority-specific stressors and the mediators leading to poor mental health outcomes may therefore increase the effectiveness of cognitive behavioral therapy (CBT) with LGBT clients.

APA GUIDELINES FOR PSYCHOLOGICAL PRACTICE WITH LGB CLIENTS As reviewed in detail by Craig et al. (2013), CBT has been criticized previously for being too focused on problems instead of strengths and not taking enough

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consideration of the societal stigma that threatens marginalized populations. How should psychologists conducting CBT with LGBT people approach this problem? First, it is critical for psychologists using CBT to carefully consider the APA Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients, which provide directives about how to understand and treat the sequelae of the stigma and marginalization experienced by LGB clients (APA, 2012). For example, Guideline 1 mandates that “psychologists strive to understand the effects of stigma (i.e., prejudice, discrimination, and violence) . . . in the lives of lesbian, gay, and bisexual people” (APA, 2012). Similarly, Guideline 5 of the APA Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (APA, 2015) underscores that “psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and wellbeing of TGNC people” (APA, 2015). In addition, the APA Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients mandate psychologists to “recognize the unique experiences of bisexual individuals” (APA, 2012, Guideline 5). Psychologists conducting CBT should be aware that bisexual people face stigma from both the dominant heterosexual culture as well as from the mainstream gay and lesbian community, and social isolation may be a contributing risk factor to their comparatively poorer mental health (APA, 2012). Therefore, bisexual individuals are also a unique subset facing different problems within the larger LGBT community, which may negatively impact their psychotherapy experiences. Taken together, these guidelines underscore the significance of the minority stress model when working with LGBT clients, and they instruct clinicians to pay close attention to history of violence, discrimination, and harassment, as well as internalized heterosexism (APA, 2012, 2015). However, Guideline 10 of the APA Guidelines for Psychological Practice With Transgender and Gender Nonconforming People underscores that psychologists should be aware that “mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress” (APA, 2015). This guidance applies to not only TGNC people but to the larger LGBT community with whom psychologists may be using CBT. Psychologists are therefore advised to engage in careful assessment prior to initiating CBT with LGBT clients to gain a clear understanding of the history and context of their presenting problems. As a second step, psychologists who have been trained in and conduct traditional CBT should be aware that CBT has been very successfully modified for multicultural populations (e.g., Hays, 2009). In line with this prior work, lesbian, gay, bisexual, and queer (LGBQ) affirmative therapy has emerged (often as a modification of CBT), defined as psychotherapy that is culturally responsive to LGBQ clients, diminishes systematic barriers, and enhances coping and strengths so that clients can psychologically and physically thrive (O’Shaughnessy & Speir, 2018). A recent metasynthesis of LGBQ-affirmative therapy reported only four randomized controlled trials (RCTs) were identified in their comprehensive search as providing LGBQ-affirmative therapy, all of which



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delivered CBT in samples of gay men and are discussed further in this chapter (Pachankis et al., 2015; Reback & Shoptaw, 2014; Shoptaw et al., 2005, 2008). Despite calls for addressing the lack of treatment research on CBT for LGBT individuals (Martell, 2001; Martell et al., 2004; Purcell et al., 1996; Safren, Hollander, et al., 2001; Safren & Rogers, 2001), there continue to be relatively few rigorous efficacy or effectiveness trials examining the use of CBT to improve the mental health and sexual health of this population. The lack of research has significant implications for the health of LGBT individuals, as most studies have samples that are predominantly or exclusively heterosexual and cisgender. Not only are studies on CBT for LGBT populations sorely lacking from the literature, rarely are sexual orientation and gender identity even reported as part of the demographic information in treatment research. For example, in a random sample of 222 RCTs for treatment of anxiety and depression published between 2004 and 2009, only one reported sexual orientation in the demographic data and zero reported gender identity (Heck et al., 2017). Mullens et al. (2017) pointed out that failure to recognize the existence of sexual orientation as a relevant factor in mental health treatment research precludes discovery of and attention to any unique treatment needs that may exist in sexual minority populations. The lack of information collected on gender identity in prior treatment research also contributes to the health care disparities faced by TGNC, who have overlapping but specific mental health care needs compared with LGB people. The goal of this chapter is to review the available research on CBT for diverse LGBT populations. The chapter reviews empirically supported cognitive behavioral approaches in individual, couples, and group-based formats to promote mental health. As RCTs provide the best methodology for evaluating CBT efficacy, our review focuses on treatments with RCT data, and when these do not exist, our secondary focus will be on nomothetic treatment outcome studies with pretreatment and posttreatment data. This chapter focuses on treatments that describe themselves as cognitive behavioral therapies (CBTs), and that use techniques familiar with CBT therapists, such as psychoeducation, cognitive restructuring, and behavioral experiments, exposures, or behavioral activation. The majority of research we review has used a traditional CBT framework; however, where possible we have identified CBT outcome studies that are consistent with an LGBQ and trans-affirmative therapy approach, which can be defined as therapy that addresses the identities of LGBQ and TGNC individuals and the social inequities they experience, and that fosters the strengths of LGBQ and TGNC clients (e.g., O’Shaughnessy & Speir, 2018). The chapter begins by reviewing the more considerable literature on empirically supported CBT-based HIV prevention and care with gay and bisexual men, and it continues with CBT for other problems faced by gay and bisexual men. The chapter continues with a focus on CBT for lesbian and bisexual women, LGBT youth, TGNC populations, and LGB populations as a composite group. The chapter concludes by summarizing the available findings and suggesting future research to advance the science and practice of CBT for diverse LGBT populations.

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GAY AND BISEXUAL MEN CBT for HIV-Negative Gay and Bisexual Men Effective Skills to Empower Effective Men (ESTEEM; Pachankis, 2014; Pachankis et al., 2015) is based upon Barlow et al.’s (2010) Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. This 10-session treatment promotes emotion regulation skills, motivation, and self-efficacy for behavior change, and also reduces avoidance. As per the Unified Protocol, techniques used are cognitive restructuring, mindfulness, self-monitoring, motivational enhancement, and interoceptive and situational exposures. ESTEEM can also be considered a gay-affirmative approach (e.g., O’Shaughnessy & Speir, 2018), as it integrated gay-specific content such as psychoeducation about minority stress and its effects, and strategies for addressing minority stressors. ESTEEM was tested using an RCT with HIV-negative gay and bisexual men ages 18 to 35 who experienced anxiety and depression symptoms in the past 90 days and who reported condomless anal sex in the past 90 days with a casual partner or a partner who was HIV-positive or of unknown HIV status. Compared with the wait-list control condition, ESTEEM reduced depressive symptoms (d  =  0.55) and alcohol use problems (d  =  1.03; Pachankis et al., 2015). This treatment was also associated with reduced sexual compulsivity (d = 0.76), improved condom use self-efficacy (d = 0.93), and past 90-day anal sex without condoms with casual partners (d = 0.59). The authors posited that both the universal processes that are the proposed mechanisms of the Unified Protocol (i.e., rumination, emotion dysregulation, low social support, and low assertiveness) and minority-stress related processes (i.e., gay-related stress, rejection sensitivity, internalized homophobia, and concealment of sexual orientation) may mediate the relation between time and reductions in psychological distress. However, there were no significant reductions in either type of mediating processes. The mechanisms underlying this successful trial are therefore still unknown. CBT in HIV-Positive Gay and Bisexual Men A considerable amount of the literature on CBT for gay and bisexual men pertains to HIV, likely due to the relative availability of research funding for HIV treatment and prevention compared with the availability of funding for research on the treatment of other concerns in this population (Brennan et al., 2017; Coulter et al., 2014). The efficacy studies reviewed here combine CBT for psychological distress with a focus on reducing adverse HIV-related medical outcomes or on adherence to HIV medications. Although the interventions described below do not necessarily include content about sexual orientation, they have all been tested in samples consisting of sexual minority men or samples in which the majority of participants are sexual minority men. Cognitive Behavioral Stress Management Stress management is relevant for people living with HIV not only because it helps mitigate psychological distress, but also due to the relation between stress



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and the immune system. Elevated levels of the stress hormone cortisol are associated with lower CD4 cell counts (Christeff et al., 1997), which is a marker of immune system function. In the absence of antiretroviral therapy (i.e., medications that limit replication of the virus and reduce the concentration of HIV in the body; Cohen et al., 2011), HIV attacks CD4 cells, putting the individual at risk of opportunistic infections. Cognitive behavioral stress management (CBSM; Antoni et al., 2007a) is a manualized intervention consisting of a 10-week group-based treatment delivered by two facilitators. A facilitator guide and workbook are available as part of the Treatments That Work series (Antoni et al., 2007a, 2007b). Weekly 135minute sessions consist of 45 minutes of relaxation training (i.e., progressive muscle relaxation, autogenic relaxation training, meditation, and guided imagery and breathing exercises) and 90 minutes of stress management using cognitive behavioral techniques including psychoeducation on the physiological effects of stress and the cognitive behavioral theory of stress and emotions, identifying automatic thoughts and cognitive distortions, cognitive restructuring, coping skills and assertiveness training, anger management, and engaging with social supports (Antoni, D. G. Cruess, et al., 2000; Antoni, S. Cruess, et al., 2000; Antoni et al., 2006). In each session, concepts are presented by the facilitators, followed by group discussion and role-plays. For example, Session 4 consists of progressive muscle relaxation using imagery (relaxation training component), followed by a focus on negative thinking and cognitive distortions (CBT component). Homework exercises entail practicing skills outside of the session. CBSM was evaluated in an RCT of HIV-positive gay and bisexual men recruited between 1992 and 1997 and assigned to CBSM or a 1-day stress management workshop (Antoni, S. Cruess, et al., 2000). Significant improvements were found in four of the six subscales of the Profile of Mood States (McNair et al., 1981), namely, anxiety, depression, anger, and confusion (all with p < .01) in the treatment group, but no significant changes were found in these measures for the control group. Significant reductions in cortisol levels, F(1, 33) = 5.32, p < .03, were also found in the treatment group but not the control group. In another set of analyses on the same study (Antoni, D. G. Cruess, et al., 2000), participants in the treatment group only had significant reductions on the Perceived Stress Scale (Cohen et al., 1983) scores, F(1, 59) = 4.29, p < .05, and treatment group participants had significantly lower norepinephrine (a marker of sympathetic nervous system activation) levels in their urine than control participants posttreatment, F(1, 57)  =  5.63, p < .025, controlling for baseline levels. Reductions in anxiety partially mediated the effects of CBSM on norepinephrine. Antoni et al. (2006) conducted another evaluation of CBSM from 1998 to 2004, following the proliferation of highly active antiretroviral therapy (HAART), an improved therapy consisting of a combination of antiretroviral medications. In this study, the authors were interested in seeing whether CBSM was superior to a pharmacy-led individualized medication adherence training

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intervention. Participants randomized to the medication adherence training condition had a 1-hour session with a pharmacist at baseline and a 1-day stress management and relaxation training workshop, followed by half-hour maintenance sessions 3 and 9 months later. In medication adherence training, the pharmacist provides information about HIV and antiretroviral therapy, proper dosing, side effects, and discussing side effects with a health care provider. Participants randomized to the CBSM intervention received medication adherence training as part of CBSM. For example, treatment adherence was addressed during skills training sessions, and participants deconstructed thoughts pertaining to treatment during cognitive restructuring exercises. Among participants with detectable HIV viral loads at baseline (77.69% of the sample), individuals in the CBSM condition had significant and sustained reductions in HIV viral load through 15-month follow-up, B  =  0.04, t(131) = 2.40, p < .05, whereas control participants did not experience a significant change in viral load (Antoni et al., 2006). Reductions in depression symptoms as measured by the Profile of Mood States were found in the treatment group, B = 1.21, t(64) = 2.83, p ≤ .01, but not the control group at the assessment immediately following treatment, but unfortunately these changes were not maintained at 15-month follow-up. There were no changes in Beck Depression Inventory (Beck et al., 1961) scores overall, but examining only the affective subscale (i.e., excluding the somatic symptoms such as appetite and fatigue, which may be affected by HIV), participants receiving CBSM had significant reductions in symptoms from baseline to posttreatment, B = 0.16, t(64) = 2.65, p  =  .01, and control participants did not. Changes in depression symptoms accounted for the reduction in HIV viral load over the 15-month period. The main limitation of the evidence supporting CBSM is that the research has all been done by the same investigators; corroboration by independent teams would strengthen support for CBSM. Furthermore, while it is one of the few CBT protocols evaluated in a sexual minority population through RCTs, it does not explicitly address minority stress, a key feature of LGBQ-affirmative psychotherapy (O’Shaughnessy & Speir, 2018). It would, therefore, be advisable for clinicians to ask their clients about the roles of heterosexism and HIV stigma as stressors and impediments to treatment adherence, including experiences of these types of discrimination from health care providers (e.g., Fiorentino et al., 2018; Schuster et al., 2005; Wagner et al., 2016). Life-Steps Life-Steps is a one-session intervention designed to support HIV treatment adherence that involves cognitive behavioral techniques, motivational interviewing, and problem solving (Safren et al., 1999; Safren, Otto, et al., 2001). It consists of a 6-minute video about problems that can arise from nonadherence and 11 steps that are covered during a 45-minute meeting with a clinician. The steps involve examining negative automatic thoughts about medication adherence and medical appointments and problem-solving anticipated challenges. For example, patients may experience difficulties communicating with their



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treatment providers, so the clinician and patient role-play asking questions and being assertive about one’s care. The patient formulates specific plans for obtaining medications, establishing and maintaining a daily medication schedule, and deciding how and where to store their medications. The session concludes with brief guided imagery through a day of medication adherence using the plans identified in the previous steps and a discussion of how to overcome the “all-or-nothing” thinking that is common in the event of a slip-up. Safren, Otto, et al. (2001) randomly assigned 49 men and seven women living with HIV who had missed a medication dose in the previous 2 weeks to Life-Steps or a self-monitoring control condition consisting of a pill diary and adherence questionnaire. The sample included heterosexual individuals, as all of the women and 11 of the 49 men in the study were heterosexual. Of the remaining men, 35 men identified as gay, two as bisexual, and one man did not report his sexual orientation. Participants who received Life-Steps had significantly better medication adherence at the 2-week follow-up than at baseline, F(1,42) = 21.94, p < .001, with an increase in mean adherence from 74% to 95%, but control group participants had nonsignificant improvements, with an increase in mean adherence from 84% to 90%. At the 12-week follow-up, Life-Steps participants had a mean adherence of 94%, and control participants, 93%. An analysis of variance (baseline versus 12-week follow-up and Life-Steps versus self-monitoring) did not find a main effect of condition or significant interaction between time and condition. Improvements in adherence were maintained in the Life-Steps group at the 12-week follow-up, suggesting that both conditions worked but that Life-Steps led to faster changes. Although Life-Steps does not include explicitly LGBQ-affirmative content, this one-session intervention could be incorporated into a broader LGBQ-affirmative treatment plan. Life-Steps is integrated into a treatment protocol for depression and body image disturbance in the sections below. CBT for Adherence and Depression CBT for adherence and depression (CBT-AD) is also part of the Treatments That Work series (Safren et al., 2007a, 2007b), and the protocol is designed for a variety of chronic illnesses. In the context of the present study evaluating CBT-AD for people living with HIV (Safren et al., 2009), Session 1 is Life-Steps (Safren et al., 1999; Safren, Otto, et al., 2001), and Sessions 2 to 12 focus more on depression. The modules entail psychoeducation about HIV and depression, motivational interviewing to explore the advantages and disadvantages of addressing depression and treatment adherence, behavioral activation strategies, cognitive restructuring, and problem solving and the development of an actionable plan. The intervention concludes with progressive muscle relaxation training and diaphragmatic breathing. At the beginning of each session, the past week’s treatment adherence data are reviewed, and the original Beck Depression Inventory is administered. Safren et al. (2009) randomly assigned 45 people living with HIV to Life-Steps, the control condition, or Life-Steps plus 10 to 12 sessions of CBT-AD,

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the experimental condition. To be eligible, participants had to be on antiretroviral therapy for at least 4 months and meet diagnostic criteria for a depressive mood disorder. Of the 38 men and seven women in the study, 37 men and two women identified as being gay or bisexual. Controlling for baseline scores, participants in the CBT-AD condition had better medication adherence, measured using data from an electronic pill-cap, at posttreatment than control group participants in both completers (d = 1.10) and intention-to-treat (d = 1.00) analyses. A similar pattern was observed in depression symptoms, as participants in the CBT-AD had greater reductions in depression symptoms than control participants on two clinician-administered scales and one self-report measure in both intention-to-treat (d = 0.91, 0.82, and 0.81, respectively) and completers analyses (d = 1.00, 0.89, and 0.93, respectively). These gains were maintained at assessments 3 and 9 months after completing the intervention. This study provides evidence that CBT for depression and HIV medication adherence works in a sample comprised mostly of gay and bisexual HIV-positive individuals. Clinical Example for CBT-AD The following case example illustrates how CBT-AD can be easily conducted by a clinician who has already been trained in CBT. To help the reader to extend CBT knowledge to this protocol, the presentation focuses on features that are not found in more common forms of CBT for depression, such as aspects associated with HIV, HIV medication adherence, coping with homophobia, and HIV stigma. The case example was amalgamated from several actual cases, and information was masked to protect confidentiality. Terrence was a 25-year-old Korean Canadian cisgender man who moved to Canada with his parents when he was in high school. He reported that despite initial challenges in coming out to his parents, he continued to be close to them and that “showing respect to your parents is really important in Korean culture.” Terrence worked at a hotel, and his shift was from 1 p.m. to 9:30 p.m. He became HIV-positive 3 years ago and believed he contracted HIV after having sex while drunk with a partner he met online. Terrence reported that his parents did not know he was living with HIV. Terrence reported symptoms consistent with major depressive disorder, recurrent, current episode moderate, and he noted that he had only taken his once-daily HIV medication four times in the past week. CBT-AD began by examining Terrence’s thoughts about taking his medications. Terrence reported automatic thoughts such as, “I am so stupid for not being able to take my medication,” “I am not responsible,” and “I don’t even deserve to feel better.” When the therapist asked about Terrence’s barriers to taking medications once per day as prescribed, Terrence responded that he usually would take his medication in the morning, but he often would stay in bed in the morning even though he was awake since he did not have to be at work until 1 p.m., and then he would feel like a failure for missing his dose. As the only requirement for his medication was that he take his medication at approximately the same time each day, the therapist asked about what other times



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would be better for Terrence to take his medication. The therapist and Terrence identified that taking his medications around noon during lunchtime was a more logical time, and Terrence agreed to try the new medication time for his homework. In Session 2, Terrence reported that he had successfully taken his medications every day between 12 p.m. and 2 p.m. but still felt like he did not deserve to “feel good.” The therapist praised his adherence to his HIV medications and then delivered psychoeducation about how depression, HIV infection, and medication nonadherence often co-occur. The therapist then guided Terrence through a decisional balance exercise about the pros and cons of not pursuing versus pursuing therapy for depression. Terrence reported pros of not pursuing therapy including, “If I don’t try, I can’t fail,” and cons such as, “I might feel like this forever.” The cons of pursuing therapy included, “It sounds like a lot of work,” and pros included, “I might be able to meet someone special if I wasn’t depressed.” After the exercise, the therapist asked how important it was for Terrence to pursue therapy, and how confident he was that he could complete the therapy, both on a 0-to-10 scale. Terrence responded with an importance rating of 9 and a confidence rating of 5. When the therapist asked why Terrence’s confidence rating was not lower than 5, Terrence responded, “Well, I got this far, so I can at least do two sessions.” In this way, the therapist used CBT-AD to strengthen Terrence’s motivation for continuing therapy. Sessions 3 to 12 focused on treating the symptoms of Terrence’s depression, with an emphasis on depression in the context of living with HIV and his struggles with medication adherence. Session 3, on activity scheduling, concentrated on scheduling pleasure and mastery activities in the morning, when Terrence was usually awake but lying in bed. Sessions 4 to 8 centered on cognitive restructuring, with a focus on Terrence’s automatic thoughts about being irresponsible and not deserving to feel happy. In Session 4, the therapist inquired why Terrence believed he did not deserve happiness, and Terrence responded that he had felt bad about himself not only for failing to get married and have children for his parents, but also for failing himself by contracting HIV by having sex without using condoms or Pre-Exposure Prophylaxis (PrEP), which are medications that prevent HIV infection. Terrence added that as someone living with HIV, he had “lowered my chances of ever making my own family or passing on my family’s culture.” Through cognitive restructuring, the therapist helped Terrence identify evidence against his automatic thoughts, such as that he wanted to get married to a man who wanted to have children, he was a good friend, he cared for his parents, and he was successful at work. Terrence then identified a more adaptive thought: “I am a good person, and I do take care of myself now.” Sessions 9 and 10 on problem solving addressed Terrence’s deficits in problem solving, as he tended to see interpersonal problems outside of work as insurmountable. The therapist helped the client generate solutions to his main concern, which was that it would be difficult as a man living with HIV to meet a man who wanted to have children. Terrence identified several solutions that

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he began to implement, such as attending events for people living with HIV and putting on his dating app profiles that he wanted to meet men who were interested in marriage and having children. Session 11 focused on diaphragmatic and progressive muscle relaxation training and practice. Finally, Session 12 discussed Terrence’s progress in therapy, how he could continue his progress after therapy termination, and relapse prevention. At the end of therapy, Terrence was not only taking his medications as prescribed, but he was pleased that he had gone on two dates with a man who shared Terrence’s values on marriage and family. Cognitive Behavioral Therapy for Body Image and Self-Care In another study integrating CBT for distress and HIV medication adherence, Blashill et al. (2017) created and tested a protocol of CBT for body image and self-care (CBT-BISC) for HIV-positive sexual minority men. CBT-BISC is a 12-session protocol that integrates medication adherence with treatment of body image disturbance. CBT-BISC begins with one session of Life-Steps (Safren et al., 1999; Safren, Otto, et al., 2001). All CBT-BISC sessions briefly review medication adherence but then focus on psychoeducation on body image, mindfulness and acceptance-based strategies, exposure to one’s visual image using mirrors, cognitive restructuring, reducing avoidance behaviors such as camouflaging and reassurance seeking, and relapse prevention. The body image disturbance techniques were adapted from existing CBT manuals (Cash, 2008; Wilhelm et al., 2013). To test CBT-BISC, a small RCT of 44 HIV-positive, sexually active men who reported significant body image disturbance on the clinician-administered Body Dysmorphic Disorder modification of the Yale-Brown Obsessive-Compulsive Scale (BDD-YBOCS; Phillips et al., 1997) was conducted. CBT-BISC was compared with a one-session protocol of Life-Steps (Safren et al., 1999; Safren, Otto, et al., 2001). Men in the CBT-BISC arm demonstrated greater reductions in body image disturbance immediately after CBT-BISC (d = 2.39) and at a 3-month follow-up (d = 2.09), less severe depression symptoms at the 3-month follow-up (d = 1.17), and relatively equivalent increases in medication adherence compared with the control condition. Healthy Living—Coping Skills and Reducing Condomless Anal Sex The Healthy Living Project intervention was designed primarily to reduce condomless anal sex among HIV-positive gay men (Gore-Felton et al., 2005; Healthy Living Project Team, 2007). This treatment consisted of 15 individual counseling sessions of 90 minutes each. Only the first five sessions focused on CBT for psychological distress, using coping effectiveness training, a group-based therapy that was efficacious in improving psychosocial adjustment among HIV-positive gay men (Chesney et al., 2003). The next five sessions occurred in Months 7 and 8 and focused on avoiding HIV transmission behaviors and disclosing one’s HIV status to potential partners. The last five sessions occurred in Months 10 to 14 and focused on HIV medical adherence, including accessing and attending medical care and HIV medication adherence.



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This program reduced HIV transmission risk behavior compared with the wait-list condition in a mixed sexual orientation sample; however, data were not stratified by sexual orientation (Healthy Living Project Team, 2007). Given that the program was hypothesized to reduce HIV transmission risk behavior via reducing psychological distress, Carrico et al. (2009) examined whether reduced psychological distress was the mechanism by which the intervention led to less transmission risk. Despite the large sample size (N = 969), there were no differences between conditions in any of the psychological measures, including anxiety and depression. The authors concluded that the dose of CBT for psychological distress may not have been sufficient to have an effect. This treatment is, therefore, only recommended for reducing the risk of HIV transmission among HIV-positive gay men. CBT for Methamphetamine-Using Gay and Bisexual Men In the only study including both HIV-positive and HIV-negative gay and bisexual men, the Matrix Model of Cognitive Behavioral Therapy (Rawson et al., 1995) was used to help clients to maintain healthy drug-reducing behaviors (Reback & Shoptaw, 2014; Shoptaw et al., 2005). CBT was offered three times a week over 16 weeks to gay and bisexual men with methamphetamine abuse. The groups focused on teaching men to recognize the cues for using stimulants; to develop alternative, healthy coping strategies for managing triggers; and to minimize the effects of potential relapses from abstinence. The efficacy of CBT was examined in a 16-week RCT of four behavioral therapies for methamphetamine abuse. The three other therapies were contingency management (Higgins et al., 1993), CBT plus contingency management, and a gay-specific CBT that used culturally specific psychoeducational materials and exercises to reduce the frequency of sexual risk behaviors (Shoptaw et al., 2005). The gay-specific CBT can be considered gay-affirmative (O’Shaughnessy & Speir, 2018), as it integrated cultural norms and values of urban gay and bisexual men into CBT and also focused on the reduction of sexual risk behaviors to reduce HIV incidence among gay and bisexual men (Reback & Shoptaw, 2014). Men reported decreases in depressive symptoms across treatment conditions at 26 weeks, and outcomes did not differ by HIV status (Peck et al., 2005). In a related study, Shoptaw et al. (2008) compared the gay-specific CBT to a time-matched gay social support group and found that gay CBT condition, compared with a gay support group condition, reduced the frequency of methamphetamine or marijuana use. The effect of the gay CBT was also large, with a 2.3-fold reduction in the number of days of methamphetamine use from baseline to the 1-year evaluation timepoint. This study also assessed changes to sexual risk behavior, but although both conditions showed reduced sexual risk behavior, they found no differences by condition. A shorter, 8-week version of the gay CBT condition, called Getting Off (Reback et al., 2014), was also tested against the use of gay CBT plus contingency management, and there were significant improvements for both, although the gay CBT alone produced more methamphetamine-free days (6.3 days of methamphetamine use in the past 30

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days for gay CBT alone versus 11.2 days of methamphetamine use in the past 30 days for the gay CBT plus contingency management) at a 24-week follow-up, and the gay CBT plus contingency management produced less sexual risk behaviors (5.20 vs. 2.51 male partners in the past 30 days, respectively) at a 26-week follow-up (Reback & Shoptaw, 2014). This treatment’s strong effects in reducing methamphetamine use and sexual risk behavior simultaneously is promising and merits additional evaluation by an independent team of researchers to demonstrate its reliability across a variety of settings. Summary of Literature on Gay and Bisexual Men RCTs using CBT have been conducted to reduce emotional distress and risky sex among HIV-negative gay and bisexual men, and among HIV-positive men, (a) to reduce stress and to promote positive HIV-related outcomes (Antoni, D.  G. Cruess, et al., 2000; Antoni, S. Cruess, et al., 2000; Antoni et al., 2006, 2007a, 2007b;), (b) to increase HIV medication adherence as a standalone intervention (Safren et al., 1999; Safren, Otto, et al., 2001), (c) to decrease depression and increase HIV medication adherence simultaneously (Safren et al., 2007a, 2009), (d) to reduce body image disturbance and risky sex (Blashill et al., 2017), and (e) to increase coping behaviors and reduce risky sex (Gore-Felton et al., 2005; Healthy Living Project Team, 2007). The only RCT that included gay and bisexual men regardless of HIV status used CBT to reduce methamphetamine use among gay and bisexual men (Peck et al., 2005; Reback et al., 2014; Reback & Shoptaw, 2014; Shoptaw et al., 2008). Many studies do not report the sexual orientation of their samples, but studies that do so have mostly had predominantly gay men, with a smaller sample of bisexual men that may be less than 5% of the sample (e.g., Blashill et al., 2017; Pachankis et al., 2015). Although CBT has been shown to also be efficacious with HIV-related outcomes, this also means that tests of the efficacy of CBT have an HIV-focused perspective. This perspective is quite limiting, as the literature still does not show if CBT is efficacious for outcomes that may not lead to improvements in HIV prevention or care. For example, it is unknown if CBT works to reduce minority stressors experienced disproportionately by gay men that may or may not lead to HIV risks, such as fears of negative evaluation due to one’s sexual orientation, the stress of discrimination or harassment, or internalized homophobia (Hatzenbuehler, 2009; Hightow-Weidman et al., 2011; Mereish & Poteat, 2015; Meyer, 2003; Pachankis, 2014; Perry et al., 2017), or psychological problems that are not directly tied to HIV outcomes, such as couples distress or psychiatric disorders such as panic disorder, agoraphobia, or specific phobias. Data are also lacking on effectiveness in real life, nonresearch clinics, and how to implement CBT in these settings.

CBT FOR LESBIANS Little information exists regarding the efficacy of CBT for lesbians. As noted earlier, the NHIS study found lesbians to have higher rates of psychological



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distress, heavy drinking, and heavy cigarette smoking compared with heterosexual women (Gonzales et al., 2016). Therefore, lesbians report significant mental health problems, nonetheless ones that are highly amenable to a CBT approach. Given that lesbians also face similar antigay discrimination alongside gay men but are additionally challenged by misogynistic attitudes and antiwomen violence in dominant society (APA, 2012), the lack of attention to CBT outcomes for this group is bewildering. We located no studies that specifically examined cognitive or behavioral therapy in lesbians, and only one RCT that compared lesbians with gay men. That study tested behavioral couples therapy (BCT) plus individual therapy (vs. individual therapy only) in a sample of 52 gay men and 48 lesbians diagnosed with an alcohol use disorder (Fals-Stewart et al., 2009). BCT was composed of 12 sessions that taught skills to help couples deal with maintaining abstinence and skills for partners to decrease behaviors associated with patient substance use, such as reducing the amount the partner engaged in behaviors that enable or trigger drinking. In addition, couples were taught skills to improve their communication, to increase their shared positive feelings, and to engage in activities together. Although the couples’ intervention used this behavioral protocol (O’Farrell and Fals-Stewart, 2006), the individual intervention followed a non-CBT individual drug counseling manual (Mercer & Woody, 1999). BCT was associated with significant reductions in the percent of heavy drinking days: 41.9% for gay men and 38.6% for lesbians at baseline, compared with 18% for gay men and 15.7% for lesbians 1 year posttreatment (p < .05). In addition, statistically significant improvements in relationship satisfaction were reported for both groups: M  =  99.23, SD  =  22.9 for gay men and M  =  92.7, SD = 20.4 for lesbians at baseline, compared with M = 106, SD = 22.8 for gay men and M = 101.4, SD = 20.4 for lesbians 1 year posttreatment (p < .05). The efficacy of BCT did not differ between lesbians and gay men. Although this treatment was not expressly designed to be LGBQ-affirmative, these findings suggest that a traditional behavioral couples approach produced positive outcomes for both lesbians and gay men. Clearly, CBT that is sensitive to the context and needs of lesbian lives is an area in great need of attention for future research.

CBT FOR TGNC INDIVIDUALS Similar to prior recommendations for using LGBQ-affirmative CBT (O’Shaughnessy & Speir, 2018), the APA Guidelines for Psychological Practice With Transgender and Gender Nonconforming People also call for psychologists to provide trans-affirmative psychological services (APA, 2015). Accordingly, Austin and Craig (2015) developed the first adapted form of CBT for TGNC people (i.e., trans-affirmative CBT [TA-CBT]), which uses the minority stress model as a framework as well as a trans-affirming approach. A trans-affirmative approach was defined by the authors as recognizing in sessions the oppression faced by

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TGNC people across multiple contexts and creating a clinical space wherein gender inclusivity is clear. The approach includes using gender-neutral language and the preferred pronouns for that specific client in addition to conducting a comprehensive assessment to understand the effect of oppression and other TGNC-specific issues related to the client’s mental health. Four important components of TA-CBT are (a) psychoeducation to help clients process the effect of discrimination on mental health and how to challenge both societal and internalized transphobia, (b) modifying transphobic self-beliefs, (c) changing the cycle of hopelessness and suicidality, and (d) encouraging transaffirmative supportive social networks. Although no efficacy data have been published as of yet, Austin et al. (2018) developed a comparable model of CBT adapted for TGNC youth, called AFFIRM, which is delivered in a group setting. Data from their pilot study of eight TGNC youth (aged 16 to 18 years) showed statistically significant reductions in depression from baseline (M  =  37.50, SD  =  12.29) to immediately posttreatment (M = 28.25, SD = 10.24, p = .001) and 3 months posttreatment (M = 29.33, SD = 6.77, p = .018). The AFFIRM intervention has also been pilot tested with a sample of 30 sexual and gender minority youth (aged 15 to 18 years; Craig & Austin, 2016). In this sample, participants self-identified with a variety of sexual orientations and identified their gender identities as female (n = 17), male (n = 6), queer (n = 11), and TGNC (n = 8). Data showed significant reductions in depression and negative cognitive appraisals from baseline to immediately after treatment (η2 = .54, p < .001 and η2 = .17, p < .05, respectively) and at a 3-month follow-up (η2 = .23, p < .05 and η2 = .18, p < . 05, respectively). Effective coping also significantly increased from baseline to follow-up (η2  =  .21, p