Handbook of Cognitive Behavioral Therapy, volume 1 1433833522, 9781433833526

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Handbook of

COGNITIVE B E H AV I O R A L THERAPY

Volume 1

Edite d by

OVERVIEW AND

A MY WENZEL

APPROACHES

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/10.1037/0000218-000 eISBN 978-1-4338-3351-9 Published in the United States of America 10 9 8 7 6 5 4 3 2 1

CONTENTS

About the Editor ix Contributors xi Introduction: The Evolution and Main Components of Cognitive Behavioral Therapy xv Amy Wenzel

I. CONTEXT 1 1. Philosophical and Historical Foundations

3

Robert L. Leahy and Christopher R. Martell

2. Theoretical Framework

31

Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann

3. The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders 51 Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, Pim Cuijpers, and Claudi L. H. Bockting

4. Empirical Status of Mechanisms of Change

91

Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, Amy Wenzel, and Jasper A. J. Smits

5. Cognitive Case Formulation

131

Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler

6. Dissemination and Implementation

157

Bradley E. Karlin

7. The Therapeutic Relationship

175

Amy Wenzel  v

vi Contents

II. STRATEGIES AND TECHNIQUES 8. Cognitive Restructuring

205 207

Christine Purdon

9. Behavioral Activation

235

Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter

10. Exposure Therapy

275

Lauryn E. Garner, Emily J. Steinberg, and Dean McKay

11. Motivational Interviewing

313

Deborah H. A. Van Horn, Amy Wenzel, and Peter C. Britton

12. Regulation of Physiological Arousal and Emotion

349

Holly Hazlett-Stevens and Alan E. Fruzzetti

13. Relapse Prevention

385

John Ludgate

III. PSYCHOTHERAPY PACKAGES 14. Cognitive Therapy

415 417

Amanda Fernandez, Keith Dobson, and Nikolaos Kazantzis

15. Rational Emotive Behavior Therapy

445

Debbie Joffe Ellis

16. Emotion-Centered Problem-Solving Therapy

465

Arthur M. Nezu and Christine Maguth Nezu

17. Schema Therapy

493

Eva Fassbinder and Arnoud Arntz

18. Dialectical Behavior Therapy

539

Hollie F. Granato, Amy R. Sewart, Meghan Vinograd, and Lynn McFarr

19. Acceptance and Commitment Therapy

567

Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin

20. Mindfulness-Based Cognitive Therapy

595

Amanda Ferguson, Lê-Anh Dinh-Williams, and Zindel Segal

21. Metacognitive Therapy

617

Peter L. Fisher

22. Applied Behavior Analysis

637

Raymond G. Miltenberger, Diego Valbuena, and Sindy Sanchez

23. Cognitive Bias Modification

673

Emily E. E. Meissel, Jennie M. Kuckertz, and Nader Amir

24. The Unified Protocol: A Transdiagnostic Treatment for Emotional Disorders Todd J. Farchione, Julianne G. Wilner Tirpak, and Olenka S. Olesnycky

701



Contents  vii

25. Contemporary Cognitive Behavioral Therapy

731

Nikolaos Kazantzis, Hoang Kim Luong, Hayley M. McDonald, and Stefan G. Hofmann

Index 757

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 trainer-consultant 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 Psychology and on Twitter @dramywenzel.

 ix

CONTRIBUTORS

Nader Amir, PhD,Director, Center for Understanding and Treating Anxiety (CUTA), Department of Psychology, Joint Doctoral Program at San Diego State University/University of California San Diego, San Diego, CA, United States Arnoud Arntz, PhD,Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands Eni S. Becker, PhD,Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands Peter J. Bieling, PhD,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Emanuele Blasioli, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Claudi L. H. Bockting, PhD,Department of Psychiatry, University Medical Centers, Academic Medical Center (AMC-UvA), Amsterdam, The Netherlands Peter C. Britton, PhD,Department of Psychiatry, University of Rochester School of Medicine and Dentistry and Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, NY, United States Pim Cuijpers, PhD,Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands Rianne A. de Kleine, PhD,Institute of Psychology, Leiden University, Leiden, The Netherlands Lê-Anh Dinh-Williams, MA,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada  xi

xii Contributors

Keith Dobson, PhD,Department of Psychology, University of Calgary, Calgary, AB, Canada Debbie Joffe Ellis, MDAM,Department of Clinical and Counseling Psychology, Columbia University, New York, NY, United States Todd J. Farchione, PhD,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Eva Fassbinder, MD,Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany Amanda Ferguson, MA,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada Amanda Fernandez, PhD,Alberta Health Services, Calgary, AB, Canada Peter L. Fisher, PhD,Psychological Sciences, University of Liverpool, England, United Kingdom Dara G. Friedman-Wheeler, PhD,Center of Psychology, Goucher College, Baltimore, MD, United States Alan E. Fruzzetti, PhD,McLean Hospital and Harvard Medical School, Belmont, MA, United States Lauryn E. Garner, MA,Department of Psychology, Fordham University, Bronx, NY, United States Hollie F. Granato, PhD,Department of Psychiatry, University of California Los Angeles, Los Angeles, CA, United States Holly Hazlett-Stevens, PhD,Department of Psychology, University of Nevada, Reno, Reno, NV, United States Stefan G. Hofmann, PhD,Department of Psychology, Boston University, Boston, MA, United States Jonathan W. Kanter, PhD,Department of Psychology, University of Washington, Seattle, WA, United States Bradley E. Karlin, PhD, ABPP,Solutions for Mental Health Change, PLLC, Cary, NC; Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States Nikolaos Kazantzis, PhD, FAPS,Principal Researcher and Research Director, Translational Clinical Psychology Research Division, Institute of Social Neuroscience, Melbourne, Australia John R. Keefe, PhD,Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States Jennie M. Kuckertz, PhD,Obsessive Compulsive Disorder Institute, McLean Hospital/Harvard Medical School, Boston, MA, United States Robert L. Leahy, PhD,Director, American Institute for Cognitive Therapy, New York, NY, United States Eric B. Lee, PhD,Department of Psychology, Southern Illinois University, Carbondale, IL, United States Lotte H. J. M. Lemmens, Department of Clinical Psychological Science at Maastricht University, Maastricht, The Netherlands Michael E. Levin, PhD,Department of Psychology, Utah State University, Logan, UT, United States



Contributors  xiii

Lorenzo Lorenzo-Luaces, PhD,Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, IN, United States John Ludgate, PhD, CBT Center, Asheville, NC, United States Hoang Kim Luong, BSc (Hons),Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia Christopher R. Martell, PhD,Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, MA, United States Hayley M. McDonald, Private Practice, Sydney, Australia Lynn McFarr, PhD,Department of Psychiatry, University of California Los Angeles, Los Angeles, CA, United States Dean McKay, PhD, ABPP,Department of Psychology, Fordham University, Bronx, NY, United States Emily E. E. Meissel, BA,San Diego State University/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States Raymond G. Miltenberger, PhD, BCBA-D,Professor, Department of Child and Family Studies, University of South Florida, Tampa, FL, United States Gabriela A. Nagy, PhD,Department of Psychiatry and Behavioral Sciences and School of Nursing, Duke University, Durham, NC, United States Arthur M. Nezu, PhD, DHL, ABPP,Distinguished University Professor of Psychology, Professor of Medicine, and Professor of Public Health, Drexel University, Philadelphia, PA, United States Christine Maguth Nezu, PhD, ABPP,Professor of Psychology and Medicine, Drexel University, Philadelphia, PA, United States Olenka S. Olesnycky, MA, Department of Psychology, Hofstra University, Hempstead, NY, United States Benjamin G. Pierce, PhD,School of Psychology, Utah State University, Logan, UT, United States Christine Purdon, PhD,Department of Psychology, University of Waterloo, Waterloo, ON, Canada Ajeng J. Puspitasari, PhD, LP, Departments of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States Sindy Sanchez, PhD, BCBA-D, Comprehensive Behavioral Consulting, LLC, Tampa, FL, United States Maria M. Santos, PhD,Department of Psychology, California State University, San Bernardino, San Bernardino, CA, United States Zindel Segal, PhD,Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada Amy R. Sewart, PhD,Department of Psychology, California State University, Dominguez Hills, Carson, CA, United States Jasper A. J. Smits, PhD,Department of Psychology, The University of Texas at Austin, Austin, TX, United States Emily J. Steinberg, MA,Department of Psychology, Fordham University, Bronx, NY, United States

xiv Contributors

Julianne G. Wilner Tirpak, MA,Department of Psychological and Brain Sciences, Boston University, Boston, MA, United States Michael P. Twohig, PhD,Department of Psychology, Utah State University, Logan, UT, United States Diego Valbuena, PhD, BCBA-D,Comprehensive Behavioral Consulting, LLC, Tampa, FL, United States Deborah H. A. Van Horn, PhD,Deborah H. A. Van Horn, PhD, LLC, West Deptford, NJ, United States Meghan Vinograd, PhD,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System; Department of Psychiatry, University of California San Diego, La Jolla, CA, United States Janna N. Vrijsen, PhD,Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center; Depression Expertise Center, Pro Persona Mental Health Care, Nijmegen, The Netherlands Amy Wenzel, PhD, ABPP,Main Line Center for Evidence-Based Psychotherapy, Havertown, PA, United States

INTRODUCTION The Evolution and Main Components of Cognitive Behavioral Therapy Amy Wenzel

C

ognitive behavioral therapy (CBT for short)—what a term that evokes a distinctive reaction in mental health professionals, in scholars and researchers in medicine and related fields, and in clients who struggle with mental health problems! What began as a simple alternative to the dominant treatments for mental health problems in the second half of the 20th century (i.e., pharmacotherapy, psychoanalysis, person-centered therapy) has evolved into a powerhouse of a theoretical and clinical framework that drives the understanding and treatment of countless emotional, behavioral, and adjustment problems. CBT is arguably the best researched of all the psychotherapeutic approaches that can be delivered to clients in need, and results from empirical studies confirm that CBT is highly efficacious in reducing psychiatric symptoms and problems in functioning and in improving satisfaction in relationships and quality of life (Butler et al., 2006). There is no succinct definition of CBT. It originated as an active, problemfocused, and time-limited approach to psychotherapy in which interventions had their foundation in the notion that problematic styles of thinking contributed to and exacerbated psychiatric symptoms (Beck, 1967). Perhaps the best way to put it is that cognitive behavioral interventions were designed to be strategic, in that regardless of what they actually involved, their goal was to shift clients’ thinking from thinking that is excessively negative, exaggerated, and/or shortsighted to thinking that is accurate, balanced, and wise. In some of the first CBTs that were developed in the 1960s and 1970s (i.e., Aaron T. Beck’s cognitive therapy [CT] and Albert Ellis’s rational emotive behavior therapy [REBT]), much of the intervention was centered directly on reshaping problematic thinking, either through guided questioning, in the case of CT, or more overt challenging of irrational logic, in the case of REBT.  xv

xvi Introduction

Although cognitive constructs gained significant attention and continue to hold central importance in explaining psychiatric symptoms, the role of behavioral explanations and interventions for psychiatric symptoms could not be dismissed. Indeed, behavioral psychotherapeutic approaches served as an alternative to psychoanalysis and person-centered psychotherapy in the time preceding the proliferation of cognitive approaches, and they regained traction in the 1980s when combined cognitive and behavioral treatments were developed and optimized for the treatment of anxiety disorders and obsessivecompulsive disorder (OCD; Barlow, 1988; Rachman, 2015; Salkovskis, 1985). It was at this time that the phrase “cognitive behavioral therapy” began to be used by scholars and clinicians (as opposed to “cognitive therapy” or “CT”), emphasizing the relatively equal importance of cognition and behavior in understanding and treating psychopathology. In fact, many regard the early behavioral approaches to treatment based in classical and operant conditioning as a “first wave” of evidence-based psychotherapy, and they view cognitively focused psychotherapeutic approaches as a “second wave” of evidence-based psychotherapy, such that the scientific principles of behaviorism were applied to internal cognitive phenomena. As many readers likely know, many scholars and clinicians regard the field as currently being immersed in a “third wave” of evidence-based psychotherapy that is characterized by two important features: (a) a focus on function, as opposed to form (e.g., purposes and consequences of thought process instead of modification of thought content); and (b) the inclusion of a focus on acceptance and mindfulness, as opposed to a dominant focus on cognitive and behavioral change and symptom reduction (e.g., Hayes et al., 1999, 2012). It is important to note that some leaders in the field do not necessarily buy into the notion of these three “waves” and them as manifestations of the same underlying principles (Hofmann & Asmundson, 2008). Nevertheless, there is no question that the family of CBTs has been heavily influenced by the proliferation of development in the areas of context, function, acceptance, and mindfulness and that contemporary cognitive behavioral practitioners readily incorporate these constructs into their case formulations and emergent treatment plans (Wenzel, 2017). In fact, I often tell my clients that CBT as it is practiced today in “real-life” settings can be represented as a three-legged barstool, with cognitive change, behavior change, and acceptance being represented by each of the legs. I state (a bit humorously) that CBT should be renamed “CBAT,” or “cognitive-behavioral-acceptance-based therapy.” Thus, as of summer 2019 when I am writing this introduction, I define CBT as an active, problem-focused, time-sensitive psychotherapeutic approach that focuses on cognitive change, behavior change, and acceptance as they apply to a host of mental health conditions and adjustment problems. In addition, I highlight several additional features of CBT that many believe are definitional in and of themselves. First, the foundation of the cognitive behavioral understanding and treatment of any one client is the case formulation, or the application of cognitive behavioral theory to understand a client’s presenting problem, developmental history, and way of experiencing their current life circum-



Introduction  xvii

stances. In fact, over an intellectually stimulating lunch that took place in 2014, Dr. Beck and I agreed that the case formulation is the “heart” of CBT beyond any specific strategy or technique. Second, CBT is semistructured. Many people mistake this to mean that CBT is rigid or formulaic. As the reader will see throughout this two-volume set, there are many, many ways to conduct CBT, and it cannot be boiled down to a specific formula or step-by-step guidelines. Nevertheless, most cognitive behavioral therapists work with their clients to focus the session on at least a couple of aims that they hope to accomplish, and they strategically work toward achieving those aims rather than talking endlessly without purpose. Finally, cognitive behavioral therapists believe that the most significant change occurs when the therapy’s principles are applied outside of session, so clients in CBT are encouraged to complete “homework,” or to engage in some sort of practice or application that will allow them to generalize the principles and skills that they are acquiring in session.

DEFINITIONS OF SPECIFIC CBT TERMS Within the broad CBT framework, there are several constructs that are mentioned in many chapters in this two-volume set. Some of the constructs that are noted most frequently in the chapters are defined below, so it is hoped that this section will serve as a reference point for the reader who is just beginning to become familiar with the nuances of CBT. Therapeutic Alliance Cognitive behavioral therapists believe that a strong therapeutic relationship is essential (though not sufficient in and of itself) to a positive outcome in treatment. Interestingly, cognitive behavioral therapists’ stance on the therapeutic relationship has long been misunderstood by clinicians who practice from different theoretical orientations. In one of his earliest books, Dr. Beck included a chapter on the therapeutic relationship, and when he lectures, he makes clear that he was heavily influenced by giants like Carl Rogers (Beck et al., 1979). Many cognitive behavioral therapists continue to publish scholarship and research on the role of the therapeutic relationship in CBT, most notably the construct of the therapeutic alliance. According to Bordin (1979), the therapeutic alliance is characterized by three constructs: (a) the mutually agreed-upon goals of therapy, (b) the tasks that take place within the process of therapy in the service of reaching therapeutic goals, and (c) the bond between the therapist and client. Research that has examined the contribution of the therapeutic alliance to outcome in CBT typically measures the therapeutic alliance using some version of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Thus, when chapter authors reference research on the therapeutic alliance, unless otherwise specified, the reader can assume that this is the self-reported perception of the client about the goals, tasks, and bonds in therapy.

xviii Introduction

Cognition and Its Modification A core strategy in the cognitive behavioral treatment of almost all mental health problems is cognitive restructuring, or the process by which therapists help their clients identify, evaluate, and, if necessary, modify unhelpful thinking that exacerbates emotional distress. Because of its central importance, this strategy is mentioned in most of the chapters in the handbook set. The type of cognition that is most commonly subjected to cognitive restructuring is the automatic thought, named as such because it is a thought that emerges seemingly instantaneously when a person is faced with a challenging or aversive situation. The specific nature of the automatic thoughts that are observed are typically influenced by the contents of a person’s underlying core beliefs, or fundamental beliefs that people hold about themselves, others, the world, or the future. Core beliefs usually develop through early life circumstances and experiences, although they can be altered (sometimes radically) by notable events that take place during adulthood. The astute reader will note that many chapter authors use the term schema, which also encompasses these underlying beliefs that shape the way a person views their life experiences. Although a few chapter authors imply that their use of schema is synonymous with core beliefs, many cognitive behavioral experts view schemas as encompassing core beliefs from a content perspective but as being a bit broader to reflect biases in information processing, or the way in which people filter information. Figure 1 depicts the way in which I view the relation between schemas and core beliefs. Cognitive restructuring uses a process of guided questioning to help clients arrive upon their own conclusions regarding the accuracy and helpfulness of their thinking, called guided discovery. The questioning used in guided discovery is called Socratic questioning, which has its roots in the teaching style of the Greek philosopher Socrates, who asked questions of his students to elicit critical thinking, rather than simply lecturing to his students and telling them what to think. Although it should be noted that guided discovery is often used by writers to capture the full extent of the cognitive restructuring process—from the identification of unhelpful cognition to the arrival of more balanced thinking—I have also seen guided discovery defined primarily as the process of uncovering previously unacknowledged problematic thinking that is associated with emotional distress. Moreover, guided discovery can also refer to the more general process, both within the process of cognitive restructuring as well as within the process of other BT strategies, in which the therapist asks questions to help the client consolidate the learning that is occurring (e.g., “What did you learn from doing this exercise?” and “How can you apply this knowledge to other circumstances in your life?”). Cognitive restructuring is typically implemented in the spirit of promoting a sense of collaborative empiricism between the therapist and client. Collaborative empiricism means that the therapist and client work together as equal members of a team (i.e., collaborative) to examine facts and evidence (i.e., empiricism) to arrive upon the most accurate way of viewing a situation. Collaborative empiricism is a fundamental tenet of CBT. Although it is referenced most often



Introduction  xix

FIGURE 1. Schemas and Core Beliefs

in the context of cognitive restructuring, as I mentioned is the case with guided discovery, it can be applied more broadly for clients to test the effectiveness of a wide range of strategies as they learn to live their lives in a different, more balanced manner. Finally, a very specific term that is referenced in many chapters is the thought record, or a form in which clients can record their cognitive restructuring work that they do in sessions and in between sessions for “homework.” Many versions of thought records exist, including those in which clients simply record thoughts that arise in upsetting situations; thought records in which clients record thoughts that arise in upsetting situations along with the evidence that does and does not support their thinking; and thought records in which clients also construct a new thought that is more accurate, helpful, and balanced as a result of Socratic questioning. Although, traditionally, thought records took the form of sheets of paper on which clients would write using a pen or pencil, over the past several years, many clients have kept “virtual” thought records whereby they record their cognitive restructuring work in electronic computer files or mobile phone applications. Behavioral Activation Behavioral activation is a common strategy in the cognitive behavioral treatment of depression. It aims to increase clients’ engagement in their lives by encouraging them to do things that give them a sense of joy, pleasure, accomplishment, and/or meaning. It is anticipated that, by more actively engaging in these sorts of activities in their lives, clients will attain a sense of response-contingent positive reinforcement, which has the potential to be just as potent as taking an antidepressant pill. Many cognitive behavioral therapists who implement behavioral activation in their sessions use an activity log so that clients can record

xx Introduction

the activities in which they are engaging, activities that they are attempting to work into their routines, ratings capturing the benefits that they receive from those activities (e.g., the degree of mastery or pleasure associated with each activity), and an overall depression rating for each day. The idea behind the activity log is that clients will readily see patterns in the “data” that they collect in support of the benefits of behavioral activation and that these benefits will contribute to clients’ motivation to adopting the principles of behavioral activation into their everyday lives. As the reader will see in the chapter on behavioral activation, research shows that it is just as efficacious as a full package of CBT (i.e., a package consisting of behavioral activation, cognitive restructuring of automatic thoughts, and cognitive restructuring of core beliefs; Dimidjian et al., 2006; Jacobson et al., 1996). Although behavioral activation is a strategy that was originally included in Dr. Beck’s traditional CT for depression approach (Beck et al., 1979), its current version (Martell et al., 2010) is also viewed by many as a member of the third wave of CBTs because of its current emphasis on recognizing the function that depressive rumination has on behavioral inactivity and on engagement of activities consistent with one’s values. Exposure The counterpart of behavioral activation in the behavioral treatment of anxiety is exposure, or the intentional and systematic contact with a feared stimulus or situation (Abramowitz et al., 2011). Many of the chapters on anxietyrelated disorders describe exposure as being a central technique in the cognitive behavioral treatment of the condition. There are many types of exposure, including (a) in vivo exposure, or contact with a “real-life” feared situation or stimulus; (b) imaginal exposure, or the facing of upsetting images, memories, or intrusive thoughts; (c) virtual reality exposure, or the use of technology to facilitate simulated contact with a feared situation or stimulus; and (d) interoceptive exposure, or participation in an activity that provokes feared bodily sensations associated with the experience of fear and anxiety themselves. When cognitive behavioral therapists facilitate exposure, they usually work with their clients to develop a fear hierarchy, or an ordered sequence of feared stimuli and situations ranging from those that are least to most anxiety provoking. The fear hierarchy serves as a guide for the selection of exposures both in and out of session. As with behavioral activation, research shows that exposure is just as efficacious as a full package of CBT involving exposure and cognitive restructuring (e.g., Foa et al., 2005; Hope et al., 1995). My observation is that clients can do wonderful cognitive restructuring work, but if they continue to avoid feared stimuli and situations, then additional intervention is necessary (and exposure is almost always the necessary intervention). In addition, the field has evolved regarding the ultimate goal of exposure. From the traditional theory based on the work of Foa and Kozak (1986), exposure was hypothesized to work via



Introduction  xxi

habituation, or a reduction in fear, and newer approaches to understanding exposure emphasize fear tolerance and the violation of outcome expectancies (Craske et al., 2008, 2012). Many cognitive behavioral therapists implement exposure in the form of a behavioral experiment, or an instance in which clients “test out” negative predictions and assumptions about what they expect to happen when they face a feared situation. Behavioral experiments facilitate exposure because clients face situations that they dread or of which they are fearful in “real time.” At the same time, they, equally, achieve the important aims of cognitive restructuring because they provide “real-life” data to reshape their negative predictions, assumptions, and expectations. Behavioral experiments are perhaps the quintessential example of the notion that cognitive and behavioral change strategies cannot be fully separated from one another, such that change achieved in one area has important implications for change in the other.

ORIENTATION TO THE TWO-VOLUME SET The reader is about to embark on an ambitious two-volume set that is meant to cover, certainly not exhaustively, the range of contemporary cognitive behavioral scholarship that defines the field today. Volume 1, Overview and Approaches, consists of three main sections. Part I provides a contextual background to understand the roots of CBT, its major theoretical and empirical findings, and current issues in the field. In Chapter 1, Robert L. Leahy and Christopher R. Martell, two giants in the field, take on the essential task of summarizing CBT’s philosophical and historical roots. Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann contribute, in Chapter 2, an equally essential piece on CBT’s theoretical foundations. Chapter 3 turns to the empirical status of CBT outcome, and Claudi Bockting and her impressive collaborators (i.e., Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, and Pim Cuijpers) updated a summary of outcome studies primarily targeting depression, anxiety disorders, OCD, and posttraumatic stress disorder (PTSD). Strategically placed immediately after this outcome chapter, Chapter 4, authored by Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, me, and Jasper A. J. Smits, extends the general notion of outcome and focuses on the mechanisms of change in successful CBT. Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler provide an excellent critical analysis of case formulation, what I view as the heart of CBT, in Chapter 5. In Chapter 6, on dissemination and implication, Bradley Karlin focuses on the practice of “real-life” CBT in real-life settings with real-life clients—an issue that is essential if we in the field are to ensure that CBT is accessible by people with mental health problems in need. In the final chapter of Part I, Chapter 7, I discuss a topic that is near and dear to my heart— the therapeutic relationship—and consider many ways in which CBT facilitates the therapeutic relationship and ways in which optimal CBT can be conducted with its focus on issues arising in the therapeutic relationship.

xxii Introduction

Part II of this set focuses on strategies and techniques that are used across many specific approaches within the family of CBTs. I define a strategy as a general intervention approach that is meant to operate according to a specific hypothesized process of change (e.g., cognitive restructuring, behavioral activation) and a technique as a specific practice that is implemented to achieve the aim of the strategy (e.g., the thought record). In Chapter 8, Christine Purdon presents a thoughtful description of cognitive restructuring and techniques to achieve that aim. Chapters 9, by Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter, and 10, by Lauryn Garner, Emily Steinberg, and Dean McKay, describe the tried-and-true behavioral strategies of behavioral activation and exposure, respectively. In Chapter 11, my colleagues, Deborah H. A. Van Horn and Peter Britton, and I describe the well-established motivational interviewing approach and the way in which it has been used prior to the commencement of CBT to increase readiness for change and during CBT when therapists face ambivalence in their clients. Chapter 12, on the regulation of physiological arousal and emotion, by Holly Hazlett-Stevens and Alan E. Fruzzetti, is an amalgam of two chapters that I had originally proposed for the set: (a) breathing retraining and muscle relaxation and (b) mindfulness and acceptance. The authors presented a compelling argument as to why these strategies should be placed together, and I agreed. Finally, John Ludgate’s discussion of relapse-prevention techniques in Chapter 13 is an important reminder for cognitive behavioral therapists to be thoughtful in their strategic approach to ending therapy, consolidating the gains made in therapy, and planning for obstacles that clients might encounter after therapy has ended. The last section of Volume 1, Part III, focuses on cognitive behavioral psychotherapy packages. The chapters in this section generally follow a format that describes the history of the approach, its main procedures, outcome data, mechanisms of change, applications to diverse populations, and dissemination. At times, chapter authors include clinical examples. In Chapter 14, Amanda Fernandez, Keith Dobson, and Nikolaos Kazantzis describe traditional cognitive therapy established by Aaron T. Beck and his colleagues, and subsequently, Debbie Joffe Ellis discusses her late husband Albert Ellis’s REBT in Chapter 15. Arthur M. Nezu and Christine Maguth Nezu summarize emotion-centered problem solving in Chapter 16. Interestingly, I had initially identified this chapter as one on problem solving as a strategy that would be included in Part II; however, the magnitude of the body of literature on problem-solving therapy over the past 30 years suggests that it is an important cognitive behavioral treatment package in its own right. Chapter 17 turns to a consideration of schema therapy by Eva Fassbinder and Arnoud Arntz, complete with two case examples of clients with personality disorders that are followed throughout the chapter to illustrate specific schema therapy techniques. In Chapter 18, Hollie F. Granato, Amy R. Sewart, Meghan Vinograd, and Lynn McFarr describe another cognitive behavioral approach for the treatment of personality disorder and/or chronic conditions: dialectical behavior therapy, a treatment package that balances delivery strategies focused on acceptance and those focused on



Introduction  xxiii

behavior change. The subsequent three chapters illustrate other cognitive behavioral treatment packages that incorporate a strong focus on acceptance: (a) Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin’s chapter on acceptance and commitment therapy (Chapter 19); (b) Amanda Ferguson, Lê-Anh Dinh-Williams, and Zindel Segal’s chapter on mindfulnessbased cognitive therapy (Chapter 20); and (c) Peter L. Fisher’s chapter on metacognitive therapy (Chapter 21). Chapter 22, by Raymond G. Miltenberger, Diego Valbuena, and Sindy Sanchez, describes applied behavior analysis (ABA). Although ABA is a field unto itself and was not specifically developed as a member of the CBT family, it is included here because many of its principles are incorporated into treatment packages with a strong behavioral basis to modify problem behavior. Emily E. E. Meissel, Jennie M. Kuckertz, and Nader Amir present a unique treatment in Chapter 23 on cognitive bias modification, which focuses on information-processing biases toward or against pathology-relevant stimuli rather than the contents of cognition itself. Part III ends with two chapters on contemporary manifestations of CBT: Chapter 24, by Todd J. Farchione, Julianne G. Wilner Tirpak, and Olenka S. Olesnycky, focuses on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, and Chapter 25, by Nikolaos Kazantzis, Hoang Kim Luong, Hayley M. McDonald, and Stefan G. Hofmann, focuses on the modern practice of CBT. The second volume of the set, Applications, opens with Part I, with chapters on applications to clinical populations. Here, chapter authors contribute pieces on the cognitive behavioral treatment of specific mental health problems and other conditions for which clients often seek treatment. The first group of chapters in this section focus, broadly, on the emotional disorders (i.e., depression and anxiety). In Chapter 1, Daniel R. Strunk, Benjamin J. Pfeifer, and Iony D. Ezawa focus on the treatment of depression, describing many specific cognitive behavioral approaches to treating depression and considering the impact of conditions with which depression is often comorbid. Kamila S. White and Vien Cheung describe the cognitive behavioral treatment of anxiety in Chapter 2, providing detailed information about the nature and efficacy of treatment for an array of specific adult and childhood anxiety disorders. Christine Purdon takes on the treatment of OCD in Chapter 3, emphasizing central cognitive behavioral constructs important in understanding this disorder’s descriptive psychopathology and corresponding pathways for intervention. In Chapter 4, Anke Ehlers and Jennifer Wild describe principles of the cognitive behavioral treatment of PTSD and emphasize the delivery of their own treatment, cognitive therapy for PTSD. The remaining chapters in this section focus on CBT for other mental health disorders and conditions that bring clients into treatment. In Chapter 5, Madelyn Ruggieri, Courtney McCuen-Wurst, and Kelly C. Allison provide a thorough description of the treatment and outcomes for the three main eating disorders—bulimia nervosa, binge eating disorder, and anorexia nervosa. Chapter 6, by A. Tom Horvath, turns to the contemporary cognitive behavioral treatment for clients with addiction; Chapter 7, by Cory F. Newman, outlines a

xxiv Introduction

comprehensive cognitive behavioral framework for understanding and treating bipolar disorder; Chapter 8, by Neal Stolar and Rebecca M. Wolfe, provides a detailed examination of CBT for psychosis; and Chapter 9, by Jason G. Ellis, Michael L. Perlis, and Donn Posner, focuses on the innovative and welldisseminated CBT for insomnia (CBT-I). The next three chapters in this section focus on cognitive behavioral approaches for externalizing problems: (a) anger (Chapter 10 by Michael Toohey), (b) suicide attempts (Chapter 11 by Abby Adler, Shari Jager-Hyman, and Gregory K. Brown), and (c) adult attentiondeficit/hyperactivity disorder (Chapter 12 by J. Russell Ramsay). The section ends with two chapters on CBT for clients with medical conditions: (a) chronic pain (Chapter 13 by John D. Otis, Alex E. Keller, and Lydia Chevalier) and (b) obesity (Chapter 14 by Jena Shaw Tronieri). Part II of the set is geared toward consideration of the delivery of CBT in various modalities and settings beyond the traditional outpatient individual psychotherapy format. In Chapter 15, Elizabeth J. Pawluk and Randi E. McCabe describe CBT as delivered in group settings and include important discussion on challenges that can be encountered in group CBT. Frank M. Dattilio and Norman E. Epstein present CBT for couples and families in Chapter 16, providing a rich theoretical and contextual background for the delivery of CBT in this modality. Medical settings are considered in the next two chapters, with Robert A. DiTomasso, Scott Glassman, Christina Berchock Shook, Anna Zacharcenko, and Michelle R. Lent discussing CBT delivered in primary care settings in Chapter 17 and Aaron Brinen discussing CBT delivered in inpatient settings in Chapter 18. Gerhard Andersson and Per Carlbring engage in a fascinating discussion of CBT delivered via the internet in Chapter 19, taking care to comment on the way in which the internet delivery of CBT compares with in-person delivery. In Chapter 20, Jesse H. Wright, Stephen O’Connor, Jessica Reis, and Michael E. Thase provide guidance on the combined delivery of pharmacotherapy and CBT, including rich data on the efficacy of a combined approach for the major mental health disorders. Finally, in Chapter 21, Donna M. Sudak and Robert P. Reiser present a compelling evidence-based approach to supervision in CBT. The final section, Part III, focuses on applications to diverse populations that are typically encountered in treatment. The first three chapters in this section focus on CBT across the lifespan, with R. Trent Codd  III and Nathan Roth describing CBT as applied to children and adolescents with externalizing disorders in Chapter 22; Amber Calloway, Nicole Fleischer, and Torrey A. Creed describing CBT as applied to children and adolescents with internalizing disorders in Chapter 23; and Kenneth Laidlaw describing CBT as applied to older adults in Chapter 24. In Chapter 25, Maegan M. Paxton Willing, Larissa L. Tate, and David S. Riggs discuss mental health conditions most often encountered in military populations and ways in which CBT can be adapted to veterans and military servicemembers. Next, in Chapter 26, Trevor A. Hart, Julia R. G. Vernon, and Tae L. Hart consider guidelines for the cognitive behavioral treatment of gay, lesbian, bisexual, and transgender individuals. Gayle Y. Iwamasa presents a compelling framework for adaptations of CBT for cultural and ethnic minorities, along with results from available empirical research with specific



Introduction  xxv

cultural groups, in Chapter 27. Finally, Chapter 28 by Moses Appel and David H. Rosmarin, ends the two-volume set with a fascinating consideration of CBT as applied to individuals of various religious groups. Two additional notes about this set are warranted. First, the astute reader will notice that some chapters refer to consumers of services as “patients,” whereas other chapters refer to consumers of services as “clients.” Indeed, the use of terminology for this purpose has sparked quite a bit of debate (e.g., Joseph, 2013). There is no absolute “correct” way to remedy this issue, so I allowed chapter authors to use their preferred terminology. I saw that a number of chapter authors used “client,” another large chunk of chapter authors used “patient,” and still other chapter authors alternated between “client” and “patient” (which prompted me to ask them to choose one or the other and use it consistently throughout, as it activated my own obsessive-compulsive tendencies). Regardless of the terminology used, cognitive behavioral therapists hold the utmost respect for each of their clients (patients), and they truly view themselves as being in a collaborative partnership with their clients (patients) in which all parties bring valuable knowledge to the working alliance. In addition, the astute reader might also notice that many of the chapters (other than the chapters in Part IV, which were targeted toward specific mental health conditions) focus on depression and anxiety much more than other mental health disorders. This is not for want of my trying diligently to encourage authors to comment on the full range of pathology beyond depression and anxiety, including bipolar disorder, psychosis, eating disorders, substance use disorders, and personality disorders. However, the continued focus primarily on depression and anxiety led me to see that this emphasis reflects the state of the literature—that empirical research on cognitive behavioral theory is much more sophisticated, to date, in its application to depression and anxiety than other mental health disorders. I elaborate upon this much more in the conclusion, where I propose tangible directions for future research that will advance the field.

LOOKING AHEAD The editorial staff at APA Books and I recognize that there are many CBT handbooks on the market. Why is another handbook warranted, and what makes this one unique? When I read comprehensive reviews on an important aspect of CBT for my own scholarly work, my reaction is that multiple chapters on the same topic, even if there is overlap, help reinforce central information and provide unique perspectives and supporting evidence to fill in the overall picture. Moreover, the field is always evolving, so there are references to empirical research in the chapters in this set that would not have been made available to authors of chapters in even recent handbooks. However, most importantly, I strove to include a balance of traditional and innovative topics. Although this handbook includes many chapters on subjects that are included in other CBT handbooks, there are a number of fairly unique

xxvi Introduction

chapters in this handbook. I take great pride in the emphasis on the therapeutic relationship in the chapter that I drafted for the handbook, as well as its consideration in other chapters. Increasingly, the field is turning its attention to dissemination and implementation of CBT, so Karlin’s chapter on this topic is timely in its summarization in the literature and work that remains to be completed. In addition to chapters on fairly “traditional” CBT approaches (e.g., CT, REBT, exposure), I also included chapters on more recent developments in CBT, such as metacognitive therapy (MCT; Fisher), cognitive bias modification (CBM; Meiseel, Kuckertz, & Amir), the United Protocol for the Transdiagnostic Treatment of Emotional Disorders (Farchione, Wilner Tirpak, & Olesnycky), and insights into the delivery of CBT from a modern, or contemporary, perspective (Kazantzis, Luong, McDonald, & Hofmann). In the realm of special populations and issues, CBT for veterans and military servicemembers (Paxton Willing, Tate, & Riggs) and religious individuals (Appel & Rosmarin) has become a popular focus for blog posts and podcasts of late. Even when authors took on fairly traditional topics, they were strongly encouraged to adopt an innovative approach to their presentation by including the latest, cutting-edge research and considering mechanisms of change, applications to special populations, dissemination, and case illustrations on client engagement or the resolution of tricky clinical issues. My hope is that, after finishing the desired chapters, readers can see the significant theoretical and empirical foundation on which the family of CBTs and its strategies and techniques rest, as well as the promise for its optimization, dissemination, and implementation in the future. CBT has transformed the lives of countless individuals, yet many individuals who suffer from mental health disorders continue not to have access to CBT. This two-volume set represents the latest attempt to highlight the rigor, power, and promise of CBT’s application in an ever-changing world.

REFERENCES Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety: Principles and practice. Guilford Press. Barlow, D. H. (1988). Anxiety and its disorders. Guilford Press. Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. Harper and Row. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16(3), 252–260. https://doi.org/10. 1037/h0085885 Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. https://doi.org/10.1016/j.cpr.2005.07.003 Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27. https://doi.org/10.1016/j.brat.2007.10.003



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Craske, M. G., Liao, B., Brown, L., & Vervliet, B. (2012). Role of inhibition in exposure therapy. Journal of Experimental Psychopathology, 3(3), 322–345. https://doi.org/10. 5127/jep.026511 Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., Gallop, R., McGlinchey, J. B., Markley, D. K., Gollan, J. K., Atkins, D. C., Dunner, D. L., & Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670. https://doi.org/10.1037/0022-006X.74.4.658 Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized trial of prolonged exposure for PTSD with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953–964. https://doi.org/10.1037/0022006X.73.5.953 Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909. 99.1.20 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press. Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28(1), 1–16. https://doi. org/10.1016/j.cpr.2007.09.003 Hope, D. A., Heimberg, R. G., & Bruch, M. A. (1995). Dismantling cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy, 33(6), 637–650. https://doi.org/10.1016/0005-7967(95)00013-N Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Consulting Psychology, 36(2), 223–233. https://doi.org/ bzjxtr Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295–304. https://doi.org/10.1037/0022-006X.64.2.295 Joseph, S. (2013, August 4). Patients or clients? What word should psychologists use to describe the people they help? Psychology Today. https://www.psychologytoday.com/ us/blog/what-doesnt-kill-us/201308/patients-or-clients Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. Guilford Press. Rachman, S. (2015). The evolution of behaviour therapy and cognitive behaviour therapy. Behaviour Research and Therapy, 64, 1–8. https://doi.org/10.1016/j.brat. 2014.10.006 Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. https://doi.org/bt7qmf Wenzel, A. (2017). Innovations in cognitive behavioral therapy: Strategic interventions for creative practice. Routledge. https://doi.org/10.4324/9781315771021

I CONTEX T

1 Philosophical and Historical Foundations Robert L. Leahy and Christopher R. Martell

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sychology was not always a discipline separate from philosophy—and, indeed, one can recognize the importance of philosophical assumptions when we realize that psychology is the study of the “psyche,” that is, the “soul.” Cognitive and behavioral models developed from a long history of philosophical debates, beginning with Plato, Epictetus, and Seneca and continuing on to Immanuel Kant, Edmund Husserl, William James, Gilbert Ryle, the early Ludwig Wittgenstein, logical positivism, British analytic philosophy, and the emergence of common language philosophy. Indeed, for much of this historical overview, the “debate” was between those giving precedence to cognition (reason, rationality, logic) and those giving precedence to emotion (the tragic sense of life, intuition) and, later, those philosophical behaviorists who rejected the “ghost in the machine”—that is, concepts of “mind” (such as thoughts, memory, intention). In the first section of our review, we will describe how these issues of rationality, emotion, choice, and value evolved over the last 2,400 years, leading to the current debates within the cognitive behavioral field. In fact, as will become clear, we hope, these debates are alive and well and are the focus of the differences among the “three waves” that continue to dominate the field. Behaviorism as a philosophical position developed as an “antidote” to the mentalism underpinning cognitive models, but the debate about the legitimacy of studying cognition and the role of cognition continues to the present time. For the sake of clarity, we will refer to cognitive therapy in our discussion of the focus on thought processes in psychopathology and to behavior therapy in our discussion of the influence of

https://doi.org/10.1037/0000218-001 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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behavioral and learning models. The field has emerged to include a synthesis that is now called cognitive behavioral therapy (CBT). Within the more general rubric of CBT, there are considerable differences that have arisen, some placing greater emphasis on cognitive content (cognitive therapy, rational emotive therapy), some placing emphasis on behavior and its consequences (behavioral activation therapy), some placing emphasis on how one relates to one’s thoughts (acceptance and commitment therapy [ACT], mindfulness, metacognitive therapy), and some placing emphasis on emotion regulation and skill acquisition (dialectical behavior therapy [DBT]). In this chapter, we have divided our discussion into two broad areas—the influences on the cognitive models and the influences on the behavioral models. Of course, the current “larger camp” of DBT can include—or not include—a synthesis of both. So let us begin with the Greeks, from whom much wisdom originates.

PHILOSOPHICAL FOUNDATIONS OF COGNITIVE THERAPY The cognitive model has a long history in philosophy, beginning with Plato, Socrates, Aristotle, Epictetus, and all the Stoics, and continuing throughout the last 2,400 years of Western philosophy. The central role of thinking as a fundamental determinant of emotion, value, and choice has privileged “rationality” over “emotion.” Indeed, one can argue that the dialectic in Western philosophy has been between those who emphasize rationality and cognition in general as contrasted with those who emphasize emotion. On the side of rationality, we have almost all of ancient Greek philosophy; on the side of emotion, we have almost all of Greek tragedy. We will see that behavioral theories developed much later in philosophical discussion. The cognitive model places considerable emphasis on the role of thinking in the activation, maintenance, and escalation of psychopathology, while recognizing that evolutionary, genetic, environmental, socialization, and significant current and past life experiences can contribute to current cognitive processes and emotional difficulties (A. T. Beck & Haigh, 2014). In the cognitive model, cognition is the “proximate” cause, suggesting that modification of the content of or the way one responds to one’s thoughts will have enduring effects on emotion. The question, of course, is whether cognition is primary or even essential—a central point in much of Western philosophy. Epistemology: The Nature of Knowing The cognitive model is based on the view that knowledge is determined partly by the structure of thinking—or the categories of thought through which we experience “external reality.” Epistemology is the study of how we know—or even whether it is possible to “know”—external reality. We can trace the origins of the epistemological model to Plato in The Republic, which describes the



Philosophical and Historical Foundations  5

following: A group of men are chained facing a wall where they observe shadows dancing across the wall in front of them. They have never known that these shadows are due to figures near the entrance to the cave moving behind them in front of a fire. To these men, the shadows are reality. One day one of the men turns around and sees that there are figures moving behind him casting their shadows across the wall in front of him. From that day on, the “reality” of the shadows no longer exists. We might view cognitive therapy as the attempt to get patients to unchain themselves and see outside the cave—to see the forms. Plato goes on to argue that the men will find it difficult to go back to their prior beliefs in the shadows on the wall now that they have been enlightened. A fundamental element of Plato’s theory of knowledge is that the true forms of reality lie within us—as innate ideas—and that inquiry and philosophical examination allow one to access the truth by questioning one’s logic. Thus, knowledge is “education” or “leading out”—“recollection”—as exemplified by Plato’s description in Meno, where he helps a young boy understand a problem in geometry (Cornford, 2003). What is essential here is that the nature of “reality,” for Plato, is the forms, or ideas, that are intrinsically knowable by a guided discovery. Through guided discovery, the questioner (Plato or, in cognitive therapy, the therapist) asks a series of questions to “uncover” or “elicit” an awareness of the potential contradictions or problems in the individual’s thinking. This is different from lecturing or memorizing “facts,” which would bypass developing the capacity for reasoning in the person questioned. Guided discovery is a key element in Beck’s cognitive therapy. Implicit in Plato’s theory of knowledge is the argument that one is inclined to prefer the logically consistent argument—what we might describe as the rational principle. Another element of Plato’s theory of knowledge was that emotion interferes with correct and rational thinking. In his allegory of the charioteer, Plato describes a horseman trying to direct and control two horses—one that is obedient (“spirit”) and the other that is wild. This tripartite psyche finds its parallel in psychoanalytic models of the ego, superego, and id. The wild horse, representing emotion and impulse, is brought under control by the charioteer who directs the horses toward a specific goal. In Plato’s model, the “goal” that is preferred represents wisdom or virtue—that is, the direction toward a “higher” functioning (Sorabji, 2000). One can view this as a series of “movements,” the first movement being the awareness of something disturbing (in Plato’s terms, “the fluttering of the soul”), followed by standing back and considering what is happening, then considering the virtuous goal (e.g., courage), and then directing the psyche or choices toward that goal (Sorabji, 2000). Indeed, we can see several of the elements of third wave thinking in The Republic, which was written 2,400 years ago. It is important to recognize that Plato’s model was one of idealism—in the sense that knowledge was based on categories of thinking, ideal forms, and the elicitation of these innate functions of mind. This is different from the Beckian model, which attempts to test out the veridicality of thoughts by collecting

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evidence in the “real world.” The Socrates in Plato’s writings bases his examination and disputation of thinking on internal logical contradictions, not on collecting information empirically. Ironically, in a true sense, the Beckian “Socratic dialogue” is not really Socratic—because the examination of thinking in the Beckian model is pragmatic, empirical, and, of course, logical (Kazantzis et al., 2014). Plato’s model was completely rational and placed little emphasis on pragmatics or empirical discovery of facts. Aristotle, who was a student of Plato’s, combined an interest in collecting information about biological specimens and historical records but was not as limited in relegating emotion and empirical facts to a lower status. In the Nichomachean Ethics, Aristotle develops a guide to living a life of “flourishing” or “happiness” based on the assumption that one’s happiness and satisfaction in life (eudemonia) will be determined by living a life consistent with virtue. Aristotle’s model of virtue was based on the character traits that one would admire in another person—that is, the goal was to become the person that you would admire. As in Plato, one’s intention and thoughts about choices were paramount in determining virtue, and correct action was to be determined by the balance of qualities—the right amount at the right time for the right reason. Thus, it would be virtuous to choose to defend a friend if the intention was to show loyalty and courage rather than to gain approval or gain advantage. Although the model of eudemonia has had little impact on the cognitive model advanced by Beck and others, it has been a major source of ideas for positive psychology, which emerged out of CBT models in general. Thus, the emphasis on what leads to happiness, flourishing, and meaning has a great deal to do with the development of character, values, and virtues, as reflected in the work of Martin Seligman, Mihaly Csikszentmihalyi (1990), Barbara Fredrickson, and others. The recognition of the importance of “a valued life” or “a life worth living” is also reflected in current developments in ACT (Hayes et al., 2011) and in DBT (Linehan et al., 2007). The Stoics—such as Zeno, Epictetus, Seneca, and Cicero—followed in the tradition of Plato and Aristotle in placing considerable emphasis on the role of reason and logic in epistemology and ethics. Epictetus proposed in the Enchiridion that circumstances or external reality (such as life events) do not determine how we feel, but rather it is our interpretations of these events that moves us: “It isn’t the events themselves that disturb people, but only their judgments about them.” Epictetus argued that our beliefs that something is necessary for our happiness, our attachment to objects or people, or our concern about the opinions of others will determine how unhappy we are. The goal in the Stoic model was to be the master of the self, to turn toward one’s own will and ideas to determine choices and emotions and to free oneself from depending on external sources of esteem and value. For example, in Enchiridion, Epictetus argued that to become too attached to another person (such as a family member) meant that one was relinquishing one’s freedom to something external to the self. The Stoic model stressed the idea that one’s happiness could be achieved by focusing on one’s own beliefs and willpower to do what is



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difficult to do and, thereby, maintain one’s freedom from the vicissitudes of everyday life. The Stoic model was one of self-sufficiency and the freedom to determine one’s emotions based on one’s thoughts rather than external consequences or convention. In the Stoic model, as in Plato’s model, emotions were viewed as in competition with rational and ethical thinking that was viewed as the only means by which flourishing or happiness could be attained. The Stoics and the Greek and Roman philosophical tradition had a considerable influence on Albert Ellis and, later, Aaron Beck in the development of their respective rational emotive therapy and cognitive therapy. Although originally trained in psychoanalytic therapy, Ellis found the psychodynamic model to be slow and ineffective, and he began to draw on the work of Epictetus and other Stoics to develop a more “rational” model that emphasized conscious thinking at the present moment while actively disputing the client’s verbal statements and beliefs. Ellis credits Epictetus with influencing his model of rational emotive behavior therapy, which stresses the idea that it is our beliefs (cognitions) that determine how we feel. Ellis outlined a wide range of “irrational beliefs” that contributed to psychopathology, including awfulizing (“It’s terrible that this happened”), should statements (“I should be successful”), low frustration tolerance (“I can’t stand being bored with work”), and other “distortions” in thinking. In the long history of Western philosophy, the primacy of the rational is a common thread that finds its strongest expression in the last 400 years in Rene Descartes’s cogito ergo sum—“I think, therefore I am.” Indeed, in Discourse on Method, Descartes argued that one could doubt any statement about external reality; “perhaps it is only a dream or hallucination,” one might speculate. But the foundation of indisputable knowledge is that I am thinking. Thus, the analysis of one’s thoughts and the primacy of cognition for one’s very existence is the cornerstone of his epistemology. I can doubt my speculations about reality, but I cannot doubt that I am thinking. The cognitive epistemology (i.e., the analysis of thought itself) is the focus in Kant’s metaphysics. For example, Kant’s (1782/2004) philosophy of mind was based on the view that reality (noumena) is never directly knowable but rather is “known” through “categories of thinking” (phenomena). Some of these categories are viewed as innate, prior to experience—the synthetic a priori: for example, categories of quantity, intensity, time, and cause and effect. Other categories of thinking are acquired, but all knowing of the noumena or external world is through the lens of the categories. Thus, “reality” is never known directly. One can see the resemblance to contemporary models of schematic processing—that is, our experience of events is determined by the categories or schemas that mediate the process of knowing, such as perception, attention, and memory. Consequently, reality is never directly knowable; we only know reality through the schemas. Moreover, Kant argued that morality or duty could be determined by a universal “categorical imperative”—that is, a logically consistent rule such that whatever rule is applied could be applied universally. For example, rather than base a moral rule on convention, authority, practical

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consequences, religious tenet, or legal agreements, the categorical imperative required that the moral rule be applied universally to all people in all circumstances. Thus, this “logically derived” rule proposed that lying is always wrong, regardless of the circumstances. This contrasts with the utilitarian model of ethics or morality, specifically, Bentham—“The greatest good for the greatest number of people.” In contrast to Kant’s emphasis on innate categories, British empiricists, such as David Hume, Jeremy Bentham, and John Locke, argued that our understanding of reality was simply a matter of “associations” of events. Locke’s (1689/1975) view (Essay Concerning Human Understanding) was that the mind at birth is a blank slate (tabula rasa) upon which external reality imprints itself—or “writes itself.” The contiguity or association of these events, often accompanied by reward or punishment, would determine the knowledge and the value that developed through experience. Locke’s view was a complete rejection of the model of innate ideas, ideal forms, or the Platonic model. Thus, if we saw that two events occurred together, we might correctly or incorrectly conclude that one was a cause of the other. Since empiricism argued that knowledge is somewhat arbitrarily based on experience—not on universal categories—it followed that “knowledge” was precisely in one’s point of view. Thus, knowledge became “relativistic” just as moral rules became relativistic. This, of course, is in contrast to the model of virtue in Aristotle and Plato and in contrast to the universal categorical imperative proposed by Kant. The emphasis on how we experience the world—rather than the emphasis on universal innate categories—gave rise to phenomenological theories of knowledge (Husserl, 1960). The phenomenologist is less interested in what “reality really is” and more interested in how reality is experienced (i.e., the “phenomenal experience”). Cognitive therapy is partly derived from this tradition: Although the therapist may assist the patient in testing their cognitions against “reality,” there is considerable emphasis in cognitive theory on the “subjective” experience of the patient. Challenges to Logical Positivism In the 1920s and 1930s, philosophy underwent a revolution led by the Vienna Circle of Logical Positivists. A major figure was the young Ludwig Wittgenstein (1923/1974), whose Tractatus Logico-Philosophicus proposed the core tenets of logical positivism. This model of epistemology argued that all statements are meaningless unless they can be verified (the verifiability principle). Thus, the meaning of a statement is determined by the means by which we observe its consistency with the facts; statements about “reality” are pictures of the world, in Wittgenstein’s formulation. Although this model had considerable influence, it was Wittgenstein himself who led the rejection of logical positivism, in Philosophical Investigations (Wittgenstein, 1967). In this seminal text—one of the most influential works of the last century in philosophy—Wittgenstein turned logical positivism on its head. He now emphasized that meaning is determined by the function or use of language and that meanings are determined by “lan-



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guage games” and the “rules” that are followed. This gave rise to the influential “common language school” of philosophy. For example, J. L. Austin (1975) indicates that the following statement is meaningful, even though we could not imagine how the verifiability principle could be applied: “Please get me a cup of coffee.” Moreover, the idea that science was driven by the discovery of facts according to the verifiability principle was disputed by those like Norwood Russell Hanson (1958), who described “patterns of discovery” (that investigation was driven by hypotheses, that is, thoughts and models) or that scientific progress was characterized by “paradigm shifts,” as proposed by Thomas Kuhn (1970). Further, philosophical debates against strict behavioral models included the classic essay “What Is It Like to Be a Bat” by Thomas Nagel (1974), which argued that behavioral descriptions cannot describe the experience that a bat has that differs from that of human experience, and arguments by others, such as John Searle (1980), that one can observe another’s behavior but not know their intention. In more recent years, Searle, a leading philosopher, has suggested that the mind–body dichotomy can be resolved, not by reductionist behaviorism but rather by positing that thinking or consciousness is a computational process analogous to software and that the hardware is the neuroscience that underlies the software. This view is consistent with Beck’s recent formulation of the cognitive model as rooted in neuroscience. Epistemology and the Cognitive Model The cognitive model is “constructivist” in that individuals “construct” or “interpret” reality rather than have reality imposed on them (e.g., as if reality forms an impression on the mind). CBT is based on a model, in which cognition and perception may often be based on arbitrarily associated events and that moral rules are individual constructions (rather than universal ideals). Thus, the early founder of cognitive therapy, George Kelly (1955), might say, “That is your construction of reality,” as if all constructions of reality are on equal footing. One can see that the Beckian model does not follow the Platonic model of innate ideas, but it does reflect both the schematic model advanced by Kant and an empiricist model, in which one’s beliefs are determined by experience. One could say that cognitive theory is derived from both the empiricism of the British associationists and the subjectivism of the phenomenological school. These traditions are integrated in what we could call dynamic structuralism—that is, the recognition that the structures of experience (schemas) are continuously modified by the individual’s interactions with reality. In a sense, the cognitive therapist assists the patient in deconstructing their experience. Just as the deconstructionists might argue that the meaning of a text is in the reader (Derrida, 1973; Fish, 1980), the cognitive therapist assists the patient in recognizing that the meaning of experience is in the perceiver. However, unlike the deconstructionists, who seem to imply that reality is unknowable, the cognitive therapist has a more “optimistic” view: that is, that the perceiver’s (patient’s) beliefs can be tested against reality. Cognitive theorists

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are not empirical nihilists like the deconstructionists; rather, they are “structuralempiricists.” This implies that the structures of knowledge—the patient’s schemas—may be tested in the real world.

THE COGNITIVE REVOLUTION IN PSYCHOLOGY In the 1960s, psychology was dominated by two major influences: psychodynamic theory and learning theory. We will discuss the development of the behavioral and learning theory models in a separate section, but here we will review how a number of developments in psychology, beginning with F.  C. Bartlett’s and Jean Piaget’s ideas about schemas, contributed to the development of the cognitive model of psychopathology. The Primacy of Cognition The primacy of cognition was a focus of a heated debate between Robert Zajonc and Richard Lazarus. Zajonc argued that “preferences need no inferences”— that is, that our decisions and emotions were not based on cognition but were rather “automatic” (Zajonc, 1980). This was in contrast to the argument made by Lazarus that cognition was a prerequisite for emotion and choice (Lazarus, 1982). One can view this as turning on the issue of automaticity—that is, some thoughts may be automatic, without reflection or awareness—as suggested by Daniel Kahneman’s (2011) Thinking, Fast and Slow. In contemporary research and theory on the nature of consciousness and automaticity, it has been argued that “conscious awareness” is seldom a key element in how people make decisions; these arguments are based on research that demonstrates that individuals are seldom aware of the stimuli or prior events that actually elicited their emotions, choices, or behavior (Bargh & Morsella, 2008). In this view, consciousness—or one’s report of one’s thoughts about a choice—is an after-thefact accounting, very much like a careless bookkeeper trying to estimate the inputs and outputs after a hangover. The issue of automaticity is important in evaluating the cognitive model because the nature of automatic thoughts involves reflection on the thoughts that one had that give rise to emotion. If one’s attempt to make conscious what are automatic processes is dubious, according to John Bargh and others, we might question whether these automatic thoughts in the Beckian model were truly the thoughts that were functioning. Cognitive Processes The cognitive revolution in psychology in the United States got a jump start with the publication of George Miller’s classic paper “The Magical Number Seven, Plus or Minus Two” in 1956 in Psychological Review. Miller (1956) contended that memory was limited and, therefore, selective, and an entire gen-



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eration followed after exploring the role of cognition in perception, memory, attention, and language acquisition. Ulric Neisser’s 1967 classic text Cognitive Psychology (Neisser, 1967/2014) provided an overview that would influence research and theory for the next 20 years. Major developments in the cognitive revolution included the following: research on episodic and semantic memory by Tulving (2002) in autobiographical memory revealed selective memory rather than simple associations; the rise of artificial intelligence in the work of Newell and Simon (1972), who proposed that computers could simulate human thinking; the development of computational models of information processing; and the introduction of the concepts of heuristics (or rules of thumb) that constituted the automatic and shortcut guides that people use (Kahneman & Tversky, 1979). Indeed, the influence of these cognitive models was not limited to laboratory studies of memory—the models would have influence on evaluating distortions in eyewitness testimony (Loftus, 1979) and on a growing field called behavioral economics (Thaler, 1992). It was in this new field of economics that the cognitive processes were elucidated and that a number of psychologists and economists won Nobel Prizes: Herbert Simon, Daniel Kahneman, Robert Shiller, and Richard Thaler. Schematic Processing A core feature of the Beckian cognitive model and, to some extent, the Ellis model is the importance of schemas. We can think of schemas as habitual patterns of perceiving or thinking based on internal models (i.e., cognitive or perceptual models). Frederick Bartlett was an early proponent of schema theory, by which he proposed that memory was reconstructive according to mental representations (schemata) rather a mere copy of previously learned stimuli (Bartlett, 1932). The role of cognition also found its way into learning theory in Edward Tolman’s (1948) model of response versus place learning, whereby organisms learned a cognitive map (or place)—that is, an internal representation—rather than simple responses that were reinforced. The concept of category or schema that determines attention, learning, and evaluation was a central element of the work on “natural categories” and “prototypes” such that categorization of color or sound appeared to follow a universal set of natural “best examples” (exemplars), stimuli closer to the prototype were easier to learn, and many of the perceptual stimulus categories could be demonstrated before the acquisition of language (Rosch, 1973). The cognitive revolution of the 1970s was also led by work by Bruner on the “new look” in perception, according to which drives and needs affect how people perceive reality (Bruner, 1956). In experimental psychology, there was growing interest in “schematic processing” in memory, including attention, valuation, recall, and reconstruction, indicating that trait concepts serve as prototypes directing attention and modifying recall and recognition (Cantor & Mischel, 1977; Taylor & Crocker, 1981). Schemas that are introduced to subjects in a study can affect recall of information subsequently presented to

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subjects, as indicated by research on false memory or false recall (Loftus, 1979). Thus, individuals may falsely recall information consistent with a schema that has been introduced by the experimenter. These aspects of the schema model were integrated into Beck’s formulation of cognitive theory of depression, which postulated that early negative concepts or schemas about self or others would perpetuate depression by biasing the attention, recall, and valuation of negative information to the exclusion of countervailing positive information. Moreover, even the area of Pavlovian conditioning began to see the importance of mediation, or what we might call “cognition,” in a classic essay by Robert Rescorla on Pavlovian conditioning as involving learning the “relationships” among stimuli (Rescorla, 1988). Owing to the work by Tolman on cognitive maps, the nature of learning was increasingly viewed as based on models of stimulus relations. Piaget’s Constructivism Constructivism gained considerable attention in the first half of the 20th century through the work of Jean Piaget. Rather than viewing the acquisition of knowledge as a simple collection of facts or associations or through direct learning, Piaget proposed what he eventually described as “genetic epistemology.” By “genetic” he meant not “inherited” but rather the growth or genesis of knowledge through a separate distinct order of stages. Rejecting the Kantian idea of the synthetic a priori, the Platonic idea of innate ideas, and the tabula rasa model advanced by Locke and later associationists, Piaget argued that concepts of substance, causality, quantity, morality, and other concepts were constructed through the child’s interaction with the external world (Piaget, 1971). The process of development was characterized by the reciprocal relationship between processes of assimilation (taking in experiences through the schemas) and accommodation (changes in the schemas as a result of successive experience). The process or genesis of knowing was not a direct copy of experience but rather an interaction between the knower and the external world—or symbolic content in formal operational thinking. Piaget traced several universal stages of the growth of knowledge from sensorimotor to preoperational to concrete operational to formal operational thinking. Piaget distinguished between what he called scheme and schema, which reflect operative and figurative intelligence, respectively. Operative intelligence was characterized by the active changes or operations—for example, sensorimotor intelligence involved understanding moving or effecting changes on objects; concrete operations involved understanding how changes in one dimension (height) are compensated by changes in another dimension (width), resulting, in this case, in conservation of quantity or volume; and formal operations involved the understanding of how symbolic or abstract content can be coordinated in a series of relationships. Piaget advanced the idea of decentering to describe the ability to flexibly step away from one dimension or stimulus element to understand how various elements in the system are coordinated through a system of reciprocal transforma-



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tions (Piaget, 1950/1954). Thus, the process of knowing is based on a two-part schema model—scheme and schema—reflecting the active, flexible coordinating operative intelligence and the static, content, figurative intelligence, respectively. As Beck became disenchanted with the psychoanalytic model, he turned to the work of Piaget and George Kelly on constructivism. One might argue that the Beckian and Ellis models describe the “depressive construction of reality.” Language Acquisition Device Concurrent with the rising importance of the cognitive model was Noam Chomsky’s rejection of B. F. Skinner’s reinforcement model of language. The Skinnerian model was one of associationism and reinforcement, which might have been an adequate model for learning words in a vocabulary list but, according to Chomsky, was entirely inadequate for learning language (Chomsky, 1965, 1968). Several lines of evidence were brought to bear to reject the behaviorist model of language: (a) The rules of syntax are so complicated even linguists cannot clearly define them. (b) Language has a creative element—the “generative” function. That is, speakers can generate sentences that they have never heard before. (c) Language involves a system of rule-guided transformations. We understand the deep structure or meaning of a sentence even though the surface structure is different. For example, “the boy threw the ball” has the same meaning as “the ball was thrown by the boy.” (d) Languages worldwide have similar rules of syntax. (e) When young children mimic their parents’ language, it is not a direct imitation but rather one of reducing the complexity to a simpler form. Chomsky (1965) proposed that humans have a “language acquisition device,” very similar in his view to innate ideas, as reflected in his books Aspects of Theory of Syntax (1965) and Language and Mind (1968). Explanatory Style and Attribution Theory The cognitive model of depression also was strongly influenced by work in social psychology, especially the work on attribution processes advanced by Bernard Weiner and others (Weiner, 1974; see also Kelley, 1972). Weiner proposed that individuals seek to explain the causes of their behavior and that of others by relying on several dimensions of causal attribution that include stable and unstable causes and internal and external causes. For example, one individual might explain their poor performance by attributing it to lack of ability (internal/stable), whereas a more optimistic individual might attribute their poor performance to lack of effort (internal/unstable) or bad luck. Seligman, Alloy, Abramson, and their colleagues noted that although noncontingency might account for rats giving up on future tasks—“learned helplessness”—it could not account for individual differences in self-esteem or self-criticism (Abramson et al., 1989; Seligman, 1975). Thus, they argued that an attribution model of depression could draw on Weiner’s attribution model to help expand

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the noncontingency model first advanced by Seligman and to account for the selfcriticism in depression that cannot be explained simply by noncontingency. Cognitive Models of Psychopathology In clinical psychology, Beck’s cognitive model was preceded by three richly elaborated cognitive models advanced by Victor Frankl (1963), George Kelly (1955), and Albert Ellis (1962). Frankl was an Austrian psychoanalyst during the 1930s who was imprisoned by the Nazis at Auschwitz. In 1946, he published Man’s Search for Meaning, which was an existential theory of how the construction of meaning and value can help individuals thrive in the most degrading and hopeless of circumstances. What was especially significant was Frankl’s break from the traditional model of psychoanalysis that stressed unconscious motivation, repression, drive, and the id-ego-superego, as well as the emphasis on the limiting effects of earlier unresolved childhood conflicts. Frankl’s model is clearly existential—indeed, the original English language title was From Death-Camp to Existentialism. As indicated earlier, the rise of existentialism, especially in Continental European philosophy during the 1920s through the 1950s, had emphasized the importance of phenomenal, conscious experience; the sense of agency and personal freedom of choice; and the central role of individuals constructing their own values. Readers familiar with current ACT may see similarities between these approaches. Kelly’s model was strictly constructivist and placed considerable emphasis on the actual structural and process aspects of knowing (Kelly, 1955). Kelly focused on how individuals construct reality by utilizing concepts that had polarity (good-bad, intelligent-stupid), permeability, and other dimensions. The underlying principle is that each person constructs their world through a series of concepts (which we might view as schemas), that these constructs limit what is known or considered relevant, and that they are often difficult for the person to disconfirm. In Kelly’s model, the individual is viewed as a scientist of sorts, seeking answers to questions generated by their constructs—such as, “Is this person trustworthy?”—often leading to selective attention to confirmatory evidence. The analogy to the schema model proposed by Beck is clear, but there are significant differences between Kelly’s and Beck’s models. Beck has identified the content of the negative “constructs” (e.g., the negative triad of depression is a negative view of self, future, and experience), whereas the content of Kelly’s construct theory is the idiosyncratic constructions of individuals. Moreover, Kelly lacks a developmental or even an experiential model, focusing almost entirely on the current conscious categorizations that people make. Albert Ellis had advanced rational emotive therapy before Beck’s cognitive model, arguing that anger, depression, and anxiety are due to specific thinking errors, such as awfulizing, “shoulds,” low frustration tolerance, and other problematic styles of thinking. Influenced by the Stoic philosopher Epictetus, Ellis drew heavily on the idea that it is not events but our interpretations of events that lead to psychological suffering. For example, the idea that “I need this” can



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be reframed to “I prefer this,” and the idea that “this is awful” can be reframed to the view that “nothing is awful if there are rewards or positive experiences available.” The Ellis model was an actively disputatious model whereby the therapist would actively point out “errors” in thinking and directly offer alternative, presumably adaptive beliefs. Unlike Beck, Ellis did not focus on the specific content of the beliefs associated with different categories of psychopathology. For example, the Beckian model posits specific content for each of the anxiety disorders, depression, personality disorders, and eating disorders. Further, Beck’s model stresses the primacy of early schemas that are established during childhood, and his model provides a cognitive architecture (i.e., levels of cognitive appraisal) with automatic thoughts, conditional beliefs or assumptions, and personal and interpersonal schemas. Ego Psychology and Cognitive Therapy The 1940s and 1950s were a time in the development of psychoanalytic thinking that moved away from certain components of Sigmund Freud’s theory, including the drive model, the topographic theory, and the emphasis on Oedipal conflicts. Emerging during this time was the ego psychology movement that focused on the “preadaptive functions” of the ego that were independent from drive conflicts. Heinz Hartmann (1939/1958) was one of the leaders of this movement, attempting to give importance to the role of reality testing, ego control, and independence of drive—as well as the work by Ernst Kris (1951), Anna Freud (1968), and Margaret Mahler (1969). The role of thinking, imagery, and reality adaptation was initially the groundwork for Beck’s cognitive model, which he viewed as a psychodynamic model during his early development of his theory. It is important to recognize that Beck had begun as a psychoanalyst with his early experiment on the dreams of depressed individuals as an attempt to test the psychodynamic model, in which depression was a result of repressed anger turned inward. He expected that the dreams of depressed patients would be characterized by an increase in hostile imagery and content because the repressive function would be lifted during dreaming. Surprisingly, Beck found that the dreams of depressed patients were filled with content of loss and defeat—not hostility. Although Beck had developed a new model of psychopathology and treatment, he continued for many years hoping that his model would be accepted by the psychoanalytic community, but these efforts were to no avail. In the 1960s and 1970s, the psychodynamic model had a challenge from within its community in the work of John Bowlby on attachment theory (Bowlby, 1968, 1973, 1980). Rejecting the drive reduction and Oedipal models that were so central to psychodynamic theory, Bowlby took an evolutionary approach to attachment, demonstrating that the bond between the infant and caregiver was not reducible to drive reduction (i.e., feeding) but rather was a predisposed tendency that was universal and was based on evolutionary forces that led infants to focus on a responsive figure of attachment—usually, but not

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always, the mother. Moreover, Bowlby’s attachment model had a core cognitive element—the internal working model—which was a cognitive schema or construction that represented the infant’s and later the child’s model of attachment figures (i.e., “Were they responsive, were they predictable, would they protect?”). Indeed, current attachment theory follows on from this cognitive model, attempting to trace the developing attachment styles of adolescents and adults that are putatively determined by these early attachment experiences and their consequent internal working models. Conclusions The cognitive models, developed by Beck and Ellis, follow a long tradition in Western philosophy beginning with the work of Plato, Aristotle, Epictetus, and others. Indeed, one can argue that a good preparation for learning how to do cognitive therapy might be to read Plato and the Stoics, especially following the nature of inquiry depicted in Socratic dialogues. The cognitive model of psychopathology was part of the cognitive revolution in many areas of psychology, including work on natural categories and prototypes, schematic processes in memory, impression formation, Pavlovian conditioning, the child’s construction of reality, language acquisition, attribution processes, causal inference, and even ego psychology in psychoanalytic thinking. However, in parallel with the development of cognitive models, we have equally important precursors of behavioral models and models of associationism, learning, and reinforcement. We turn now to review these developments.

THE PHILOSOPHICAL AND HISTORICAL PRECURSORS OF BEHAVIORAL MODELS The behavioral underpinnings of learning theories did not follow a strictly linear path. Current cognitive behavioral treatment approaches are informed by different schools of behaviorism. Early in the 20th century, there were varied ideas concerning what constituted the area of legitimate study as psychologists grew increasingly dissatisfied with traditional psychoanalytic ideas and with introspection as a method of psychological investigation. The evolution of the field of CBT has included research using human subjects as well as basic research that, on occasion, went unnoticed for decades before having a major impact on the theory and practice of behavior therapy and CBT. While a full history of learning theory and the variety of theorists who made substantial contributions cannot be covered in a chapter, we will trace the major figures in the development of behavior therapy and its evolution to CBTs. Broadly, the strongest influence on behavior therapy came from the discipline of learning theory. However, the field of learning theory is replete with theories and findings regarding how learning occurs; the nature of reinforcement; what is reinforced; the effects of punishment; and the importance of



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need, perception, and information in the establishment of behavioral responses. As is true in the nature of psychological science generally, the behaviorists and cognitive behaviorists often conducted research from unrelated labs and came to similar conclusions, and some research was conducted with the explicit intent to disprove the theories of others within the same behavioral orientation. Our focus will be on the trajectory of theories and research that are at the heart of CBT. These ideas did not develop in a clean series of uninterrupted ideas in a timely, systematic fashion. Rather, many researchers explored their ideas contemporaneously with varied emphases and with adherents to particular philosophies or treatment strategies, all under the rubric of CBT. Similarly, the philosophical traditions that influenced behavior therapy varied in importance within the specific behavioral theories that were articulated. Behaviorism is not a unitary idea but rather a set of ideas and traditions that have evolved into differing paths, which we will elucidate throughout this chapter. The psychologists and physicians who pioneered behaviorism as a scientific method and as a treatment practice were not philosophers, but they were influenced by developments in modernity—that is, explaining the world through observation and discovery rather than by a belief in an ultimate truth or the workings of spiritual forces. A core philosophical basis for behaviorism, broadly defined, is not so much the philosophical positions adhered to but rather the philosophy that was opposed—namely, Cartesian dualism. The behaviorists did not differentiate mind and matter, particularly because mind was considered an elusive conception. They were logical positivists, insisting upon linking what was abstract and theoretical to what could be observed. This was Aristotelian and naturalistic as opposed to Platonic and mentalistic. The subject of study was behavior itself, not what behavior symbolized or represented. Skinner differentiated between two types of behaviorism: methodological behaviorism and radical behaviorism. According to Skinner (1974), methodological behaviorism “might be thought of as a form of logical positivism or operationalism” (p. 16). He concluded that although the issues of concern to the methodological behaviorists differed from those of the logical positivists and operationalists, the former maintained that mental events are unobservable. Skinner (1974) would conclude that the methodological behaviorists were successful in disposing of “many of the problems raised by mentalism” (p. 16) but that there continued to be problems in that “most” methodological behaviorists “granted the existence of mental events while ruling them out of consideration” (p. 17). He stated the position of his radical behaviorism differently: “What is felt or introspectively observed is not some nonphysical world of consciousness, mind, or mental life but the observer’s own body” (Skinner, 1974, p. 17). Early Behaviorism and Learning Theory Early behaviorism was articulated by researchers in many parts of the world. Ivan Pavlov was a Russian physiologist who won the Nobel Prize for his research

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on what was then known as the conditioned reflex. It was not likely the intention of Pavlov to be the forbearer of a movement that would change the practice of psychiatry, psychology, and other fields that addressed human behavioral and mental functioning. However, Pavlov’s finding about salivating dogs (Pavlov, 1927) and buzzers represents some of the earliest—but not the only— findings in associative learning and the beginning of modern behaviorism. In associative learning, an unconditioned stimulus (in Pavlov’s case, dog food powder) results in an unconditioned response (such as salivation in Pavlov’s dogs). An unconditioned stimulus is a stimulus that is not learned and that elicits a response, the unconditioned response. With repeated pairings of a conditioned stimulus (in Pavlov’s case, a bell or buzzer) with the unconditioned stimulus, the conditioned stimulus takes on the same function of the unconditioned stimulus. In the classic Pavlovian studies, the dogs would salivate at the sound of a buzzer (the conditioned stimulus) even when the food powder (unconditioned stimulus) was not presented. Several decades before publication of Pavlov’s notable findings, Edward L. Thorndike had written his doctoral dissertation at Teachers College, Columbia University, in the United States on associative processes in animals (Thorndike, 1898, as cited in Bolles, 1979). Thorndike showed that hungry cats would relatively rapidly learn to manipulate a small string with their paw in order to escape from a box and get food. There were individual differences in the learning curves, but all showed a steady decline in the number of seconds it took to escape from the box, demonstrating that learning had taken place. Thorndike also noted that the behavior of the cat was dependent on the type of consequence upon leaving the box. Receiving food upon opening the door resulted in the cats quickly manipulating the rope in order to escape from the box and eat. When the cat was punished for leaving the box, it would not leave. Thorndike called this the “law of effect” as learning occurred because the behavior had an effect on the environment (Bolles, 1979). The law of effect proposes that behavior that is reinforced increases in frequency. Thorndike’s law of effect was in line with the philosophy of associationism dating back to Aristotle and continuing with Hobbes, Locke, Hume, Wundt, and others (Postman, 1947). Thorndike’s theory also reflected the work of Darwin. Darwin’s evolutionary theory of natural selection of species informed the law of effect, which emphasized the selection of behavior by its consequences (Catania, 1999). Leo Postman also argued that a third philosophical idea was important to the law of effect, specifically hedonism. According to Postman (1947), “Associationism is concerned with the laws of connection of mental elements: it has little to say about the role of motives in the acquisition of learned responses” (p. 490). Postman proposed that the philosophy of hedonism, which emphasized the governing principles of pleasure and pain, influenced the law of effect. Thus, Postman suggested that this philosophy dates back as far as Plato and Aristotle, to Hobbes’s proposition that humans seek pleasure and avoid pain, and to the doctrine of utilitarianism, “which regarded self-interest as a sufficient principle to account for most of individual and social action” (Postman, 1947, p. 490).



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While agreement with Thorndike’s conclusions vary, his influence on behavioral and cognitive behavioral psychology is beyond doubt. Academic psychology in the United States was also heavily influenced by behaviorism following the work of J. B. Watson in the early 20th century. Watson rejected traditional introspection and questions about the mind as legitimate subjects for scientific inquiry. Watson was solidly a logical empiricist, rejecting as meaningless anything that could not be directly observed by an outsider. The interest initially was academic, investigating the acquisition of fear and the application of principles of conditioning to human as well as animal behavior. Watson—and then graduate student Rosalie Rayner—conducted experiments in fear conditioning based on the associative learning principles of his behavioral theory that was later published in the classic case of “Little Albert” (Watson & Rayner, 1920). “Albert,” a toddler who showed no fear of rats, rabbits, or other fluffy animals, was conditioned to respond with fear through the pairing of a presentation of a stimulus (i.e., a white rat, and then a white rabbit) with the loud clang of a metal bar from behind as soon as he reached for the stimulus. After repeated pairings of the rat with the loud noise, Albert began to cry when the rat alone was presented (without the startling clang). The Little Albert experiment is one of the most cited research papers on early conditioning, but later reviews have shown the limitations of that work. Researchers today would not use a single case to confirm an entire theory, but the impact of this study was substantial for the field. Also, because there was no follow-up with Albert, who has basically been lost to history, it is unclear whether the conditioned fear response was temporary or whether Albert maintained his fear of white furry animals. Recently, several teams have reviewed archived information to discover the identity of Albert, but there is disagreement as to the veracity of the results (H.  P. Beck et al., 2009; Powell et al., 2014). Watson did not have the opportunity to experiment with deconditioning the fear that was experimentally induced, but 3 years later Mary Cover Jones (1924) conducted an experiment with the case of “Peter,” whom she described as “almost to be Albert grown a bit older” (p. 309). In other words, Peter was not afraid of anything except white furry animals (i.e., a rat, a rabbit) and objects (i.e., a little fur rug, a white fur coat, and to some extent, cotton). Although this was not a true deconditioning experiment because the fear was not a conditioned fear, Cover Jones and colleagues were able to extinguish the fear of a rabbit by pairing proximity to the rabbit with food that Peter enjoyed. They also demonstrated that Peter was more likely to touch the rabbit if he observed others doing so. This experiment anticipated later work of Albert Bandura (Bandura & Walters, 1963) on observational learning, whereby conditioning occurs by observing a model in contact with the stimulus, and copying the model results in new behavior. Attempts to extend this research outside the university and into the clinical arena did not begin in earnest until the 1950s. From that point on, interest in applying this work to the treatment of psychological and behavioral disorders led to the development of specifically behavioral treatments.

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Although the focus of the early behaviorists was not exclusively on human learning, the applicability of their animal learning and conditioning experiments to human behavior was considered feasible at the turn of the 20th century following a paradigm shift in psychology, engendered by Darwin’s studies of evolution. Human beings, as more advanced species along the evolutionary trajectory, are subject to many of the same basic contingencies as less complex organisms. The experimental work naturally led to applications of learning theory with humans and to interventions with clinical interventions. Just as B.  F. Skinner articulated two types of conditioning—Pavlovian or classical (respondent) conditioning and operant conditioning—behavioral interventions were developed initially emphasizing each of these types of conditioning. Classical or respondent conditioning derived from the work of Pavlov, Watson, and others. Skinner referred to it as “respondent” because it is the conditioning of responses to a stimulus. Consider the Little Albert experiment where the child was conditioned to respond to white objects with fear after the pairing of such objects with a loud, aversive noise. Operant conditioning considers how the individual and the environment impact each other. The three-term contingency of the operant paradigm is the “ABC” of antecedent, behavior, and consequence. Behavior is determined by its consequences. Under certain circumstances, that is, a specific antecedent (A), a behavior (B) is more likely to occur, or is reinforced, because of the consequence (C), or if the consequence is in some way aversive, the behavior may decrease and we would say it has been punished. Locke’s emphasis on the necessity of experience in learning can also be seen in the writing of the behaviorists, particularly that of Skinner. Skinner’s assertion that behavior is determined by its consequences, rather than by an innate will, is consistent with Locke’s philosophy, as discussed earlier. Philosophers like Hume and Locke had prescribed the behavior of scientists, and behaviorists like Skinner, Moore, and Catania echoed this idea that science is dependent on individuals engaging in the behavior of science (Nuzzolilli & Diller, 2015). The scientist’s behavior is controlled by the same processes as those of the subjects. In 1938, O. H. Mowrer and W. M. Mowrer published an article on a treatment method for enuresis that differed from the many methods used at the time. They refer to “innumerable drugs and hormones, special diets . . . massage, bladder and rectal irrigations” (Mowrer & Mowrer, 1938, p.  436) that were being used at the time to no avail, while they were able to use principles of classical conditioning to help the child develop new habits. Their method came to be known as the bell and pad method, which is still used today. In treatment of adult psychiatric disorders, behavior therapy was also associated with the work of Joseph Wolpe (1958) in South Africa, Hans Eysenck in the United Kingdom, and Ogden Lindsley in the United States (Öst, 2008). These researchers based their work on classical conditioning principles and applied behavior analysis using procedures based on operant principles. The term “behavior modification” was once used to encompass the entire field of applied learning theory (Goldfried & Davison, 1976), although that term is less pre-



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ferred as stereotypical images of manipulation of human behavior (e.g., Stanley Kubrick’s A Clockwork Orange) have cast a negative pall over it. Behavior therapy, however, has been characterized since its first and second decades by diversity of conceptualizations (O’Donohue et al., 2001). According to Goldfried and Davison (1976), there were “several trends” (p. 4) in the early development of behavior therapy. One trend was experimentation on the acquisition and extinction of fear through Pavlovian conditioning. Researchers associated with this trend were Joseph Wolpe and Arnold Lazarus in South Africa, M. B. Shapiro and H. J. Eysenk in the United Kingdom, and Andrew Salter in the United States. Wolpe’s medical school animal experiments led him to extend the strategy used by Cover Jones to anxious patients by pairing deep muscle relaxation with imagining an anxietyevoking situation. Wolpe’s (1958) treatment of reciprocal inhibition—that is, pairing incompatible responses (anxiety and relaxation)—became an early standard behavior therapy procedure and was influential in the development of exposure treatments for anxiety disorders. Pavlov’s study of experimental neurosis appealed to Wolpe, as did the work of Clark Hull that described basic principles based on experimentation with animals that could be applied to humans. Taking a lead from Pavlov, Wolpe embarked on an investigation of the causes and cures for the neuroses (Poppen, 2001). The importance of Wolpe’s work in the development of behavior therapy cannot be overstated. Stanley Rachman (2015) chronicled the development of behavior therapy, articulating the burgeoning work that occurred alongside that of Wolpe’s treatment of anxiety disorders. Rachman noted that it was a behaviorist, Victor Meyer, who first used repeated exposure in the treatment of obsessive-compulsive disorder (OCD), which was, at that time, mostly considered untreatable. This first use of exposure and response prevention resulted in the publication of two case studies from patients treated by Meyer at Maudsley Hospital, and following those publications, others applied the procedure in the treatment of OCD. A second trend in behavior therapy was the use of operant principles applied to human behavior. This early work was more prominent in the United States (Rachman, 2015). Skinner’s research on reinforcement was applied to work with psychiatric inpatients and with institutionalized clients with developmental disabilities. Other scholars reworked psychoanalytic principles from a behaviorist perspective, most notably Dollard and Miller (1950), Andrew Salter (1949), and Charles Ferster (1973). With the exception of Tolman, the early behaviorists did not consider cognition as they eschewed unobservable phenomena as a legitimate focus of study (Bolles, 1979). Skinner’s (1957) formulation of cognition as private “verbal behavior” allowed him to apply learning principles to thinking and language and legitimized the study of behavior that is not observable apart from self-report. The early behaviorists’ insistence on scientific rigor led to a stereotype of behaviorism as lacking in depth and as denying the importance of human experience beyond overt muscle movements. However, the concern of behaviorism has not been to deny that people think or that there is a variety of human emotion but

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rather to ensure that the focus of research be on operationally defined, measurable phenomena. As Skinner (1974) himself stated, “It is often said that a science of behavior . . . neglects the person or self. What it neglects is a vestige of animism, a doctrine which in its crudest form held that the body was moved by one or more indwelling spirits” (p. 184). For Skinner and other behaviorists, it was important to understand the complexity of human behavior without resorting to dualism, designating so-called mental processes as somehow different from physical ones. As Skinner would say, the “world within the skin” followed all of the same principles as the world outside the skin. Behavioral Models The work of Albert Bandura had a major impact on the development of behavior therapy and CBT. Bandura’s research focused on the impact of the social environment on learning, and he took umbrage with the psychodynamic models in vogue in the early 1960s therapy settings. Bandura was intrigued by the impact of direct modification of unwanted behavior on client improvement (Bandura, 2004). While Bandura emphasized the influence of social factors on the performance of observers, his findings still emphasized the importance of consequences on the actor’s behavior in concert with the observed consequences of the modeled behavior. He stated that observed consequences may have different behavioral effects under conditions where the reinforced performers and the performers are members of the same group who are present in the same setting and interacting with the same social agents. Observers who witness other members rewarded for a certain pattern of behavior may temporarily increase similar responding, but if their behavior is consistently ignored they are apt to discontinue the modeled behavior or even respond negatively to the agent’s preferential treatment. (Bandura, 1969, p. 32)

Bandura (1969) also emphasized the impact and importance of selfreinforcement in governing social behavior. He concluded that “there exists a substantial body of evidence that modeling processes play a highly influential role in the transmission of self-reinforcement patterns” (Bandura, 1969, p. 33). During the 1960s, behavior modification and therapy became well established as treatments for a variety of human problems. Examination of the first volume of the Journal of Applied Behavior Analysis provides a good illustration of the breadth of the field. There were articles that articulated the theory and principles of behavioral analysis that became classics in the field (i.e., Ayllon & Azrin, 1968; Baer et al., 1968) as well as articles on work in schools (e.g., Madsen et al., 1968), in psychiatric hospitals (e.g., Ayllon & Azrin, 1968), in the treatment of autism (e.g., Boer, 1968), with developmentally delayed children (e.g. Hopkins, 1968), and in the treatment of phobias (e.g, Leitenberg et al., 1968). The advisory editors included prominent behavior therapists such as Donald Meichenbaum, who was influential in the development of treatment that focused on cognition, which ultimately became known as cognitive behavior modification (Meichenbaum, 1977)—or now CBT.



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Bandura identified several changes in the explanation of human change processes that occurred during the 1960s. First, the analysis of causes shifted “from unconscious psychic dynamics to transactional psychosocial dynamics” (Bandura, 2004, p. 616). There was a shift from categorizing people into psychopathological types and diagnostic labeling to conducting functional analyses of human behavior. Research occurring in the laboratory or in the field replaced analytic interviews as the mechanism for the study of behavior change. Treatment was action oriented rather than insight oriented, and the “modes of treatment were altered in content, locus, and agents of change” (Bandura, 2004, p. 616). The common thread in all the behavior therapies was the commitment to experimental science, and the behaviorist therapists were able to demonstrate that their procedures were efficacious in treating these various human ills. The reliance on empiricism continued as behaviorists became more interested in cognition, and this same requirement for demonstrating outcomes that are supported by rigorous research is a hallmark of CBT. Contemporary clinical behaviorism tends to be separated into behavior therapy or behavior analysis. While the differences are by no means absolutely distinct, behavior therapy treatment developers, researchers, and clinicians apply the principles and protocols to disorders such as anxiety, mood, and some personality disorders and often use procedures based more on classical or respondent conditioning paradigms. Behavior analysts typically work from an operant conditioning paradigm and treat developmental disorders such as autism spectrum disorder or intellectual disabilities. Behaviorism Today Complexities in behaviorism continue today. To a large extent, disagreements over whether cognitive therapy adds anything to behavior therapy that were common in the 1980s (Latimer & Sweet, 1984) have substantially been put to rest. As Emmelkamp (1994) stated, “Most cognitive procedures have clear behavioral techniques in them, and, although less obvious, most behavioral procedures also contain cognitive elements” (p. 379). Even when research demonstrates that a primarily behavioral intervention is of similar or greater efficacy than a primarily cognitive intervention, as was demonstrated in several studies of behavioral activation and cognitive therapy for depression (Dimidjian et al., 2006), efficacy trials do not address theory, and it is possible that behavioral interventions change beliefs, which in turn improve symptoms. The search for mechanisms of change continues, and discussions in the behavioral literature today are more nuanced in the search for what accounts for the efficacy of certain procedures. The use of exposure and response prevention in the treatment of OCD has evolved to incorporate cognitive features, particularly in the treatment of obsessions or mental contamination (Rachman, 2015). Current research on prolonged exposure in the treatment of PTSD serves as a good example.

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For many years, the reduction in fear following exposure therapy was attributed to the process of habituation, or the reduction in physiological arousal within and between treatments of prolonged exposure. Contemporary models of prolonged exposure offer differing explanations of its mechanisms. Emotional processing theory (Foa & Kozak, 1986) suggests that the fear structure includes representations of the feared stimuli, fear responses, and the meaning of the stimuli and responses. When escape and avoidance responses are easily triggered by harmless stimulus events that are erroneously associated with threat, the fear structure becomes pathological (Foa et al., 2007). Emotional processing theory proposes several possible mechanisms. Emotional engagement provides disconfirming evidence for the erroneous interpretation of stimulus events, and habituation dissociates stimulus from response elements, extinguishing the fear response. Repeated imaginal exposure also facilitates reorganization of the trauma narrative. Michelle Craske has proposed the mechanism of fear inhibition learning (Craske et al., 2014) in exposure therapies. According to this model, it is not important for habituation to occur, but rather there should be repeated exposure in the absence of trauma so that a competing association is formed that signals the absence of danger. The reduction in fear is not seen to be as important as the emotional engagement with the exposure exercises without distraction or use of safety behaviors. While emotional processing theory and inhibition learning theory differ in emphasis, they are not completely at odds. Each has important implications for the conduct of prolonged exposure therapy; there is less controversy here and more of a search for clarification of best treatment and empirically supported theory. Perhaps a slightly more divergent thinking from the behavioral analysis stream of CBT has developed roughly over the past 30 years from a perspective that has come to be known as contextualist. A specific treatment, ACT (Hayes et al., 1999), and an explanation of human cognition, relational frame theory (RFT; Hayes et al., 2001), have gained many proponents and have often been referred to as a third wave of the behavioral therapies (the first wave being the behavioral therapies, the second being the cognitive and cognitive behavioral therapies, and the third being contextually based therapies). To some extent, treatments such as DBT (Linehan, 1993) fall into the category of the third wave, although much of DBT makes use of very traditional behavioral interventions. The contextual therapies are defined by a focus on acceptance and mindfulness methods. In ACT, additional methods similar to cognitive distancing (A. T. Beck, 1976), referred to as defusion, are also employed. ACT diverges from traditional CBT by rejecting the conceptualization that cognitions or emotions play a causal role in behavior. ACT is said to be based in contextualism, and Hayes and colleagues (1988) have asserted that behavior analysis in general is contextualist. To the contextualist, the criterion for discovering truth is pragmatic. What is true is what works, what is useful. It is beyond the scope of this chapter to provide a comprehensive account of ACT or to provide a critical analysis of the newer behavior therapies. The point is that behavior therapy has incorporated varied theories and applications from the beginning and continues to do so today. Since adherence to scientific



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principles rather than introspection or theory without science has defined the behavioral therapies, it is logical that ideas will come and go. Some therapeutic strategies will be shown to be more effective than others and will gain popularity. Some theories will more clearly explain human behavior and clinical phenomena. The early behaviorists were charting new ground and worked against predominant ideas in both the basic study of psychological science and, later, the application to clinical problems. That the behavioral and cognitive behavioral researchers and practitioners are continuing to look for greater understanding and to move in unexpected directions is a unifying feature in what often looks like a field of varied, sometimes oppositional views.

CONCLUDING THOUGHTS This chapter provides a panoramic view of the philosophical and historical foundations of CBT in general with particular focus on the separate influences on the cognitive and behavioral models, respectively. As many of us in the CBT field know, the larger umbrella of CBT is a moving target with continued growth in approaches that now attempt to focus on common processes rather than specific diagnostic categories. Thus, we can think of CBT as evolving toward “transdiagnostic approaches”—that is, approaches to treatment and techniques that are not dependent on specific DSM diagnoses but rather focus on processes that may affect many different disorders. Examples of these processes include rumination, avoidance, memory, attention, cognitive processing, and more. The learning and behavioral theories that have informed contemporary CBT were varied, and sometimes contradictory, from the outset. In one way or another, the theories were heavily influenced by philosophical roots of associationism and of Darwinian evolution, which tied the various learning theories together. It is our hope that those of us who focus on the behavioral and learning traditions gain some awareness of the strong theoretical and empirical work that is the foundation of this valuable and effective treatment. Too often psychology may be equated with what has been going on in the last 3 years as opposed to the last 2,400 years. In addition, the cognitive approach has branched out to include cognitive processing therapy, schema-focused therapy, metacognitive therapy, and other integrative and innovative models. Newer wave approaches such as DBT and ACT draw heavily on the Buddhist tradition and that merits its own historical review. We have seen how philosophical approaches to the psyche have developed into psychological models, treatment approaches, and empirical programs of research. Many of the major approaches could merit their own philosophical and historical review—and we welcome those ideas. And it is also possible that we can still reach back into the past and find that the “ancient wisdom” from many centuries ago can still inform us as to which direction we should pursue. Indeed, one can argue that positive psychology is the reemergence of Aristotle in a different form.

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2nd ed.). Cambridge University Press. https://doi.org/10.1017/CBO9780511808517 (Original work published 1782) Kazantzis, N., Beck, J., Clark, D., Dobson, K., Hoffman, S., Leahy, R., & Wong, W. (2014). Clinical round table: The use of Socratic dialogue for guided discovery in cognitive behavior therapy [Workshop]. International Congress of Cognitive Psychotherapy, Hong Kong, China. Kelley, H. H. (1972). Causal schemata and the attribution process. General Learning Press. Kelly, G. A. (1955). The psychology of personal constructs. Norton. Kris, E. (1951). Ego psychology and interpretation in psychoanalytic therapy. Psychoanalytic Quarterly, 20(1), 15–30. https://doi.org/10.1080/21674086.1951.11925828 Kuhn, T. S. (1970). The structure of scientific revolutions. University of Chicago Press. Latimer, P. R., & Sweet, A. A. (1984). Cognitive versus behavioral procedures in cognitive-behavior therapy: A critical review of the evidence. Journal of Behavior Therapy and Experimental Psychiatry, 15(1), 9–22. https://doi.org/10.1016/0005-7916 (84)90116-2 Lazarus, R. S. (1982). Thoughts on the relations between emotion and cognition. American Psychologist, 37(9), 1019–1024. https://doi.org/10.1037/0003-066X.37.9. 1019 Leitenberg, H., Agras, W. S., Thompson, L. E., & Wright, D. E. (1968). Feedback in behavior modification: An experimental analysis in two phobic cases. Journal of Applied Behavior Analysis, 1(2), 131–137. https://doi.org/10.1901/jaba.1968.1–131 Linehan, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. Guilford Press. Linehan, M. M., Bohus, M., & Lynch, T. R. (2007). Dialectical behavior therapy for pervasive emotion dysregulation: Theoretical and practical underpinnings. In J. Gross (Ed.), Handbook of emotion regulation (pp. 581–605). Guilford Press. Locke, J. (1975). An essay concerning human understanding (P. H. Nidditch, Ed.). Oxford University Press. (Original work published 1689) Loftus, E. F. (1979). Eyewitness testimony. Harvard University Press. Madsen, C. H., Jr., Becker, W. C., & Thomas, D. R. (1968). Rules, praise, and ignoring: Elements of elementary classroom control. Journal of Applied Behavior Analysis, 1(2), 139–150. https://doi.org/10.1901/jaba.1968.1-139 Mahler, M. F. (1969). On human symbiosis and the vicissitudes of individuation. International Universities Press. Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. Springer. https://doi.org/10.1007/978-1-4757-9739-8 Miller, G. A. (1956). The magical number seven, plus or minus two: Some limits on our capacity for processing information. Psychological Review, 63(2), 81–97. https://doi. org/10.1037/h0043158 Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis—A method for its study and treatment. American Journal of Orthopsychiatry, 8(3), 436–459. https://doi.org/b9xwrz Nagel, T. (1974). What is it like to be a bat? Philosophical Review, 83(4), 435–450. https:// doi.org/10.2307/2183914 Neisser, U. (2014). Cognitive psychology: Classic edition. Psychology Press. https://doi.org/ 10.4324/9781315736174 (Original work published 1967) Newell, A., & Simon, H. A. (1972). Human problem solving. Prentice Hall. Nuzzolilli, A. E., & Diller, J. W. (2015). How Hume’s philosophy informed radical behaviorism. The Behavior Analyst, 38(1), 115–125. https://doi.org/10.1007/s40614014-0023-0 O’Donohue, W. T., Henderson, D. A., Hayes, S. C., Fisher, J. E., & Hayes, L. J. (2001). Introduction. In W. T. O’Donohue, D. A. Henderson, S. C. Hayes, J. E. Fisher, & L. J. Hayes (Eds.), A history of the behavioral therapies: Founders’ personal histories (pp. 17–40). Context Press.



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Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296–321. https:// doi.org/10.1016/j.brat.2007.12.005 Pavlov, I. P. (1927). Conditional reflexes: An investigation of the physiological activity of the cerebral cortex. Oxford University Press. Piaget, J. (1954). The construction of reality in the child (M. Cook, Trans.). Routledge; Kegan Paul. https://doi.org/10.1037/11168-000 (Original work published 1950) Piaget, J. (1971). Genetic epistemology. Norton. Poppen, R. (2001). Joseph Wolpe: Challenger and champion for behavior therapy. In W. T. O’Donohue, D. A. Henderson, S. C. Hayes, J. E. Fisher, & L. J. Hayes (Eds.), A history of the behavioral therapies: Founders’ personal histories (pp. 73–108). Context Press. Postman, L. (1947). The history and present status of the law of effect. Psychological Bulletin, 44(6), 489–563. https://doi.org/10.1037/h0057716 Powell, R. A., Digdon, N., Harris, B., & Smithson, C. (2014). Correcting the record on Watson, Rayner, and Little Albert: Albert Barger as “psychology’s lost boy.” American Psychologist, 69(6), 600–611. https://doi.org/10.1037/a0036854 Rachman, S. (2015). The evolution of behaviour therapy and cognitive behaviour therapy. Behaviour Research and Therapy, 64, 1–8. https://doi.org/10.1016/j. brat.2014.10.006 Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43(3), 151–160. https://doi.org/10.1037/0003-066X.43.3.151 Rosch, E. H. (1973). Natural categories. Cognitive Psychology, 4(3), 328–350. https://doi. org/10.1016/0010-0285(73)90017-0 Salter, A. (1949). Conditioned reflex therapy, the direct approach to the reconstruction of personality. Creative Age Press. Searle, J. R. (1980). Minds, brains, and programs. Behavioral and Brain Sciences, 3(3), 417–424. https://doi.org/10.1017/S0140525X00005756 Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. W. H. Freeman. Skinner, B. F. (1957). Verbal behavior. Appleton-Century-Crofts. https://doi. org/10.1037/11256-000 Skinner, B. F. (1974). About behaviorism. Alfred Knopf. Sorabji, R. (2000). Emotion and peace of mind: From stoic agitation to Christian temptation. Oxford University Press. Taylor, S. E., & Crocker, J. (1981). Schematic bases of social information processing. In E. T. Higgins, C. P. Herman, & M. Zanna (Eds.), Social cognition: The Ontario symposium on personality and social psychology (Vol. 1, pp. 89–134). Lawrence Erlbaum. Thaler, R. (1992). The winner’s curse: Paradoxes and anomalies of economic life. Princeton University Press. Tolman, E. C. (1948). Cognitive maps in rats and men. Psychological Review, 55(4), 189–208. https://doi.org/10.1037/h0061626 Tulving, E. (2002). Episodic memory: From mind to brain. Annual Review of Psychology, 53, 1–25. https://doi.org/10.1146/annurev.psych.53.100901.135114 Watson, J. B., & Rayner, R. (1920). Conditioned emotional reactions. Journal of Experimental Psychology, 3(1), 1–14. https://doi.org/10.1037/h0069608 Weiner, B. (1974). Achievement motivation and attribution theory. General Learning Press. Wittgenstein, L. (1967). Philosophical investigations (G. E. M. Anscombe, Trans.; 2nd ed.). Blackwell. Wittgenstein, L. (1974). Tractatus logico-philosophicus (D. F. Pears and B. F. McGuinness, Trans.). Routledge; Kegan Paul. (Original work published 1923) Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press. Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35(2), 151–175. https://doi.org/10.1037/0003-066X.35.2.151

2 Theoretical Framework Keith Dobson, Amanda Fernandez, and Stefan G. Hofmann

C

ognitive behavioral therapy (CBT) is a term that is often used to describe a therapeutic intervention derived from the basic principles of Beck’s cognitive theory (Beck, 1967) and traditional behavioral interventions. This use of the term is a common error, however, as CBT is not a single model of therapeutic intervention but a family of interventions (Dobson, 2009) that comprise a number of different therapies aimed at thought processes and behavior. CBTs range from cognitive therapy, which focuses on identifying and modifying dysfunctional thoughts (Beck, 1967), to mindfulness-based cognitive therapy, which focuses on increasing present awareness and relating to experience in an open and nonjudgmental manner (Dobson & Dozois, 2019; Segal et al., 2013). Differences among the various CBTs exist in terms of the degree of focus and importance that is placed on thought and behaviors, as well as the way in which they conceptualize therapy techniques that target these two domains. An example of one such difference can be seen in the realist assumption, which reflects the notions that a “real world” exists that is independent of our perception and that it is possible to misinterpret or misperceive this reality (Dobson, 2013; Dobson & Dobson, 2017). If this assumption were to be considered on a continuum, most CBTs would fall somewhere in the middle. In other words, proponents of CBTs often postulate that there is a “real world” but that the meaning we attach to that world is also important. Therefore, depending on where specific CBTs fall on this continuum, more weight may be placed on

https://doi.org/10.1037/0000218-002 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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restructuring thoughts to be more “realistic,” or more weight may be placed on changing the way in which one relates to the meaning attached to that thought. Taken together, the core theoretical concepts of CBT were conceived from an amalgamation of influences from various theoretical orientations and empirical findings. As a result, it has been argued that CBT lacks clarity as a therapeutic system, as its blending of different models and methods has incorporated theoretical ambiguities and nomenclature with diverse origins and uses (e.g., Mansell, 2008; Mansell & Taylor, 2012). However, advantages of the assimilation of these varied influences are that CBT also incorporates considerable flexibility and encompasses many techniques that can alleviate distress associated with experienced thoughts and behaviors. In fact, despite the differences in specific therapies housed under the cognitive behavioral umbrella, the main tenet of the CBTs can be distilled into the notion that people’s cognitions are critical influences on their emotional state and behavior. Although this tenet may appear to oversimplify what constitutes a CBT, the core consensus between all CBTs is that thought processes, emotions, and behavior are interdependent. This chapter examines the underlying theoretical concepts of CBT in order to offer insight into the theoretical coherence of the CBT family. Specifically, we discuss the assortment of theories that inform early and recent CBT therapies, differences in the way in which cognition is conceptualized, and the shift from diagnostically specific to transdiagnostic CBT modalities.

EARLY THEORETICAL DEVELOPMENTS The CBTs have a blend of different influences that contributed to their theoretical development over time. That said, they were derived from two main theoretical frameworks. Behavior therapy was first developed in the early 1900s as a response to the lack of empirical support for psychological theory and clinical applications (Hayes, 2004). Behavior theory avoided unobservable processes, such as cognition or emotion, and instead focused on associations of observable events, such as behavioral responses to external stimuli. Consistent with this model, behavior therapy focused mainly on principles of learning in order to modify pathological behaviors and distressing emotions (Hayes, 2004; Hupp et al., 2008). Although behavior therapy showed promising results for treatment of less complex pathologies, such as the anxiety disorders, there were significant limits to the treatment of more complex presentations, such as psychotic disorders (Ingram & Siegle, 2010). As a result of these limitations, cognitive theorists attempted to incorporate cognitive mediation into the theoretical models while still preserving the empirical importance founded by behavioral psychologists. Thus, in the 1970s and 1980s, concepts such as vicarious learning (learning by observing others), social modeling (teaching others by modeling or demonstrating desired behaviors), and self-efficacy (the perceived ability to engage in various tasks) were introduced into theory to extend the stricter behavioral models of behavior.



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CBTs resulted from a bidirectional movement that was heavily influenced by an increased importance placed on mediational models of therapy and an understanding of the importance of overt methodology involved in behaviorism (Kendall & Hollon, 2013). The main purpose of CBT was to preserve the efficiencies of behavior modification within a less rigid context and to incorporate cognitive activities in the efforts to produce and enhance therapeutic outcomes (Kendall & Hollon, 2013). One clear example of this extension occurred in the models of depression. Ferster (1974) developed a behavioral model that emphasized diminished social reinforcement (whether by poor social skills, loss of social reinforcers, or increased sensitivity to social punishment) as a key mechanism for the genesis of depression. Building on this model, Lewinsohn and his colleagues (e.g., Lewinsohn et al., 1976) developed a behavioral treatment for depression that included social skills training and increased engagement in positive activities as fundamental components. When the cognitive behavioral model of depression emerged (Beck et al., 1979), it continued to incorporate the idea of increased social engagement, although it also included a focus on the meaning attached to social engagement and the interpretations made by the patient about their increased engagement as important components of the treatment. Thus, although the behavioral activation aspect of behavior therapy for depression was maintained, the CBT approach scaffolded cognitive interventions upon the more elemental process of activation. CBTs also adopted the concept of a therapeutic relationship from classical psychoanalysis. However, as opposed to viewing the therapeutic relationship as the vehicle of change, as was the case in classical psychoanalysis, CBTs postulated a therapeutic relationship as necessary but insufficient to produce therapeutic effects alone (Beck et al., 1979; Kazantzis et al., 2017). The therapeutic relationship is viewed within the CBTs as an environment or context that allows an individual to thrive and move toward the attainment of therapeutic goals (Cronin et al., 2015). Although therapeutic relationships involve listening, expressed empathy, and positive regard, collaboration and working alliance in CBT are also distinct elements of the therapeutic relationship within the CBTs (Cronin et al., 2015; Markin, 2014). Specifically, within CBT, the therapeutic relationship is defined as a collaborative bond and agreement on the goals of therapy and tasks to attain those goals (Bordin, 1979; Cronin et al., 2015). Indeed, the importance of relationships within therapy and their components of collaboration, empathy, and positive regard have all been empirically supported (Castonguay & Beutler, 2006; Norcross & Lambert, 2011). Although therapeutic alliance is not the focus of the current chapter, its importance in the implementation of CBTs can be traced back to its theoretical foundations. Although many specific theories and approaches contributed to the development of modern CBTs, three dominant concepts can be identified. The first postulate that strongly influenced early CBT theory is that cognitive processes (variously termed attitudes, beliefs, expectancies, and thoughts) are central to the understanding of behaviors associated with psychopathology (Kendall &

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Hollon, 2013). Beck’s (1969) cognitive theory and Ellis’s (1962) rational-emotive theory both emphasized the importance of thinking patterns that developed from early experiences and contributed to psychopathology (Mansell & Taylor, 2012). The earliest forms of such therapies included methods that involved the individual testing their beliefs against the “real world.” These methods helped shift cognitive processes to a more evidence-based and realistic perspective. A second influential assumption involved the notion that cognitions and overt behaviors can be shaped using the same laws of learning (Ingram & Siegle, 2010; Kendall & Hollon, 2013). Concepts like Bandura’s (1977) social learning theory and theory of self-efficacy elucidated the relation between cognitive models and behavioral interventions (Ingram & Siegle, 2010; Kendall & Hollon, 2013). Such theories provided a framework for cognitive variables to be conceptualized as observable and testable processes that could be integrated into behavioral paradigms. Clinicians used this idea to apply behavioral strategies, such as functional analysis (i.e., monitoring a target behavior over time and manipulating antecedents and consequences to determine what may predict and influence behavior; Wilson & Murrell, 2002), to cognitive processes (Kendall & Hollon, 2013). The addition of such theoretical understandings of cognition paved the way for clinicians to modify overt therapeutic strategies to work with covert psychopathological factors. The combination of cognitive and behavioral treatment strategies led to the third influential concept in early CBT, which is that both behavioral and environmental change can facilitate cognitive restructuring and subsequent cognitive change (Kendall & Hollon, 2013). This concept specified that there is an association between overt behaviors and covert cognitions, which in turn allowed the hypothesis that cognitive processes operate somewhat outside of behavioral laws and warranted causal status in dysfunction as well as mediation for behavior (Ingram & Siegle, 2010). In short, three fundamental principles arose: (a) cognitions affect behavior, (b) cognition can be monitored and altered, and (c) behavior change may be affected through cognitive change. Despite these influential theoretical origins and principles, recent criticisms have targeted this traditional CBT framework. First, it has been observed that the cognitive components of CBT do not necessarily outperform the behavioral strategies implemented in treatment (e.g., Dimidjian et al., 2006; Longmore & Worrell, 2007). Component analysis studies that have examined the efficacy of each component of therapy often report similar results between those that employ cognitive behavioral strategies and those that employ behavioral strategies (Gaudiano, 2008; Longmore & Worrell, 2007). This finding suggests that cognitive components of CBT are not necessary to invoke change. Along this vein of criticism is also the notion that there is a failure to show predicted mechanisms of action involved in the treatment outcomes of CBT. For example, changes in dysfunctional beliefs do not necessarily affect treatment outcomes (Gaudiano, 2008; Longmore & Worrell, 2007). Second, as the CBTs have at times developed through clinical observations, there is sometimes a lack of coherence between empirical findings of cognitive



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psychology and theoretical concepts (Gaudiano, 2008). This discontinuity raises the question of whether the theoretical component of cognitive change is actually necessary in therapy. Although concerns about the empirical support of cognitive components have been reported, rebuttals to these criticisms indicate that their foundations are based on common misconceptions about mediation models of treatment change (e.g., Hofmann, 2008). Specifically, arguments against these critiques have detailed that (a) component analyses are inadequate to test mediation, (b) changes in cognitions can occur and mediate treatment outcomes without explicit procedures that restructure these cognitions, and (c) a small number of mediation tests exist for treatment change because the statistical techniques to evaluate them have only recently been developed (Hofmann, 2008).

RECENT THEORETICAL DEVELOPMENTS Whereas earlier approaches to CBT focused on the identification and modification of the content of thought processes, more recent developments have tended to focus on the function of thoughts. This shift in therapeutic approach has decreased the use of techniques geared toward examining the evidence that does or does not support a specific idea and thereby changing the substance of the thought, and it has instead encouraged a focus on people’s relationship to their thoughts and the meanings that they attach to their thoughts and more general experience. Thus, contemporary CBTs target the context and function of thoughts, sensations, and emotions rather than targeting their content, validity, or frequency (Hayes et al., 2011). Context and function are targeted through techniques such as increasing awareness or acceptance of thoughts and feelings, increasing cognitive flexibility, increasing flexibility of attention, and distancing oneself from unpleasant thoughts and feelings. Therapies in this domain include but are not limited to mindfulness, acceptance and commitment therapy (ACT), and metacognitive therapy. Both contemporary and traditional CBT models address emotion regulation; however, they teach coping mechanisms for different stages of emotional processing (Hofmann & Asmundson, 2008; Hofmann et al., 2010). Emotion regulation can be implemented successfully in two manners: first by manipulating the evaluation of emotional cues (antecedent focused) and second by manipulating the response or experience of emotions (response focused; e.g., Gross, 1998; Gross & John, 2003). Traditional CBT modalities emphasize antecedent-focused strategies that include situation-specific modification and cognitive restructuring. In contrast, contemporary CBTs have shifted to response-focused therapeutic interventions, which attempt to alter the way in which individuals experience emotions once they have been instigated by teaching methods to increase acceptance of emotional experience and to counter emotional suppression (Hofmann & Asmundson, 2008). Suppression and failure to accept emotional states have been linked to increases in negative affect (Campbell-Sills et al., 2006).

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The response-focused CBT therapies have been described as a “third wave” movement. Proponents of this terminology have argued that such therapies constitute a different class of therapy from traditional CBTs because they adopt a more contextual and experiential approach (Hayes, 2004; Hayes et al., 2006; Hofmann et al., 2010). More specifically, this terminology was adopted because these treatment approaches appeared to represent a set of assumptions and theories that differed from traditional behavioral and CBT approaches (Hayes et al., 2011). However, the term third wave implies that such therapies have replaced more traditional forms of CBT (which presumably went through two previous waves), which has been argued as manifestly untrue. From our perspective, the more recent models are best conceptualized as contemporary members of the family of CBTs, which are both similar to and different from earlier CBT conceptualizations that preceded them, just as those therapies have similar and different approaches from the behavior therapies that preceded them (Wilson et al., 2011). Fundamentally, such therapies are related to CBT by sharing therapeutic principles related to modifying aspects of cognition (e.g., metacognition) in order to decrease emotional distress and problematic behaviors (Hofmann et al., 2010). Further, some theoretical and practical overlap exists between early CBT models and more recent therapeutic developments. Finally, it has been argued that the term third wave has been confusing and has become obsolete because many strategies are now part of modern CBT. Instead, some authors have argued to adopt instead the term process-based therapies (Hayes & Hofmann, 2017). As a result, the current chapter refrains from referring to these recent developments as third wave. Analysis of the theoretical foundations and concepts of contemporary CBT models reveal similarities with traditional CBTs, even as far back as Beck’s earlier work on cognitive therapy (e.g., Beck et al., 1985). Although the focus of cognitive therapy has been primarily on cognitive change, it has long been recognized that this change can be realized through direct cognitive restructuring, behavioral strategies, and acceptance and that resisting, avoiding, or suppressing a negative experience may paradoxically intensify and prolong it (Dozois & Beck, 2011). Thus, acceptance and mindfulness-based approaches fit within the founding cognitive therapy framework. For example, mindfulnessbased interventions are believed to counter experiential avoidance strategies, as they teach an individual to respond reflectively and openly to experiences of distress (Hofmann et al., 2010). Indeed, a change in the relation that a person has to their thought processes may promote a change in the thought itself. Therefore, successful CBTs of all types involve the individual’s acceptance of negative experiences. The primary objective of this principle is to promote acceptance of internal experiences to bring about cognitive change and symptom relief. Paradoxically, accepting distress through methods such as exposure habituates the individual to the uncomfortable experiences and shifts the appraisals of these experiences such that they no longer carry a threating meaning (Dozois & Beck, 2011). Although the goals of exposure for traditional and recent CBT modalities may differ (e.g., reduce arousal vs. increase behavioral



Theoretical Framework  37

flexibility in presence of anxiety; Hayes et al., 2011), both incorporate an element of acceptance into therapy. Another example of similar theoretical principles between traditional and contemporary CBT involve the concept of decentering. Decentering is the ability to observe thoughts and feelings as temporary events rather than true reflections of the self (Fresco et al., 2011; Safran & Segal, 1990). The concept of decentering or distancing oneself from thoughts can be found in traditional CBT modalities, as achieving distance from one’s cognitions is the first step to cognitive restructuring and minimizing suffering (Beck et al., 1985; Dalai Lama & Beck, 2005; Fresco et al., 2011; Herbert and Forman, 2011). Although the concept of decentering can be found in early CBT approaches that emphasize techniques such as the thought record, a difference between contemporary and traditional CBT approaches is the conceptualized mechanisms of change. Specifically, both traditional and contemporary CBT approaches agree that decentering is theoretically involved in successful therapeutic outcomes; however, in traditional CBT, it is believed to be the first step in therapeutic intervention, whereas in contemporary CBT, it is believed to be the factor that produces change (Fresco et al., 2011; Teasdale et al., 2002). Despite this difference in focus between cognitive restructuring and acceptance or distancing, it has been noted that cognitive change can occur even when therapeutic techniques do not explicitly aim to modify maladaptive cognitions. In other words, cognitive restructuring can occur even when this process is not explicitly incorporated into treatment (Hofmann, 2008; Hofmann et al., 2010). Therefore, it could be argued that although contemporary CBT approaches emphasize flexibility of thought and acceptance of experiences, cognitive restructuring may still occur.

APPROACH TO THE CONCEPTUALIZATION OF COGNITION CBT models vary in the extent to which they focus on the structure and process of thought. These two varying dimensions of CBT can best be conceptualized through the influence of Beck and Haigh’s (2014) generic cognitive model (GCM) and Hayes et al.’s (2001) relational frame theory, both discussed below. The GCM broadly postulates that psychological problems and clinical disorders are extensions of normal functioning. Specifically, adaptive functioning involves the utilization of cognitive, affective, and behavioral strategies to help cope with distress or attain goals. When the activation of these adaptive systems becomes disproportionate to life events, the systems are used inappropriately, and they become maladaptive. Maladaptive functioning results from an exaggeration of negative and positive biases found in normal processing. A negative bias is defined as an exaggeration of a threat or challenge, and a positive bias is defined as an exaggeration of a perceived reward. According to the GCM, the way an individual processes information is the mechanism that determines their adaptive or maladaptive functioning. Specifically, when information processing

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provides inaccurate information, cognitions, emotions, and behaviors are activated and engender a maladaptive response. In addition, the GCM suggests that through experience, individuals develop schemas, defined as stable internal representations of ideas or experiences. Schemas directly influence the way that an individual processes information. When a schema is activated, the meaning it holds interacts with cognitive, emotional, and behavioral systems. Schemas control information processing through two interacting subsystems: the automatic processing subsystem and the reflective processing system. The automatic processing subsystem rapidly processes and fits information into crude categories consistent with schemas. In contrast, the reflective processing system processes information deliberately and refines the interpretations of experience. The reflective processing system works with the automatic processing system through reappraisals of initial interpretations. In addition to schemas, the GCM accounts for motivations, such as goals and obligations. These modes represent the consolidation of schemas into belief systems, rules, and concepts, such as self-esteem. They reflect aspects of an individual’s personality through two dimensions: the self-expansive mode and the self-protective mode. The self-expansive mode is primarily concerned with increasing personal value, whereas the self-protective mode is primarily concerned with early detection of danger signals to mobilize when a threat is encountered. An exacerbation of the self-expansive mode is theorized to relate to symptoms of mania, whereas a deficit in this mode can lead to depression. An enhanced self-protective mode can be manifested in either paranoia or anxiety. The components described previously all contribute to a fundamental hypothesis of the GCM, which is that certain beliefs constitute a vulnerability to psychopathology (Beck, 2005). This hypothesis is often referred to as the diathesis– stress model of psychopathology. According to the diathesis–stress model, maladaptive schemas develop early in life in response to adverse experiences and remain dormant until triggered by a later stressful event (Beck, 1967). The schemas related to the self will influence the way in which an individual interprets or experiences events throughout the lifetime (Riskind & Alloy, 2006). In other words, individuals who have underlying maladaptive schemas carry a cognitive vulnerability for psychopathology. More specifically, these schemas, and their associated modes and their effects on information processing systems, can transform normal adaptive reactions into disorders by affecting the way an individual thinks, as well as the meaning and interpretations one derives from experience. Biased beliefs associated with these schemas are postulated to occur on a continuum; when a belief becomes distinctly biased in one direction (i.e., positive or negative), the probability of experiencing psychopathology increases. CBTs that focus on the structure and content of thought develop their treatment approach on the basis of this model. Each component of the model offers a point of intervention that, theoretically, will influence all other components, as all components are interconnected in this model. Content-focused cognitive behavioral therapists can intervene at the level of beliefs, the way information is processed (e.g., attention and memory), and/or behavior. First, belief inter-



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ventions target schemas and motivated goals. This work may include behavioral activation strategies to create obtainable goals, cognitive restructuring, behavioral tests, and/or reality testing in order to identify and evaluate erroneous beliefs. Information processing interventions include the use of thought records to identify biases in attention and cognition and the development of restructuring and reappraisal coping strategies to redirect information processing to function in a more adaptive way. Finally, behavioral interventions include reinforcing prosocial behaviors or relaxation coping strategies, as necessary. In summary, in the GCM, it is theorized that cognition, emotion, and behaviors associated with psychopathology occur when beliefs are significantly distorted. This theory of distorted adaptive functioning shaped content-focused CBTs, which distinguish between adaptive and maladaptive content. This dichotomy provides a concrete outline of what an individual’s thought content should reflect when they adopt and exhibit nonpathological cognitions. In contrast to structural models of cognition and thought content-specific CBTs, relational frame theory (RFT; Hayes et al., 2001) conceptualizes cognition in terms of its relation and meaning to the individual. This theory approaches cognition from a process-related perspective. Specifically, it is argued that factors such as language are instances of a type of operant behavior that is associated with arbitrary relational responding (Hughes & Barnes-Holmes, 2016). This theory postulates that both humans and nonhumans can respond to the physical relation between a stimulus and event (e.g., relate or categorize shapes based on physical similarity), but human behavior can also derive relations between stimuli and events independent from physical characteristics due to socioverbal and abstract abilities (Hughes & Barnes-Holmes, 2016). Language is based on the learned relations among events that form from arbitrary cues. For example, Hayes et al. (2011) provide an example of this phenomenon using a simple nickel and dime. A nickel can be viewed as “larger than” a dime according to physical attributes like size; however, the term “larger than” can also be applied arbitrarily to represent a dime being “larger than” a nickel in terms of its monetary value. When humans interact with their own behavior, the psychological meaning of both the verbal interpretation and the behavior itself can change as a result (Hayes et al., 1996). This bidirectional property of language and behavior is useful and adaptive because it allows humans to change the function of situations and behaviors depending on occasion or context (Hayes et al., 1996, 2011). However, research suggests that any event can acquire a negative function even it is not associated with another aversive event and does not share physical properties (Dymond & Roche, 2009). The ability to associate function and emotion with events that do not share physical properties means that any event may be associated with adversity, as language has the power to manipulate the meaning we derive from any given event (Hayes et al., 2011). Because of their ability for abstraction, humans tend to require a label or cognitive appraisal for their experience (Lazarus, 1982). This appraisal carries implications with respect to how to approach or avoid the associated experiences

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(Hayes et al., 1996). For example, “anxiety” is not only a set of bodily sensations but also a descriptive verbal label that integrates experiences, thoughts, and evaluations (Hayes et al., 1996). If anxiety is labeled as a “bad emotion,” the bidirectionality of language and stimulus can create the belief that the emotion inherently is bad, as opposed to the view that the emotion is perceived as bad (Hayes et al., 1996). Verbal relations can then lead to experiential avoidance (i.e., the unwillingness to focus on private experiences such as body sensations, thoughts, and emotions) that functions as a negatively reinforced behavior (Hayes et al., 1996) and influences psychopathology (Chawla & Ostafin, 2007; Feldner et al., 2003). Using this model as a foundation, practitioners of contemporary CBTs, such as ACT and mindfulness-based interventions, attempt to alter the effect of cognitions by changing the way an individual processes and relates to them, as opposed to directly modifying them. Contemporary CBTs encourage the individual to engage with, bring awareness and attention to, and consider their own experiences in a nonevaluative manner in order to counter avoidance of events and current experiences. In doing so, these methods target the function of psychological events such as thoughts, sensations, and emotions, rather than the content, validity, or frequency of such experiences (Hayes et al., 2011). Changes in the psychological and social context of psychological events are, then, the topic of focus. Contextual and process-oriented targets are diverse and may include aspects of awareness, decentering, acceptance, cognitive flexibility, attention, and readiness to change (Hayes et al., 2011). One example of process-oriented CBT frameworks is mindfulness-based cognitive therapy, which encourages changes in awareness and relationship to thoughts (Segal et al., 2004). A second example is metacognitive therapy, which attempts to modify the way thoughts are experienced and regulated (Wells, 2008). A third example is ACT, which focuses on the way in which language and verbal activity support its use as behavioral regulation (Hayes et al., 1999) and encourages the commitment to make value-based decisions for future behavioral directions. Overall, process-oriented CBT conceptualizations of cognition tend to be transdiagnostic in nature, as they are usually quite broad in their approach and are able to apply techniques flexibly. In addition, process-oriented or contextual CBT approaches tend to include many components and techniques that are utilized in the content-focused approaches described previously (Hayes et al., 2011). However, the purpose for employing these strategies differs in that techniques are often used to allow awareness of processes in order to decrease experiential avoidance and increase behavioral flexibility. This approach to CBT continues to develop (Hayes & Hofmann, 2017, 2018) and will undoubtedly exert an important and continuing influence on the field. It is important to note that whether any given CBT adheres to a GCM model or RFT model, its clinical application to a patient will necessitate a nuanced interpretation. The CBTs require a sophisticated understanding of theory, but its application to an individual’s presentation is equally as essential for proper



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therapeutic engagement. Case conceptualization has been described as a foundation of CBT and the heart of evidence-based practice (Bieling & Kuyken, 2003; Kuyken et al., 2008), as it explains a client’s clinical presentation in a way that helps inform the selection and timing of interventions. Case conceptualization involves the collaboration of the therapist and client to interpret presenting issues with the cognitive behavioral model. Thus, it is a tool that helps describe clinical presentations in a way that is theoretically informed, coherent, and meaningful and that leads to effective interventions (Kuyken et al., 2008). Case conceptualization has several key components (Kuyken, 2006), including the implementation of the cognitive behavioral model to develop a useful descriptive framework of the patient’s presenting problems. Case conceptualization also permits the development of explanatory inferences about etiology and maintenance of presenting problems, and it creates a foundation for informed interventions (Kuyken, 2006). Two primary approaches to case conceptualization have been identified. Clinicians can conceptualize a client’s presenting problems and individualized information into a disorder-specific model, or they can conceptualize on the basis of a generic model (Kuyken et al., 2008). Generic case conceptualization is associated with more nonspecific cognitive theories for emotional disorders and is typically used for more complex or comorbid presentations, as it identifies underlying assumptions or core beliefs that contribute to multiple presenting problems (Kuyken et al., 2008). Both approaches to conceptualization are important to the CBT process and implementation.

DIAGNOSIS-SPECIFIC AND TRANSDIAGNOSTIC THERAPY CBTs employ primarily three different types of treatment techniques to evoke cognitive change (Dobson & Dobson, 2017). These techniques address cognitive process in different ways. One technique involves identifying and changing thoughts as they arise. CBTs that focus predominantly on changing thoughts often employ evidence-based interventions to help evaluate and restructure our understanding of events, feelings, and behaviors. Referring to the realist assumption as a continuum described previously (Dobson, 2013; Dobson & Dobson, 2017), such techniques have their basis in the notion that there is a “real world” with concrete facts and that our thought processes can be changed to align with this real world. A second type of technique involves finding novel, alternative, and more flexible ways to think, to help shift cognitive processes (Dobson & Dobson, 2017). Such techniques are less rigid in their approach to the real world and incorporate the individual’s perspectives, values, and goals to cultivate a more nuanced, complete, and helpful perspective. The third class of techniques involves the examination of the meaning attached to our thoughts (Dobson & Dobson, 2017). This technique is perhaps the most liberal with respect to the realist assumption and identifies the meaning attached to an individual’s perspective rather than the extent to which it truly matches the real world.

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Historically, therapies have adapted these techniques to fit with disorderspecific presentations. Such diagnosis-specific CBTs arose from the contentspecificity hypothesis (Beck, 1967), which postulated that each emotional disorder could be characterized by specific and unique cognitive content related to that disorder (Beck, 2005). For example, the typical maladaptive cognitions associated with anxiety disorders focus on the future possibility of danger or threat, and each specific form of anxiety disorder is characterized by cognitions about danger and/or uncontrollability associated with specific stimuli, situations, or experiences (Hofmann et al., 2010). This disorder-specific tailoring of therapeutic interventions has historically proved to be efficacious (e.g., Butler et al., 2006; Hofmann & Smits, 2008). Although a diagnostically related approach to therapy is empirically supported, many issues can arise. First, many patients present with comorbidities, the presence of which challenges disorder-specific theories of etiology and pathology (Lilienfeld & Treadway, 2016). Comorbidities imply that disorders may consist of common etiological factors. The diagnostic-specific approach is also associated with treatment manuals and more “formulaic” treatments, which may minimize clinical complexity and miss information that would otherwise promote successful treatment outcome (Mansell & Taylor, 2012). Finally, a diagnostic-specific framework is contingent on the current knowledge and validity of the diagnostic system itself. As these systems are, themselves, the subject of ongoing discussion and edits, a treatment framework that relies on diagnosis may incorrectly distinguish categories that are actually variations of broader underlying syndromes (Barlow et al., 2004; Brown et al., 1998). Further, only about 50% to 80% of patients who receive treatment for emotional disorders achieve clinically significant improvement (Barlow et al., 2004), which means that 20% to 50% of individuals do not experience improvement. These results imply that current CBT approaches may not fully address the full range of mechanisms suggested by disorder-specific presentations. Recent developments in the etiological models of mental disorders have shifted focus away from diagnosis-specific interventions and toward transdiagnostic modalities in an effort to rectify the weaknesses evident in diagnosisspecific treatment modalities. Rather than create and implement a specific treatment for each diagnostic disorder, transdiagnostic treatment approaches apply the same underlying treatment principles across mental disorders. Transdiagnostic models decrease the importance placed on disorder-specific symptoms and instead emphasize the underlying mechanisms and processes related to mental disorders in general. In transdiagnostic theoretical frameworks, there is a focus on underlying processes that will reduce comorbid disorders through the use of generalized and flexible treatment approaches that promote coping strategies and treatment principles that can be broadly applied to daily life (McEvoy et al., 2009). Although most current transdiagnostic models and therapies examine the influence of multiple processes on a range of different disorders (Norton & Paulus, 2016), other transdiagnostic models exist that evaluate mechanisms that underlie specific symptoms across diagnostic labels and that



Theoretical Framework  43

examine universal processes that underpin psychopathology (Mansell et al., 2009; Norton & Paulus, 2016). Transdiagnostic therapies have been established with one of two primary approaches (Clark & Taylor, 2009; Norton & Paulus, 2016). The pragmatic approach to transdiagnostic treatment development involves a reliance on clinical intuition, as well as trial and error, and the commensurate consideration of whether a treatment for one disorder may be effective for another (Clark & Taylor, 2009; Norton & Paulus, 2016). For example, a treatment technique found to be effective for one anxiety disorder may be applied to another anxiety disorder to examine whether it can be used across diagnoses. In contrast, the theory-driven approach employs a bottom-up framework to treatment development. This approach involves identification of core processes that underlie several disorders or clinical presentations and then development of treatment modalities on the basis of those processes (Clark & Taylor, 2009; Norton & Paulus, 2016). Transdiagnostic treatment from this perspective focuses on processes across the domains of attention, memory, imagery, thinking, reasoning, and behavior that have been found to commonly maintain distress in people with psychological disorders (Patel et al., 2015). The most recent CBT developments have moved to emphasize underlying cognitive mechanisms and processes rather than symptom presentation (Hayes & Hofmann, 2017, 2018). With recent advances in theory and treatment, fundamental components that can be deployed in the treatment of emotional disorders, broadly speaking, have been developed. Transdiagnostic therapeutic principles have been highlighted by Barlow and colleagues (2004, 2011) and are implemented in a similar context as diagnosis-specific CBT protocols, such as the encouragement of emotional expression through exposure exercises. Specifically, the goal of the therapy is to alter cognitive appraisal that precedes varied emotional disturbance and, in doing so, discourage emotional avoidance and encourage actions not associated with the aversive emotion. These treatment approaches go beyond traditional CBT approaches in that they target cognitive, behavioral, and emotional avoidance tendencies (Barlow et al., 2004; Dobson & Dobson, 2017). The successful provocation of emotions in order to implement treatment components is conceptualized as the mechanism of action in this treatment modality (Barlow et al., 2004). Such treatment components target factors such as the ability to regulate emotions and increased attentional control and flexibility (Hayes et al., 2011). Transdiagnostic treatments target their therapy components toward broad and flexible techniques that can be adapted to a number of different clinical presentations. These treatments have shown similar efficacy to that of diagnosis-specific treatments (Barlow et al., 2017).

SUMMARY AND CONCLUSIONS This chapter has reviewed the theoretical foundations of the cognitive behavioral family of interventions. The CBTs are a diverse group of interventions

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that have developed over the years, drawing upon a wide variety of theoretical principles (Dobson & Dozois, 2019). Despite the diversity among traditional and contemporary CBTs, all maintain that cognitive processes, emotions, and behaviors are interdependent. The conceptual principles of CBT have grown from early to contemporary CBT modalities. Behavior therapy initiated a movement in clinical psychology and psychiatry that moved clinical applications of psychology toward evidence-based and empirical models of therapeutic interventions. The bidirectional movement and amalgamation of behavior and cognitive therapies in the early 1900s allowed for the preservation of the empirical foundations of behavioral interventions, even as it incorporated cognitive activities into similar behavioral laws. This evolution permitted cognition to be modified using similar overt strategies as behavioral interventions and allowed for the development of the three fundamental principles of the traditional CBT models: (a) cognitions affect behavior, (b) cognition can be monitored and altered, and (c) behavior change may be affected through cognitive change. More recent developments within CBTs include an emphasis on context and functional processes associated with psychopathology, as opposed to a focus on cognitive content. Although there has been debate over whether approaches such as mindfulness, ACT, and metacognitive therapy constitute forms of CBTs, their conceptual foundations and therapeutic techniques can be linked and related to the CBT family (Beck, 1967; Hofmann et al., 2010). Differences among specific therapies can be conceptualized according to which stage of emotional processing the therapeutic intervention targets. Earlier CBTs tend to emphasize antecedent-focused strategies to modify unhelpful cognitive content, whereas contemporary CBT models implement response-focused interventions to decrease experiential avoidance and suppression (Hofmann & Asmundson, 2008). Differences in cognition have been identified to play an important role in the way in which CBTs organize their therapeutic techniques and outcome variables. Two approaches to cognition have been conceptualized and implanted into CBTs. According to the GCM (Beck & Haigh, 2014), schemas specific to an individual’s beliefs and goals affect the manner in which they process information. When the ability of an individual to process information becomes distorted, the risk of psychopathology increases, as it interferes with and alters their ability to engage in adaptive thought and emotional and behavioral processes. The GCM’s conceptualization of cognition offers a framework to evaluate whether the content of an individual’s thoughts or behaviors are adaptive or maladaptive, permitting clinicians to apply cognitive and behavioral strategies to “correct” or “adjust” these distortions. In contrast, RFT (Hayes et al., 2001) conceptualizes cognition in terms of its meaning and function. Language and verbal capabilities allow individuals to draw connections and associations between symbolic and arbitrary cues and personal experiences (Hayes et al., 2011; Hughes & Barnes-Holmes, 2016). As a result, CBTs that align with process- or context-oriented conceptualizations of cognition tend to be associated



Theoretical Framework  45

with therapeutic strategies targeting awareness and acceptance of thought, emotions, and behaviors in order to improve behavioral and cognitive flexibility and mitigate distress. The shift from diagnosis-specific to transdiagnostic CBT modalities reflects the shift toward more generic models of psychopathology. Early CBT models postulated that each specific disorder was associated with unique content-specific presentations and cognitive characterizations (Beck, 1967), and therapies were developed and implemented to target specific disorder presentations. However, due to the continuing controversies associated with diagnostic nosology (Lilienfeld & Treadway, 2016), new etiological models of psychological disorders have been theorized that highlight common underlying processes associated with psychopathology in general. Novel treatment approaches attempt to bridge this shift, and transdiagnostic therapies have been created with broad and flexible techniques that can be implemented across many disorder presentations. The transdiagnostic approach to CBT appears to demonstrate efficacy in the treatment of a range of disorders (Farchione et al., 2012; McEvoy et al., 2009; Reinholt & Krogh, 2014). There is a growing scholarly literature devoted to the future of CBT (e.g., Hayes, 2016; Persons, 2016; Thompson-Hollands et al., 2014). Transdiagnostic models and theories are commonly cited as a critical direction for the CBTs. The classification of diagnoses as discrete categories has been shown to decrease validity and undermine common core mechanisms found among disorders (Barlow et al., 2004; Mansell & Taylor, 2012; Thompson-Hollands et al., 2014). CBTs that are refined in the future may emphasize transdiagnostic moderators and mediators, such as temperament or motivation, in order to circumvent some of the perceived limitations of more specific treatment models (Hayes, 2016; Thompson-Hollands et al., 2014). Process-oriented models in CBT (e.g. Hayes & Hofmann, 2017, 2018) may also deemphasize the importance of syndromic classification systems. Consistent with transdiagnostic models of treatment, process-oriented models will encourage research, theory, and treatments related to generic psychopathological mechanisms. This said, transdiagnostic and process-oriented approaches to treatment should be grounded on the recent developments of cognitive, behavioral, emotional, and neuroscience research to optimally identify the mechanisms of psychopathology. These models also must tailor their interventions to the unique presentation of a given patient in order to maximize the fit, utility, and acceptability of therapy (Thompson-Hollands et al., 2014). Future directions in CBT may shift to a more flexible framework that adopts a predominantly process-oriented or transdiagnostic approach but also embodies the foundational importance of case conceptualization at the heart of evidence-based practice. REFERENCES Bandura, A. (1977). Social learning theory. Prentice-Hall. Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35(2), 205–230. https://doi.org/dgqwsf

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Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https:// doi.org/10.1017/S1352465808004815 Lazarus, R. S. (1982). Thoughts on the relations between emotion and cognition. American Psychologist, 37(9), 1019–1024. https://doi.org/10.1037/0003-066X.37.9. 1019 Lewinsohn, P. M., Biglan, A., & Zeiss, A. S. (1976). Behavioral treatment of depression. In P. O. Davidson (Ed.), The behavioral management of anxiety, depression and pain (pp. 91–146). Brunner/Mazel. Lilienfeld, S. O., & Treadway, M. T. (2016). Clashing diagnostic approaches: DSM-ICD versus RDoC. Annual Review of Clinical Psychology, 12, 435–463. https://doi.org/10. 1146/annurev-clinpsy-021815-093122 Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27(2), 173–187. https://doi.org/10. 1016/j.cpr.2006.08.001 Mansell, W. (2008). The seven C’s of CBT: A consideration of the future challenges for cognitive behavior therapy. Behavioural and Cognitive Psychotherapy, 36(6), 641–649. https://doi.org/10.1017/S1352465808004700 Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy, 23(1), 6–19. https://doi.org/10.1891/0889-8391.23.1.6 Mansell, W., & Taylor, J. L. (2012). What is CBT and what isn’t CBT. In W. Dryden & R. Branch (Eds.), The CBT handbook (pp. 5–24). Sage. Markin, R. D. (2014). Toward a common identity for relationally oriented clinicians: A place to hang one’s hat. Psychotherapy: Theory, Research, & Practice, 51(3), 327–333. https://doi.org/10.1037/a0037093 McEvoy, P. M., Nathan, P., & Norton, P. J. (2009). Efficacy of transdiagnostic treatments: A review of published outcome studies and future research directions. Journal of Cognitive Psychotherapy, 23(1), 20–33. https://doi.org/10.1891/0889-8391. 23.1.20 Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy: Theory, Research, & Practice, 48(1), 4–8. https://doi.org/10.1037/ a0022180 Norton, P. J., & Paulus, D. J. (2016). Toward a unified treatment for emotional disorders: Update on the science and practice. Behavior Therapy, 47(6), 854–868. https://doi.org/10.1016/j.beth.2015.07.002 Patel, T., Mansell, W., & Veale, D. (2015). The cognitive behavioral processes questionnaire: A preliminary analysis within student, mixed clinical and community samples and the identification of a core transdiagnostic process. Cognitive Therapy and Research, 39(2), 193–203. https://doi.org/10.1007/s10608-014-9641-9 Persons, J. B. (2016). Science in practice in cognitive behavior therapy. Cognitive and Behavioral Practice, 23(4), 454–458. https://doi.org/10.1016/j.cbpra.2016.01.003 Reinholt, N., & Krogh, J. (2014). Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: A systematic review and meta-analysis of published outcome studies. Cognitive Behaviour Therapy, 43(3), 171–184. https://doi.org/10. 1080/16506073.2014.897367 Riskind, J. H., & Alloy, L. B. (2006). Cognitive vulnerability to emotional disorders: Theory and research design/methodology. In L. B. Alloy & J. H. Riskind (Eds.), Cognitive vulnerability to emotional disorders (pp. 1–29). Erlbaum. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Basic Books. Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In S. C. Hayes, V. M., Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 45–65). Guilford Press.

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Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press. Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275–287. https://doi.org/ 10.1037/0022-006X.70.2.275 Thompson-Hollands, J., Sauer-Zavala, S., & Barlow, D. H. (2014). CBT and the future of personalized treatment: A proposal. Depression and Anxiety, 31(11), 909–911. https://doi.org/10.1002/da.22301 Wells, A. (2008). Metacognitive therapy: Cognition applied to regulating cognition. Behavioural and Cognitive Psychotherapy, 36(6), 651–658. https://doi.org/10.1017/ S1352465808004803 Wilson, K. G., Bordieri, M. J., Flynn, M. K., Lucas, N. N., & Slater, R. M. (2011). Understanding acceptance and commitment therapy in context: A history of similarities and differences with other cognitive behavior therapies. In J. D. Herbert & E. M. Forman (Eds.), Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies (pp. 233–263). John Wiley & Sons. https://doi.org/10.1002/9781118001851.ch10 Wilson, K. G., & Murrell, A. R. (2002). Functional analysis of behavior. In M. Hersen & W. H. Sledge (Eds.), Encyclopedia of psychotherapy (pp. 833–839). Academic Press.

3 The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders Lorenzo Lorenzo-Luaces, Lotte H. J. M. Lemmens, John R. Keefe, Pim Cuijpers, and Claudi L. H. Bockting

D

iagnoses of depressive and anxiety disorders are among the most common and disabling health conditions worldwide (Murray et al., 2012; World Health Organization, 2017). It was once thought that these conditions could only be treated with pharmacological therapies or that they required lengthy and intensive talking cures. The advent and empirical evidence for cognitive behavioral therapies (CBTs) changed this and suggested that brief therapies that were symptom focused and emphasized themes of the present could efficaciously target symptoms of internalizing pathologies (Rush et al., 1977). The development of CBTs can be traced back to the work of Ellis (1962) and Beck (1963), who highlighted the role of biased thinking processes in the onset and maintenance of psychopathology. Consequently, Beck and Ellis developed therapeutic protocols, cognitive therapy (CT) and rational therapy, respectively, that addressed biases in thinking by the use of psychoeducation and logicorational procedures as well as behavioral strategies aimed at changing cognition. With posterity, these therapies have been branded as the “second wave” of CBTs in an attempt to describe historical changes in the field. Beck has twice expanded the theory that underlies CBTs (Beck, 1996; Beck & Haigh, 2014), but the core principles remain much the same. The historical precursors to the CBTs were the behavior theories that ignored or downplayed the role of cognition in influencing behavior, now sometimes referred to as the “first wave” of CBTs. The behavior therapies, which focused on associative and nonassociative learning models, highlighted that overt behavioral changes were the primary goal of therapy. https://doi.org/10.1037/0000218-003 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

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

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There have been at least two attempts to succeed the “traditional” or second wave CBTs, which were focused on changing behaviors as well as altering the content of beliefs, thinking patterns, and other underlying cognitive vulnerabilities. One is the so-called third wave of CBTs, characterized by acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and other less commonly practiced and researched therapies like competitive memory training (Dimidjian et al., 2016). If there is a commonality to these therapies, it is that their stated aim is not to change the content of the person’s thoughts but to change their internal responses and relations to the thoughts. An additional point of commonality among the third-wave CBTs is that they use therapeutic techniques that had hitherto been “reserved for the less empirical wings of clinical intervention and analysis, emphasizing issues as acceptance, mindfulness, cognitive defusion, dialectics, values, spirituality, and relationship” (Hayes, 2004, p. 640). Other therapies are more ambiguously categorized as third-wave therapies, such as behavioral activation (BA) or dialectical behavioral therapy (DBT), the latter of which has more evidence as a treatment for nonsuicidal self-injury or borderline personality disorder than for depression or anxiety. The second advancement in the conceptualizations and treatment of depression and anxiety with CBT concerns the development of transdiagnostic CBT treatments. In the past decades, disorder-specific treatment-CBT protocols have been developed for anxiety disorder, depressive disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). These protocols describe different interventions, although they all share a cognitive behavioral model. Transdiagnostic CBT protocols aim to target the underlying vulnerability to negative affectivity as opposed to addressing symptoms of single disorders. Among the best studied of these is Barlow’s Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders (Barlow, Farchione, SauerZavala, et al., 2017). The UP emphasizes the shared CBT interventions to treat mental health disorders instead of disorder-specific interventions. As its name implies, the UP is a single treatment protocol that applies to depression, the anxiety disorders, OCD, and PTSD. Because the UP is a single protocol that can be used across a range of problems that are frequently comorbid, one of its aims is to be more user friendly for clinicians and patients. The family of CBTs is arguably the best studied group of psychological interventions for anxiety and depression. Hofmann et al. (2012) identified 269 meta-analytic studies examining the efficacy of CBTs for a wide range of mental disorders (e.g., substance use disorders, somatoform disorders), as well as depression and anxiety. They concluded that there was strong support for the efficacy of CBTs for anxiety disorders and mixed support for CBTs for depression, with some studies finding very strong support and other studies suggesting that these effects are overestimated. In addition, they concluded that for somatoform disorders, bulimia, anger control problems, and general stress, there is strong support for the efficacy of CBT. Although CBT for bulimia was considerably more effective than other forms of interventions, less is known for



The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders  53

other eating disorders. For bipolar disorder, the efficacy of CBT was small to medium in comparison with treatment as usual, although the treatment of depressive symptoms within bipolar disorder was well supported. For the treatment of substance use disorders, the effect sizes of CBT ranged from small (for opioid and alcohol dependence) to medium (for treating cannabis and nicotine dependence). For treating schizophrenia and other psychotic disorders, CBT was especially effective in reducing the positive symptoms and secondary outcomes in the psychotic disorders. However, for this population, CBT was less effective than medication and family interventions. For personality disorders, studies showed considerable variation, but there was some evidence for superior efficacy of CBT as compared with other psychosocial treatments. Subsequent meta-analytic reviews have by and large confirmed these findings. For example, CBT appears to be one of the most efficacious treatments available for bulimia, outperforming interpersonal psychotherapy (IPT) as well as other psychosocial interventions (Linardon et al., 2017). Similarly, CBT for psychosis may be especially effective at reducing positive symptoms when compared with nontreatment controls, standardized mean difference (SMD) = −0.29, 95% CI [−0.55, −0.03]; treatment as usual (TAU), SMD = −0.30, 95% CI [−0.45, −0.14]; or supportive therapy, SMD = −0.47, 95% CI [−0.91, −0.03], though the quality of this evidence is relatively low (Bighelli et al., 2020). For the purpose of the current chapter, we provide an updated summary of the state of the evidence of CBTs for emotional disorders, including major depressive disorder and anxiety as well as its historically related disorders, OCD and PTSD, which were only recently removed from the category of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). We focus on these internalizing disorders because they are among the most common and better studied of the DSM-5 disorders.

METHOD Using search terms similar to those of Hofmann et al. (2012), we systematically searched three databases (PubMed, PsycInfo, and Cochrane) for potentially relevant papers that were published in English in peer reviewed journals between fall 2011 and summer 2018. Specifically, we crossed search terms indicating article type (meta-analysis/quantitative review) with terms indicating the type of intervention (CBTs) and the target problems (e.g., depression, OCD). A full search string can be found in Appendix 3.1. In order to be included, papers had to be quantitative reviews (i.e., metaanalyses, not research papers, qualitative reviews, theoretical essays, commentaries, or replies) of various CBTs (C[B]T, BA, ACT, MBCT, exposure) for patients (all ages) with a diagnosis of a depressive and/or anxiety disorder (including OCD and PTSD) that were delivered either individually or in group format. Meta-analyses that did not include an outcome measure of depression/anxiety

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severity were excluded, as were those that focused on purely self-guided or internet-/web-/chat-/text-/email-delivered CBTs. Furthermore, we excluded studies that focused on primary prevention. For meta-analyses with a focus on psychotherapy or psychological interventions in general, we examined the proportion of CBT studies included. If this was at least 90%, or if authors reported subgroup analyses on the CBTs, the manuscript was included. For papers that later were corrected (corrigendum), we included only the corrected version (see Appendix 3.2 for more details). Our initial search yielded 1,281 hits, of which 319 were duplicates and had to be excluded. Of the 962 unique articles that were identified, 851 did not meet our inclusion criteria and were therefore excluded. A total of 111 papers met inclusion criteria and were selected for further review. We asked several experts with long-standing experience in the research field and clinical practice to check the list that was generated and to provide us with additional relevant papers. This led to the addition of eight papers, resulting in a total of 119 papers that were further explored. The full list of references can be found in Appendix 3.3. A selection of these studies is discussed in more detail in the next section. As relevant, we also discuss earlier landmark randomized controlled trials (RCTs), theoretical reviews, and older meta-analyses when we could not find more recent ones. Although our search was focused on meta-analyses studying the efficacy of CBT across age groups, here we focus the discussion on CBT for adult populations.

RESULTS The majority of the data in this section are presented in terms of effect sizes, which characterize the magnitude of the effect under investigation. Table 3.1 presents remission rates for key mental health disorders described in this chapter to help the reader understand the percentage of people who achieve remission following a course of CBT. Major Depressive Disorder Overall Effects Cuijpers and his colleagues have built an online database of clinical trials exploring the efficacy of psychotherapies for depression including CBTs (Cuijpers, van Straten, et al., 2008). Various meta-analytic reviews have been the product of this data set (Cuijpers, Andersson, et al., 2011). By and large, these meta-analyses show that the effects of CBTs for depression are large, g = −0.98, 95% CI [−1.17, −0.80], when contrasted to wait list control conditions (WLCs; Cuijpers, Cristea, et al., 2016). These meta-analyses also support the efficacy of CBT relative to TAU, although the differences tend to be more modest, g = −0.60, 95% CI [−0.75, −0.45]. Meta-analyses have also supported the idea that although CBT for major depressive disorder is efficacious, its effects have been overestimated because of publication bias (Cuijpers, Berking, et al., 2013).



The Efficacy of Cognitive Behavioral Therapy for Emotional Disorders  55

TABLE 3.1. Mean Remission Rates Reported in Studies of Cognitive Behavioral Therapy (CBT) for Depressive and Anxiety Disorders

n

Mean

95% CI

Major depression

17

66%

58%–73%

Generalized anxietyb

3

51%

36%–67%

Social anxietyb

10

40%

30%–51%

Panic or agoraphobiab

13

48%

40%–56%

PTSDb

20

53%

45%–61%

OCDb

6

38%

31%–45%

a

Note. CI = confidence interval, PTSD = posttraumatic stress disorders, OCD = obsessivecompulsive disorder. All rates reported for intent-to-treat (ITT) samples. a Cuijpers, Karyotaki, et al. (2014) definition: not meeting criteria for major depression after therapy. bSpringer et al. (2018) study-specific remission criteria including not meeting diagnostic criteria, good functioning, a score below a threshold, or a combination of criteria.

There are no indications that CBT is more or less efficacious than other psychotherapies or pharmacotherapy (Cuijpers, Andersson, et al., 2011). Fewer comparisons against pill or psychological placebos exist, and, as with the comparisons to TAU, the data suggest a statistically significant but more modest advantage of CBT. Some meta-analyses (e.g., Cuijpers, Cristea, et al., 2016) provide an optimistic estimate of the effects of CBT versus placebo, g = −0.55, 95% CI [−0.81, −0.28], albeit with a small number of studies (n = 5). Other meta-analyses have painted a more modest picture of the relative effects of CBT versus placebo, g = −0.33, 95% CI [−0.50, −0.16], though these effects seem comparable to antidepressant medication (Cuijpers, Turner, et al., 2014). Study features other than the control group appear to inflate the efficacy of CBT. Notably, CBT appears more efficacious than control conditions in lower quality studies (e.g., those that do not adequately generate the randomization sequence, have suboptimal concealed allocations for participants and personnel, handle missing data by using completers analyses; see also risk of bias assessment tool by Higgins & Green, 2008), as well as in studies that are conducted by proponents of CBTs, and studies with higher effect sizes are more likely to get published, thus inflating outcomes (see also Cuijpers, Andersson, et al., 2011). Group formats appear as efficacious as the individual format, though Feng et al. (2012) noted that there are few studies assessing the relapse-prevention effect seen in individual CBT for acute depression. Combining CBT and antidepressants leads to superior outcomes versus providing either treatment as a monotherapy, although the difference is small in magnitude (Tolin, 2017). Interpersonal Psychotherapy Aside from supportive therapy, the psychotherapy that CBT has been most frequently compared with is IPT. In a meta-analysis of 10 RCTs, Zhou et al. (2017) reported a small difference favoring CBT over IPT on the Beck Depression Inventory–II (BDI-II; Beck et al., 1996) but not on the Hamilton Rating Scale for Depression (Hamilton, 1960). This difference of 1.31 BDI-II points

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(SD = 0.12–2.49) falls below most of the conventional thresholds for clinical significance (Button et al., 2015). The authors cautioned against interpreting the findings from these 10 studies, as they were dependent on the outcome measures utilized and run counter to prior findings of meta-analytic summaries showing no differences between CBT and IPT (Cuijpers, Donker, et al., 2016; Cuijpers, Geraedts, et al., 2011; Lemmens et al., 2015). Severe Depression The report from the landmark Treatment for Depression Collaborative Research Program (TDCRP: Elkin et al., 1989) suggested that CBT was equally efficacious as placebo plus clinical management for patients with severe depression, whereas the other treatment conditions (IPT and antidepressants) outperformed CBT and the control. Although the TDCRP has been variously criticized, its findings led to skepticism regarding the use of CBT for this patient subgroup, formally instantiated in specific treatment guidelines suggesting that CBT monotherapy should be reserved for mild to moderate, but not severe, depression. A subsequent trial comparing BA, CBT, placebo, and antidepressants found similar results (Dimidjian et al., 2006). In that study, there were no differences between the four treatment conditions for patients with mild to moderate depression, which was defined as an HRSD ≥ 20. By way of contrast, for patients with severe depression, the outcomes for the BA condition were quite positive. Response rates on the BDI-II, for example, were 76% in BA, 46% in CT, and 49% receiving antidepressants. This finding renewed concerns regarding the efficacy of CBT for severe depression but suggested that BA may be a particularly potent treatment for severe major depressive disorder. However, not all studies suggest skepticism regarding the efficacy of CBT for severe depression. DeRubeis et al. (2005) randomized patients with moderate to severe depression to CBT or antidepressants for 16 weeks in a trial that included an 8-week placebo control. At 8 weeks, response rates in medications (50%) and CBT (43%) groups were both superior to the placebo (25%) group. At the end of treatment, 58% of patients in CBT and 58% of the patients in antidepressants had responded. Furukawa et al. (2017) approached the question of the effects of CBT for severe depression by conducting an individual patient data meta-analysis (IPD-MA). An IPD-MA pools together the individual patient-level data as opposed to the study-level averages, allowing researchers to test for the effect of symptom severity on individual-level outcomes. They added five studies comparing CBT to placebo (n = 509) but failed to find any baseline severity by treatment interaction in predicting outcomes, indicating that the effects of CBT versus placebo do not vary according to baseline severity (Furukawa et al., 2017). Another IPD-MA of 16 studies comparing antidepressant monotherapy to CBT also failed to find a severity by treatment interaction when comparing antidepressants and CBT. This same IPD-MA, however, reported a main effect of antidepressant monotherapy over CBT roughly equivalent to a 1-point dif-



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ference on the HRSD, as well as a nonsignificant trend similarly equivalent to a 1-point difference on the BDI and BDI-II. The authors of the study call into question the clinical significance of the finding of a superiority of antidepressants over CBT. However, the small superiority of antidepressants over CBT is the product of pooling together trials in which the effects of CBT have varied by site (DeRubeis et al., 2005), severity (Dimidjian et al., 2006), and both site and severity (Elkin et al., 1989). This highlights that whereas CBT for depression is efficacious on average, its performance can be highly variable across studies. Overall, there is evidence that CBT for depression is feasible and efficacious for the whole range of severity, although there is also evidence indicating a small superiority of antidepressants over CBT alone. Long-Term Effects Perhaps the most promising finding regarding acute treatment with CBT is that acute treatment has relapse-prevention effects that persist following acute treatment. These effects are noteworthy in light of the high probability of relapse for patients in clinical settings. Cuijpers, Hollon, et al. (2013) reviewed studies in which long-term outcomes of acute-phase CBT were compared with the effects of pharmacotherapy when it was discontinued or continued over the long term. They identified nine studies in which acute-phase CBT was compared with pharmacotherapy delivered acutely but withdrawn at the long-term follow-up. Patients who received acute CBT were less likely to go on to relapse than those who received antidepressant medication and had it discontinued, OR = 2.61, 95% CI [1.58, 4.31]. Further, a trend in the data (based on five studies) suggested that acute CBT was superior to keeping patients on pharmacotherapy, OR = 1.62, 95% CI [0.97, 2.72]. These findings were confirmed by a subsequent meta-analysis including mostly CBT studies, though the protective effect significantly decreased over follow-up time of longer than 6 months (Karyotaki, Smit, de Beurs, et al., 2016). Moreover, another meta-analysis demonstrated that adding psychotherapy to antidepressants resulted in better long-term outcomes as compared with antidepressants alone, OR = 3.02, 95% CI [1.74, 5.25] (Karyotaki, Smit, Holdt Henningsen, et al., 2016). Interestingly, this same meta-analysis did not find that long-term outcomes were superior with combined treatment relative to psychotherapy alone, OR = 1.51, 95% CI [0.79, 2.86]. Most people who seek help for their depression are treated with antidepressants (Olfson & Marcus, 2009). Within this context, preventive cognitive interventions have specifically been developed that start after full or partial recovery/ remission from antidepressants to prevent relapse and recurrence. MBCT and preventive cognitive therapy (PCT) are mostly studied in the past decades (Biesheuvel-Leliefeld et al., 2015, 2017; Bockting et al., 2005, 2009, 2018; Bockting, Smid, et al., 2015; Klein et al., 2018; Teasdale et al., 2000). Both MBCT and PCT consist of eight sessions given in 8 weeks (Bockting, Hollon, et al., 2015). PCT and MBCT are efficacious in preventing relapse and recurrence over follow-ups of at least 1 year and up to 10 years (for meta-analyses, see

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Biesheuvel-Lelieveld et al., 2015; Guidi et al., 2016; Kuyken et al., 2016; Piet & Hougaard, 2011; Vittengl et al., 2007). Results from several RCTs have shown that PCT and MBCT are suitable alternatives for continuation of antidepressants in remitted individuals with multiple previous episodes (Bockting et al., 2018; Kuyken et al., 2008, 2015; Segal et al., 2010). However, a three-arm RCT demonstrated that adding PCT to continuation of antidepressants after recovery resulted in the lowest relapse risk as compared with continuation of antidepressants alone and to PCT alone. The combination of PCT and antidepressants resulted in an additional 41% risk reduction as compared with antidepressants alone (Bockting et al., 2018), whereas no significant risk reduction was found in an RCT comparing adding MBCT to antidepressants and antidepressants alone (Huibers et al., 2015). Continuation of only antidepressant use was not better than PCT for relapse over 2 years. Some meta-analyses have found evidence that the preventive effect of these relapse-prevention interventions is mainly found in individuals with more recurrent depression (defined as more than one or more than two prior episodes; Piet & Hougaard, 2011). Others have failed to find a moderating effect of previous episodes (e.g., Biesheuvel-Lelieveld et al., 2015), including an IPD-MA pooling individual study data of 1,258 patients (Kuyken et al., 2016). The theory of change underlying MBCT for depression proposes that the intervention targets vulnerability to depression relapse and that its effect should be pronounced among those with more prior episodes. Interestingly, the Kuyken et al. (2016) analysis suggested that the superiority of MBCT relative to controls may be pronounced among individuals with greater residual symptoms following acute treatment. Anxiety Disorders Overall, meta-analytic results support the efficacy of CBTs for anxiety, OCD, and PTSD relative to waiting lists and TAU, the control conditions to which they have most frequently been compared. Fewer studies include a pill or psychological placebo-controlled comparison, but these studies also support the efficacy of CBT for anxiety and related disorders (Carpenter et al., 2018). In addition to yielding improvements in symptom-specific measures, CBT seems to lead to improvements in quality of life (Hofmann et al., 2014). Generalized Anxiety Disorder Cuijpers, Sijbrandij, et al. (2014) conducted a meta-analysis of all existing psychotherapies for generalized anxiety disorder (GAD). Most (85%) of the 41 studies included a CBT arm, indicating that CBT is the most widely researched psychological therapy for GAD, but also highlighting the need for more comparative outcome research. Although the data supported the efficacy of CBTs for GAD, most of the studies used a waiting list as a control. There were not enough studies to evaluate the long-term effects of CBT for GAD or its effect relative to other treatments. In the most recently published



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meta-analysis on pill- or psychological placebo-controlled RCTs, only two studies of CBT for GAD were identified (Carpenter et al., 2018). Both supported the efficacy of CBT for GAD, but both were very small studies. Cuijpers, Cristea, et al. (2016) reported large effects of CBT for GAD when compared with waiting list controls, g = −0.85, 95% CI [−0.99, −0.72], or placebos, g = −1.32, 95% CI [−1.81, −0.83], with smaller effects in comparison with TAU, g = −0.45, 95% CI [−0.64, −0.26]. Hanrahan et al. (2013), in a prior review, found somewhat larger effects of CBT versus nontherapeutic (e.g., waiting list) controls, d = −1.81, 95% CI [−2.37, −1.26]. These authors noted that the treatment effect size is higher relative to other meta-analyses and that outcome studies investigating the efficacy of newer forms of CBT may be the explanation for the higher effect size. For example, unlike Cuijpers, Cristea, et al. (2016), they included metacognitive therapy, which is distinct in its addressing of metacognitive beliefs about worry, in their analyses. Although the data support the efficacy of CBT for GAD, more comparative research is needed, particularly with newer forms of CBT. Specific Phobias Meta-analytic estimates from years not covered in the scope of our review suggest that CBT, particularly in vivo exposure, is an evidence-based treatment for specific phobias, outperforming inactive and psychological placebo controls (Wolitzky-Taylor et al., 2008). The effects of exposure relative to a waiting list control are large, d = −1.03, 95% CI [−1.16, −0.91]. We could not locate a newer meta-analytic estimate of the effect of CBT for this target group against placebo (Carpenter et al., 2018), but the meta-analysis by Wolitzky-Taylor et al. (2008) suggested a medium effect, d = −0.48, 95% CI [−0.72, −0.25]. CBT also appears to be superior to relaxation therapy in the treatment of specific phobias, with a small effect-size advantage, d = −0.22, 95% CI [−0.42, −0.03] (Montero-Marin et al., 2018), although the authors noted that these results were sensitive to the number and quality of studies included. One advancing trend in the treatment of specific phobias is the use of virtual reality (VR) as the setting for exposure to feared stimuli. VR may have particular advantages when access to the feared stimuli is expensive or difficult to obtain (e.g., spiders, flying) or as an intermediate step for in vivo exposure. Overall, specific phobia virtual reality exposures are efficacious as compared with WLC (Morina et al., 2015; Opriş et al., 2012), even when just considering improvements on behavioral approach tasks (Morina et al., 2015). Interestingly, in the few studies testing virtual reality exposure against in vivo exposure, there were no significant differences between the modalities in efficacy at termination or follow-up (Morina et al., 2015; Opriş et al., 2012). Social Anxiety Disorder Cuijpers, Cristea, et al. (2016) reported that the effects of CBTs for social anxiety relative to waiting lists were large, g = −1.00, 95% CI [−1.40, −0.61]. The effects of CBT for social anxiety versus TAU, g = −0.47, 95% CI [−0.77, −0.12],

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n = 3, or placebos, g = −0.47, 95% CI [−0.70, −0.24], n = 5, were in the medium range and appeared similar in magnitude, though there were few studies available to make the comparison. When the authors restricted the analyses to studies that met their specific designation of “high quality” and to those that were also compared with TAU or a pill placebo, there were not enough studies available to assess the efficacy of CBT for social anxiety disorder. Other meta-analyses also support the efficacy of CBT for social anxiety when compared with controls (Carpenter et al. 2018), as well as the comparable efficacy of individual CBT versus group-based CBT (Wersebe et al., 2013). Mayo-Wilson et al. (2014) conducted a systematic review and network metaanalysis of psychological and pharmacological treatments for adults with social anxiety disorders, including CBTs. Network meta-analysis differs from traditional meta-analysis in that it provides a quantitative summary of the effects of multiple interventions (e.g., CBT, IPT, antidepressants) across studies making different comparisons (e.g., CBT vs. IPT vs. a waiting list in one study, CBT vs. a waiting list in another study, and IPT vs. antidepressants in another one study). It can provide a summary of the expected difference between treatments directly based on comparisons that are available as well as indirectly based on treatment having a shared comparator (e.g., the comparison of CBT vs. WLC and IPT vs. WLC allows an estimation of the expected difference between CBT vs. IPT). Mayo-Wilson et al. (2014) distinguished between individual CBT (i.e., combining behavioral strategies such as cognitive restructuring and exposure), group CBT, and exposure plus social skills training (i.e., in which the aim was behavioral training devoid of explicit cognitive training). The authors reported that all these CBT interventions were more efficacious than WLC. Of note, individual CBT was the only intervention that also had a greater effect on outcomes than interventions that were classified as psychological placebos, pill placebos, psychodynamic therapy, and “other therapies” (e.g., IPT). Mayo-Wilson et al. found that CBT according to the Clark and Wells (1995) model, which highlights the negative processing of the self with a special focus on self-focused attention, tended to produce the largest effects. Panic Disorder With or Without Agoraphobia In a Cochrane Review, Pompoli et al. (2016) reviewed the effects of psychological therapies for panic with or without agoraphobia on symptomatic remission. More than half of the 54 studies included CBT (n = 32), pure behavior therapy (n = 12), pure cognitive therapy (n = 3), or third-wave CBTs (n = 2). By and large, results supported the efficacy of CBTs for panic disorder relative to WLC. Additionally, the authors found that across 10 studies, the full course of CBT appeared to be more efficacious than pure behavior therapy. The authors noted that more comparisons to other treatments (e.g., psychodynamic therapy) are needed. In another review by the same group, Pompoli et al. (2018) used component network meta-analysis to identify efficacious elements of CBT for panic disorder. Component network meta-analysis is an extension of standard network meta-analysis in which the effect of an intervention (e.g., CBT vs. WLC)



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is assumed to be the sum of different components of the intervention. For example, in some studies, CBT consists of psychoeducation, breathing retraining, cognitive restructuring, interoceptive exposure, and in vivo exposure, whereas in other studies, it is simply done via psychoeducation, interoceptive exposure, and in vivo exposure. Network meta-analysis attempts to elucidate the incremental effect of components by examining differences in outcomes between studies that do and do not include specific components. The results of this meta-analysis suggest that the most efficacious CBT for panic disorder would be one that is delivered face-to-face and with psychoeducation, psychological support, cognitive restructuring, and interoceptive exposure. In their comparison to relaxation therapy, Montero-Marin et al. (2018) found differences between CBT and relaxation therapy only for panic disorder at the long-term follow-up. Thus, despite evidence that CBT for panic disorder is efficacious, including indications that its specific cognitive and behavioral ingredients are efficacious, there is certainly room for improvement in terms of its efficacy relative to treatments that are often intended to be nonspecific. Posttraumatic Stress Disorder CBT for PTSD exists as trauma-focused CBTs and non-trauma-focused CBTs. In the trauma-focused category, the three major CBT treatments for PTSD are prolonged exposure (PE; Foa & Rothbaum, 1998), cognitive processing therapy (CPT; Resick et al., 2002), and trauma-focused CBT (TF-CBT; J. A. Cohen et al., 2006). Questions have been raised regarding whether eye-movement desensitization and reprocessing (EMDR) is best considered as a CBT involving imaginal exposure and cognitive restructuring (Tolin, 2014). However, as it tends not to be classified as such by its proponents, it will not be taken into consideration here. The non-trauma-focused CBTs include stress inoculation training, progressive muscle relaxation, and related treatments that use present-focused behavioral and cognitive principles but do not directly address trauma. Both trauma-focused and non-trauma-focused CBTs have been found to be efficacious when compared with waiting lists and TAU, SMD = −1.62, 95% CI [−2.03, −1.21] (28 studies), and SMD = −1.22, 95% CI [−1.76, −0.69] (4 studies, for trauma-focused and non-trauma focused CBTs respectively; Bisson et al., 2013). Although non-trauma-focused CBTs tend be efficacious following acute treatment, there are indications that trauma-focused CBTs are more efficacious for adult survivors of childhood sexual abuse specifically (Ehring et al., 2014) and in the longer term for patients with chronic PTSD (Bisson et al., 2013). Broadly categorized, CBT treatment for PTSD appears to be efficacious when compared with pill/psychological placebos, OR = −1.85, 95% CI [−2.59, −1.32] (Carpenter et. al, 2018). Efficacy data suggest that CBT for PTSD can generally be delivered in a group format with similar effects as seen in individual format. However, there are some indications that when treatment protocols include in-group exposures, dropout rates tend to be higher (26.4% vs. 18.9% in protocols with and without in-group exposures, respectively, OR = 1.90, 95% CI [1.29, 2.79]; Barrera

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et al., 2013). The composition of the group may also matter, as lower effect sizes tend to be reported in studies that are restricted to men and in studies of combat exposure or childhood sexual abuse relative to other types of traumas (Barrera et al., 2013; Ehring et al., 2014). Obsessive-Compulsive Disorder CBT protocols involving exposure and response prevention with or without cognitive restructuring are the psychosocial interventions that have proved most efficacious in the treatment of OCD. Öst et al. (2015) identified 37 RCTs comparing CBT to WLC, placebo, or one of its components. Large effect sizes were found when comparing CBT to WLC, g = −1.31, 95% CI [−1.55, −1.08], or placebo, g = −1.33, 95% CI [ −1.76, −0.91]. CBT for OCD is such a potent intervention that the existing evidence suggests it is superior to antidepressant medications, and the combination of CBT and medication is superior to medication alone (McGuire et al., 2015; Öst et al., 2015; Romanelli et al., 2014; Sánchez-Meca et al., 2014; Skarphedinsson et al., 2015). Data from follow-up studies suggest that the effects of CBT are long lasting (pooled long-term remission rate of 53%, 95% CI [42%, 65%], mean duration of follow-up 4.9 years; Sharma et al., 2014). A recent meta-analysis of comparative RCTs suggested no differences in outcomes or dropout rates between individual and group CBT for OCD (Pozza & Dèttore, 2017), though patient samples that are characterized as more chronic, severe, or early onset tended to show higher relapse rates. General Issues In addition to examining the efficacy of CBTs for major depression and anxiety, the meta-analytic reviews we identified also considered various other issues germane to characterizing the evidence base supporting the efficacy of CBTs. CBT Versus Other Therapies Meta-analytic reviews that have examined the relative efficacy of CBT versus psychological treatments other than IPT (Baardseth et al., 2013; Tolin, 2014) have addressed a very heated debate within the history of psychology. By and large, there is no consistent evidence that CBT for major depression and anxiety and related disorders reduces symptoms to a greater degree than other therapies. In this contrast between CBT and other therapies, several points are worth noting. For some disorders, such as OCD, CBTs are the only treatments that have been studied, that meet criteria for being empirically supported, and that have been compared against rigorous controls (Lorenzo-Luaces, 2018). Second, in most instances, when meta-analyses find differences between CBTs and other therapies, they tend to favor CBTs, and the effect sizes for CBTs tend to be larger relative to those of other treatments on primary symptom measures (DeRubeis & Lorenzo-Luaces, 2017). Neither of these observations should be taken to imply that other treatments will be found not to be efficacious in the treatment of specific disorders (e.g., psychodynamic therapy for OCD), though



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this of course is an empirical question. CBTs at times outperform supportive therapy and relaxation therapy, especially for OCD and PTSD (Montero-Marin et al., 2018), but the question remains as to whether these findings are better accounted for by the researcher’s allegiance to the therapy in question. Transdiagnostic Therapy The meta-analytic reviews that included transdiagnostic CBT treatments (tCBTs), including David Barlow’s UP, examined their overall efficacy as well as the potential that they were superior to so-called disorder-specific CBT. In one such meta-analysis, Andersen et al. (2016) identified eight RCTs comparing tCBT with various control conditions (primarily WLC) in patients (older than 16 years) who met diagnostic criteria for an anxiety or depressive disorder. All studies included a measure of depression, anxiety, or generic psychological well-being. The authors concluded that tCBT was more efficacious than control conditions, but there were not enough data to perform a meta-analytic estimate of depression and anxiety outcomes. A more recent review of studies comparing tCBT and diagnostic-specific CBT appears to have included more studies because the authors cite an analysis of 83 studies, but only 10 of these were RCTs focused on tCBT (Pearl & Norton, 2017). The authors reported a difference in effect size between tCBT and standard CBT that was statistically significant (p = .008), but an overlap of confidence intervals indicated a lack of clinical significance. It should be noted, however, that this comparison was derived not from comparative outcome studies but from two different meta-analytic estimates. Newby et al. (2015) identified 31 RCTs in their metaanalysis by also including internet-based therapy studies. Their meta-analysis supported the efficacy of tCBT with large effects in anxiety and depression relative to WLC (g = −0.70, 95% CI [−0.84, −0.56] for anxiety, and g = −1.00, 95% CI [−1.30, −0.69] for depression) and attention controls (g = −0.80, 95% CI [−1.08, −0.52] for anxiety and g = −0.69, 95% CI [−0.91, −0.46] for depression), but smaller effects relative to TAU (g = −0.24, 95% CI [−0.43, −0.05] for anxiety and g = −0.57, 95% CI [−0.76, −0.38] for depression). The meta-analysis also presented a subgroup analysis of three studies, suggesting that tCBT may be superior to diagnosis-specific CBT in depression outcomes but not in anxiety outcomes. This same meta-analysis also found superior outcomes for tCBT protocols when compared with diagnosis-specific mindfulness/acceptance protocols. Taken together, these meta-analyses suggest that tCBT is more efficacious than WLC and other control conditions. However, there is little in the way of convincing evidence that tCBT is superior to diagnosis-specific CBT. This is consistent with the findings of recent large RCTs, which fail to support the hypothesis that transdiagnostic treatment is superior to disorder-specific treatment (Barlow, Farchione, Bullis, et al., 2017). Third-Wave Therapies In a Cochrane Review, Churchill et al. (2013) could identify only four small studies of third-wave therapy versus TAU for depression, totaling 224 participants.

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The studies examined different third-wave CBTs, including ACT, competitive memory training, and BA, which was classified as a third-wave therapy by these authors. The authors noted that the data were severely limited by virtue of the fact that there appeared to be an allegiance to the active treatment under investigation, as well as the fact that there was limited evidence about various aspects of the study design. None of the studies had a long-term follow-up. In another Cochrane Review comparing third-wave therapies against other psychological therapies, Hunot et al. (2013) could only identify three studies, totaling 144 eligible participants. Two of these were ACT studies comparing the earliest versions of ACT, comprehensive distancing, to a version of CBT. The third study examined BA, which was classified as a third-wave CBT, to CBT. Overall, no significant differences between the third-wave therapies and CBT were found, risk ratio (RR) of clinical response = 1.14, 95% CI [0.79, 1.64]. This finding was confirmed by another meta-analysis (A-Tjak et al., 2015). Goldberg et al. (2018) conducted a meta-analysis of mindfulness-based interventions (MBIs) for a broad range of problems (e.g., pain, substance use disorders) as well as depression and anxiety. The authors identified 18 studies focused on anxiety and 49 focused on depression. Overall, the results supported the efficacy of MBIs relative to no treatment for anxiety, g = −0.89, 95% CI [−1.17, −0.62], and depression, g = −0.59, 95% CI [−0.73, −0.46], as well as active comparators (e.g., TAU) for depression, g = −0.38, 95% CI [−0.46, −0.12]. MBIs were not superior to active comparators for anxiety, g = 0.15, 95% CI [−0.16, 0.46], or evidence-based treatments for depression, g = −0.01, 95% CI [−0.19, 0.16], and anxiety, g = −0.18, 95% CI [−0.41, 0.60]. Similar effects were reported by Hedman-Lagerlöf et al. (2018), who also conducted a meta-analysis specifically focusing on MBIs. The authors found a total of 19 studies across which MBIs were found to be more efficacious than no treatment, g = −1.07, 95% CI [−1.92, 0.21], and TAU, g = −0.40, 95% CI [−0.61, −0.19], but not in comparison with placebos, g = −0.17, 95% CI [−0.39, 0.05], or other active treatments, g = −0.01, 95% CI [−0.35, 0.33]. The authors judged that there was only one disorder (i.e., hypochondriasis) for which MBIs could be considered probably or possibly efficacious. They contrasted these conclusions to those other meta-analyses (e.g., the one by Goldberg et al., 2018) that lumped together studies focusing on the acute and relapse-prevention phase of treatment and that have not required that samples have psychiatric diagnoses. Thus, the existing data suggest that MBIs are probably more efficacious than no treatment and are probably efficacious for prevention of relapse in recurrent depression, but more data are needed to evaluate their efficacy in the acute phase of treatment when compared with more active treatments. Characterizing the Effects of CBT The effects of CBT are often expressed in relative terms (i.e., as compared with results of other interventions/control conditions). An alternative is to focus on clinically meaningful indices of change. Several meta-analyses



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focused on characterizing the effects of CBTs by using binary measures of improvement, such as symptom remission. The concept of symptom remission implies that the patient is symptom-free or is having very few symptoms, but it has been defined inconsistently across studies. Cuijpers, Karyotaki, Weitz, et al. (2014) reported that, on average, 49%, 95% CI [32%, 66%], of patients are reported as achieving symptom remission in trials of CBT when defined as a score of less than 7 on the HRSD. Around two thirds (66%), 95% CI [58%, 73%], no longer meet criteria for major depression by the end of treatment. By way of contrast, 27%, 95% CI [15%, 43%], of patients with major depression are in remission and 43%, 95% CI [34%, 52%], are diagnosis-free across a range of control groups. Springer et al. (2018) reported that intent-to-treat remission rates following CBT for anxiety disorders were 47.9% posttreatment, 95% CI [43.4%, 52.4%], and 53.5% at follow-up, 95% CI [47.6%, 59.3%]. The authors noted that the highest rates of symptom remission were observed for GAD and PTSD.

DISCUSSION We searched for recently published English-language reviews of meta-analyses of RCTs of CBTs for emotional disorders, including major depressive disorders, anxiety disorders, and the related disorders OCD and PTSD. By and large, the published meta-analytic reviews support the efficacy of CBTs. A consistent theme across the reviews is that the strongest effects of CBTs are evident when they are compared against a WLC. The effects are more modest when CBTs are compared against TAU or placebo, although CBTs still appear to be efficacious in this contrast. Moreover, the number of studies is reduced when considering only the studies that are considered of “high quality.” This should not be taken as a specific indictment against the evidence base for CBT, which is the most widely studied form of therapy (Lorenzo-Luaces, 2018). CBT appears to be more efficacious than relaxation for OCD and PTSD, perhaps also outperforming relaxation over the long term for panic and specific phobias (Montero-Marin et al., 2018). Otherwise, there is no consistent evidence that CBT is superior to other forms of psychotherapy. Despite this, CBTs are the only types of treatments that meet the American Psychological Association Division 12’s category of “strong support” for OCD, panic disorder, social anxiety, specific phobia, and GAD. Further, CBT has enduring effects, and brief sequential relapse-prevention interventions (MBCT and PCT) are efficacious in reducing relapse risk, as has especially been demonstrated for depression. Adding CBT to antidepressant treatment during the acute depressed phase has enduring effects relative to antidepressants alone (Karyotaki, Smit, et al., 2016). Moreover, adding PCT after recovery/remission to continuation of antidepressants reduces relapse risk considerably (Bockting et al., 2018). In their review, Hofmann et al. (2012) failed to identify a meta-analysis focused on specific subpopulations beyond children or the elderly. Similarly,

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our systematic search did not yield a single meta-analysis that focused on specialized subgroups, though we did find a meta-regression analysis on 56 studies that reported race or ethnicity in psychotherapy trials. The analysis included all RCTs in which the effect of psychotherapy, including CBT, for adults with a depressive disorder or depressive symptomatology was compared with a control condition, mainly TAU or WLC. An overall moderate effect size (g = −0.50) in favor of psychotherapy was found, with no moderating effect of ethnicity (Ünlü Ince et al., 2014). Single RCTs of culturally adapted CBT have been published as well for ethnic minorities and low-income samples (Rosselló & Bernal, 1999), as have reviews focused on psychotherapy adapted to ethnic minority populations (Benish et al., 2011; Griner & Smith, 2006). Our inability to find a CBT-specific review in our systematic search reflects the lack of attention that the field has given to special populations, but there is increasing evidence that CBTs can be delivered in low-income and related settings (Arjadi et al., 2018; Bockting et al., 2016; Ünlü Ince et al., 2014). The generalizability of the CBT research base is constrained by geographic limitations and by the entry criteria that studies employ. Studies of CBT for major depression often exclude participants on the basis of symptom severity, substance abuse, psychosis, and suicidality (Lorenzo-Luaces et al., 2018; van der Lem et al., 2012). Studies of psychotherapy for GAD, social anxiety, and PTSD often exclude participants on the basis of comorbid depression, secondary anxiety disorders, substance use, or psychosis (Franco et al., 2016; Hoertel et al., 2012, 2013). Given the increased recognition that mental disorders are highly comorbid and represent a shared vulnerability, more research is needed that utilizes fewer exclusion criteria. For example, it is troubling that more is not known about the efficacy of well-established procedures such as exposure for PTSD or OCD in the context of comorbid conditions like bipolar disorder or alcohol use disorder. Other exclusion criteria appear to influence who can enter a trial but do not appear to reliably relate to outcomes. For example, Hoertel et al. (2013) noted that most studies of panic disorder used current major depressive disorder as an exclusion criterion, even though this variable is not a reliable predictor of outcomes in CBT for panic disorder. We identified only a single meta-analytic review of CBTs delivered in the context of treating comorbid substance use disorders (Roberts et al., 2015). A wealth of data support the efficacy of CBTs when conducted in the context of RCTs, which are considered the gold standard of research designs to test psychotherapy outcomes. Despite this, there is clear evidence that design factors are associated with effect sizes reported across studies. As mentioned throughout the chapter, the control group, publication bias, and study quality significantly affect the reported effect size of CBT (Cuijpers, Cristea, et al., 2016; Cuijpers, Smit, et al., 2010; Driessen et al., 2015), as they likely do for other treatments as well. However, it is important to observe that the choice of the comparison groups is ultimately contingent on the nature of the research question at hand and changes the nature of the conclusions that can be drawn from the results of a study (Freedland et al., 2011; Mohr et al., 2009).



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Increasing Access to CBTs As this updated review reconfirms, CBTs are efficacious for a wide range of depressive and anxiety disorders. A key question concerns how to expand the reach of evidence-based CBT protocols. Kazdin and Blase (2011) noted that individual face-to-face psychotherapy is unlikely to reduce the burden of mental illness because there is scarcity of highly trained mental health providers relative to the large number of individuals who meet criteria for common mental health disorders. Recent high-profile studies have confirmed that CBTs for depression can also be delivered by paraprofessionals (Richards et al., 2016) and lay counselors (Bower et al., 2013). This suggests that one way that the burden of mental illness can be alleviated is by training a large number of paraprofessionals or lay counselors to deliver CBT-type interventions. Another way in which the reach of CBT can be expanded is by delivering it in the format of group psychoeducation to large numbers of patients. For example, White et al. (1992) developed a six-session transdiagnostic CBT protocol for depression and anxiety dubbed “stress control” that can be delivered in groups of six to 100 patients. Stress control has been studied in large research practice networks and benchmarked relative to the findings of guided self-help (Delgadillo et al., 2016). Providing support for its efficacy, Delgadillo et al. reported that 42% of cases that initially scored in the clinical range of anxiety experienced reliable and clinically significant improvement. A similar number of patients experienced clinically significant improvement in depression. There have been other efforts to capitalize on the use of brief CBT groups as a way of making the delivery of treatment more efficient (Mörtberg et al., 2007). Additionally, there is evidence for the efficacy of concentrated CBT treatments (i.e., those that are carried out with more than one session a week), especially in the delivery of CBTs for youth with anxiety (Öst & Ollendick, 2017). Finally, the development of internet-based CBTs (iCBTs) has been among the most promising progresses in mental health treatment of the past several decades. Research suggests that unguided (Karyotaki et al., 2017) and guided (Karyotaki et al., 2018) iCBT can be efficacious relative to control conditions and that guided iCBT can be as efficacious as face-to-face CBT (Andersson et al., 2014). It is likely that in the future, a significant burden of treatment will be delivered via iCBTs. Personalized Medicine Given the lack of strong or consistent evidence that CBT is more efficacious than other forms of treatment, it has been suggested that it may be more promising to focus on identifying subgroups of patients who experience better response with CBTs than other therapies and vice-versa (DeRubeis & Lorenzo-Luaces, 2017). This is broadly consistent with an interest in psychology in the concept of “personalized” or “precision” medicine (Z. D. Cohen & DeRubeis, 2018; DeRubeis et al., 2014). The past several decades have seen growing interest in the topic of personalized medicine in the field of mental health. Relatedly, there is a

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growing interest in the topic of moderators of the efficacy of CBTs and other interventions for depression and anxiety. There is a growing recognition even among proponents of CBT that it may be misguided to argue for the superiority of CBT above and beyond all forms of therapy and that, instead, CBT may be best for individuals who are well suited to this type of treatment (DeRubeis & Lorenzo-Luaces, 2017; Lorenzo-Luaces et al., 2017). This, in turn, suggests the existence of individuals who are ill-suited for CBT and who would be better served by other forms of therapy. Cuijpers, Ebert, et al. (2016) conducted a meta-analysis of the efficacy of psychotherapy across patient subgroups (e.g., older adults, patients with cancer) to determine whether there was enough evidence to personalize recommendations to CBT or other treatments based on patient characteristics. They found preliminary evidence that CBTs for depressive symptoms may be superior to other therapies among college students, older adults, and those with substance use problems. These authors also concluded that most studies were underpowered (Cuijpers, Reynolds, et al., 2012). Various data-analytic techniques, including meta-analytic techniques, have been developed to answer the question of optimal treatment selection that rely on the idea of combining moderator variables (DeRubeis et al., 2014; Kraemer, 2013). Huibers et al. (2015) used the approach suggested by DeRubeis et al. (2014) in a comparison of CBT versus IPT for depression and identified five predictors (i.e., gender, employment status, anxiety, personality disorder, and quality of life) and six moderators (i.e., somatic complaints, cognitive problems, paranoid symptoms, interpersonal self-sacrificing, attributional style, and number of life events) of treatment outcomes. These variables were subsequently combined in an algorithm that produced a measure of the predicted advantage in one therapy compared with the other, the so-called personalized advantage index (PAI). Patients who had better outcomes in IPT rather than CBT were more likely to have cognitive problems, whereas patients who experienced better outcomes in CBT rather than IPT had somatic complaints, paranoid symptoms, a self-sacrificing style, a more negative attributional style, and a higher number of life events pretreatment. Researchers have also turned to genetics (Bockting et al., 2013), intensive within-person data collection (Fisher & Boswell, 2016; Rubel et al., 2018), and neuroimaging (Drysdale et al., 2017; Dunlop & Mayberg, 2014) to facilitate personalized medicine. Mechanisms It is common to observe that despite consistent support for the efficacy of CBT, research has provided only little confirmation about the mechanisms through which CBTs lead to symptom change (Cuijpers et al., 2019; Kazdin, 2007). In addition to verifying basic theories, such knowledge is expected to enhance treatment elements and techniques that are crucial for therapeutic change, thereby optimizing treatment outcomes. According to the cognitive behavioral model, interventions (e.g., psychoeducational, cognitive, behavioral) aimed at altering the function, content, and



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structure of biased patterns of thinking will lead to symptom change. The idea that cognitive change accounts for therapeutic change is a popular hypothesis. Dozens of studies have examined the role of cognitive processes, such as automatic thoughts, dysfunctional attitudes, attributional style, and other cognitive distortions both in CBTs and in other psychological interventions (see overview papers of, e.g., Cristea et al., 2015; Garrat et al., 2007; Kazantzis et al., 2018; Lemmens et al., 2016; Lorenzo-Luaces et al., 2015; Spinhoven et al., 2018). Meta-analyses generally support the effects of CBT on variables that are hypothesized to be mechanistically related to outcomes. Unfortunately, only a few studies have included efforts to detect the direction of causality. Studies that have attempted to disentangle the direction of causality are supportive of the CBT model, which is also consistent with basic research (see Lemmens et al., 2016; Lorenzo-Luaces et al., 2015). However, more research is needed. As a result, it remains unclear whether changes in cognitions precede or follow from changes in depression and anxiety during treatment. More knowledge about the mechanisms of change in CBTs could lead to improved outcomes in existing treatment components.

CONCLUSION Given the wealth of evidence supporting the efficacy of CBTs, a central question that emerges from efforts to evaluate the evidence base is how to evaluate the overlapping data for CBTs. A number of authors have used the technique of network meta-analysis as a way of integrating evidence across studies (MayoWilson et al., 2014; Pompoli et al., 2016, 2018). Regardless of the way in which one chooses to evaluate the evidence for CBTs, the data are clear. CBTs are the most commonly studied psychotherapies for depression, anxiety, and related disorders. They are efficacious, and although their mechanisms of change have not been clearly elucidated, their theories of change comport with basic science (Hofmann et al., 2013). We expect that the coming decades will see a greater interest in efforts to disseminate CBT as an individual treatment and to deliver it in novel formats that have a greater capacity to reduce the public health burden of mental disorders. Moreover, there will likely be continued interest in efforts to personalize the delivery of CBTs and elucidate their mechanisms of change.

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treatments for pediatric obsessive-compulsive disorder: A meta-analysis. Journal of Anxiety Disorders, 28(1), 31–44. https://doi.org/10.1016/j.janxdis.2013.10.007 Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., & Levitan, R. D. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256–1264. https://doi. org/10.1001/archgenpsychiatry.2010.168 Sharma, E., Thennarasu, K., & Reddy, Y. C. (2014). Long-term outcome of obsessive-compulsive disorder in adults: A meta-analysis. Journal of Clinical Psychiatry, 75(9), 1019–1027. https://doi.org/10.4088/JCP.13r08849 Skarphedinsson, G., Hanssen-Bauer, K., Kornør, H., Heiervang, E. R., Landrø, N. I., Axelsdottir, B., Biedilæ, S., & Ivarsson, T. (2015). Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A systematic review of effect estimates across comparisons. Nordic Journal of Psychiatry, 69(2), 81–92. https://doi.org/10.3109/08039488.2014.941395 Spinhoven, P., Klein, N., Kennis, M., Cramer, A. O. J., Siegle, G., Cuijpers, P., Ormel, J., Hollon, S. D., & Bockting, C. L. (2018). The effects of cognitive-behavior therapy for depression on repetitive negative thinking: A meta-analysis. Behaviour Research and Therapy, 106, 71–85. https://doi.org/10.1016/j.brat.2018.04.002 Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical Psychology Review, 61, 1–8. https://doi.org/10. 1016/j.cpr.2018.03.002 Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615–623. https://doi.org/10.1037/0022-006X.68.4.615 Tolin, D. F. (2014). Beating a dead dodo bird: Looking at signal vs. noise in cognitivebehavioral therapy for anxiety disorders. Clinical Psychology: Science and Practice, 21(4), 351–362. https://doi.org/10.1111/cpsp.12080 Tolin, D. F. (2017). Can cognitive-behavioral therapy for anxiety and depression be improved with pharmacotherapy? A meta-analysis. Psychiatric Clinics of North America, 40(4), 715–738. https://doi.org/10.1016/j.psc.2017.08.007 Ünlü Ince, B., Riper, H., van ’t Hof, E., & Cuijpers, P. (2014). The effects of psychotherapy on depression among racial-ethnic minority groups: A metaregression analysis. Psychiatric Services, 65(5), 612–617. https://doi.org/10.1176/appi.ps.201300165 van der Lem, R., de Wever, W. W., van der Wee, N. J., van Veen, T., Cuijpers, P., & Zitman, F. G. (2012). The generalizability of psychotherapy efficacy trials in major depressive disorder: An analysis of the influence of patient selection in efficacy trials on symptom outcome in daily practice. BMC Psychiatry, 12, 192. https://doi.org/10. 1186/1471-244X-12-192 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 White, J., Keenan, M., & Brooks, N. (1992). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 20(2), 97–113. https://doi.org/10.1017/S014134730001689X Wersebe, H., Sijbrandij, M., & Cuijpers, P. (2013). Psychological group-treatments of social anxiety disorder: A meta-analysis. PLOS ONE, 8(11), e79034. https://doi.org/ 10.1371/journal.pone.0079034 Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021–1037. https://doi.org/10.1016/j.cpr.2008.02.007

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World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. Zhou, S.-G., Hou, Y.-F., Liu, D., & Zhang, X.-Y. (2017). Effect of cognitive behavioral therapy versus interpersonal psychotherapy in patients with major depressive disorder: A meta-analysis of randomized controlled trials. Chinese Medical Journal, 130(23), 2844–2851. https://doi.org/10.4103/0366-6999.219149

APPENDIX 3.1: KEY-TERM SCHEME FOR DATABASE SEARCH (meta-analysis OR “meta analysis” OR “quantitative review”) AND (CBT OR BT OR cognitive-behav* OR “cognitive therapy” OR BA OR “behavioral activation” OR “behavioural activation”) AND (depress* OR anxiety OR dysthym* OR panic OR OCD OR PTSD OR “obsessive-compulsive” OR trauma OR “posttraumatic stress disorder”)

APPENDIX 3.2: OVERVIEW OF INCLUSION AND EXCLUSION CRITERIA Publication type Language Article type Intervention

Target group

Included (peer reviewed) journal articles English Meta-analysis/ Quantitative Review Cognitive-behavioral therapy (CBT), cognitive therapy (CT), behavioral activation (BA), acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), exposure (delivered individually or in group format) Patients (all ages) with a diagnosis of depression or anxiety disorder (including PTSD and OCD).

Excluded Books, book chapters, dissertations, dissertation abstracts, posters Every other language Systematic literature reviews, research papers, commentaries, replies Other interventions, studies focusing on purely self-guided and internet/web/ chat/text/email CBTs (except when internet was the medium to deliver traditional CBT, e.g., CBTs via Skype. Note: For meta-analyses with a focus on “psychotherapy” or “psychological interventions” in general, we examined the proportion of studies that examined CBTs. If this was > 90% (or if authors included subgroup analyses on CBTs), the paper was included. Meta-analyses focusing on symptoms (instead of diagnoses), meta-analyses that focused on (effects of CBT for) other diagnoses (on depression/ anxiety). Note: We included meta-analyses that examined effects of CBT for depression/anxiety in specific populations (e.g., effects of CBT for depression in people with autism; double diagnosis), as well as those that examined effects of CBT for depression on anxiety (and vice versa).



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Outcome

Other

Depression/anxiety severity Meta-analyses focusing on other outcomes than depression/anxiety (e.g., dropout, predictors, moderators, components, cost-effectiveness, well-being, quality of life, self-harm, suicidality, perfectionism) Meta-analyses focusing on Meta-analyses focusing on primary prevention of relapse, prevention meta-analyses focusing on effects of continuation treatment. Note: For papers that later were corrected, we included only the corrected version.

APPENDIX 3.3: LIST OF SELECTED PAPERS (N = 119) 1

Andersen, P., Toner, P., Bland, M., & McMillan, D. (2016). Effectiveness of transdiagnostic cognitive behaviour therapy for anxiety and depression in adults: A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 44(6), 673–690.

2

Baardseth, T. P., Goldberg, S. B., Pace, B. T., Wislocki, A. P., Frost, N. D., Siddiqui, J. R., Lindemann, A. M., Kivlighan, D. M., III, Laska, K. M., Del Re, A. C., Minami, T., & Wampold, B. E. (2013). Cognitive-behavioral therapy versus other therapies: Redux. Clinical Psychology Review, 33(3), 395–405.

3

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. Journal of Anxiety Disorders, 39, 44–64.

4

Barrera, T. L., Mott, J. M., Hofstein, R. F., & Teng, E. J. (2013). A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review, 33(1), 24–32.

5

Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews. https://doi.org/10. 1002/14651858

6

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624.

7

Calati, R., Pedrini, L., Alighieri, S., Alvarez, M. I., Desideri, L., Durante, D., Favero, F., Iero, L., Magnani, G., Polmonari, A., Raggini, R., Raimondi, E., Riboni, V., Scaduto, M. C., Serretti, A., & De Girolamo, G. (2011). Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis. Acta Neuropsychiatrica, 23(6), 263–271.

8

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514.

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9

Chan, A. T., Sun, G. Y., Tam, W. W., Tsoi, K. K., & Wong, S. Y. (2017). The effectiveness of group-based behavioral activation in the treatment of depression: An updated meta-analysis of randomized controlled trial. Journal of Affective Disorders, 208, 345–354.

10

Chen, L., Zhang, G., Hu, M., & Liang, X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: Systematic review and meta-analysis. Journal of Nervous and Mental Disease, 203(6), 443–451.

11

Churchill, R., Moore, T. H., Furukawa, T. A., Caldwell, D. M., Davies, P., Jones, H., Shinohara, K., Imai, H., Lewis, G., & Hunot, V. (2013). “Third wave” cognitive and behavioural therapies versus treatment as usual for depression. Cochrane Database of Systematic Reviews. https://doi.org/ 10.1002/14651858.CD008705.pub2

12

Crowe, K., & McKay, D. (2017). Efficacy of cognitive-behavioral therapy for childhood anxiety and depression. Journal of Anxiety Disorders, 49, 76–87.

13

Cuijpers, P., Andersson, G., Donker, T., & van Straten, A. (2011). Psychological treatment of depression: Results of a series of meta-analyses. Nordic Journal of Psychiatry, 65(6), 354–364.

14

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry, 58(7), 376–385.

15*

Cuijpers, P., Cristea I. A., Ebert, D. D., Koot, H. M., Auerbach, R. P., Bruffaerts, R., & Kessler, R. C. (2016). Psychological treatment of depression in college students: A meta-analysis. Depression and Anxiety, 33(5), 400–414.

16

Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), 245–258.

17

Cuijpers, P., Cristea, I. A., Weitz, E., Gentili, C., & Berking, M. (2016). The effects of cognitive and behavioural therapies for anxiety disorders on depression: A meta-analysis. Psychological Medicine, 46(16), 3451–3462.

18*

Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. American Journal of Psychiatry, 173(7), 680–687.

19

Cuijpers, P., Gentili, C., Banos, R. M., Garcia-Campayo, J., Botella, C., & Cristea, I. A. (2016). Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis. Journal of Anxiety Disorders, 43, 79–89.

20

Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open, 3(4), e002542.

21

Cuijpers, P., Karyotaki, E., Pot, A. M., Park, M., & Reynolds, C. F., III. (2014). Managing depression in older age: Psychological interventions. Maturitas, 79(2), 160–169.

22*

Cuijpers, P., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2018). Who benefits from psychotherapies for adult depression? A meta-analytic update of the evidence. Cognitive Behaviour Therapy, 47(2), 91–106.



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23*

Cuijpers, P., Karyotaki, E., Reijnders, M., Purgato, M., & Barbui, C. (2018). Psychotherapies for depression in low- and middle-income countries: A meta-analysis. World Psychiatry, 17(1), 90–101.

24

Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A metaanalysis. Clinical Psychology Review, 34(2), 130–140.

25*

Cuijpers, P., Turner, E. H., Mohr, D. C., Hofmann, S. G., Andersson. G., Berking, M., & Coyne, J. (2014). Comparison of psychotherapies for adult depression to pill placebo control groups: A meta-analysis. Psychological Medicine, 44(4), 685–695.

26

Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128–141.

27

DiMauro, J. (2014). Exposure therapy for posttraumatic stress disorder: A metaanalysis. Military Psychology, 26(2), 120–130.

28

Dorrepaal, E., Thomaes, K., Hoogendoorn, A. W., Veltman, D. J., Draijer, N., & van Balkom, A. J. (2014). Evidence-based treatment for adult women with child abuse-related complex PTSD: A quantitative review. European Journal of Psychotraumatology, 5, 23613.

29

Ebrahim, S., & Bance, S. (2012). Correcting and interpreting the effect of cognitive therapy versus exposure in anxiety disorders. BMC Psychiatry, 12, 202.

30

Ehring, T., Welboren, R., Morina, N., Wicherts, J. M., Freitag, J., & Emmelkamp, P. M. (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34(8), 645–657.

31

Ewing, D. L., Monsen, J. J., Thompson, E. J., Cartwright-Hatton, S., & Field, A. (2015). A meta-analysis of transdiagnostic cognitive behavioural therapy in the treatment of child and young person anxiety disorders. Behavioural and Cognitive Psychotherapy, 43(5), 562–577.

32

Feng, C. Y., Chu, H., Chen, C. H., Chang, Y. S., Chen, T. H., Chou, Y. H., Chang, Y. C., & Chou, K. R. (2012). The effect of cognitive behavioral group therapy for depression: A meta-analysis 2000–2010. Worldviews on Evidence-Based Nursing, 9(1), 2–17.

33

Furukawa, T. A., Weitz, E. S., Tanaka, S., Hollon, S. D., Hofmann, S. G., Andersson, G., Twisk, J., DeRubeis, R. J., Dimidjian, S., Hegerl, U., Mergl, R., Jarrett, R. B., Vittengl, J. R., Watanabe, N., & Cuijpers, P. (2017). Initial severity of depression and efficacy of cognitive–behavioural therapy: Individual-participant data meta-analysis of pill-placebo-controlled trials. British Journal of Psychiatry, 210(3), 190–196.

34

Galante, J., Iribarren, S. J., & Pearce, P. F. (2013). Effects of mindfulness-based cognitive therapy on mental disorders: A systematic review and metaanalysis of randomised controlled trials. Journal of Research in Nursing, 18(2), 133–155.

35

Gerger, H., Munder, T., Gemperli, A., Nüesch, E., Trelle, S., Jüni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis: Relative effectiveness of psychological interventions for adults with post-traumatic stress disorder. Psychological Medicine, 44(15), 3151–3164.

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36

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52–60.

37

Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Cognitive behavioral therapy for depression in older people: A meta-analysis and metaregression of randomized controlled trials. Journal of the American Geriatrics Society, 60(10), 1817–1830.

38

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.

39

Hacker, T., Stone, P., & MacBeth, A. (2016). Acceptance and commitment therapy—Do we know enough? Cumulative and sequential meta-analyses of randomized controlled trials. Journal of Affective Disorders, 190, 551–565.

40

Hall, J., Kellett, S., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of cognitive behavioral therapy for generalized anxiety disorder in older adults: Systematic review, meta-analysis, and meta-regression. American Journal of Geriatric Psychiatry, 24(11), 1063–1073.

41

Hanrahan, F., Field, A. P., Jones, F. W., & Davey, G. C. (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33(1), 120–132.

42

Hans, E., & Hiller, W. (2013). A meta-analysis of nonrandomized effectiveness studies on outpatient cognitive behavioral therapy for adult anxiety disorders. Clinical Psychology Review, 33(8), 954–964.

43

Hans, E., & Hiller, W. (2013). Effectiveness of and dropout from outpatient cognitive behavioral therapy for adult unipolar depression: A metaanalysis of nonrandomized effectiveness studies. Journal of Consulting and Clinical Psychology, 81(1), 75–88.

44

Hedman-Lagerlöf, M., Hedman-Lagerlöf, E., & Öst, L. G. (2018). The empirical support for mindfulness-based interventions for common psychiatric disorders: A systematic review and meta-analysis. Psychological Medicine, 48(13), 2116–2129.

45

Hetrick, S. E., Cox, G. R., Witt, K. G., Bir, J. J., & Merry, S. N. (2016). Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews. https://doi.org/10. 1002/14651858.CD003380.pub4

46

Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder–Is it all in the homework then? European Review of Applied Psychology, 62(4), 253–260.

47

Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect of cognitivebehavioral therapy for anxiety disorders on quality of life: A meta-analysis. Journal of Consulting and Clinical Psychology, 82(3), 375–391.

48

Honyashiki, M., Furukawa, T. A., Noma, H., Tanaka, S., Chen, P., Ichikawa, K., Ono, M., Churchill, R., Hunot, V., & Caldwell, D. M. (2014). Specificity of CBT for depression: A contribution from multiple treatments metaanalyses. Cognitive Therapy and Research, 38(3), 249–260.

49

Huang, F. F., Li, Z. J., Han, H. Y., Xiong, H. F., Ma, Y. (2013). Cognitive behavioral therapy combined with pharmacotherapy for obsessive compulsive disorder: A meta-analysis. Chinese Mental Health Journal, 27(9), 643–649.



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50

Hunot, V., Moore, T. H., Caldwell, D. M., Furukawa, T. A., Davies, P., Jones, H., Honyashiki, M., Chen, P., Lewis, G., & Churchill, R. (2013). “Third wave” cognitive and behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews. https://doi. org/10.1002/14651858.CD008704.pub2

51

Jakobsen, J. C., Hansen, J. L., Simonsen, S., Simonsen, E., & Gluud, C. (2012). Effects of cognitive therapy versus interpersonal psychotherapy in patients with major depressive disorder: A systematic review of randomized clinical trials with meta-analyses and trial sequential analyses. Psychological Medicine, 42(7), 1343–1357.

52

Jakobsen, J. C., Hansen, J. L., Storebø, O. J., Simonsen, E., & Gluud, C. (2011). The effects of cognitive therapy versus “no intervention” for major depressive disorder. PLOS ONE, 6(12), e28299.

53

Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747–768.

54

Johnsen, T. J., & Thimm, J. C. (2018). A meta-analysis of group cognitive– behavioral therapy as an antidepressive treatment: Are we getting better? Canadian Psychology, 59(1), 15.

55

Jonsson, H., Kristensen, M., & Arendt, M. (2015). Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Journal of Obsessive-Compulsive and Related Disorders, 6, 83–96.

56*

Karyotaki, E., Smit, Y., de Beurs, D. P., Henningsen, K. H., Robays, J., Huibers, M. J. H., Weitz, E., & Cuijpers, P. (2016). The long-term efficacy of acute phase psychotherapy for depression: A meta-analysis of randomized trials. Depression and Anxiety, 33(5), 370–383.

57*

Karyotaki, E., Smit, Y., Holdt-Henningsen, K., Huibers, M. J. H., Robayse, J., de Beurs, D., & Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders, 194(1), 144–152.

58

Kishita, N., & Laidlaw, K. (2017). Cognitive behaviour therapy for generalized anxiety disorder: Is CBT equally efficacious in adults of working age and older adults? Clinical Psychology Review, 52, 124–136.

59

Kliem, S., & Kröger, C. (2013). Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling. Behaviour Research and Therapy, 51(11), 753–761.

60

Lenz, A. S., & Hollenbaugh, K. M. (2015). Meta-analysis of trauma-focused cognitive behavioral therapy for treating PTSD and co-occurring depression among children and adolescents. Counseling Outcome Research and Evaluation, 6(1), 18–32.

61

Ma, D., Zhang, Z., Zhang, X., & Li, L. (2014). Comparative efficacy, acceptability, and safety of medicinal, cognitive-behavioral therapy, and placebo treatments for acute major depressive disorder in children and adolescents: A multiple-treatments meta-analysis. Current Medical Research and Opinion, 30(6), 971–995.

62

Martin, F., & Oliver, T. (2018). Behavioral activation for children and adolescents: A systematic review of progress and promise. European Child & Adolescent Psychiatry, 28(4), 427–441.

63

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network metaanalysis. Lancet Psychiatry, 1(5), 368–376.

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4 Empirical Status of Mechanisms of Change Janna N. Vrijsen, Rianne A. de Kleine, Eni S. Becker, Amy Wenzel, and Jasper A. J. Smits

C

ognitive behavioral therapy (CBT) is an established first-line intervention for psychological disorders. Numerous randomized controlled trials (RCTs) and meta-analyses indicate that CBT outperforms wait-list and placebo conditions and evidences comparable efficacy to other efficacious interventions such as pharmacotherapies (Cuijpers et al., 2010; Hofmann & Smits, 2008). In addition, more recent efforts reveal that CBT can also exert positive effects when delivered via the internet as opposed to in person, thus showing promise for widespread dissemination (Cuijpers et al., 2017). As is true for any intervention for any indication, the response to CBT has been highly variable within and across trials. In fact, a sizeable group of patients who enter these trials leaves treatment prematurely or completes the intervention without experiencing meaningful symptom reduction. This observation highlights the importance of studying mechanisms of change, that is, why and how changes occur. When we know how an intervention exerts its effects, we are in a better position to improve upon the treatment. Identifying key mechanisms of change can guide the development of augmentation strategies—adding pre-, in-, or postsession actions that can engage these core targets of therapeutic change. Moreover, identifying mechanisms of change can aid the development of treatment algorithms—optimizing outcomes by matching interventions with personal characteristics at different stages of the disorder and treatment. For mechanisms of change to be identified and substantiated by evidence, research needs to fulfill certain criteria. Kazdin (2007) proposed that

https://doi.org/10.1037/0000218-004 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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identifying a mediator is a first step in understanding treatment mechanisms. A mediator is a variable that accounts for at least part of the effect of an independent variable (e.g., treatment received) on a dependent variable (e.g., anxiety symptom severity). This means that studies need to demonstrate that a treatment, like CBT, causes variation in the variable (i.e., the proposed mechanism, often measured by a task or questionnaire) and that this variable, in turn, causes symptom reduction (mostly assessed using a questionnaire or structured clinical interview). Research should also examine the specificity of the association between the proposed mediator and symptom reduction. That is, studies should demonstrate that this mediator, specifically, accounts for the change in symptoms and not other plausible variables. Furthermore, examining the temporality of change, or when the proposed mediator affect symptoms change during treatment, is also important to guide clinical innovations. Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Identifying a mediator is, thus, a first step in structurally evaluating mechanisms of change. As outlined by Kazdin (2007), research on mechanisms of change in CBT needs to (a) identify possible mechanisms based on theory and/ or correlational or preclinical research, (b) (experimentally) manipulate the mechanistic processes, (c) execute RCTs measuring multiple possible mechanisms in all or most sessions (to address the aspects of specificity and temporality), and (d) ultimately disseminate the gained knowledge to use in CBT practice. In this chapter, we provide a narrative review of studies examining putative mechanisms of action of CBT for depression and anxiety disorders, and we also briefly address research in other mental health disorders later in the chapter. Although we recognize that there are likely multiple mechanisms of action operating at multiple levels (e.g., psychological, biological), we have focused our review in this chapter on core behavioral (e.g., fear extinction, avoidance) and cognitive (e.g., cognitive reappraisal, cognitive bias) mechanisms of action as tested by self-report measures or behavioral measures. Because sustainable treatment effects should be reflected by changes in the brain, specifically in areas related to proposed mechanisms of change, researchers have started relating brain activation in areas related to such processes with CBT outcome (see review by Clark & Beck, 2010; Månsson et al., 2016). Some relevant neurocognitive research will, therefore, be discussed as well. We illustrate how mechanistic research can guide treatment development and finish by offering some directions for research in this important area.

LEARNING MECHANISMS In essence, CBT is a learning therapy. In CBT we encourage patients to learn to think or act differently. Is this learning of new thoughts or behavior cardinal to change in symptoms? If so, what should patients learn, and how do we facili-



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tate this learning? In the following section, we focus on learning as a mechanism of change in CBT. We first address fear conditioning and extinction as a model for exposure therapy for the treatment of anxiety and related disorders, which is the best investigated mechanism of action of CBT (Kazdin, 2009). Next and related, we address avoidance learning. Then, we discuss generalization of learning experiences outside the context of cognitive behavioral treatment. Last, we discuss the exciting new field of enhancers of memory and learning essential to therapeutic change. This novel line of research aims at improving CBT outcome by (pharmacologically) enhancing the learning mechanisms thought to be crucial during CBT. Fear Extinction: Learning New Associations Between Stimuli The fear conditioning and extinction model has proved to be a valuable model to study anxiety disorders and their treatment (Craske et al., 2008; Kindt, 2014; Scheveneels et al., 2016). In classical (Pavlovian) fear conditioning, fear is acquired via the coupling of a neutral stimulus (conditioned stimulus [CS]), such as a tone, with an aversive stimulus (unconditioned stimulus [US]), such as a mild electric shock (see Figure 4.1). After several pairings of the CS with the US, the presentation of the previously innocuous stimulus alone will elicit the fear response. The extinction of fear results from repeated presentations of the CS without the occurrence of the US. It is easy to see the relevance of this classical conditioning paradigm to the development and treatment of anxiety disorders. For instance, Mr. G. has social anxiety disorder (SAD). His anxiety may originate from a conditioning experience wherein he felt humiliated (US) during an oral presentation (CS) he gave in high school. Ever since, whenever he gives a presentation, he anticipates humiliation and experiences intense FIGURE 4.1. Representation of Experimental Fear Acquisition and Extinction

b.

a. Extinction CS/noUS

CBT-Exposure CS/noUS

Fear

Fear

Acquisition CS/US

Time

Time

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fear. During CBT, his therapist aims to extinguish this excessive fear by encouraging him to repeatedly engage in speech exposures without experiencing a negative consequence like humiliation. Progress in the basic science of learning and memory has taught us that extinction learning does not lead to erasure of the fear associations; extinction learning is a form of new learning (e.g. Bouton, 1993). That is, during extinction an inhibitory association between the CS and the nonappearance of the US is learned (i.e., CS/no US association), often referred to as inhibitory learning. Importantly, it is believed that the original CS/US association is unaffected by extinction learning and thus remains intact. This idea is supported by observations that extinguished fears easily return (see for review Vervliet et al., 2013). In the fear literature, three different phenomena are used to describe the return of fear. Spontaneous recovery refers to finding that merely by the passing of time fear responses to the extinguished CS can recover (Quirk, 2002). Reinstatement refers to the observation that when presentations of the US occur without prior warning (e.g., after fear extinction, the mild electric shock is given without forewarning), fear responses to the extinguished CS can return (Rescorla & Heth, 1975). Renewal refers to the observation that fear responses to the CS return when testing of extinction learning takes place in a different context from extinction training (e.g., in animal studies, when extinction training was done in Cage A and subsequent testing in Cage B; Bouton, 2002). These phenomena may help us understand the clinical counterpart of the return of fear, or relapse. For example, Mr. G. experiences a marked reduction in anxiety symptoms following a course of CBT for his SAD. However, he may experience a relapse if he must give a presentation at work several months after treatment completion (i.e., spontaneous recovery), if he experiences anxiety symptoms during periods of high workload and stress (i.e., reinstatement), or if he has practiced presentations at his own workplace but now must give a presentation for a different company (i.e., renewal). Studies on return of fear have taught us that “fear extinction is relatively easy to ‘learn’, but difficult to ‘remember’” (Vervliet et al., 2013, p. 215). Translated to CBT mechanisms, this suggests that CBT sessions should be set up to strengthen the inhibitory association (in order for this association to inhibit the threat-related association) to reduce the risk for relapse. Suggestions have been made on how this might be done, such as by conducting exposure sessions over various contexts (e.g., giving speeches at work and during town hall meetings) or by spreading sessions over longer periods of time (Craske et al., 2014). However, whether these interventions indeed lead to better CBT outcomes over the long term still needs to be determined (Jacoby & Abramowitz, 2016). Fear conditioning studies have demonstrated that people at risk for anxiety disorders and those who have already developed an anxiety disorder exhibit impaired fear and extinction learning (for review, see Duits et al., 2015; Lissek et al., 2005). Although in the previous paragraph a conditioning paradigm with one conditioning stimulus (CS; see also Table 4.1) was used to explain the



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TABLE 4.1. Overview of Abbreviations and Terms Used in the Fear Conditioning

Literature Example Explanation Experimental Clinical A stimulus that Electric shock Panic attack US generates a fear response A neutral stimulus Red rectangle Shopping mall CS that predicts the occurrence of the US Conditioned A neutral stimulus Red rectangle Shopping mall CS+ stimulus, that predicts the danger cue occurrence of the US in a discriminative conditioning paradigm Conditioned A neutral stimulus Blue circle CS− stimulus, that predicts the safety cue nonoccurrence of the US in a discriminative conditioning paradigm Fear Learned association The person has A person CS/US acquisition between the learned that the associates association conditioned red rectangle going to the stimulus and the predicts an shopping mall aversive outcome electric shock, with a panic and they attack and respond with experiences fear when fear when presented with going to the the red rectangle shopping mall Fear Learned association The person has A person has CS/no US extinction between the learned that the learned that association nonoccurrence of red rectangle no going to a the US followlonger predicts shopping mall ing the CS the shock, and does not they no longer necessarily lead respond with to aversive fear when outcome, and presented with they no longer the red rectangle fear shopping malls Generalization A stimulus that The person has A person fears GS stimulus resembles the CS learned that the supermarkets and elicits similar red rectangle as well as responses predicts the shopping malls shock, and they respond with fear to a red square A stimulus that is A yellow star is An accompanying Inhibitory CS Inhibitory condipresented presented next person in the tioned alongside the CS to the red shopping mall stimulus and predicts the rectangle nonoccurrence of the US Abbreviation

Term Unconditioned stimulus Conditioned stimulus

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model (i.e., single cue conditioning), in most fear conditioning studies, a paradigm with two conditioning stimuli is used (i.e., differential conditioning). In these paradigms, people are presented with (a) a stimulus that predicts the US, referred to as the CS+ or danger cue, and (b) a stimulus that never predicts the occurrence of the US, referred to as the CS− or safety cue. For instance, people see intermittently a red rectangle and a blue circle on a computer screen. The red rectangle (CS+) is followed by the electric shock (US), whereas the blue circle (CS−) is never followed by the electric shock. After several pairings, people learn that the CS+ predicts danger, whereas the CS− predicts safety. Patients with anxiety disorders, however, lack discrimination between these danger and safety cues and respond fearfully to both stimuli. This may reflect an overgeneralization of fear to neutral stimuli. Alternatively, this may indicate an incapacity to inhibit fear responses in a threatrelated context (i.e., the conditioning context). Moreover, during the extinction phase of the experiment, or the phase wherein the US no longer occurs, patients with anxiety disorders show elevated fear responses to the CS+ in comparison to those without anxiety disorders. In other words, they are slower to learn that the stimulus that was previously predictive of danger now no longer predicts an aversive outcome. This finding is highly relevant to CBT’s mechanism of action. During CBT, patients with anxiety disorders need to learn that contact with their feared stimulus does not lead to a hazardous outcome, but, apparently, they have difficulty acquiring this new association and keep expecting an aversive outcome. It is important to note that these impairments were found in groups of individuals (with different anxiety disorders and posttraumatic stress disorder [PTSD]) in comparison to healthy (nondisordered) individuals and that many open questions remain. Are there individual differences in patients with regard to fear learning? Further, are these deficits related to treatment response? We review here the existing evidence to answer these questions. In light of the facts that patients are marked by deficits with respect to safety and extinction learning and that these learning processes are implicated as mechanisms of change that are particularly responsible for outcomes in CBT, the question arises whether these learning deficits hamper CBT efficacy. Remarkably, empirical studies aimed at investigating this question are sparse (Scheveneels et al., 2016). Some studies have assessed extinction learning before CBT treatment and related this to treatment outcome. Specifically, these studies investigated brain activation during extinction learning. The neural bases of extinction are well understood (Kindt, 2014; LeDoux, 2000; Rauch et al., 2006). Decades of research in both animals and humans have demonstrated that the amygdala is critically involved in extinction learning, although a broader network of brain areas is also implied to play a crucial role (including the anterior cingulate cortex [ACC], hippocampus, insula, and ventromedial prefrontal cortex [vmPFC]). Activations and interactions in this so-called fear network during fear conditioning can be related to CBT outcome. In a recent study, Ball et al. (2017) tested whether individual differences in extinction



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learning were predictive of exposure outcome for public speaking anxiety. Better extinction learning (as expressed by less negative CS ratings following the extinction phase of the experiment) and brain activation during extinction learning (including greater activation in the vmPFC and less activation in the amygdala) prior to treatment were indeed predictive of lower anxiety symptoms 2 weeks following the exposure session. Similarly, Hahn et al. (2015) were able to predict, by whole brain activation during fear conditioning and extinction prior to treatment, who responded to 12 sessions of CBT for the treatment of panic disorder and agoraphobia (with high sensitivity, 92%). In line, Lueken et al. (2013) demonstrated that, compared with CBT responders, CBT nonresponders displayed enhanced activation of threat-related brain systems (i.e., the ACC, hippocampus, and amygdala) in response to safety cues during an extinction task pretreatment. Together, these findings comport well with the cross-sectional studies demonstrating deficient safety and extinction learning in anxiety disordered individuals (Duits et al., 2015), and they add to the literature by suggesting that these deficits in safety and extinction learning hamper CBT effectiveness. Another way to gain more insight into fear learning as a mechanism of change in CBT is by examining changes in extinction learning following (successful) CBT treatment. If extinction deficits are trait factors of those with anxiety disorders, one would expect to find that someone’s performance on an extinction learning task would not be affected by CBT. Essentially, personality traits are thought to be relatively stable over time. Alternatively, CBT may improve someone’s extinction learning capacity. Indeed, Duits et al. (2016) found no differences in extinction learning between those treated with CBT for their anxiety disorder and nonanxious controls, suggesting that any preexisting extinction deficits had been resolved following CBT. Another indication that CBT affects extinction learning capacity comes from a study by Schienle et al. (2007), who compared changes in brain activation between a group of people with spider phobia who received one session of exposure therapy and a control group. Those who had received exposure showed more pre-to-post increase in the activation of the orbitofrontal cortex (OFC), an area that is implicated in extinction learning and specifically thought to be related to the learning of the CS/no US association. Similarly, Kircher et al. (2013) demonstrated that, as compared with nonpatient controls, patients who had received CBT for their panic disorder had better connectivity between cerebral regions (inferior frontal gyrus [IFG]) and fear-related areas (i.e., amygdala, insula, ACC) during a fear conditioning task, suggesting that CBT improves emotional control. Taken together, these studies suggest that patients with anxiety disorders are marked by extinction deficits and those with more deficits profit less from CBT but also that these learning deficits are reversible and can change following successful CBT. Clearly, more work needs to be done to unravel the association between fear learning and CBT outcome. Are “bad performers” able to profit from CBT under certain conditions or will they never learn? Do they need longer sessions, more sessions, explicit contingency

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learning, or cognitive enhancement? Linking the paradigms of the experimental fear conditioning literature with CBT effectiveness research has opened interesting new avenues to study the mechanisms of action of CBT and might ultimately guide interventions to improve CBT efficacy. For example, poor performance on a fear conditioning experiment before treatment may lead to the prescription of longer or more exposure exercises or pharmacotherapy (see also the section on pharmacological enhancement below). Importantly, there is currently no well-established way to assess extinction learning during CBT sessions. Measuring extinction learning over the course of treatment would provide crucial information on the temporal association between extinction learning and symptom change in CBT. Some have used change in subjective fear levels during and across CBT sessions (i.e., fear habituation) as an index of extinction learning (Berry et al., 2009; de Kleine et al., 2015; Smits, Rosenfield, Otto, Powers, et al. 2013). But, although the reduction of fear may point to extinction learning, fear habituation is not equivalent to extinction learning. Fear habituation in itself may be an indicator of change, but the empirical evidence that fear habituation mediates exposure therapy outcome is unstable (for review, see Craske et al., 2008, 2014) To summarize, linking the empirical evidence for extinction learning as a mechanism of action to Kazdin’s mediation criteria, (a) there is strong theoretical and preclinical work that supports extinction learning as a crucial mechanism of change in CBT, (b) extinction learning appears to improve following CBT, and (c) whether extinction learning during CBT sessions drives CBT’s efficacy requires further study. Avoidance Learning Avoidance is behavior that is carried out to protect oneself from confrontations with feared danger (see for review Krypotos et al., 2015). When dangers are real, avoidance can help prevent harmful outcomes. However, when fears are irrational and there is no real danger, avoidance is unnecessary. Importantly, avoidance precludes learning opportunities to see that fears are irrational. Persistent avoidance behavior in response to “false alarms” is, therefore, not only a hallmark of anxiety disorders but also an important maintaining factor. In the section that follows, we focus on the influence of avoidance on change mechanisms during CBT. Theoretical Accounts of Avoidance Remarkably, the fear conditioning and extinction learning research has mostly focused on fear (i.e., physiological arousal, freezing, or subjective fear) and not as much on avoidance behavior. However, avoidance behavior is a cardinal symptom of all anxiety disorders, underscoring the need to understand what role avoidance plays in the origin and maintenance of anxiety problems. Here, we discuss the empirical evidence for the impact of avoidance on extinction learning, in both experimental fear conditioning and clinical studies.



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In the two-factor theory, Mowrer (1951) proposed that fear is first acquired via the coupling of a conditioned stimulus with an aversive outcome (classical conditioning; first factor) and, next, that avoidance behavior is reinforced by reduction of this learned fear (instrumental learning; second factor). Thus, a patient experiences a panic attack (US) in a supermarket (CS) and becomes fearful of supermarkets (CS/US association). Next, avoiding the supermarket is reinforced by the reduction of fear. According to this theory, fear is the motor of avoidance behavior, and the reduction of fear reinforces avoidance behavior. But this model has been criticized, as it has been repeatedly shown that avoidance behavior can persist following fear extinction, suggesting that fear is not necessary for avoidance behavior (Bravo-Rivera et al., 2014; Solomon et al., 1953; Vervliet & Indekeu, 2015). Most recently, LeDoux et al. (2017) proposed that avoidance behavior follows not only from classical conditioning and instrumental learning but also from habitual learning. Habitual learning refers to the process whereby after many repetitions, actions become habits, which are highly persistent and insensitive to outcome. In this case, for a person who avoids the supermarket repetitively over a period of years, their avoidance may become habitual. Clinically, this is highly relevant, as habitual responses tend to resist extinction (see LeDoux et al., 2017). With regard to the mechanisms of change associated with CBT, the idea that avoidance might result from different processes suggests that different therapeutic strategies may be required to reduce avoidance behavior. The Impact of Avoidance on Fear Learning Aiming to teach patients that their fears are irrational, CBT programs for anxiety disorders encourage patients to have contact with feared stimuli without engaging in avoidance behaviors. Here, it is worth noting that these avoidance behaviors—also termed “safety behaviors”—can range from high-cost actions (e.g., not going out of the house or to work) that hinder normal life functioning to more subtle or low-cost behaviors. For example, a patient with panic disorder and agoraphobia may still visit crowded stores, but only when accompanied by a trusted partner. Theoretically, these safety behaviors are conditioned inhibitors of the fear response because they predict the absence of the US. These safety signals are thought to be detrimental to extinction learning, a phenomenon called protection from extinction. Protection from extinction refers to the finding that when the CS is presented in conjunction with an inhibitory CS (i.e., a predictor of the nonoccurrence of the US) during extinction, the CS again elicits the fear reaction when presented without the inhibitory CS at a later time point (Lovibond et al., 2009; see Table 4.1 for examples). Clinical studies have demonstrated the unfavorable effect of safety behaviors on CBT efficacy. Exposure with explicit instructions to reduce safety behaviors proved more efficacious than exposure without such instructions (Salkovskis et al., 1999; Wells et al., 1998). A study wherein the use of safety behaviors was experimentally manipulated demonstrated that people with claustrophobia who were allowed to use safety behaviors during in vivo exposure reported

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more fear at posttreatment and follow-up compared with those who could not use safety behaviors but were encouraged to focus on threat reevaluation (Sloan & Telch, 2002). Moreover, in a further refinement of this study design, Powers et al. (2004) demonstrated that it is not the use of safety behaviors per se but rather the availability of safety strategies that interferes with exposure efficacy. Clinically, this implies that to effectively treat anxiety disordered patients with exposure, patients should be encouraged not only to not use safety strategies (e.g., taking an anxiety pill) but also to limit the availability of the safety aid (e.g., carrying the pill). It should be noted that several studies failed to find detrimental effects of safety behavior on exposure efficacy (Deacon et al., 2010; Hood et al., 2010; Olatunji et al., 2013; Rachman et al., 2011; Sy et al., 2011). An alternative view on safety behavior is that it may help patients engage in exposure therapy and, thereby, promote the acceptability of treatment. Clearly, more work is warranted here to obtain a more thorough perspective about the specific conditions under which safety behaviors are either helpful or detrimental. For now, it is unclear the extent to which safety behaviors hinder (or help) the learning (i.e., extinction learning) thought to be crucial for CBT mechanisms. Avoidance in Depression In contrast to the anxiety disorders, less is known about avoidance behavior in those with depressive disorders. Whereas avoidance in anxiety specifically relates to the avoidance of a circumscribed threat event, avoidance in depression has been qualified as a problem-solving style, coping strategy, or personality trait (Ottenbreit & Dobson, 2004). Ferster (1973) suggested a central role for avoidance in depression. He posited that depressed individuals tend to avoid or escape situations that are considered to be unpleasant. Frequent avoidance would lead to decreased opportunities for positively reinforced behavior and social interactions and, thereby, promote apathy and inaction. Behavioral activation (BA) has its basis in Ferster’s functional analysis of depression and aims to reduce avoidance behavior (Lewinsohn et al., 1976). In BA, patients are taught coping and problem-solving skills to overcome avoidance and increase their activities in order to increase the likelihood of response-contingent positive reinforcement from their environment (Jacobson et al., 2001). BA has proven to be as efficacious as cognitive therapy in the treatment of depression (Cuijpers et al., 2007), some studies even showing superior efficacy (Dimidjian et al., 2006). What is more, a dismantling study of CBT for depression by Jacobson et al. (1996) showed that BA alone was as efficacious as BA combined with cognitive therapy in both reducing depressive symptoms and altering negative thinking, suggesting that exposure to reinforcing contingencies might be an important change mechanism in treatment for depression. However, determining whether the reduction of avoidance behavior (and thereby the increase of positively reinforcing activities) is indeed the mechanism of action of BA requires further study (Manos et al., 2010).



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Generalization of Fear Learning Fear learning is not limited to the specific instances in which conditioning has occurred. For example, stimuli that have not been associated with the aversive event but that resemble the CS can come to elicit the fear response as well. This resemblance between the CS and the associated stimulus can be either perceptual or symbolic. For instance, someone who experienced a panic attack (US) in a shopping mall (CS) can come to fear other shopping contexts (e.g., grocery stores), all crowded spaces (e.g., fairs or festivals), or situations that share no perceptual similarities to shopping malls but are related to the feared object on a conceptual level (e.g., train rides, which can also foster feelings of entrapment; for an overview, see Dymond et al., 2015). In clinical care, it is not always possible or fruitful to get an idea of the conditioning history, as the route from the original conditioning experience to current fear may be quite complex. In experimental paradigms, generalization is examined by presenting participants with stimuli that in more or lesser degree resemble the CS, called generalization stimuli (GSs), and it is then assessed whether these generalization stimuli elicit the fear response. Patients with anxiety disorders have been shown to display an overgeneralization of fear when compared with healthy controls; that is, they show fear responses to GSs that show less perceptual resemblance to the CS (Lissek et al., 2010, 2014). Aside from the acquisition of fear, overgeneralization might influence the extinction of fear. Until now, studies investigating generalization effects on extinction are sparse, although these studies would obviously be of great clinical relevance. In clinical care, it is often not possible or ethical to expose a patient to the original CS (for instance, in PTSD), and there is no other option than to expose to resembling stimuli. The experimental studies that have examined generalization in extinction provide a somewhat gloomy picture. Whereas extinction of the original CS transfers to related stimuli, the opposite appears not to be true, as extinction of a GS does not affect fear of the CS (Boddez et al., 2012; Vervliet et al., 2005; Vervoort et al., 2014). This pattern of results suggests that CBT might be most effective when exposure exercises include exposure to the original CS, but again, this is often not possible. Recently, it was shown that verbal information about the typicality of the CS as predictor of the US (e.g., the stimulus “Labrador” is typical for all danger stimuli “dogs”) could reduce the return of fear following extinction (Scheveneels et al., 2017). It has been suggested that people perceive the omission of the US during extinction as “an exception to the rule” (Bouton, 2002; Scheveneels et al., 2017). Explicitly labeling a stimulus as a typical exemplar of a certain category (and thus not an exception) might, thus, enhance learning and optimize outcome. Whether this suggestion indeed holds in clinical care requires further study. There are no clinical studies examining the effect of exposure to the original CS versus exposure to GSs. Some work has been done on stimulus variation, with the idea that extinction to multiple GSs might enhance retention of learning experiences. Indeed, there are some indications that variation of stimuli

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during exposure leads to better outcome as compared with constant stimulus presentation (Lang & Craske, 2000; Rowe & Craske, 1998), but more work should be done to allow clinical recommendations. In sum, although fear acquisition is easily generalized across stimuli and contexts, extinction of fear does not easily transfer. This provides a challenge for the efficacy of CBT, especially in the long term (i.e., after treatment completion). However, more work is warranted to examine whether generalization of extinction learning across stimuli and contexts mediates CBT outcome and, if so, the way in which generalization of extinction learning can be facilitated. Pharmacological Enhancers of Extinction Learning Over the last decade, researchers have attempted to boost therapeutic effects for anxiety and related disorders by combining CBT with pharmacological strategies thought to enhance memory and learning processes underlying CBT efficacy. In the previous paragraphs, we reviewed the evidence for extinction learning as a mechanism of action of CBT. Animal studies have shown that several pharmacological agents can facilitate extinction learning. That is, administration of such a drug leads to faster learning or better retention of learning experiences. Translating this paradigm to the clinic, researchers have given pharmacological agents in conjunction with a CBT session. If extinction learning is indeed a crucial mechanism of action of CBT, one would expect to find that those who receive a drug that improves extinction learning would improve faster or more over treatment than those who receive a placebo. Relating this field of research to Kazdin’s (2007) criteria for research on mechanisms of change, we see that theoretical and preclinical knowledge about a mechanism of action of CBT (i.e., extinction learning; Criterion 1) is used for experimental manipulation (i.e., pharmacological augmentation; Criterion 2) and tested in RCTs (i.e., comparing the effects of CBT plus pharmacological agent versus CBT plus pill placebo on symptom change; Criterion 3). The first drug that was examined within this paradigm was D-cycloserine (DCS), a partial agonist of the NMDA receptor that is thought to enhance the consolidation of extinction learning. Whereas the first human studies demonstrated that those who received DCS prior to CBT sessions had better treatment outcomes than those who received placebo (Hofmann et al., 2006; Ressler et al., 2004), subsequent studies have reported weaker or null findings (see meta-analysis by Mataix-Cols et al., 2017). Thus, whereas early work (in animals and humans) generated strong evidence that DCS enhances extinction memory consolidation and that this learning and memory process is likely implicated in CBT efficacy, it is unclear whether DCS given in conjunction with exposure therapy leads to superior therapy outcomes. Importantly, ongoing research has shown that the efficacy of DCS is influenced by different patient and treatment characteristics. For instance, some found that DCS effects are dependent on the success of the exposure session (Smits, Rosenfield, Otto, Marques, et al., 2013; Smits, Rosenfield, Otto, Powers, et al., 2013). This makes



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sense, as DCS is thought to enhance the consolidation of extinction learning. Thus, initially, this line of research was aimed at improving CBT outcome by augmentation of an identified mechanism of action—extinction learning. Accumulative science has pointed to moderators of DCS enhancement effects. Apparently, DCS does not augment CBT efficacy for all patients under all conditions. Future studies should investigate these moderators and mediators and identify for whom and when DCS might improve CBT efficacy. DCS is the most studied drug within this paradigm, but the effects of several agents thought to enhance extinction learning have been tested in clinical trials. For instance, yohimbine (Meyerbroeker et al., 2012; Powers et al., 2009; Smits et al., 2014), methylene blue (Telch et al., 2014), oxytocin (Acheson et al., 2015; Guastella et al., 2009), and hydrocortisone (de Quervain et al., 2011; Soravia et al., 2006, 2014; Yehuda et al., 2015) have all been given in conjunction with exposure sessions, with the aim of boosting extinction learning during these sessions and, thereby, improving treatment effects. Of note, the effects of these drugs may not be restricted to extinction enhancement but might involve other mechanisms of action underlying CBT. For instance, hydrocortisone (cortisol) is known to reduce emotional memory retrieval (de Quervain et al., 2009), and oxytocin promotes social learning (Guastella et al., 2008). Thus, these agents might boost CBT effects via different mechanisms. Future studies will shed more light on the mechanisms of action of these drugs and enlighten the promises and limitations of different enhancement strategies.

COGNITIVE MECHANISMS Challenges are part of our lives; however, the way we think about them influences how well we will cope, which in turn will have consequences for our mental health. The same trigger, such as losing a job, can, in this way, lead to a psychological disorder, such as a depressive episode, or to a positive change in life. If the loss triggers self-devaluation and hopelessness (e.g., “I failed; this is catastrophic”), a phase of negativity and eventually even depression might follow. For someone else, losing a job opens new possibilities and is regarded as a positive change. In this manner, the way in which we think about a possible event—as a new beginning, or another failure—influences how well we do. Importantly, the way we process information, rather automatically and often involuntarily, also can further or hinder change. What we attend to and how we evaluate information can have dramatic consequences. Unfortunately, automatic processes such as these are not easily influenced. In this next section, we review processes that have been studied as mechanisms of change for CBT, starting with the emotion regulation strategy of cognitive reappraisal and moving to more automatic processes such as modification of cognitive biases, distancing from repetitive thinking, and adoption of more positive mental imagery. We also briefly discuss change in brain processes as a possible correlate of change in CBT mechanisms.

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Cognitive Reappraisal Cognitive reappraisal is fundamental to CBT. According to the theory that underlies CBT (Beck, 2008; Beck & Haigh, 2014), people who struggle with mental health disorders often view their life circumstances in an inaccurate and/or unhelpful manner. An important focus of CBT, then, is to help patients craft more accurate and helpful interpretations and views of these circumstances, which is expected to soften negative emotional reactions. This is a form of cognitive reappraisal that in turn is a very important and well-researched form of emotion regulation (Gross & Thompson, 2007). According to the appraisal theory, the way a person thinks about or appraises the meaning of their experiences influences their emotional responses (Frijda, 1986; Lazarus, 1991). The notion that emotions partly depend on the way a person thinks about events means that the capacity of a person to alter their way of thinking is important for emotional well-being (Gross, 2001). Research shows that successful cognitive reappraisal is effective in reducing negative emotions. For example, in Arimitsu and Hofmann’s (2017) study, over 200 healthy individuals performed a writing assignment in which they used one CBT strategy to change self-critical thinking about a past event. Participants completed either a cognitive reappraisal exercise or an exercise focused on another CBT strategy, such as responsibility reattribution (i.e., helping the patient step back and consider different factors that contributed to the occurrence of an event), self-deflection (i.e., inviting the patient to focus on their positive characteristics in reinterpreting events), or self-compassion (i.e., inviting the patient to approach their feelings and thoughts in a caring and accepting way), or were given no instructions as a control condition. Results indicated that cognitive reappraisal, together with self-compassion, was associated with lower levels of negative emotions, compared with the responsibility reattribution and control conditions. Relatedly, other studies comparing different emotion regulation methods that are used in CBT with patients have found cognitive reappraisal to be a particularly effective emotion regulation strategy for disorders such as depression, anxiety, and addiction and more effective than suppression of negative or unwanted thoughts (Beadman et al., 2015; Moscovitch et al., 2012). Cognitive reappraisal has been studied as a CBT working mechanism mainly in (social) anxiety. In general, anxious individuals are less effective than nonanxious individuals in deploying cognitive reappraisal (Goldin et al., 2009). Also, cognitions about reappraisal itself may play a role in CBT. For example, socially anxious individuals believe that they are not effective in applying this emotion regulation strategy (Goldin et al., 2009). Goldin et al. (2012) found that, in SAD patients, 16 sessions of individual CBT improved patients’ belief that they can successfully employ cognitive reappraisal. The change in cognitive reappraisal mediated the effect of CBT on anxiety symptoms, providing some indication for the role of cognitive reappraisal in CBT efficacy. Also, research shows that early acquisition of cognitive reappraisal skills during CBT predicts subsequent symptom reduction in patients with SAD (Moscovitch et



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al., 2012), providing additional evidence for its mechanistic role in CBT. In this study, SAD patients underwent 12 sessions of group CBT, and cognitive reappraisal and emotion suppression strategies were measured pre-, mid-, and posttreatment. CBT responders had a higher level of cognitive reappraisal skills by midtreatment compared with nonresponders, but responders did not differ from nonresponders in their use of emotion suppression strategies throughout the course of treatment. Another study randomized SAD patients over 16 sessions of CBT or a wait-list condition (Brozovich et al., 2015). Researchers measured social anxiety symptom severity, cognitive reappraisal, and rumination (a possible mechanism of change we discuss in detail later), not only at the beginning, the middle, and the end of treatment but also weekly during the course of CBT. Rumination, but not cognitive reappraisal, was related to symptom change over the course of CBT. Finally, examining modification of underlying beliefs rather than situation-specific thoughts, Gregory et al. (2018) demonstrated that change in maladaptive self-beliefs predicted reduction in social anxiety at the end of treatment, implying that successful modification of unhelpful beliefs is a key mechanism of action in the successful cognitive behavioral treatment of SAD. Cognitive reappraisal as a mechanism of change in CBT for SAD has also been examined in various subtypes of CBT (broadly speaking). Kocovski et al. (2015) examined cognitive reappraisal and mindfulness and acceptance as mechanisms of change in patients with SAD who were randomly assigned to traditional group CBT or mindfulness and acceptance-based group therapy. Cognitive reappraisal mediated symptom change in traditional group CBT, such that self-reported use of cognitive reappraisal, had a greater impact on social anxiety symptoms and on the rate of change in social anxiety symptoms in traditional group CBT than in the mindfulness and acceptance group. Interestingly, mindfulness mediated treatment and ultimate symptom change in both groups. A review by Smits et al. (2012) focused on a specific form of cognitive reappraisal as mechanism of change in CBT for anxiety, namely threat reappraisal. Anxious individuals tend to overestimate the likelihood and negative consequences of harm. During threat reappraisal, these faulty appraisals are modified by crafting accurate and helpful interpretations and ideas about the (consequences) of the expected harm. In the review, studies on threat reappraisal in CBT in anxiety disordered patients were included only if they had a longitudinal design (i.e., multiple assessments over time) and if they investigated threat reappraisal as a mediating factor in the association between CBT and clinical outcome. Approximately half of the studies found evidence for mediation, and threat reappraisal seems to be related to anxiety symptom improvement with CBT (though one study found that threat reappraisal mediated the relationship between CBT and depressive symptoms; Bryant et al., 2001). However, only a few studies met the criteria set forth in the introduction of this chapter that are necessary to conclusively demonstrate that threat reappraisal causes symptom improvement in CBT. A subsequent review (Powers et al., 2017) reported that,

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of 25 studies examining the threat reappraisal mediation hypothesis, 13 of 14 that examined statistical mediation demonstrated evidence for mediation, and six of seven studies that examined causality demonstrated that threat appraisal resulted in a reduction in anxiety. To conclude, change in cognitive reappraisal, including threat reappraisal, has been examined as a mediator on several occasions (see criteria put forward by Kazdin, 2007), and the evidence for their mechanistic role in CBT is mixed but promising. One goal of CBT is for patients to leave treatment with an enhanced sense of self-efficacy, or the belief that they can effect positive changes in their lives (Bandura, 1977). Thus, it is possible that patients improve in CBT in part because they acquire belief that they are able to embrace the strategies that they are being taught and make a positive difference in their lives, such that they have modified their thoughts about their own coping abilities. In fact, in a study of patients with panic disorder, it was found that within-session change in selfefficacy, but not within-session change in catastrophic misinterpretations (which would be modified using cognitive reappraisal), was associated with reductions in anxiety at the end of treatment (Fentz et al., 2013; see also Hoffart, 1995, for similar results). An increase in self-efficacy has also been implicated as a mechanism of change in SAD, as it would suggest that CBT helps socially anxious patients acquire confidence that they will be able to make their desired impression on others (Hofmann, 2000). Although the vast majority of the empirical literature, as reviewed above, focuses on cognitive reappraisal as a mechanism of change in the successful cognitive behavioral treatment of anxiety and related disorders, cognitive reappraisal is also a hallmark feature of CBT for depression. Surprisingly, empirical evidence for the causal influence of cognitive change on symptom change has been mixed (Longmore & Worrell, 2007). Several studies failed to demonstrate a temporal relation between reduction in unhelpful thinking and treatment outcome (e.g., Burns & Spangler, 2001), and one study reported that reduction in depression occurred before, not after, a reduction in unhelpful thinking (Stice et al., 2010). However, other studies have found that cognitive change precedes symptom improvement in CBT but not in a distinctly different approach to treatment, pharmacotherapy (e.g., DeRubeis et al., 1990), though this result was not replicated when cognitive therapy was compared with BA (Jacobson et al., 1996). In a recent study, Schmidt et al. (2019) demonstrated in a sample of 126 depressed patients receiving CBT that self-reported immediate cognitive change at the end of the session was associated with symptom change at the end of treatment, an association that was explained by selfreported sustained cognitive change, or lasting cognitive change that was endorsed at the start of each subsequent session. Although this literature is complicated, it is generally concluded that cognitive change contributes to symptom change in depression, regardless of exactly how it is achieved (LorenzoLuaces et al., 2015). In sum, a robust literature is accumulating that has examined the role of cognitive reappraisal as a mechanism of change in CBT for the two most common categories of emotional disorders—anxiety-related disor-



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ders and depression. According to theory, the modification of inaccurate and unhelpful cognition plays a central role in facilitating successful treatment of these emotional disorders, and research generally shows that patients who complete CBT for these conditions demonstrate a greater ability to use cognitive reappraisal skills, a greater belief in their ability to use cognitive reappraisal skills, lower levels of dysfunctional cognitions, higher levels of self-efficacy, and less maladaptive underlying beliefs. In many instances, assessments of these constructs midway through treatment predict ultimate outcome. However, the pattern of results supporting cognitive mediation in anxiety-related disorders is stronger than it is for depression, and preliminary evidence suggests that other mechanisms of change (e.g., reduction in ruminative processes, mindfulness) also account for variance in treatment outcome. Cognitive Biases One way in which CBT aims to decrease symptom severity is to modify dysfunctional beliefs. Dysfunctional beliefs about the self, the world, and the future are often based on stressful (early childhood) experiences and result in negative mental schemas (Beck, 2008). CBT teaches patients to change their dysfunctional processing style and adopt a healthier, more positive processing style. This is done in an overt way, that is, through talking explicitly about the dysfunctional beliefs, as is often done in cognitive reappraisal. However, dysfunctional beliefs not only are expressed though negative thoughts but also influence the way information is processed automatically. Such a schema-based automatic processing style is called a cognitive bias (Beck, 2008; Beck & Haigh, 2014). Based on Beck’s theory, change in cognitive biases is a proposed mechanism in CBT. Emotions bias our cognitive processing; they give a special weight to information that is congruent with how we feel. For example, anxiety ensures that we attend to threat, whereas sadness or depression ensures that we pause and take more time to reflect. Biased processing is observed across different cognitive domains, of which attention, interpretation, and memory are most frequently studied, in relation to mental health problems. Important to note is that healthy (or rather, nondisordered) individuals show a processing style toward the preferential processing of positive information (Cummins & Nistico, 2002; Gotlib & Joormann, 2010; Mathews & MacLeod, 2005). Specifically, healthy individuals tend to attend more to positive relative to negative information and are more likely to interpret ambiguous events and stimuli in a positive way (Mathews & MacLeod, 2005). Healthy individuals also remember positive information better than negative information (Matt et al., 1992). This means that neither healthy nor disordered individuals are “correct” and that we all are characterized by cognitive biases. Instead, it makes clear that cognitive biases are ubiquitous and that some are just less beneficial to our mental health than others. Different mental disorders are characterized by either facilitated attention to and/or difficulties with disengaging from relevant stimuli, such as alcohol-related

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cues in alcohol addiction, high-caloric food in eating disorders, angry faces in SAD, and negative self-descriptions in depression (Faunce, 2002; Field & Cox, 2008; Gotlib & Joormann, 2010; Mathews & MacLeod, 2005; Van Bockstaele et al., 2014; van Hemel-Ruiter et al., 2016). Consider, again, Mr. G., who has SAD. He has always been self-conscious and shy, but his symptoms have deteriorated because of recent stress. When Mr. G. enters the meeting room at work, his anxiety spikes. As a result, he avoids making eye contact, but he scans the facial expressions of the people around him. His attention is drawn quickly and automatically to expressions of anger and disapproval, causing him to appraise the situation as unpleasant and possibly harmful. By focusing solely on those negative facial expressions, he is likely to remember uncomfortable encounters especially well, which in turn reinforces his avoidance behavior. This example illustrates anxiety-related attention, interpretation, and memory biases in a daily-life setting and how they tend to be interrelated (Everaert et al., 2012). The causal relation between biases and mental problems has been researched most in depression and anxiety (see reviews by De Raedt & Koster, 2010; Van Bockstaele et al., 2014), though there is tentative evidence that biases may be global markers for psychopathology and thus present in a wide range of disorders in addition to anxiety and depression (Vrijsen et al., 2017). Attention and interpretation bias in anxiety have been most frequently studied as mechanisms of change in CBT. For example, a study in highly anxious adolescents showed that attentional bias for threat decreased after CBT (Hadwin & Richards, 2016). A study in patients with SAD compared CBT responders (i.e., with decrease in symptoms) with nonresponders (i.e., with no change in symptoms) and found that only responders showed a decrease in attentional bias for disorder-specific social threat words (Lundh & Öst, 2001). Mediation of attentional bias change on the effect of CBT on symptoms was not examined. Waters et al. (2008) assessed both attentional bias and interpretation bias before and after CBT in clinically anxious children (including children with SAD and generalized anxiety disorder [GAD]) and found that negative interpretation bias but not attentional bias decreased during CBT. Mediation was again not examined. Finally, Davis et al. (2016) examined whether observed improvements in attentional bias mediated CBT effects on social anxiety symptoms in SAD patients, but they showed that these changes did not mediate symptom improvement. Taken together, attentional bias as a CBT mechanism of change has only very sparsely been evaluated according the Kazdin (2007) criteria, and the evidence available does not indicate it as a mechanism of change. Change in interpretation of ambiguous information has also been studied as a mechanism of change for CBT, although also only in a few studies. For example, negative interpretation bias decreased after four sessions of computerized CBT in a sample of individuals with high social anxiety (Bowler et al., 2012). Importantly, this change in bias mediated the effect of CBT on symptoms. In a moderately socially anxious adolescent sample, no difference between individuals receiving CBT and individuals receiving no treatment was found on



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interpretation bias reduction from baseline to the 2-year follow-up (de Hullu et al., 2017). Mediation was, however, not examined. In their review on attentional and interpretation bias change after CBT in anxious children, Ege and Reinholdt-Dunne (2016) concluded that, in children, the evidence regarding the effect of CBT on attentional bias is mixed, and there is limited empirical evidence to indicate that CBT changes interpretation bias. This partially contrasts with more recent evidence of interpretation bias, as well as perceived control, as a strong mechanism of change in anxious children (Pereira et al., 2018). As with attentional bias, structural examination of interpretation bias as a CBT mechanism of change is very limited, and, hence, we cannot conclude whether attentional bias and interpretation bias are mechanisms of change in CBT. So far, memory bias has received even less attention in research on CBT mechanisms of change. A study in depressed patients showed that negative recall bias decreased over the course of CBT but that this change did not mediate a CBT treatment effect in depressed patients (Quilty et al., 2014). There is also some evidence from research in bipolar patients showing that negative memory bias decreased after CBT (Docteur et al., 2013). However, mediation was not studied. No evidence for memory bias as CBT mechanism of change exists. In addition to biased attention, interpretation, and recall of emotional information, automatic negative implicit associations have been studied in relation to CBT outcomes. Implicit associations are also a form of processing bias, as people have either relatively more positive or more negative associations with disorder-related versus neutral words. For example, individuals with GAD show stronger negative than positive associations with worry-related and neutral words on a computer task (Reinecke, Rinck, et al., 2013). In a sample of patients with GAD, negative worry-related associations became more positive after 15 weeks of CBT, and patients showed fewer worry-related intrusive thoughts after CBT (Reinecke, Hoyer, et al., 2013; Reinecke, Rinck, et al., 2013). CBT effects on implicit associations have also been found in individuals with high spider anxiety (Reinecke et al., 2012), such that implicit threat associations were lower after CBT. Implicit associations were also examined in the socially anxious adolescent sample discussed previously (de Hullu et al., 2017) but did not change from before CBT to 2 years after CBT. Importantly, mediation was not examined in any of these studies. Thus, although implicit association may change in some anxiety patients, evidence for implicit associations as a mechanism of change in CBT does not exist at this point. Change in bias has been studied more structurally in relation to antidepressant treatment. This means that mediation was examined and bias was assessed, not only before and at the end of treatment but also multiple times during treatment, thus conforming to the recommendations put forward by Kazdin (2007). From pharmacological treatment studies, we know that change in bias may precede symptom change during treatment (Harmer & Cowen, 2013). Serotonergic antidepressants may change the brain’s reactivity to emotional

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stimuli, encouraging a relatively more positive attentional bias (Browning et al., 2010) and, in turn, contributing to symptom reduction. Studies that show support for bias modification as a mechanism of change for CBT are limited at this time, mostly because of a lack of adequately designed studies for testing this putative change mechanism. On the basis of Beck’s cognitive theory of depression, change in biases is expected to precede symptom change during CBT, in line with the pharmacological studies. Overall, cognitive processing seems to become less negatively biased after CBT. But because (a) most studies do not include mediational analyses on the role of change in bias on symptom change during CBT and (b) there are no studies, as far as we know, measuring bias during the course of CBT, we currently cannot either accept or reject cognitive biases as CBT mechanisms of change. What studies are needed that can yield data that would allow us to fully conclude whether changes in cognitive biases can be considered mechanisms of change? Considering the criteria put forward by Kazdin (2007), again, we need RCTs in which not only bias but also other hypothesized mechanisms of change are measured after every (couple of) session(s) and mediation of symptom change during CBT by bias change is analyzed. This will inform us about the temporality (i.e., when does change occur?) and specificity (i.e., is symptom change related to bias specifically?) of biases as mechanisms of change. Important to note here is that we are now clustering evidence on biases in different cognitive domains (e.g., attention, interpretation, memory, associations) on the basis of different measurements used (e.g., reaction time tasks, explicit verbal tasks), and for different stimulus types (e.g., disorder-specific or more general stimuli, pictures, words). Although we assume that all tasks used measure the same underlying construct of cognitive bias, we currently do not know to what extent the variation in measurement affects the (generalizability of the) results. Moreover, the research on change in cognitive biases as a mechanism of CBT needs to be extended to include the study of disorders beyond anxiety and depression, such as eating disorders and addiction. The question of whether cognitive biases are mechanisms of change remains unanswered until we have sufficient high-quality evidence. Repetitive Negative Thinking: Rumination and Worry Negative repetitive thinking patterns are prominent in many mental disorders, rumination being the best researched of those patterns. According to cognitive theory, negative cognitive schemas (Beck, 2008) drive this negative and preservative processing style. While ruminating, an event is retrieved from memory and the causes and consequences are repeatedly processed without engaging in active problem solving (Nolen-Hoeksema et al., 2008). Worry is a similar activity, but the focus instead is on future negative events. Individuals use repetitive negative thinking to cope with emotional distress, which maintains this unhealthy cognitive style. Many patients are concerned about the negative consequences of their repetitive negative thoughts, which results in even more



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distress and contributes to psychopathology. Both rumination and worry are experienced as excessive and uncontrollable. Rumination and worry have been most frequently linked to depression and anxiety, respectively. However, both are also well researched as more global risk factors for mental problems (Ehring & Watkins, 2008; Harvey et al., 2004), such as eating disorders, substance abuse, suicidal ideation, and depression/anxiety comorbidity (Gibb et al., 2012; Miranda & Nolen-Hoeksema, 2007; Nolen-Hoeksema, 2000; Nolen-Hoeksema et al., 2007). A special form of rumination linked to SAD is postevent processing (Clark & Wells, 1995). Socially anxious individuals tend to extensively review past embarrassing or stressful events. Socially anxious individuals are likely to have experienced anxious feelings and heightened self-focus during the event, and these negative feelings are likely to be a prominent part of the memory. Moreover, reviewing a past event and evaluating it as negative will likely trigger memories of other instances of perceived social failure, contributing to the negative impact of postevent processing. Consider, once again, Mr. G., who has SAD. He feels anxious and down, but he still manages to go to work. At work, he gave what many viewed as a good presentation. Despite this feedback, Mr. G. has difficulty letting go of the thought that he responded badly to a question. He is unable to stop thinking about how this could happen and what the others now might think. Ruminating over this incident does not change what happened, nor will it help him perform better the next time. It simply increases his emotional distress. Changes in rumination and worry are proposed as mechanisms of change in CBT and have been related to CBT outcomes. For example, a study of SAD found that negative rumination decreases after 12 weeks of CBT (Abbott & Rapee, 2004). However, mediation of the treatment effect by change in rumination was not examined, and all SAD patients received CBT, meaning that treatment effects cannot be attributed to CBT with certainty. As presented previously in the section on cognitive reappraisal, Brozovich et al. (2015) measured social anxiety symptom severity, rumination, and cognitive reappraisal weekly during the course of CBT and found rumination to be associated with weekly changes in social anxiety. Change in worry has been mostly studied in GAD patients as a mechanism of change in CBT. In one study focusing on individual response trajectories, seven GAD patients completed a daily questionnaire, including items assessing symptoms and worry during 10 to 12 weeks of CBT (Bosley et al., 2018). All patients showed improvement in (controllability of) worry over the course of CBT. However, the authors did not relate change in worry to symptom change. Another study found that early decreases in worry (after the first month of CBT) predicted treatment response not only immediately after 10 sessions of CBT but also 1 year after the end of treatment (Bradford et al., 2011). Moreover, the magnitude of early reduction in worry predicted symptom decrease from posttreatment to 1 year later. Lemmens et al. (2016) reviewed studies examining, among other constructs, rumination and worry as mechanisms of

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change in various forms of psychotherapy including CBT and concluded that (a) rumination and worry are associated with depressive symptom change in the majority of studies, but (b) few studies conducted mediation analyses, and the results on the role of rumination and worry in symptom change are mixed. They furthermore posited, “Research aimed at identifying the active ingredients of psychotherapy for depression would benefit from a further refinement of research methods to disentangle mechanisms of change” (Lemmens et al., 2016, p. 105). This is, indeed, the conclusion that can be drawn when reviewing literature on rumination and worry as mechanisms of change in CBT, as change in both seem related to symptom change, but thorough and structural (see criteria put forward by Kazdin, 2007) examination of worry and rumination as mechanisms of change (starting with mediation analyses) is largely lacking. Mindfulness-based cognitive therapy (MBCT; Teasdale et al., 1995) combines mindfulness with elements of CBT such as activation and psychoeducation. As with CBT, MBCT is based on the assumption that patients with mental disorders differ from healthy individuals in cognitive processing (Ma & Teasdale, 2004; Teasdale et al., 1995). Reduction in rumination is a proposed mechanism of change of MBCT, as for CBT. To illustrate, one study compared MBCT with CBT in depressed patients and found that both treatments affect rumination to the same extent and that posttreatment rumination was related to posttreatment depressive symptom levels for both treatment types (Manicavasagar et al., 2012). Mediation of treatment effect by rumination change was, however, not studied. Gu et al. (2015) conducted a meta-analysis of mediation studies on the mechanisms of change in MBCT for depression, anxiety, stress, and overall psychopathology. They included six studies on rumination and/or worry and found moderate consistent evidence for rumination and worry as mediators for clinical outcomes. Taken together, and in contrast to traditional CBT, the evidence for change in rumination and worry as a mechanism of change in MBCT is rather consistent and based on several mediation studies. Experimental research on the central role of rumination in depression instigated a new translational approach to CBT specifically targeting ruminative thinking called rumination-focused CBT (Watkins, 2009). In this form of CBT, patients learn to switch from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises, and behavioral experiments. This means that rumination is explicitly implemented as a mechanism of change. So far, this novel approach to CBT has been tested in remitted depressed patients and appears efficacious in improving residual depressive and comorbid symptoms (Watkins et al., 2007, 2011). Moreover, research shows that change in rumination mediates treatment outcome in one study comparing treatment as usual plus rumination-focused CBT to treatment as usual alone (Watkins et al., 2011). Although compelling, the clinical effects and mechanisms of change of this novel form of CBT need to be studied further. Taken together, the theoretical background of CBT and some experimental work indicates that decreases in rumination and worry are related to CBT efficacy.



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Emotional Mental Imagery Mental imagery has received much attention in psychological research, and the adoption of more positive mental imagery has been proposed as a mechanism of change in CBT. Mental imagery refers to the “perceptional experience in the absence of sensory input” (Ji et al., 2016, p. 703) and is often described as “seeing with the mind’s eye” and “hearing with the mind’s ear” (Kosslyn et al., 2001, p.  635). A mental imagery representation of an emotionally charged stimulus activates a network of related information that largely mimics the actual experience of encountering this stimulus. Imagery interventions in CBT are based on the idea that emotional mental imagery has a strong effect on emotional processing. Consider again Mr. G., who has SAD. Mr. G forgot his keys in the meeting room at work. Thinking about going back to the workplace prompts upsetting mental images—Mr. G. sees the meeting room with his mind’s eye (i.e., perceptual information), and he also feels how uncomfortable and anxiety provoking it is to be in the meeting room (i.e., affective information). Even his muscles react involuntarily by tensing up. Hence, the imagined confrontation with the stimulus (i.e., the meeting room) evokes emotional responses in a similar fashion to the actual interaction with the stimulus on a perceptual, semantic, affective (Moulton & Kosslyn, 2009), and even physiological level (for an overview, see Ji et al., 2016). Negative imagery contributes to the development and maintenance of anxiety disorders such as SAD and PTSD (Clark & Wells, 1995; Ehlers & Clark, 2000) and is also present in depression (e.g., Holmes et al., 2007). Specifically, as proposed in the model by Clark and Wells (1995), when in a feared or overall negative situation, anxious and depressed patients experience excessive negative images of themselves. They erroneously base their conclusions about constructs like their own performance or own worth on these images. Negative images tend to represent abstracted core ideas about how patients think about themselves. Emotional mental imagery might, thus, be a strong target for treatment because it impacts emotional response even more so than verbal processing, which is a central target of CBT (Ji et al., 2016). As presented in the section on learning mechanisms, exposure is a CBT technique often used to treat anxiety disorders such as SAD, obsessivecompulsive disorder (OCD), GAD, and PTSD (see Holmes & Mathews, 2010; Ji et al., 2016), as well as depression (Hayes, 2015). Imaginal exposure occurs when the patient vividly imagines the feared situation and its consequences and does not avoid the subsequent experience of anxiety. Mental imagery is used to evoke emotions during imaginal exposure, and this affective response is also a requirement for imaginal exposure to yield effects on symptomatology. Emotional mental imagery is, hence, a key element of exposure therapy and is therefore proposed to be a mechanism of change. Although far from being part of standard CBT for depression, imaginal exposure may also reduce intrusive memories in depression (see, for example, a case study by Kandris & Moulds, 2008).

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Imagery rescripting is another imagery-based CBT technique that is increasing in popularity among cognitive behavioral therapists. In imagery rescripting, the patient and therapist find an alternative, more positive outcome for an intrusive image or memory. Subsequently, the patient is prompted to focus on the content of the image or memory and rehearse imagining the previously generated alternative outcome. Imagery rescripting has been proved effective in lowering symptom levels, especially when combined with exposure or classic CBT in the treatment of PTSD, anxiety, depression, OCD, and personality disorders (see Ji et al., 2016; Veale et al., 2015), and it may even work as stand-alone treatment (see, for evidence in depression, Brewin et al., 2009). As for imaginal exposure, emotional mental imagery is a key component of this technique but has not been explicitly studied as a mechanism of change so far. The role of emotional imagery in emotional problems and related psychopathology is evident. To date, emotional mental imagery is used as a treatment target in anxiety (and sometimes depression), but research (e.g., mediation studies) directly examining emotional mental imagery as a mechanism of change seems to be lacking. Nevertheless, we think imagery is a possible mechanism worth mentioning because it will likely continue to attract attention in the clinical research field in the coming years.

MECHANISMS OF CHANGE IN OTHER MENTAL HEALTH DISORDERS As is evident in this chapter, the majority of theoretical inquiry and empirical research on mechanisms of change has focused on anxiety disorders and depression. Thus, the potential candidates to serve as mechanisms of change that have primarily been subjected to empirical scrutiny are generally those that are in line with cognitive behavioral theories of anxiety-related disorders and depression. Clearly, there is a great need to extend consideration of processes of change to other types of mental health disorders. In this section, we present examples of research on the mechanisms of change associated with CBT of other mental health disorders. Perhaps the most complicated mental health disorder that has been subjected to mechanism-of-change analyses is alcohol use disorder, as the extant research shows that purported mechanisms of change typically only apply to subsets of the samples under consideration. For example, Roos et al. (2017) demonstrated that self-reported coping (e.g., finding alternative activities, seeking social support, using stimulus control techniques, thinking about the benefits of changing drinking habits) at the end of treatment mediated the positive effects of CBT in patients with high (but not low or moderate) baseline dependence severity. Although this study highlights the importance of the acquisition of a wide array of coping skills, its limitation is that self-reported coping skill was not measured at various intervals throughout the course of treatment. Hallgren et al. (2019) found that abstinence status at the time of treatment commencement is important, with those already abstinent when treatment



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started reporting higher levels of self-efficacy and use of coping skills throughout treatment and those committing to abstinence at some point during the course of treatment reporting improvements on these variables the same week. In a relatively recent review, Magill et al. (2015) highlighted that methodological limitations (e.g., inadequate measurement of coping skills) might explain the lack of compelling data supporting the acquisition of coping skills as a mechanism of change for alcohol and drug use disorders in research conducted through the mid-2000s. More recent research has indeed supported the notion that increased coping skills mediate the relation between specific CBTs and outcomes for gambling (Petry et al., 2007), alcohol use disorder (Witkiewitz et al., 2012), and drug use disorder (Kiluk et al., 2010). In the realm of eating disorders, Dingemans et al. (2007) examined mediators of outcome in CBT for binge-eating disorder. Results indicated that a reduction in self-reported weight concerns, a cognitive variable, mediated the outcome (i.e., abstinence of binge eating) posttreatment. However, patients generally demonstrated a rapid response to treatment, with a significant reduction in binge-eating episodes in the first half of treatment before mediators were measured midtreatment. Thus, we cannot conclude that reduction in weight concerns caused response to treatment that was measured after treatment had ended. Research has very recently ventured into the territory of examining potential mediators involved in CBT for psychosis. Mehl et al. (2018) considered various relevant cognitive factors that could serve as mediators in the successful reduction of delusions, such as a change in reasoning biases, changes in self-schemas, and improvements in self-esteem. Variables were measured only pretreatment and posttreatment, so conclusions about temporal changes in putative mediators could not be made. Regardless, the only cognitive variable that showed a reduction in treatment was implicit associations associated with self-esteem, and none of these variables demonstrated a mediating effect on strength of delusions posttreatment. This research clearly suggests that more critical examination into the mechanisms of change in CBT for psychosis is warranted.

CONCLUSIONS AND FUTURE DIRECTIONS In this chapter, we reviewed evidence for mechanisms of change in CBT. Fear extinction and avoidance learning are regarded as important learning mechanisms, and cognitive processes such as cognitive reappraisal, cognitive biases, repetitive negative thinking, and mental imagery all are central to theoretical accounts guiding CBT. Although the empirical literature on mechanisms of change of CBT has grown, the quality and quantity of evidence supporting theory is limited at this time. Indeed, there is considerable heterogeneity in the quality of research on mechanisms of change (Kazdin, 2007, 2009; Maxwell & Cole, 2007). Although most proposed mechanisms are related to symptom

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improvement in CBT, there are few studies that meet the criteria to conclude that the mechanism indeed causes symptom improvement in CBT (see Kazdin, 2007, 2009) and that it is not reflecting a nonspecific therapeutic change mechanism. Considering the research criteria and phases identified by Kazdin (2007) and described at the beginning of this chapter, we can conclude the following. First, mechanisms are, in fact, generally selected based on theory or previous correlational or preclinical research. Most mechanistic processes have been manipulated, and RCTs measuring the different mechanisms discussed in this chapter have been conducted. The main caveat in current literature seems to be the execution of mediation studies, as well as studies measuring the proposed mechanistic process together with other processes in multiple CBT sessions. This means that, for the future, it will be important to do RCTs specifically designed to examine the specificity and temporality of mechanisms of change and then to disseminate this knowledge to CBT practice. Mechanisms of change may differ between disorders, just as there is variation in (key) risk factors for different disorders. Focusing on the examination of certain mechanisms (e.g., extinction learning) in certain disorders (e.g., anxiety) makes sense. However, to be able to draw conclusions about the general and disorder-specific mechanisms of change in CBT, future research should include a broader range of disorders. Related to this is the weakness that comorbidity as well as severity of current and past disorders is often ignored in this line of research. It seems plausible that mechanisms of change differ depending on differences in comorbid disorders, severity, and psychiatric past. In addition to addressing these weaknesses, future research in this area may focus more on experimental approaches that directly target putative mechanisms of change (e.g., blocking, augmenting). Some examples of ongoing research in this area include the work on cognitive enhancers described above (Mataix-Cols et al., 2017), as well as research on the effects of neurostimulation, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), on treatment response (De Raedt et al., 2015) and research on exercise augmentation (e.g., Powers et al., 2015). The large variation in measurements (e.g., from implicit computer tasks to self-report questionnaires) may be a methodological limitation that helps explain the lack of compelling evidence for certain mechanisms of change in CBT. As a field, we are clustering different modes of measurement together and assuming we are all measuring the same aspect of a certain mechanism. It is striking that within the clinical research field, “cognition” is measured as a change in content, a change in self-reported skill or usage of a certain cognitive technique, or one’s belief in the ability to apply this cognitive technique. Comparing measurements and creating uniformity in the measurements used should be a goal of future research on mechanisms of change of CBT. We encourage future researchers to compare different types of mechanisms of change within the same sample to determine their relative explanatory power. In one example, Chu et al. (2015) examined the mediational power of



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youth coping (both cognitive and behavioral strategies), therapist interventions (both cognitive reappraisal and exposure), and youth-interfering behaviors (e.g., avoidance, escape, compulsions) in a trial of exposure with response prevention for youth with OCD. Results from this study indicated that all three clusters of variables were important in understanding treatment outcome, having great clinical importance for therapist behavior during exposure and interventions and education provided to clients. Of additional note in this study is that the mediating variables were coded observationally, which is an advantage over self-report measures because it establishes actual behaviors that are contributing to change, rather than patient or therapist perceptions of such behaviors. In another innovative study examining mechanisms, Hayes-Skelton and Marando-Blanck (2019) determined that a reduction in anticipatory processing preceded improvements in decentering in group CBT for social anxiety. In other words, both variables served as mediators of change, but an important temporal order emerged that has implications for the way in which interventions are delivered. These studies raise awareness of the value of comprehensive investigation of mediators of change within the same study and using multiple approaches to measurement. Clearly, much work remains to be completed before we have an understanding of the mechanisms of change associated with CBT that is on par with our understanding of CBT’s efficacy and effectiveness. We encourage researchers to frequently collect data relevant to the broad array of possible mechanisms of change, including those that are cognitive, metacognitive, emotional, and behavioral in nature. We also encourage researchers to distinguish the specific mechanisms of action associated with the lower order distinctive variants of CBT, including cognitive therapy (e.g., Schmidt et al., 2019), schema therapy (e.g., Renner et al., 2018), exposure with response prevention (e.g., Chu et al., 2015), and BA (Jacobson et al., 1996). Of course, it would be ideal for research to demonstrate that different mechanisms of change are at work in distinctively different approaches to treatment, such as CBT and interpersonal psychotherapy, but thus far, there is little empirical support for the notion that different processes are at work in treatments associated with different theoretical frameworks (Lemmens et al., 2017). Understanding the workings of these experimental manipulations can inform us about what changes in whom during CBT. Hence, such research can provide valuable information on CBT mechanisms of change.

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after extinction. Behaviour Research and Therapy, 43(3), 357–371. https://doi.org/10. 1016/j.brat.2004.02.005 Vervoort, E., Vervliet, B., Bennett, M., & Baeyens, F. (2014). Generalization of human fear acquisition and extinction within a novel arbitrary stimulus category. PLOS ONE, 9(5), e96569. https://doi.org/10.1371/journal.pone.0096569 Vrijsen, J. N., van Amen, C. T., Koekkoek, B., van Oostrom, I., Schene, A. H., & Tendolkar, I. (2017). Childhood trauma and negative memory bias as shared risk factors for psychopathology and comorbidity in a naturalistic psychiatric patient sample. Brain and Behavior, 7(6), e00693. https://doi.org/10.1002/brb3.693 Waters, A. M., Wharton, T. A., Zimmer-Gembeck, M. J., & Craske, M. G. (2008). Threat-based cognitive biases in anxious children: Comparison with non-anxious children before and after cognitive behavioural treatment. Behaviour Research and Therapy, 46(3), 358–374. https://doi.org/10.1016/j.brat.2008.01.002 Watkins, E. R. (2009). Depressive rumination: Investigating mechanisms to improve cognitive behavioural treatments. Cognitive Behaviour Therapy, 38(Suppl. 1), 8–14. https://doi.org/10.1080/16506070902980695 Watkins, E. R., Mullan, E., Wingrove, J., Rimes, K., Steiner, H., Bathurst, N., Eastman, R., & Scott, J. (2011). Rumination-focused cognitive-behavioural therapy for residual depression: Phase II randomised controlled trial. British Journal of Psychiatry, 199(4), 317–322. https://doi.org/10.1192/bjp.bp.110.090282 Watkins, E. R., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., Kennell-Webb, S., Moulds, M., & Malliaris, Y. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45(9), 2144–2154. https://doi.org/10.1016/j.brat.2006.09.018 Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1998). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 29(3), 357–370. https://doi.org/10.1016/S00057894(98)80037-3 Witkiewitz, K., Donovan, D. M., & Hartzler, B. (2012). Drink refusal training as part of a combined behavioral intervention: Effectiveness and mechanisms of change. Journal of Consulting and Clinical Psychology, 80(3), 440–449. https://doi.org/10.1037/ a0026996 Yehuda, R., Bierer, L. M., Pratchett, L. C., Lehrner, A., Koch, E. C., Van Manen, J. A., Flory, J. D., Makotkine, I., & Hildebrandt, T. (2015). Cortisol augmentation of a psychological treatment for warfighters with posttraumatic stress disorder: Randomized trial showing improved treatment retention and outcome. Psychoneuroendocrinology, 51, 589–597. https://doi.org/10.1016/j.psyneuen.2014.08.004

5 Cognitive Case Formulation Peter J. Bieling, Emanuele Blasioli, and Dara G. Friedman-Wheeler

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his chapter provides an overview of cognitive case formulation, its purpose, and key areas of patient assessment that contribute to it. We then review the extant empirical evidence for cognitive case formulation and share our thoughts about its potential role in the newer cognitive behavioral therapy (CBT) treatments. A complete guide to developing and using cognitive case formulation is beyond the scope of this chapter; there are several excellent resources available that address this topic more fully (e.g., Eells, 2007; Persons, 2008). Here, we focus on the definition of case formulation and then move on to the broader topics of function and utility.

WHAT IS CASE FORMULATION? Case formulation is a tool that therapists use to assist them in treating patients. Specifically, “case formulation is a hypothesis about the causes, precipitants and maintaining influences of a person’s psychological, interpersonal and behavioral problems” (Eells, 2007, p. 4). In other words, case formulation involves both describing a patient’s current problems and developing hypotheses about factors contributing to the onset and maintenance of these problems. These hypotheses have a basis in theory, and they influence intervention decisions. Case formulations tend to comprise the following elements, regardless of theoretical perspective: (a) a description of the presenting problem(s), (b) distal causal factors, (c) proximal precipitating factors, (d) factors maintaining the https://doi.org/10.1037/0000218-005 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  131 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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problem(s), (e) coping strengths and challenges, and (f) implications for treatment (Bieling & Kuyken, 2003). In describing these factors, the formulation helps the clinician consider hypotheses about the ways in which the factors interact to bring the patient to the current moment and suggest interventions that will be particularly helpful for the patient. Cognitive case formulation uses cognitive theory to explain the patient’s systems of beliefs, behaviors, and thoughts. Different models of cognitive case formulation emphasize different components of the formulation (i.e., behaviors, thoughts, underlying beliefs) and use different methods and frameworks in constructing the formulation. These differences can lead to a very distinct “look and feel,” and many practitioners will develop a preference for one model over another. There are several commonly cited models of cognitive behavioral case formulation, including those developed by Nezu et al. (2004), Persons (2008), J. S. Beck (2011), and Kuyken et al. (2008). We briefly describe these four models next. Nezu et al. (2004) identified the practitioner as a problem solver and an expert in recognizing the patient’s particular approach to challenging life circumstances. A problem-solving strategy is used to work toward identified goals. In this model, CBT case formulation helps the clinician to identify the patient’s problems; identify the variables involved in the problems presented; and build a treatment plan clarifying treatment targets, goals, and objectives. A key point of this model is its “problem orientation” (Nezu et al., 2004, p. 14), grounded on two methodological approaches. The first one refers to the multiple causality framework (Shadish, 1993). When applied to the context of clinical assessment, the multiple causality framework advocates a multiplicity of factors (e.g., biological, psychological, social) contributing to the symptom, leading to a variety of treatment strategies in CBT. The second approach refers to the systems perspective, according to which the factors mentioned previously interact reciprocally. This approach can, potentially, help the therapist to identify a variety of clinical targets for the treatment and increase the likelihood of a successful outcome (Nezu et al., 2004). On the basis of empirical evidence regarding mechanisms, underlying symptoms, and disorders, Persons’s (2008) model emphasizes adapting this evidence to the situations of individual patients. The main goal of a case formulation is to guide a treatment. Persons noted that evidence-based treatments and practices for psychiatric disorders and psychological problems represent an important achievement; unfortunately, in many circumstances these protocols do not provide the needed guidance to the clinician, such as with patients who have comorbidities, a history of treatment failure, or nonadherence to the treatment (Persons, 2008). The structure of a complete case formulation, according to the author, consists of four main components: (a) a clear description of “the patient’s symptoms, disorders and problems” (Persons, 2008, p. 5); (b) the formulation of hypotheses to explain the “mechanisms” involved with problems and disorders; (c) hypotheses about the recent “precipitants” of problems and disorders; and (d) an investigation of the “origins” of the mechanisms (Persons, 2008, p. 5). Persons argued that a strong formulation needs to be internally coherent. This characteristic will help the clinician in understanding the



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relation that exists among different problems and in developing an efficient treatment plan. The development of a case formulation starts with a nomothetic (general) formulation that is ideally translated into an idiographic (individualized) formulation that supports the therapist’s clinical decision making. A case formulation is developed at three nested levels, each one guiding different aspects of a treatment: case, disorder or problem, and symptom (Persons, 2008). Case formulation in CBT results from a principle-driven approach to treatment, providing the necessary flexibility to address the various difficulties encountered by the therapist. Within this framework, the therapeutic relationship is seen both as a pillar for the development of the treatment and as “an assessment and intervention tool itself” (Persons, 2008, p. 13). Judith S. Beck (2011) described the way in which the cognitive case formulation brings to life the basic constructs of CBT for each individual patient. In this context, the case formulation is a continuous process that helps the clinician conceptualize the patient’s difficulties and problems in cognitive terms. The case formulation not only describes problems and their cognitive origins; it is at the same time a “road map” (J. S. Beck, 2011, p. 39) that guides the therapist toward the achievement of the goals discussed with the patient by selecting treatment strategies that target specific problematic emotions, thoughts, and behaviors. According to J. S. Beck (2011), “if the conceptualization is on target, patients confirm that it ‘feels right’—they agree that the picture the therapist presents truly resonates with them” (p. 40). In this model, and consistent with the cognitive model, different levels of cognition are considered, from automatic thoughts in reaction to “here and now” situations, to deeper conditional assumptions, and finally the deeper level of core beliefs or schemas. In addition, this model highlights features of the patient’s history that may have given rise to maladaptive core beliefs and makes note of maladaptive compensatory strategies. The conceptualization (used here in a way that is synonymous with the concept of formulation) is a fluid and continuous process that begins at the first contact with the patient. All interpretations must be based on the data collected from the patient as therapy progresses. The discovery of new data can lead the clinician to modify the conceptualization, testing the hypotheses at various phases to confirm, disconfirm, or refine them (J. S. Beck, 2011). A case example using this model is below.1 Finally, Kuyken et al. (2008) proposed a model that emphasizes the developing nature of conceptualization in CBT as well as the essential contribution of collaborative empiricism. According to the authors, conceptualization is seen as a process that evolves over time, starting from a descriptive level and evolving toward higher, more complex, models of explanation, such as targeting how the symptomatology of a disorder is maintained. The authors used the metaphor of the crucible to introduce their model, according to which the case conceptualization encompasses three elements: (a) theoretical and empirical foundations of CBT, (b) the patient’s experience and strengths, and (c) collaborative empiricism. Some basic principles are seen to guide the formulation. Clinical examples are disguised to protect patient confidentiality.

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The first principle refers to the stratification and evolution of the case conceptualization, namely that conceptualization evolves over time, as new information becomes available to the therapist. The evolution of a formulation, according to this model, follows a typical pattern, moving from an initial descriptive level toward an increasingly explanatory level as therapy progresses. The second principle refers to the adoption of collaborative empiricism, a systematic process based on mutual collaboration between the therapist and the patient. As noted by Kuyken et al. (2008), collaborative empiricism relates to the utilization of a solid theoretical approach in CBT on one side, supported by an empirical method of observation and investigation with each patient on the other side. The third principle focuses on the inclusion of the patient’s strengths and resiliency within the conceptualization. In this context, a strength-focused approach helps the patient in two directions, relieving the distress and building on positive abilities at the same time (Kuyken et al., 2008). Sample Case and Partial Formulation Case Description Emma is a 56-year-old cisgender White Canadian woman with major depression (recurrent, moderate). Her Beck Depression Inventory–II (BDI-II) score at treatment initiation is 33. Emma works as a nurse. She has three grown sons and is not currently married. Emma has two bachelor’s degrees, in English literature and in nursing. She stayed home with her children when they were young, and she pursued her degrees in her 30s and 40s. In addition to this episode, Emma has had one other clearly defined episode of depression, nearly 20 years ago when her first husband announced that he was “in love with another woman.” During the subsequent separation and divorce, she drank heavily and was quite depressed for over a year. Although her depression eventually abated, she abused alcohol for 10 years before seeking rehabilitation (her only experience as an inpatient). At the time of the assessment, she had not had a drink in 5 years. Emma was married for a second time 10 years ago, and 4 years thereafter, her husband died of cancer. Although she found this to be extremely upsetting, she did not become depressed after his death. Within a year, she was dating again and felt that her grief had resolved. With regard to history, Emma acknowledged that her mother was affectively unstable (possibly borderline). Emma recalled never quite knowing which of her “mothers” she would find at home and trying to alter her own behavior to gain her mother’s approval. Emma’s recent episode of depression was related to a relationship. She had been seeing a man named Mark for close to a year. Although she found, initially, that he was “dynamic, bright, and challenging,” another side of him emerged over the course of the first months of the relationship. She found that he became controlling and angry when she did not do as he wished and was manipulative much of the time. Emma described ambivalence about the relationship, acknowledging that he was not a “healthy choice” for her and that his



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behavior was not acceptable. Nonetheless, she was reluctant to end the relationship, fearing she would be lonely and have regrets. When asked to describe specific events that she experienced as difficult and distressing, she described a recent incident with Mark. She was returning his phone call when he began to berate her for taking too long to get back to him. She felt extremely hurt and sad, and she wondered what she had done wrong and whether there was any hope for making things right. When they met up again, she decided to wear an outfit that he had given her as a gift even though it was not to her taste. At that date, he criticized her for wearing something she was not confident about and insisted that she change outfits. Partial Initial Formulation According to J. S. Beck’s model, two important factors to identify would be Emma’s conditional beliefs and her core beliefs. From the above description, we might hypothesize that Emma has conditional beliefs such as “If someone important to me is mad at me, I must have done something wrong” and, conversely, “If I do everything right, I will be loved.” The therapist might also hypothesize that Emma’s core beliefs relate to her own inadequacy or inherent flawedness and to the importance of pleasing others. The clinician might also be on the lookout for core beliefs related to Emma’s history of alcohol use disorder, such as “I can’t cope with negative emotions on my own” or “Bad feelings are unbearable.” These are but two aspects of the case formulation, and it is important to note that they are just hypotheses on the part of the clinician. As Emma shares more about her history and her distress, the therapist may adjust these hypotheses on their own, perhaps in response to data gained through cognitive restructuring. At some point the hypothesized beliefs should be shared with Emma for her feedback. If they appear to be accurate and relevant, the beliefs should be targeted in treatment, through, for example, discussions of the basis of individuals’ worth (perhaps using Socratic questioning) and examination of evidence for her inability to cope effectively. Comparison of Models All of these models have something to offer; indeed, the work on formulation (much like in a therapy case) is unlikely to be “finished” in some perfected way. Each has interesting aspects; for example, J. S. Beck’s model is particularly “diagrammatic” in its form, and the Kuyken model specifically highlights strengths. Indeed, much more could be written comparing each of these approaches, particularly their differences. However, in this chapter we focus more on the “generic” cognitive behavioral formulation rather than analyze subtleties. These approaches have a great deal in common. Each is structured, directive, and diagrammatic, especially as compared with the conceptualization frameworks of other theoretical orientations. In practice, cognitive behavioral therapists may use eclectic and less formal approaches to formulation, based on

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concepts from the models reviewed here and, perhaps, those of other theoretical perspectives. Just how common it is for cognitive behavioral therapists to use formulation is difficult to ascertain, given the diversity of formulation methods, health disciplines, settings, and patient populations. In addition, of course, there are multiple cognitive formulation models, and none has been demonstrated to be superior to the others. Indeed, data are lacking as to the costs and benefits of engaging in a formal and structured case formulation process, and without such data, it may be difficult to justify the time required to do so. Therefore, clinicians may be more likely to choose less formal approaches to formulation, prioritizing efficiency and relying in part on clinical judgement. It seems as though formulation tends to be taught later in training, perhaps as an “advanced” aspect of CBT. In addition, instruction in formulation also seems to emphasize challenging cases. Research data about practitioners’ training would be particularly meaningful if we consider that case formulation, despite the proliferation of various manuals and methods, is a core skill in psychotherapy that relies largely on a clinician’s judgment (Kendjelic & Eells, 2007). Zivor et al. (2013) considered not only the impact of training for case formulation for a specific anxiety disorder (obsessive-compulsive disorder [OCD]) but also the relation between the level of expertise in case formulation and the perception of self-competence in clinicians. The study confirmed other results according to which clinicians tend to overestimate their competence. In particular, less competent clinicians in case formulation are also less able to recognize the lower quality of their formulation. As observed by the authors, the perception of competency in CBT formulation tends to be lower than the perception of overall competency in CBT, confirming that formulation is indeed likely to be an advanced skill in CBT (Zivor et al., 2013). Another relevant gap in research relates to the investigation of which critical ingredients cognitive behavioral therapists consider important to conceptualization in CBT and what practices are implemented in their actual clinical practice. The training background might influence a therapist’s decision to endorse practices related to the consultation of theory or evidence-based practices relevant to the problems presented by the patient, as hypothesized by Huisman and Kangas (2018). These practices are rated as significantly more important by clinical psychologists and clinicians with more experience when compared with general psychologists. However, the authors noted that the level of experience did not seem to play a role in the implementation of these practices. Huisman and Kangas suggested that training programs should address the difficulties of less experienced clinicians in using external sources related to evidence-based practices in case formulation. Returning to the issue of patient complexity, the value of formal approaches to formulation may be particularly salient for cases that go beyond standard protocols. Arguably, the clearest marker of such complexity is comorbidity, where multiple diagnoses seem to apply and no single protocol or manual will offer a comprehensive treatment plan. Clinical experience would also tell us that not even multiple diagnostic categories applied to the same person, par-



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ticularly when there are personality factors and more acute symptoms, fully reflect what the person is struggling with or suggest clear treatment goals. In such cases, the cost-benefit analysis seems clearer: The benefits of better organizing the clinical information seem likely to outweigh the cost of the time needed to develop the formulation. In other words, “Three most important things for a difficult case? Formulate, formulate, formulate!” (origin unknown). Below, we examine this notion, specifically with respect to the context, content, and validity of cognitive formulation.

WHAT ARE THE ROLE AND FUNCTION OF CASE FORMULATION? Case formulation functions primarily as a way of mapping broad theories onto individual patients’ situations to inform the selection of treatment interventions. As such, it requires clinicians to remain up-to-date with respect to developments in cognitive theories, particularly as they relate to factors influencing the development and maintenance of psychological difficulties. This thorough understanding of current cognitive theory provides the foundation of a solid formulation. In addition, the capacity to conduct a thorough and culturally responsive assessment and to extrapolate critical information is essential to obtain a high-quality case formulation. Finally, a good formulation should inform treatment planning, grounded in empirically supported treatments, and point to important variables to be evaluated throughout treatment to evaluate treatment effectiveness. Thus, some of the main elements of a good quality case formulation—that is, to ensure both quality inputs and outputs—are • a thorough and current understanding of cognitive theory; • competent, comprehensive, and culturally responsive assessment, including (when possible) standardized scales; • implementation of evidence-based practices (i.e., empirically supported treatments for the relevant problems); • capacity to monitor the progression of treatment quantitatively and qualitatively and make adjustments as new information arises; and • the ultimate arbiter of success: the patient’s progress. Case formulation aims to provide substantial guidance as therapy progresses, when a higher effort is required for therapists in integrating the information to formulate more complex and comprehensive inferences. An evidence-based case formulation offers critical guidance in these cases through the integration of three major components in evidence-based practice in psychology: (a) research, (b) expertise, and (c) patient characteristics (Eells, 2016). Schulte and Eifert (2002) argued that therapists tend to deviate from manuals “too soon, too often, and occasionally for the wrong reason” (p. 312). A case formulation

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aligned to the criteria mentioned above might provide the necessary support for better clinical decision making, especially when decisions are required under time pressure and in situations where there is high uncertainty. Case formulation has many potential benefits, although research examining these benefits is in its infancy. Research supporting manualized CBT, on the other hand, is abundant (A. T. Beck & Dozois, 2011; Chambless & Ollendick, 2001; Leichsenring et al., 2006). This discrepancy could lead practitioners to question whether they should in fact engage in case formulation. Certainly, manuals can be applied without case formulation. We argue, however, that there are many strong theoretical reasons to use case formulation in the context of manualized treatments. First, a case formulation requires therapists to attend to the many factors that may contribute to the onset or maintenance of a patient’s difficulties, potentially yielding a richer and more comprehensive description and understanding of the presenting problems, for both therapist and patient. This enhanced understanding may result in a stronger therapeutic relationship, based on a shared understanding and on increased therapist empathy for the patient. A comprehensive, systematic formulation that sheds light on key factors contributing to a patient’s difficulties and considers them within the patient’s cultural context(s) also helps guide the therapist toward interventions that address these factors. In addition, when difficult situations arise that are not accounted for by a manualized treatment, case formulation can help a therapist determine how to proceed. Formulation should, ideally, help the therapist understand the obstacles and challenges that occur in treatment and suggest alternative approaches for navigating these situations. Treatment protocols generally specify what the therapist should do in treatment; formulation can help predict or understand how the patient might react to these interventions. One of the most common situations that clinicians face that is not always addressed by treatment protocols is comorbidity. Often patients have more than one presenting problem, and therapists need to determine how best to address each, choosing interventions to address one problem or another or perhaps addressing multiple problems at once. Formulation can inform these decisions, identifying which problems may be most pressing and which factors may contribute to the most significant difficulties. Case formulation can be helpful in organizing a team of treatment providers. The formulation may help clarify overall goals of treatment and the role of each treatment provider in addressing these goals. Having a formulation may help providers collaborate more effectively, avoid redundancy, and ensure that their interventions are consistent or, at least, not working in contradictory ways. Case formulation may be of particular value when there is no empirically supported treatment available for the patient’s disorder or when the problem is not a diagnosable disorder (e.g., perfectionism). In such cases, formulation can help guide treatment decisions. Indeed, even when a manualized treatment does exist, therapists need to make many clinical decisions throughout treatment. For example, although sets of dysfunctional cognitions have been identi-



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fied for many psychological disorders, determining just which thoughts are present and which are causing the most problems for a given patient remains up to the clinician and patient to determine. Case formulation may help address these questions. Formulation may also help clinicians understand reasons for nonadherence to treatment. In some cases, formulation may help clinicians predict when nonadherence is likely and may even help clinicians to avoid that outcome— perhaps because it prioritizes the particular patient over a particular protocol (Persons, 2008). A culturally responsive formulation may help the therapist realize when a treatment developed on or for one type of patient of one particular background may not be appropriate to apply to a member of a different group. Finally, case formulation can help clinicians choose an alternative intervention if a given protocol is not resulting in the desired outcomes. In summary, case formulations can complement treatment manuals by filling in the framework provided by the manual and guiding the decisions clinicians must make when tailoring the treatment to a given patient. Ultimately, a case formulation approach to treatment should lead to enhanced outcomes for patients. Case formulation can be conceptualized as existing on a continuum: At one end of the spectrum is an entirely nomothetic approach, where the same treatment protocol would be used for all patients, and at the other, a tailored approach. In some straightforward cases, a manual on its own may be sufficient to deliver high-quality CBT. Some relatively straightforward problems can be addressed with a highly structured, standardized treatment, and some group interventions are highly manualized, following a set “curriculum.” Such interventions do not tend to require formal case conceptualization, and overall, group interventions in CBT have a solid evidence base (Bieling et al., 2009). However, as argued previously, even when using a manualized treatment, there is a role for case formulation in guiding decisions, whether such formulation is formal or not. Clinicians tend to anticipate how patients might react, in terms of cognitions and behaviors, to different interventions or what they might present in a given session, and the ability to make these predictions suggests that the clinician holds at least an implicit formulation. In a way, explicit case formulation is just a more formal version of what clinicians are already doing, and it stands to reason that formalizing this process might result in more efficient treatment, improved therapeutic alliances, and improved adherence to treatment. Similarly, it follows logically that case formulation would be increasingly useful as the complexity of a case increases. This question is, of course, an empirical one, and to date we do not have the data to support the claim. Indeed, research on the dissemination of CBT suggests that manualized CBT treatments can be delivered effectively by community therapists who, theoretically, have less experience with CBT case formulation, whether implicit or formal. However, inferences about the utility of case formulation from this research are indirect at best; research is needed that directly evaluates the utility of CBT case formulation, especially in complex cases. Such research would need to

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consider a variety of different patient populations and settings and a variety of CBT formulation approaches.

OPTIMIZING CASE FORMULATION THROUGH ASSESSMENT As previously noted, there are several components that compose a case formulation, which correspond to these tasks for therapists2: 1. Create a problem list. 2. Generate hypotheses about causal mechanisms. 3. Uncover the origins and precipitants of mechanisms. 4. Connect hypotheses and inferences in one cohesive explanation of the patient’s problems. 5. Determine implications for treatment and continue to refine the formulation over the course of treatment. Each of these components can be approached in a variety of ways, as discussed below. Developing a Problem List The problem list should be comprehensive. Symptoms from Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition [DSM-5]; American Psychiatric Association, 2013) diagnoses should certainly be included, but a case formulation should go beyond symptoms and consider multiple domains, including interpersonal functioning, medical problems, and access to treatment, among other factors. The problem list should be tailored to the individual patient and should take into consideration the patient’s cultural identities. Clinical interviews may be used to arrive at a diagnosis that is derived from the DSM-5 or International Classification of Diseases (ICD); other measures should assess cultural factors, quality of life, and the patient’s functioning more broadly. Finally, and in keeping with the scientific approach inherent in CBT, objective, specific symptom measures for known problems should be used. The selection of such assessment tools should be driven by the patient’s presenting problems. Therapists should search the literature periodically for reliable and valid psychometric tools to aid in formulation and may also be guided by other resources and compilations of measures (e.g., Antony & Barlow, 2011; Antony et al., 2001; Corcoran & Fischer, 2013; Hunsley & Mash, 2018; Nezu et al., 2000). Seeking information in these ways allows therapists to develop hypotheses based on objective information and helps them become aware of disconfirming evidence. Clinical psychologists will likely be comfortable using such tools, although members of other professional groups may not feel as comfortable. List inspired by Bieling and Kuyken (2003).

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Nonetheless, CBT has such a strong tradition of objective assessment that using reliable and valid measures remains an important gold standard to which the field, as a whole, should be committed. In that spirit, we would suggest using structured clinical interviews such as the Structured Clinical Interview for DSM Diagnosis (SCID; First, 1997, 2014) and the Mini-International Neuropsychiatric Interview (MINI; Rogers et al., 2009; Sheehan et al., 1998, 2010) to at least aid in developing the problem list at a sophisticated level. The patient’s cultural context(s) should be explicitly assessed, perhaps using the Cultural Formulation Interview for DSM-5 (American Psychiatric Association, 2013); the Culturally Informed Functional Assessment (Tanaka-Matsumi et al., 1996), which provides guidance specifically for culturally informed cognitive behavioral assessment; or the Jones Intentional Multicultural Interview Schedule (Jones, 2009), which assesses the constructs in the ADDRESSING framework (Hays, 2008): age/generational influences, developmental or other disability, religion and spiritual orientation, ethnic and racial identity, socioeconomic status, sexual orientation, Indigenous heritage, national origin, and gender. In addition, we recommend tools that assess functional impairments and broad symptom inventories to help understand what is the “most” important issue (presumably individual scales with the highest scores), as well as to what extent, and how these difficulties compare with norms in the population. For this we suggest the Short Form 36 (SF-36) Health Survey Version 2 (Ware et al., 2000) and the Symptom Checklist-90-Revised (Derogatis & Unger, 2010). Self-report measures for specific symptoms might include the Beck Depression Inventory–II (A. T. Beck et al., 1996) and the Penn State Worry Questionnaire (Meyer et al., 1990; Zlomke, 2009), as appropriate to the patient’s problem areas. In addition (and with the patient’s permission), reports from other health care providers and collateral information from sources, such as family members, can be extremely valuable, particularly in more complex cases. Clinicians should take care to consider the impact that culture might have on patients’ reactions to information gleaned from any of these sources. Reinforcing an observation made previously, much of the assessment strategy will be determined by the patient’s presenting problems, so in addition to any “omnibus” measures, specific symptoms might require modifications to the instruments used. As important as such objective measures are, they should always be accompanied by patient-centered questions about what patients are struggling with the most; what outcomes would reflect success in therapy; and what changes they seek in themselves, their situations, or their lives. A patient’s cultural contexts and identities should be considered throughout the formulation and treatment processes and are perhaps especially important here. Issues that are brought up in both the answers to these more open-ended questions and the data from the objective measurement tools are likely the most important areas be addressed (see Haynes et al., 2009, for a step-by-step guide to the development and evaluation of idiographic assessment tools).

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Developing Mechanism Hypotheses One of the most useful and important aspects of case formulation is the generation of hypotheses about psychological, biological, and/or sociocultural mechanisms that may be causing or maintaining the problems on the patient’s problem list. Strategies for developing these hypotheses include (a) referring to a theory associated with a specific disorder and an empirically supported treatment or (b) referring to a broader psychological theory (e.g., learning theory or the cognitive model; Persons, 2008). Either way, the therapist starts with the theory that fits the patient and their problems the best and then seeks information about how this theory may apply to the individual patient. In the context of cognitive case formulation, the assessment should address the patient’s automatic thoughts, underlying assumptions, and core beliefs. The theory chosen may inform which exact tools are used in this assessment process, and, again, there is likely to be a combination of “objective” tools and clinical inferences made by the practitioner. Two commonly used self-report scales that may be useful in generating hypotheses about cognitive mechanisms are the Dysfunctional Attitudes Scale (Weissman, 1979a, 1979b) and the Young Schema Questionnaire – Short Form (Young & Brown, 1998), followed by a more recent version, the Young Schema Questionnaire – Short Form 3 (Young, 2005). These measures aim to (a) examine a level of cognition that is “deeper” than inventories that measure negative thoughts and (b) give some insight into the patient’s likely problematic beliefs. Of course, it is also true that such beliefs are highly idiosyncratic, as it is far easier to assess and map out symptoms and functional impairments of an anxiety or mood disorder than it is to objectively assess the beliefs that give rise to such difficulties. Therefore, it is often helpful to probe for unhelpful thoughts in stressful situations and/or beliefs about the self, the world, and others. Further information about potential cognitive mechanisms may also be gleaned by having patients self-monitor their thoughts and behaviors. Uncovering Origins and Precipitants of Potential Mechanisms Next, the therapist attempts to determine where the patient learned or acquired the mechanisms that may have caused their symptoms as well as any recent stressors that may have activated their current problems. Information regarding the distal causes of the patient’s problems often comes from a clinical interview and any historical information available, such as the patient’s descriptions of their early upbringing, their relationships with caretakers, any significant childhood events (e.g., trauma, neglect), and family history of psychiatric illness. Here again, cultural considerations are critical, including understanding how psychiatric illness is understood in the patient’s culture(s). The clinician’s task here is to relate the patient’s presenting problems to their early life experiences, taking care that the interview does not become overwhelming. Therefore, the interview should not comprise a complete biographical overview but rather should focus on particular people, experiences, and cultural influences



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that led the patient to interpret their experiences in a way that might contribute to their current problems. Objective measures are less likely to be useful for gathering this kind of historical information, and a great deal of clinical discernment is called for. A clinical interview is also the main source of information about the proximal precipitants of a patient’s current problems; indeed, most clinicians ask patients about recent stressors during an initial assessment. In addition, a survey that lists common stressful life events may help identify precipitants. Often, precipitating life events are particularly relevant to a patient’s maladaptive beliefs (e.g., job loss for a patient who believes that they are worthless). The events identified as the main cause of the problem or difficulty can be analyzed along two dimensions: qualitative and quantitative (Kuyken & Dudley, 2013). In particular, focusing on the qualitative dimension provides the therapist an opportunity to consider the personal meaning of the event, thereby addressing the individual’s particular vulnerability to stress. This is probably one of the most important aspects of case formulation, and it provides a contrast between the formulation process and the diagnostic process, making explicit that human suffering is an individual comprehensible response to intolerable circumstances.

Developing a Cohesive Explanation, Determining Treatment Implications, and Continuing to Refine the Formulation The process of connecting these hypotheses and inferences in one cohesive explanation—and of determining treatment implications—requires the therapist to integrate the information collected with cognitive behavioral theories and evidence-based treatments. One note of caution: Although multiple sources of information are valuable, and we would recommend at least some reliable and valid assessment tools be used in most formulation work, the use of too many such measures can have its own unintended consequences. First using a very large battery of measures can produce enough variables that integration with more subjective patient reports becomes a challenge, especially when measures produce inconsistent results. Second, in some settings, a series of scores on inventories can too easily become a substitute for true formulation, which requires the patient’s real-world experiences and problems to be considered. Once the initial formulation is drafted, a critical step is discussion with the patient, both to educate and to receive feedback on the formulation. In this discussion, it is important to keep the patient’s cultural values and perspectives in mind, as well as the therapist’s cultural vantage point and potential biases, as these may lead to gaps in understanding of the patient’s problems and experiences. Over the course of treatment, self-report measures of symptoms may be used for assessment but are also no substitute for qualitative feedback from the patient. Other sources of information include patient self-monitoring of daily activities, responses to exposure practice, and subjective ratings of distress. Sources of feedback such as these not only monitor treatment progress but also

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provide continuing evidence for (or against) the hypothesized mechanisms of the patient’s problems. The formulation should thus be continually revisited to incorporate this new information, revising hypotheses as appropriate. In addition, therapists may opt to evaluate cognitive vulnerabilities and other hypotheses directly and explicitly to enhance these aspects of the formulation and to guide, in an ongoing way, the selection of appropriate interventions, ultimately leading to more effective treatment.

RESEARCH EVIDENCE FOR THE UTILITY OF CASE FORMULATION Case formulation, across theoretical orientations, is believed to be beneficial (e.g., Binder, 2004; Hersen & Porzelius, 2002), but there is limited research supporting these claims (Eells et al., 2011). In considering the utility of cognitive case formulation, we should evaluate the formulations’ reliability and validity, in addition to their potential impact on treatment (Bieling & Kuyken, 2003). Below we review some of the research that has been conducted. Reliability and Validity of Case Formulation Reliability for some aspects of the case formulation may be higher than for others. For example, it appears that clinicians are more likely to agree on the more concrete aspects of the formulation (e.g., the problem list) than on the more hypothetical aspects (e.g., underlying beliefs; Bieling & Kuyken, 2003). In addition, on the basis of the limited research available, it seems that both the reliability (Kuyken et al., 2005) and the quality of case formulation may increase with training (Kendjelic & Eells, 2007). In order to evaluate the quality of case formulation, Kuyken et al. (2005) used a rating scale previously developed to specifically address this aspect: the Quality of Cognitive Case Formulation Rating Scale (Fothergill & Kuyken, 2002). The reliability of case formulation was assessed with a different method, examining the percentage of agreement among participants (Kuyken et al., 2005). Kendjelic and Eells (2007) utilized the Case Formulation Content Coding Method (CFCCM; Eells et al., 1995, 1998, 2005) to code the formulations and rate their quality by using specific scales embedded in the instrument. Measures of quality are assessed through different Likert-type scales from 1 to 5, addressing the overall quality as well as other constructs, such as complexity and degree of inference. It may also be the case that expert therapists develop formulations of higher quality (Eells et al., 2011), which is consistent with the idea that more training may improve formulation. As reported by Eells et al. (2005), experts produced formulations that were more comprehensive, better elaborated, more precise in terms of language articulation and specificity, more complex and coherent, and more likely to be characterized by the inclusion of a systematic formulation process, as compared with nonexperts. Experts’ formulations also showed better goodness of fit to the treatment plan. It is difficult to evaluate the validity of



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case formulations with respect to the accuracy of the inferences contained in it; without any information about the “true” mechanisms and causes of patients’ problems, some types of validity, in particular, are hard to assess. One proposed method for validating case formulations emphasizes the importance of understanding the patient’s idiosyncratic cognitive schema (ICS), a construct used to explain the way in which assumptions, attitudes, and beliefs contribute to the generation of automatic thoughts (Mumma, 2004). During the first stage, a dynamic factor analysis is used to test the convergent and discriminant validity of the ICS. In the second stage, these hypotheses about beliefs are tested on their ability to predict symptoms and distress. Moreover, during this second stage, convergent and discriminant validity are further examined, “assessing structural relationships between the daily ICS scores and the daily scores of theoretically (or conceptually) important constructs (the psychological distress scales)” (Mumma, 2004, p. 241). This approach is intended to address the problem of assessing convergent and discriminant validity of both idiographic measures and case formulations in a variety of frameworks, including the cognitive framework (Mumma, 2004). This method, however, requires a fair amount of time and labor on the part of both the assessor and the patient, who provides large amounts of data. As previously mentioned, case formulation is subject to continuous change over time, typically moving from a descriptive level toward a more complex explanatory level. Reliability of the formulation is negatively affected by the increase of complexity related to the inference process, in which a therapist theorizes the mechanisms involved (Kuyken et al., 2008). It is not surprising that providers would tend to agree more on observable self-reported problems and somewhat less on the underlying processes that led to the problems. In general, the existing research suggests that therapist training and experience may increase the reliability and validity of case formulation. It is unclear, however, whether the reliability and validity of cognitive case formulation approaches are acceptable at present. A formulation is valid if it represents the person’s particular presenting problems and underlying cognitions accurately and completely and if it provides guideposts for treatment. Testing this in a practical, empirical way is a challenge. However, we would suggest that formulation could be considered to have at least some predictive validity if it were shown to be associated with improvements in outcome, and we review this literature next. Effects of Case Formulation on Treatment Outcome Although it is theoretically possible to evaluate the impact of case formulation on treatment outcomes, research doing so is scant. One such study looked at formulation-guided CBT as compared with manual-based CBT in the treatment of 50 patients with bulimia (Ghaderi, 2006). Logical functional analysis (Hayes & Follette, 1992) was used to develop formulation and treatment. Logical functional analysis considers four dimensions: (a) inadequate antecedent stimulus

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control, (b) inadequate consequential control, (c) inadequate motivational conditions, and (d) restricted repertoire of behaviors. The manual-based condition used a manualized cognitive behavioral treatment for bulimia nervosa (Fairburn et al., 1993). Duration and frequency of sessions were matched across conditions. Both groups showed improvements at end of treatment that were sustained at 6-month follow-up, though participants in the formulationguided intervention showed greater improvements on some outcomes. Of those who were categorized as treatment nonresponders, most (80%) were in the manual-based treatment condition. These results suggest that individualizing treatment may have benefits for patients, although clearly more research is needed. Whether or not individualized case formulation has substantial benefits for treatment may be complicated. For one, treatment outcomes are multidetermined. In addition, any effects of formulation on treatment outcome may be moderated by patient characteristics such that more complex cases are associated with greater benefits. There is some evidence that patients with multiple comorbidities may benefit from empirically supported interventions guided by case formulation (Persons et al., 2006). Unfortunately, this study did not include a comparison group that did not receive treatment guided by case formulation, so the implications are limited. Nattrass et al. (2015) argued that most of the research investigating the effectiveness of case formulation focused on randomized control trials (RCTs) comparing the outcomes of CBT treatments delivered with and without patient-centered case formulation, finding that “CBT with patient-centered case formulation is no different or only marginally better” (Nattrass et al., 2015, p. 591). One study evaluated the effectiveness of individualized case formulation-based CBT in a sample of youths (9–17 years old) suffering from anxiety disorders (and their parents) who did not respond to group treatment based on manualized CBT (Lundkvist-Houndoumadi et al., 2016). In this study, 57% of the sample responded to the individualized case-formulation-based CBT, and the percentage increased to 79% after a 3-month follow-up. The response to treatment was assessed using the Clinical Global Impression-Improvement Scale (CGI-I; Guy, 1976), a 7-point Likert-type scale commonly used in clinical trials to study the response to treatment. The stability of the results was confirmed at 1-year follow-up, according to the authors, with significant improvements related to self-reported anxiety and life interference. However, this study, too, lacked a control group. Esbjørn et al. (2015) studied the impact of case-formulation-driven CBT on 54 children (7–12 years old) with anxiety disorders. Both treatments in the study were rooted in a formulation approach and included both parents and children; they were found to have a similar impact to manualized CBT treatments based on meta-analyses. Another study investigated the content, quality, and impact of case formulation treating a group of 29 patients with OCD (Nattrass et al., 2015). The authors concluded that formulation, routinely implemented in the early stages of the OCD treatment, had a significant impact on



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reducing patients’ OCD symptoms and psychological distress and on improving therapeutic alliance during the postformulation phase. The authors adopted three measures: the Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman et al., 1989), the Clinical Outcomes in Routine Evaluation–Short Form (CORE-SF; Evans et al., 2002), and the Agnew-Davies Relationship Measure (ARM-12; Cahill et al., 2012). Content and quality of case formulation were assessed using the Case Formulation Content Coding Manual Version 2 (CFCCM v2; Eells et al., 1998). No significant association between quality and outcome was found. However, an important limitation of this study is represented by the lack of a control group (Nattrass et al., 2015). Although this work suggests that case formulation has an impact in the early phases of treatment, the mechanisms underlying the improvements remain poorly defined and understood. Finally, a recent review on CBT case conceptualization concludes that its utility “has yet to be empirically demonstrated,” clarifying whether it directly or indirectly enhances treatment outcomes and the mechanisms involved (Easden & Kazantzis, 2018, p. 26). The effectiveness of case-formulation-driven CBT is comparable to that of single-diagnosis protocols and can be considered as a well-​grounded option to the latter (Waltman & Sokol, 2017). It remains possible that future research will find greater benefits of individualized cognitive case formulation for patients with complex problems as compared with simpler cases. There remain many unanswered questions about the reliability, validity, and utility of cognitive case formulation. Increased training and experience may yield better case formulations, providing “more descriptive, diagnostic, inferential, and treatment planning information” (Eells et al., 2011, p. 349). There are not, however, sufficient studies to suggest that a specific type of training or a particular approach to case formulation leads to higher reliability and validity. More research is needed to compare case-formulation approaches with respect to their feasibility, in terms of training and time required by the clinician; their reliability and validity; and their effects on treatment outcomes. In addition, more RCTs comparing individualized, formulation-based treatment to standard manual-based treatment could yield important information. Based on prior research, therapist expertise and skill in case formulation may be important variables to consider (Eells et al., 2011) when evaluating the utility of case formulation in treatment outcomes. Patient characteristics (in particular, case complexity) may be important to assess as well. The notion that the case formulation may be more valuable as case complexity increases is an interesting one. It may well be that for cases that are more routine, the nomothetic guide from a protocol that was likely developed for such cases provides sufficient grounding and actually fits the patient rather well. However, as complexity and comorbidity rise, it stands to reason that “off-the-shelf” protocols simply are not as valuable as a guide and that it is well worth producing a truly individualized formulation that fits this particular person, with these particular problems, and at this particular time. Assuming that future studies support the utility of case formulation in general, next steps should include dismantling studies, to determine which aspects

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of case formulation are the “active ingredients.” For example, is it a comprehensive problem list that is the most essential part of the formulation, or are the hypothesized mechanisms that maintain the problems a key component? Ideally, future research will establish (a) what sorts of training and/or experience are necessary to generate reliable and valid cognitive case formulations, (b) which approach to case formulation or which components of the approach lead to enhanced treatment outcomes, and (c) for whom these approaches are beneficial.

CASE FORMULATION AND NEWER COGNITIVE BEHAVIORAL INTERVENTIONS It stands to reason that, as CBT evolves, the role of case formulation may also change. Recent developments in CBT include low-intensity CBT, transdiagnostic approaches, and mindfulness-based treatments. We consider these in turn. Low-Intensity CBT Low-intensity CBT holds promise for increasing access to care. Although there is no agreed-upon standard definition of a low-intensity intervention, a unifying element is that low-intensity treatments ought to require substantially fewer clinical resources compared with conventional psychological therapies (National Collaborating Centre for Mental Health, 2011). Low-intensity CBT can take several forms, including guided use of patient manuals, online CBT, and large-group CBT. These interventions all require less therapist time for each patient and less emphasis on individualized case formulation; they, therefore, generally take a nomothetic approach. Given the therapist’s decreased role, patients must themselves figure out how the CBT model and associated interventions apply to them and their situations. Patients may essentially create their own informal case formulations of their problems, or they may just use the strategies suggested without seeking to understand the rationale for doing so. It seems likely that many patients would gain a deeper understanding of the factors that contribute to their difficulties. Consistent with the moderation model posited above, these low-intensity approaches may be largely sufficient for patients with less complex problems, whereas an approach that allows for individualized case conceptualization by a therapist may better serve patients with multiple or more severe difficulties. Transdiagnostic Interventions As the name suggests, transdiagnostic interventions, such as the unified protocol for the treatment of emotional disorders (Barlow et al., 2011), de-emphasize diagnosis in selecting treatment interventions, as compared with treatments that are geared toward one particular mental health disorder. Indeed, varia-



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tions in symptoms across disorders are considered to be “relatively trivial” (Barlow et al., 2011, p. 15). The transdiagnostic approach makes use of treatment modules that can be selected based on patients’ particular presentations. Therefore, clinical decision making is key, suggesting an important role for individualized case conceptualization. Formulation in a transdiagnostic framework should be used to identify specific presenting problems and symptoms, cognitive mechanisms, and distal causes; indeed, it could be argued that absent a clear primary diagnosis, even more emphasis should be placed on understanding each individual in their unique context. Mindfulness-Based Interventions Interventions that incorporate mindfulness have become increasingly popular in recent years, and research on them has proliferated as well. These approaches include mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT). Case formulations for mindfulness-based approaches share several components, but each also reflects different hypotheses about mechanisms, based on the theoretical underpinnings of the specific approach. For example, MBCT is based on a model that posits an increased cognitive vulnerability to depression relapse or recurrence as more episodes are experienced (Lau et al., 2004; Teasdale, 1988). According to this model, case formulation of a patient with recurrent depression would consider the patient’s awareness of patterns of negative thoughts as factors that might contribute to the development of current and future depressive episodes. In contrast, a traditional cognitive case formulation would focus on the content of thinking patterns, which suggest underlying negative core beliefs. Therefore, treatment from a traditional CBT perspective focuses on modifying the content of these negative thoughts whereas treatment from an MBCT perspective would seek to help the patient develop a new relationship with these thought patterns. One element of MBCT involves helping patients develop a plan for preventing relapse and maintaining wellness. This plan incorporates several aspects of formulation, including the kinds of thoughts and beliefs that might be triggered in the future. Another difference between traditional CBT approaches and mindfulness-based approaches to formulation is the emphasis that mindfulness-based interventions place on identifying patient strengths as well as vulnerabilities, whereas traditional cognitive formulation tends to focus more on difficulties and relatively less on strengths. Finally, when mindfulness-based treatment takes place in a group format, the therapist’s role in case formulation may be less important, and patients may be encouraged to seek a deeper understanding of the factors that contribute to their difficulties themselves. The emphases of case formulation within newer cognitive behavioral treatments may vary depending on the theoretical basis of the specific intervention, and the importance of formulation may likewise vary, depending on how much

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emphasis is placed on tailoring treatment to individual patients in the given approach. It seems likely, however, that most interventions derived from a CBT framework will always retain, in one sense or another, the notion of presenting problems and symptoms, underlying cognitive mechanisms, and distal causes that give rise to both.

FUTURE DIRECTIONS FOR CASE FORMULATION AND RESEARCH Interest in formulation in CBT continues to grow, and the topic of formulation has been taken up not only by individual authors but also by larger bodies representing professional groups. For example, in 2011, the Division of Clinical Psychology of the British Psychological Society published a document, Good Practice Guidelines on the Use of Psychological Formulation, that reviews definitions, contexts, skills, and implications of formulation. It also, interestingly, contains explicit and implicit messages about the role of formulation in the profession of psychology; in particular, it describes many unknowns in the evidence base and concludes that formulation is an advanced, critical skill. Such “position papers” encapsulate the fascinating dilemmas for formulation, which we enumerate as follows in a series of paradoxes: • Formulation is critical to psychotherapy but is variably defined and practiced. • There is enormous potential for formulation to benefit therapy and outcomes, but we have great difficulty “proving” this. • Formulation is done best by “advanced” practitioners, but the pathway toward becoming expert is not clear. We take no issue with any of these paradoxes, as they do reflect the state of the field at this time. What is needed to move on is described in the following simple (we hope) ideas: • We need to get a clearer picture of everyday use of case formulation by therapists in practice, including what methods and models are most frequently used, how much time is devoted to formulation, and so on. • More research is needed on the reliability and validity of case formulation and of its components, within and across approaches to formulation. In addition, research is needed to identify the types of clinician training and experience necessary to meet this standard. • Dismantling studies on the efficacy of case formulation are needed. Such studies should evaluate the relative contributions of the various components of case formulation. • Ideally, and especially if we could establish the three things above, RCTs comparing standard manualized treatment to individualized, formulation-based treatment are needed. These studies should consider therapist characteristics



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(such as experience or training in case formulation) as well as patient characteristics (such as level of case complexity) as possible moderator variables. • Finally, research conducting cost-benefit analyses of case formulation would be very useful. How much time is necessary for a therapist to create a helpful case formulation (including training, experience, and time spent constructing an individual formulation)? How does that amount of time compare to the magnitude of benefit to the patient, in terms of, for example, the degree of symptom improvement, the number of sessions needed to achieve desired outcomes, or longer term health outcomes? This research should be conducted in a wide variety of cultural groups and with attention to cultural considerations to determine whether implications are different for different groups and whether cultural adaptations to the formulation process are warranted. It may be that this “plan” is not particularly feasible; such points are easy to write and harder to execute. We posit that formulation (in CBT and elsewhere) remains one of the central topics for clinical psychology and that the questions raised by it (more than answered by it) are both fascinating and important.

REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Antony, M. M., & Barlow, D. H. (2011). Handbook of assessment and treatment planning for psychological disorders. Guilford Press. Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.). (2001). Practitioner’s guide to empirically based measures of anxiety. Springer Science & Business Media. https://doi. org/10.1007/b108176 Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press. Beck, A. T., & Dozois, D. J. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62(1), 397–409. https://doi.org/10.1146/annurevmed-052209-100032 Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory– II (2nd ed.). Psychological Corporation; Harcourt Brace. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Bieling, P. J., & Kuyken, W. (2003). Is cognitive case formulation science or science fiction? Clinical Psychology: Science and Practice, 10(1), 52–69. https://doi.org/10.1093/ clipsy.10.1.52 Bieling, P. J., McCabe, R. E., & Antony, M. M. (2009). Cognitive-behavioral therapy in groups. Guilford Press. Binder, J. L. (2004). Key competencies in brief dynamic psychotherapy: Clinical practice beyond the manual. Guilford Press. Cahill, J., Stiles, W. B., Barkham, M., Hardy, G. E., Stone, G., Agnew-Davies, R., & Unsworth, G. (2012). Two short forms of the Agnew Relationship Measure: The ARM-5 and ARM-12. Psychotherapy Research, 22(3), 241–255. https://doi.org/10. 1080/10503307.2011.643253

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Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. https://doi.org/10.1146/annurev.psych.52.1.685 Corcoran, K., & Fischer, J. (2013). Measures for clinical practice and research: Vol. 1. Couples, families, and children. Oxford University Press. Derogatis, L. R., & Unger, R. (2010). Symptom Checklist-90-Revised. In The Corsini encyclopedia of psychology. https://doi.org/10.1002/9780470479216.corpsy0970 Easden, M. H., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Journal of Clinical Psychology, 74(3), 356–384. https://doi.org/10.1002/jclp.22516 Eells, T. D. (2007). History and current status of psychotherapy case formulation. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., pp. 3–32). Guilford Press. Eells, T. D. (2016). Psychotherapy case formulation. American Psychological Association. Eells, T. D., Kendjelic, E., & Lucas, C. (1995). Case formulation content coding manual [Unpublished manuscript]. Eells, T. D., Kendjelic, E. M., & Lucas, C. P. (1998). What’s in a case formulation? Development and use of a content coding manual. Journal of Psychotherapy Practice and Research, 7(2), 144–153. Eells, T. D., Lombart, K. G., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The quality of psychotherapy case formulations: A comparison of expert, experienced, and novice cognitive-behavioral and psychodynamic therapists. Journal of Consulting and Clinical Psychology, 73(4), 579–589. https://doi.org/10.1037/0022-006X.73.4.579 Eells, T. D., Lombart, K. G., Salsman, N., Kendjelic, E. M., Schneiderman, C. T., & Lucas, C. P. (2011). Expert reasoning in psychotherapy case formulation. Psychotherapy Research, 21(4), 385–399. https://doi.org/10.1080/10503307.2010.539284 Esbjørn, B. H., Reinholdt-Dunne, M. L., Nielsen, S. K., Smith, A. C., Breinholst, S., & Leth, I. (2015). Exploring the effect of case formulation driven CBT for children with anxiety disorders: A feasibility study. Behavioural and Cognitive Psychotherapy, 43(1), 20–30. https://doi.org/10.1017/S1352465813000702 Evans, C., Connell, J., Barkham, M., Margison, F., McGrath, G., Mellor-Clark, J., & Audin, K. (2002). Towards a standardised brief outcome measure: Psychometric properties and utility of the CORE-OM. British Journal of Psychiatry, 180(1), 51–60. https://doi.org/10.1192/bjp.180.1.51 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. First, M. B. (1997). Structured clinical interview for the DSM-IV Axis I disorders: SCID-I/P, Version 2.0. Biometrics Research Dept., New York State Psychiatric Institute. First, M. B. (2014). Structured Clinical Interview for the DSM (SCID). In The encyclopedia of clinical psychology. https://doi.org/10.1002/9781118625392.wbecp351 Fothergill, C., & Kuyken, W. (2002). The quality of cognitive case formulation rating scale [Unpublished manuscript]. Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy, 44(2), 273–288. https://doi.org/10.1016/j. brat.2005.02.004 Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011. https://doi.org/10.1001/archpsyc.1989.01810110048007



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Guy, W. (Ed.). (1976). ECDEU assessment manual for psychopharmacology (Rev. ed.). National Institute of Mental Health. Hayes, S. C., & Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behavioral Assessment, 14(3), 345–365. Haynes, S. N., Mumma, G. H., & Pinson, C. (2009). Idiographic assessment: Conceptual and psychometric foundations of individualized behavioral assessment. Clinical Psychology Review, 29(2), 179–191. https://doi.org/10.1016/j.cpr.2008.12.003 Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). American Psychological Association. Hersen, M., & Porzelius, L. K. (2002). Diagnosis, conceptualization, and treatment planning for adults: A step-by-step guide. Lawrence Erlbaum Associates Publishers. Huisman, P., & Kangas, M. (2018). Evidence-based practices in cognitive behaviour therapy (CBT) case formulation: What do practitioners believe is important, and what do they do? Behaviour Change, 35(1), 1–21. https://doi.org/10.1017/bec.2018.5 Hunsley, J., & Mash, E. J. (Eds.). (2018). A guide to assessments that work (2nd ed.). Oxford University Press. https://doi.org/10.1093/med-psych/9780190492243.001. 0001 Jones, J. M. (2009). Counseling with multicultural intentionality: The process of counseling and integrating client cultural variables. In J. M. Jones (Ed.), The psychology of multiculturalism in the schools: A primer for practice, training, and research (pp. 191–213). National Association of School Psychologists. Kendjelic, E. M., & Eells, T. D. (2007). Generic psychotherapy case formulation training improves formulation quality. Psychotherapy: Theory, Research, & Practice, 44(1), 66–77. https://doi.org/10.1037/0033-3204.44.1.66 Kuyken, W., & Dudley, R. (2013). Case formulation in cognitive behavioural therapy: A principle-driven approach. In L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of people’s problems (2nd ed., pp. 38–64). Routledge. Kuyken, W., Fothergill, C. D., Musa, M., & Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behaviour Research and Therapy, 43(9), 1187– 1201. https://doi.org/10.1016/j.brat.2004.08.007 Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https:// doi.org/10.1017/S1352465808004815 Lau, M. A., Segal, Z. V., & Williams, J. M. G. (2004). Teasdale’s differential activation hypothesis: Implications for mechanisms of depressive relapse and suicidal behaviour. Behaviour Research and Therapy, 42(9), 1001–1017. https://doi.org/10.1016/j. brat.2004.03.003 Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: Techniques, efficacy, and indications. American Journal of Psychotherapy, 60(3), 233–259. https://doi.org/10.1176/appi. psychotherapy.2006.60.3.233 Lundkvist-Houndoumadi, I., Thastum, M., & Hougaard, E. (2016). Effectiveness of an individualized case formulation-based CBT for non-responding youths with anxiety disorders. Journal of Child and Family Studies, 25(2), 503–517. https://doi.org/10. 1007/s10826-015-0225-4 Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28(6), 487–495. https://doi.org/10.1016/0005-7967(90)90135-6 Mumma, G. H. (2004). Validation of idiosyncratic cognitive schema in cognitive case formulations: An intraindividual idiographic approach. Psychological Assessment, 16(3), 211–230. https://doi.org/10.1037/1040-3590.16.3.211

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National Collaborating Centre for Mental Health. (2011). Common mental health disorders: Identification and pathways to care. British Psychological Society. Nattrass, A., Kellett, S., Hardy, G. E., & Ricketts, T. (2015). The content, quality and impact of cognitive behavioural case formulation during treatment of obsessive compulsive disorder. Behavioural and Cognitive Psychotherapy, 43(5), 590–601. https:// doi.org/10.1017/S135246581400006X Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2004). Cognitive-behavioral case formulation and treatment design: A problem-solving approach. Springer. Nezu, A. M., Ronan, G. F., Meadows, E. A., & McClure, K. S. (2000). Practitioner’s guide to empirically-based measures of depression. Springer Science & Business Media. Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press. Persons, J. B., Roberts, N. A., Zalecki, C. A., & Brechwald, W. A. (2006). Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients. Behaviour Research and Therapy, 44(7), 1041–1051. https://doi. org/10.1016/j.brat.2005.08.005 Rogers, G. M., Park, J.-H., Essex, M. J., Klein, M. H., Silva, S. G., Hoyle, R. H., Curry, J. F., Feeny, N. C., Kennard, B., Kratochvil, C. J., Pathak, S., Reinecke, M. A., Rosenberg, D. R., Weller, E. B., & March, J. S. (2009). The dysfunctional attitudes scale: Psychometric properties in depressed adolescents. Journal of Clinical Child and Adolescent Psychology, 38(6), 781–789. https://doi.org/10.1080/15374410903259007 Schulte, D., & Eifert, G. H. (2002). What to do when manuals fail? The dual model of psychotherapy. Clinical Psychology: Science and Practice, 9(3), 312–328. https://doi.org/ 10.1093/clipsy.9.3.312 Shadish, W. R. (1993). Critical multiplism: A research strategy and its attendant tactics. New Directions for Program Evaluation, 1993(60), 13–57. https://doi.org/10.1002/ev. 1660 Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22–33. Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., Milo, K. M., Stock, S. L., & Wilkinson, B. (2010). Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). Journal of Clinical Psychiatry, 71(3), 313–326. https://doi.org/10.4088/ JCP.09m05305whi Tanaka-Matsumi, J., Seiden, D. Y., & Lam, K. N. (1996). The Culturally Informed Functional Assessment (CIFA) Interview: A strategy for cross-cultural behavioral practice. Cognitive and Behavioral Practice, 3(2), 215–233. https://doi.org/10.1016/ S1077-7229(96)80015-0 Teasdale, J. D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2(3), 247–274. https://doi.org/10.1080/02699938808410927 Waltman, S. H., & Sokol, L. (2017). The generic model of cognitive behavioral therapy: A case conceptualization-driven approach. In S. G. Hofmann & G. J. G. Asmundson (Eds.), The science of cognitive behavioral therapy (pp. 3–17). Elsevier. https://doi.org/10. 1016/B978-0-12-803457-6.00001-5 Ware, J. E., Snow, K. K., & Kosinski, M. (2000). SF-36 Version 2 Health Survey: Manual and interpretation guide. Quality Metric Inc. Weissman, A. N. (1979a). Dysfunctional Attitude Scale (DAS). In J. Ciarrochi & L. Bilich (Compilers), Acceptance and commitment therapy. Measures package [Unpublished manuscript]. http://integrativehealthpartners.org/downloads/ACTmeasures. pdf



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Weissman, A. N. (1979b). The Dysfunctional Attitude Scale: A validation study [Doctoral dissertation, University of Pennsylvania]. ScholarlyCommons. http://repository. upenn.edu/edissertations/1182 Young, J. E. (2005). Young Schema Questionnaire – Short Form 3 (YSQ-S3). Cognitive Therapy Center. Young, J. E., & Brown, G. (1998). Young Schema Questionnaire: Short Form. Cognitive Therapy Center. Zivor, M., Salkovskis, P. M., Oldfield, V. B., & Kushnir, J. (2013). Formulation in cognitive behavior therapy for obsessive–compulsive disorder: Aligning therapists, perceptions and practice. Clinical Psychology: Science and Practice, 20(2), 143–151. https://doi.org/10.1111/cpsp.12030 Zlomke, K. R. (2009). Psychometric properties of internet administered versions of Penn State Worry Questionnaire (PSWQ) and Depression, Anxiety, and Stress Scale (DASS). Computers in Human Behavior, 25(4), 841–843. https://doi.org/10.1016/j. chb.2008.06.003

6 Dissemination and Implementation Bradley E. Karlin

F

or more than 40 years, cognitive behavioral therapy (CBT) has been established as the gold standard of psychological treatments. Initially developed for depression, CBT is now available and recognized as an evidence-based treatment for a number of other mental and behavioral health conditions. Indeed, for some conditions (e.g., posttraumatic stress disorder [PTSD] and other anxiety disorders, insomnia), CBT has been shown to be substantially more effective and have longer lasting effects than medications (e.g., Butler et al., 2006; Institute of Medicine, 2007). And for several conditions, CBT is recommended by experts at the highest level and as a first-line treatment (e.g., Department of Veterans Affairs & Department of Defense, 2017; National Institute for Clinical Excellence, 2005; National Institutes of Health, 2005). Unfortunately, however, the practice of CBT has remained far behind the science, resulting in its largely unrealized promise and potential.1 To this day, CBT remains largely unavailable on the front lines of communities (Finley et al., 2018; Lu et al., 2016; C. S. Rosen et al., 2004). In fact, it is estimated that as few as 5% of adults with depression or anxiety receive an evidence-based psychotherapy (EBP; Layard & Clark, 2014). Indeed, the gap between what we know works and the delivery of CBT (and other EBPs) is far greater than the research-to-practice gap in virtually any other area of health care. If one has diabetes, for example, and walks into the office of their primary An earlier version of this chapter was presented as part of Dr. Karlin’s Presidential Address for the Society of Clinical Psychology at the 124th Annual Convention of the American Psychological Association.

1

https://doi.org/10.1037/0000218-006 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  157 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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care provider or endocrinologist, they can be assured that they would reliably receive, or have the option to receive, the first-line, Grade A recommended treatment for that condition—insulin. But, if that same person has PTSD or another anxiety disorder, insomnia, or maybe even depression, there is a low likelihood that they will receive the corresponding recommended treatment. Most likely, they will receive medication—maybe an antidepressant or an anxiolytic—that for many mental health conditions has relatively limited efficacy, at least as a monotherapy (Zibman, 2014). In fact, psychopharmacotherapy has increased considerably over the past decade, though the same has so far not been true of psychotherapy, particularly CBT (Greenblatt et al., 2018). When it is delivered, CBT is often delivered with limited treatment fidelity such that treatment components that may be intended as CBT do not resemble the treatment as it was intended and shown to be efficacious (Creed, Wolk, et al., 2016; Madson & Campbell, 2006). The enduring gap in the delivery of CBT and other EBPs is largely a function of too little focus and guidance on strategic implementation—an area of substantial need and opportunity within clinical psychology and, more broadly, professional psychology. For decades, there has been perhaps an overreliance on developing effective interventions and little focus on how we make these available and utilized—accounting for both implementation process and context. The goal of the present chapter is to examine key principles, strategies, and findings related to the dissemination and implementation of CBT, based on findings from implementation science and practice. The chapter then reviews recent advances in the dissemination and implementation of CBT within large public and private systems incorporating structured implementation approaches.

MULTILEVEL ACCOUNTING FOR THE LIMITED DELIVERY OF CBT A growing literature seeking to account for the limited delivery of CBT and other EBPs has documented significant barriers to delivery at a number of levels, including provider, system, and patient levels (Aarons et al., 2011; Fixsen et al., 2005; Tabak et al., 2012). This literature reveals that requirements that are at different levels and that are highly context specific must be met for treatments, especially fairly complex treatments, to be delivered. Provider-level barriers generally relate to limited preparedness among clinicians to deliver CBT. Although mental health providers often receive training related to CBT as part of graduate training, this training generally consists of knowledge-based training designed to promote knowledge or awareness of CBT and its general components. This is very different from competency-based training that is required for skill mastery and requires ongoing practice and feedback on the clinical implementation of treatment components (Beidas et al., 2012; Newman, 2010; R. C. Rosen et al., 2017). Many therapists, in fact, significantly overestimate their CBT skills. In an empirical examination of therapist perceived versus actual CBT competency, Creed, Wolk, et al. (2016) compared



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therapist-labeled therapeutic orientation with expert ratings of the same therapists’ therapy sessions. Although the great majority of therapists reporting a therapeutic orientation at baseline identified CBT as composing all or part of their clinical work, only a small proportion of these therapists demonstrated minimum competency in CBT, based on expert ratings of session audio recordings. Further, the overall level of CBT competency among these therapists was similar to that of participants endorsing a therapeutic orientation other than CBT (e.g., psychodynamic, play therapy, family systems). In addition to limited behavioral preparedness that may limit CBT adoption is limited psychological preparedness, or unfavorable attitudes toward CBT. Some clinicians do not have favorable attitudes toward CBT and other evidencebased practices due to the perception that such interventions are overly structured, rigid, or not individualized (Aarons, 2004; Cook et al., 2017). Similarly, among some clinicians, there is the perception that EBPs, like CBT, emphasize techniques over the therapeutic relationship (Karlin & Cross, 2014a). This is unfortunate because competent delivery of CBT places significant emphasis on both “common factors” and therapeutic techniques. This inaccurate perception of CBT is a function of limited in-depth understanding of CBT practice and what I have referred to as a “contamination” of the CBT label resulting from its application to purely psychoeducational or skills-based approaches that, while possibly based on cognitive or behavioral principles, do not represent cognitive behavioral therapy (Karlin & Cross, 2014a, 2014b). A growing body of evidence has demonstrated that key to addressing providerlevel needs for promoting adoption and delivery of CBT is competency-based training that incorporates foundational training in the theoretical and applied aspects of CBT, followed by ongoing consultation on the application of newly learned skills. While initial foundational training, which usually takes the form of in-person workshop training, has been shown to increase knowledge, positive attitudes, and intention to deliver CBT, it is clear that ongoing consultation with regular feedback on audio- or video-recorded CBT sessions is necessary for promoting CBT competency (Beidas at al., 2012; Karlin et al., 2019; Stirman et al., 2017). One-time training does little to change clinical behavior. Foundational training that is more experientially oriented (as opposed to primarily didactic in nature) and includes participant and observer role-plays and interactive discussion and exercises tends to have greater impact on learner outcomes, including knowledge, positive attitudes, self-efficacy to deliver CBT, and initial skill development (Beidas at al., 2012; Karlin et al., 2019). In recent years, there has been growing interest in utilizing technologyfocused, distance-based approaches as alternatives to in-person training in CBT. The use of technology, such as video conferencing and web-based training approaches, for delivering foundational CBT training is intriguing for promoting efficiency and scale due to having greater reach and not requiring travel of training participants. Despite the interest and potential utility of distance-based approaches to training in CBT and other EBPs, empirical support for and training participant engagement in alternative training modalities for foundational

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training are more limited than for in-person training modalities (R. C. Rosen et al., 2017; Smith et al., 2017). However, telephone-based and video-based modalities for ongoing training consultation following initial foundational training have consistently been shown to be very effective, particularly when training consultation groups are conducted in small groups, led by a trained CBT training consultant, and developed and framed as a supportive learning opportunity as opposed to an evaluative process (Karlin & Cross, 2014a; Karlin et al., 2019; Stirman et al., 2017). Furthermore, recent findings suggest that training that is individualized to training participants through the identification of personal strengths and weaknesses and specific training goals, in addition to overall competency attainment, is especially useful for maximizing meaning, engagement, and outcomes (Karlin et al., 2019). In addition, CBT training and treatment protocols that provide for or even emphasize individualization of treatment, as opposed to highly structured approaches, appear to increase clinician interest and engagement in the treatment process (Cook et al., 2017; Karlin et al., 2019). At the systems level, most mental health care systems and facilities lack a clinical infrastructure to support the delivery of treatments such as CBT that require eight to 16 weekly sessions of 50 or more minutes each. Most facilities also lack an organized structure for identifying for whom more front-end intensive treatments like CBT are most appropriate (versus, for example, low-intensity treatments) and for organizing staff and stepped care processes accordingly so that resources can be appropriately aligned and available to support the delivery of treatments like CBT when clinically indicated. Moreover, many systems lack a treatment culture that is consistent with an evidence-based treatment model, as opposed to a supportive or palliative approach to mental health care. At the patient level, consumers often have very limited awareness of evidencebased psychological treatments or even of what “evidence-based” means, and the alphabet soup of acronyms for treatment labels (CBT, IPT, ACT, etc.) can be dizzying. This is largely a failure of the mental health care community in marketing these treatments, such as through direct-to-consumer education and outreach, in comparison with the considerable success in this arena of the pharmaceutical industry (Gallo et al., 2015; Karlin & Brenner, 2020; Karlin & Cross, 2014a). This limited public awareness of CBT contributes to limited treatment uptake and motivation.

MOVING TOWARD MORE SOPHISTICATED IMPLEMENTATION For decades, approaches to dissemination or spread of EBPs have generally relied on unidimensional approaches that have typically focused on individual clinicians and have neglected critical needs of the system, the local organization or clinic, and especially patients or consumers. Further, they have usually involved passive methods of information exchange, such as clinical practice



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guidelines, clinical reminder systems, and toolkits—for which we often have expectations that generally far exceed their possibilities. The need to better and faster implement evidence-based treatments across the health care delivery continuum has given rise to the field of implementation science, which is developmentally now well into gangly adolescence. Before turning to the components of effective implementation borne out by scientific and applied implementation, it is important to define a few key terms. Although dissemination and implementation are often used interchangeably, they have different meanings. Dissemination refers to the distribution of an innovation generally to a defined audience or group. Implementation refers to the strategic integration of an innovation within an identified setting or context. Relative to dissemination, implementation consists of a more strategic and specific process for initiating or promoting the delivery of the innovation in one or more specific settings. For example, dissemination may involve actively spreading treatment manuals, toolkits, or other resources to one or more target provider groups, whereas implementation involves actively and strategically working at multiple levels of an organization to promote the adoption and delivery of an intervention and typically involves addressing and leveraging barriers and facilitators to delivery that are specific to the organization or setting. Unlike passive approaches to promoting uptake of interventions, implementation involves a number of distinguishing characteristics (see Figure 6.1). First, implementation is planful and intentional—implementation is the intervention. Second, it is strategic. Third, it is informed by empiricism—accounts for facilitators and barriers identified in the literature. Fourth, it is context sensitive—the intervention approach accounts for the characteristics of the local context. Fifth, it is multilevel—it addresses implementation requirements not just at the practitioner level but usually at several other levels as well. And, finally, implementation begins before implementation—it does this through assessing and promoting preimplementation readiness to maximize the likelihood of implementation success. This critically important, but often overlooked, part of implementation is where I turn next. Preimplementation Readiness A major component of the preimplementation readiness phase is assessing the organization’s readiness for implementing the innovation at many levels, including, for example, the organization, staff, and often patients. This process has multiple functions and benefits. First, it provides due notice or “informed consent” so that the organization is aware, at the outset, of what is required for implementing the innovation. Second, it allows for enhancing preparedness before active implementation. This includes preparedness of various stakeholders or actors who will play a part in the implementation process, including but not limited to system or facility leadership, clinic leadership, clinical staff, administrative staff, information technology staff, labor representation, and potential community stakeholders. Third, the process allows for the important

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FIGURE 6.1. Characteristics of Effective Implementation

tailoring of implementation to best meet organizational needs, rather than applying it in nomothetic or “off-the-shelf“ fashion. Significantly, research shows that approaches to implementation that work to promote system fit generally yield greater success (Fixsen et al., 2005; Mittman, 2012). Key organizational readiness domains and examples are summarized in Table 6.1. To facilitate preimplementation assessment, organizational readiness assessment measures and checklists have been developed and are now available in different fields (e.g., public health, health care, mental health; see Chaudoir et al., 2011, for a review). While useful to support initial assessment and planning, most of these measures have little or no psychometric data available. One measure designed specifically for supporting the implementation of evidencebased interventions in behavioral health care organizations is the Checklist to Assess Organizational Readiness (CARI) for Evidence-Informed Practice (EIP) Implementation (Barwick, 2011). This measure includes 25 items with response choices rated on a 4-point Likert scale (1 = not even close, 4 = we’re there). Examples of items include “The service funder recognizes the importance of EIP”; “Technical assistance (e.g., EIP training, coaching, ongoing support) is available for the EIP(s) being implemented”; “Implementing the selected EIP is aligned with organizational, regional, or system goals”; “Senior leadership is willing and able to lead and shape the implementation”; and “There is an implementation framework selected to guide the implementation process (e.g., NIRN model).” Information yielded by the CARI is used to facilitate preimplementation planning and preparation along the different domains assessed by the measure (e.g., staff preparedness, leadership support, financial resources) to facilitate greater organizational readiness for implementation. The CARI is free to use and may be accessed at http://melaniebarwick.com/implementation-tools/.



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TABLE 6.1. Key Organizational Readiness Domains Organizational domain

Examples

Organizational and system capacity

Financial resources, staffing, incentives

Organizational culture/climate

Alignment to mission, attitudes, beliefs

Staff capacity

Readiness for learning/practice change, plan for staff selection

Evaluation and communication of impact

System for assessing and communicating impact and continuous performance improvement

Implementation plan

Implementation model identified, implementation team formed

Staff training

Foundational training, ongoing consultation and feedback on implementation, sufficient time allotted for training

Leadership support

Commitment, ongoing involvement, support

Patient characteristics

Perceived utility, preference

Note. Data from Chaudoir et al. (2011), Lusthaus et al. (2002), and Powell et al. (2012).

Implementation Process and Frameworks Moving from preimplementation to the overall implementation process, a growing number of specific dissemination and implementation frameworks and models have been developed to guide the implementation process. In recent years, as the field of implementation science has matured and the need for guiding models for promoting, classifying, and evaluating intentional and empirically informed implementation approaches has become increasingly needed, the number of implementation frameworks has grown to now include many dozens of frameworks. These frameworks identify specific factors that are likely to impact implementation (determinant frameworks) and include facilitators and barriers to implementation as well as the processes or strategies for addressing such (process models; Nilsen, 2015). Several review articles are now available that synthesize the elements of the many frameworks, which can appear quite similar or vary widely from one another (see, for example, Albers et al., 2017; Flottorp et al., 2013; Moullin et al., 2015; Tabak et al., 2012). Notably, some frameworks are more specific to prevention innovations (public health) and others are more specific to health care innovations. Furthermore, there is considerable variability in the degree to which available frameworks focus on dissemination, implementation, or both dissemination and implementation, as well as the specific level(s) or context of focus (e.g., organization, system, policy, individual) and the degree of breadth versus specificity. Tabak et al. (2012) provide a useful three-part typology for classifying specific frameworks based on where on the dissemination versus implementation spectrum they fall, the level of construct flexibility (i.e., broad vs. detailed, step-by-step actions), and the level(s) of focus (i.e., system, community, organization, individual). When considering among the many dissemination and implementation

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frameworks that now exist, it is essential that the chosen framework be specific to the innovation (prevention practice vs. complex treatment) and setting (community vs. health care system). Moreover, the implementation framework or model should be tailored to best fit the needs and circumstances of the system or organization rather than be nomothetically applied (Karlin & Cross, 2014a; Tabak et al., 2012). An interactive website for searching and adapting various dissemination and implementation frameworks may be accessed at http://www.dissemination-implementation.org/index.aspx. Following their review of implementation frameworks of innovations in healthcare, Moullin et al. (2015) developed the Generic Implementation Framework (GIF), which provides an elegant composite depiction of metaprocesses and core concepts of implementation. The GIF is a useful overarching heuristic to guide administrators, policymakers, practitioners, and researchers in developing and organizing specific implementation activities. As visually depicted in Figure  6.2, general stages of implementation are represented by preimplementation, implementation, and postimplementation (key for sustainability). The specific steps or stages within each of these general stages vary across individual frameworks. The innovation to be implemented is at the center, affected by the specific context that should be accounted for, specific factors that may facilitate or impede implementation, and strategies for addressing these. FIGURE 6.2. Generic Implementation Framework

Note. From “A Systematic Review of Implementation Frameworks of Innovations in Healthcare and Resulting Generic Implementation Framework,”" by J. C. Moullin, D. Sabater-Hernández, F. Fernandez-Llimos, and S. I. Benrimoj, 2015, Health Research Policy and Systems, 13(16), p. 8 (https://doi. org/10.1186/s12961-015-0005-z). CC BY 4.0. Reprinted with permission.



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Implementation strategies consist of “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” (Proctor et al., 2013, p. 2). Powell et al. (2012) have developed a compilation of implementation strategies, as well as a subsequent refinement based on expert consensus of 73 discrete strategies using a modified Delphi process (an iterative process of gathering expert feedback and consensus; Powell et al., 2015). Examples of implementation strategies are competency-based training (e.g., foundational training followed by consultation and feedback), financing (e.g., securing funding, incentive structures), restructuring (e.g., clinic restructuring, adaptations to professional roles), and policy change (e.g., policies prioritizing or emphasizing the innovation). In light of the foregoing, how might one interested in implementing an innovation generally proceed? French and colleagues (2012) developed a generic, step-by-step action framework, known as the Theoretical Domains Framework, that provides a systematic, yet streamlined, guide for developing a theoryinformed implementation intervention. As presented in Table 6.2, the framework includes four steps framed as questions, with specific associated tasks. TABLE 6.2. Theoretical Domains Framework Step

Tasks

Step 1: Who needs to do what differently?

• Identity evidence-practice gap • Specify behavior change/innovation • Specify target group

Step 2: Using a theoretical framework, which barriers and enablers need to be addressed?

• Select framework/theories to inform implementation and identification of barriers/facilitators

Step 3: Which intervention components could overcome barriers and enhance enablers?

• Use framework/theories and empirical evidence to inform implementation strategies • Develop implementation intervention that is feasible, locally relevant, and acceptable to current project

Step 4: How can behavior change be measured and understood?

• Select appropriate and feasible variables to be measured

Note. From “Developing Theory-Informed Behaviour Change Interventions to Implement Evidence Into Practice: A Systematic Approach Using the Theoretical Domains Framework,” by S. D. French, S. E. Green, D. A. O’Connor, J. E. McKenzie, J. J. Francis, S. Michie, R. Buchbinder, P. Schattner, N. Spike, and J. M. Grimshaw, 2012, Implementation Science, 7(38), p. 3 (https://doi. org/10.1186/1748-5908-7-38). CC BY 2.0. Adapted with permission.

STRATEGIC DISSEMINATION AND IMPLEMENTATION IN PRACTICE: BRINGING CBT TO LARGE HEALTH CARE SYSTEMS In recent years, large public systems and, even more recently, private systems have developed strategic implementation initiatives designed to make CBT and other EBPs more widely available in routine practice settings and to close the

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research-to-practice gap. As described in more detail below, organized efforts to leverage these treatments, utilizing strategic and individualized approaches to training and implementation, have witnessed robust improvements on multiple outcome domains. In 2005, the Department of Veterans Affairs (VA) health care system, the largest integrated health care system in the United States, launched a national initiative to disseminate and implement EBPs as part of the transformation of the service system to an evidence-based and recovery-oriented system of care (Karlin & Cross, 2014a). Beginning with specialized versions of CBT for PTSD (i.e., cognitive processing therapy and prolonged exposure therapy), the initiative ultimately extended to 16 EBPs addressing PTSD, depression, substance use disorders, serious mental illness, insomnia, chronic pain, relationship distress, and motivation and adherence. To maximize impact and sustainability, such that these treatments would be woven into and prioritized within the fabrics of the VA health care system, a multilevel approach to dissemination and implementation was developed and used to guide the implementation process. This dissemination and implementation model, based on the findings of implementation science, included important focus and specific activities at policy, provider, local systems, patient, and accountability levels (Karlin & Cross, 2014a). Significantly, specific strategies across these levels of implementation intervention included both push and pull activities tailored to the VA health care system. Push strategies, such as competency-based training and system policies designed to prioritize or incentivize a specific service, consist of “top-down approaches to push a product or service out to the field,” whereas pull strategies are designed to “promote interest in and demand for a product or service among potential users or other stakeholders or advocates (e.g., family members)” (Karlin & Cross, 2014a, p. 26). The dissemination and implementation of EBPs in the VA health care system, which has included the training of more than 14,000 VA mental health staff in one or more EBPs, represents the largest undertaking of its kind in the nation. Program evaluation findings from many of these training programs have demonstrated that EBP training and implementation is associated with large improvements in therapist preparedness to deliver CBT and other EBPs, including large increases in competencies and more favorable attitudes toward EBPs. Across a number of these training programs, the rate of competency achievement at the end of training was in the 80%–90% or greater range, which was generally at least twice the rate of competency achievement demonstrated at the beginning of training (e.g., Karlin et al., 2012, 2013; Stewart et al., 2014; Walser et al., 2013). Most significantly, EBP training and implementation in real-world clinical settings serving veterans has been consistently associated with robust improvements on multiple patient outcome domains, including reductions in symptoms in the medium to large effect size range and improvements in psychological and physical quality of life generally in the medium effect size range (e.g., Eftekhari et al., 2013; Karlin et al., 2012; Ruzek et al., 2016; Stewart et al., 2014, 2015; Trockel et al., 2015; Walser et al., 2013).



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Notwithstanding the positive outcomes associated with the broad dissemination and implementation of CBT and other EBPs throughout the VA health care system, recent data measuring the delivery of these treatments indicate that a relatively small proportion of veterans who can benefit from these treatments receive them (e.g., Kehle-Forbes et al., 2016; Lu et al., 2016). Among the most significant, but underrecognized, factors contributing to the low uptake and delivery of EBPs among veterans (and nonveterans) are individual patient factors, namely limited treatment awareness and patient engagement (Karlin & Cross, 2014a). To address these patient-level barriers, VA has developed and launched a unique, direct-to-consumer outreach and engagement strategy that centers around a national web-based platform (https://www.TreatmentWorksForVets. org) designed to promote EBP uptake and engagement using a two-factor engagement approach (Karlin & Brenner, 2020). The first part of this two-factor approach involves a national EBP public awareness website (veteran portal) designed to increase veteran (and nonveteran) awareness, interest, and initial help-seeking or conversation about CBT and other EBPs. It uses an innovative and creative design approach, along with animated, character-based content and interactive exercises, to promote veteran and family member knowledge of mental health conditions, EBPs, and the treatment process, as well as treatment locator tools for finding treatment. The second part of the engagement strategy involves developing a shared decision-making process prior to the initiation of treatment for increasing patient knowledge, informed choice, and treatment motivation once they are “in the door.” This is the focus of the provider portal of the Treatment Works For Vets platform (https://www.TreatmentWorksForVets.org/Provider) and the EBP Shared Decision-Making Toolkit for Mental Health Providers (Karlin & Wenzel, 2018), which may be accessed through the provider portal for increasing the engagement of veteran and nonveteran patients in EBPs and other mental health treatments. The toolkit may also be downloaded as a standalone resource, freely available. A primary focus of the toolkit is the Shared DecisionMaking (SDM) Session (Karlin & Wenzel, 2018), a structured yet flexible pretreatment intervention, typically delivered in a single session, that we have developed for promoting initial engagement in treatment. The toolkit also includes key processes and strategies for promoting ongoing treatment engagement for patients that choose to initiate treatment, including strategies and tools for assessing and enhancing the therapeutic alliance and for incorporating principles and processes of measurement-based care. Greater focus on pretreatment shared decision-making, patient engagement, and treatment readiness is essential for maximizing CBT uptake, engagement, and outcomes (Karlin & Brenner, 2020). With similar goals to make EBPs widely available on the clinical frontlines, the public health care system in the United Kingdom (U.K.) has embarked on a national initiative to disseminate and implement CBT and other EBPs, which has included the training of more than 7,000 therapists (Clark, 2018). This effort has demonstrated significant training outcomes among therapists and

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substantially increased consumer access to EBPs and yielded significant clinical improvements among patients, including a 51% recovery rate (Clark, 2018; Gyani et al., 2013). An additional implementation initiative designed to promote the availability of cognitive therapy within the public mental health care system in Pennsylvania is the Beck Community Initiative (BCI; Creed et al., 2014). Through a partnership between the University of Pennsylvania and the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, the initiative provides competency-based training and implementation support for promoting the availability of cognitive therapy among children, adolescents, and adults experiencing various mental health conditions. Training is provided through several intensive in-person workshops, followed by 6 months of weekly, group-based consultation on the application of newly learned skills. Based on data reported on 274 clinicians who have completed the BCI training (of 348 who initiated training), 60% reached competency by the end of training. When including work samples submitted by some clinicians after the training, the competency achievement rate was 80% (Creed, Frankel, et al., 2016). Clinicians reported overall high levels of acceptability and satisfaction with the training (Creed, Frankel, et al., 2016). Patient-level outcomes have not been reported. Following the successful initiatives to disseminate and implement EBPs within some of the largest public health care systems in the world, Kaiser Permanente (KP), one of the largest private nonprofit health care systems in the United States, recently developed and implemented a pilot initiative to disseminate and implement CBT for depression (CBT-D), designed for treating depression and co-occurring anxiety (Karlin et al., 2019). This initiative includes top-down (e.g., competency-based training) and bottom-up (CBT-D peer consultation groups) implementation strategies for increasing CBT delivery and sustainability, tailored to the KP system. As with the approach to EBP dissemination and implementation in the VA, U.K., and BCI initiatives, a central component of the KP CBT-D dissemination and implementation initiative is a competency-based and self-sustaining CBT-D training program. The CBT-D treatment protocol adapted for the KP health care system (Brown & Karlin, 2017) includes several distinguishing features for promoting the individualization of treatment, while ensuring high fidelity to the CBT model. This includes placing significant emphasis on the therapeutic alliance, a case conceptualization approach to treatment (including both cognitive and behavioral formulations to guide treatment), measurement-based care principles and processes, and a focus on co-occurring anxiety, which is common among KP members. In addition to the important emphasis placed on the individualization of treatment, the approach to CBT training in KP has placed significant and unique emphasis on individualizing the training experience for maximizing the engagement and outcomes of very busy clinicians in a large, private health care system. Similar to the experiences in the VA and U.K. systems, program evaluation results reveal that training in and implementation of CBT-D in the KP health



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care system is associated with robust therapist and patient outcomes (Karlin et al., 2019). Notably, while early in the process, 100% of therapists trained through the KP CBT-D Training Program to date have achieved CBT competency and successfully completed the training, which may be attributed in part to the unique individualized training approach as well as to the fact that the approach to treatment is one that is not overly structured but is individualized and honors clinical decision-making and broad therapy skills. Moreover, improvements in therapist skills, based on both observer and self-report, extended well beyond CBT-specific skills to include overall therapy skills (e.g., Understanding, Interpersonal Effectiveness, Collaboration, and Feedback; Karlin et al., 2019). Finally, as part of the focus on promoting internal CBT training capacity and sustainability within KP, the initiative has included the development of a comprehensive manual for training CBT training consultants (Brown & Karlin, 2018) as well as the CBT Training Consultant Rating Scale (Brown et al., 2018), modeled after the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980), for rating and providing feedback to training consultants leading training consultation sessions. Finally, particularly encouraging from a health economics standpoint is that, in addition to staff and patient-level improvements, researchers have documented significant service and cost offset—the “holy grail” in health care delivery—associated with the delivery of EBPs. Specifically, researchers within the VA health care system have demonstrated service and cost offset on the order of approximately 30% to 40% among veterans receiving EBPs (Meyers et al., 2013; Tuerk et al., 2013). In addition, recent research within the KP health care system has similarly demonstrated significant cost offset associated with the delivery of CBT (Dickerson et al., 2018). In fact, based on their findings, the investigators reported a greater than 90% probability that CBT is cost-effective over a 1- and 2-year period (Dickerson et al., 2018). The foregoing findings and additional research likely to emerge demonstrating CBT yielding back-end savings are essential for making the “business case” for CBT implementation, which is often necessary for eliciting leadership support for the front-end investment in CBT training and implementation. Demonstrating such a business case is often especially important in the mental health care arena, where concerns about access and clinical efficiency are particularly salient and where “front-heavy” 10- to 16-session treatments are typically not the norm.

CONCLUSION Despite its established efficacy and status as a highly recommended treatment in many clinical contexts, CBT remains largely unavailable and its potential unrealized in most community and health care settings. This wide and enduring research-to-practice gap is largely a consequence of unsophisticated, onedimensional, and passive attempts to promote CBT delivery. For too long, the field of clinical psychology, and the mental health care sector more broadly, has

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placed too much focus on the “what” (development of specific treatments) and too little focus on the “how” (how to get established treatments into routine clinical settings). Applying established principles and processes from the emerging field of implementation science provides significant opportunities for developing more informed, strategic, and multilevel approaches to promoting the delivery and sustainability of CBT on the clinical front lines. Just as empiricism guides the clinical application to CBT, so too should it increasingly guide organizational and system dissemination and implementation of CBT. Recent efforts within large public and private health care systems to actualize this promise provide significant optimism for the potential of strategic, intentional, and individualized approaches to CBT dissemination and implementation for increasing the availability of Grade A recommended mental health treatments in routine practice settings. Most significant is the impact yielded by these organized efforts at therapist, patient, and system levels, findings that have consistently and rather convincingly demonstrated the feasibility, effectiveness, and, most recently, cost-effectiveness of CBT delivered in real-world settings. As the experiences of these systems demonstrate, moving from the “what” to the “how” for leveraging evidence-based psychological treatments presents an opportunity for truly realizing the promise of science and for transforming the quality and delivery of mental health care. REFERENCES Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidencebased practice: The Evidence-Based Practice Attitude Scale (EBPAS). Mental Health Services Research, 6(2), 61–74. https://doi.org/10.1023/B:MHSR.0000024351. 12294.65 Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health, 38(1), 4–23. https://doi.org/10.1007/s10488-010-0327-7 Albers, B., Mildon, R., Lyon, A. R., & Shlonsky, A. (2017). Implementation frameworks in child, youth and family services: Results from a scoping review. Children and Youth Services Review, 81, 101–116. https://doi.org/10.1016/j.childyouth.2017.07.003 Barwick, M. (2011). Checklist to assess organizational readiness (CARI) for EIP implementation. Hospital for Sick Children Toronto. https://www.melaniebarwick.com/ implementation.php Beidas, R. S., Edmunds, J. M., Marcus, S. C., & Kendall, P. C. (2012). Training and consultation to promote implementation of an empirically supported treatment: A randomized trial. Psychiatric Services, 63(7), 660–665. https://doi.org/10.1176/appi. ps.201100401 Brown, G. K., & Karlin, B. E. (2017). Cognitive behavioral therapy for depression: A manual for Kaiser Permanente therapists. Education Development Center. Brown, G. K., & Karlin, B. E. (2018). Cognitive behavioral therapy for depression: A manual for Kaiser Permanente training consultants. University of Pennsylvania; Education Development Center. Brown, G. K., Karlin, B. E., & Creed, T. E. (2018). Cognitive behavioral therapy training consultant rating scale. University of Pennsylvania; Education Development Center. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. https://doi.org/10.1016/j.cpr.2005.07.003



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Chaudoir, S. R., Dugan, A. G., & Barr, C. H. I. (2011). Dissemination and implementation measurement compendium: A systematic review of structural, organizational, provider, patient, and innovation level measures. Connecticut Institute for Clinical and Translational Science. https://chipcontent.chip.uconn.edu//wp-content/uploads/2015/09/ DI-Measurement-Compendium.pdf Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology, 14, 159–183. https://doi.org/10.1146/annurev-clinpsy-050817-084833 Cook, S. C., Schwartz, A. C., & Kaslow, N. J. (2017). Evidence-based psychotherapy: Advantages and challenges. Neurotherapeutics, 14(3), 537–545. https://doi.org/10. 1007/s13311-017-0549-4 Creed, T. A., Frankel, S. A., German, R. E., Green, K. L., Jager-Hyman, S., Taylor, K. P., Adler, A. D., Wolk, C. B., Stirman, S. W., Waltman, S. H., Williston, M. A., Sherrill, R., Evans, A. C., & Beck, A. T. (2016). Implementation of transdiagnostic cognitive therapy in community settings: The Beck Community Initiative. Journal of Consulting and Clinical Psychology, 84(12), 1116–1126. https://doi.org/10.1037/ ccp0000105 Creed, T. A., Stirman, S. W., Evans, A. C., & Beck, A. T. (2014). A model for implementation of cognitive therapy in community mental health: The Beck Initiative. Behavior Therapist, 37(3), 56–64. https://www.abct.org/docs/PastIssue/37n3.pdf Creed, T. A., Wolk, C. B., Feinberg, B., Evans, A. C., & Beck, A. T. (2016). Beyond the label: Relationship between community therapists’ self-report of a cognitive behavioral therapy orientation and observed skills. Administration and Policy in Mental Health Services Research, 43(1), 36–43. https://doi.org/10.1007/s10488-014-0618-5 Department of Veterans Affairs & Department of Defense. (2017). VA/DoD clinical practice guideline for management of posttraumatic stress disorder and acute stress disorder (Version 3.0). https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal. pdf Dickerson, J. F., Lynch, F. L., Leo, M. C., DeBar, L. L., Pearson, J., & Clarke, G. N. (2018). Cost-effectiveness of cognitive behavioral therapy for depressed youth declining antidepressants. Pediatrics, 141(2), e20171969. https://doi.org/10.1542/ peds.2017-1969 Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949–955. https://doi.org/10.1001/ jamapsychiatry.2013.36 Finley, E. P., Noël, P. H., Lee, S., Haro, E., Garcia, H., Rosen, C., Bernardy, N., Pugh, M. J., & Pugh, J. A. (2018). Psychotherapy practices for veterans with PTSD among community-based providers in Texas. Psychological Services, 15(4), 442–452. https:// doi.org/10.1037/ser0000143 Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute. Flottorp, S. A., Oxman, A. D., Krause, J., Musila, N. R., Wensing, M., Godycki-Cwirko, M., Baker, R., & Eccles, M. P. (2013). A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science, 8, 35. https://doi.org/10.1186/1748-5908-8-35 French, S. D., Green, S. E., O’Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., Buchbinder, R., Schattner, P., Spike, N., & Grimshaw, J. M. (2012). Developing theoryinformed behaviour change interventions to implement evidence into practice: A systematic approach using the Theoretical Domains Framework. Implementation Science, 7, 38. https://doi.org/10.1186/1748-5908-7-38

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Gallo, K. P., Comer, J. S., Barlow, D. H., Clarke, R. N., & Antony, M. M. (2015). Direct-to-consumer marketing of psychological treatments: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(5), 994–998. https://doi. org/10.1037/a0039470 Greenblatt, D. J., Harmatz, J. S., & Shader, R. I. (2018). Update on psychotropic drug prescribing in the United States: 2014–2015. Journal of Clinical Psychopharmacology, 38(1), 1–4. https://pubmed.ncbi.nlm.nih.gov/29215384/ Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: Lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597–606. https://doi.org/10.1016/j.brat.2013.06.004 Institute of Medicine. (2007). Treatment of PTSD: An assessment of the evidence. National Academies Press. Karlin, B. E., & Brenner, L. A. (2020). Improving engagement in evidence-based psychological treatments among veterans: Direct-to-consumer outreach and pretreatment shared decision-making. Clinical Psychology: Science and Practice. Advance online publication. https://doi.org/10.1111/cpsp.12344 Karlin, B. E., Brown, G. K., Jager-Hyman, S., Green, K. L., Wong, M., Lee, D. S., Bertagnolli, A., & Ross, T. B. (2019). Dissemination and implementation of cognitive behavioral therapy for depression in the Kaiser Permanente health care system: Evaluation of initial training and clinical outcomes. Behavior Therapy, 50(2), 446– 458. https://doi.org/10.1016/j.beth.2018.08.002 Karlin, B. E., Brown, G. K., Trockel, M., Cunning, D., Zeiss, A. M., & Taylor, C. B. (2012). National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes. Journal of Consulting and Clinical Psychology, 80(5), 707–718. https://doi. org/10.1037/a0029328 Karlin, B. E., & Cross, G. (2014a). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System. American Psychologist, 69(1), 19–33. https://doi.org/10.1037/a0033888 Karlin, B. E., & Cross, G. (2014b). Enhancing access, fidelity, and outcomes in the national dissemination of evidence-based psychotherapies. American Psychologist, 69(7), 709–711. https://doi.org/10.1037/a0037384 Karlin, B. E., Trockel, M., Taylor, C. B., Gimeno, J., & Manber, R. (2013). National dissemination of cognitive behavioral therapy for insomnia in veterans: Therapistand patient-level outcomes. Journal of Consulting and Clinical Psychology, 81(5), 912– 917. https://doi.org/10.1037/a0032554 Karlin, B. E., & Wenzel, A. (2018). Evidence-based psychotherapy shared decision-making toolkit for mental health providers. Education Development Center. https://www. treatmentworksforvets.org/Provider/ Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice, and Policy, 8(1), 107–114. https://doi.org/10.1037/tra0000065 Layard, R., & Clark, D. M. (2014). Thrive: The power of evidence-based psychological therapies. Allen Lane. Lu, M. W., Plagge, J. M., Marsiglio, M. C., & Dobscha, S. K. (2016). Clinician documentation on receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. Journal of Behavioral Health Services & Research, 43(1), 71–87. https://doi.org/10. 1007/s11414-013-9372-9 Lusthaus, C., Adrien, M., Anderson, G., Carden, F., & Montalván, G. (2002). Organizational assessment: A framework for improving performance. IDRC Books.



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Madson, M. B., & Campbell, T. C. (2006). Measures of fidelity in motivational enhancement: A systematic review. Journal of Substance Abuse Treatment, 31(1), 67–73. https:// doi.org/10.1016/j.jsat.2006.03.010 Meyers, L. L., Strom, T. Q., Leskela, J., Thuras, P., Kehle-Forbes, S. M., & Curry, K. T. (2013). Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder. Military Medicine, 178(1), 95–99. https://doi.org/10.7205/MILMED-D-12-00302 Mittman, B. S. (2012). Implementation science in health care. In R. Browson, G. Colditz, & E. Proctor (Eds.), Dissemination and implementation research in health: Translating science to practice (pp. 400–418). Oxford University Press. https://doi.org/ 10.1093/acprof:oso/9780199751877.003.0019 Moullin, J. C., Sabater-Hernández, D., Fernandez-Llimos, F., & Benrimoj, S. I. (2015). A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework. Health Research Policy and Systems, 13. https://doi.org/10.1186/s12961-015-0005-z National Institute for Clinical Excellence. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care (Clinical Guideline 26). National Institutes of Health. (2005). National Institutes of Health State of the Science Conference statement on manifestations and management of chronic insomnia in adults, June 13–15, 2005. Sleep, 28(9), 1049–1057. https://doi.org/10.1093/sleep/ 28.9.1049 Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational, functional, and supervisory aspects. Psychotherapy: Theory, Research, & Practice, 47(1), 12–19. https://doi.org/10.1037/a0018849 Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10, 53. https://doi.org/10.1186/s13012-015-0242-0 Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., Glass, J. E., & York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review, 69(2), 123–157. https://doi.org/10.1177/1077558711430690 Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10, 21. https://doi.org/10.1186/s13012015-0209-1 Proctor, E. K., Powell, B. J., & McMillen, J. C. (2013). Implementation strategies: Recommendations for specifying and reporting. Implementation Science, 8, 139. https://doi.org/10.1186/1748-5908-8-139 Rosen, C. S., Chow, H. C., Finney, J. F., Greenbaum, M. A., Moos, R. H., Sheikh, J. I., & Yesavage, J. A. (2004). VA practice patterns and practice guidelines for treating posttraumatic stress disorder. Journal of Traumatic Stress, 17(3), 213–222. https://doi. org/10.1023/B:JOTS.0000029264.23878.53 Rosen, R. C., Ruzek, J. I., & Karlin, B. E. (2017). Evidence-based training in the era of evidence-based practice: Challenges and opportunities for training of PTSD providers. Behaviour Research and Therapy, 88, 37–48. https://doi.org/10.1016/j.brat. 2016.07.009 Ruzek, J. I., Eftekhari, A., Rosen, C. S., Crowley, J. J., Kuhn, E., Foa, E. B., Hembree, E. A., & Karlin, B. E. (2016). Effects of a comprehensive training program on clinician beliefs about and intention to use prolonged exposure therapy for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 348–355. https://doi.org/10. 1037/tra0000004 Smith, T. L., Landes, S. J., Lester-Williams, K., Day, K. T., Batdorf, W., Brown, G. K., Trockel, M., Smith, B. N., Chard, K. M., Healy, E. T., & Weingardt, K. R. (2017).

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Developing alternative training delivery methods to improve psychotherapy implementation in the U.S. Department of Veterans Affairs. Training and Education in Professional Psychology, 11(4), 266–275. https://doi.org/10.1037/tep0000156 Stewart, M. O., Karlin, B. E., Murphy, J. L., Raffa, S. D., Miller, S. A., McKellar, J., & Kerns, R. D. (2015). National dissemination of cognitive-behavioral therapy for chronic pain in veterans: Therapist and patient-level outcomes. Clinical Journal of Pain, 31(8), 722–729. https://doi.org/f7kcbh Stewart, M. O., Raffa, S. D., Steele, J. L., Miller, S. A., Clougherty, K. F., Hinrichsen, G. A., & Karlin, B. E. (2014). National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes. Journal of Consulting and Clinical Psychology, 82(6), 1201–1206. https://doi.org/10.1037/a0037410 Stirman, S. W., Pontoski, K., Creed, T., Xhezo, R., Evans, A. C., Beck, A. T., & CritsChristoph, P. (2017). A non-randomized comparison of strategies for consultation in a community-academic training program to implement an evidence-based psychotherapy. Administration and Policy in Mental Health and Mental Health Services Research, 44(1), 55–66. https://doi.org/10.1007/s10488-015-0700-7 Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research and practice: Models for dissemination and implementation research. American Journal of Preventive Medicine, 43(3), 337–350. https://doi.org/10.1016/j. amepre.2012.05.024 Trockel, M., Karlin, B. E., Taylor, C. B., Brown, G. K., & Manber, R. (2015). Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep, 38(2), 259–265. https://doi.org/10.5665/sleep.4410 Tuerk, P. W., Wangelin, B., Rauch, S. A. M., Dismuke, C. E., Yoder, M., Myrick, H., Eftekhari, A., & Acierno, R. (2013). Health service utilization before and after evidencebased treatment for PTSD. Psychological Services, 10(4), 401–409. https://doi.org/10. 1037/a0030549 Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., & Taylor, C. B. (2013). Training in and implementation of acceptance and commitment therapy for depression in the Veterans Health Administration: Therapist and patient outcomes. Behaviour Research and Therapy, 51(9), 555–563. https://doi.org/10.1016/j.brat.2013.05.009 Young, J., & Beck, A. (1980). Cognitive Therapy Scale: Rating manual [Unpublished manuscript]. Center for Cognitive Therapy. https://beckinstitute.org/wp-content/ uploads/2015/10/CTRS-current-10-2011-Cognitive-Therapy-Rating-Scale-2.pdf Zibman, C. (2014, October). Expenditures for mental health among adults, ages 18–64, 2009–2011: Estimates for the U.S. civilian noninstitutionalized population (Statistical Brief No. 454). U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. https://meps.ahrq.gov/data_files/publications/st454/stat454. pdf

7 The Therapeutic Relationship Amy Wenzel

T

he therapeutic relationship between a mental health provider who delivers psychotherapy and a client is arguably one of the most intimate yet complex relationships in which a person can engage. Many clients seek psychotherapy when they are in distress and are enduring a particularly difficult time in their lives; thus, they are searching for someone to help them. Even when clients seek psychotherapy for other reasons when their lives are going relatively well, such as for personal growth or for working through of problematic events from their pasts, they are still entering into a relationship in which they will be prepared to disclose personal, and sometimes embarrassing, information about themselves. In instances in which clients embark on a course of psychotherapy with a negative attitude toward treatment, such as when a spouse threatens to leave them if they do not get help or when they are court ordered to participate in psychotherapy, the therapeutic relationship can be the very factor that helps them come around and extract something positive out of the experience. The therapeutic relationship has been recognized as one of the most important factors to which clinicians should attend and cultivate in delivering successful psychotherapy (Castonguay et al., 2006; Doran, 2016; Wolfe & Goldfried, 1988). At the time of the writing of this chapter, a PsycInfo search using the keywords “therapeutic relationship” yielded 7,314 hits. Despite the pervasiveness of scholarship and clinical attention to the therapeutic relationship, cognitive behavioral therapy (CBT) is often (and incorrectly, from my perspective) viewed as a therapeutic approach that minimizes the importance of the https://doi.org/10.1037/0000218-007 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  175 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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therapeutic relationship (Gluhoski, 1994). Critics of CBT perceive it to be a technique-oriented treatment approach in which clinicians follow a step-bystep “recipe” regardless of what is happening in the therapeutic relationship and regardless of the needs and preferences of the individual client. At times, CBT is contrasted with other therapeutic approaches for which the therapeutic relationship is a central curative factor in a way that implies that the majority of what occurs in CBT is bland, overly structured, and overly didactic (e.g., Shedler, 2010). Although it is true that expert cognitive behavioral therapists view a strong therapeutic relationship as being necessary but insufficient to achieve a successful outcome from a course of psychotherapy (J. S. Beck, 2011), in no way do cognitive behavioral therapists ignore or neglect the importance of the therapeutic relationship. In fact, the therapeutic relationship is increasingly assuming a central focus of scholarly and clinical attention among cognitive behavioral therapists (e.g., Gilbert & Leahy, 2007; Kazantzis et al., 2017). Although, to give credit where credit is due, it most certainly has been addressed even in the earliest writings of the “father” of CBT, Aaron T. Beck (e.g., A. T. Beck et al., 1979). In this chapter, I describe the ways in which cognitive behavioral therapists foster and attend to the therapeutic relationship during the course of CBT. In fact, I argue that some of the very best CBT occurs in “real time” when the therapist and client address and work through something that is happening in the therapeutic relationship. To achieve these aims, I first describe basic definitions that are relevant to understanding the therapeutic relationship. Next, I consider the components of CBT that specifically enhance the therapeutic relationship. Then, I summarize empirical research on the impact of the therapeutic relationship on the process and outcome of psychotherapy, with an emphasis on results from studies that have examined aspects of the therapeutic relationship within the context of CBT. I also supply some clinical guidelines to guide cognitive behavioral therapists in the use of the therapeutic relationship as they deliver CBT, illustrating some of these guidelines with exemplars from my own clinical practice, and I include a clinical example that is modeled after a true case.1 I end the chapter with considerations for future scholarship and research, calling on cognitive behavioral therapists who are interested in this topic to reach beyond the CBT literature and consult the writings of scholar-clinicians who practice from other theoretical orientations to think deeply about the therapeutic relationship and apply their constructs within the cognitive behavioral framework.

DEFINITIONS According to Kazantzis et al. (2017), the therapeutic relationship is defined as the “exchange between therapist and client that develops for the purpose of sharing intimate thoughts, beliefs, and emotions in an endeavor to facilitate Clinical examples are disguised to protect patient confidentiality.

1



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change. This relationship is characterized by the safe, open, nonjudgmental atmosphere that imbues trust and confidence” (p. 17). I have had many clients express that there is nothing in the world that can replicate the experience of another person being fully attentive, devoted, and benign, without a competing agenda, in a calm, serene environment. Indeed, I have witnessed many clients almost sinking into their chairs as I begin to ask about their experiences in a warm, interested, undistracted manner. Clients become poised for self-examination and the implementation of meaningful changes in their lives when they are operating from a foundation in which there is an assumption that even if they are struggling or have flaws, they are decent human beings who are doing their best and who deserve respect, care, and concern. Therapeutic Alliance No construct associated with the therapeutic relationship has received as much attention as the therapeutic alliance (also called the working alliance; Doran, 2016). Although the construct was first developed within the psychoanalytic community (Greenson, 1965, 1967), the term as it is used in contemporary literature that cuts across theoretical orientations (cf. Doran, 2016) was advanced by Bordin (1979), who identified three key components: (a) the agreement of the therapist and client on therapeutic goals, (b) the agreement of the therapist and client on therapeutic tasks, and (c) the emotional bond between the therapist and client. More recently, Constantino et al. (2002) stated that “it is generally agreed that the alliance represents interactive, collaborative elements of the relationship (i.e., therapist and client abilities to engage in the tasks of therapy and to agree on the targets of therapy) in the context of an affective bond of positive attachment” (p. 86). Some scholar-clinicians have regarded the therapeutic alliance as the most essential ingredient in facilitating change in psychotherapy (Horvath & Bedi, 2002; Lambert & Simon, 2008), and many assessment tools have been constructed to operationalize the construct and measure its key components (Elvins & Green, 2008). It is not difficult to surmise ways in which a strong therapeutic alliance would facilitate a client’s positive experience in psychotherapy. When a therapist and client have agreed on the goals and tasks of therapy, it stands to reason that their work will be focused on important problems that both parties believe have great promise in achieving meaningful change. Such agreement has the potential to make therapeutic work efficient and productive, leaving the client with the sense that they are really “doing something” about their problems. Moreover, a strong emotional bond between the therapist and client can nurture an environment in which the client feels comfortable disclosing personal information and making a commitment to take risk in the spirit of enacting change. Very similar to what is posited by attachment theorists (e.g., Bowlby, 1969), the therapist can serve as a secure base from which the client can test out assumptions, practice new behaviors, and accumulate life experiences that are different and (presumably) healthier than those in which the client was immersed when they sought treatment. From a less profound standpoint, a strong emotional bond

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could also be associated with simple by-products such as the client looking forward to attending regular sessions and feeling eager to report new developments to the therapist, which certainly bode well for outcome. In psychotherapy research, when scholars include measures of the therapeutic relationship into their designs, they almost always focus specifically on the therapeutic alliance. Thus, the therapeutic alliance is the construct associated with the therapeutic relationship that has, by far, the most extensive base in the clinical science research literature. However, this construct is not without its critics. For example, some have argued that it focuses excessively on the agreement between the therapist and client without acknowledging other avenues to the development of a strong therapeutic relationship, making it more about compliance than the relationship itself (Cushman & Gilford, 2000). Others have raised the possibility that a strong therapeutic alliance conceptualized in this manner actually represents a pseudoalliance, such that the therapist and client ignore their own needs to attend to the needs of the other, or when the therapist and client agree with one another in order to avoid discord (Bender, 2005; Wachtel, 2008). These provocative insights raise the possibility that clients with certain personality characteristics, such as dependency or submissiveness, score higher on inventories of the therapeutic alliance than clients who do not have these characteristics (e.g., Muran et al., 1994). Not only would scores on the therapeutic alliance be artificially inflated in these cases (cf. Bender, 2005), but if therapists are guided by this way of understanding the therapeutic alliance, then they might deliver therapy in a manner that reinforces, rather than corrects, an interpersonal style that has contributed to a client’s life problems. Finally, it has been posited that the aspects of the therapeutic relationship that are reported by clients as being important to them are not typically represented in scales measuring the working alliance (Bachelor, 1995). Thus, the therapeutic alliance is undoubtedly a central aspect of the therapeutic relationship that has been subjected to rigorous empirical scrutiny. However, it is equally as important to recognize that the notion of the therapeutic relationship is broader than the therapeutic alliance and that the terms cannot be used interchangeably. Other Components of the Therapeutic Relationship What, then, are those other factors that could account for variance in our broad understanding of the “therapeutic relationship” in addition to the therapeutic alliance? Greenson (1971), for example, identified three unique components of the therapeutic relationship: (a) the working alliance, (b) transference and countertransference, and (c) the “real relationship” between the therapist and client. In the previous section, the therapeutic alliance was considered; now let us turn our attention to the other constructs identified by Greenson. Transference occurs when the client has a distinct reaction to the therapist, which is often reminiscent of something that happened in an important relationship in the client’s past. In many cases, that important relationship is with



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a parent, and the client is reacting to something that reminds them of a message that was either overtly or subtly communicated by the parent. Countertransference occurs when the therapist has a distinct reaction to the client, which also could be reminiscent of something that happened in a previous relationship. Transference and countertransference reactions are powerful to acknowledge and work through, as they provide a crucial learning opportunity for the client to resolve interpersonal issues and generalize that learning to their life. Practitioners of some schools of psychotherapy, such as psychodynamic psychotherapy, believe that good outcome in treatment is most likely to occur when transference and countertransference are identified and successfully addressed during the course of psychotherapy. Although the identification and resolution of transference and countertransference are not necessarily central tasks in CBT, these reactions can, without a doubt, serve as a vehicle for in-session CBT work to be done to resolve the issue, allow the client an opportunity to observe the firsthand application of cognitive behavioral skills in resolving relationship tension, and achieve important learning that can be applied to close relationships in the client’s life outside of sessions. The “real relationship” is a construct that, to my knowledge, has not been considered within the CBT literature. Charles Gelso and his collaborators have argued that the real relationship is the most important component of the therapeutic relationship and consists of a genuine relationship between two people that involves realistic perceptions of one another (Gelso, 2011; Gelso & Hayes, 1998). Research is mixed, however, on the degree to which the real relationship taps into a significantly different construct from the working alliance (e.g., Greenberg, 1994). What it does suggest is that there is something important that occurs when the therapist and client share genuine feelings and thoughts about their relationship and the work that they are doing together. As I have stated in my previous work (Wenzel, 2019), it is my belief that it is this sort of intangible connection that brings any type of psychotherapy to a higher level and sets up the therapist and client for a successful therapeutic experience (and an experience that can make a difference in both of their lives). Nonspecific Therapeutic Skills Many of the basic counseling skills that mental health trainees develop in their early coursework go a long way in establishing a sound therapeutic relationship. Karlin and Wenzel (2018), among many, many others throughout the past century, have described the skills that cultivate this relationship. For example, the skills of paraphrasing, reflecting, and summarizing communicate to clients that the therapist has heard and understood what they have communicated. Expressed empathy occurs when the therapist communicates genuine appreciation of the emotion associated with difficult experiences that the client is describing. All the while, the therapist’s tone of voice is characterized by warmth, or an inviting stance that signals to the client that the therapist is interested in hearing more about their experience and cares about their feelings. When the

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therapist exhibits confidence that they can be of service, this, in turn, instills hope in the client and can shape a positive expectation for treatment. Moreover, unconditional positive regard is demonstrated when the therapist shows full support and acceptance of the client regardless of what the client is describing or how they are behaving. In my professional experience, I have found it invaluable to periodically review lists of nonspecific therapeutic skills, such as those described in the previous paragraph, and check myself to be sure that I am cognizant of them during a session. Of course, the expression of these factors comes “from the heart” and cannot be manufactured or prescribed; in other words, they are wholly genuine. However, consider my experience as a supervisor of trainees who are hoping to achieve competence in the delivery of CBT and who are rated according to the Cognitive Therapy Rating Scale (Young & Beck, 1980), which includes items rating these nonspecific factors. Part of what goes into a higher score on the “Understanding” item (obviously something all therapists strive to achieve) is the overt expression of empathy. I have almost never rated a session in which I viewed a therapist delivering CBT as having been unempathetic; however, for a therapist to receive the highest rating on this scale, I must hear overt expressions of empathy. Without feedback, many therapists do not realize that they are making very few overt expressions of empathy. Therapists readily adjust their behavior when I provide this feedback, and when they make overt expressions of empathy in addition to communicating it in a nonverbal manner, overall scores on their sessions (not only scores on this single item) soar. I view this as occurring because therapists are more mindfully attending to these nonspecific therapeutic relationship elements and cultivating the relationship in an even more thoughtful manner, which, in turn, is associated with increased skillfulness in the delivery of CBT.

FEATURES OF CBT THAT FACILITATE THE THERAPEUTIC RELATIONSHIP There are many core aspects of CBT that were developed, in part, with the intention of fostering the therapeutic relationship. I elaborate upon many of these features in this section, including collaboration, the solicitation of feedback, respect for individual differences, and guided discovery. Collaboration Collaboration is a fundamental tenet of CBT, such that the therapist and client function as equal members of a team (Kazantzis et al., 2017; Okamoto et al., 2019). Both parties bring to each session issues that they believe are important to address, both parties make insightful observations about events that happen in the client’s life, and both parties contribute to the development of practice in which the client will engage between sessions. CBT has long been regarded as



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an active approach to treatment, the idea being that both the therapist and client are equally as active in working together to ensure that sessions are focused, efficient, and productive. Cognitive behavioral therapists do not simply tell their clients what to do or how to think—they respect the fact that clients are the ones living their own lives and that it would presumptuous to prescribe a course of action without having lived life in their shoes. It is hoped that the collaborative stance will contribute to clients’ sense that their input is valued and that they are working with someone who is truly invested in their wellbeing and progress toward life goals. Solicitation of Feedback Along with collaboration is the regular solicitation of feedback from the client. Cognitive behavioral therapists seek feedback in many different ways for many different reasons. Two opportunities for feedback come from two fundamental components of CBT session structure: (a) the bridge from the previous session that occurs near the beginning of the current session and (b) the final summary and feedback that occurs near the end of the session (Wenzel, 2019). In both of these instances, I have advocated for cognitive behavioral therapists to ask clients about what they have learned from their cognitive behavioral work, rather than simply supplying a brief summary of the cognitive behavioral work for them. This type of feedback allows for clients to put their own words onto cognitive behavioral strategies and principles of change, which will allow them to solidify their new knowledge so that there is an increased likelihood that they can retrieve and use it on their own outside of sessions. Questions to achieve these aims include “What did you take away from the previous session that ultimately made a difference in your life?” or “What have you learned today that you expect to observe or live out in between sessions?” When clients provide a thoughtful response that indeed reflects the cognitive behavioral strategies and principles that were considered in session, it provides important information to the therapist that they are on the same page with their clients and that their clients are learning something from sessions. In contrast, when clients falter when asked such a question, it raises the possibility that there is a disconnect in their therapeutic relationship, such that the therapist is not matching the client’s style or addressing needs that are important to the client. When the former occurs, the therapeutic relationship is often enhanced because clients realize how much they are taking from their cognitive behavioral work. When the latter occurs, it can be food for discussion in session so that the therapist and client can realign and ultimately strengthen their agreement on the goals and tasks of treatment. At an even more basic level, cognitive behavioral therapists routinely check in with their clients to ensure that they have an accurate understanding of what the client is expressing (cf. J. S. Beck, 2011). An example of a question to facilitate such understanding is “What I’m hearing you say is [insert sentiment that the client expressed]. Do I have that right?” When therapists ask a question

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like that, it communicates to clients that they have listened intently, that they are curious about clients’ lives, and that they care about making sure that they have accurate information. Such a question also reinforces an important aspect of the cognitive behavioral process—namely, that it is important to ask questions of clarification to ensure that one has the facts before proceeding and potentially acting upon inaccurate information. Finally, cognitive behavioral therapists check in with clients to ask whether they got anything wrong in their understanding of what the client was saying or whether the client experienced anything in the session as aversive or off-putting (J. S. Beck, 2011). Such explicit questioning increases the likelihood that any misunderstandings that could affect the therapeutic relationship are acknowledged by both parties. In addition, it communicates that the therapist is willing to hear honest feedback, discuss it, and work through it in order to repair any aspects of the therapeutic relationship that have been damaged. When clients affirm that something the therapist has said or done bothers them, time is taken in session to discuss it further, and it is followed up upon in subsequent sessions. Respect for Individual Differences Cognitive behavioral therapists assume a tremendous respect for individual differences, or the psychological characteristics that make each person unique and different from the next. Respect for individual differences means that cognitive behavioral therapists celebrate the fact that each person has unique strengths and proclivities that set a context for a very distinct way of experiencing the self, others, the world around us, and the future. In almost all instances in therapy, I work with my clients to see the “other side of the coin” to the tendencies that they view as problematic and that brought them into treatment in the first place. I remember distinctly a client I saw many, many years ago, who was perhaps the most painfully shy, introverted person I had ever met. Unfortunately, she viewed this trait as a weakness, to the point that she had formed the core belief “I’m defective.” As therapy progressed, she (quite brilliantly) developed her own homework exercise, in which she constructed a survey about her shyness and its advantages and disadvantages and administered it to several family members and friends. Although each survey responder indicated that they viewed her as shy, they all highlighted positive attributes of her demeanor, such as being “loyal” or “a good listener” (or “not being worried about you being obnoxious if we take you out in public!”). Cognitive behavioral therapists, then, help their clients dig deep to embrace the adaptive elements of characteristics that might have caused them problems in the past, helping their clients to make these characteristics work for them, rather than against them. When this occurs, the therapeutic relationship strengthens tremendously because clients see that their therapist believes in them and sees the best in them. In addition, respect for individual differences means that cognitive behavioral therapists understand that their clients might view their circumstances in a way that is different from how they might view those circumstances or differ-



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ent from the way in which many others would view those circumstances. Cognitive behavioral therapists understand that there is at least a grain of truth in their clients’ thinking, if not several grains of truth, and that their viewpoint is not wholly invalid. This point cannot be overstated, as in my experience, a mechanistic approach to cognitive restructuring can give the client the message that their thinking is “abnormal,” “distorted,” or “invalid” and that the problem is truly “in their head.” Skilled cognitive behavioral therapists instead help clients acknowledge and accept the facts of the situation and consider alternatives for the aspects of their thinking that might be assumptive or conjecture, arriving upon a conclusion that is accurate and balanced. When cognitive restructuring is approached in this manner, such that clients’ viewpoints of their life circumstances are validated, the therapeutic relationship can be strengthened. I have had many clients express gratitude for my support of their adopting an “unpopular” viewpoint among other people in their support system (e.g., reasons for remaining in a relationship with someone who has not treated them well), on the basis of careful examination of the facts and ways in which their mindset was adaptive for them. Finally, cognitive behavioral therapists also carry the utmost respect for individual cultural differences, broadly speaking (cf. Okamoto et al., 2019). The eminent psychologist Pamela Hays (e.g., Hays, 2016) developed a framework to guide clinicians in developing cultural competence in working with clients. This framework, referred to as ADDRESSING, is an acronym that calls clinicians’ attention to the following individual difference variables: (a) age and generational influences, (b) developmental or other disability, (c) religion and spiritual orientation, (d) ethnic and racial identity, (e) socioeconomic status, (f) sexual orientation, (g) Indigenous heritage, (h) national origin, and (i) gender. Although these variables are not necessarily psychological in nature, they often provide the context for distinctive beliefs and behavioral patterns to develop. Thus, cognitive behavioral therapists are cognizant to recognize the forces associated with these variables as they develop cognitive case formulations of their clients’ presenting problems. Moreover, they are encouraged to gain competence when they are working with a client characterized by one or more of these factors with which they are unfamiliar. Such competence could be developed by consulting writing or video resources, supervision or consultation, taking a course, or even (and in some cases, preferably) asking the client for their views about the influence of these factors on their cognitive and behavioral ways of responding to the world. Cognitive behavioral therapists who practice according to the ADDRESSING framework will almost undoubtedly enhance their therapeutic relationships because they are making the utmost effort to understand the internal (and often external) realities of their clients. Guided Discovery Guided discovery is a construct, as well as a strategy, that is often misinterpreted both within and outside the CBT community. Within the CBT community,

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sometimes it is used to define the process by which therapists question clients to identify their key thoughts and beliefs associated with the way they are making sense of a particular situation. In other instances, it is used to define a process of questioning (i.e., the application of Socratic questioning, named after the Greek philosopher Socrates) to help the client arrive upon a more adaptive way of viewing a situation than they were originally intending. I view the process of guided discovery as achieving both of these aims—helping clients identify the most fundamental meanings associated with situations and circumstances that cause emotional upset and using questioning to help clients arrive upon the most balanced and helpful way of viewing the situation or circumstances that feels right to them. I also view this as enhancing the therapeutic relationship because the therapist (a) demonstrates curiosity about the client’s subjective experience; (b) instills hope that there might be some relief by (possibly) shifting the client’s view of their subjective experience; (c) communicates that there, very well, is some truth in how they are experiencing the subjective experience; and (d) suggests that therapy has something tangible to offer as a “way out” of their emotional distress. In my clinical experience, many clients have remarked that they truly enjoyed and believed that they got much out of their previous therapeutic experiences, but they also realized that they were (regrettably) in a similar situation some years later when they were initiating treatment with me. Guided discovery often provides clients with the sense that something “more” can be added to the therapeutic experience. It facilitates the therapeutic relationship by helping the therapist develop a keen sense of the client’s internal reality and simultaneously cultivating client skill in critically evaluating the way in which they view the self, others, and the world; make sense of problems and current life experiences; and conceptualize a pathway to change. At times, clients joke that they are a bit exhausted after CBT sessions because they have been called upon to “think” to such a significant extent, but they also comment that they have developed a great deal of trust in the therapist and the therapeutic process and, therefore, perceive that their time, energy, and resources have been well spent. A Critic’s Perspective Despite these aspects that have been lauded by many experts as being essential in developing a strong therapeutic relationship, some critics continue to be skeptical about the importance that cognitive behavioral therapists place on the therapeutic relationship. One such critic is the renowned psychodynamic therapist Jonathan Shedler, who has often contributed critical thought about the comparison between psychodynamic psychotherapy and CBT. In one of his blog posts, Dr. Shedler highlighted an article about CBT that indicated that in order to build a strong therapeutic alliance, cognitive behavioral therapists must work collaboratively with clients, ask for feedback, and demonstrate warmth and interest in their clients’ lives. Shedler (2015) wrote in response,



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I expect that much from my hair stylist or real estate broker. From a psychotherapist, I expect something more. The CBT thought leader seemed to have no concept that the therapy relationship is a window into the patient’s inner world, and a relationship laboratory and sanctuary where lifelong patterns can be recognized and understood, and new ones created. (para. 14)

I do not know the original article to which Dr. Shedler is referring, and his criticism could certainly be interpreted as being a bit harsh. Nevertheless, in this narrative, he highlights just how crucial the therapeutic relationship is, as what happens between the therapist and client usually reflects the way in which the client interacts with others outside the therapy session. He also points out that the therapeutic relationship provides an invaluable corrective learning experience for the client to have a different kind of relationship with the therapist that can generalize to the client’s current and future relationships. In other words, it is important for all therapists, including cognitive behavioral therapists, to attend closely to the interactional pattern that unfolds in the therapeutic relationship, to notice the reactions that the client evokes in them, and to use these observations to create a different relationship from one the client might have had in their life, which will ultimately help improve their relationships. Dr. Shedler (2015) ends his blog post by stating, Some people may be satisfied with therapists who “work collaboratively” while conducting therapy according to an instruction manual. . . . Those who want to change their destiny will want a therapist with the self-awareness, knowledge, and courage to see and speak about what matters. (para. 15)

I could not agree more with this insightful statement. In the section below on clinical guidelines, I provide some guidance as to ways to apply CBT within the context of the therapeutic relationship to “see and speak about what matters.”

SELECT RESEARCH ON THE THERAPEUTIC RELATIONSHIP At least two major meta-analyses have aggregated data on the association between the most heavily researched aspect of the therapeutic relationship— the therapeutic alliance—and outcome. Reporting remarkably consistent findings, Horvath and Symonds (1991) obtained an effect size of r = .26, and Martin et al. (2000) obtained an effect size of r = .22. These values represent small effect sizes, indicating that a substantial proportion of the variance in outcome can be explained by other variables. Nevertheless, the fact that this magnitude of association has been obtained in many studies across a wide variety of samples suggests that this is a stable factor to which clinicians should attend in their work with their clients. At times, when my clients are having difficulty resonating with the cognitive behavioral concepts in strategies that I am attempting to share with them, I highlight aspects of our therapeutic relationship that are strong and educate them about the manner in which the relationship, itself, can influence outcome. I let them know that even if, at the moment, it seems that the cognitive behavioral strategies are not yielding their desired outcome,

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what we are doing with the relationship, itself, means something, and that will carry us through. A major question in the alliance-outcome literature is whether a strong therapeutic alliance has a causal influence on outcome or whether the therapeutic alliance strengthens as clients achieve gains in therapy (Barber, 2009). There is correlational evidence for both directions of causality. As stated previously, it is logical that clients would attend sessions, share information, and take risks when they believe they are respected, are cared for, and have mutually agreeable goals with their therapist, and conversely, it is logical that, when they begin to feel better, they would reflect with increasing fondness on the therapeutic relationship. The extant research on the role of the therapeutic relationship and outcome, specifically in CBT, focuses almost exclusively on the therapeutic alliance. Early research on the therapeutic alliance (as measured in the early sessions of treatment) and outcome in CBT found that the strength of the therapeutic alliance increased after prior symptom change, contrary to the prevailing assumption that a sound alliance is necessary before symptom change can occur (DeRubeis & Feeley, 1990; Feeley et al., 1999). When sudden gains occur in session (e.g., a substantial drop in scores on a standard depression inventory from one session to the next), the strength of the therapeutic alliance increases, which is presumed to set the stage for important cognitive changes in subsequent sessions (Tang & DeRubeis, 1999). Falkenström et al. (2016) found that the alliance predicted depressive symptoms not only in the subsequent session but also in the session thereafter in clients receiving either CBT or interpersonal psychotherapy (IPT). More generally, research on the association between alliance and outcome in the broader psychotherapy research literature has found that the strength of the alliance predicts outcome even when prior change has been controlled (Barber et al., 2000; Klein et al., 2003). Results from the studies clearly demonstrate the broad trend that outcome in CBT (and in psychotherapy in general) is associated with the therapeutic alliance. However, the specific mechanism by which the therapeutic alliance enhances outcome, either in a single session or at the end of the course of therapy, remains elusive. Specifically within the context of CBT, there is still a question as to whether the strength of the alliance is more or less important than adherence to concrete cognitive therapy techniques (Webb et al., 2012). Moreover, some research has yielded results that are not particularly compelling; for example, in one study, the association between the strength of the therapeutic alliance and outcome was rendered nonsignificant when usage of antidepressant medications was covaried in analyses (Strunk et al., 2012). As might be expected in light of CBT’s distinctive problem focus, cognitive behavioral therapists have a particular interest in discerning the specific components of the therapeutic alliance that are associated with outcome in CBT. The therapeutic alliance components that focus on the agreement between the therapist and clients about the goals and tasks of therapy appear very consistent with the most central tenets of CBT, whereas the emotional bond with the



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therapist is a factor that is central but equally as important in all psychotherapeutic approaches. Webb et al. (2011) examined just this issue. Their results indicated that early session ratings of goals and tasks predicted subsequent symptom change. Moreover, when therapeutic alliance was measured later in the course of therapy, both agreement on goals and tasks and the strength of the emotional bond were predicted by prior symptom change. Webb et al. concluded that this pattern of results reinforces the importance of early agreement on the goals and tasks of therapy and that the strength of the bond between the therapist and client may be more of a function of the gains clients make in treatment. All the research described to this point in this section used a measure of the therapeutic alliance based upon Bordin’s (1979) definition. One unique study investigated the therapeutic alliance and its association with outcome using a different definition of the therapeutic alliance in 193 depressed inpatients participating in intensive CBT (Schwartz et al., 2018). Two aspects of the therapeutic alliance considered in this study were the clients’ reports of their emotional bonds and contentment (or satisfaction) with their therapist. Not only did results indicate that higher ratings in these domains were associated with lower depression scores posttreatment, the authors determined that the contentmentoutcome link was mediated by clients’ reports of mastery and self-efficacy. These results suggest that satisfaction with the therapeutic relationship might instill confidence in clients in their ability to enact cognitive and behavioral change, which creates a positive self-fulfilling prophecy that facilitates a good outcome. In contrast, no mediator emerged to explain the association between clients’ reports of emotional bonds with their therapist and outcome. Consistent across the select studies reviewed in this section is that when separate components of the alliance are considered, components like collaboration and contentment, rather than the emotional bond, have stronger associations with outcome. An argument could also be made that there is a synergy between the strength of the therapeutic alliance and therapist adherence to the CBT approach and that, together, they predict outcome. Weck et al. (2015) examined the contributions of the therapeutic alliance and therapist adherence and competence in predicting treatment successes and failures in clients receiving CBT for depression, social anxiety, or hypochondriasis. The therapeutic alliance was measured by an inventory different from the one used by DeRubeis, Webb, and their colleagues, described previously, and it was focused primarily on collaboration between the therapist and client in working together toward mutually defined goals. Success was defined as either no longer meeting diagnostic criteria by the end of treatment or demonstrating a significant symptom drop on a clinical interview or self-report measure of the corresponding mental health problem. Failure was defined as dropout, diagnosis still present at the end of treatment, or an increase in symptoms on a clinical interview or self-report inventory. Results indicated that the therapeutic alliance was rated higher in treatment successes than in treatment failures. Moreover, when therapists had a better

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therapeutic alliance, therapist adherence was more strongly related to treatment outcome. In all, this body of research suggests that the therapeutic alliance is associated with outcome, although the direction of effect is still in question. Moreover, it seems that agreement and collaboration between the therapist and client on the goals and tasks of therapy, and the client’s satisfaction with that agreement, are more directly associated with outcome than the emotional bonds between the therapist and client. As indicated by the writings of A. T. and J. S. Beck, a strong therapeutic relationship is, indeed, essential in CBT, although there are clearly other elements of treatment that are associated with outcome, such as therapist adherence, therapist competence, and a host of other variables that have been considered by expert cognitive behavioral therapists and are not the subject of this chapter. It is intriguing that the emotional bond between the therapist and client is not consistently associated with outcome. Although it could easily be surmised that this dimension of the therapeutic alliance is less important than other dimensions in explaining outcome in CBT, I would exert caution in drawing this conclusion. It could be that the emotional bond between the therapist and client facilitates other important outcomes, such as retention in treatment, the completion of homework, or the return to therapy when a relapse is recognized. All of these alternative outcomes could be considered in future research in which outcome is defined more broadly than the reduction of symptoms or the absence of a psychiatric diagnosis.

CLINICAL GUIDELINES Previously, ways in which some of the fundamental tenets of CBT cultivate and enhance the therapeutic relationship were described. In this section, specific approaches for modeling the use of CBT strategies to strengthen the relationship are considered, along with ways to handle common occurrences that emerge in therapeutic relationships over time. In addition, this section highlights events that can occur in the therapeutic relationship (e.g., ruptures, transference, countertransference) and ways in which CBT interventions can be quite powerful in addressing them. It is hoped that the examples begin to illustrate ways to achieve what Jonathan Shedler (2015) described as the goal of meaningful psychotherapy—therapist self-awareness, knowledge, and courage to see and speak about what matters. Psychoeducation Cognitive behavioral therapists provide psychoeducation to their clients about the cognitive behavioral model, cognitive and behavioral principles of change, and CBT’s efficacy. The aim of psychoeducation is to empower clients with knowledge so that they need not remain in therapy indefinitely and so that they develop the know-how and confidence to generalize cognitive behavioral



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principles into their everyday lives without relying on a therapist. Cognitive behavioral therapists do not impose psychoeducation upon clients; instead, they respond to clients’ unique inquiries with psychoeducation, and when they sense a need to elaborate a bit upon it, they ask clients’ permission that it is okay to do so. Psychoeducation enhances the therapeutic relationship because it instills confidence about the promise for change. Many clients report that they appreciate the information that is provided through psychoeducation because it helps them better understand themselves and the problems that they bring to treatment. At times, clients present with a negative attitude toward treatment, perhaps because they perceive CBT as being overly simplistic or because they believe that they have tried CBT in the past and that it did not “work.” In these cases, cognitive behavioral therapists ask their client if it is okay to shed some light on their concerns, and they deliver psychoeducation in a warm, supportive manner, all the while monitoring the impact it is having on the client’s negative attitude and adjusting as necessary. Many clients indicate that the patience and care that cognitive behavioral therapists demonstrate in delivering psychoeducation to quell any concerns they might have about therapy go a long way in establishing a trusting therapeutic relationship. Cognitive Restructuring Cognitive restructuring is the process of identifying, evaluating, and modifying unhelpful thinking that exacerbates emotional distress. Cognitive behavioral therapists regularly help their clients acquire these skills and then apply them to upsetting situations that their clients encounter in their daily lives. However, savvy cognitive behavioral therapists are alert for ways in which cognitive restructuring can be applied to enhance the therapeutic relationship or to address issues that arise within it. Many clients, for example, have concerns about being judged negatively by others, and this concern extends to the therapist. The therapist might pursue gentle Socratic dialogue such as “Tell me what you know about me from our work together, and how that jibes with being judgmental of you” or “Has there been a specific time in your past when you felt judged by another person? How does what is happening between the two of us feel similar or dissimilar?” When cognitive behavior therapists ask these kinds of questions in a gentle, curious, and nonthreatening manner, most clients see that they are imposing their fears about being judged negatively onto the therapist, and they realize that the therapist is truly accepting of them regardless of what they are discussing. Taking the time to examine the accuracy of clients’ reactions toward the therapist can be an important learning experience because clients (a) learn to recognize when they are making assumptions about others’ views of them and (b) gain practice in checking out these assumptions in an interpersonally appropriate manner to base their views in evidence rather than conjecture. Moreover, the process of applying cognitive restructuring in this way provides an important

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experiential learning opportunity, as it supplies evidence that is inconsistent with a common prediction that clients often report, which is that talking openly about something that is happening in the relationship will necessarily lead to conflict, discomfort, and hard feelings. Social Skills Modeling Social skills are the verbal and nonverbal skills we use to communicate messages to others and engage in back-and-forth interaction. Cognitive behavioral therapists can make use of their interactions with clients in session to model appropriate social skills and provide a space for their clients to practice the use of appropriate social skills. Verbal content-based social skills training helps clients craft what to say in an array of situations ranging from small talk to potentially difficult conversations about hot or conflictual topics. Verbal social skills unrelated to content can also be considered, such as the speed or loudness of speech. Moreover, many cognitive behavioral therapists provide coaching in nonverbal social skills, such as eye contact, gestures, fidgetiness, and posture. Social skills can be targeted in treatment indirectly as the therapist continually models appropriate and effective skills in interactions with the client. However, the therapist can also use what is happening in the therapeutic relationship to teach about, model, and practice the modification of social skills that are causing life interference for clients. Cognitive behavioral therapists seize the very first opportunities to model appropriate social skills when they are scheduling the first appointment with a client and when they meet a client for the first visit. They speak confidently, but they model the tone, loudness, and rate of speech on the basis of the client’s reaction to them and other aspects of the client’s clinical presentation that are relevant to social interaction. They demonstrate warmth and openness to what their clients are saying by asking follow-up questions, looking directly at clients (instead of around the room or down at the chart), and assuming an open postural stance and even leaning forward to demonstrate interest in what the client is saying. If a client is describing problems with social skills and makes a comment like, “Well, it is easy for you, you really have a knack for connecting with others,” the therapist can ask a question like, “What is it about the way in which I interact with you that you find inviting? How might you infuse that into your interactions with others?” Such questioning prompts clients to consider social skills in the context of the therapeutic relationship and apply that learning to relationships in their everyday lives. When a potential rupture arises in the therapeutic relationship, the handling of it with the utmost social skill can provide a corrective learning experience for the client. In most cases, empathy and validation can go a long way. In but one example, upon entering my waiting room, a new client berated me for giving her substandard directions to my office and for having paperwork that she viewed as too cumbersome. Rather than responding in a defensive manner, I said (in a warm, inviting voice) something like, “Well, gosh, I will have to take another look at the directions that I send to my new clients. I’m so glad you



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made it here, nonetheless. Can I get you some coffee or water before we get started? I realize you have walked a good distance from the outer parking lot.” By the end of the session, she apologized for her abrupt stance with me, indicating that I was nothing like she had expected me to be (which, apparently, was the expectation that I would be stern and rigid) and that she was afraid that my response toward her would be anger because she did not complete all of the new client paperwork. I attributed her change of attitude toward me to the socially skilled, nondefensive stance that I took when she was initially confrontational toward me. At times, therapists will find themselves in the position in which clients do not “come around” with empathy and validation alone, such that clients continue to behave in a mildly belligerent or inappropriate manner. In these cases, I encourage cognitive behavioral therapists to take a dialectic stance, communicating empathy and validation while maintaining firm and consistent boundaries. After the situation has resolved, it can be helpful to ask the client what they learned from the experience, including the way in which the “lesson learned” can be applied to other relationships and reflection on which social skills were central in resolving the issue. Finally, cognitive behavioral therapists can help clients practice the use of social skills to facilitate interpersonal relationships. For example, for clients who worry about making small talk, therapists can have the client make small talk with them right in session. Not only does this exercise give the client a unique opportunity to practice social skills, but it also can enhance the therapeutic relationship because the therapist can learn things about the client that had not been evident until that time. My favorite instance of this was when I was working on social skills development with a young man who had been diagnosed with a psychotic disorder and struggled mightily with social anxiety. He enjoyed frequenting music venues, and he very much wanted to talk with others who attended shows at these venues with the goal of developing friendships with like-minded people. To address this goal, the two of us practiced a 5-minute small talk conversation about music, favorite bands, area venues, and the like, which had the potential to be relevant to conversations he would have with others who would frequent such a venue. I emerged from the conversation with a genuine feeling of closeness to my client, which I had not felt to that point, and the client indicated that he learned many ideas for keeping conversations going. Thus, the practicing of small talk allowed the client to acquire important skills that could apply in an arena that he very much valued. Moreover, our therapeutic relationship was enhanced significantly because of the genuine pleasure that we experienced in our interaction, the learning that occurred about one another’s preferences in music, and the client’s satisfaction that we were focusing on an area that had great relevance to his life. Ruptures A rupture occurs when there is a breakdown in the collaborative relationship between the client and therapist, ranging from mild tension to significant

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conflict or withdrawal (Safran et al., 2011). Drawing from Bordin’s (1979) conceptualization of the therapeutic alliance, Safran and Muran (2000) indicated that a rupture consists of “strains in the alliance . . . consisting either of disagreements about the tasks and goals of therapy or problems in the bond dimension” (p. 16). Ruptures allow for clients to have corrective emotional experiences (Alexander & French, 1946) that can help them generalize their new learning to improve relationships outside the psychotherapy session, much in the same way that I suggested earlier in regard to transference and countertransference. Thus, in the past two decades, attention has been devoted to how therapists handle rupture and tension in the therapeutic relationship to ultimately strengthen the relationship, often termed negotiation (Doran, 2016; Safran & Muran, 2006). Ruptures have only occasionally been the subject of study in research on CBT outcome. An intriguing study examining ruptures within the context of cognitive therapy for personality disorders found that both the strength of the early therapeutic alliance (i.e., before symptom change occurred) and the presence of an episode in which a rupture occurred but was repaired successfully predicted outcome in treatment (Strauss et al., 2006). In fact, most of the clients who experienced one of these “rupture-repair” episodes reported pre-post treatment symptom reductions of over 50% or greater on all outcome measures. This pattern of results suggests that a moderate level of tension in the therapeutic relationship has the potential to be optimal. Too little tension could signal that the therapist and client are overlooking areas that require focused work (which can be difficult at times) and the necessary expression of distressing affect, and too much tension could signal a breakdown in the therapeutic alliance that interferes with progress in treatment. However, it is important to note that one recent study found that ruptures and subsequent increases in the therapeutic alliance are more strongly associated with outcome in psychodynamic psychotherapy than in CBT (Zilcha-Mano et al., 2019). Thus, more empirical research and clinical thoughtfulness is needed to understand ways to maximize the repair of ruptures within a cognitive behavioral framework. The clinical implication of this is to acknowledge the rupture and deal with it in a nondefensive, above-board manner with the client. Cognitive behavioral therapists can be in tune with subtle expressions of negative affect from clients during the course of a session and use guided questioning to detect their presence and associated meaning. They can facilitate the use of cognitive restructuring to evaluate the manner in which clients have interpreted the therapist’s behavior or their interaction with the therapist, described in more detail in the subsequent section. They can model effective interpersonal skills in talking in an open, sensitive manner about the rupture and use social problem solving to arrive upon a mutually satisfactory solution. All the while, they communicate a warm, inviting, and validating stance to demonstrate that they can be present with the client’s negative affect and possible negative evaluation of them, normalize the client’s reaction, and help the client gain wisdom and growth from the experience.



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Transference and Countertransference One of the most common comments I receive from supervisees who are hoping to become certified cognitive behavioral therapists is that they believe acknowledgement and consideration of transference and countertransference are off-limits in CBT. Although it is true that many cognitive behavioral therapists might not necessarily use the words “transference” and “countertransference” or interpret them in the same way that a psychodynamic clinician might, the reactions clients have to their therapist and the therapeutic process and the reactions that therapists have to their clients provide very important information for the case formulation and very fertile grounds for important cognitive behavioral work to be done. When a cognitive behavioral therapist suspects that a client is demonstrating a transference reaction to them, the therapist might make a general observation such as “I’m noticing that you’re having a strong reaction toward me right now,” and they might ask a general question such as “Could you put words onto what you are experiencing, internally, right now?” When the client arrives upon an important realization (e.g., “That made me feel exactly like I was 12 years old again and was being scolded by my mother.”), the cognitive behavioral therapist provides an explicit statement of acknowledgement and validation (e.g., “Oh what a powerful reaction! No wonder you’ve found our conversation so upsetting.”). The cognitive behavioral therapist is simultaneously cognizant of demonstrating a stance of unconditional positive regard and empathy and providing space for the client to emote, while framing it in light of the case formulation that has been developed in collaboration with the client and gently posing Socratic questions to examine the accuracy and helpfulness of the reaction. As the client develops insight into the (possibly) maladaptive cognitive behavioral pattern into which they are falling, the cognitive behavioral therapist asks questions to facilitate a corrective learning experience, such as “What wisdom are you taking from this discussion here?” and “How might the insight you are gaining apply to other relationships in your life?” One of my favorite (albeit fairly basic) examples of dealing with my own reaction to a client’s style or behavior was with a young man who was diagnosed with obsessive-compulsive disorder and who demonstrated some traits of autism spectrum disorder. In session, he spoke very quickly and provided so much detail that I found it difficult to follow him; over time, I began to dread seeing him and often conjured the image of a babushka doll in which he told stories, within stories, within stories, and often did not respond readily to redirection. Despite my reaction to him, our therapeutic relationship developed nicely over time because he was quite compliant with homework, and he experienced significant reductions in his obsessive-compulsive symptoms. After approximately 12 sessions, he was describing some negative feedback he received about his interpersonal style, and I asked permission to share my observation about the way in which he communicated. I shared my feedback in a gentle way, free of judgment, and doing so allowed him to recognize that

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his communication style was actually another manifestation of his obsessivecompulsive disorder in that he believed that he needed to provide every single detail about scenarios he was describing or else the other person would not truly understand him. Moreover, he quickly recognized that this very interpersonal style had been associated with negative repercussions, as some time before the commencement of therapy, he had been promoted to a managerial position but then quickly demoted because he could not communicate effectively with his supervisees. He took the feedback as a challenge to practice effective social skills (and, thus, we used some of the guidelines described in the previous section to practice social skills in the context of our relationship). At the time of his final session, he was participating in speed dating sessions, something I could never have imagined for someone with his interpersonal style. Now, I reflect back upon the course of our therapeutic work with nothing but fondness. In all, clients’ reactions to their therapist and the therapeutic process and the therapists’ reactions to their clients’ behavior and interpersonal styles have the potential to facilitate highly effective cognitive behavioral work in session. Cognitive behavioral therapists are encouraged to be well versed in strategies to have keen awareness of their own and others’ cognitive and emotional reactions in order to facilitate a focus on these reactions during the course of treatment. When conceptualized as fertile ground for the advancement of the case formulation and the demonstration of cognitive and behavioral strategies in “real time,” these reactions can be viewed as opportunities for growth for both the client and therapist, rather than experiences that are to be dreaded or avoided. Personally, some of my fondest memories of clients are of instances in which a client and I experienced a rupture in the therapeutic relationship characterized by distinctively negative emotional reactions, we repaired it skillfully using the cognitive behavioral framework, and by the end of treatment, the client regarded the work done in treatment as transformative and pivotal.

CASE ILLUSTRATION: USING COGNITIVE BEHAVIORAL STRATEGIES TO REPAIR A RUPTURE “Jane” is a 52-year-old woman with a mixed depressive-anxious clinical presentation who sought treatment for stress associated with her job as assistant manager of a large restaurant. She formed a strong relationship with her therapist and readily acquired and applied many cognitive behavioral tools (e.g., cognitive restructuring, problem solving) to address her life problems. In fact, she sometimes sent her therapist messages in between sessions saying that she “CBT’d the hell” out of a stressor that she was facing, which was endearing to her therapist and served to strengthen their bond. During the course of treatment, it became evident that avoidance of close relationships was a significant factor that perpetuated loneliness, isolation, and behavioral inactivity (especially on her days off work). After her initial treatment goals were met, she



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continued in CBT with her therapist at a maintenance level (i.e., sessions every 2–4 weeks) to monitor and devise creative strategies to slowly modify this interpersonal pattern. During the course of maintenance treatment, Jane became romantically involved with a much younger man in his 20s with whom she worked. She kept the relationship secret because she was his supervisor. She and her therapist spent time in several sessions evaluating the strengths and drawbacks of this relationship, the therapist demonstrating unconditional acceptance of the unorthodox nature of the relationship. It was even concluded that, in some ways, the relationship was helping her achieve important growth because she was engaging in rather than avoiding a close relationship and learning how to let down her guard. The relationship lasted for a few months, and right before the therapist was going to go on maternity leave, Jane indicated that she was going to end the relationship because, even if it helped her grow, it was also inconsistent with the ethical standards on which she prided herself at work. The therapist expressed support for Jane’s decision and helped her consolidate the way in which this relationship contributed to the modification of negative beliefs about close relationships that Jane held so closely. The therapist went on maternity leave, and when she returned 10 weeks later, Jane came in for a session. The following conversation took place: JANE:

Oh yeah, I forgot to tell you that I’m back with John.

THERAPIST: Oh really? I’m surprised. [Therapist spontaneously expressed

this sentiment while remembering Jane’s conviction that she was going to end the relationship.] JANE:

[smiling] Yeah, I guess it didn’t stick.

THERAPIST: Well, as we had contemplated in previous sessions, there cer-

tainly are good reasons for remaining in the relationship. Nothing more was said about the relationship in this session, and Jane and her therapist continued to focus on the other issues that Jane had identified as being important to cover in that session. Jane had scheduled another session 2 weeks later. She was 10 minutes late for session, which was unlike her, and she seemed much more distant than usual. The following conversation took place during the bridge from the previous session: THERAPIST: Did you have any negative reactions to our session 2 weeks ago,

or was there anything that you thought I got wrong? JANE:

[narrowing her eyes] Yes! I just felt so judged by you!

THERAPIST: [using an empathic tone of voice] Oh my goodness, you felt

judged by me. [pause] First of all, I really have to commend you

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for bringing this to my attention. It takes a lot of courage to do that. And second, I’d very much like to talk more about this so that we might resolve any hard feelings. JANE:

Well, I don’t know what more there is to say, I just felt judged when I told you I was back with John.



[Therapist again expressed empathy, warmth, and praise for bringing this to the fore; confirmed with Jane that it was, indeed, okay to discuss it further; and asked Jane if there were any other issues she had hoped to address in session before diving into discussion of this one.]

THERAPIST: First and foremost, I would like to apologize to you for con-

ducting myself in a manner that seemed judgmental. That certainly is never my intent with you. And, I truly do believe that there are aspects of this relationship that are helping you to practice closeness with others, so in my heart, I truly do not view it in a negative light. [modeling the social skill of taking responsibility for making a mistake without being overly ingratiating] JANE:

Yeah, I know you do. I don’t know why I felt so judged.

THERAPIST: Would it be helpful to examine it more closely to see what we

can learn from it? [modeling the cognitive restructuring process of evidence gathering] JANE:

Sure, let’s do that.

THERAPIST: Can I share what I remember about that conversation? JANE:

Yes, go ahead.

THERAPIST: What I remember is that you told me that you were back with

John, and my response was something like, “Oh, I’m surprised.” Now, granted, that might not have been my best therapeutic moment! [Jane and her therapist both chuckle, as a shared experience of humor had been part and parcel of their therapeutic relationship to this point.] However, I had that reaction because I had been recalling the conviction with which you had decided that it wasn’t in the best interest to continue the relationship. So, my genuine response was truly that I was surprised. But that surprise had no valence associated with it—I was not viewing the fact that you were back with John as good or bad, because I truly don’t view it as a good or a bad thing. JANE:

It’s really interesting that you say that. [pause] You know what I think is going on?



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THERAPIST: [smiling warmly] What’s that? JANE:

I think I was judging myself. I know how much I’ve criticized other people in management for sleeping with their employees, and I don’t want to be like that. So I’m being a hypocrite. Rather than facing something about myself that is embarrassing, I turned it on you.

THERAPIST: [continue to smile warmly] Hmmm, you’re right, this is interest-

ing. So, the original way you were viewing this situation is that I was being judgmental, but now? [prompting Jane to articulate an adaptive viewpoint to replace her original perception] JANE:

Now I realize that it’s really myself not liking the choice that I made. You were fine. You’re never judgmental of me. That’s why I’ve worked with you for this long.

THERAPIST: It goes to show that there are many forces that contribute to the

way that we view a situation. I’d also encourage you to give yourself a break. There are several layers to this particularly complex situation. JANE:

Thank you for saying that. It just feels like if anyone else knew what I was doing, they would look at me as if I were the worst human being on the planet.

THERAPIST: [expressing unconditional positive regard] I think you’re far, far

from the worst human being on the planet. You’re a human being who has been isolated from others for many years, and a reminder of what it is like to connect with another person can feel amazing. JANE:

I guess we need to work on ways for me to get that connection in more appropriate ways?

THERAPIST: [smiling] Yes, we can absolutely do that. Perhaps we can revisit

the goals for our work together in light of this conversation? JANE:

That would be great.

THERAPIST: Before we do that, can you tell me what you have learned from

this misunderstanding between the two of us? JANE:

That you’re never being judgmental of me. That it’s on me if I feel like that.

THERAPIST: Well, it is true that I would not intentionally be judgmental of

you. But, again, I’d like to help you to be a bit kinder to yourself. There very well have been and will again be times in which I might not respond optimally to something that you have said. So it’s not all on you. A good lesson I’m taking away from this is

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that you and I are both human, with warts and all, and that we can use kindness, compassion, and the good will that we have developed in our relationship as a lens to interpret any exchange we might have that might not seem quite right. JANE:

Fair enough! I think that this is a great lesson to take away from all of this.

Jane continued to see her therapist for six more sessions, at which time she truly ended the relationship with John and focused on rebuilding relationships with some college friends whom she had recently run across at a reunion. She applied the cognitive restructuring, social skills, and self-compassion tools that she developed in therapy, including as a result of this possible rupture, to enhance these relationships. In the subsequent several years, she sent her therapist occasional selfies taken with her three college friends vacationing at the beach, expressing that therapy helped her see the value of close relationships and gave her an opportunity to practice negotiating them (and she included the relationship with the therapist among her close relationships). Approximately 6 years after the completion of CBT, Jane contacted the therapist to resume sessions after she had been diagnosed with terminal cancer, stating that the therapeutic relationship was extremely valuable to her and that she hoped to have some of the comfort of that relationship as she dealt with end-of-life issues.

CONCLUSIONS AND FUTURE DIRECTIONS It is my firm belief that some of the best examples of CBT are done in the context of understanding, addressing, and resolving an issue in the therapeutic relationship in a way that advances the client’s treatment goals and provides an important corrective learning experience. Many fundamental aspects of CBT (e.g., collaboration, solicitation of feedback, respect for individual differences, guided discovery) contribute a great deal to the development, enhancement, and repair of the therapeutic relationship. Mindfulness of nonspecific features of psychotherapy, such as warmth, genuineness, and unconditional positive regard, can provide an inviting tone or context in which these fundamental aspects are executed in general, as well as in instances in which the relationship is the focus of therapeutic work. It is also my belief that, when CBT is delivered with an eye toward seizing opportunities to enhance the therapeutic relationship, the connection that is formed is quite heartfelt, meaningful, and memorable to both the therapist and client. The future directions for research on the role of the therapeutic relationship in CBT are abundant. With a few exceptions (e.g., borderline personality disorder; Bedics et al., 2015; bulimia nervosa; Accurso et al., 2015), the majority of the research on the therapeutic relationship in CBT has focused on clients with depression. Clearly, it is important for empirical research to extend to other



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types of psychopathology. In but one example, I often lecture about the importance of a strong therapeutic relationship in the delivery of exposure therapy for clients with anxiety-related disorders, as facing their “worst fears” is exceptionally brave and, at times, requires a great deal of support in the early stages of treatment. A useful addition to the literature would be an empirical demonstration of the manner in which the strength of the therapeutic relationship early in the course of exposure-based CBT for anxiety-related disorders is associated not only with outcome but also with client retention and completion of homework in between sessions. A second line of future research would be to examine a very wide array of components of the therapeutic relationship and their association with outcome. I am struck by the definition of the therapeutic alliance described by Bedics et al. (2015), who focused on client commitment, therapist understanding, and agreement on goals as being paramount to the alliance. Although these factors are, undoubtedly, important ones to consider, they are also decidedly in the “CBT spirit” and do not focus on clients’ perception of connectedness, felt sense of being understood, and sense of being in a safe, nonjudgmental environment, all of which are also important for a strong therapeutic relationship. Indeed, many scholar-clinicians have identified important aspects of the therapeutic relationship other than the “tasks” associated with the alliance, including expressed empathy, positive regard, and genuineness (Castonguay & Beutler, 2006; Cronin et al., 2015; Norcross & Lambert, 2011). Thus, it is possible that research demonstrating that the therapeutic alliance (relationship) is a significant predictor of outcome in CBT has achieved its results as an artifact of the way in which the therapeutic alliance (relationship) is defined. Continued scholarly inquiry into the aspects of the therapeutic relationship beyond collaboration and agreement on the tasks and goals of therapy would be welcomed. A third line of scholarly inquiry would be to examine what makes a session “successful” or “unsuccessful” from the perspective of the therapeutic relationship. For example, when a cognitive behavioral intervention, such as cognitive restructuring or exposure, yields its desired outcome, is this itself the factor that is associated with a reduction in symptoms or an increase in functioning, or is it the shared experience with the therapist providing support, guidance, and cheerleading that affects this positive outcome? Or are there instances when a cognitive behavioral intervention proves to be unsuccessful but the therapeutic relationship is enhanced, nevertheless, which in turn affects outcome? These sorts of questions are ones that require sophisticated research designs and statistical models. However, from a clinical perspective, they raise the possibility that a skilled and interpersonally effective handling of an unsuccessful intervention by the clinician could provide an even more pivotal clinical experience than if the intervention had been successful in a more straightforward manner. More broadly, much scholarship has been published over the past century on the importance of the therapeutic relationship in psychotherapeutic traditions outside the cognitive behavioral realm. I call upon those in the CBT community to become familiar with this important, often older, literature and contemplate the lessons that can be learned from these traditions to elevate our

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work, especially in the realm of using the therapeutic relationship as a catalyst for change.

REFERENCES Accurso, E. C., Fitzsimmons-Craft, E. E., Ciao, A., Cao, L., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., Crow, S. J., Wonderlich, S. A., & Peterson, C. B. (2015). Therapeutic alliance in a randomized clinical trial for bulimia nervosa. Journal of Consulting and Clinical Psychology, 83(3), 637–642. https://doi.org/10.1037/ccp0000021 Alexander, L. B., & French, T. (1946). Psychoanalytic therapy. Ronald Press. Bachelor, A. (1995). Clients’ perceptions of the therapeutic alliance: A qualitative analysis. Journal of Counseling Psychology, 42(3), 323–337. https://doi.org/10.1037/ 0022-0167.42.3.323 Barber, J. P. (2009). Toward a working through of some core conflicts in psychotherapy research. Psychotherapy Research, 19(1), 1–12. https://doi.org/10.1080/ 10503300802609680 Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2000). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Journal of Consulting and Clinical Psychology, 68(6), 1027–1032. https://doi.org/10. 1037/0022-006X.68.6.1027 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press. Bedics, J. D., Atkins, D. C., Harned, M. S., & Linehan, M. M. (2015). The therapeutic alliance as a predictor of outcome in dialectical behavior therapy versus nonbehavioral psychotherapy by experts for borderline personality disorder. Psychotherapy: Theory, Research, & Practice, 52(1), 67–77. https://doi.org/10.1037/a0038457 Bender, D. S. (2005). The therapeutic alliance in the treatment of personality disorders. Journal of Psychiatric Practice, 11(2), 73–87. https://doi.org/10.1097/00131746200503000-00002 Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16(3), 252–260. https://doi.org/10. 1037/h0085885 Bowlby, J. (1969). Attachment and loss: Vol. 1. Loss. Basic Books. Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change: A task force on participants, relationships, and techniques factors. Journal of Clinical Psychology, 62(6), 631–638. https://doi.org/10.1002/jclp.20256 Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, & Practice, 43(3), 271–279. https://doi.org/10.1037/0033-3204.43.3.271 Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the “scientist-practitioner” model in psychotherapy. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 81–131). Allyn & Bacon. Cronin, T. J., Lawrence, K. A., Taylor, K., Norton, P. J., & Kazantzis, N. (2015). Integrating between-session interventions (homework) in therapy: The importance of the therapeutic relationship and cognitive case conceptualization. Journal of Clinical Psychology, 71(5), 439–450. https://doi.org/10.1002/jclp.22180 Cushman, P., & Gilford, P. (2000). Will managed care change our way of being? American Psychologist, 55(9), 985–996. https://doi.org/10.1037/0003-066X.55.9.985



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DeRubeis, R. J., & Feeley, M. (1990). Determinants of change in cognitive therapy for depression. Cognitive Therapy and Research, 14(5), 469–482. https://doi.org/10.1007/ BF01172968 Doran, J. M. (2016). The working alliance: Where have we been, where are we going? Psychotherapy Research, 26(2), 146–163. https://doi.org/10.1080/10503307.2014. 954153 Elvins, R., & Green, J. (2008). The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review, 28(7), 1167–1187. https:// doi.org/10.1016/j.cpr.2008.04.002 Falkenström, F., Ekeblad, A., & Holmqvist, R. (2016). Improvement of the working alliance in one treatment session predicts improvement of depressive symptoms by the next session. Journal of Consulting and Clinical Psychology, 84(8), 738–751. https:// doi.org/10.1037/ccp0000119 Feeley, M., DeRubeis, R. J., & Gelfand, L. A. (1999). The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 67(4), 578–582. https://doi.org/10.1037/0022006X.67.4.578 Gelso, C. J. (2011). The real relationship in psychotherapy: The hidden foundation of change. American Psychological Association. https://doi.org/10.1037/12349-000 Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship: Theory, research, and practice. Wiley. Gilbert, P., & Leahy, R. L. (Eds.). (2007). The therapeutic relationship in cognitive behavioral psychotherapies. Routledge. https://doi.org/10.4324/9780203099995 Gluhoski, V. L. (1994). Misconceptions of cognitive therapy. Psychotherapy: Theory, Research, & Practice, 31(4), 594–600. https://doi.org/10.1037/0033-3204.31.4.594 Greenberg, L. S. (1994). What is “real” in the relationship? Comment on Gelso and Carter (1994). Journal of Consulting Psychology, 41(3), 307–309. https://doi.org/b5zqbp Greenson, R. R. (1965). The working alliance and the transference neurosis. Psychoanalytic Quarterly, 34(2), 155–181. https://doi.org/10.1080/21674086.1965.11926343 Greenson, R. R. (1967). Techniques and practice of psychoanalysis. International Universities Press. Greenson, R. R. (1971). The “real” relationship between the patient and the psychoanalyst. In M. Kanzer (Ed.), The unconscious today: Essays in honor of Max Schur (pp. 213– 232). International Universities Press. Hays, P. A. (2016). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (3rd ed.). APA Books. https://doi.org/10.1037/14801-000 Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). Oxford University Press. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. https://doi.org/fjvvfk Karlin, B. E., & Wenzel, A. (2018). Evidence-based psychotherapy shared decision-making toolkit for mental health providers. Education Development Center. Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavioral therapy: A clinician’s guide. Guilford Press. Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., Arnow, B., Blalock, J. A., Manber, R., Markowitz, J. C., Riso, L. P., Rothbaum, B., McCullough, J. P., Thase, M. E., Borian, F. E., Miller, I. W., & Keller, M. B. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Consulting and Clinical Psychology, 71(6), 997–1006. https://doi.org/cmsqch

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Lambert, M. J., & Simon, W. (2008). The therapeutic relationship: Central and essential in psychotherapy outcome. In S. F. Hick & T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp. 19–33). Guilford Press. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. https://doi.org/10.1037/0022-006X.68.3.438 Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62(1), 185–190. https://doi.org/ 10.1037/0022-006X.62.1.185 Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy: Theory, Research, & Practice, 48(1), 4–8. https://doi.org/10.1037/a0022180 Okamoto, A., Dattilio, F. M., Dobson, K. S., & Kazantzis, N. (2019). The therapeutic relationship in cognitive behavioral therapy: Essential features and common challenges. Practice Innovations, 4(2), 112–123. https://doi.org/10.1037/pri0000088 Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press. Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, & Practice, 43(3), 286–291. https://doi.org/10.1037/0033-3204.43.3.286 Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy: Theory, Research, & Practice, 48(1), 80–87. https://doi.org/10.1037/ a0022140 Schwartz, C., Hilbert, S., Schlegl, S., Diedrich, A., & Voderholzer, U. (2018). Common change factors and mediation of the alliance-outcome link during treatment of depression. Journal of Consulting and Clinical Psychology, 86(7), 584–592. https://doi. org/10.1037/ccp0000302 Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378 Shedler, J. (2015, March 18). The therapy relationship in psychodynamic therapy versus CBT: A good therapy relationship is more than warm feelings. Psychology Today. https://www.psychologytoday.com/us/blog/psychologically-minded/201503/ the-therapy-relationship-in-psychodynamic-therapy-versus-cbt Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., Laurenceau, J. P., & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337–345. https://doi.org/10.1037/0022-006X.74.2.337 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 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 Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67(6), 894–904. https://doi.org/10.1037/0022-006X.67.6.894 Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. Guilford Press. Webb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S. (2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom change. Journal of Consulting and Clinical Psychology, 79(3), 279–283. https://doi.org/10.1037/a0023252 Webb, C. A., Derubeis, R. J., Dimidjian, S., Hollon, S. D., Amsterdam, J. D., & Shelton, R. C. (2012). Predictors of patient cognitive therapy skills and symptom change in two randomized clinical trials: The role of therapist adherence and the therapeutic



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alliance. Journal of Consulting and Clinical Psychology, 80(3), 373–381. https://doi.org/ 10.1037/a0027663 Weck, F., Grikscheit, F., Jakob, M., Höfling, V., & Stangier, U. (2015). Treatment failure in cognitive-behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. British Journal of Clinical Psychology, 54(1), 91–108. https://doi.org/10.1111/bjc.12063 Wenzel, A. (2019). Cognitive behavioral therapy for beginners: An experiential learning approach. Routledge. https://doi.org/10.4324/9781315651958 Wolfe, B. E., & Goldfried, M. R. (1988). Research on psychotherapy integration: Recommendations and conclusions from an NIMH workshop. Journal of Consulting and Clinical Psychology, 56(3), 448–451. https://doi.org/10.1037/0022-006X.56.3.448 Young, J. E., & Beck, A. T. (1980). Cognitive Therapy Scale rating manual [Unpublished manuscript]. University of Pennsylvania. Zilcha-Mano, S., Eubanks, C. F., & Muran, J. C. (2019). Sudden gains in the alliance in cognitive behavioral therapy versus brief relational therapy. Journal of Consulting and Clinical Psychology, 87(6), 501–509. https://doi.org/10.1037/ccp0000397

II STRATEGIES AND TECHNIQUES

8 Cognitive Restructuring Christine Purdon

I

n the 1960s, Dr. Aaron T. Beck observed that people with depression exhibited internal thoughts and images that accounted logically for the problematic emotional and behavioral responses characteristic of their depression and that were fully accessible to awareness. He reasoned that accessing and altering these cognitions could produce constructive behavioral and emotional change. At around the same time, other theorists were also beginning to posit that cognition mediates the relation between a stimulus and behavior (e.g., Mahoney, 1974), an idea that is now considered fact (Dobson & Dozois, 2019). Furthermore, there was emerging evidence that altering internal selftalk produces improvement in mood and performance (e.g., Meichenbaum, 1974). Cognitive therapies began emerging in the 1970s and were distinctive in that, unlike behavioral models, they emphasized the importance of cognition, and, unlike psychodynamic models, they viewed the cognition-explaining emotional and behavioral symptoms as accessible and as a key to understanding and treating mental health difficulties in and of itself, as opposed to being a product of conflicts inaccessible to consciousness. Although A. T. Beck’s cognitive theory represents a departure from behaviorism and psychoanalysis, his theory incorporates key ideas of those traditions. For example, the model includes principles of classical and operant conditioning, and it recognizes that early childhood experiences help form core ideas about self, world, and future, which, in turn, inform the assumptions and situational appraisal that influence moment-to-moment emotion and behavior (A. T. Beck, 1976). For a more https://doi.org/10.1037/0000218-008 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  207 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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detailed history, see Dobson and Dobson (2017) and Volume 1, Chapter 1 of this book. A. T. Beck’s cognitive theory is based on assumptions that are empirically testable, and there is a vast literature now dedicated to examining the validity of its tenets. In turn, the model has evolved in response to empirical data, which may be why it arguably has been the dominant cognitive model since its introduction. Cognitive therapy and the family of cognitive behavioral therapies (CBTs) have also been subject to decades of empirical examinations of efficacy and effectiveness and are now identified in practice guidelines as a first-line treatment (with or without medication) for a wide range of mental health problems. This chapter focuses on cognitive restructuring as introduced by A. T. Beck and developed by scholar-practitioners such as Greenberger and Padesky (2016), Dobson and Dobson (2017), and J. S. Beck (2011). Cognitive restructuring is a fundamental feature of CBT. It is the process by which selected cognitions are treated as hypotheses rather than facts and examined within the context of all relevant information as opposed to just the information that is implicitly available via automatic attentional, memory, and other cognitive processes, as well as learning history. If situational appraisals (e.g., “My boss was really abrupt with me—I must have made an important error and now it’s going to be noted in my performance review!”) can be reconsidered in light of all available evidence (e.g., “He is under substantial pressure today from the head office and is being abrupt with everyone, and my work has been of the same quality as always.”), then there is opportunity for constructive emotional and behavioral change (e.g., “There actually is no reason to assume I have made an important error.”). As the person begins to identify the thoughts mediating the behavioral and emotional responses of complaint, recognize that thoughts are not facts, and bring the range and breadth of relevant information to bear on the appraisal, the beliefs and assumptions evoking that appraisal start to become untenable. Cognitive restructuring is the hallmark of cognitive therapy and of many therapies within the family of CBTs and has been a central therapeutic tool from the genesis of the model and the treatment deriving from it.

UNDERLYING THEORY The central theoretical premises underlying cognitive restructuring are that (a)  the special meaning of an event is “encased” in cognition, (b) cognition mediates the emotional and behavioral response to an event, (c) cognition is accessible and amenable to change, and (d) the accuracy and usefulness of cognition is subject to evaluation (A. T. Beck, 1976; Dobson & Dozois, 2019). The latter assumption derives from philosophers of the Stoic tradition who, according to A. T. Beck (1976), “considered man’s [sic] conceptions (or misconceptions) of events rather than the events themselves as the key to his emotional upsets” (p. 3). The cognitive model generally assumes that mental health diffi-



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culties are more likely to be characterized by poorly informed ideas about emotionally relevant events than by well-informed ideas, and even when an idea is well informed, a catastrophic misconception regarding its meaning or importance is likely to occur. Another idea that is central to A. T. Beck’s model is that people not only have an innate ability to successfully override misinterpretations, they also do so frequently, even when experiencing a mood disturbance. In general, people respond adaptively to their environment by recognizing the logical fallacy of initial misinterpretations, acquiring adequate information, and modifying their ideas accordingly. A. T. Beck (1976) wrote, “Man [sic] has the key to understanding and solving his psychological disturbance within the scope of his awareness” (p. 3). For example, if one of our family members has an accident at an intersection on a snowy day, our immediate response could be to perceive the intersection to be dangerous. However, after considering the actual base rate of accidents at the intersection and the number of times that we and others we know have used that intersection without incident, we are able to modify our conclusion to “this intersection is actually no more dangerous than most intersections; snow can make any intersection more dangerous.” Another construct of central importance to A. T. Beck’s model is that of the schema. In the field of psychology, this term refers to an operating framework for a category of people, places, and things in which previously encoded information about that category is stored. Schemata allow us to 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 (i.e., beliefs) about that category. For example, when we enter an establishment called a “restaurant,” we require no effortful processing to expect that there will be a menu from which we will choose something to eat, that what we choose will subsequently be served to us, and that we will need to pay for that food. We will also know that we cannot go into the kitchen to help ourselves, that we cannot take the things on the table home with us, and that we are expected to be courteous to those who serve us. The mental image the schema produces will be based on salient past experiences. One person’s image may be a luxurious carpeted dining room in which one eats a four-course meal served by black-clad waitstaff, or it may be a bustling place on a busy street where one lines up to order food and then carries it to a melamine table. All of this knowledge requires no effortful processing of the situation; it is implicit, produced by our schema for “restaurant.” Some schemata are active more of the time than others. Whereas our schema for restaurants may only be active when we are actively searching for a place to eat or when passing by a restaurant, schemata for self, world, and future are likely to be active much of the time. These “core” schemata 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., stories of planes crashing), whereas information inconsistent with it tends to be ignored, trivialized,

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or discounted (e.g., impressive statistics on flight safety). Thus, schemata can readily give rise to information-processing biases. Within the context of mood and anxiety difficulties, negative schemata about self, world, and future are activated and direct the prioritization of information that is attended to and encoded, producing enumerative generalizations that are based on this subset of information. Neutral and positive information is ignored, discounted, or trivialized; mood state declines; and the capacity to identify, reflect on, and modify misconceptions deriving from the schema is compromised. For example, Sarmila has generalized anxiety disorder and believes that she is uniquely vulnerable to harm. This core belief is the evaluative summation of one of her primary self-schemata.1 Based on childhood experiences, she has grown to believe that she can and should be able to anticipate and plan against potential harm and that if harm occurs, it is her fault for failing to have done so; thus, her self-schema is built upon the idea that she lacks capacity to prevent harm and is therefore vulnerable. Hearing about a family member’s accident at an intersection on a snowy day activates Sarmila’s core idea of unique vulnerability. She readily recalls accidents that have been reported in the news and by people she knows, as well as memories for times that she has had “near misses” while driving. Meanwhile, Sarmila also recalls instances in which she was scolded for not having better anticipated and thwarted problems and instances of authoritative people criticizing others for not being proactive enough in avoiding difficulties rather than responding compassionately. When she thinks about driving through the intersection, she experiences a vivid flash forward in which she gets into an accident and her family members are reluctant to come to her aid because they view her as having brought it on herself by using that intersection in the first place. She thus appraises the intersection as a threat to be avoided. However, as a result of avoidance, Sarmila is unable to learn anything new about the safety of the intersection, so she will continue to appraise it as dangerous. At the same time, Sarmila is likely to attribute the nonoccurrence of driving accidents to the wise course of avoidance, and memories of past times in which avoidance was followed by the nonoccurrence of a feared event are likely to be quite accessible. Were she to cross the intersection without incident, she would likely attribute the nonoccurrence of an accident to luck. Ironically, then, the lack of incident at the intersection actually reinforces her core idea of unique vulnerability. If she were to have an accident, the experience would heavily reinforce her schema, and she would likely conclude that the accident happened because she simply was not good enough at anticipating and planning against threat, which in turn would make her feel more anxious and uniquely vulnerable. Finally, the appraisal of the intersection as dangerous is now highly primed, and her fear may begin to generalize to a wider range of driving situations (“If it could happen there, it could happen anywhere!”). Clinical examples are disguised to protect patient confidentiality.

1



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The identification of Sarmila’s thoughts elucidates the internal logic of her emotional and behavioral responses. It is clear that the central culprits in Sarmila’s anxiety are the schema of unique vulnerability and the assumption that one can and should anticipate and plan against threat. In turn, these generate situation-specific appraisal of danger/harm/threat, as well as behavioral responses, which, although reasonable responses to the perception of threat, prevent new learning and perpetuate the system. Notice that Sarmila’s cognitions are predicated on information from external (e.g., news, anecdotes from family and friends) and internal (e.g., memories, predictions) sources that are indicative of threat. Our ability to function adaptively in the environment relies on an attentional system that prioritizes internal and external information, such that information relevant to key goals readily receives attentional capture. There is a wealth of evidence that mood states influence attentional scope, making mood-congruent information from both external and internal sources (e.g., threat-relevant information in anxious states, failure/loss information in depressed states) more accessible and experienced as more important. Thus, once Sarmila’s sense of threat was aroused, information relevant to that threat became highly salient and received priority processing, whereas other information (e.g., the number of times her family member had traversed the intersection without getting into an accident, information regarding her own excellent driving record, information that the vast majority of accidents do not result in injury) was not. Similarly, information relevant to the importance of accurately anticipating and planning against harm was given full priority, such as memories of being scolded for not having planned better to avoid a problem or of trusted adults stating confidently that “forewarned is forearmed” or of times that threat was averted because of advance planning. At the same time, information relevant to the cost versus benefits of attempting to anticipate and plan against harm and the extent to which other people experienced problems relative to how frequently she experienced problems did not come readily to mind. We all possess many and diverse schemata. Here is an experiential exercise that may illustrate your own schema in action. In this exercise, you will be presented with a hypothetical scenario followed by a yes-or-no question. When you read the question, answer it instantly, with no deliberation. You are walking in a wealthy area of the downtown of a large city. A stretch limo drives by and pulls up ahead of you. A woman in a fur coat with a large diamond ring emerges and begins striding purposefully toward the entrance to a hair salon and spa. There is a homeless person near the entrance asking for money. Does the woman give him money?

Now reflect on what ideas and assumptions guided your immediate answer. The scenario may have activated a number of relevant schemata, including schemata about people with ostentatious wealth, homeless people, women, people who wear furs, people who reside in cities, or people in a hurry. As your answer may illustrate, schemata influence the way in which we process information. This is not in and of itself problematic because, first, schemata help us

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navigate a very complex world by providing information-processing shortcuts and, second, they are amenable to change. If your initial answer was an immediate and confident “yes” or “no,” this may reflect that it was being evoked by an absolute schema (e.g., “Wealthy people never give money to the poor”). However, since answering, you may have already identified the schema as overgeneralized and have modified it accordingly (“Actually, how do I know for sure what she will do? It is quite possible that many wealthy people give money; when I think about it, I have often heard of wealthy people who give money to the poor.”). According to the cognitive model, the problem in mental health difficulties is that schemata about self, world, and/or future are negative and absolute, permitting only a narrow range of information to be assimilated; yielding priority processing of negative information at the expense of other, equally valid (or even more valid) information; and trivializing, discounting, or ignoring disconfirming information. This prevents accommodation and produces enumerative generalizations (e.g., “I am more vulnerable to harm than others.”) that are informed by only a subset of information. Because the schemata at play are those that define the self, world, and future, they are of maximal importance. Furthermore, they are activated within the context of high emotional arousal when motivation to assuage the emotional arousal and protect the self is especially high. Thus, in the moment, it can be difficult for people to identify the key appraisal driving emotion and responses, broaden their awareness, and adjust their ideas in response to this broadened perspective, even if they realize afterward that their response was out of proportion. What, then, is the goal of cognitive restructuring? One long-standing myth about CBT is that its goal is to replace negative thinking with positive thinking. However, A. T. Beck et al. (1979) pointedly emphasized that the goal of cognitive restructuring is not to induce a state of spurious optimism that things are better than they are. Instead, the role of cognitive restructuring in overcoming emotional disturbance is to facilitate the reconsideration of ideas that yield the emotional and behavioral responses of complaint, which in turn fosters the development of new, more flexible schemata.

DESCRIPTION OF MAIN PROCEDURES The primary methods of cognitive restructuring include (a) downward arrow (i.e., asking successive questions through which the core personal meaning or importance of an event is revealed), (b) Socratic dialogue (i.e., engaging in dialogue in which hypotheses about a situation, person, or thing are examined and rejected or accepted), (c) evidence weighing (i.e., identifying a key hypothesis and examining the evidence that supports it and that which does not support it), and (d) core belief continua (i.e., identifying a core belief about the self and placing it on a continuum between worst and best exemplars of that category). Each of these methods is described later in the chapter. It is important to note that exposure (i.e., putting the client in the situation and having them stay until



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distress decreases substantially) and behavioral experiments (i.e., testing a hypothesis in the real world, collecting data, and accepting or rejecting the hypothesis) yield new learning that has a powerful effect on appraisal, assumptions, schemata, and behavioral responses, but this chapter focuses exclusively on the cognitive methods used in CBT. Another important point is that cognitive (and behavioral) strategies were never developed or intended to be used outside a strong cognitive behavioral formulation for the persistence of the presenting problem(s). A. T. Beck et al. (1979) wrote, “The specific therapeutic techniques employed are utilized within the framework of the cognitive model of psychotherapy and we do not believe that the therapy can be applied effectively without knowledge of the theory” (p. 4). There are several reasons why this is the case. First, people experience thousands of thoughts in a given day. In order to identify an appropriate target for restructuring, the therapist and client must understand which thoughts are mediating the emotional and behavioral responses of complaint. This, in turn, requires that the therapist and client share an understanding of the idiographic formulation of the client’s distress. The idiographic formulation is collaboratively derived and is based on specific types of information regarding cognition that the client provides, which is unlikely to be well solicited outside the context of an assessment of the problem from a cognitive perspective. A corollary to this would be for a cognitive behavioral therapist to embark on dream analysis without having conducted a psychodynamic-oriented assessment or developed a formulation regarding the unconscious conflicts driving the presenting problem. Second, the client in CBT is systematically empowered to identify, reflect on, and, if warranted, modify cognition produced by the information processing biases that occur during emotional arousal. Therapy proceeds in phases, each phase building on the last. Before a client is likely to benefit from cognitive restructuring, they need first to understand the problem within the cognitive framework, then become able to identify key “hot” thoughts mediating the emotional and behavioral responses of complaint, and finally develop a new awareness of thoughts not as facts but as hypotheses that are derived from and maintained by a myriad of internal and contextual cues. Unlike facts, hypotheses are open to examination and reconsideration. Only then is cognitive restructuring introduced in order to facilitate that exploration and reconsideration. My personal observation is that when CBT fails, the cause is most often that cognitive restructuring has been introduced before the previous skills and insights have been consolidated, and it degenerates into the therapist attempting to persuade the client of their own perspective on the thought. This is also a sign that the therapist has not established a therapeutic relationship characterized by collaborative empiricism, as described in the subsequent section. Collaborative Empiricism and Guided Discovery A. T. Beck et al. (1979) used the term collaborative empiricism to describe the process of working with the client to broaden their understanding of mediating

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thoughts and facilitate empirical tests of their hypotheses, via behavioral experiments, exposure, and reasoning. Tee and Kazantzis (2011) observed that although collaborative empiricism is considered a hallmark of CBT, it has not been well defined in the literature and is identified variously as a therapy philosophy, characteristic, or technique. Following a comprehensive review, they proposed that collaborative empiricism is best understood as an approach to therapy that is based on self-determination and empiricism. Meanwhile, as Overholser (2011) noted, the term guided discovery has also not been well defined. He suggested that it is best understood as the use of thoughtful questions to develop a case formulation and identify and examine hypotheses that mediate the emotional and behavioral response of complaint. Taken together, we can perhaps most profitably view collaborative empiricism as an approach to therapy that is based on self-determination and empiricism and that uses guided discovery to facilitate understanding and amelioration of the presenting problem(s). In the spirit of collaborative empiricism, then, the therapist engages the client as an active participant in understanding and overcoming the problem(s) of complaint. The therapist is naive as to the cognitions that mediate the behavioral and emotional responses of complaint and is genuinely ignorant of and curious about the internal and external evidence that informs the client’s hypotheses. The client and therapist consider hypotheses together and examine how well they account for the broad range of relevant information, as opposed to the narrow subset of information/evidence accessible to the client in the moment. The client then evaluates the hypotheses and generates hypotheses that best account for the relevant information. A common misconception about CBT is that it involves challenging negative thoughts. As J. S. Beck (2011) wrote, “challenging a cognition violates a fundamental principle of CBT, that of collaborative empiricism” (p. 170). Overholser (2011) similarly asserted that the goal of collaborative empiricism is not to replace a client’s irrational beliefs but to “develop skill in objective thinking and hypothesis testing” (p. 63). In the spirit of true collaborative empiricism, the therapist uses guided discovery to identify the internal (e.g., memories, images, predictions, bodily sensations) and external (e.g., facial expressions, environmental cues) evidence that, in the moment, supports the mediating hypothesis and introduces consideration of other types of information/evidence in the appraisal of the situation. The hypotheses are mutually explored, but it is the client who revisits the original hypothesis and modifies it; the therapist trusts the client to make decisions about their hypotheses (Overholser, 2011). Indeed, to challenge a thought is to prejudge it as unworthy, which is just as biased as prejudging the thought as worthy. Furthermore, therapeutic change pivots on the client’s, not the therapist’s, understanding of the hypothesis (e.g., Overholser, 2011). In challenging a thought, the therapist imposes their own understanding of its meaning, and “therapy” becomes little more than an attempt to persuade the client of that understanding. The myth that CBT is focused only on changing the content of thoughts may have its origins in this corruption of its practice.



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Best Practices for Cognitive Restructuring Cognitive restructuring is conducted within the context of a strong case formulation that does not simply describe the problem but elucidates the causes of the persistence of the problem and provides a simple (but not simplistic) explanation for the central emotional and behavioral responses of complaint. The therapist and client agree on the central culprits, or causes, of the problem, and both understand the role the culprits play in the persistence of the difficulty. Otherwise, the client may experience cognitive restructuring as an attempt on the therapist’s part to induce spurious optimism and, out of fear of being lulled into a false sense of complacency, may begin working at odds with the therapist to defend their perspective. By the time clients seek therapy, they have typically been barraged with well-intended but ineffective reassurances by family and friends (e.g., that they are good people, that there is nothing to worry about, that everything will be okay) and may feel especially let down and alienated if the therapist seems to be offering only similar reassurances. Cognitive behavioral therapists are expected to have a solid training in basic therapeutic skills of active listening, paraphrasing, reflection, and empathic responding. A long-standing myth about CBT is that it is simply a “bag of techniques” that are applied outside the context of a therapeutic relationship. Given (a) that from his earliest writings, A. T. Beck has emphasized the importance of the therapeutic alliance and (b) that a hallmark of CBT is the solid collaboration between therapist and client, this is one of the more surprising myths. However, it is the case that cognitive restructuring can be quite misunderstood and poorly executed. As mentioned previously, one mistake therapists can make is failing to engage in true collaborative empiricism and instead simply attempting to persuade the client of their interpretation of the thought. When embarking on cognitive restructuring, the therapist proceeds gently, warmly, and respectfully. In my experience, the best result occurs when the therapist is agnostic about the outcome of the cognitive restructuring, with both parties discovering new insights into the cognition. There is no doubt that the therapist is typically able to spot logical fallacies, inconsistencies, and biased information processing before the client, but therapeutic change rests on the client’s examination of the evidence that supports the hypothesis and that which does not. Furthermore, the therapist will often have little advance knowledge of the nature, range, and breadth of the internal information (e.g., memories, images, learning history) that supports the client’s unique thoughts and must provide enough space in the execution of cognitive restructuring to allow this to emerge.

Language It is not uncommon to see the words “distortions,” “dysfunctional,” and “maladaptive” used to describe targets for CBT, and in fact a commonly used means of identifying negative automatic thoughts is a monitoring form titled the Daily

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Record of Dysfunctional Thoughts. Clients can experience these words as accusatory and as suggestive of general deficits in their cognitive functioning, poor motivation, and/or lack of willpower. Referring to “negative thinking” can also be problematic because thoughts that are negative do not lack merit simply because they are negative. Furthermore, North American clients will have undoubtedly been exposed to the popular culture idea that thinking negatively is a willful act of self-sabotage and that we can avoid problems if we simply choose to think positively. In my view, there is considerable utility in assuming a more neutral attitude toward mediating thoughts, understanding them as logical products of the information-processing system as it currently is, and treating the target schema and assumptions behind them as having developed in ways similar to how any schema develops and persists over time. Certainly, there seems little to be lost in discussing “immediate conclusions” and “hypothesis at the time” as opposed to “distortions,” referring to “appraisals that were hijacked by anxiety/depression” rather than “maladaptive thinking,” or identifying the “hot thought” as opposed to the “dysfunctional thought.” Laying the Necessary Groundwork The success of cognitive restructuring methods relies on identification of the most useful targets for restructuring, which, as already discussed, can be derived only from a solid case formulation. An effective way to lay the groundwork for identifying specific mediating thoughts, as experienced by the client in the moment, is to have the client complete thought records right from the first session (described in more detail later in the chapter). The records at this stage need include only the following columns: date, situation, cognitions (best labeled more accessibly as “What was going through my mind”), feelings, and responses (best labeled as “How I coped/what I did”). After receiving a clear rationale and appropriate psychoeducation, clients complete a record when they notice their mood changing for the worse. The benefits are numerous: For example, (a) the client learns from the start to be an active participant in treatment, (b) the client begins developing skill at introspecting early on, (c) the client can begin to observe for themself the relation between situational appraisal and emotional/behavioral responses, and (d) the information is valuable in the development of the case formulation. As A. T. Beck (1976) observed, “A person who is trained to track his thoughts can observe repeatedly that his interpretation of a situation precedes his emotional response” (p. 23). Of course, research has clearly established that the relation between mood and thought is reciprocal, and A. T. Beck fully acknowledged this, but the point is that introspection helps the client develop awareness of the associations between mood, thoughts, and behavioral responses as they unfold in real time. Another strategy that therapists can use to assist clients in recognizing that thoughts are not facts is to provide clients with a taxonomy of informationprocessing biases, or cognitive distortions such as all-or-nothing thinking, cata-



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strophizing, overgeneralization, discounting the positive, and mind reading (see J. S. Beck, 1995, 2011). Once clients begin to identify the mediating thoughts, they can gain objective distance by identifying the bias represented in the thought. However, it is important to emphasize that the goal is to recognize thoughts as products of information processing, rather than the act of proper taxonomizing itself. Selecting Targets of Restructuring Identifying the target of restructuring requires a solid case formulation and good collaboration on the part of the therapist and client. The goal is to identify the thought that is the main culprit when the emotional and/or behavioral response of complaint occurs. At the start of therapy, most clients are aware of thoughts such as “This is awful,” “I want to get out of here,” or “I hate this.” These thoughts are accurate statements of the client’s experience of the situation. The therapist’s job is to help the client see beyond their opinion of the situation to the meaning of the situation or its outcome, which causes them to feel that so much is at stake in what are most often very ordinary situations (e.g., attending a party, meeting a friend, starting a report). The thought that captures this meaning is the best target for restructuring. Greenberger and Padesky (2016) referred to this as the “hot thought,” observing that examination and reconsideration of the hot thought will have the most therapeutic benefit. J. S. Beck (2011) advised that an excellent way to facilitate introspection is to have the client mentally relive a recent situation in which they experienced the emotional or behavioral response of complaint. In her instructional video, Padesky (1996b) deftly demonstrated the process of identifying the hot thought using a three-column thought record of situation, moods, and automatic thoughts. The client, whose presenting problem was depression, had completed a record, noting the situation, her feelings, and her thoughts. Padesky first asked a number of questions about the situation. This is an important step because it helps the therapist apply the case formulation to understanding the aspects of the client’s response to the situation that have been “hijacked” by the anxiety or mood disturbance. For example, if the client had reported a situation in which she had just received a summons to her boss’s office and was overwhelmed with dread and hopelessness, it would be helpful to find out more about her work environment, her relationship with her boss, her work performance evaluations, and the nature of the boss. If the boss is reasonable and the work history positive, it is likely that the emotional response is being driven by biased information processing. If the boss truly is arbitrary, harsh, and intolerant, it is reasonable for the client to be quite concerned and potentially pessimistic about the summons, and the therapist can make a mental note to consider catastrophic predictions about what it would mean to have a negative meeting with the boss (e.g., that she will end up homeless). If none are present, then the emotional response is not symptomatic of the mood disturbance of complaint; just because thoughts are

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negative does not mean they are pathological. Furthermore, it is often useful to determine what the client feels is at stake in the situation. For someone with social anxiety, the situation of attending a party may be viewed as the sole opportunity to make a good impression, and thus it is not simply a social occasion for them. Once the situation had been better understood, Padesky (1996b) then reviewed the emotions that the client listed. The client had also rated her intensity. Padesky reviewed each emotion, clarified the relative intensity of each, and asked if there was any other emotion the client may have been feeling but did not recognize or record. In the above work-related example, a catastrophic prediction of homelessness may be associated with a feeling of despair that the client had not fully recognized. Padesky then reviewed the thoughts that the client had listed. The therapist is looking for thoughts that, in and of themselves, explain the breadth and range of the emotions experienced and their intensity, as well as the behavioral response; that is, at this point the therapist is looking for the internal logic of the system, or the thoughts that mediate the responses. One effective strategy for identifying the key thoughts is the downward arrow technique. Downward Arrow Technique The downward arrow technique is simply a series of questions used to help identify the thought that mediates the behavioral and emotional responses of complaint. Consider the example of Ben, a client with social anxiety who brought in a thought record regarding a recent social situation. Ben is attracted to a woman who recently joined an organization of which he is a member. In the situation he reports, he was attending a picnic held by the organization, and he saw her sitting alone. He joined her and struck up a conversation about the organization, but after a few moments, she announced that she needed something to drink and left for the drinks table. A couple of minutes later, Ben saw her standing with a drink and chatting with a group of people. In the Feelings column Ben had written “embarrassed” and “miserable,” the latter being the most intense. In the Response column, he noted that he left the picnic quite soon thereafter. In the Thoughts column, Ben identified his hot thought as “She doesn’t like me.” Ben’s thought “She doesn’t like me” may well be the product of biased information processing, and there is no doubt it was the gateway to the emotional and behavioral responses for which he was seeking treatment. However, it actually does not, in and of itself, account for his misery and his abrupt departure from the party. Someone in the same situation could think “She doesn’t like me, and that’s too bad, but there are other women who will like me.” To identify the mediating thought, we need to understand what it means to him if she does not like him. The therapist can use the downward arrow technique to identify the hot thought that truly mediates the emotional and behavioral response of concern:



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BEN:

She got up and left, which means she doesn’t like me.

THERAPIST: What does it mean, for you, if she doesn’t like you? BEN:

Well, she’s a really nice woman who seems to like everyone; it shows that I am incapable of being likeable to women.

THERAPIST: Okay, let’s examine this a little more. What is the worst part

about being incapable of being likeable to women, for you? BEN:

Well, it means I will never find a wife.

THERAPIST:

Which we know is an awful prospect because you want to marry and have a family. Let’s just go one more step together with this—what does it mean if you will never find a wife?

BEN:

It means I am unlovable.

The therapist has now identified the thought that accounts for both Ben’s despair and his early departure from the picnic (“I am incapable of being likeable to women”) as well as a core belief (“I’m unlovable” or “Maybe I’m unlovable”). Like all CBT strategies, the downward arrow technique should be introduced and explained, for example: “Let’s figure out what made this so intense for you.” It needs to be executed gently and collaboratively; the tone is supportive, warm, and curious. The therapist is not interrogating the client or belittling their appraisal, but rather the client and therapist are working together to identify the mediating thought, or the culprit. Additional questions can include “What bothers you the most about that?” “What’s the worst part about that for you?” and “If that happened, what would it mean about self/world/future?” (see Greenberger & Padesky, 2016, for more examples). It is also important to emphasize that the therapist and client seek the meaning the thought had in the moment when the client was distressed; sometimes, in retrospect, clients recognize that the situation realistically should not mean much, but in the moment, it felt like it did. One final point is that the therapist may want to avoid treating ideas that have not been examined yet as facts. In the above example, the client had concluded that the woman’s departure meant she did not like him. The therapist and client had yet to mutually establish whether this hypothesis best fit the available information. Thus, rather than repeat a hypothesis that may ultimately prove to poorly account for the range of relevant information, the therapist instead says, “What would that mean, if she doesn’t like you?” as opposed to “What does that mean that she doesn’t like you?” Obviously, if there is clear evidence that the woman did not like him, the latter is appropriate. Cognitive restructuring begins once the client understands the way in which hot thoughts mediate emotional and behavioral responses to complaint (as well as how the consequences of their responses feed back into schemata and assumptions) and is able to use the downward arrow technique themself to

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identify hot thoughts that mediate mood and their response. The goal of cognitive restructuring is to help the client learn to override the automatic processes producing the hot thought and reevaluate the hypothesis within the context of all relevant information. Through repeated reevaluation and overriding information-processing biases, the assumptions and schemata become untenable (e.g., Padesky, 1996a). Socratic Dialogue Definition Although Socratic dialogue is considered to be a hallmark feature of CBT, there are few formal definitions of the term and very few clear explications of its components, process, and goals. A. T. Beck and Dozois (2011) defined Socratic dialogue as “a method of guided discovery in which the therapist asks a series of carefully sequenced questions to help define problems, assist in the identification of thoughts and beliefs, examine the meaning of events, or assess the ramifications of particular thoughts or behaviors” (p. 401). This definition offers a sound description of the circumstances under which the strategy is used, although it does not explain what is being discovered or the purpose of doing so. Clark and Egan (2015) defined Socratic dialogue as “verbal exploration (incorporating questions, summaries and reflections on part of both patient and therapist) that helps patients become aware of, reflect upon and achieve insight regarding, a particular subject of discussion and which prompts patients to generate their own conclusions” (p. 865). Finally, Overholser (1993) described the Socratic dialogue as “a series of questions designed to facilitate independent thinking” (p. 67). Drawing from modern philosophy and pedagogy, one might more clearly define Socratic dialogue as a form of cooperative discussion during which a facilitator (i.e., the therapist) promotes independent, reflective, and critical thinking, through which the validity of hypotheses is evaluated, those hypotheses that lead to contradictions are abandoned, and new hypotheses are formed. Within the context of CBT, hot thoughts, assumptions, and schemata can all be understood as hypotheses (e.g., Ben’s hypothesis is that the woman left his company because she did not like him). In the course of a Socratic dialogue, the client and therapist first identify the hypothesis to be discussed. The therapist then facilitates a dialogue in which the merits of the hypothesis are discussed and new hypotheses are generated. The dialogue is facilitated by systematic questions meant to transcend information gathering and instead develop a rich integration and synthesis of different sources of information, using inductive reasoning to explore hypotheses and their consistency with the range of available information (Overholser, 1993). Power of Persuasion Versus Facilitation of Self-Discovery Therapists will rely on the case formulation and their own observations during the discovery process to keep the dialogue focused and the questions systematic, but whether or not the therapist should be leading the client to the thera-



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pist’s own predetermined conclusions has been a matter of debate in the literature (Carey & Mullan, 2004; Clark & Egan, 2015). Some therapists assume the role of prosecuting attorney, putting the client on the stand and, bent on challenging the legitimacy of the client’s thoughts, assault them with leading questions until the client finally gives up and admits that their thoughts are “wrong” and that the therapist’s interpretation is the “correct” one. Overholser (1993) observed that although the Socratic form of inquiry originally followed a cross-examination format designed to force students or adversaries to admit their ignorance, the resultant public humiliation renders this style inappropriate for therapy. In my experience, this approach is at best ineffectual and at worst results in leaving clients with a sense of being small, stupid, and powerless. Padesky (1993) encouraged therapists to use the Socratic dialogue as a means of guided discovery rather than as a means of changing minds. Overholser (2011) emphasized the merits of “Socratic ignorance,” in which “collaborative empiricism is combined with sincere intellectual modesty about clients and their struggles” (p. 64). The cognitive restructuring techniques described in the next sections of this chapter adopt this latter viewpoint. Not only is it more respectful of the client; it also facilitates better communication and understanding, and it better fosters the client’s innate ability to identify, address, and modify overgeneralized hypotheses. This, in turn, enhances self-efficacy for independent management of the behavioral and emotional responses of complaint. Finally, from a process perspective, it requires the client to assume an active role in understanding and overcoming their presenting problems and to share ownership of the therapy process. Conducting the Socratic Dialogue Within the context of the Socratic dialogue, the therapist and client examine key hypotheses (e.g., “I am not capable of being attractive to women,” “I am more vulnerable to harm than others”), considering all of the experiences relevant to the hypothesis and making an inductive generalization based on the expanded base of information. In addition to questions, the therapist can use analogies, which are powerful ways of comparing objects, people, or events, based on relevant but not obvious similarities. For example, in Ben’s case, the therapist could make the observation that he seems to have likened himself to Charlie Brown (of Peanuts fame) and examine similarities and differences between Ben and this exemplar of the traits he believes they have in common. Padesky (1993) offered a detailed description of the Socratic dialogue. She identified the following four components of the dialogue: (a) informational questions, (b) empathic listening, (c) frequent summaries, and (d) synthesizing questions. Informational questions have two purposes. First, they are used to better understand the extent to which the hypothesis is consistent with the available objective information. Returning to Ben, the hypothesis in question is that he is incapable of being attractive to women. The therapist would want to ask informational questions about Ben’s dating history, frequency of contact with women, clear versus ambiguous indicators of rejection, and Ben’s social skills

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when interacting with women. That is, the questions are directed at considering relevant external information. Second, informational questions are used to identify the information, images, ideas, memories, experiences, bodily sensations, feelings, and predictions that lead the client to conclude that the mediating thought is valid, or perhaps even fact; that is, internal information. One of the keys to understanding the internal logic of the client’s presenting problem is empathic listening. Empathic listening and warmth were, of course, identified by Carl Rogers as essential to the therapeutic relationship and considered the building blocks of therapeutic change. Empathic listening is integral to assessment and the execution of all components of CBT (e.g., Thwaites & Bennett-Levy, 2007). Within the context of the Socratic dialogue, the term refers to active listening to glean an understanding of the reasoning that leads to the hypothesis under consideration, attending to what the client says (e.g., “My boss wants me to speak up more in meetings”) and what the client does not say (e.g., that the client had just received a promotion), as well as nonverbal language. Empathic listening is a hallmark of collaborative empiricism in that the therapist is genuinely curious about how the client’s hypotheses are framed and the information on which they are based. The therapist mentally notes contradictions in the hypothesis, all the while checking in and ensuring that their understanding of the client’s discourse is correct. The therapist also provides frequent summaries of the discussion to help them both keep track of the key insights in the discussion and maintain focus. Once the client and therapist have richly considered the hypothesis and the external and internal information that supports it, the therapist begins to ask synthesizing questions to illustrate contradictions. For example, examination of Sarmila’s hypothesis “I can and should be able to predict and prevent harm” revealed that her attempts to do so interfered significantly with her happiness and ability to focus on her studies. Not only did these strategies fail to stave off harm, they actually created problems for her. The therapist might therefore say, “You have noticed that despite your best attempts to prevent harm, bad things still happen. I’m wondering what that means about the feasibility of preventing all harm, all the time?” and “If we look at how there is a 100% chance that trying to prevent harm actually interferes with your ability to do the things you want to do, and the harm you are trying to prevent is vague and uncertain, is there merit in reconsidering the idea that you can and should prevent harm?” Synthesizing questions can also be interspersed with psychoeducation about learning, memory, and attentional processes that influence information processing and generate hypotheses at an implicit level. For example, in Ben’s case, the client and therapist learned that the hypothesis “I am incapable of being attractive to women” was supported by memories of being taunted by his first crush; his perception of himself as awkward, weak, and physically unattractive; and his experience at the picnic when the woman in whom he was interested left his company. As part of the case formulation, the therapist will already have implicated anxiety-driven biases in information processing and the impact of autonomic arousal on behavior. The therapist can remind Ben of these pro-



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cesses and ask him how they may have influenced his conclusions and his decision to leave the picnic. The therapist can validate the strength of Ben’s conviction in his conclusion by observing that the only information immediately available to him in the moment is that supporting his conclusion; information that does not support it either failed to breach his attentional threshold or was ignored, trivialized, or discounted. Sometimes clients can have difficulty recognizing that their hypotheses are inconsistent with available information. Myriad strategies have been developed to help therapists illustrate inconsistencies. For example, Sarmila might have difficulty recognizing the factors besides her own behavior that can influence outcomes and, therefore, finds it hard to treat her hypothesis that she is responsible to prevent harmful outcomes as anything but fact. One way to help her broaden her perspective would be to use a pie chart, as well explicated by Dobson and Dobson (2017). The therapist simply asks the client to record all the factors contributing to an outcome, in addition to their actions (or inactions), and then assign the proportion of responsibility each factor bears, with their portion left until last. The proportions are then charted on a pie graph. The visual effect can powerfully illustrate the contradiction. Purdon and Chiang (2016) illustrated the probability calculation method for addressing the overestimation of a feared outcome. The client and therapist identify all the steps that would have to occur for the outcome to be realized and then estimate the rough probability of each step occurring. In their example, a client with obsessive-compulsive disorder (OCD) feared that she would fail to turn the stove off before leaving for work and that her cat would burn himself. The therapist helped the client identify all the steps necessary for this to happen, which included (a) failing to turn the stove off after using it, (b) failing to see that the stove was on when checking before leaving the house, and (c) the cat jumping onto that specific burner despite the heat. The probabilities were then multiplied and the result subtracted from 100. In this example, the probability of the feared event not happening was 99.9997%. However, the probability that her elaborate stove-checking routines resulted in her being late for work was 85%. This provided a solid grounding for discussing the morality and feasibility of reducing checking behavior in the service of improving her work performance. Note that the goal is not to disabuse the client of the validity of obsessive thought but instead to learn to accept uncertainty and take reasonable risks in order to meet key proximal goals rather than compromise the latter by pursuing vague, distal, and impossible goals. These are just two examples, but many more are available in books on CBT. The therapist is free to develop their own strategies to identify contradictions. For example, to help clients recognize that they may not be able to accurately understand what someone else is thinking (i.e., that they are mind reading), I have used an empty chair technique. The client is seated beside an empty chair and conducts a dialogue between themself and the other person as if that person were in the other chair. The client is asked to distinguish between what is known versus what they have surmised about the other’s thoughts or potential

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responses, as well as to consider the issue from the other’s perspective by switching chairs. Finally, the therapist role plays the other person as if they are thinking what the client fears, and together they examine how important and survivable that is. The strategy used is not as important as ensuring that (a) the idea in question has been articulated and agreed upon as a culprit, (b) the strategy is effective in illustrating contradictions, and (c) the strategy will be compelling for the client. It is worthwhile to note that, in the early stages of intervention, the idea that thoughts may not be facts but rather are products of information processing is typically still novel for clients. Recall that, in Ben’s case, although the downward arrow technique revealed that the hot thought concerned his ability to be attractive to women, the thought that initiated the cascade (i.e., “She doesn’t like me”) appeared to be the product of information-processing biases, as there was no clear evidence that the woman disliked him. Such gateway thoughts can be targeted early on as a means of illustrating how mood state, assumptions, and schema can hijack situational appraisal. Thought Records Thought records are relied upon in CBT as means of helping clients develop the skills of identifying hot thoughts, overriding the automatic processes that produce them, and modifying the ideas/hypotheses as appropriate. The thought record is meant to help the client learn these skills well enough that they are able to override information-processing biases mentally in the moment, as opposed to after the fact. As discussed previously, CBT proceeds in stages, each stage building on the last. The goal of the first stage is to help clients learn to identify the thoughts that mediate the mood and behavioral responses of complaint and begin to recognize that thoughts are not facts. In this stage, clients record the situation, feelings, thoughts, and responses. The client and therapist work to help the client develop their ability to (a) understand noteworthy aspects of the situation and the stakes (e.g., the situation was perceived as the sole opportunity to make friends); (b) identify the range of feelings experienced and label them precisely (e.g., rather than just record “upset,” unpack the components of that feeling, such as “frustrated,” “anxious,” “pessimistic”); (c) identify thoughts that go beyond the client’s opinion of the situation (e.g., not just “this is awful,” but the reason it was awful) as well as begin to notice images, memories, and predictions; and (d) identify all the strategies used to cope with the situation (e.g., safety behaviors, avoidance, escape, cautious behavior) and recognize the role of those behaviors in the persistence of schemata, assumptions, mood, and capacity to achieve new learning. The therapist and client also begin to identify key culprits that perpetuate the problem. Once the client is able to introspect in this manner, they are ready to identify the thought(s) that mediate the emotional and behavioral responses of complaint. The therapist helps the client look for the ideas that account for the most intense emotions and logically lead to the behavioral response. In this stage,



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clients learn to use the downward arrow technique to identify their hot thoughts and move into identifying contradictions in the hypotheses implicit in them. The thought record is now expanded to include columns for “evidence that supports the hot thought” and “evidence that does not support the hot thought.” The therapist can then use Socratic dialogue to add to the two columns. Using informational questions, empathic listening, and frequent summaries, the therapist helps the client identify the internal and external evidence that supports the hypothesis while mentally noting potential biased information processing and contradictions. The client records the evidence as it emerges. The therapist then helps the client identify information that does not support the hypothesis, and again the client records as they go. Finally, synthesizing questions are used to help the client reconcile the two columns and identify a hypothesis that does not have contradictions. The client then forms a new hypothesis. Padesky (1996b) provided an excellent demonstration of this process. Throughout the three stages of thought record use, the client is encouraged to do mental thought records whenever the problematic emotional or behavioral response is experienced, with the goal of being able to identify and modify hot thoughts before those responses become acute. Once the client becomes skilled in this, the new hypotheses begin to prevail, and the assumptions and core beliefs start to become less tenable. Meanwhile, in session, the therapist and client rely increasingly less on the written thought records and move to exclusively verbal Socratic dialogues. Addressing Core Beliefs The core beliefs of concern in CBT are broad, general, deeply held ideas about the self, world, and future. They have often framed an individual’s perspective for many years and are experienced as facts. Because they operate at an implicit level, they are seldom explicitly identified or explored independently. Clients may feel especially worried about being lulled into a false sense of complacency regarding the self, world, and/or future, the exposure of which will be devastating. Dobson and Dobson (2017) also observed that the process of addressing core beliefs may involve facing painful experiences and seeing loved ones in a different light. Finally, a shift in core belief may not be well tolerated by the client’s loved ones. For example, someone who moves from believing they are flawed and worthless and into viewing themself as worthy as anyone else may no longer be as tractable as their loved ones are accustomed, which may generate hostility. There may even be active resistance from the client’s loved ones to changes in schemata. I worked with a young woman with OCD whose core idea was that she was less worthy than others, and her assumption was that she had to compensate for that. Many of her rituals involved protecting the family from harm, to the point of almost total sacrifice of her own goals. There was a high degree of enmeshment between one parent and the client and the client’s

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sister, along with a high level of family discord. Within the family, the accepted explanation for the latter was that the discord resulted from the stress created by the client’s rituals. Once the client began shifting to a less negative self-view and did not experience the same need to compensate for perceived shortcomings, her rituals at home decreased substantially, and she began to establish and enforce greater interpersonal boundaries. However, the absence of her rituals and the challenge to enmeshment exposed the other profound family problems, and the enmeshed parent began thwarting the client’s treatment in passive but highly effective ways. Dobson and Dobson (2017) recommended that the therapist discuss the core beliefs examined through schema work with the client so they can make a fully informed decision as to whether or not to proceed. Dobson and Dobson also pointed out that, in two studies, adding core belief change work to behavioral activation in treatment of depression did not result in an improvement in outcome over behavioral activation alone, nor did it reduce relapse. However, there is very little research in this area, and, on the basis of anecdotal experience, core belief work is advocated by many clinicians. Also, it is important to point out that once the client has had considerable experience in overriding situational appraisal and intermediate beliefs/assumptions, and as symptoms are becoming less intense, the core belief may already start to weaken or a previously dormant, less absolute schema may start to become active. One of the most commonly used strategies for addressing core beliefs is the cognitive continuum method. As in all cognitive restructuring, the goal is to help clients identify contradictions in the hypotheses that mediate the behavioral and emotional response of complaint. In the case of core beliefs, hypotheses will be about the self, world, or future and will be quite general and often absolute. To begin, the therapist and client identify a specific core belief of concern and review its role in the persistence of the presenting problem. To help understand the possible origin of the belief, the therapist may choose to observe links between it and relevant autobiographical details. For example, in Sarmila’s family, it was accepted that people can and should anticipate and prevent harm and that failure to do so was considered irresponsible and was associated with harsh criticism and withdrawal of support. When the discussion includes parental behavior or that of other loved ones, it is important to be clear that the goal is not to blame or judge but rather to understand how the core idea might have been formed, as well as the subsequent learning history that helped sustain it. It is also important to acknowledge good intention rather than simply its impact. For example, Sarmila’s parents were trying to help her learn to avoid harm. Once the therapist and client have agreed to examine the core belief, the therapist writes the core belief at the top of the page and draws a horizontal line with 0 and 100 as the anchors. The therapist then asks the client to add descriptors to the scale anchors vis-à-vis the core belief. For example, if the core belief is “I am a bad person,” the client may choose to use the descriptors “Worst



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person in the world” at 0 and “Best person in the world” at 100. The therapist then asks the client to identify someone from any period of history who they would put near 0 (many clients identify Hitler) and write that name at the anchor, and then identify someone who they would put near 100 (a common choice is Mother Theresa) and write in the name. The therapist can then foster a discussion of what qualities the client considered most in placing those individuals on the continuum. This helps the client develop awareness of their implicit assumptions about the quality in question. Clients are then asked to identify someone they know whom they would put near 0 on the continuum and write in the name, as well as someone they know who falls near 100 on the continuum. Often clients begin to realize that even the people they loathe/ admire fall at least at some distance from the exemplars of each anchor. Clients then plot their spouse/significant other or very closest friend and then two of their friends. Finally, the client plots themself. Clients typically cannot place themselves on par with the exemplar of the 0 end of the continuum (if only because they have at least not been responsible for murder), and this automatically means that the schema, as worded, is not consistent with fact. The therapist and client then discuss what qualities the client attends to when plotting themself, identify hypotheses about the self and the quality, and engage in a Socratic dialogue to identify contradictions. Is the client holding themself to a higher standard than others? Is the client only attending to specific criteria or past events/behaviors at the expense of other criteria? Is the client weighting some criteria much more heavily than others? Have the client’s friends and loved ones ever made errors or hurt someone? If clients have placed themselves at a distance from their spouse and friends, the therapist can observe and query what qualities they lack that their loved ones have and discuss whether the idea that they lack that important quality is consistent with all relevant information. Once these ideas have been considered, clients are invited to reconsider where they are on the continuum. The client is then enjoined to reexpress the belief in words that are more consistent with all the information reviewed. Finally, the therapist and client can process the implications of the new core belief. If the client shifts from “I am bad” to “I am not as good as I would like but not as bad as I thought,” what compensatory strategies may no longer be necessary? What information-processing biases can be targeted? For example, it may be that the client has attended to perceived indications that one is “bad” (e.g., thinking something negative about a coworker) and has ignored instances of behavior they view as worthy (e.g., helping a coworker, doing volunteer work) because the latter is viewed as “a given” or a minimum standard of behavior. Clients can make it a point to catch themselves engaging in what they consider to be worthy behavior, even if it is just their minimum standard. Clients can also be enjoined to catch the old belief in action, ask themselves what appraisal would derive from the new belief, and then try behaving in a way consistent with it.

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OUTCOME DATA In their review of meta-analyses of the efficacy of CBT, Hofmann et al. (2012) concluded that the evidence base of CBT is “very strong and especially so for anxiety disorders” (p. 436). However, they also identified a continued need for rigorous randomized control trials examining its efficacy. Clark and Egan (2015) noted that in studies of client experiences of what was effective for them, clients identified use of thought records and learning to interpret experiences differently. Newman and Fisher (2010) found that in people undergoing CBT for generalized anxiety disorder, treatment expectancy and the credibility of treatment increased between the fourth and seventh sessions of treatment and that this change accounted for 40% of symptom reduction. One extrapolation from these findings is that the collaborative empiricism, in which the client and therapist build the formulation together, is effective in enhancing the treatment credibility and instills optimism. However, more research is required on the impact of the structure and process of CBT on expectancy and credibility as compared with other treatment modalities. Very few studies have been conducted on the efficacy of specific cognitive restructuring methods. As Clark and Egan (2015) noted, Socratic dialogue is considered integral to, or indeed the essence of, CBT, as are guided discovery, the downward arrow method, and thought records. Thus, it would not make sense to conduct dismantling studies to attempt to isolate their impact on outcome; executing CBT without cognitive restructuring would be like executing client-centered therapy without practicing unconditional positive regard. Froján-Parga et al. (2011) reported on the development of a system for coding the functionality of Socratic questions. On the basis of previous work, they hypothesized that a Socratic question has one of seven functions: (a) discriminative (i.e., elicits a verbal or nonverbal response), (b) elicitation (i.e., elicits an emotional response), (c) reinforcement (i.e., provides agreement, reward), (d) punishment (i.e., expresses disagreement), (e) instructional (i.e., promotes a behavior outside the therapy session), (f) motivational (i.e., highlights benefits from a course of action), and (g) informative (i.e., includes any function not capture by the previously mentioned features). Froján-Parga et al. (2009) analyzed Socratic debates in a case study, finding that reward and punishment shaped the client’s verbalizations in ways consistent with the therapeutic outcome. In a larger follow-up study, CaleroElvira et al. (2013) examined 65 fragments of sessions from seven clients, and they again found that together their use shapes the client’s response in the desired therapeutic direction. The strategy of analyzing the impact of the therapist’s response on that of the client follows the tradition of Carl Rogers (1977). Operationalization of the therapeutic goal is critical for future research. However, this series of studies seems to suggest that the therapist has a specific outcome in mind with respect to the content of the thought they desire or that there is a correct answer to the therapist’s questions. Furthermore, the questions posed by the therapist in the examples given are often closed, so the client



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produces either yes or no answers and thus has a 50/50 chance of responding “correctly.” It may be more important to study whether, for example, a synthesizing question produces a shift in the client’s hypothesis. Braun et al. (2015) used a more basic approach to examine the impact of Socratic questioning on symptoms of depression in people undergoing a 16-session treatment for depression. The audiotapes of the first four sessions of treatment were coded for frequency of use of Socratic questions. They found that more frequent use of Socratic questioning in one session was associated with a reduction in depression symptoms the following session, controlling for depression in the current session as well as general factors such as therapeutic alliance. Subsequently, Stone and Strunk (2020) examined cognitive change from session to session of treatment and found that therapeutic alliance and therapist use of cognitive methods predicted high (versus low) cognitive change. Meanwhile, there is a wealth of evidence suggesting that CBT results in cognitive change that is concomitant with changes in symptoms (see A. T. Beck & Dozois, 2011). Examples include Kleim et al. (2013), who conducted a largescale study of CBT for posttraumatic stress disorder (N = 268) and found that change in appraisal of the trauma led to a subsequent reduction in symptoms. Change in appraisal has been found to precede change in symptoms in treatment of chronic pain (Burns et al., 2003), panic disorder with agoraphobia (Bouchard et al., 2007), panic disorder (Hofmann et al., 2007), OCD (Wilhelm et al., 2015), posttraumatic stress disorder (Kleim et al., 2013), and depression (e.g., Kwon and Oei, 2003). Goldin et al. (2012) found that perceived capacity to reappraise thoughts mediated the effect of CBT for social anxiety. In their large study of cognitive therapy for depression, Jarrett et al. (2007) found that changes in cognition could be detected early and differentiated treatment responders from nonresponders, although they found that change in depressive symptoms preceded change in cognition, rather than vice versa. Finally, Schmidt et al. (2019) examined cognitive change between and within sessions in people receiving cognitive therapy for depression. They assessed cognitive change at the end of each session (i.e., immediate cognitive change) and at the beginning of the next session (i.e., sustained cognitive change). When examining within-session change, they found that sustained cognitive change mediated the relations between immediate cognitive change and symptom change. Thus, Hofmann et al.’s (2013) conclusion that there is strong evidence that changes in cognition mediate change in symptoms continues to be supported.

COGNITIVE REAPPRAISAL VERSUS COGNITIVE RESTRUCTURING There is a large body of literature on emotion regulation, the process of changing emotions. James Gross and his colleagues (2014) have identified a number of strategies that people use to change or control their emotions, of which cognitive reappraisal is one. Whereas some emotion regulation strategies are

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considered maladaptive (e.g., suppression, punishment), cognitive reappraisal is considered adaptive. McRae et al. (2012) defined cognitive reappraisal as “altering emotions by changing the way one thinks” (p. 250). As in the cognitive behavioral model, appraisal is assumed to mediate the relation between situational events and emotional response. However, there are important distinctions between the two constructs. The goal of cognitive restructuring is to identify the idea, or hypothesis, that is associated with the behavioral and/or emotional response of complaint, revisit that idea in light of all relevant information, and where appropriate, form new hypotheses. That is, the goal is not emotion regulation, although the reduction of certain emotions and the increase of others may result from the process. However, there is no doubt that cognitive restructuring changes the way one thinks and can technically be viewed as cognitive reappraisal. Furthermore, in some studies investigating cognitive reappraisal as an emotion regulation strategy, cognitive reappraisal is generally conceptualized as thinking positively about negative events; that is, by finding the silver lining (e.g., Troy et al., 2010). That is emphatically not the goal of cognitive restructuring.

APPLICATION TO DIVERSE POPULATIONS Cultural competence is considered a core competence now for psychologists, regardless of theoretical orientation. Therapists need to 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. It is also important to be familiar with verbal and nonverbal behavior that can give offense, as well as cultural attitudes toward topics relevant to the client’s problem (e.g., sexuality, suicidality). Therapists also need to be aware of cultural variations in communication styles to avoid misinterpreting nonverbal behavior. For example, in some cultures, it is not appropriate to make full eye contact with someone in authority or with someone of another gender. It is also helpful to understand the events and celebrations that have important meaning for clients. However, it is also important not to assume that a client conforms to the norms of their culture. The bottom line is that therapists will do well to identify and avoid acting solely on their own cultural assumptions. Cognitive restructuring relies on verbal strategies, and thus the therapist must have superb verbal fluency in the client’s language or have an interpreter with this degree of fluency in both languages who can readily translate the vocabulary of therapy/mental health in general and CBT specifically. Another consideration is that metaphor and analogy are a common means of illustrating inconsistencies, but, of course, to be effective they need to be culturally relevant. Earlier in the chapter, the cartoon character Charlie Brown was referenced, but this analogy only works with a certain demographic within North America. However, clients themselves can provide a rich supply of analogies and metaphors if you simply ask them. For example, the therapist can ask



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about literary or historical figures the client has in mind when they think of a “loser,” or what scriptural texts are relevant to the situation under discussion. Finally, in cognitive restructuring, the therapist is on the lookout for inconsistencies between the client’s hypotheses and relevant information. Therapists need to be aware of the influence of cultural norms on how they guide discovery. For example, suppose the therapist is working with a woman from a nonWestern culture who reports feeling deep shame, anxiety, and despair about having caused her husband embarrassment at a public gathering. According to Western cultural norms, the wife’s actual behavior at the gathering was quite reasonable and the embarrassed response of the husband was an overreaction. If the therapist applies Western cultural norms to the situation, the therapist might then view the client’s acceptance that she had behaved poorly as an inconsistency. However, within the client’s culture, failure to preserve one’s husband’s dignity in public is a breach of one’s principal duty as a wife (a role that she fully accepts). The inconsistency is that she sees this (actual) breach as evidence of being generally incompetent in multiple domains and wholly incompetent in her role as a wife.

CONCLUSION AND FUTURE DIRECTIONS In sum, the goal of cognitive restructuring is to mutually examine hypotheses with the client, observe contradictions, and reconsider the original hypothesis in light of those contradictions. Through this process, the client begins to recognize that thoughts are not facts and that the evidence supporting them may include ideas, memories, and autobiographical information that are outdated and/or are the products of information-processing biases. While engaging in cognitive restructuring, the therapist is genuinely interested in and curious about the external and internal information that informs the client’s hypotheses. The therapist’s goal is not to change the client’s mind or prove their hypotheses wrong but rather to guide the client’s discovery of contradictions in their hypothesis and facilitate their reconsideration. Thus, cognitive restructuring is not intended to challenge thoughts, nor is its goal to change the content of thoughts. Instead, it seeks to help the client override the automatic processes that yield the behavioral and emotional responses of complaint. There is strong evidence that CBT is effective (although there is a need for more randomized controlled trials) and that changes in cognition precede symptom reduction. Cognitive restructuring is a key instrument of therapeutic change in CBT. There is evidence that changes in hot thoughts, assumptions, and beliefs mediate symptom reduction. There has been little research on clients’ subjective experience of cognitive restructuring methods and what they personally found transformative. There could be considerable merit in developing a better understanding of client engagement with cognitive restructuring methods. There is also very little research on the extent to which the intent of cognitive restructuring methods equals its impact. The goal of cognitive restructuring is to

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override automatic processes driving the emotional and behavioral responses of complaint by explicit processing of information, considering a broader range of information to assess the “goodness of fit” of hypotheses, and improving critical thinking as applied to the self. Traditionally, we examine the success of an intervention in terms of symptom reduction, which is the distal goal. Research that examines the functionality of a specific Socratic question and examination of its impact on a moment-to-moment basis will help clarify mechanisms of action. Another outcome measure may be the speed with which a new conclusion is developed and the range of information that is considered when drawing a conclusion. However, it may also be interesting to examine the larger proximal milestones required for symptom reduction to occur. There is a large literature in the area of education that examines the impact of use of Socratic techniques on learning and critical thinking. For example, in one small study, use of Socratic dialogue to explore students’ solution to a medical problem was associated with better performance on the California Critical Thinking Test (Yang et al., 2005). Such a framework has obvious relevance to the evaluation of cognitive restructuring within larger CBT packages.

REFERENCES Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press. Beck, A. T., & Dozois, D. J. A. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62, 397–409. https://doi.org/10.1146/annurevmed-052209-100032 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. Guilford Press. Beck, J. S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). Guilford Press. Bouchard, S., Gauthier, J., Nouwen, A., Ivers, H., Vallières, A., Simard, S., & Fournier, T. (2007). Temporal relationship between dysfunctional beliefs, self-efficacy and panic apprehension in the treatment of panic disorder with agoraphobia. Journal of Behavior Therapy and Experimental Psychiatry, 38(3), 275–292. https://doi.org/10. 1016/j.jbtep.2006.08.002 Braun, J. D., Strunk, D. R., Sasso, K. E., & Cooper, A. A. (2015). Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression. Behaviour Research and Therapy, 70, 32–37. https://doi.org/ 10.1016/j.brat.2015.05.004 Burns, J. W., Kubilus, A., Bruehl, S., Harden, R. N., & Lofland, K. (2003). Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis. Journal of Consulting and Clinical Psychology, 71(1), 81–91. https://doi.org/10.1037/0022-006X.71.1.81 Calero-Elvira, A., Froján-Parga, M. X., Ruiz-Sancho, E. M., & Alpañés-Freitag, M. (2013). Descriptive study of the Socratic method: Evidence for verbal shaping. Behavior Therapy, 44(4), 625–638. https://doi.org/10.1016/j.beth.2013.08.001 Carey, T. A., & Mullan, R. J. (2004). What is Socratic questioning? Psychotherapy: Theory, Research, Practice, Training, 41(3), 217–226. https://doi.org/dz9z5c



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Clark, G. I., & Egan, S. (2015). The Socratic Method in cognitive behavioural therapy: A narrative review. Cognitive Therapy and Research, 39(6), 863–879. https://doi.org/ 10.1007/s10608-015-9707-3 Dobson, D., & Dobson, K. S. (2017). Evidence-based practice of cognitive-behavioral therapy (2nd ed.). Guilford Press. Dobson, K. S., & Dozois, D. J. A. (2019). Historical and philosophical bases of the cognitive behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 16–52). Guilford Press. Froján-Parga, M. X., Calero-Elvira, A., & Montaño-Fidalgo, M. (2009). Analysis of the therapist’s verbal behavior during cognitive restructuring debates: A case study. Psychotherapy Research, 19(1), 30–41. https://doi.org/10.1080/10503300802326046 Froján-Parga, M. X., Calero-Elvira, A., & Montaño-Fidalgo, M. (2011). Study of the Socratic method during cognitive restructuring. Clinical Psychology & Psychotherapy, 18(2), 110–123. https://doi.org/10.1002/cpp.676 Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., & Gross, J. J. (2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology, 80(6), 1034–1040. https://doi.org/10.1037/a0028555 Greenberger, D., & Padesky, C. A. (2016). Mind over mood (2nd ed.). Guilford Press. Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (p. 3–20). Guilford Press. Hofmann, S. G., Asmundson, G. J. G., & Beck, A. T. (2013). The science of cognitive therapy. Behavior Therapy, 44(2), 199–212. https://doi.org/10.1016/j.beth.2009. 01.007 Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1 Hofmann, S. G., Suvak, M. K., Barlow, D. H., Shear, M. K., Meuret, A. E., Rosenfield, D., Gorman, J. M., & Woods, S. W. (2007). Preliminary evidence for cognitive mediation during cognitive-behavior therapy of panic disorder. Journal of Consulting and Clinical Psychology, 75(3), 374–379. https://doi.org/10.1037/0022-006X.75.3.374 Jarrett, R. B., Vittengl, J. R., Doyle, K., & Clark, L. A. (2007). Changes in cognitive content during and following cognitive therapy for recurrent depression: Substantial and enduring, but not predictive of change in depressive symptoms. Journal of Consulting and Clinical Psychology, 75(3), 432–446. https://doi.org/10.1037/0022006X.75.3.432 Kleim, B., Grey, N., Wild, J., Nussbeck, F. W., Stott, R., Hackmann, A., Clark, D. M., & Ehlers, A. (2013). Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 383–393. https://doi.org/10.1037/a0031290 Kwon, S.-M., & Oei, T. P. S. (2003). Cognitive change processes in a group cognitive behavior therapy of depression. Journal of Behavior Therapy and Experimental Psychiatry, 34(1), 73–85. https://doi.org/10.1016/S0005-7916(03)00021-1 Mahoney, M. J. (1974). Cognition and behavior modification. Ballinger. McRae, K., Ciesielski, B., & Gross, J. J. (2012). Unpacking cognitive reappraisal: Goals, tactics, and outcomes. Emotion, 12(2), 250–255. https://doi.org/10.1037/a0026351 Meichenbaum, D. H. (1974). Cognitive behavior modification. General Learning Press. Newman, M. G., & Fisher, A. J. (2010). Expectancy/credibility change as a mediator of cognitive behavioral therapy for generalized anxiety disorder: Mechanism of action or proxy for symptom change? International Journal of Cognitive Therapy, 3(3), 245–261. https://doi.org/10.1521/ijct.2010.3.3.245

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Overholser, J. C. (1993a). Elements of the Socratic method: I. Systematic questioning. Psychotherapy: Theory, Research, & Practice, 30(1), 67–74. https://doi.org/10.1037/00333204.30.1.67 Overholser, J. C. (2011). Collaborative empiricism, guided discovery, and the Socratic method: Core processes for effective cognitive therapy. Clinical Psychology: Science and Practice, 18(1), 62–66. https://doi.org/10.1111/j.1468-2850.2011.01235.x Padesky, C. (1993, September 24). Socratic questioning: Changing minds or guiding discovery? [Keynote address]. European Congress of Behavioural and Cognitive Therapies, London, England. Padesky, C. (1996a). Identifying the hot thought. New Harbinger Publications; The Center for Cognitive Therapy. Padesky, C. (1996b). Socratic dialogue. New Harbinger Publications; The Center for Cognitive Therapy. Purdon, C., & Chiang, B. (2016). Treatment of obsessive-compulsive disorder. In A. Carr & M. McNulty (Eds.), The handbook of adult clinical psychology: An evidence-based practice approach (2nd ed., pp. 492–514). Routledge. Rogers, C. R. (1977). Carl Rogers on personal power. Delacorte Press. Schmidt, I. D., Pfeifer, B. J., & Strunk, D. R. (2019). Putting the “cognitive” back in cognitive therapy: Sustained cognitive change as a mediator of in-session insights and depressive symptom improvement. Journal of Consulting and Clinical Psychology, 87(5), 446–456. https://doi.org/10.1037/ccp0000392 Stone, S. J., & Strunk, D. R. (2020). Fostering cognitive change in cognitive therapy of depression: An investigation of therapeutic strategies. Cognitive Therapy and Research, 44(1), 21–27. https://doi.org/10.1007/s10608-019-10055-6 Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science and Practice, 18(1), 47–61. https://doi.org/10.1111/j.1468-2850.2010.01234.x Thwaites, R., & Bennett-Levy, J. (2007). Conceptualizing empathy in cognitive behavior therapy: Making the implicit explicit. Behavioural and Cognitive Psychotherapy, 35(5), 591–612. https://doi.org/10.1017/S1352465807003785 Troy, A. S., Wilhelm, F. H., Shallcross, A. J., & Mauss, I. B. (2010). Seeing the silver lining: Cognitive reappraisal ability moderates the relationship between stress and depressive symptoms. Emotion, 10(6), 783–795. https://doi.org/10.1037/a0020262 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 Yang, Y.-T. C., Newby, T. J., & Bill, R. L. (2005). Using Socratic questioning to promote critical thinking skills through asynchronous discussion forum in distance learning environment. American Journal of Distance Education, 19(3), 163–181. https://doi.org/ 10.1207/s15389286ajde1903_4

9 Behavioral Activation Maria M. Santos, Ajeng J. Puspitasari, Gabriela A. Nagy, and Jonathan W. Kanter

A

long-standing characteristic of behavioral activation (BA) is its potential for widespread dissemination to reduce the burden of depression, particularly among populations that have been and continue to be underserved (Dimidjian et al., 2011; Kanter & Puspitasari, 2016). Across several decades, empirical findings have accumulated showing that the use of BA successfully reduces depression and produces other desirable outcomes across a variety of populations and contexts (Dimidjian et al., 2011). Client improvements have been observed among affluent, European-origin individuals treated in university settings and low-income, non-European-origin individuals treated in community settings. Given these findings and others described below suggesting its cost-effectiveness (e.g., Richards et al., 2016), BA is a recommended treatment package for depression in low-resource settings worldwide (World Health Organization, 2016). Specific features of BA, which may contribute to its promise for broad dissemination, include its culturally adaptable rationale and specific techniques that can be easily learned and tailored to what is meaningful for and needed by individuals in diverse settings. The BA rationale suggests that depression is reduced when a person reengages in their life through value-based and meaningful activities in response to adversity and despair. The task of determining what is “value based” and “meaningful” is largely one of eliciting from the client and assessing what is valuable and meaningful in their life. Thus, the BA rationale is considered to be cross-culturally adaptable, and BA has been found to be acceptable to individuals of diverse backgrounds (e.g., Kanter et al., 2015). https://doi.org/10.1037/0000218-009 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  235 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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BA’s core components are flexible and broadly applicable and usable alone or in combination with non-BA techniques (e.g. Beck et al., 1979). Selected BA techniques may also be implemented in a variety of provider settings, including primary care and other medical settings where underserved individuals traditionally seek care for mental health concerns. Techniques may be delivered within a relatively short time span, an important consideration given time constraints that exist within systems of care and the issue of early service termination among underserved individuals. Collectively, these features speak to BA’s promise for broad, effective dissemination. This chapter reviews BA’s history, theory, mechanism, core techniques, and empirical support before engaging in a thorough discussion of issues surrounding BA dissemination and implementation. Henceforth, we refer to the BA strategy to mean the entire treatment package, composed of specific BA techniques. A theme throughout is that the core BA technique of activity scheduling may exist as a primary component of stand-alone BA packages (which we discuss below) but may also be implemented in the context of other treatment approaches, whenever a clinician seeks to activate a client toward a behaviorally defined treatment-related goal.

HISTORY BA has its origin in the philosophy of science of radical behaviorism, put forth by the influential American psychologist B. F. Skinner. Skinner’s approach led scientists and clinicians, particularly Peter Lewinsohn (1974), to examine environmental factors and people’s sensitivity and responsiveness to their environments to understand depression and its treatment. According to Lewinsohn, depression occurs when stable sources of positive reinforcement are lost and an individual lacks the social skills to reestablish lost sources of reinforcement. Treatment, therefore, should encourage activity scheduling to reestablish contact with positive reinforcement and skills training to target behavioral deficits that interfere with contacting reinforcement (Lewinsohn et al., 1976). The 1970s witnessed the development of interventions based on this basic behavioral model of depression and studies in support of their efficacy and effectiveness (Kanter, Manos, et al., 2010), stimulating the development of multiple interventions that varied in their degree of consistency with Lewinsohn et al.’s (1976) approach. Interventions based on alternative behavioral models were also developed, some of which did not incorporate exclusively behavioral techniques (e.g., McLean, 1976; Rehm, 1977). These treatments have been identified as variants of BA by researchers who have conducted meta-analyses of the efficacy of BA treatments as a group (e.g., Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009). These analyses have documented that BA and its variants, collectively, perform very well in randomized controlled trials. BA consistently outperforms wait-list and no-treatment controls and, in general, is comparable to cognitive therapy at the end of treatment and follow-up (Cuijpers et al., 2007; Ekers et al., 2008; Mazzucchelli et al., 2009).



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Toward the end of the 1970s, largely in line with the zeitgeist of the time rather than scientific findings, use of strictly behavioral intervention techniques were abandoned in favor of cognitive techniques or a combination of cognitive and behavioral techniques. Cognitive approaches to depression treatment ascended in popularity. Two studies by Lewinsohn and colleagues were influential in propelling this shift toward cognitive approaches. First, in a small yet impactful comparison of cognitive and behavioral techniques, cognitive techniques outperformed the behavioral in terms of significantly fewer depressive symptoms (Shaw, 1977). Second, in an analysis of the components of Lewinsohn et al.’s (1976) approach, no differential effectiveness was observed between activity scheduling (i.e., a key component of BA), skills training (not unique to BA and recommended to address skills deficits), and cognitive techniques (Zeiss et al., 1979). These findings culminated in Lewinsohn and his colleagues adopting a cognitive behavioral therapy (CBT) rather than a strictly behavioral approach to the treatment of depression, evidenced by the publication of the self-help book Control Your Depression (Lewinsohn et al., 1978) and the therapy manual Coping With Depression (Lewinsohn et al., 1984). After this point, although behavioral techniques continued to be used, they were generally implemented within a cognitive change framework. Thus, the primary BA technique of activity scheduling continued to be implemented within CBT, and development of stand-alone BA packages stagnated. Within CBT, rather than help a person through behavior change, behavioral methods were meant to help shift a person’s underlying assumptions or irrational beliefs. Such was the case with Beck et al.’s (1979) Cognitive Therapy of Depression, the most widely investigated and utilized set of techniques for treating depression (DeRubeis & Crits-Christoph, 1998). The CBT model reigned as the gold standard framework for the psychotherapeutic treatment of depression until the 1990s, when Jacobson et al. (1996) conducted a dismantling study in which they compared the full CBT package to the treatment’s components, including the element focused on BA. They found no differential effectiveness (i.e., recovery and relapse rates, number of well weeks, and survival time to relapse) of behavioral and cognitive techniques at the end of treatment and 2 years later (Gortner et al., 1998). They concluded that adding cognitive techniques to BA did not improve outcomes. In addition, they raised the notion that BA techniques were superior to cognitive techniques given their comparable efficacy and, at the same time, that BA techniques had greater efficiency with regard to training and in-session implementation. Jacobson et al.’s (1996) findings inspired renewed interest in implementing exclusively behavioral strategies and the development of contemporary standalone BA techniques grounded in behavioral conceptualizations of depression and treatment. Since the early 2000s, two variants in particular have surfaced as the dominant approaches, namely BA (Jacobson et al., 2001; Martell et al., 2001, 2013) and behavioral activation treatment for depression (BATD; Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011). Combined, BA and BATD have been the basis of abundant research with individuals from an array of populations and pathology profiles, which we discuss later in this chapter.

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Although the two primary variants of BA share core components, noteworthy differences exist between them. In the early 2000s, Martell et al. (2001) developed a treatment manual for BA that was grounded in contextualism. Given this theoretical underpinning, key to understanding the nature of an individual’s depression and the ideal strategies to treat it was understanding the client’s full historical and environmental context. Martell et al. (2001) also considered that treatment intervention for the client should be determined by the functional analysis of client behaviors. A functional analysis helps a therapist and client develop hypotheses about the events that lead to, maintain, and strengthen client behaviors that create problems and interfere with improvement. More specifically, it helps them develop hypotheses about the events that produce the behavior for the client at that particular time and under those conditions (Kanter et al., 2004). In BA, therapists and clients use the straightforward Antecedent-Behavior-Consequences (A-B-C) model to identify the events/antecedents (A) that lead to the client’s clinically relevant behavior (B) and the consequences (C) that maintain it. A major focus of BA is to help a client develop and engage in healthy or adaptive behaviors when presented with events that have historically led to engagement in depressed behaviors (such as those that function to escape or avoid aversive situations). Martell et al.’s (2001) approach to BA can be delivered over 10 to 16 sessions. It is both comprehensive and flexible concerning the pacing of BA techniques used throughout treatment. To that end, Martell and colleagues described BA as an approach rather than a treatment composed of a series of techniques. Contemporaneously, Hopko, Lejuez, and colleagues developed BATD (Lejuez, Hopko, & Hopko, 2001). The BATD protocol can be implemented over eight to 10 sessions and is focused on distilling core BA techniques into a condensed session-by-session treatment package. Their aim was to create a treatment package that was easy to teach and could be implemented in a range of settings. Additionally, BATD incorporated a formal values assessment in various life domains (i.e., inventory of the client’s personally held values) to facilitate values-consistent activation through treatment.

UNDERLYING THEORY A Behavioral Account of Depression In line with BA’s behavioral origins, reinforcement has been a central concept in its models of depression. A reinforcer is any consequence that makes it more likely that a specific behavior will occur in the future when that consequence occurs soon after the behavior occurs. For example, in an attempt to obtain a hug, Mike asks his partner, “Can I have a hug?” Presuming hugs are indeed reinforcing for Mike, if Mike’s verbal request (i.e., behavior) results in a hug (i.e., consequence), Mike is more likely to make the same or similar request of his partner when he wants a hug in the future. In this case, the consequence of



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receiving the hug is the positive reinforcer that makes it more likely that Mike will ask for a hug. The conceptual work of Ferster (1958, 1973, 1974) informed the thinking of other BA experts. Ferster hypothesized that nondepressed, healthy behaviors maintained by positive reinforcement likely were absent from the repertoires of individuals with clinically significant problems. Furthermore, Ferster proposed that a person with clinically significant problems might be more likely to engage in behaviors reinforced by escaping from or avoiding aversive events and that this might effectively limit their access to positive reinforcement for healthy behavior. In more technical terms, such a person’s behaviors would be primarily maintained by negative reinforcement. For instance, whenever Martha, who is diagnosed with depression, spends time with friends, she feels sadness and anxiety. Martha might decline invitations to spend time with her friends to avoid these aversive consequences. Although the behavior of declining invitations has the consequence of avoiding difficult feelings (i.e., negative reinforcement), it simultaneously serves as an obstacle for attaining positive reinforcement for healthy behavior and feeling better. Ferster (1958) also hypothesized that individuals with environments characterized by impoverished reinforcement might engage in the indicated healthy behaviors but at inappropriate times or when the behavior is not likely to be reinforced. For example, Martha might call on a friend unannounced at work with the desire to have an intimate interaction with her friend. Rather than respond as Martha had hoped, the friend hurriedly explains that she is running late to a meeting. Although Martha engaged in a desirable healthy behavior, she did so at a time when the consequence that might maintain her behavior in the future was not likely to occur. Although these early theoretical writings on depression emphasized positive reinforcement, negative reinforcement, and issues of timing and reinforcer availability, Lewinsohn’s (1974) behavioral theory of depression largely emphasized reductions in contact with positive reinforcement, as exemplified by the case of George. George worked hard at his job to provide financial stability for his family. In his free time, George began growing tomatoes and chilies (i.e., behavior) after he discovered that he enjoyed and felt accomplished upon harvesting his yield (i.e., positive reinforcement). He also received a favorable response from his family and believed that he had contributed meaningfully to the family (i.e., more positive reinforcement). In addition to providing fresh food from his garden, George also bonded with his children by partaking in their activities, taking them on outings, and reading to them at night. According to Lewinsohn’s model, depression is the product of losses of, reductions in, or chronically low levels of response-contingent positive reinforcement (RCPR), or positive reinforcement that is dependent on specific behaviors. When George developed an illness that severely limited his physical abilities, much of the mentioned positive reinforcement was lost. After the onset of his illness, George was no longer able to engage in a variety of physical activities that helped him contribute to meeting his family’s needs, including tending to his garden and

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working for an income. He continued to read to his children regularly, but the illness significantly interfered with his ability to join in their activities and take them on outings. As a result of these behavioral changes, George experienced multiple losses of and reductions in sources of positive reinforcement. In time, George experienced an extinction of other healthy behavior as he stopped talking to his wife and close others. Lewinsohn (1974) proposed that RCPR depends on three factors: (a) differences between individuals in what is reinforcing, (b) the availability of that which is reinforcing in a particular individual’s environment, and (c) an individual’s skill at obtaining and maintaining contact with the necessary reinforcement. For example, in George’s case, gardening and family involvement are very reinforcing, but consider Louise, who, in contrast, is less family oriented but is reinforced by spending time with friends and engaging in sports activities. To avoid depression, it is best for George to live near his family and have a plot of land available so he can garden, whereas it is best for Louise to live near friends and within access to a park where she and her friends can play sports. Furthermore, it is beneficial that George knows how to successfully keep his garden alive, whereas Louise can experience success at sports due to her athletic ability. According to the behavioral model, these conditions are important for BA therapists to consider as they develop treatment plans (discussed below). To bring together the lines of conceptual work of these BA pioneers (Ferster, 1973, 1974; Lewinsohn, 1974) and modern BA developers (e.g., Lejuez, Hopko, & Hopko, 2001; Martell et al., 2001), Manos et al. (2010) clarified a comprehensive and current BA model of psychopathology, which is visually depicted in Figure 9.1. According to this model, depression involves four interrelated elements, namely reinforcement, mood, behavior, and depression. Psychopathology starts with an environment typified by losses of, reductions in, and/or chronically low levels of positive reinforcement, due to individual differences in what is reinforcing (which can include genetic factors), the availability of reinforcement in the environment, and the person’s skill in obtaining it. The onset of depression is also characterized by the greater availability of negative reinforcers in the environment. Lejuez, Hopko, LePage, et al. (2001) emphasized a third reinforcement process in their behavioral activation variant, BATD, which is the positive reinforcement of depressed behavior. Combined, these changes in reinforcement occur such that positive reinforcement for healthy behavior is subsequently reduced, lost, or chronically deficient in a person’s environment. In response, a person will experience affective changes associated with depression, such as depressed mood, irritability, and anhedonia. Because of environmental changes, the person—simply put—feels depressed (Kanter et al., 2008, 2009). Behavioral changes occur as a consequence of changes in reinforcement as well. When positive reinforcers are lost, reduced, or chronically low, the model predicts reductions in or the extinction of healthy behaviors. A person with this positive reinforcement environmental profile may be expected to engage in fewer specific behaviors that had previously led to contact with positive

Reinforcement   R+ for healthy behavior (  R– and R+ for depressed behavior)

Behavior

  activation (  avoidance and depressed behavior)

Treatment

Provision of BA techniques

  depressed mood

Mood

 depressive symptoms

  activation (  avoidance and depressed behavior)

  depressed mood

  R+ for healthy behavior (  R– and R+ for depressed behavior)

Treatment

Depression

Behavior

Mood

Reinforcement

Psychopathology

FIGURE 9.1. Psychopathology and Treatment Mechanism Underlying Behavioral Activation (BA)

  depressive symptoms

Depression

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reinforcers (e.g., going to work, engaging in hobbies, taking care of personal responsibilities). If changes in reinforcement for a person include increases in negative reinforcers, the model predicts increases in avoidance behaviors, wherein the depressed person engages in behaviors to escape or avoid aversive experiences. A person’s environment may also be characterized by increases in positive reinforcement for depressed behaviors, which would lead to greater engagement in these behaviors, such as complaining to friends and subsequently receiving warmth and attention. According to the model, clinically significant depression occurs when initial changes in reinforcement, mood, and behavior lead to a self-sustaining cycle of further changes in the relations among these elements that lead to and maintain a depressive environment or lead to worsening of depressive symptoms. Take the case of Alexis, who took on a job from which she believed she gained very little (e.g., did not allow her to develop new skills, did not offer many opportunities for upward mobility) and that resulted in relatively low positive reinforcement and feelings of dissatisfaction and unhappiness. She disengaged from her job (i.e., quit) before finding alternative employment and, as a result, lost a major source of positive reinforcement and began to feel “down” most days. Alexis’s job had allowed her to meet financial responsibilities and engage in a variety of social activities (e.g., enjoying dinner with friends regularly, attending artistic events), which she was no longer able to do once unemployed. In time, Alexis disengaged from other healthy behaviors (e.g., paying bills, going out with friends) and felt even worse, experiencing another worsening in difficult feelings. In this case, Alexis experienced a reduction in positive reinforcement and a sense of dissatisfaction and unhappiness when she began her job. The level of available positive reinforcement was insufficient to maintain her engagement in the job. Upon leaving her job, she lost the job-related sources of positive reinforcement altogether, automatically felt other difficult feelings (i.e., depressed mood and anxiety), disengaged from other healthy behaviors, lost other sources of positive reinforcement, and felt considerably worse over time. A Behavioral Approach for Reversing the Cycle of Depression Manos et al. (2010) also clarified the corresponding BA treatment model and the hypothesized mechanism through which BA treatment techniques affect depression change. Specifically, it is proposed that the cycle of depression is reversed in the context of BA when treatment techniques are implemented and subsequently lead to activating new or reactivating previous healthy behavior that has decreased. In particular, activity scheduling is the primary technique for increasing a person’s engagement in healthy, nondepressed behavior. Treatment implementation also involves the use of secondary treatment techniques to address issues that interfere with the ultimate goal of increasing a person’s activation, namely avoidance, depressed behaviors, skills deficits, and contingency management. Through increases in activation, a



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person experiences increases in contact with positive reinforcement that is available in the environment, which strengthens desirable changes in behavior over time. With sustained successful contact with positive reinforcement, a person is expected to experience improvements in mood and, ultimately, decreased depressive symptoms. In some cases, a person’s efforts to engage in activation and disengage from avoidance and other depressed behaviors may be hindered by an environment in which consequences (i.e., reinforcers) are not supporting improved behavior and/or are sustaining problematic behavior. The provision of BA treatment in these cases would include the use of contingency-management techniques to alter the environment to support desired behavioral changes. In combination, changes in the client’s behavior and direct contingency-management techniques result in changes in the environment (more specifically, changes in reinforcers) that ultimately reverse the cycle of depression. Thus, BA’s fundamental goal is to help a client become activated to increase contact with diverse and stable sources of positive reinforcement, which should lead to a reduction in or elimination of depression. Over time, a client not only changes their behavior but also begins to understand the BA model itself. The client learns how behavior, environment, and mood are related and learns to predict situations that might lead to loss of positive reinforcement. The client, then, is able to maintain healthy behavior in those situations and prevent future episodes of depression.

DESCRIPTION OF MAIN PROCEDURES Multiple treatment manuals are available for readers wishing for detailed descriptions of treatment techniques and specific protocols that have been employed in BA research studies (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011; Martell et al., 2001, 2013). These manuals present a host of BA treatment techniques, ideas, and options for clinicians depending on the clinician’s specific needs. The Lejuez manuals are relatively brief and structured, with concrete session-by-session guidelines, specific homework, and other forms that can be used. The Martell manuals are longer, with more clinical examples and discussion of behavioral processes as part of the text. Our analysis of these and other BA protocols is that a set of core BA techniques can be distilled and identified from the multiple BA treatment approaches that have been published and empirically supported (Kanter, Manos, et al., 2010). In our view, these core techniques represent the functional essence of BA—activating a client to engage in antidepressant behavior per a unique case conceptualization of that client— and allow clinicians to flexibly implement BA across diverse settings and clients, without requiring lengthy training protocols that provide details that may be unrealistic for a given setting. Therefore, the core BA techniques also may be employed within the context of other treatment approaches, whenever a clinician wishes to engage in specific behaviors (i.e., activate) as part of a larger treatment plan.

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In previous work, microskills for each of the techniques we describe have been operationalized, and brief training protocols have been developed and evaluated for effectively increasing competence in implementing them (Puspitasari et al., 2013, 2017). Here, we present an overview of each core BA technique, including (a) provision of a BA rationale, (b) assessment techniques (i.e., values assessment and activity monitoring), (c) activity scheduling, and (d) techniques to cope with avoidance and other barriers to activation. Presenting a Rationale Though it is common to all psychotherapies (e.g., Ilardi & Craighead, 1994), the provision of a rationale for treatment is considered a core BA treatment technique (Puspitasari et al., 2013). Simply put, the BA rationale is that when people face difficult life circumstances, they are likely to get depressed, shut down, and stop engaging in life. Thus, BA will help the client get active again. How the client gets active will be determined through a collaborative process between the therapist and the client and will be sensitive to the unique needs and circumstances of the client’s life. The therapist and client will identify weekly activation goals, schedule these assignments specifically, discuss and problem solve obstacles to successful activation, monitor how increasing activation is addressing the client’s depression and life problems, and modify the action plans accordingly to maximize the chance that increased activation will affect the key variables maintaining depression in the client’s life. A strength of BA is that this rationale, while based on a strong scientific theory and empirical findings, is seen as simple and easy to understand by clients, including clients who may come from cultures in which the Western medical model of depression is foreign (Kanter et al., 2012). According to this rationale, BA techniques may be helpful when a client is experiencing negative life circumstances, is feeling down as a result, and wants to reengage in life. The BA rationale often empowers clients to persevere in the face of difficult life circumstances and offers therapeutic assistance and techniques to do so. There is no need for the therapist to educate the client about the symptoms of depression per Western medicine or even to use the term “depression” for that matter. The therapeutic tasks are primarily listening to the client’s narrative of life circumstances and helping the client actively pursue personal goals and meaning with respect to their life circumstances. In its simplest form, the BA rationale can be “I’d like to help you stay active and engaged in the things that are important to you.” In its more elaborated form, the rationale can be presented as in the following exchange between a therapist and hypothetical client Alice. THERAPIST: Alice, I would like to take a few minutes now to share my views

on how you have come to feel as you do and how you can go about improving how you feel. Would that be alright? ALICE:

Yes, definitely, please.



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THERAPIST: It makes a lot of sense to me that you have been feeling as you

have been over the last few months given what you’ve lived recently. You experienced the loss of your husband—a major source of connection and support. With his loss have also come other losses and hardship. It sounds like you are experiencing financial insecurity and there is some uncertainty about how you will be able to provide for your two children now that you cannot rely on a second income. Since your husband passed, it sounds like you have been struggling with deep sadness, and as time has progressed, you have also come to feel very little interest and motivation to carry out your life as you did prior to his passing. Does this map on to what you’ve shared? ALICE:

Yeah, that’s exactly what’s happened . . .

THERAPIST: When people undergo the types of experiences you have, they

tend to feel like you are now. When they feel as you do, they often respond by disengaging from life, which I call “shutting down.” In listening to you, it sounds like you may have shut down in some important ways. I wonder if this is reflected in your decision to stop attending your bimonthly book club and in your recent decision to have your children carpool with friends to their weekend activities. What do you think? ALICE:

I hadn’t thought of things that way. I think it’s fair to say that I have pulled out of my old life. I just don’t have the energy and desire to do much of anything.

THERAPIST: Again, it makes sense to me that in the face of everything that’s

happened and the feelings that constantly come up for you, you would shut down. Now, the way I see it given my experience working with others in similar situations, we can work together to help you tackle your depression with behavioral activation. This means helping you plug back into your life in such a way that you are doing things that are important to you. For instance, we would figure out how to get you doing things that help solve problems, give you a sense of purpose, and bring about enjoyment. We would also get you doing things that you may be putting off but that are key to living your life meaningfully. In my experience, when a person plugs back into life, the changes in feelings they are looking for often follow. By getting more active, you will be able to live the life you envision for yourself, and there is a good chance your sadness will lessen and your interest and motivation will increase. We suggest that such an intuitively straightforward rationale may help therapists work cross-culturally within the BA model by presenting a rationale that is likely to resonate with culturally diverse clients while staying open to their

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cultural needs and experiences. For example, consider Rahim, a Muslim client who quit his job and became depressed after experiences of discrimination at his workplace. He subsequently stopped going to his mosque, which further isolated him since much of his social engagement came through his religious practice and community. Rahim presented primarily with somatic symptoms of depression, such as feeling tired and lacking energy, rather than emotional symptoms. The BA therapist was not Muslim but was able to recognize the sequence of losses of reinforcers in Rahim’s life, per BA’s model of depression, and provide a rationale that was consistent with Rahim’s experience, using his language rather than behavioral jargon (Mir et al., 2015). The therapist explained that BA could focus on helping Rahim reactivate to find new employment and reengage with his religious practice and social community, even though he was feeling tired and lacking energy. The therapist suggested that once Rahim started getting more active in these ways, it was expected that he would feel less tired and have more energy. Activity Monitoring and Other Assessment Techniques In the above example, the primary targets for activation were fairly clear from an initial examination of Rahim’s presenting problem. However, it is often the case that BA therapists will implement specific assessment techniques to develop a list of activation targets tailored to the client’s values and life circumstances. A primary technique, which has existed in BA since its early days (Kanter, Manos, et al., 2010), is activity monitoring. To achieve the aims of activity monitoring, the client is asked to keep a detailed record of their activities over the course of the week for the therapist to review. This record may also include ratings associated with each activity, such as the client’s mood during the activity, experience of enjoyment during the activity, and experience of mastery during the activity. Through these ratings, the client and therapist can discuss together how certain activities result in the client feeling better, experiencing more enjoyment, or experiencing more mastery and how other activities (or lack of activity) result in the client feeling more depressed, experiencing less enjoyment, or experiencing less mastery. Identifying these relations between activity and mood can be helpful for identifying activities to assign. The following is a hypothetical exchange between Alice and her therapist as they work to identify treatment targets. THERAPIST: I’m looking forward to going over your activity monitoring form

this session. As we discussed last session, one way this form will be useful is that it will help us get a clearer picture of your level of activity right now, as well as the feelings that come up for you when you carry out your activities. Another way in which it will be useful is by helping us home in on which activities we want to see more of and which activities we want to work to decrease to reverse your depression. How does that sound?



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ALICE:

Okay, that makes sense to me. At first, I was not sure what I could learn from this. Coming in, I thought I had a pretty good sense for what I’m up to, which is not much, and how I feel.

THERAPIST: Tell me, what did you learn? ALICE:

Well, I spend a lot more time on my phone than I realized.

THERAPIST: Let’s take a look at when you were on your phone throughout

the week. What was your mood like after being on your phone for a while? ALICE:

On Monday I didn’t go in to work. I woke up with a very bad headache, so I called out from work. I stayed in bed all morning and got up like at 1:00 or 2:00. I was on my phone pretty much the whole time, on and off. I felt very depressed after that.

THERAPIST: What happened on Wednesday? What was your mood like after

being on your phone for a good chunk of time that day? ALICE:

So that was 3 hours after work when I was supposed to be doing meal prep for my kids for the week . . . I felt like a terrible mother. Meal prep didn’t get done. [sigh]

THERAPIST: What came up for you? ALICE:

I felt so guilty and worthless . . . That was probably my lowest point of the week. I was extremely depressed after that.

THERAPIST: It really comes across how important it is to you that you follow

through on that task. Why is that task so important to you? ALICE:

My kids are the most important people in my life. When I don’t do things that are meant to keep them happy and healthy, it really brings me down.

THERAPIST: Alice, based on what we’ve learned from your activity form just

now, I think an important activity we could schedule is meal prepping. It sounds like a very important activity and we could develop a plan that makes it more likely you will succeed at carrying it out. What do you think of that? ALICE:

Okay, yeah, I really need to turn that around.

THERAPIST: It also sounds like we could explore your phone use a bit more.

Right now, it sounds like phone use, at least in certain situations, leads you to feel pretty down on yourself. We could work to reduce phone use and get you doing things that are important to you during that time instead. Thoughts? ALICE:

I definitely think I spend too much time on my phone. Yeah, I think that makes sense.

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Activation assignments in BA, however, generally are not solely the product of activity monitoring. In addition, the therapist is continuously informally learning about the client’s life circumstances, cultural issues, values, and goals, thereby developing ideas for activation from multiple sources of information. Per Puspitasari et al. (2013), four additional sources of influence may be considered. First, BA therapists look for behaviors and activities that clients used to do but stopped doing as they became depressed, as well as new activities that clients want to start doing. Because these activities are not in the client’s current repertoire, activity monitoring will not reveal them to the therapist, so the therapist must ask about these activities. Second, per Ferster’s (1973, 1974) focus on avoidance in depression, which is heavily emphasized in BA by Martell et al. (2001, 2013), BA therapists should assess behaviors that the client is avoiding because they feel overwhelming or aversive. These may be difficult, but important, behaviors to activate. Third, per BATD (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), BA therapists may employ a formal and structured assessment of different life areas (e.g., education, family) and the client’s values in each area (e.g., attending college, improving a relationship with a sibling) that would lead to specific activation assignments. Fourth, BA therapists may assess daily routines (e.g., exercise, sleep, personal hygiene) that have been disrupted in depression. Although the specific assessment techniques described above may be helpful to therapists in developing activation assignments, assessment in BA is an ongoing process and not restricted only to the techniques described in this section. Essentially, BA therapists are always listening for ideas from the client about which behaviors may be important to activate and which behaviors are contributing to depression. Furthermore, as activity scheduling occurs, therapists are listening for what has worked and not worked, as well as which activities have helped the client experience decreased depression and which have not. Therapists make adjustments to the conceptualization as therapy unfolds. Activity Scheduling The core technique of BA is activity scheduling. Each week, the therapist and client together develop a specific list of antidepressant activities in which the client plans to engage that week. Some of these activities may be discussed and scheduled in detail, whereas others may simply be mentioned and assigned in passing. In BATD (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), the therapist and client, early in treatment, complete a specific activity hierarchy, which is a list of all the activities identified during assessment for the client to complete over the course of treatment, ranked in terms of difficulty and priority. This hierarchy then determines the assignment of activities, although adjustments are regularly made with respect to the client’s current functioning, capacities, and goals. Other variants of BA are less structured, such as determining activities to schedule, leaving the weekly choices to the discretion of the therapist and the client.



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In our experiences, we have found that approximately three to five activities are assigned to the client each week, representing a mix of difficult and simple assignments across life areas. For example, the activities assigned to the client on a given week may involve an exercise or hygiene activity, maintaining a commitment or an obligation rather than avoiding it, searching for a job, and doing something enjoyable with a friend or family member. In a typical 50-minute therapy session, there will be time to discuss two or three of these activities in detail. Such detailed discussion involves concretely identifying what the activity will be and where, when, and with whom the activity will occur. For example, a client may decide to invite a friend for a jog around a nearby lake at 10:00 a.m. on Saturday morning. The therapist and the client will also identify and problem solve potential obstacles to successful completion of the assignment, such as the possibility that the friend will be unavailable, that the client will feel too tired to get out of bed Saturday morning, or that it will rain. Alternative plans are typically developed. The following is a hypothetical exchange between Alice and her therapist as they work to develop Alice’s activity plan. THERAPIST:

Let’s come up with a plan for helping you prepare meals for your children each week. What do you usually aim to accomplish during your meal prep sessions?

ALICE:

My goal is usually to prepare three dinner meals for the week so that I make sure that the kids are getting proper meals. I want to have different kinds of meals so that they don’t get bored of eating the same thing over and over again. I have wanted to cook the meals at once because I find it hard to cook many times during the week, but this just hasn’t worked out . . .

THERAPIST: It sounds like you are working toward a very productive

cooking session! Let’s work on helping you meet that goal as part of our work together. I often find that one way to help clients succeed at accomplishing their goals is to start off by breaking down an activity into chunks. It sounds to me that your meal prep plan involves many smaller activities. For instance, each meal can be thought of as one activity. I would suggest that we start off by scheduling a meal prep session that involves cooking one meal. Right now, it sounds like it’s very difficult to get going with things that are usually not difficult for you to do when you are feeling like yourself and not depressed. I think it’s important to take into consideration that things are difficult to do at this time. By setting a realistic plan that considers how difficult it is to do the activity, we make it more likely that you will be able to succeed at carrying it out. What do you think of starting off with preparing one meal during your cooking session?

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ALICE:

I suppose that sounds more realistic than my current plan. I’m willing to try that.

THERAPIST: Great. I recall you planned to prepare meals on Wednesdays.

How did you decide on Wednesday? ALICE:

It’s the day I get off of work early enough to cook in the evening. I have been wanting to avoid cooking on the weekends since there is a lot going on during those already.

THERAPIST: It sounds like you’ve given a lot of thought to when would be a

good day to cook. Would you like to stick to that day then? ALICE:

Yes.

THERAPIST: Okay, when on Wednesday is a good time to meal prep? ALICE:

I usually plan to do it after dinner.

THERAPIST: How has that worked? ALICE:

Well, I haven’t really meal prepped in a long time, so not very well, I suppose.

THERAPIST: What has gotten in the way of doing the activity at that time? ALICE:

After dinner, all I want to do is sit down and doze off.

THERAPIST: It sounds like you’re tired by the time meal prep time comes

along. Would it be possible to do it earlier? ALICE:

Mmm . . . I could do it as soon as we get home while the kids are doing their homework. I have protected that time to just do homework or to sit and unwind after a long day at work.

THERAPIST: Would you consider prepping meals as soon as you get home? ALICE:

Mmm . . . I suppose I could. I just really feel that I need the time for myself and to help the kids with their homework.

THERAPIST: You sound ambivalent. Would it work to switch your “me time”

to after dinner? ALICE:

Okay, that could work. I’m tired after dinner anyway.

THERAPIST: Sounds good. I assume you will want to cook at home in your

kitchen. Is that right? ALICE:

Yes.

THERAPIST:

Wonderful. Now, let’s put our heads together and think through what could get in the way of you completing this activity this week.

Activities to assign will be a function of assessment and tailored to the unique cultural and life circumstances of the client. For example, in our study wherein



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we evaluated BA at a community clinic that primarily served low-income Latino clients, a variety of activities were assigned and completed by clients over the course of the study (Kanter et al., 2015). These activities included dancing, walking, exercising, playing sports, attending community center activities (e.g., relaxation groups, stress management groups), attending a community fiesta (i.e., party), going to fun places or events (e.g., museums, seasonal free concerts, library), attending church activities and events, visiting friends, playing with children/grandchildren, reading Spanish-language magazines, listening to Spanish-language music, preparing a traditional family meal, cleaning the house, knitting, seeking employment, attending medical appointments and maintaining medical care (e.g., diabetes care), calling family and friends in their country of origin, working on social service agency problems, asking others for help, saying no to a request, spending time with family, taking English-language and computer classes, maintaining personal hygiene, and talking with a spouse/ partner about parenting issues. Clients who receive BA will be asked to monitor completion of activities as they occur, possibly using a similar form to activity monitoring. As with activity monitoring, the client may be asked to track how they felt before, during, and after the activity, using the same format they used in activity monitoring. After the initial assessment sessions in a course of BA, the typical session will involve first reviewing the previous week’s assigned activities, problem solving obstacles that occurred and celebrating successes, and developing new assignments. This process composes the bulk of the BA session. Techniques to Cope With Avoidance and Other Barriers to Activation The final set of core BA techniques concerns how to address avoidance and other barriers to activation. Techniques to address avoidance are explicated in detail by Martell et al. (2001, 2013), who suggested that a primary goal of BA is not only to activate clients as we have discussed above but also to teach clients how to proactively identify their tendencies to avoid engaging in important antidepressant behaviors because the behavior may lead to aversive feelings or other negative outcomes. For example, many individuals who do not exercise regularly avoid exercise because it requires a lot of effort and energy and potentially causes physical pain, both during and after exercise. Yet we know that exercise is antidepressant, and only over time does it become enjoyable and reinforcing. Thus, BA therapists teach clients to identify the triggers that might lead to avoidance (e.g., an assignment to exercise), the thoughts and feelings associated with the assignment (e.g., “I will feel exhausted and out of shape.”), and the tendency toward avoidance that results from this sequence. In general, the overall BA rationale presented to clients is seen as relevant to the problem of avoidance, as the belief in BA is that one can engage in behavior and do difficult activities even when one does not feel like doing so. Per Martell et al. (2001), this may be thought of as an “outside-in” approach to therapeutic change, in that one may first change “outside” behaviors, and this change will

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influence how one feels on the “inside.” This may contrast with an “inside-out” approach, with which a client may be more familiar, in which one first has to change how one feels on the inside before one can change what one does on the outside. Clients may be encouraged to think of examples in their lives when they were successfully able to do something even though they did not feel like it. Overall, avoidance is addressed in a variety of ways by BA therapists. For example, clients may be encouraged to engage others to help them complete difficult activities, such as by establishing contracts with others to complete the task. Per Martell et al. (2001, 2013), the therapist may also teach clients to engage in the present moment through mindfulness techniques that help the client disengage from aversive feelings and thoughts that control avoidance (i.e., rumination), thereby making valued behavior more likely. All told, it must be recognized that for some clients, the urge to avoid is very strong, and this remains one of the most difficult issues BA therapists face. When avoidance is an issue, the therapist must balance the provision of techniques to help the client overcome the avoidance with reconsideration of the original difficulty level of the task, in the context of exquisite validation of difficulty of activating and associated emotions and thoughts. Therapists may work with clients to make tasks less difficult and try again. Patience, persistence, and flexibility, in combination with warmth and validation, are necessary therapeutic qualities here, as is the ability to recognize small improvements in the client.

OUTCOME DATA Efficacy and Effectiveness of Integrated BA Components Although most of BA’s evidence base exists with respect to BA components integrated into stand-alone treatment packages, the efficacy and effectiveness of individual BA techniques has been demonstrated as well in many cases. Regarding BA packages, the results of multiple meta-analyses of BA trials (Cuijpers et al., 2007; Ekers et al., 2008, 2014; Mazzucchelli et al., 2009) provide clear indication that these protocols, as a group, demonstrate superior efficacy in treating depression compared with control conditions, evidenced by large effect sizes in favor of BA. A more recent meta-analysis found a small, albeit significant, short-term superiority of BA relative to antidepressant medication (Ekers et al., 2014). Data also indicate that BA is comparable to cognitive therapy and antidepressant medication with regard to maintaining gains at 2-year follow-up (Dobson et al., 2008). Given the accumulated evidence, BA has been designated a well-established, validated treatment for depression by the American Psychological Association (APA; Chambless et al., 1998). Evidence also suggests that BA strategies can reduce the burden of depression among groups taxed with chronic mental health conditions leading to hospitalization or other mental health problems that are not depression. Specifically, several studies have noted decreases in clinical symptom severity in a range of populations, including clients with posttraumatic stress disorder (PTSD; Acierno



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et al., 2016; Strachan et al., 2012; Jakupcak et al., 2010; Nixon & Nearmy, 2011), binge eating disorder (Alfonsson et al., 2015), and substance abuse (Daughters et al., 2008; Magidson et al., 2011). Additionally, several studies have demonstrated significant changes in activation and avoidance with clients in inpatient settings (Folke et al., 2015), with binge eating disorder (Alfonsson et al., 2015), and with substance abuse (Magidson et al., 2011). Also, clients with PTSD (Jakupcak et al., 2010) or substance abuse (Daughters et al., 2008) report a high level of satisfaction with BA. BA has shown promise for individuals coping with mental and physical health problems. BA has evidenced reductions in depressive symptoms in clients with cancer (Hopko, Armento, et al., 2011), HIV infection (Magidson et al., 2014), functional impairments (Wesson et al., 2014; Hellerstein et al., 2015), cognitive impairment (Snarski et al., 2011), and intellectual disabilities (Jahoda et al., 2015), as well as in clients who smoke (MacPherson et al., 2010). Additionally, BA holds promise as a depression-prevention tool, already having garnered some support to indicate prevention of depression in individuals with age-related macular degeneration (Rovner et al., 2014). BA also produces high treatment satisfaction in clients with cancer (Hopko, Armento, et al., 2011). As discussed in Dimidjian et al. (2011), BA has been researched across a wide array of depressed subpopulations, not limited to prototypical samples (i.e., White and affluent), who are diverse with regard to ethnicity, socioeconomic status, accessibility (e.g., rural vs. urban), problem profile (e.g., comorbid with psychological disorders or other health conditions), and geographical region. A substantial amount of research has been conducted on BA with lowincome Latinos, and results indicate significant changes in activation and avoidance (Collado et al., 2014), clinically meaningful depression symptom reduction (Collado et al., 2014, 2016; Kanter, Santiago-Rivera, et al., 2010; Kanter et al., 2015), and greater engagement and retention (Kanter et al., 2015). Research with Black samples has been supportive of BA’s ability to reduce depressive symptomatology (Jacob et al., 2013; MacPherson et al. 2010). BA techniques may be well suited for adaptation to address treatment disparities encountered by individuals with low mobility, geographic barriers, and other issues of access through alternative modes of delivery. BA has led to significant symptom improvement when delivered via telephone (Au et al., 2015; Gellis et al., 2014; Lyons et al., 2015), internet website (O’Mahen et al., 2014), videoconferencing (Acierno et al., 2016; Egede et al., 2015; Luxton et al., 2016), and mobile applications (Ly et al., 2014, 2015). Although some results suggest the slight benefit (i.e., reductions in depressive symptomatology) of in-person BATD (Luxton et al., 2016), other findings suggest that home-based and in-person activation treatments are comparable (Acierno et al., 2016; Egede et al., 2015). BA may be poised to address the burden of depression worldwide, both in regions with access to mental health care and regions with limited access and considerable need. Randomized and pilot trials of BA to reduce depression symptoms have been conducted in the United Kingdom (e.g., Jahoda et al.,

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2015), Sweden (e.g., Alfonsson et al., 2015; Folke et al., 2015), Japan (Takagaki et al., 2016), China (Au et al., 2015), India (Chowdhary et al., 2016), Iran (Moradveisi et al., 2013; Soleimani et al., 2015), and Iraq (Bolton et al., 2014). BA strategies led to lower depression-severity scores compared with a control after 2 months of treatment in India (Chowdhary et al., 2016); greater reductions in depression severity, particularly among the more severely depressed, compared with treatment as usual (TAU) in Iran (Moradveisi et al., 2013); and a significant effect on depression and dysfunction among survivors of systematic violence in Northern Iraq (Bolton et al., 2014). A current initiative by the APA is examining the existing research support for BA using recently recommended criteria, which consider quality of research methodologies, cost of interventions, and relevance for clinical practice (Tolin et al., 2015). We predict that BA will continue to be deemed to have strong research support, considering the accumulated empirical evidence on BA for depression and comorbid conditions when provided to diverse populations and in various clinical settings. Empirical Support for Individual BA Components Presenting the Treatment Rationale BA experts have suggested that the delivery of the treatment rationale is an indispensable initial treatment step and that a poor delivery of the treatment rationale may be a potential mechanism of BA treatment failure (Hopko, Magidson, & Lejuez, 2011). Thus, BA should be offered within a collaborative framework in which other treatment approaches are considered by the therapist and client if the client is minimally satisfied with, disagrees with, or is resistant to the rationale after presentation and discussion. In studies of CBT, acceptance of the treatment rationale (ATR) has generally been consistently linked to positive treatment outcomes. In a trial in which CBT was compared with TAU, a subset of CBT clients but not TAU clients showed a very rapid response to treatment. Rapid responders tended to more strongly endorse the treatment rationale than slow responders. Thus, ready acceptance of the treatment conceptualization appeared to be an important characteristic distinguishing rapid from slow responders (Fennell & Teasdale, 1987). In a component analysis of cognitive therapy for depression, a comparison of the BA and cognitive therapy components showed a different pattern of association between perceptions of the treatment (i.e., treatment helpfulness, measured after the session in which the treatment rationale was presented) and outcome (Addis & Jacobson, 1996). In BA, early reactions to the treatment were positively associated with outcome, whereas in cognitive therapy, the same trend was observed but did not reach significance. However, using the same data set, ATR was shown to predict change halfway through treatment and treatment outcome across treatment component conditions (Addis & Jacobson, 2000). That said, the current literature does not contain studies on the relation between ATR and outcomes for contemporary versions of BA. Kanter et al. (2015) speculated that strong agreement with the BA treatment rationale may have been an important



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mechanism for improved treatment engagement among Latinos in a community clinic setting. Given the research on presenting the rationale for treatment in CBT for depression and indications that client expectancies for improvement predict various treatment outcomes (e.g., Devilly & Borkovec, 2000), studies on the BA rationale-outcome association are needed. Assessment Techniques Traditionally, activity monitoring has been considered a necessary precursor to the achievement of behavior change, a factor that guides behavioral interventions (e.g., Kanter, Manos, et al., 2010). In fact, self-monitoring has been used as a control condition in various intervention studies, in which it has been found to be inferior to interventions that include more active components. However, there is evidence that activity monitoring alone produces increases in activity for individuals with depression (Snippe et al., 2016), and a mobile phone monitoring application was found to decrease depression in a sample of adolescents, leading the authors to recommend self-monitoring programs delivered via mobile phone as an ideal first-step intervention for adolescent depression (Kauer et al., 2012). Activity monitoring may also uniquely contribute to desirable outcomes for issues such as smoking (i.e., smoking cessation rates; McFall, 1970), binge eating (i.e., binge eating frequency; Latner & Wilson, 2002), and ruminative thinking (i.e., rumination episodes; Frederiksen, 1975), though data on whether tracking activity (e.g., physical activity) yields benefits above and beyond other interventions are mixed (e.g., McMurdo et al., 2010). Given the drawbacks of existing treatments for depression, such as poor medication adherence (Pampallona et al., 2002) and limited psychotherapy availability (Beck, 2005), researchers have been called to consider “out-of-the box” interventions for depression, such as monitoring of daily behaviors and emotional responses using momentary assessment methodologies, especially for individuals who are less likely to seek traditional care (Wichers et al., 2011). According to proponents, moment-to-moment activity monitoring may provide depressed individuals feedback through which they may gain insight into emotional and behavioral patterns that can inform concrete steps to change daily life patterns and facilitate recovery (Snippe et al., 2016; Wichers et al., 2011). Further evaluation of prospective activity monitoring via electronic technology is needed to determine whether it alone may positively impact outcomes. Activity Scheduling A meta-analysis of randomized studies of activity scheduling by Cuijpers et al. (2007) found clear-cut support for its efficacy without other BA techniques in treating depression at posttreatment, with gains maintained through follow-up periods, including comparability to a full package of CBT in a subset of 10 randomized studies. A review of more recent literature suggests the importance of diversifying activities scheduled and for emphasizing intentional and nonpassive social activity. Specifically, Riebe et al. (2012) found that older primary care individuals in successful depression care management engaged in a wide

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variety of activities, including deliberate social engagement in contrast to both passive social and solitary activities, resulting in positive scores on self-reported engagement and depression outcomes. One study has offered evidence challenging the clinically accepted practice in BA of scheduling activities according to level of difficulty (i.e., moving from the least to most difficult activity over time). Specifically, in a single-subject multiple baseline study, participants engaged in low-, moderate-, and high-difficulty activities at the start of and throughout treatment (Bailey & Arco, 2010). The authors found that participants were more likely to complete activities of moderate to high difficulty over low difficulty, suggesting the importance of scheduling activities of greater difficulty early in treatment and offering clients more therapist support for more difficult activities. Moreover, results from this study indicated that activity completion resulted in decreases in depression. Procedures Targeting Avoidance Although there is ample evidence that avoidance is positively associated with depression (e.g., Ottenbreit & Dobson, 2004; Wagener et al., 2016), including evidence that avoidance predicts future depression severity after controlling for baseline depression and activation (Shudo et al., 2017), there is no direct support for the use of techniques targeting avoidance as component interventions in BA (Kanter, Manos, et al., 2010). A primary question, for example, is whether the multifaceted and presumably more difficult-to-train version of BA by Martell et al. (2001, 2013), which targets avoidance substantially, will have a greater benefit than the simpler version of BATD by Lejuez and colleagues (Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011), which does not include direct techniques targeting avoidance. That said, avoidance likely is addressed in a functional way in Lejuez, Hopko, and Hopko (2001) even if no explicit techniques are discussed. BATD developers recognize that moving a client away from a lifestyle characterized by avoidance toward one characterized by an active way of life is essential for successful treatment (Hopko et al., 2003). It is unlikely that trials will be conducted to test these differences, as they would be expensive and possibly produce null results, which would be of little value to clinicians. Furthermore, we see no harm in having multiple versions of BA empirically supported and available. That said, it would be beneficial to clinicians for researchers to examine the most effective techniques for addressing and overcoming client avoidance during treatment, as it is clinically obvious that avoidance is a substantial obstacle to treatment progress and thus to improvement in the lives of clients.

MECHANISMS OF CHANGE DATA According to the theory underlying BA, depression is due to losses of, reductions in, and/or chronically low levels of positive reinforcement, which produce the behavioral and emotional changes that typify depression. In turn, BA



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techniques are designed to increase activation, which increases positive reinforcement and reverses the cycle of depression (Kanter, Manos, et al., 2010). In theory, the primary objective of BA is to increase contact with RCPR (Hopko et al., 2015), and in practice, BA is designed to increase contact with RCPR by increasing activation. Thus, RCPR and activation are two key treatment model processes theorized to account for changes in BA treatment. In contrast to research on BA’s efficacy and effectiveness, less work has been done to understand how BA works. We review empirical findings in support of these processes using recommended process measures (Mazzucchelli et al., 2016) developed over the last decade to improve on the limitations of prior measurement tools. These include the Environmental Reward Observation Scale (EROS; Armento & Hopko, 2007) and the Reward Probability Index (RPI; Carvalho et al., 2011). These measures assess environmental reward or, more specifically, the subjective experience of environmental reward and reward probability as a proxy for RCPR. Another conceptually rigorous measure is the Behavioral Activation for Depression Scale (BADS; Kanter et al., 2007), from which a short form with stronger psychometric properties has been developed (BADS-SF; Manos et al., 2011). Associations Between Purported Mechanisms and Depression Congruent with the BA model, associations between activation (measured with the BADS or BADS-SF) and environmental reward (measured with the EROS or RPI) have been observed in multiple studies (Armento & Hopko, 2007; Barraca & Pérez-Álvarez, 2010; Carvalho et al., 2011; Manos et al., 2011; Wagener & Blairy, 2015). The empirical relations between BA’s theorized mechanisms and depression have been demonstrated as well. Specifically, greater self-reported depression is associated with decreased activation (Barraca & Pérez-Álvarez, 2010; Manos et al., 2011; Petts et al., 2016; Wagener & Blairy, 2015) and increased avoidance (Petts et al., 2016). Shudo et al. (2017) demonstrated a predictive association between avoidance (but not activation) and depression severity scores 8 weeks later in the absence of intervention. Change in Mechanism Processes and Outcomes Over Time Changes in activation, environmental reward, and depression in patterns that are consistent with BA theory have been demonstrated in the context of BA treatment with diverse samples. For example, Petts et al. (2016) found that activation changes were significantly associated with depression change during an intervention phase but not during a baseline phase in a sample of adolescents treated with BA. Likewise, Gawrysiak et al. (2009) found that a BATD group showed greater increases in reinforcement and a significant reduction in depression in a randomized controlled trial comparing a single-session BATD protocol with a no-treatment control group for university students with moderate

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depression symptoms. Daughters et al. (2008) found that BATD, compared with TAU, produced greater improvements in perceived reward value of activities in a sample of illicit drug users. MacPherson et al. (2010) found that depressive symptoms reduced over time in a sample of low-income smokers with depression who received BATD; however, no treatment-linked changes in perceived reward from daily activities were observed. The same research team similarly documented that a BATD treatment targeting smoking and depression in youth produced decreases in depression and increases in activation, but no consistent changes in perceived reward value of activities were observed (MacPherson et al., 2017). Although these studies used the EROS to measure environmental reward, lack of support for environmental reward as a mediator of BA treatment has been observed with the RPI as well (e.g., Read et al., 2016). Analyses have been conducted to determine whether purported mechanisms mediate the relations between treatment and outcome. Nasrin et al. (2017) randomized depressed clients to a brief BATD intervention or control condition. BATD clients experienced significant reductions in depression and increases in activation compared with controls, and activation changes mediated the relations between treatment and symptom reduction. Dimidjian et al. (2017) evaluated the effectiveness of BA for depression in pregnant women relative to TAU. Compared with TAU clients, BA clients evidenced significantly higher levels of activation and environmental reward, and early change in these variables mediated subsequent depression change. For a sample of depressed cancer clients treated with BATD, Ryba et al. (2014) found that participant compliance with assigned activities (but not the total number of activities completed) was causally related to depression change, and the best outcome was achieved by clients who completed all assigned activities. However, perceived reward did not mediate this association between activation and depression change. Temporal Association Between Processes and Outcomes To demonstrate a treatment mechanism, the temporal sequence of change must be established, such that there is evidence that change in the mechanism variable (e.g., activation, positive reinforcement) temporally precedes change in the outcome variable, such as depression (e.g., Borckardt et al., 2008; Gaynor & Harris, 2008; Kazdin, 2007). Therefore, support of a robust nature for BA’s mechanisms would be provided by studies showing that when clients make less contact with positive reinforcement or are less active, they subsequently are more depressed, and when clients contact more positive reinforcement or are more active, they subsequently are less depressed. Gaynor and Harris (2008) conducted an early evaluation of this more rigorous mechanism hypothesis with a small, within-subject sample. They concluded that for two of four BA clients, temporal precedence was established, such that increased activation could plausibly explain improvements in depression. Similarly, in an analysis of two BA clients, Manos et al. (2011) showed



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that change in activation preceded change in depression for one client, but change in activation and depression co-occurred within the same time window for another client. Folke et al. (2015) investigated BA’s mechanisms with six individuals in inpatient psychiatry using a multiple-baseline design. Once the BA treatment phase was initiated, activation behaviors gradually increased in five of six inpatients and avoidance decreased in four of six inpatients. However, although changes in activation and avoidance preceded or occurred concurrently with changes in depression symptoms, results of hourly diary ratings showed that changes in mood preceded changes in activation in several instances. Folke et al. suggested that the BA model allows for such variability in the timing of changes between activation, avoidance, and mood. For example, although the effect of activation on mood may be instant given immediate contact with positive reinforcement, the effect on mood also may be delayed. A person may need to engage in an activation behavior (e.g., studying) multiple times before contacting natural reinforcement and improving mood (e.g., getting desired score on a test at end of term). In a pilot trial of BATD for Latinos with limited English proficiency with no control condition, Collado et al. (2014) observed significant decreases in depression symptoms and increases in activation and environmental reward over the course of treatment, and they found that changes in activation occurred concurrently with changes in depression whereas changes in perceived reward preceded changes in depression. Collado et al. (2016) replicated their findings that activation and environmental reward increased over the course of treatment in a larger study of BATD for Spanish-speaking Latinos compared with supportive counseling. However, findings on whether changes in BA mechanisms temporarily preceded change in depression were not reported. Santos et al. (2017) used cross-lagged correlations to test whether change in behavioral activation predicted, co-occurred with, or was predicted by depression scores in a study of BA for Latinos with depression (BAL) compared with TAU. Forty-three percent of BAL clients, but no TAU clients, demonstrated cross-lagged correlations that were supportive of BA theory. Specifically, these clients reported increases in activation that temporally preceded decreases in depression. Further, 71% of BAL clients, but no TAU clients, showed significant concurrent correlations that were consistent with BA theory. Specifically, these participants reported increases in activation that corresponded with decreases in depressive symptomatology during the same window of time. Moreover, only 21% of BAL clients evidenced correlations that did not support BA theory. Overall, the results suggested that activation was a plausible mechanism of change for 79% of BAL clients and no TAU clients. The evidence base for BA’s treatment model is growing. The extant literature lends empirical support for activation as a mechanism of change in BA treatment for many but not all successful BA clients, as data consistently suggest that changes in activation appear to temporally precede changes in depression for many but not all BA clients. This literature base, although nascent, is

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strengthened by its inclusion of diverse samples and methodologies. Research that examines whether environmental reward drives change in BA treatment is less convincing and generally not supportive of it as mechanism of change for most clients.

DISSEMINATION AND IMPLEMENTATION According to traditional translational science models in health (Sussman et al., 2006), most BA research is considered Type 1 (i.e., translational research that uses discoveries generated through controlled laboratory research or efficacy trials) and Type 2 (i.e., translational research that focuses on the enhancing use of efficacious interventions by the target group). However, whereas Type  2 research includes effectiveness, diffusion, and dissemination studies, most existing BA trials only examine effectiveness. Considering the limited amount of dissemination and implementation research on BA, there is still much to learn about how to best scale up BA in “real-world” clinical practice. To facilitate discussion of current efforts to disseminate and implement BA in clinical practice, it is important to define several key terms. Dissemination is defined as the targeted distribution of information and intervention materials to a specific public health or clinical practice group, and dissemination research is the systematic study of processes and factors that lead to widespread use of an evidence-based intervention by the target group (Johnson et al., 1996). Implementation, in turn, is the use of strategies to adopt and integrate evidencebased health interventions and change practice patterns within specific settings (National Institutes of Health, 2009). Clinical guidelines have been published in the United States and internationally that list BA as one of the recommended treatments for major depression. For example, the U.S. Department of Veterans Affairs recommends BA as one of the first-line treatments for uncomplicated mild-to-moderate depression and combining pharmacotherapy and BA for severe, chronic, or recurrent depression (Management of MDD Working Group, 2016). Similarly, the U.K. National Institute for Health and Care Excellence (NICE) identified BA as one of the recommended psychotherapies for mild-to-moderate depression (National Collaborating Centre for Mental Health, 2010). The World Health Organization (WHO) has recommended BA as one of the psychotherapies for mild-to-moderate depression for people who live in both high- and low-resource settings (WHO, 2016). However, these guidelines do not prescribe methods for disseminating BA to target groups or ensure effective implementation. The most commonly used BA dissemination efforts are the publication of scientific journal articles and treatment manuals based on efficacy and effectiveness trials (e.g., Kanter et al., 2009; Lejuez, Hopko, & Hopko, 2001; Lejuez et al., 2011; Martell et al., 2013; McCauley, Schloredt et al., 2016). These literatures mainly target mental health providers and academic faculty who provide psychotherapy and research



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training. Although some resources are available for free, practicing mental health providers mostly need to have subscriptions to academic journal publications or independently purchase the published treatment manuals. Thus, cost might be a significant barrier for providers to learn specific BA techniques to implement with their clients. Another BA dissemination effort targets the consumers or psychotherapy clients directly. For instance, a self-help book was published to help clients with depression practice BA skills in conjunction with psychotherapy (Addis & Martell, 2004). With the advancement of technology, several new mobile phone applications for BA have been developed and are available to the public. For example, the U.S. Department of Veterans Affairs (2016) developed Mood Coach, which is intended for service members and veterans to learn and practice BA. Another self-help phone application that is currently under study in a clinical trial is Moodivate (Behavioral Activation Tech, 2016b), which is intended for individuals who have been experiencing some depressive symptoms but are not yet interested in enrolling in individual therapy. Along these lines, a clinical support phone application, called Behavioral Apptivation, has been developed to support successful BA treatment (Behavioral Activation Tech, 2016a). This phone application allows clients to record their moods and activities, which can be immediately accessed by their providers. Efforts to translate BA from research into clinical practice are encouraging initial steps. Yet most of these efforts have not been studied empirically, so their effectiveness is unknown. Furthermore, they rely heavily on passive dissemination strategies (e.g., publication of scientific articles and treatment manuals and clinical guidelines; Rabin et al., 2006), which assume that mental health organizations and providers will actively seek the most recent evidence on BA (or other evidence-based practices [EBPs]), purchase the published treatment manuals, and learn and implement BA techniques independently. However, numerous EBP implementation barriers exist. Some commonly reported barriers include lack of financial and human resources to support successful EBP implementation, limited training that could be costly, negative attitudes toward new EBPs, and organizational climates and cultures that are not fully conducive to implementation of new EBPs. In fact, research has shown that scaling up new evidence-based interventions requires a more active and systematic approach to facilitate adoption, implementation, and sustainment of these interventions in clinical practice. It could take up to 17 years to translate 14% of health care research and innovations to benefit patient care, especially without additional support and effective strategies to implement interventions successfully (Balas & Boren, 2000). Whereas there are several emerging BA dissemination strategies, there are few implementation strategies documented in the BA literature. Continuing education (CE) training is the most commonly used strategy to support BA implementation in clinical practice. In the context of effectiveness trials, Ekers et al. (2013) found that health care providers with no previous psychotherapy experience could be trained in BA with CE-style training, yielding comparable

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outcomes to providers who were more experienced in providing psychotherapy. A large randomized controlled, noninferiority trial was recently conducted in the United Kingdom and concluded that BA can be delivered by less experienced mental health providers who have undergone less intensive and costly training, and they still produced the same results compared with CBT (Richards et al., 2016). Puspitasari et al. (2013) examined trainer-led BA training strategies that can be effectively delivered online to increase access for providers in diverse geographical locations. Guided by learning principles, this BA training protocol included active learning strategies (e.g., modeling, practicing, and feedback) and focused primarily on building providers’ skills for delivering BA in clinical practice. When compared with a self-paced BA online training, mental health providers who received the trainer-led BA online training showed greater increases in BA skills at posttraining and 6-week follow-up (Puspitasari et al., 2017), suggesting the potential effectiveness of this training as an evidencebased implementation strategy for BA. However, further research is needed to examine whether receiving BA training is adequate to support successful adoption, implementation, and sustainment of BA in diverse clinical settings.

CONCLUSION AND FUTURE DIRECTIONS In summary, we propose that BA is a promising treatment for depression, suitable for large-scale implementation. Effectiveness trials point out several features of BA that might increase feasibility and appropriateness of BA when delivered to diverse populations and in various settings. First, BA effectiveness remains when delivered to clients with comorbid depression and other psychological (Acierno et al., 2016; Papa et al., 2013) and medical conditions (Alfonsson et al., 2015; Hopko, Armento, et al., 2011; Lyons et al., 2015; Magidson et al., 2014). Second, BA has been tested across developmental ages and shown to be effective for adolescents (McCauley, Gudmundsen, et al., 2016; Ritschel et al., 2011), adults (Dimidjian et al., 2006), and older adults (Katon et al., 2006). Third, BA protocols have been adapted culturally and shown to be effective when delivered to clients with diverse cultural backgrounds, from both developed and developing countries (Bolton et al., 2014; Chowdhary et al., 2016; Collado et al., 2016; Kanter, Santiago-Rivera, et al., 2010; Kanter et al., 2015; Moradveisi et al., 2013). Fourth, BA can be flexibly delivered in either individual or group settings (Chu et al., 2016), as a guided self-help treatment (Soucy Chartier & Provencher, 2013), and remotely using online or phone technology (Carlbring et al., 2013; Eisma et al., 2015; Huguet et al., 2016). Fifth, BA has also been shown to be compatible with other evidence-based strategies and treatments such as mindfulness (McIndoo et al., 2016), motivational interviewing (Balán et al., 2016), exposure (Eisma et al., 2015), and acceptance and commitment therapy (Carlbring et al., 2013). Lastly, evidence highlights the ease of BA training whereby paraprofessionals or those with less experience in



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mental health and psychotherapy can be trained in BA and produce desirable clinical outcomes. Future research should examine various implementation strategies that might facilitate the translation of BA from research to practice, including creating learning collaboratives, building implementation teams within a clinical setting, providing incentives, and identifying and preparing local champions (Powell et al., 2015). Research should also be guided by existing implementation science theoretical frameworks and models (e.g., Aarons et al., 2012; Damschroder et al., 2009). Existing BA efficacy and effectiveness trials have focused primarily on client-level outcomes. When the goal is to scale up and implement BA in clinical practice, other integral outcomes should be measured, such as acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability (Proctor et al., 2011). We know little about how to scale up BA in clinical practice. Increasing access to evidence-based treatments for depression, such as BA, is crucial given that the majority of individuals with depression do not receive adequate treatment for depression (Olfson et al., 2002). Current dissemination and implementation efforts are still limited in numbers, mostly rely on passive dissemination strategies, and have not been empirically studied. Future studies should examine strategies to successfully implement BA in clinical settings, and current knowledge from implementation science may be used to guide the development of BA implementation research and practice.

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Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B., & Munizza, C. (2002). Patient adherence in the treatment of depression. British Journal of Psychiatry, 180(2), 104– 109. https://doi.org/10.1192/bjp.180.2.104 Papa, A., Sewell, M. T., Garrison-Diehn, C., & Rummel, C. (2013). A randomized open trial assessing the feasibility of behavioral activation for pathological grief responding. Behavior Therapy, 44(4), 639–650. https://doi.org/10.1016/j.beth.2013.04.009 Petts, R. A., Foster, C. S., Douleh, T. N., & Gaynor, S. T. (2016). Measuring activation in adolescent depression: Preliminary psychometric data on the Behavioral Activation for Depression Scale–Short Form. Behavior Analysis: Research and Practice, 16(2), 65– 80. https://doi.org/10.1037/bar0000036 Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21. https://doi.org/10.1186/ s13012-015-0209-1 Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 38(2), 65–76. https://doi.org/10.1007/s10488-010-0319-7 Puspitasari, A., Kanter, J. W., Murphy, J., Crowe, A., & Koerner, K. (2013). Developing an online, modular, active learning training program for behavioral activation. Psychotherapy, 50(2), 256–265. https://doi.org/10.1037/a0030058 Puspitasari, A. J., Kanter, J. W., Busch, A. M., Leonard, R., Dunsiger, S., Cahill, S., Martell, C., & Koerner, K. (2017). A randomized controlled trial of an online, modular, active learning training program for behavioral activation for depression. Journal of Consulting and Clinical Psychology, 85(8), 814–825. https://doi.org/10.1037/ ccp0000223 Rabin, B. A., Brownson, R. C., Kerner, J. F., & Glasgow, R. E. (2006). Methodologic challenges in disseminating evidence-based interventions to promote physical activity. American Journal of Preventive Medicine, 31(4 Suppl.), S24–S34. https://doi. org/10.1016/j.amepre.2006.06.009 Read, A., Mazzucchelli, T. G., & Kane, R. T. (2016). A preliminary evaluation of a single session behavioural activation intervention to improve well-being and prevent depression in carers. Clinical Psychologist, 20(1), 36–45. https://doi.org/10.1111/cp. 12084 Rehm, L. P. (1977). A self-control model of depression. Behavior Therapy, 8(5), 787–804. https://doi.org/10.1016/S0005-7894(77)80150-0 Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., O’Mahen, H., Watkins, E. R., Wright, K. A., Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K. (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): A randomised, controlled, non-inferiority trial. Lancet, 388(10047), 871–880. https://doi.org/10.1016/S0140-6736(16)31140-0 Riebe, G., Fan, M. Y., Unützer, J., & Vannoy, S. (2012). Activity scheduling as a core component of effective care management for late-life depression. International Journal of Geriatric Psychiatry, 27(12), 1298–1304. https://doi.org/10.1002/gps.3784 Ritschel, L. A., Ramirez, C. L., Jones, M., & Craighead, W. E. (2011). Behavioral activation for depressed teens: A pilot study. Cognitive and Behavioral Practice, 18(2), 281–299. https://doi.org/10.1016/j.cbpra.2010.07.002 Rovner, B. W., Casten, R. J., Hegel, M. T., Massof, R. W., Leiby, B. E., Ho, A. C., & Tasman, W. S. (2014). Low vision depression prevention trial in age-related macular degeneration: A randomized clinical trial. Ophthalmology, 121(11), 2204–2211. https://doi.org/10.1016/j.ophtha.2014.05.002

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Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal of Consulting and Clinical Psychology, 82(2), 325–335. https://doi.org/10.1037/a0035363 Santos, M. M., Rae, J. R., Nagy, G. A., Manbeck, K. E., Hurtado, G. D., West, P., Santiago-Rivera, A., & Kanter, J. W. (2017). A client-level session-by-session evaluation of behavioral activation’s mechanism of action. Journal of Behavior Therapy and Experimental Psychiatry, 54, 93–100. https://doi.org/10.1016/j.jbtep. 2016.07.003 Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 45(4), 543–551. https://doi.org/10.1037/0022-006X.45.4.543 Shudo, Y., Yamamoto, T., & Sakai, M. (2017). Longitudinal predictions of depression symptoms using the activation and avoidance subscales of the Japanese Behavioral Activation for Depression Scale–Short Form. Psychological Reports, 120(1), 130–140. https://doi.org/10.1177/0033294116680794 Snarski, M., Scogin, F., DiNapoli, E., Presnell, A., McAlpine, J., & Marcinak, J. (2011). The effects of behavioral activation therapy with inpatient geriatric psychiatry patients. Behavior Therapy, 42(1), 100–108. https://doi.org/10.1016/j.beth.2010.05.001 Snippe, E., Simons, C. J. P., Hartmann, J. A., Menne-Lothmann, C., Kramer, I., Booij, S. H., Viechtbauer, W., Delespaul, P., Myin-Germeys, I., & Wichers, M. (2016). Change in daily life behaviors and depression: Within-person and between-person associations. Health Psychology, 35(5), 433–441. https://doi.org/10.1037/hea0000312 Soleimani, M., Mohammadkhani, P., Dolatshahi, B., Alizadeh, H., Overmann, K. A., & Coolidge, F. L. (2015). A comparative study of group behavioral activation and cognitive therapy in reducing subsyndromal anxiety and depressive symptoms. Iranian Journal of Psychiatry, 10(2), 71–78. Soucy Chartier, I., & Provencher, M. D. (2013). Behavioural activation for depression: Efficacy, effectiveness and dissemination. Journal of Affective Disorders, 145(3), 292– 299. https://doi.org/10.1016/j.jad.2012.07.023 Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C. W., & Acierno, R. (2012). An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: Preliminary findings. Behavior Therapy, 43(3), 560–569. https://doi.org/10.1016/j.beth.2011.03.003 Sussman, S., Valente, T. W., Rohrbach, L. A., Skara, S., & Pentz, M. A. (2006). Translation in the health professions: Converting science into action. Evaluation & the Health Professions, 29(1), 7–32. https://doi.org/10.1177/0163278705284441 Takagaki, K., Okamoto, Y., Jinnin, R., Mori, A., Nishiyama, Y., Yamamura, T., Yokoyama, S., Shiota, S., Okamoto, Y., Miyake, Y., Ogata, A., Kunisato, Y., Shimoda, H., Kawakami, N., Furukawa, T. A., & Yamawaki, S. (2016). Behavioral activation for late adolescents with subthreshold depression: A randomized controlled trial. European Child & Adolescent Psychiatry, 25(11), 1171–1182. https://doi.org/10.1007/ s00787-016-0842-5 Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122 Wagener, A., Baeyens, C., & Blairy, S. (2016). Depressive symptomatology and the influence of the behavioral avoidance and activation: A gender-specific investigation. Journal of Affective Disorders, 193, 123–129. https://doi.org/10.1016/j.jad.2015. 12.040 Wagener, A., & Blairy, S. (2015). Validation and psychometric properties of the French versions of the Environmental Reward Observation Scale and of the Reward Probability Index. Psychologica Belgica, 55(2), 71–86. https://doi.org/10.5334/pb.bg



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Wesson, M., Whybrow, D., Gould, M., & Greenberg, N. (2014). An initial evaluation of the clinical and fitness for work outcomes of a military group behavioural activation programme. Behavioural and Cognitive Psychotherapy, 42(2), 243–247. https://doi.org/ 10.1017/S135246581300043X Wichers, M., Simons, C. J. P., Kramer, I. M. A., Hartmann, J. A., Lothmann, C., MyinGermeys, I., van Bemmel, A. L., Peeters, F., Delespaul, P., & van Os, J. (2011). Momentary assessment technology as a tool to help patients with depression help themselves. Acta Psychiatrica Scandinavica, 124(4), 262–272. https://doi.org/10.1111/ j.1600-0447.2011.01749.x World Health Organization. (2016). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (Version 2.0). http://www.who.int /mental_health/mhgap/mhGAP_intervention_guide_02/en/ Zeiss, A. M., Lewinsohn, P. M., & Muñoz, R. F. (1979). Nonspecific improvement effects in depression using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of Consulting and Clinical Psychology, 47(3), 427–439. https://doi.org/10.1037/0022-006X.47.3.427

10 Exposure Therapy Lauryn E. Garner, Emily J. Steinberg, and Dean McKay

E

xposure therapy has been demonstrated as a highly efficacious intervention, used primarily in the treatment of anxiety and obsessive-compulsive disorders (McKay, 2016) and posttraumatic stress disorder (PTSD; Courtois et al., 2017). Its application has been evaluated as a stand-alone intervention and as a component of a broader program of cognitive behavioral therapy (CBT). This chapter has the following aims: first, to briefly review the history and underlying theory of exposure therapy; second, to provide a description of the primary procedures in exposure; third, to summarize the outcome data associated with the approach and highlight the mechanisms of change; and finally, to cover the application of exposure to diverse populations.1 The chapter concludes with future directions in the applications of exposure therapy.

HISTORY Exposure as a method for reducing anxiety is predicted from the original experimental work of Pavlov (summarized in Pavlov, 1927). Specifically, with repeated presentation of a conditioned stimulus in the absence of the unconditioned stimulus, the conditioned response should weaken and ultimately result in habituation. Application of this procedure implies, however, that the individual will experience an adverse emotional state en route to experiencing relief. Accordingly, proper application requires gradual presentation of portions Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-010 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  275 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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of the stimulus, referred to as the stimulus complex (discussed later in the Underlying Theory section). The earliest documented use of exposure as a therapeutic method comes from Jones (1924) in the treatment of fear of small animals in a 2-year-old boy. In this case illustration, Jones carefully detailed the process of gradually presenting small furry animals to the child and, under different conditions, successfully eliminating his fear. The gradual approach adopted closely resembles that employed in exposure therapy, as will be shown in this chapter. Jones’s intent was to illustrate that principles of behaviorism could be demonstrated through the elimination of problem behavior, which stood in contrast to the conditioned fear experiment by Watson and Rayner (1920). Extensive experimental work was conducted to demonstrate the efficacy of exposure for treating specific phobias. After years of laboratory research detailing the applicability of exposure in alleviating fear in analogue and client samples, Krasner (1971) described exposure therapy as a component of desensitization. However, desensitization was associated with a procedure that paired deep muscle relaxation with the aversive stimuli as a means to reduce the fear in a process of competition between incompatible responses (Wolpe, 1958). Specifically, in systematic desensitization (also referred to as reciprocal inhibition), the client is first taught cued deep muscle relaxation. This entails practicing muscle relaxation procedures, whereby the relaxation is associated with specific words like “relax.” The intention is that the client may produce the relaxation response independently through this learning experience. Once this is mastered, the clinician then develops a hierarchy of feared stimuli and situations (hierarchies are discussed later in this chapter). Through imagery, the client is asked to visualize the feared stimuli, based on the hierarchy, and, when anxiety is experienced, they are then instructed to engage in muscle relaxation. In this way, the desensitization process is hypothesized to counter the anxiety experience through an incompatible response (relaxation). Since the time systematic desensitization was developed, it has been found that exposure, without relaxation, is more efficient in reducing anxiety and maintaining change (Marks, 1987). Relaxation training remains a part of comprehensive treatment protocols for anxiety disorders, but systematic desensitization would not generally be recommended as a primary treatment modality. Concurrent with the developing laboratory models of fear reduction through exposure, treatment research began on what was otherwise an intractable problem, namely obsessive-compulsive disorder (OCD). Meyer (1966) first reported on a case series of individuals with OCD treated with exposure with response prevention (ERP). ERP consists of exposure to the specific feared stimuli that serve as the impetus for compulsive behaviors; continued exposure through the prevention of compulsive responses, therefore, was shown to reduce symptoms. Shortly following this case series, controlled experimental research began in earnest to examine the applicability of ERP to different symptom presentations of OCD, such as checking or washing (i.e., Rachman et al., 1973).



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Recognizing the role of exposure in anxiety reduction, practitioners extended the intervention to alleviate the fear reactions in trauma survivors. The earliest case description by Keane and Kaloupek (1982) was the treatment of a 36-yearold Vietnam veteran, conducted over a 3-week period of inpatient hospitalization, with 19 total sessions where exposure focused on memories of combat trauma. Since that time, extensive research has accumulated to support the application of exposure for PTSD, and exposure is one of the recommended interventions in the American Psychological Association’s practice guidelines for trauma (Courtois et al., 2017).

UNDERLYING THEORY The theory underlying the effectiveness of exposure treatments has changed over the years. The early model emphasized presentation of the conditioned stimuli (CS) in the absence of the unconditioned stimulus (US) in order to achieve extinction (the cessation of the CS eliciting the conditioned response [CR]). This was the guiding principle in early tests in phobic individuals (e.g., Gelder et al., 1967) and was based on the original conceptualization of the extinction process from Pavlov. This early conceptualization was predicated on how any CS can be extinguished without regard for the specific psychopathology related to anxiety. However, anxiety theorists had asserted that the emotional state, when at pathological levels, was a result of a reinforcement process that strengthened avoidance (i.e., Mowrer, 1960). Further, the original model anticipated spontaneous recovery of CS activation of CR, often occurring following a long rest period between exposure sessions (discussed in Domjan, 2018). In order to explain the efficacy of exposure for anxiety and describe the underlying mechanisms of the procedure, Foa and Kozak (1986) highlighted how to maximize successful fear reduction. Specifically, they suggested that avoidance resulting from anxiety management leads to memories of fear and its management. In order to effectively disrupt this process, exposure must be of sufficient intensity to engage the fear structure but not so great that new emotional learning is formed. This model of fear reduction was the first to articulate a way in which exposure could be harmful if conducted improperly (i.e., too quickly or with too high an intensity). This model is explicitly oriented to the neuroscience underlying anxiety, where the focus is on specific brain structures and their role in classical conditioning of fear, and has been supported extensively in laboratory and clinical research (see Dębiec & LeDoux, 2009). This model set the stage for recommended parameters for the conduct of exposure, such as session duration. Because engagement of the fear structure is essential and the elicitation of fear must be of sufficient intensity to promote change, one would need to ensure the therapy session is long enough that extinction occurs during the session. Otherwise, given the propensity to avoidance

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that is associated with anxiety, session termination before anxiety alleviation would lead to avoidance of therapy itself. More recently, it has been observed that provocation of fear during exposure is not a necessary condition for anxiety reduction. This perspective is articulated in the inhibitory learning model (Abramowitz, 2013; Craske et al., 2014), in which the aim of exposure therapy is to disconfirm the feared outcomes articulated by anxious individuals. This means that under this perspective, there is an implicit recognition of cognitive processes, namely prediction of outcomes following exposure to the CS. This builds on basic experimental research that had previously been underappreciated by clinicians but nevertheless was foundational in basic learning theory (Rescorla, 1987, 1988). Specifically, laboratory research suggests that CSes permit for predictions of what will follow, and without prior experience, the predictions of outcomes are crystallized. With repeated presentation of the CS, these predictions weaken, assuming the feared outcome fails to materialize. Interestingly, the concept of exposure being effective in the absence of fear elicitation was demonstrated experimentally by Foa and her colleagues long before the Foa and Kozak (1986) model was articulated (Foa et al., 1977). In some ways, the practice of exposure from the inhibitory learning perspective is in line with how most successful clinicians likely operated already. In-session elicitation of fear is challenging, and doing so repeatedly can make for substantial reluctance to engage in treatment. Indeed, the reputation of exposure therapy as intense and scary has created barriers to clients arriving at the clinicians’ offices and has led some to remark that there is a public relations problem for the approach (Richard & Gloster, 2006). Figure 10.1 lays out a basic schematic depicting each of the theoretical models described above.

DESCRIPTION OF MAIN PROCEDURES Although seemingly straightforward and deceptively simple in its basis, exposure therapy is a highly complex treatment procedure. In order to carry it out properly, the clinician must carefully assess the nature of the fear, develop a hierarchy of fears, and consider different avenues for best presenting the feared stimuli as well as the setting for conducting the treatment. Hierarchy Development Before initiating exposure therapy, a fear hierarchy must be constructed. While most anxiety sufferers will report fears in broad terms (e.g., spiders, contaminated places/situations, social encounters), these fears can be broken into smaller components. Thus, most fears are described in terms of components of the stimulus complex. To make this explicit, consider the case of spider fear. The most obvious and intensely anxiety-evoking stimulus would be a live spider. However, it is likely that a spider-fearful individual would find a photo of a



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FIGURE 10.1. Theoretical Bases of Exposure: Three Perspectives

spider less anxiety producing than a live one that is physically present. Likewise, seeing a spider 10 feet away would be less anxiety provoking than one that is 6 inches away. Using the concept of a stimulus complex, a hierarchy can be constructed that depicts components of the feared stimuli from least to most anxiety provoking. A detailed discussion of hierarchies in the context of OCD for children is available in McKay (2018). This exercise requires recognition that a CS is really composed of a multitude of components that collectively refer to the stimulus complex. In order to begin developing a fear hierarchy with a client, it is essential to establish the anchor points for a rating scale that will be used by the client in estimating the fear that would be experienced for each component of the stimulus complex. This scale is known as the Subjective Units of Distress Scale (SUDS; see Wolpe, 1958, 1990). The range for this scale is typically either 0–10 or 0–100. Establishing the anchor for the lowest point might include asking the client to imagine the feeling of greatest comfort they can picture, such as when imminently going to sleep, and then setting that as 0. Next, the clinician may ask the client to picture the time when they felt the highest level of fear in their life and set this at 100 (or 10 if that is the clinician’s preference; for the purposes of this chapter we will retain a 0–100 scale). Once this is established, the clinician identifies aspects of the stimulus complex that elicit different levels of fear as rated by the client under hypothetical exposure. That is, during the construction of the hierarchy, no exposure occurs, only the presentation of the idea of different components of the stimulus complex. This places a responsibility on the clinician to identify components of the stimulus complex that might be anticipated to produce anxiety that the client

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might not notice. Construction of the hierarchy is a phenomenological process, the clinician visualizing situations and objects that might elicit anxiety based on the primary presenting fear (see McKay, 2018, for a discussion of this process in relation to childhood OCD). Developing the hierarchy can be challenging, therefore, if there is insufficient awareness of the client’s environment, insufficient experience with aspects of the stimulus complex, or a limited familiarity with the objects and situations associated with the feared stimuli. To illustrate the variety of stimuli that may be associated with even basic phobic objects, Figure 10.2 shows components of the stimulus complex for spider phobia. To help the reader appreciate further the extent to which one might delve into the stimulus complex even for putatively straightforward feared stimuli and experiences, Figure 10.3 shows a range of items that might appear on a hierarchy for contamination fear associated with OCD. Using the items from Figure 10.3, a hypothetical fear hierarchy is displayed in Table 10.1. Initiating Exposure Once the hierarchy is established, it is advisable to start exposure gradually in order to guarantee that the client will be successful in completing the exercise. It is often useful to inform clients that the anticipated anxiety (as predicted for construction of the fear hierarchy) is typically greater than the actual experience of anxiety when faced with individual stimuli. This phenomenon has been demonstrated in two experiments (Arntz et al., 1994). In the first experiment, over FIGURE 10.2. Basic Stimulus Complex



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FIGURE 10.3. Detailed Stimulus Complex

TABLE 10.1. Illustrative Fear Hierarchy for Contamination Fear Situation/object

Anticipated SUDS (0–100)

Dirty undergarments

10

Washing machine

10

Bathroom odor

15

Bathroom soap dispenser

20

Bathroom door handle

25

Observed fecal consistency, firm

30

Hospital/medical patient waiting areas

40

Child with sticky food on fingers

50

Child with dirt on shirt

50

Child with runny nose

60

Customers appearing sick in drug store

65

Pharmacy counter

70

Toilet seat

75

Fecal consistency, loose

80

Door handle, drug store

85

Door handle, hospital

90

Note. SUDS = subjective units of distress.

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10 exposure sessions, 37 individuals with a range of primary anxiety disorders (i.e., panic disorder, social anxiety, OCD, specific phobia) consistently rated their anticipated anxiety higher than the experienced anxiety, with anticipatory anxiety mean range of 43.2–57.9 versus experienced anxiety mean range of 37.5– 51.5 (with SUDS scale maximum of 100). This finding was replicated in a second experiment with 11 anxiety-disorder patients (i.e., panic disorder, generalized anxiety disorder [GAD], social anxiety), with mean predicted anxiety of 69.1 and mean experienced anxiety of 47.3 (again with SUDS maximum of 100). As noted previously, each session should end with the client experiencing less anxiety than when the session began in order to prevent treatment dropout. In Vivo Exposure In vivo exposure occurs when the stimuli are presented directly to the client. To illustrate, in the case of a client with contamination fear associated with OCD, direct contact with stimuli such as those listed in Table 10.1, beginning with lower items on the hierarchy (e.g., washing machines, bathroom soap dispensers), should occur. This is the most common means of presenting stimuli in experimental evaluations of exposure given that the stimuli can be operationalized and effectively described. It also forms the basis for behavioral avoidance tests (BATs), whereby the client comes closer and closer to the feared stimuli and improvement can be quantified. In Imagery (Plus Implosion) Early proponents of exposure conducted the procedure by creating imagery of situations where the feared stimuli were present, relying on the hierarchy to develop scenes to move to more intense situations. This was in line with the approach developed by Wolpe (1958), such that the feared stimuli was presented in imagery but paired with muscle relaxation. Implosion entails incorporating additional aspects of the feared situation that are inferred to contribute to the persistence of anxiety. For example, socially anxious clients might report that they are most concerned with embarrassment, but the therapist may also infer that the fear is a result of rejection by potential romantic partners. Accordingly, the implosive scene might incorporate additional feared components. Therapists should use implosion with great caution given problems in memory formation during intense emotional arousal (discussed in McNally, 2003)2 and instead adhere more closely to manifest content when conducting exposure exercises with imagery. The use of imagery also allowed clinicians to develop scenes that were not physically possible to experience in vivo. For example, the clinician may take Excitement around the potential of procedures like implosion to “unlock” repressed memories reached a peak in the late 1990s, when clinicians would employ the procedure to attempt to resolve traumatic events for clients. However, research accumulated showing that, when under intense emotional duress, individuals may be more susceptible to developing recall for events that did not likely occur (Kaplan et al., 2016). As a result, unless approached with care, implosion and associated exposure methods where clinicians might engage in a type of “pattern completion” approach with clients can lead to “false memory syndrome” (reviewed in McNally, 2003).

2



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liberties in the imagery to develop scenes associated with assumed functional relations between the feared stimuli and outcomes, such as fears of death, illness, or other outcomes. This was first articulated as an intervention that permitted behavior therapists to address underlying concerns that clients might not be capable of articulating, such as in unconscious processes (Stampfl & Levis, 1967). Modern applications of imagery procedures often take the form of therapeutic recordings that clients develop with the therapist and then listen to between sessions. These typically involve images with items on the hierarchy that are carried to some extreme that might not be possible in vivo. In Vivo and in Imagery When conducting exposure in vivo, it is sometimes unclear what role the clinician plays while the client is processing the situation. However, it is entirely possible that the client is engaged in a cognitive process of avoidance. Foa and Kozak (1986) illustrated this process well when they described a contaminationfearful client who engaged in “freezing” during exposure where the contaminant was cognitively isolated to minimize the experience of anxiety. In order to circumvent this process, the clinician may provide additional imagery during the in vivo exposure and thereby enhance the outcome of treatment. In the aforementioned example from Foa and Kozak (1986), the client had a contaminant on his forearm. If imagery were included, the clinician might have stated how the contaminant was penetrating the skin as through a semipermeable membrane, entering the bloodstream and contaminating the entire soma. Exposure With Response Prevention (In Vivo, in Imagery, Combined) Individuals with OCD engage in compulsions as a means of avoiding the feared stimulus after they experience it in the environment. For example, in contamination fear, exposure to a contaminant leads to excessive handwashing in order to prevent experiencing anticipated feared consequences. Therefore, the response-prevention portion of ERP is a continuation of exposure. Although ERP is most frequently associated with treatment for OCD, it is generally recommended for any occasion where the client engages in systematic efforts to avoid or undermine the exposure to the feared stimulus. For example, individuals with panic disorder might check for the presence of anxiolytics (e.g., as needed anxiety medications, water). The availability of these items may serve to reduce any anxiety evoked in session prematurely, thus diminishing the benefit of treatment. Accordingly, blockage of these anxiety-reducing rituals would enhance the therapeutic effort of the exposure procedures. Prolonged Exposure for Trauma Models of psychopathology associated with trauma have relied on bioinformational theory, which suggests that in the face of overwhelming experiences, individuals systematically avoid memories and other reminders of trauma as a means to process the events (discussed in Drobes & Lang, 1995). Presently, prolonged exposure (PE) for trauma, along with several associated interventions (i.e., cognitive processing therapy; Resick et al., 2010; narrative exposure

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therapy; Schauer et al., 2011) is one of the recommended interventions in the recently published clinical practice guidelines (Courtois et al., 2017). Common to each variant of exposure treatment for trauma involves recalling specific aspects of the traumatic event, including the physical experiences, and recalling aspects of the event that might have been suppressed through strategic avoidance (see Green et al., 2017, for a detailed summary). Exposure Therapy With Children Recall that the first documented case of therapeutic exposure was conducted by Jones (1924) in treating fear of small animals in a child. Since that time, the application of exposure to childhood psychopathology has covered all the major anxiety problems present in youth. Carrying out exposure with children calls for highly specific skills by the clinician, including efforts to make exposure a game and rely on altering expectancies as described in the inhibitory learning model. The approach has documented efficacy in outpatient GAD clinics (Whiteside, Deacon, et al., 2016; Whiteside, Sattler, et al., 2016) and is a component of a major treatment program for child anxiety disorders (Coping Cat; Hourigan et al., 2012). Interoceptive Exposure Many anxiety sufferers are acutely aware of physical sensations and react to changes in these physical sensations as dangerous. This is referred to as anxiety sensitivity, and although it was originally conceptualized to account for panic disorder (Reiss et al., 1986), extensive research has shown it to be elevated in all anxiety disorders. Olatunji and Wolitzky-Taylor (2009) showed that, across all anxiety disorders, there was a large difference compared with nonanxious controls (d = 1.61) and that individuals with panic disorder had the highest anxiety sensitivity compared with other anxiety disorders. More recent investigations have emphasized a role for anxiety sensitivity in PTSD and associated substance use (i.e., Vujanovic et al., 2018). Measures of anxiety sensitivity suggest that there are three broad domains for the construct: (a) fear of physical symptoms, (b) fear of publicly observable symptoms, and (c) fear of loss of cognitive control. These factors have been observed across ethnic and racial groups (e.g., Jardin et al., 2018) and in children and adolescents (Bernstein et al., 2007). Interoceptive exposure targets these manifestations of anxiety sensitivity. Virtual Reality Exposure Exposure therapy is highly efficacious, particularly so when conducted in vivo. Some common fears, however, do not readily lend themselves to in vivo exposure. This could be due to either low access to the situations associated with the feared stimuli, potential concerns with safety, or lack of feasibility to conduct therapy in a repeated manner. To illustrate, a common fear, acrophobia, would necessitate exposure in an elevated location, which could pose serious logistical problems to conduct in vivo (e.g., access, time demands) and safely (e.g., conducting exposure in a place where the feared situation might involve limited



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barriers to the edge). These feared situations with these logistical challenges would also frustrate any effort to conduct the exposure therapy repeatedly, often a necessary component of successful therapy. Virtual reality therapy has become relatively accessible in light of the increased speed and memory of modern computer technology. This approach to therapy involves a computer “environment” that represents a set of feared situations, such as heights, flying, public speaking, agoraphobia (e.g., in a supermarket), and other settings where therapists would struggle to develop replicable and graded exposure situations. Virtual reality exposure has an added advantage in that the feared situation can be terminated, if the therapist inadvertently proceeds too rapidly up the hierarchy, and restarted at a lower level. To illustrate, in the treatment of fear of flying, virtual reality exposure may be initiated in a session, and should the client find it too challenging, it can be stopped and restarted at a level associated with less anxiety. Additionally, virtual reality exposure allows for multiple exposure trials of otherwise complicated situations in a single session. For example, in fear of public speaking, a virtual “audience” can be assembled for the client to deliver a speech several times in a session. Research suggests that virtual reality applications of exposure are efficacious in PTSD (Motraghi et al., 2014), flying fear (Cardoş et al., 2017), and specific phobias (Côté & Bouchard, 2008), as well as social anxiety and panic with agoraphobia (reviewed in Krijn et al., 2004). Further, research has shown that therapist alliance and treatment expectancies (i.e., anticipation of benefiting from the procedure) were high in virtual reality-based exposure (Meyerbröker & Emmelkamp, 2010). Inhibitory Learning To this point, it has been emphasized that a necessary mechanism of successful exposure therapy is activation of the fear memory network, which in turn leads to corrective processing (Foa & Kozak, 1986). Recent research has suggested that this may not be a necessary ingredient and that instead several other facets of exposure may successfully lead to fear reduction. The original model depicting the way in which a conditioned response ceases to produce its response considered it to be through inhibition of the neural connections that were formed in the CS-CR learning association (discussed in Rescorla & Wagner, 1972). This means that exposure to the feared stimulus is the crucial element, not necessarily fear activation. Interestingly, this had been shown previously, where phobia reduction was demonstrated experimentally through the use of pleasant imagery (Foa et al., 1977). With this new perspective, termed the inhibitory learning model, there are several important distinctions regarding how exposure may be delivered and how exposure produces its effects (Craske et al., 2014). These fall into the following broad categories: • Expectancy violation: Rescorla (1988) described the process of classical conditioning as one predicated on the formation of expectations around the outcome for a stimulus. Accordingly, exposure should set the stage for individuals to have a new prediction of outcome when exposed to the feared

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stimulus.3 Clinicians can facilitate this process through the imagery produced during exposure (e.g., by making humorous remarks) or through in vivo exercises that are contrary to the anticipated outcome (e.g., in fear of dogs and conducting exposure to puppies). • Exposure in multiple contexts: By the time clients seek treatment, their fear has likely generalized to multiple settings and situations. Accordingly, in order to produce enduring change, exposure should be conducted in numerous settings. • Deepened extinction: Moving up the hierarchy with clients often involves selecting a single component of the feared stimulus. Once all the single or small set of feared stimuli are mastered, then one might conclude that treatment was successful. However, in order to fully alleviate fear, exposure to multiple features of the feared stimuli, together, can produce lasting fear reduction. • Occasional reinforced extinction: “Real-life” experience of phobic stimuli does not necessarily mean there will not be any adverse consequences. For example, with the fear of contamination, at the end of treatment, the client still may develop minor illnesses when taking the ordinary precautions that unaffected individuals take. This would mean that in order for the benefits of exposure to fully accrue, the client (when appropriate) would also come into contact with the feared outcome. Recent work employing this facet has been shown to be instrumental in improving outcome for social anxiety disorder, through “social mishaps” (clinical application discussed in Fang et al., 2013, and elaborated on below in our consideration of social anxiety disorder). • Removal of safety cues: Safety cues signal that even if the feared stimulus is present, the feared outcome will not occur. For example, many panic disorder sufferers keep antianxiety medication on hand as a signal that should a panic attack happen, there is ready access to a relaxant. These safety signals serve as an impediment to full fear reduction that might be realized in the course of exposure, and, hence, practice in exposure in the absence of maladaptive safety cues is necessary. • Variability: Once a client has mastered much of the hierarchy, practice in exposure to varied feared stimuli along the hierarchy in turn fosters more enduring fear reduction.

The Rescorla and Wagner model was derived from animal models of learning. At the time, there was intense interest in evaluating how animals (up to and including humans) form expectancies (Bolles, 1972). One concern was that this perspective prematurely introduced cognition, as it requires organisms to predict outcomes through hypothetical mental structures (discussed in Jenkins, 1984). Since that time, cognition has been embraced as part of a comprehensive system of treatment and has been fully integrated in the movement of CBT.

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• Affect labeling: In the course of exposure, it is assumed that clients experience fear. However, clients may not recognize the emotional experience, may mislabel the experience, or may have an emotional reaction other than fear. Practice in labeling the experience and its associated change in the course of exposure facilitates the process of fear reduction and, more importantly, alleviates the urge to avoid feared situations. The inhibitory learning model has been the focus of considerable recent clinical conceptualization and is drawn largely from experimental lab research (discussed in Craske et al., 2014; Frank & McKay, 2019). Research on the efficacy of specific components of the inhibitory learning conceptualization of exposure in alleviating clinically significant fear has not yet been demonstrated.

Delivery Methods Treatment using exposure approaches can be conducted in several different settings or through different delivery modes. The most common is in an outpatient office. However, it can also be conducted in inpatient and residential settings, in the client’s home environment, or remotely. In Office In office is the most common delivery method, and it typically relies heavily on imagery methods described earlier. Treatment using this method is also instructional, in that clients are given specific between-session homework exercises aimed at fostering exposure outside the office, which is not therapist guided. Inpatient and Residential Specialized inpatient and residential treatment programs for anxiety disorder have been developed where more intensive exposure can be conducted. This would entail practicing exposure for multiple hours per day over consecutive days in order to alleviate symptoms. Prominent examples include programs for OCD (Shikatani et al., 2016), trauma in youths (Cohen et al., 2016), and panic with agoraphobia (Pollard et al., 1987). Out in the Field As noted earlier, in vivo exposure is generally more effective than in imagery and often necessitates leaving the office to conduct therapist-assisted exposure. Although this is the most effective approach to conducting exposure, it is also the approach that prompts the greatest hesitancy among providers and stands as a barrier to proper dissemination (Powers & Deacon, 2013). The benefit of leaving the office to conduct exposure allows for an enhanced ability to practice the kind of exposure that clients need to conduct as part of between-session behavioral homework, and it provides the clinician with opportunities to observe potential barriers to exposure that the client might encounter but would not recognize to report.

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Remote Treatment Delivery (Telehealth) In the event that there are institutional restrictions on conducting therapistguided exposure outside the office, advances in computer technology have allowed for treatment to take place remotely. The research in this area is still in active development, so specific methods to optimize delivery have not been fully described. However, the research thus far is encouraging. In the case of OCD, for example, telemental health approaches have large effect sizes for symptom reduction (Herbst et al., 2012). This has likewise been shown for obsessive-compulsive related disorders (Brand & McKay, 2012) and PTSD (Acierno et al., 2016). In addition to guided exposure through telemental health approaches, treatment can be delivered through internet-guided methods (e.g., via email; see Jacob & Storch, 2015).

OUTCOME DATA Research has established CBT, including an exposure component, as a firstchoice treatment for anxiety and as a more efficacious intervention for anxiety disorders than a number of other therapies (Hofmann et al., 2012; Tolin, 2010). In addition, there is strong evidence suggesting the efficacy of CBT as a method to treat a wide array of other mental health issues including bulimia, somatoform disorders, anger control issues, and overall stress, pointing to the widespread benefits of CBT across disorders and symptoms (Hofmann et al., 2012). As most CBT models for anxiety disorders include exposure or some variant such as behavioral experiments, this component has been described as the one accounting for the greatest amount of variance in outcome data. For example, Abramowitz, Taylor, and McKay (2005) showed that behavioral experiments were effectively exposure-based interventions when applied in OCD and were the primary means of prompting symptom improvement.

Phobias Exposure therapy is the preferred treatment for specific phobias (see Barlow et al., 2002). In a meta-analysis conducted by Wolitzky-Taylor et al. (2008), exposure therapy for phobias led to greater symptom improvement at posttreatment (d = 0.44) as well as at follow-up (d = 0.35) compared with nonexposure treatment, with the average individual who received exposure outperforming 64% of those given a nonexposure treatment. Additionally, this meta-analysis revealed that exposure alone is as efficacious as the combination of exposure and cognitive techniques. Furthermore, in vivo exposure for phobias has been found to be superior to other forms of exposure, such as the use of imagery, and to nonexposure and placebo conditions when results are evaluated at posttreatment (for review, see Choy et al., 2007; Olatunji et al., 2010). However, in vivo exposure may only be superior to other forms of exposure immediately following treatment (d = 0.38), as these different forms of exposure were found to



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have similar outcomes at follow-up (Wolitzky-Taylor et al., 2008). Additional methods for administering exposure have developed with new technology, including the use of virtual reality. In a meta-analysis conducted by Parsons and Rizzo (2008), virtual reality exposure therapy was shown to significantly reduce symptoms of specific phobias, with effect sizes (d) ranging from 0.92 to 1.59. Finally, exposure therapy has had remarkable effects on fear reduction for many different types of phobias. For example, 79% to 92% of participants treated for animal phobia, height phobia, driving phobia, or claustrophobia were able to complete a fear-inducing activity (e.g., handling an animal) without fear following treatment compared with only 0% to 18% of participants who were in a control condition (for a review, see Choy et al., 2007). Panic With and Without Agoraphobia The use of interoceptive exposure (i.e., exposure to somatic cues) in treatment for panic disorder, with and without agoraphobia, is common practice and often increases symptom improvement. A combination of cognitive restructuring and interoceptive exposure was found to be most efficacious when treating panic disorder (d = 0.88) compared with multiple other combinations of CBTs (Gould et al., 1995). Gould et al. (1995) also found that CBT in general had a larger impact on panic disorder symptoms (d = 0.68) compared with pharmacological treatments or combination treatments, which were characterized by effect sizes of d = 0.47 and d = 0.56, respectively. Though there is scant research directly comparing exposure therapy to cognitive therapy (without exposure or behavioral experiments4), there is some evidence that exposure therapy and cognitive therapy may be equally as efficacious for panic disorder (Arntz, 2002; Bouchard et al., 1996). In one study conducted by Arntz (2002) that compared cognitive therapy to interceptive exposure, 75% to 92% of individuals in both conditions improved, with no significant differences in symptom improvements across conditions. Although it is clear that using interoceptive exposure in treatment is central for panic disorder, additional evidence is necessary to determine the benefit of using exposure alone. Beyond treating panic disorder, exposure is also particularly helpful for treating agoraphobia (Gloster et al., 2011; Jansson & Öst, 1982). In a study conducted by Gloster et al. (2011), therapist-guided exposure (compared with exposure that was prescribed) led to greater improvements in agoraphobic avoidance and in panic attacks. For individuals with panic disorder with agoraphobia, one study revealed that following exposure therapy, 68% of participants were no longer experiencing panic following treatment (Fava et al., 2001). More specifically, when comparing cognitive restructuring combined Behavioral experiments, in the context of anxiety disorders, entail creating situations whereby situations that are typically avoided are faced with the aim of eliciting unhelpful cognitions. These cognitions are then subject to direct modification in vivo. However, given the exposure component inherent in behavioral experiments, many scholars suggest that behavioral experiments are effectively exposure exercises (for a review, see McMillan & Lee, 2010).

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with either interoceptive exposure or breathing retraining in individuals with panic disorder with agoraphobia, those who received interoceptive exposure had better outcomes for panic frequency and severity as well as functioning at posttreatment (Craske et al., 1997). Thus, individuals suffering from panic with agoraphobia may benefit the most from the use of exposure within treatment, supporting the benefit of combining cognitively based techniques with exposure. Follow-up research on panic disorder with agoraphobia has shown that a high percentage of individuals who receive exposure therapy maintain their gains at follow-up. Follow-up data in one longitudinal study revealed that only 23% of exposure treatment responders relapsed during a 2- to 14-year followup period (Fava et al., 2001). For individuals treated with both exposure and cognitive therapy in another longitudinal study, 81% were panic-free after 2 years (Craske et al., 1991). Generalized Anxiety Disorder As with other anxiety disorders, exposure therapy is also an important component of CBT for GAD, although the exact impact of exposure alone on outcomes for GAD is understudied. Often, imagery is used to expose individuals to anxiety-related cues and worries. In one study comparing applied relaxation and CBT with imaginal exposure, generally anxious individuals who received CBT demonstrated better long-term outcomes (Borkovec & Costello, 1993). Because applied relaxation does not include exposure, this finding provides evidence that exposure may be central in promoting long-lasting change in GAD. Additionally, Dugas and Robichaud (2012) highlighted the importance of using exposure procedures for GAD to combat the intolerance of uncertainty, a core component of excessive worry. Specifically, they described the use of imaginal exposure to address worries surrounding hypothetical scenarios with uncertainty-inducing elements and to limit cognitive avoidance. In one study evaluating the efficacy of CBT that included exposure to uncertainty, CBT fared better at posttreatment than applied relaxation, with pretest to posttreatment effect sizes of d = 0.74 and d = 0.34 for CBT and applied relaxation, respectively (Dugas et al., 2010). Social Anxiety Disorder CBT is the most studied intervention for social anxiety disorder and has been found to be very beneficial for symptom reduction. Empirical research has found that exposure on its own can be as efficacious as, or even superior to, cognitively based treatments or their combination, particularly for social anxiety (Feske & Chambless, 1995; Gould et al., 1997; for a review, see Deacon & Abramowitz, 2004). For example, in a meta-analysis conducted by Gould et al. (1997), exposure therapy alone produced an effect size of d = 0.89, but when combined with cognitive restructuring, it produced an effect size of d = 0.80. Cognitive restructuring alone yielded an effect size of d = 0.60. Exposure therapy, therefore, is considered a highly effective treatment for social anxiety disorder.



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Recent advances in technology as well as developments in exposure procedures have expanded the format and techniques by which exposure is conducted. For example, virtual reality has been found to be efficacious for those with social anxiety around public speaking (for review, see Krijn et al., 2004). Recent research emphasizes a specific facet of exposure for social anxiety that involves social mishaps, which entails exposure to situations that may involve fearing a negative social outcome (also referred to as “social cost” exposure; Fang et al., 2013). This facet of exposure bridges the divide between behavioral practice and cognitive dimensions in the treatment of social anxiety, whereby individuals hold catastrophic beliefs regarding the consequences of social mishaps (Hofmann, 2007). Obsessive-Compulsive Disorder There is strong evidence demonstrating the efficacy of CBT consisting of ERP for OCD. Research has shown the best outcomes in CBT for OCD (d = 1.37) relative to many anxiety and related disorders, such as social anxiety (d = 0.62), panic disorder (d = 0.35), and PTSD (d = 0.62; Hofmann & Smits, 2008; Hofmann et al., 2012). Of note, this evidence challenges the common perception that OCD is among the most treatment-resistant disorders in clinical practice, even if it is the case that practitioners indeed come across treatment-resistant cases in clinical settings. The findings in research settings and in clinical practice may seem particularly discrepant due to the extreme heterogeneity of symptoms and severity that is typical of OCD (Hofmann & Smits, 2008). A number of individual studies have examined the efficacy of CBT and its components. Within a medication-refractory sample, the combination of cognitive restructuring and ERP was found to produce greater improvement in OCD symptoms than ERP alone (Rector et al., 2005, in Butler et al., 2006). Although some research has found ERP to be comparable to cognitive therapy for OCD (Abramowitz, 1997), more recent findings suggest that behaviorally based treatments, such as ERP, may actually be more beneficial than cognitively based treatments and their combination. For example, for self-reported symptoms of OCD, behaviorally based treatment produced an effect size of d = 1.46, cognitive therapy yielded an effect size of d = 1.09, and combined cognitive and behavioral therapy yielded an effect size of d = 1.30 (for a review, see Deacon & Abramowitz, 2004; McKay et al., 2015). It is important to note that OCD is a highly complex and heterogeneous condition. There are several subtypes of the disorder in adults (McKay et al., 2004) and children (McKay et al., 2006), and these subtypes have different expected outcomes (see, for example, Abramowitz et al., 2003). There are different models of subtypes, though the most consistently identified are checking and obsessions (aggressive, sexual, religious, or somatic); symmetry, ordering, and counting obsessions and repeating compulsions; and contamination obsessions and cleaning obsessions (Abramowitz, McKay, & Taylor, 2005). In general, when conducting specialized ERP for OCD, clients and therapists can achieve good outcomes for all subtypes, but duration of treatment may vary in

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part based on the symptom presentation in adults (McKay et al., 2015) and children (Franklin et al., 2015). In the case of children, behavioral effort may necessitate exposure sessions of shorter duration but with more frequent practice, whereas in adults, sessions often call for 90 minutes or more in order to ensure adequate within-session habituation. This is particularly the case for complex symptoms, symptoms with a long lag between exposure and feared consequences (e.g., in obsessions for blasphemy), or where in vivo practice is necessary to ensure adequate contact with the full stimulus complex.

Posttraumatic Stress Disorder There is also strong evidence supporting the efficacy of exposure therapy for PTSD (Bradley et al., 2005; Jonas et al., 2013; Watts et al., 2013), and it is a first-line recommended intervention for the disorder in the practice guidelines of the American Psychological Association (Courtois et al., 2017). In one study, participants receiving exposure therapy demonstrated a greater decrease in symptoms involving avoidance and reexperiencing, and more participants no longer met criteria for PTSD, compared with those receiving other forms of treatment, including relaxation training and eye-movement desensitization and reprocessing (EMDR; Taylor et al., 2003). Exposure therapy yielded the greatest percentage of participants exhibiting clinically significant symptom reductions. By both posttreatment and follow-up, 73% of those who had received exposure therapy maintained clinically significant reductions in reexperiencing symptoms; this percentage was significantly more than that of both the relaxation training group (33%) and the EMDR group (27%). Additionally, 67% of those in the exposure therapy group maintained clinically significant reductions in avoidance, which was a significantly greater percentage of participants than that of both the relaxation training group (27%) and the EMDR group (27%; Taylor et al., 2003). Further support for exposure therapy in PTSD comes from research on one specific type of exposure therapy, PE. When PE was compared with stressinoculation training (SIT) and a combination thereof in a sample of women with chronic PTSD, comparable reductions in symptoms were found across treatments. However, PE resulted in lower anxiety and had the largest impact on PTSD severity (in the completer sample, d = 1.92), depression (d = 1.47), and anxiety (d = 1.44) compared with SIT (d = 1.61, 1.00, and 0.89, respectively) and combined treatment, (d = 1.50, 0.91, and 0.67, respectively; Foa et al., 1999). This finding is notable because SIT includes several components of CBT such as relaxation training, coping strategy role playing, and cognitive restructuring, but it de-emphasizes exposure (see Meichenbaum, 2009). However, other research has suggested that, while efficacious, exposure-based treatment for PTSD is not substantially more efficacious than cognitively based treatment (Bradley et al., 2005) or a combination of the two treatment types (Olatunji et al., 2010), indicating that further research is warranted.



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Childhood Anxiety Similar to findings in adult samples, CBT has been found to be efficacious for children and adolescents and is considered the treatment of choice for anxiety and depressive disorders in youth (Albano & Kendall, 2002; Compton et al., 2004; Silverman et al., 2008). CBT for youth commonly utilizes both imagined and in vivo exposure and often emphasizes parental involvement in exposure practice, particularly with young children (Crowe & McKay, 2017). Although some studies have found CBT to be as efficacious for youth anxiety disorders as various other psychotherapies, there is strong evidence that CBT is superior to both passive and active control groups for youth with anxiety (Compton et al., 2004; Reynolds et al., 2012). Findings from a meta-analytic review of psychotherapy for youth anxiety indicated a small yet significant effect size when comparing CBT to passive control groups among 34 studies (d = −0.39) and a moderate-to-large effect size when comparing CBT to active control groups among 17 studies (d = −0.77; Reynolds et al., 2012). In another recent review of meta-analyses examining CBT for youth anxiety and depressive disorders, CBT was again deemed an efficacious treatment in comparison to active control groups (e.g., supportive counseling, psychoeducation; d = 0.40) and even more superior passive control groups (e.g., wait-list control; d = 0.76). A similar trend occurred for youth PTSD, with largest effect size occurring when CBT was compared with passive control (d = 1.40), followed by when CBT was compared with mixed control (d = 0.67), and the smallest effect size when CBT was compared with an active control (d = 0.47). For youth OCD, a large weighted effect size was also found when comparing CBT to mixed control groups (d = 1.37; Crowe & McKay, 2017). CBT for youth anxiety has also been modified to target specific disorders, with disorder-specific CBT showing greater effectiveness than generic CBT (whereby cognitive restructuring may be a significant focus of treatment). Whereas generic CBT for youth anxiety disorders has demonstrated a moderate overall effect size (d  =  −0.53), disorder-specific CBT has demonstrated a moderate-to-large overall effect size (d = −0.77; Reynolds et al., 2012). Disorder-specific CBT has been studied among many anxiety and related disorders, including social anxiety disorder, OCD, and PTSD (Reynolds et al., 2012). Disorder-specific CBT for PTSD is superior to generic CBT, with a moderate effect size (d = −0.68), as is disorder-specific CBT for social anxiety disorder, which has a moderate-to-large effect size (d = −0.79). For youth with OCD, CBT for OCD is particularly superior over generic CBT, with a large overall effect size (d = −1.79) compared with both generic CBT and other psychotherapy for anxiety, which aligns with findings among adults with anxiety disorders (Hofmann & Smits, 2008; Reynolds et al., 2012). Although the efficacy of CBT in the short term has been established for youths, as well as its efficacy in the short-term posttreatment, further research including longer follow-up periods is needed to understand the long-term impact of CBT for youth with anxiety and depression (Crowe & McKay, 2017).

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Separation Anxiety Disorder With an age of onset aligning with the occurrence of the normative developmental fear of separating from parents, separation anxiety disorder (SAD) tends to have an early onset, commonly around ages 6 to 9 years (Albano & Kendall, 2002). Because GAD, social anxiety disorder, and SAD are all common among children and tend to co-occur, they have often been studied together. In the largest randomized controlled trial of youth anxiety disorders, 488 youth with GAD, SAD, or social anxiety disorder received CBT, sertraline, a combination, or placebo. Findings suggest that CBT, sertraline, and their combination are all efficacious over placebo and that combined treatment is most efficacious for these disorders, as it yielded the largest effect size (g = 0.86), followed by sertraline alone (g = 0.45) and CBT alone (g = 0.31). Of note, there was no significant difference in efficacy between CBT and sertraline (Walkup et al., 2008). Further research comparing standard CBT to exposure-focused CBT has indicated that focusing on parent-coached exposure therapy early in treatment for SAD can lead to better outcomes, in fewer sessions, than treatment that emphasizes anxiety-management strategies early on (Whiteside et al., 2015). Selective Mutism While selective mutism (SM) is among the least studied of all anxiety disorders, a comprehensive review of psychosocial interventions for SM indicated that behavioral and cognitive behavioral treatments are most effective for youth with this disorder (Cohan et al., 2006; Fung et al., 2002). Specifically, within behavioral treatment, systematic desensitization—combining relaxation skills with graduated exposure, both imaginal and in vivo—has been found to be effective for youth with SM (for a review, see Cohan et al., 2006). For younger children, the graduated exposure component alone, focusing on in vivo exposure, may be most effective, due to developmental difficulty with relaxation and the use of imagery (Cohan et al., 2006; Compton et al., 2004). Because SM can be difficult to recognize in youth and is less prevalent than many other anxiety disorders, many studies on the disorder are based on case studies and few include large samples and comparison treatment groups. More recently, however, there has been an increase in better controlled studies of SM. One controlled study with a slightly larger sample found improvement of speaking in public for eight of nine youths and found better outcomes from child-focused exposure-based practice than from parent-focused contingency management (Muris & Ollendick, 2015; Vecchio & Kearney, 2009). In a larger randomized study of 24 youths with SM, those who received an intervention consisting of defocused communication (i.e., sit next to, instead of opposite, the child; joint attention on an activity instead of focus on the child) and behavioral methods (i.e., exposure) demonstrated significantly increased speech at school in comparison to wait-list control (Muris & Ollendick, 2015; Oerbeck et al., 2014). Another treatment exhibiting positive outcomes among youth with SM is integrated behavioral therapy (IBT), a newly



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developed treatment that involves the child, parent, and teacher and includes exposure activities as well (Bergman et al, 2013; Muris & Ollendick, 2015). In a randomized controlled trial assessing the efficacy of IBT among youth with SM, youth were randomized to receive IBT, consisting of exposures to take place in home, school, and clinic settings, as well as behavioral techniques, or were assigned to wait-list control. Whereas 67% of those who received IBT no longer met criteria for SM at posttreatment, all in the wait-list control group still met criteria. Further, 75% of those who received IBT were deemed treatment responders, compared with none among the wait-list control group. Moreover, according to parent and teacher reports on standardized measures, youth in the IBT group had increased functional speaking, compared with none in the wait-list control group (Bergman et al, 2013; Muris & Ollendick, 2015). In addition, improvements among those in the IBT group were maintained at 3 months posttreatment, which strengthens support for this intervention for youth with SM (Bergman et al, 2013; Muris & Ollendick, 2015).

MECHANISMS OF CHANGE DATA Experimental research has accumulated to show that exposure produces beneficial changes at the neural level in pathways associated with learning. Pavlov (1927) postulated that conditioning occurs in specific neural pathways and, further, that habituation is the learning of responses that inhibit the previously learned CR. This means that once a CS is established, it is not lost, but instead new learning blocks the previously learned response. In this way, Pavlov anticipated findings from neuroscience related to neural connections for fear learning, such as the N-methyl-D-aspartate (NMDA) pathways. This pathway is significant, as basic animal and human research has shown its involvement in new learning, particularly during fear reduction (Baker et al., 2018; Lee & Kim, 1998; Myskiw et al., 2014). Recent translational work examining the facilitation of habituation by including the NMDA agonist D-cycloserine (DCS) has shown that when DCS was administered approximately 2 hours before exposure, improvement occurred faster in several anxiety disorders (i.e., phobias, social anxiety, and OCD) but also that, over time, individuals who were not administered DCS achieved the same level of symptom improvement (e.g., Hofmann et al., 2006; reviewed in Norberg et al., 2008). Laboratory experimental findings suggest that extinction is facilitated when practiced in multiple settings and under multiple contexts (i.e., under varied threat potential), such that it leads to lower risk of recovery of fear (Dunsmoor et al., 2015). On the other hand, under conditions of heightened arousal (i.e., elevated noradrenergic response), fear responses may be consolidated rather than alleviated (Dębiec et al., 2011). This suggests that exposure should be conducted in varied settings and under varied conditions, but while the client is at a comparably normal mood state (i.e., not under acute fear) in order to facilitate the benefits of exposure.

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In addition to the neural changes observed in laboratory experiments, several different cognitive changes have been identified as mechanisms of change in anxiety reduction with exposure therapy. For example, Hofmann (2008) reviewed the literature on cognitive processes in exposure therapy and concluded that exposure reduces harm expectancy in anxiety disorders and thus could be a mechanism by which exposure therapy causes symptom reduction. In the aforementioned research on reduced fear recovery in multiple contexts of exposure (Dunsmoor et al., 2015), it was also observed that intolerance of uncertainty decreased. Individuals with combat-related trauma who had positive outcome in exposure showed a reduction in trauma-related guilt (Trachik et al., 2018). In addition, a general reduction in panic-related cognitions was observed in individuals who showed sudden gains in exposure treatment (Nogueira-Arjona et al., 2017), and changes in panic-related cognitions led to changes in the severity of panic symptoms (Hofmann et al., 2007). Other research has demonstrated that cognitions related to physical consequences of anxiety changed in the successful treatment of both agoraphobia and social anxiety (Vögele et al., 2010). Moreover, changes in an individual’s estimation of social cost were related to symptom change following CBT for social anxiety (Hofmann, 2004). Finally, it has been shown that individuals with compulsive checking showed changes in the perceived need to control thoughts, intolerance of uncertainty, and perception of danger in general following successful treatment (Overton & Menzies, 2005). This is not an exhaustive review of the cognitive mechanism of change data, but it illustrates that when exposure is conducted and there is clinically significant symptom reduction, cognitions change as a consequence (reviewed in Hofmann et al., 2018). The experimental findings also suggest that cognitive restructuring is not required in order to achieve cognitive change. One of the key means of achieving cognitive change is through shifts in expected outcomes following exposure and through experiencing the stimuli with different emotional states. When individuals encounter feared stimuli in the natural environment before treatment, they strategically avoid the full stimulus complex (i.e., Huijding & de Jong, 2006). During clinician-guided exposure, the full stimulus complex is presented (and elaborated on in imagery), leading to the aforementioned changes in expectancies through direct experience. These processes are consistent with the mechanisms of change predicted by the inhibitory learning model (Craske et al., 2014; see also Jacoby & Abramowitz, 2016).

DISSEMINATION As noted earlier, clinicians are generally reticent to practice exposure, often out of concerns that there is litigation risk or that clients will decompensate and then drop out of treatment instead of experiencing beneficial outcome. These attitudes have profound consequences for the dissemination of exposure. Indeed, recently, blog posts have been posted that decry the application of PE



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for trauma following the recommendations of the clinical practice guidelines. These blog posts often report erroneously on the dangers of exposure and state that clients will be harmed rather than helped by the procedures (see, for example, Shedler, 2017; see also response, McKay & Lilienfeld, 2017). The concerns over litigation and dropout are greatly inflated. Exposure therapy is on firm footing as an appropriate and acceptable form of treatment, leaving clinicians with little fear of litigation stemming from its use (Olatunji et al., 2009). As for dropout, there is little evidence that it is higher than for other psychotherapies (in PTSD, Imel et al., 2013; in OCD, Ong et al., 2016). Najavits (2015) identified several significant factors contributing to premature dropout from exposure, including client factors, such as severity, which can make exposure difficult to tolerate, and other mental illness, which could complicate information processing of exposure. Important clinician factors play a role in dropout as well, such as confidence the provider holds in the procedure, depth of familiarity with behavioral principles of change, and deviation from exposure protocol. The deviation from the procedure is a problem that exists more generally (Waller, 2009) but is exacerbated in the case of PTSD, given the complexity of the disorder and sensitivity to intensity of exposure that is specific to this group. In addition to improving the training that clinicians receive in conducting exposure, a move to conduct direct-to-consumer marketing of evidence-based treatments has been proposed. These efforts focus on educating consumers in the benefits of evidence-based treatment (e.g., symptom alleviation, efficiency of interventions), reducing stigma, and educating consumers regarding the core features of proper treatment (Gallo et al., 2013). Although CBT’s empirical support is strongly established, most individuals seeking treatment for a psychiatric disorder receive suboptimal CBT or do not receive CBT at all. One study demonstrated that only 33% of individuals treated for a psychiatric disorder received minimally adequate treatment, providing evidence that empirically supported treatments (ESTs) are rarely used (Wang et al., 2005). Furthermore, behavioral methods (e.g., exposure), which are an integral part of CBT, are used less often than other treatment approaches such as supportive therapy and medication (Goisman et al., 1993). One study demonstrated that only 17% of clinicians reported using exposure to treat individuals with PTSD, despite its established efficacy (Becker et al., 2004). Yet even among a sample of individuals who did receive CBT, less than half received the exposure component, demonstrating that clinicians often suboptimally implement CBT (Stobie et al., 2007). Further, even when exposure therapy is utilized, therapist-assisted exposures are rarely employed, and imaginal exposures are more commonly used than in vivo despite strong empirical support for in vivo exposure (Goisman et al., 1993; Hipol & Deacon, 2013). Inadequate dissemination and implementation of CBT including exposure is a widespread issue, particularly affecting populations with the greatest unmet need for mental health treatment. Racial minorities, the elderly, residents of rural areas, low-income individuals, and those without insurance are most likely to be underserved by current mental health services (Wang et al., 2005).

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There are a variety of barriers challenging the maximization of CBT in community settings. Among the most considerable are clinicians’ lack of CBT-specific training and available resources. Lack of training in CBT is common among clinicians, as only approximately 20% of social work and PsyD programs require supervision in CBT (Weissman et al., 2006). Clinicians, therefore, must seek out supplementary training opportunities to become well versed in CBT, which can be time consuming and costly and thus not feasible for many (Addis, 2002; Stewart et al., 2012). Research indicates that mental health counselors use CBT infrequently and usually do not have adequate training to correctly implement ESTs (Addis, Hatgis, et al., 1999; Addis, Wade, & Hatgis, 1999). This may, in part, explain why ESTs are less effective in clinical settings than in research settings (Weisz et al., 2014). Master’s-level clinicians tend to make up the majority of mental health providers, especially among community mental health centers. This is of particular concern, as master’s-level clinicians in community settings are often providers for low-income and minority populations. Even when clinicians are knowledgeable and well trained in CBT, it is common for them to worry about their ability to master EST implementation, especially when adequate supervision is unavailable when they are learning to refine new skills (Addis, Wade, & Hatgis, 1999; Cook et al., 2009). Despite these barriers, there is promising evidence that ESTs can be implemented adequately in community mental health centers, creating a recent push in the field to increase dissemination efforts and thereby eliminate barriers to treatment (Shafran et al., 2009; Wade et al., 1998). An increase in dissemination and adherent implementation of ESTs in community clinics would help provide better mental health treatment, most notably benefiting elderly and minority individuals who are currently underserved by mental health providers overall (Harvey & Gumport, 2015; Wade et al., 1998). Novel technological advances may help increase access to ESTs for these populations. In particular, computerized and internet-based CBT have shown positive outcomes (Craske et al., 2009). One study offering computer-assisted CBT for anxiety disorders in primary-care settings found that participants using this program not only rated it highly and found it beneficial but also were able to understand the material, fully participate, and develop skills in CBT (Craske et al., 2009). Moreover, this method of CBT implementation yielded positive results among novice clinicians, perhaps suggesting this treatment modality as a suitable starting point for clinicians lacking experience providing CBT. For example, in this study, the clinicians’ overall opinion regarding the computer program was positive, with a mean score of 6.08 out of 7. For anxiety disorders in particular, computer-based treatment can offer a unique opportunity to incorporate both still images and video of anxiety-provoking stimuli in hierarchies during exposure treatment, while allowing for careful control of the progression of exposure to such stimuli (Khanna et al., 2007). Treatment modalities involving the use of technology may provide more widespread care to individuals who cannot afford care at treatment centers or cannot engage in such care in person due to geographic location or scheduling logistics. Reducing addi-



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tional barriers, such as a lack of financial resources, childcare, and transportation, is important when trying to increase the application of ESTs to diverse populations (Harvey & Gumport, 2015).

APPLICATION TO DIVERSE POPULATIONS Efforts to disseminate exposure-based procedures to a wide range of settings have been hampered by the negative attitudes many clinicians hold toward the procedure. Dissemination and implementation research has suggested that community mental health centers in particular do not adopt exposure procedures, that they are more likely to employ relaxation methods in lieu of exposure, and that the negative attitudes permeate up through the administrative layers of the settings (Becker-Haimes et al., 2017). Although it is widely expected that exposure is effective with underrepresented groups, it has also been acknowledged that the research on diverse populations has lagged far behind work with majority members. For example, although OCD is known to affect ethnic and racial minorities, there is comparably low recruitment and participation in treatment trials, limiting the extent that demographic variables may be studied to determine ways to optimize treatment delivery, if necessary, for different patient samples (Williams et al., 2010). Despite the limited availability of work with underrepresented groups, there are some emerging efforts to develop culturally sensitive approaches. For example, Pina et al. (2009) described a culturally sensitive model of exposure treatment, with an illustration with Mexican American youth that included key modifications such as specifically building rapport with the family, sharing culturally personal anecdotes, adopting values-based approaches to exposure, considering economic- and social-based goals, and relying on metaphors to facilitate exposure. Owing to the assumptions held around the risks of conducting exposure, many clinicians assume that the presence of different medical conditions precludes the conduct of exposure. The assumption that provoking anxiety as part of a therapeutic intervention will lead to complications in a patient with a known medical condition is embraced as common clinical lore. However, the evidence generally does not support this belief. For example, it has been shown that exposure therapy with pregnant women neither leads to complications in pregnancy nor increases risk of miscarriage (see Arch et al., 2012). Research in older adults suggests that exposure is as suitable for them as it is for younger adults with comparably few health complications (Flint, 1998; Jayasinghe, et al., 2017). Although less extensive, a large clinical trial (N = 60) demonstrated that PE for PTSD was safe when conducted with individuals who had experienced prior myocardial infarctions (Shemesh, et al., 2011). In each of these illustrations, it was strongly recommended that clinicians consult with medical providers about the possible risks to clients before initiating treatment.

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In summary, although research has lagged with underrepresented groups and with medical populations, it appears that exposure can be conducted across populations. These may require modifications to address the unique needs of the presenting client, but nonetheless exposure can be safely practiced and clinicians can expect comparable outcome to research conducted with majoritymember samples.

CLINICAL EXAMPLE Janet, age 37, reported severe fears of contracting illnesses. This fear led to a wide range of compensatory behaviors including making frequent doctor visits, checking her body for possible tumors, washing to ensure limited contact with pathogens, and seeking reassurance from family members regarding the association between minor aches and pains and likelihood of significant health risks. When she presented for treatment, she was married and had two young children. She reported that she spent much of each day worrying about contracting illnesses, checking, or washing, leaving little time for other activities. She was unemployed, despite a desire to resume her professional career that she had put on hold when she had her children. Assessment Before initiating treatment, Janet completed a battery of measures aimed to assess severity of anxiety and associated anxiety-disorder symptoms and to rule out other potential diagnoses. Following this assessment, it was determined that she had clinically severe OCD but also had met criteria for panic disorder. On further evaluation, a functional analysis was developed that suggested the panic symptoms took priority and that the obsessive-compulsive symptoms were a consequence of interoceptive awareness that prompted illness anxiety. Hierarchy Development Janet’s hierarchy focused on several dimensions. The first was centered on interoceptive experiences that prompted anxiety reactions. The second focused on contamination sources that were associated with washing rituals. The third was on images of particular illnesses that caused her anxiety. However, the latter two were later revised following the targeting of Janet’s panic symptoms, as will be described. Initiating Exposure Janet’s treatment plan was described to her, and after some collaborative discussion of what she could expect, it was determined that interoceptive exposure was the most effective starting point for intervention. It is essential to note



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that in clients with no health risks, interoceptive exposure is considered harmless. Clinicians reluctant to engage in interoceptive exposure are encouraged to practice some of these exercises themselves in order to experience the physical sensations engendered. This allows for the clinician to more accurately address the resultant responses clients will experience when practiced in session. The first exposure session with Janet focused on a hyperventilation challenge. This was chosen because she reported that her panic symptoms were most centered on heart rate and pulmonary sensations (see Kircanski et al., 2009, for a discussion of panic subtypes). Janet was then guided through the lowest level item on the hierarchy for hyperventilation, namely breathing at a rate of 30 breaths a minute into a paper bag for 1 minute. The mechanics of this exercise involved specifically instructing Janet to stand, with feet together, and then breathe into a paper lunch bag for 1 timed minute. When completed, she was instructed to close her eyes and focus on the physiological sensations (slight dizziness, wobbly feeling, shortness of breath) and to open her eyes only when the sensation passed. Her peak fear rating for this exercise was a 5 out of a possible 10. Because this was her initial exposure session, she was instructed to practice the hyperventilation exercise one to two times each day. The next two sessions focused on continued hyperventilation exposure, increasing to a maximum of 4 minutes. During this period, Janet reported significant declines in panic experiences and a corresponding reduction in illness anxiety generally. Exposure Progress Janet’s panic symptoms largely subsided after the third session of hyperventilation. However, she reported continued residual contamination concerns. As she reported to the clinician, “Well, I’m less panicky, but the world is still filled with all kinds of germs that could harm me. And, now I wouldn’t feel it in my chest, so I might not be on guard for the risk!” This led to additional discussion of the role exposure plays in anxiety management generally, and treatment then shifted to her contamination and illness anxiety fears. However, since it was determined that panic symptoms elevated her anxiety in other areas, the hierarchy was revisited and updated to reflect the changes in her perceived fears. Exposure With Response Prevention In addressing Janet’s contamination and illness anxiety, exposure was initiated for contaminants. As the research has shown that in vivo exposure is most effective when practiced in conjunction with imagery, Janet’s first exercise involved touching the door for the single-occupant bathroom in a less frequently used corridor in the clinician’s office. Once Janet came into contact with this door, the clinician then proceeded to guide her in developing an image of contracting a minor illness (a head cold). The selection of an image involving a minor illness was in line with the hierarchy. Janet was also instructed

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to refrain from any handwashing for at least one hour and, when she did wash, to then recontaminate by touching a doorknob in her home. This proceeded for five additional sessions, building in intensity to the final exposure session, whereby Janet touched the sink top in the more widely used restroom in the clinician’s office building and imagined contracting a severe illness (hepatitis) and requiring hospitalization. By the end of this process, Janet’s panic symptoms did not return, and she reported a significant reduction in OCD symptoms. It is worth noting that Janet’s exposure course of treatment was followed by ongoing exposure for illness concerns. However, her treatment then moved to other areas, such as returning to work, which aroused contamination-based anxiety that was not reported in the initial phase given that it was not salient. Following 6  months of treatment, her symptoms had receded such that she resumed working, which was a primary goal she wished to attain with therapy.

CONCLUSION Exposure therapy is a major evidence-based intervention that is either a standalone treatment or part of comprehensive treatment programs for anxiety disorders. The accumulated evidence suggests that the intervention produces large effect sizes for symptom reduction, has indirect benefits for other psychopathology, and changes core cognitive biases associated with anxiety disorders. The biggest barrier to wider adoption of exposure rests with the negative attitudes clinicians hold toward the approach (i.e., risk of litigation, conflict with theoretical orientation) and assumptions about the ability of clients to tolerate anxiety. At the present time, major initiatives in funding agencies stress “personalized medicine.” This approach stresses the identification of multiple patient characteristics and the determination of a multipronged approach to treatment that draws on psychosocial interventions as well as biomedical ones. This model in mental health is derived from the movement in medicine generally, in which patient care is understood holistically (e.g., Hamburg & Collins, 2010). Exposure therapy has been characterized by its detractors as a one-size-fits-all approach to treatment (e.g., Shedler, 2017). However, as has been shown in this chapter, we could easily characterize exposure as a personalized medicine approach. Treatment is specifically tailored to the needs of the client, it is embedded in a culturally appropriate context, medical variables are accounted for, and consultation with appropriate medical providers is suggested. These factors should all be considered before clinicians conclude that multiple interventions are necessary. Personalized medicine calls for the identification of the full range of salient variables while determining the most efficient course of treatment. This means that treatment requires not necessarily more interventions, only the most targeted ones. In many instances, exposure can serve that purpose when crafted properly.



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mutism: Defocused communication and behavioural techniques. Child and Adolescent Mental Health, 19(3), 192–198. https://doi.org/10.1111/camh.12045 Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: A review of meta-analytic findings. Psychiatric Clinics of North America, 33(3), 557–577. https://doi.org/10.1016/j.psc.2010.04.002 Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cognitive and Behavioral Practice, 16(2), 172–180. https://doi.org/10.1016/j.cbpra.2008.07.003 Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic review and synthesis. Psychological Bulletin, 135(6), 974– 999. https://doi.org/10.1037/a0017428 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 Overton, S. M., & Menzies, R. G. (2005). Cognitive change during treatment of compulsive checking. Behaviour Change, 22(3), 172–184. https://doi.org/10.1375/ bech.2005.22.3.172 Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250–261. https://doi.org/10.1016/j.jbtep.2007. 07.007 Pavlov, I. P. (1927). Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex. Dover. Pina, A. A., Villalta, I. K., & Zerr, A. A. (2009). Exposure-based cognitive behavioral treatment of anxiety in youth: An emerging culturally-prescriptive framework. Behavioral Psychology/Psicología Conductual, 17(1), 111–135. Pollard, C. A., Obermeier, H. J., & Cox, G. L. (1987). Inpatient treatment of complicated agoraphobia and panic disorder. Hospital & Community Psychiatry, 38(9), 951–958. https://doi.org/10.1176/ps.38.9.951 Powers, M. B., & Deacon, B. J. (2013). Dissemination of empirically supported treatments for anxiety disorders: Introduction to the special issue. Journal of Anxiety Disorders, 27(8), 743–744. https://doi.org/10.1016/j.janxdis.2013.09.013 Rachman, S., Marks, I. M., & Hodgson, R. (1973). The treatment of obsessivecompulsive neurotics by modelling and flooding in vivo. Behaviour Research and Therapy, 11(4), 463–471. https://doi.org/10.1016/0005-7967(73)90105-8 Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24(2), 1–8. https://doi.org/d6c6m7 Rescorla, R. A. (1987). A Pavlovian analysis of goal-directed behavior. American Psychologist, 42(2), 119–129. https://doi.org/bq4z68 Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43(3), 151–160. https://doi.org/ckx62w Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. Prokasy & W. F. Black (Eds.), Classical conditioning II: Current theory and research (pp. 64–99). AppletonCentury. Resick, P. A., Monson, C. M., & Chard, K. M. (2010). Cognitive processing therapy: Veteran/ military version: Therapist’s manual. U.S. Department of Veterans Affairs. Reynolds, S., Wilson, C., Austin, J., & Hooper, L. (2012). Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review. Clinical Psychology Review, 32(4), 251–262. https://doi.org/10.1016/j.cpr.2012.01.005



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Richard, D. C. S., & Gloster, A. T. (2006). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In D. C. S. Richard & D. L. Lauterbach (Eds.), Handbook of exposure therapies (pp. 409–425). Academic Press. Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy: A short-term treatment for traumatic stress disorders (2nd ed.). Hogrefe Publishing. Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M., & Wilson, G. T. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47(11), 902–909. https://doi.org/10.1016/j.brat.2009.07.003 Shedler, J. (2017, November 19). Selling bad therapy to trauma victims. Psychology Today. https://www.psychologytoday.com/blog/psychologically-minded/201711/ selling-bad-therapy-trauma-victims Shemesh, E., Annunziato, R. A., Weatherley, B. D., Cotter, G., Feaganes, J. R., Santra, M., Yehuda, R., & Rubinstein, D. (2011). A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness. Journal of Clinical Psychiatry, 72(2), 168–174. https://doi.org/10.4088/JCP.09m05116blu Shikatani, B., Vas, S. N., Goldstein, D. A., Wilkes, C. M., Buchanan, A., Sankin, A., & Grant, J. E. (2016). Individualized intensive treatment for obsessive-compulsive disorder: A team approach. Cognitive and Behavioral Practice, 23(1), 31–39. https://doi. org/10.1016/j.cbpra.2014.09.002 Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37(1), 105–130. https://doi.org/10.1080/ 15374410701817907 Stampfl, T. G., & Levis, D. J. (1967). Essentials of implosive therapy: A learning-theorybased psychodynamic behavioral therapy. Journal of Abnormal and Psychology, 72(6), 496–503. https://doi.org/10.1037/h0025238 Stewart, R. E., Stirman, S. W., & Chambless, D. L. (2012). A qualitative investigation of practicing psychologists’ attitudes toward research-informed practice: Implications for dissemination strategies. Professional Psychology, Research and Practice, 43(2), 100– 109. https://doi.org/10.1037/a0025694 Stobie, B., Taylor, T., Quigley, A., Ewing, S., & Salkovskis, P. M. (2007). “Contents may vary”: A pilot study of treatment histories of OCD patients. Behavioural and Cognitive Psychotherapy, 35(3), 273–282. https://doi.org/10.1017/S135246580700358X Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330–338. https://doi.org/cwzfjq Tolin, D. F. (2010). Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30(6), 710–720. https://doi.org/ 10.1016/j.cpr.2010.05.003 Trachik, B., Bowers, C., Neer, S. M., Nguyen, V., Frueh, B. C., & Beidel, D. C. (2018). Combat-related guilt and the mechanisms of exposure therapy. Behaviour Research and Therapy, 102, 68–77. https://doi.org/10.1016/j.brat.2017.11.006 Vecchio, J., & Kearney, C. A. (2009). Treating youths with selective mutism with an alternating design of exposure-based practice and contingency management. Behavior Therapy, 40(4), 380–392. https://doi.org/10.1016/j.beth.2008.10.005 Vögele, C., Ehlers, A., Meyer, A. H., Frank, M., Hahlweg, K., & Margraf, J. (2010). Cognitive mediation of clinical improvement after intensive exposure therapy of agoraphobia and social phobia. Depression and Anxiety, 27(3), 294–301. https://doi. org/10.1002/da.20651

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Vujanovic, A. A., Farris, S. G., Bartlett, B. A., Lyons, R. C., Haller, M., Colvonen, P. J., & Norman, S. B. (2018). Anxiety sensitivity in the association between posttraumatic stress and substance use disorders: A systematic review. Clinical Psychology Review, 62, 37–55. https://doi.org/10.1016/j.cpr.2018.05.003 Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and Clinical Psychology, 66(2), 231–239. https://doi.org/b57fps 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 Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour Research and Therapy, 47(2), 119–127. https://doi.org/10.1016/j.brat.2008.10.018 Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 629– 640. https://doi.org/10.1001/archpsyc.62.6.629 Watson, J. B., & Rayner, R. (1920). Conditioned emotional reactions. Journal of Experimental Psychology, 3(1), 1–14. https://doi.org/10.1037/h0069608 Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541–e550. https://doi.org/gfzwjn Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., Fitterling, H., & Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925–934. https://doi.org/10.1001/archpsyc.63.8.925 Weisz, J. R., Ng, M. Y., & Bearman, S. K. (2014). Odd couple? Reenvisioning the relation between science and practice in the dissemination-implementation era. Clinical Psychological Science, 2(1), 58–74. https://doi.org/10.1177/2167702613501307 Whiteside, S. P. H., Ale, C. M., Young, B., Dammann, J. E., Tiede, M. S., & Biggs, B. K. (2015). The feasibility of improving CBT for childhood anxiety disorders through a dismantling study. Behaviour Research and Therapy, 73, 83–89. https://doi.org/10. 1016/j.brat.2015.07.011 Whiteside, S. P. H., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29–36. https://doi.org/10.1016/j.janxdis.2016.04.001 Whiteside, S. P. H., Sattler, A., Ale, C. M., Young, B., Hillson Jensen, A., Gregg, M. S., & Geske, J. R. (2016). Exposure therapy for child anxiety disorders in a medical center. Professional Psychology, Research and Practice, 47(3), 206–214. https://doi.org/ 10.1037/pro0000077 Williams, M., Powers, M., Yun, Y. G., & Foa, E. (2010). Minority participation in randomized controlled trials for obsessive-compulsive disorder. Journal of Anxiety Disorders, 24(2), 171–177. https://doi.org/10.1016/j.janxdis.2009.11.004 Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021–1037. https://doi.org/10.1016/j.cpr.2008.02.007 Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press. Wolpe, J. (1990). The practice of behavior therapy. Pergamon.

11 Motivational Interviewing Deborah H. A. Van Horn, Amy Wenzel, and Peter C. Britton

W

hen clients present for psychotherapy, it is easy for the treating clinician to assume that they are ready and willing to make substantial changes in their lives. After all, many people who seek out psychotherapy do so of their own volition when they have drawn the conclusion that they are not happy or satisfied with their lives or when they acknowledge that unhelpful cognitive, emotional, and/or behavioral styles are interfering with the attainment of valued life goals. Nevertheless, the prospect of change can be quite daunting for clients, even when they clearly indicate that they want their lives to be different. The tension between the desire for change and the fear of making change can create a state of ambivalence, which in turn often prevents clients from fully embracing all that psychotherapy has to offer. Furthermore, it is not difficult to imagine a particularly pronounced amount of ambivalence, or even a decidedly negative attitude about treatment, in clients who have not proactively sought services on their own but who were instead pushed or mandated to participate in treatment by a spouse, family member, or other entity, such as a court. Psychotherapists, then, are faced with the challenge not only of delivering high-quality psychotherapy but also of understanding and responding to their clients’ readiness for treatment. Cognitive behavioral therapy (CBT) is clearly an action-oriented treatment. This means that the cognitive behavioral therapist and client, together, actively structure sessions to maximize productivity, agree on specific problems to address in session so that tangible solutions can be achieved, and (in many cases) practice a skill that the client can apply to problems in their life in https://doi.org/10.1037/0000218-011 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  313 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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between sessions. Because of CBT’s problem-oriented nature, CBT solutions can at times feel counterintuitive; for example, anxious individuals are asked to face their fears and depressed people are encouraged to be more active. Clients who are ambivalent, or who have a negative attitude about treatment, likely will experience (and even express) disdain about these tasks if they are not fully “on board” with the structure, goals, and process of treatment. Such disdain has the potential to result in an impaired therapeutic alliance, therapyinterfering behaviors (e.g., missed sessions, dropouts), and failure to implement action plans between sessions. This state of affairs does not imply that there is something wrong with most clients who present for psychotherapy or CBT in particular. In fact, ambivalence about change characterizes the majority of clients who seek psychotherapy (Prochaska & Norcross, 2001). This state of affairs also need not imply that CBT is a poor match for most clients who present for psychotherapy. In fact, “good” CBT proceeds from a client-centered perspective in which clients’ readiness for treatment is assessed and treatment is shaped in a way that creates a context for the cultivation of a sound therapeutic alliance, resolution of clients’ ambivalence, collaborative development of mutually agreed-upon goals, and identification of a pace that minimizes clients’ feeling overwhelmed (e.g., Wenzel et al., 2009; cf. Driessen & Hollon, 2011; Wenzel, 2017). That is, although the “heart” of CBT is, indeed, active and problem oriented, much legwork takes place before most active CBT strategies are implemented to maximize the likelihood that clients will be receptive to them. As many graduate students and young clinicians learn, the difference between more or less successful courses of CBT often lies in the therapist’s ability to customize the activities that comprise CBT. Although this approach to practicing CBT was developed in its early days (e.g., A. T. Beck et al., 1979), over time, CBT acquired the reputation (inaccurate in our view) of being so active and problem focused that cognitive behavioral practitioners paid little attention to process, cultivation of the therapeutic alliance, and important individual differences among clients. One way this viewpoint has been addressed over the past decade is with the publications of key scholarly compilations with clinical relevance on the therapeutic alliance in CBT (e.g., Gilbert & Leahy, 2007; Kazantzis et al., 2017). A second way—and that is the topic of this chapter—is of the use of motivational interviewing principles and techniques in conjunction with CBT to maximize clients’ readiness for this active, problem-focused approach to treatment (Arkowitz et al., 2015; Westra, 2012). The popularity of the approach suggests that motivation is a common problem that clinicians face in treatment, and motivational interviewing provides them with a strategy for identifying and addressing client’s needs and desires to increase their readiness to change. Motivational interviewing (MI) is a client-centered intervention that uses reflective listening to provide space for clients to identify and embrace personal reasons for change (Miller & Rollnick, 2012). As is explained in greater detail in the next section, it grew in response to a tradition in alcohol and drug counsel-



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ing in which clients were told that they must change their behavior, often in a way that shamed them and deprived them of their autonomy. William Miller and Stephen Rollnick, the developers of this approach, observed that clients ultimately achieved better outcomes and were more likely to stay in treatment when a different approach was taken, such that clients’ reasons for not changing were respected and clients were given time to first identify and the elaborate on reasons to begin to move toward change (Miller & Rollnick, 1991). When clients identify their own reasons for changing, rather than reasons that are imposed on them by outside forces, they are more likely to convince themselves that change is in their best interest, take ownership over the treatment process, and make a more meaningful commitment to enact behaviors to make these changes. Within a CBT framework, it is logical to implement an MI intervention in the early sessions of CBT in order to help clients embrace reasons for changing and commit to CBT’s active, change-focused process (e.g., Baer et al., 1999). Moreover, our clinical observation suggests that it is wise to be mindful of MI principles throughout the course of treatment, as motivation for and ambivalence about treatment can wax and wane depending on the perceived difficulty of cognitive behavioral interventions and unexpected problems that arise in clients’ lives. MI can also be applied when clients have an incomplete response to CBT and additional effort will be needed to achieve the desired outcome (Westra, 2004). Although MI primarily focuses on motivation for change and CBT for developing the skills for enacting change (Baer et al., 1999; Carroll, 1998), there are many overlapping features between the two approaches (cf. Naar & Flynn, 2015). Both approaches utilize a problem-focused orientation, whereby clients and providers discuss problem behavior, its impact on the client’s life, and ways that life might be different if the problem behavior were to be remedied. In addition, both approaches rely on a careful understanding of the client’s individualized clinical presentation to identify realistic goals for intervention that have the potential to yield the greatest change. Moreover, both approaches may include cognitive restructuring and behavioral activation to achieve a balanced perspective about behavioral change and to move clients toward taking action, albeit using different specific techniques. Good CBT takes into account clients’ ambivalence and motivation, but many clinicians require additional guidance on how to be person-centered yet directive in a manner that both respects and resolves client’s ambivalence toward changing. These clinicians often find that MI provides them with the guidance and skills they need to address motivation in an empathic yet productive way. Although CBT may address the motivational issues targeted in MI, there are also important differences between the two approaches. CBT is grounded in learning theory and is oriented toward identifying and either remedying or accepting maladaptive patterns of thought, feeling, and behavior. Although CBT is collaborative when done well, the cognitive behavioral therapist remains the expert who provides psychoeducation and guidance toward learning new

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skills, at least in the beginning stage of treatment when clients are acquiring a new framework for addressing their life problems. MI is explicitly grounded in humanistic psychology and oriented toward evoking client strengths; therefore, although the therapist may contribute expertise regarding the problem and/or possible solutions, the emphasis is on drawing out meaning and solutions from the client. Finally, whereas CBT provides a comprehensive theoretical framework for understanding and intervening in a wide range of problems in living, MI is targeted to the specific challenge of helping people initiate and maintain change. As is outlined in more detail later, the MI therapist is guided in that more specific effort by attention to in-session shifts in client motivation; development of a case formulation encompassing cognitive, behavioral, and emotional contributions to the presenting problem is downplayed. The purpose of this chapter is to describe theory, research, and clinical application of the integration of CBT and MI. The chapter begins with a discussion of the history of the development of MI, as well as the way in which it has evolved over time with reworkings of its framework. Next, MI’s main procedures and techniques are presented. Then, data on MI’s outcome are presented, highlighting outcome studies that have integrated MI and CBT for a variety of mental health conditions. There are well over 200 randomized controlled trials (RCTs) in which MI was used for a wide variety of outcomes, which makes a comprehensive description of the literature beyond the scope of this chapter. To ensure that adequate attention can be given to the nuances of the research we reviewed, we focused on the literature for substance use disorders, as they were the original target of MI; anxiety disorders, for which there is a rich literature examining the integration of MI with CBT approaches; and for suicide prevention, for which there is relatively new literature examining the potential of MI approaches, based on the severity of the problem. Those interested in treatment for other disorders can learn from the research reviewed here but may also benefit from reviewing the available literature that was not included. In addition, we consider hypothesized mechanisms of change to explain the pathways by which this integration works, the dissemination of integrated CBT and MI to the mental health community, and applications to diverse populations. We also include a brief clinical example to illustrate the application of MI to a client with obsessive-compulsive disorder (OCD) who is ambivalent about an aspect of treatment.1 We end the chapter with a consideration of the conclusions that can be drawn on the basis of scholarly work to this point, as well as compelling directions for future research.

HISTORY AND EVOLUTION MI was developed pragmatically as an effort to state explicitly the implicit principles that guided Miller’s (1983) clinical work with problem drinkers. These Clinical examples are disguised to protect patient confidentiality.

1



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principles were informed by direct clinical experience and from research findings showing that therapist empathy predicted a substantial portion of the variance in outcomes in behavior therapy for problem drinking (Miller et al., 1980). In the initial manuscript describing MI, Miller (1983) outlined a model of motivation that stood in contrast to the then-dominant view of motivation as a characteristic of the individual. According to the traditional model of the time, it was believed that individuals with substance use disorders had to “hit bottom” in order to break through denial with regard to consequences of addictive behavior and be sufficiently motivated to benefit from treatment. In contrast, Miller’s view was that “denial” emerges predictably in the interaction between an ambivalent client and a confrontive or directly persuasive counselor and that it could be avoided by a counselor who empathically supports and empowers the client to connect with their own reasons to change. Simply stated, the goal of MI was for the client, rather than the therapist, to voice arguments for change (change talk; Miller & Rollnick, 2002) and to avoid the arguments against change (sustain talk; Miller & Rollnick, 2002). Having described an interpersonal model of motivation and a clinical method geared toward eliciting and reinforcing the client’s own arguments for change, Miller drew on existing social psychological theories of cognitive dissonance (Festinger, 1957) and self-perception theory (Bem, 1967) and on Carl Rogers’ view of the centrality of accurate empathy in the helping process (C. R. Rogers, 1957) to state a rationale for its likely effectiveness. Later, upon review of the growing literature demonstrating MI’s effectiveness across a wide range of target behaviors and early process research in MI, Miller and Rose (2009) outlined an “emergent” theory of MI that posited two complementary active components. The first component reflects a relational pathway regarding MI’s efficacy, such that the relationship itself, and particularly therapist empathy, is expected to directly promote positive change The second, the technical pathway, grew from the underlying hypothesis that eliciting meaningful client change talk would promote behavior change and that eliciting client in-session sustain talk would inhibit change. The technical pathway, therefore, implies that the therapist’s skillful use of MI-consistent strategies will increase client change talk and decrease client sustain talk, which will in turn predict behavior change. As described later in this chapter, a growing body of research has found partial support for both hypotheses. The evolution of MI can be tracked through the refinement of its definition. The first edition of the MI text (Miller & Rollnick, 1991) avoided a definition in favor of a broader statement regarding the applicability of MI, the role of the therapist, and key strategies. In this statement, MI is described as “a particular way to help people recognize and do something about their present or potential problems. . . . It is intended to help resolve ambivalence and get a person moving along the path to change” (Miller & Rollnick, 1991, p. 52). The chapter outlined five broad principles to guide clinical practice: (a) express empathy, (b) develop discrepancy, (c) avoid argumentation, (d) roll with resistance, and (e) support self-efficacy. In addition, it emphasized that MI is conceptualized as

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a way of being with clients over a set of techniques for doing counseling. In the second edition of the MI text (MI-2; Miller & Rollnick, 2002), the authors defined MI as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). Retained in this definition from earlier writings was the juxtaposition of a client-centered “way of being” together with the intention to help “get the person unstuck” (Miller & Rollnick, 1991), which anticipated the relational and technical hypotheses of MI’s efficacy. Of critical importance, as well, is the directive that the tasks of MI were to explore and resolve ambivalence. In the third edition of the MI text (MI-3; Miller & Rollnick, 2012), MI is defined as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (p. 29). This definition retains the emphasis on communication style rather than specific techniques, as well as the dual technical-relational theoretical underpinnings. Gone was the exploration of ambivalence, which was replaced by exploration of the person’s own reasons for change. This change was driven by linguistic process outcome research addressing in-session speech among clients with more and less successful outcomes finding that client change talk, specifically strength of commitment to change, was associated with better drug use outcome (Amrhein et al., 2003). It is important to note that recognition of the importance of ambivalence was not lost. MI is about motivating people to make positive behavioral changes and, thus, should focus on reasons to change. This increases the emphasis on the directive component of MI, further differentiating it from its Rogerian roots. At the same time, it recognizes that ambivalence about making life changes is natural and must be accepted with compassion. It is equally important to note some of the specific qualities MI has retained across these iterations. Often administered in one to four sessions, MI has always been practiced as a brief intervention with a distinct ending. MI is also focused on a specific behavior rather than a diagnosis or disorder, making it a transdiagnostic intervention. Furthermore, although a clinician cannot motivate someone to overcome a problem, for example posttraumatic stress, they can motivate that person to engage in exposure-based treatments that reduce symptoms. In this regard, the integration of MI with CBT approaches is a natural fit.

DESCRIPTION OF MAIN PROCEDURES As implied in its definition, MI marries strategies for helping clients increase motivation and commitment for change with a client-centered counseling style. Strongly influenced by Carl Rogers’s work, MI is characterized by an overarching “spirit” of interacting with clients. MI spirit includes four elements: (a) partnership, (b) acceptance, (c) compassion, and (d) evocation. Partnership



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refers to the extent to which MI is an active collaboration, done “for” or “with” a person, not “to” them (Miller & Rollnick, 2009, 2012). Metaphors to describe this aspect of spirit are guiding or dancing, which may be contrasted with directing, following, or wrestling. Acceptance includes respect for the absolute worth of each individual, accurate empathy for the client’s experience and worldview, support for the client’s autonomy and freedom of choice, and affirmation of the client’s strengths and efforts. Compassion refers to the active promotion of the client’s welfare and best interests as primary. With a connotation of benevolence, rather than sympathy or pity, compassion is intrinsic to ethical practice of counseling or psychotherapy and helps distinguish between MI and cynical efforts to manipulate or trick others into change. Evocation refers to the emphasis in MI on drawing out the client’s own motivation and resources, rather than attempting to instill them, and on activating client strengths rather than ameliorating client deficits. The MI practitioner is attentively curious about the client’s perspective, using strategies such as carefully chosen open questions to help the client give voice to their own intrinsic motivation. The flow of MI—the “what to do when”—is represented by four processes: (a) engaging, (b) focusing, (c) evoking, and (d) planning. Each is a prerequisite for the next, yet there is no assumption that progress will be strictly linear. Engaging refers to establishing rapport and a working alliance. Focusing is the development and maintenance of a specific direction for the conversation about change, such as determining the topic and goals of the intervention. Evoking is at the strategic heart of MI. Once there is an agreed-upon topic of conversation, the provider elicits the client’s own thoughts on why and how to change. The techniques associated with this process—evocative questions, skillful reflective listening, and selective summaries—are all intended to help the client, rather than the therapist, make the argument for change. As the balance begins to tip toward change, the process of planning includes consolidating commitment to change and determining a course of action. Within an MI framework, no further intervention may be needed once the client has decided to make a change; alternatively, commitment may be a first step toward making use of an action-oriented treatment. MI includes a strategic focus on client speech representing movement toward and away from change. With open questions and reflective listening, the MI therapist elicits and selectively reinforces client change talk, or statements indicative of and, theoretically, instrumental in motivation. Change talk includes statements of client desire, ability, reasons, need, and commitment for change, statements of commitment being most closely associated with later change (Amrhein et al., 2003). Rather than consider all opposition to change within the single construct of “resistance,” MI includes two components: sustain talk, or the expression of the status quo side of ambivalence, and discord, or disruption in the therapeutic alliance. The “dance” of MI involves eliciting and reinforcing change talk while minimizing sustain talk and resolving discord, within a fundamentally empathic relationship where the client’s values and autonomy are paramount.

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Core skills of MI are mainly those of a client-centered counseling style: (a) open questions, (b) affirmations, (c) reflective listening, (d) summarizing, and (e) informing. Open questions that allow for a range of responses are preferred to closed questions, the latter of which often serve to reinforce a hierarchical model in which the therapist is the active expert, and the client is the passive recipient of care. Common MI techniques that use open questions to evoke change talk in a context of acceptance include asking about the client’s satisfaction with their current habits or coping skills, discussing the client’s concerns, or seeking the client’s insights as to how they could be most successful at making a change. Because of the desire to have the client make the argument for change, the MI therapist usually does not ask why the client has not yet changed. Affirming the client’s strengths and efforts, such as catching the client doing something “right” rather than pointing out what the client is doing “wrong,” conveys acceptance and fosters hope by supporting the client’s selfefficacy for change. Reflective listening is the most fundamental skill of MI. Being able to examine one’s own perspective and experience while being nonjudgmentally heard is viewed as helpful in itself, independent of any strategic guidance or direction. Therefore, the MI therapist is encouraged to use at least twice as many reflective listening statements as questions. Simple reflections that stay close to the client’s stated meaning convey understanding and acceptance; complex reflections that add emphasis or guess at meaning or emotion deepen the relationship and invite new perspectives. Double-sided reflections, bringing together both sides of the client’s ambivalence, can be especially useful for acknowledging and softening the client’s sustain talk and providing an opportunity to bring the discussion back toward change. Reflective listening can also serve to invite consideration of new perspectives. At the very least, summarizing is an essential skill within any talk therapy to help keep the conversation focused on the topic at hand. Important for the technical hypothesis for MI’s efficacy, the clinician gets to decide what to reinforce through inclusion in a summary. The MI practitioner is particularly attentive to and curious about the client’s change talk, responding with reflection and affirmation and asking for elaboration in order to strengthen and amplify it. One strategic use of summaries in MI is to arrange a “bouquet” of the client’s change talk (Miller & Rollnick, 2012), bringing together and helping crystalize the client’s thoughts and, ideally, building toward a commitment to change. Informing can often increase motivation by helping clients understand the nature of the problem, the association between their behavior and their presenting problems, and possible ways to feel better. In MI, the clinician is encouraged to value the client’s expertise and avoid persuading with facts and giving advice because of the risk of psychological reactance leading to sustain talk and discord. Therefore, the process of informing in MI is conceptualized in terms of an exchange of information with the client. MI-consistent information exchange often follows the formula of “ask, tell, ask.” First, clinicians ask about the client’s knowledge, experience, or ideas. They use reflective listening to acknowledge—



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and then they decide whether their added expertise is still necessary. Subsequently, they tell clients what they think they need to know, clearly in manageable doses and using language supportive of autonomy. Finally, they invite the client’s reaction to the information, acknowledging with reflection. Because a therapist would not be doing MI if clients were not ambivalent about change, sustain talk is likely to arise. Indeed, clinicians often seek training in MI to learn to “roll with resistance,” a principle for practice outlined in the first two editions of the MI text but superseded by the reframing of resistance into sustain talk and discord in the current formulation. Nevertheless, it remains a helpful rule of thumb in addressing inevitable sustain talk and discord. Rather than meet sustain talk head-on with persuasion, confrontation, or disagreement, sustain talk is acknowledged and minimized through reflective responses that demonstrate empathy and respect before moving on to further elicitation of change talk. Should discord arise, responses are often similar, reflection remaining the most common and useful tool for repairing a rupture in the therapeutic alliance. Nothing about the spirit, processes, or core skills of MI is alien to sound practice of CBT, and in fact we faced some disagreement among ourselves when attempting to articulate a clear boundary between the two approaches. CBT includes a range of effective interventions such as skill training or problem solving that are generally beyond the scope of MI. There are also differences in the role of the therapist and in how assessment and case formulation are used to guide therapeutic interventions. In CBT, the clinician assesses the client’s clinical presentation in order to develop a case formulation incorporating the client’s maladaptive cognitive, behavioral, and emotional responses. While collaboration is essential, the therapist is often described as a teacher or coach who provides expertise on how best to ameliorate presenting problems and who may actively structure the intervention for the client’s benefit (J. S. Beck, 2011; Tolin, 2016). In MI, the question-and-answer format typical of formal assessment is viewed as a potential barrier to engagement and is therefore minimized and, when possible, delayed until after the patient is clearly engaged in the session. In MI, formal assessment becomes helpful to the client when results are provided in the context of an MI-consistent discussion. More importantly, therapist interventions in MI are mainly guided by the shifting dynamic of motivation and commitment as represented by client speech and only secondarily by a broader case formulation. Stylistically, MI is often less Socratic and psychoeducational than CBT and may feel less “active” to practitioners accustomed to relying on their content expertise to help clients solve problems.

OUTCOME DATA Results from practitioner surveys point to many obstacles to client participation in psychotherapy, approximately two thirds of practitioners observing a lack of client willingness to engage and a lack of client motivation (Committee on

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Building a Two-Way Bridge Between Research and Practice, 2010). Moreover, many clients report reservations about psychotherapy, including concerns and fears about process, change, and outcome (e.g., Borkovec & Roemer, 1995). Because of these reasons, over the past 2 decades, MI has increasingly been considered more for the treatment of major mental health disorders beyond problematic alcohol and drug use (Westra et al., 2011). It has been incorporated into treatment packages in many ways, from being implemented before clients embark on a course of an active treatment like CBT (Simpson et al., 2008), to being integrated throughout the course of treatment as part of a larger package (e.g., Steketee et al., 2010), to being used as a method to increase participation in treatment among those who are not actively seeking or who have refused treatment (Maltby & Tolin, 2005; Simpson & Zuckoff, 2011), to being used to increase medication compliance (Interian et al., 2010). In this section, we review outcome data from studies examining the combination of MI and CBT for three major mental health conditions: (a) alcohol and drug use problems, (b) anxiety and related disorders, and (c) suicide risk. Alcohol and Drug Use MI originated as an approach to treating addictive behaviors, and it has generated such a substantial body of clinical research in that field that at the time of this writing there have been over 34 systematic reviews and meta-analyses examining the efficacy and effectiveness of MI and MI-based interventions in the treatment of addictive behaviors (DiClemente et al., 2017). The developers of MI opted against taking a “gatekeeper” approach to its training and practice, instead allowing it to continue to evolve through collaborative practices (Miller & Rollnick, 2012). It has, therefore, become a common refrain to note the heterogeneity of the interventions under study in the MI outcome research literature, encompassing variability in setting, providers, role in treatment, intensity, additional treatment components, and fidelity, among other dimensions (e.g., Hettema et al., 2005; Lundahl et al., 2010; Miller & Moyers, 2017). In fact, it can be argued that the interventions under study in most “MI” outcome research across target behaviors are best considered adaptations of MI, given the frequent presence of elements such as a prescribed session structure or inclusion of non-MI treatment components (e.g., assessment feedback, advice to change) that depart from the definition of MI as a counseling style, as well as adaptations to the MI counseling style for a wide range of practitioners and settings (Britt et al., 2004; Burke et al., 2002, 2004; Miller & Rollnick, 2012). One of the most commonly studied adaptations of MI is motivational enhancement therapy (MET; Miller et al., 1992). Developed for the Project MATCH multisite treatment outcome study for alcohol use disorders (Project MATCH Research Group, 1997), MET is a brief intervention, typically structured to include four sessions, that includes assessment feedback and change planning conducted in an MI-consistent style.



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Despite the heterogeneity in the literature, some general conclusions can be drawn. In brief, there is substantial evidence across multiple reviews supporting the efficacy and effectiveness of MI and related interventions targeting alcohol, cannabis, and tobacco use—the substances for which it has been most studied—with effects in the small to medium range. For alcohol and cannabis use, MI appears to be more effective than inactive or no-treatment controls; however, there is little evidence of its differential effectiveness when compared with other active treatments. For example, a review of four meta-analyses found effect sizes in the range of d = 0.18–0.39 for alcohol-related outcomes and an effect size of d = 0.30 for cannabis-related outcomes immediately posttreatment when compared with “weak” comparison groups, whereas effect sizes were in the d = 0.03–0.41 range for alcohol outcomes, most studies showing no advantage for MI, and d = 0.07 for cannabis outcomes when compared with “strong” comparison groups (Lundahl & Burke, 2009). More recent meta-analyses have echoed these findings for alcohol-related outcomes (e.g., Lundahl et al., 2013; Stewart, 2012) and have shown larger effect sizes for cannabis-related outcomes, albeit with low- to moderate-quality evidence (Gates et al., 2016). MI and MI-informed brief interventions for alcohol use have often performed comparably to more extensive interventions, likely contributing to enthusiasm for the approach and to its rapid diffusion (DiClemente et al., 2017; Miller & Rollnick, 2012; Project MATCH Research Group, 1997). For tobacco cessation, the most comprehensive review found a favorable effect of MI versus all control groups (risk ratio = 1.26; Lindson-Hawley et al., 2015), with the paradoxical finding that MI showed greater effectiveness when compared with active treatment controls versus inactive or self-help controls. Other large metaanalyses have shown similar overall findings, albeit with smaller effect sizes and with disagreement as to MI’s performance in comparison with active versus inactive controls (Heckman et al., 2010; Hettema & Hendricks, 2010; Lundahl et al., 2013). The evidence for other drugs of abuse is sparser, with mixed results, both reflecting and contributing to a consensus that motivational interventions alone may be inadequate for those populations (DiClemente et al., 2017). In contrast to findings indicating no advantage for MI alone relative to other active treatments for substance use disorders, some meta-analyses have shown a relative advantage for MI when added as a prelude to another active treatment (Burke et al., 2003; Hettema et al., 2005). These findings provide an empirical rationale for combining MI with other active elements in an effort to improve outcomes. For example, MI has been widely adopted as an element of opportunistic brief interventions for non-treatment-seeking patients, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT; Babor et al., 2007). It has often been combined with other approaches, including CBT, in an effort to improve engagement and outcome in the “primary” treatment, to develop combined or integrated treatments incorporating evidence-based elements from diverse sources, or to address more severe problems or complex patient populations. Most studies of combined MI and CBT have added MI or

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MET interventions before or in the early phases of CBT, rather than attempting to integrate the approaches (Miller & Moyers, 2017), reflecting the differential emphasis in MI on preparation for change and in CBT on building the skills for change (Baer et al., 1999; Burke et al., 2004; Carroll, 1998). Typical of the combined approach in which MI serves as a prelude to CBT are combined MI/CBT treatments for cannabis use, often targeted to more severe use or clinically complex populations (DiClemente et al., 2017). Combined treatments typically include up to four sessions of MI to bolster motivation for change, followed by CBT strategies to support efforts toward change (Davis et al., 2015; Gates et al., 2016). A recent comprehensive review indicated that whereas MI/CBT combination interventions were more effective at reducing cannabis use (in terms of days used) at 30-day follow-up among adults relative to inactive controls (mean difference = 7.38), they did not consistently outperform other active treatments; rather, more intensive active treatments outperformed less intensive active treatments overall (Gates et al., 2016). A more unique combined MI/CBT is that described by McKee et al. (2007), in which a three-session intervention that included a single session of MI plus two sessions of CBT delivered with an MI counseling style outperformed a standard three-session CBT intervention at facilitating attendance in standard outpatient specialty treatment for cocaine dependence. However, results indicated that there were no differences in cocaine use outcomes. MI has also been combined with CBT to address alcohol and/or drug use disorders in patients with co-occurring mental health diagnoses being treated with CBT, particularly for populations likely to have low motivation to change substance use (Barrowclough et al., 2001) or when the co-occurring disorder is being addressed in a structured protocol, complicating efforts at integrating treatment (Kehle-Forbes et al., 2016). Two research groups have tested explicitly integrated MI and CBT treatments for substance use disorders with well-delineated rationales, processes, and decision rules for when to use each approach (Anton et al., 2006; Vidrine et al., 2013). The Combined Behavioral Intervention (CBI; Miller, 2004) was designed to incorporate elements of empirically supported psychosocial treatments for substance use disorders within an overall framework of CBT and MI. It features a modular structure, with one or more sessions of MI, functional analysis, and treatment planning delivered to all clients, whereas specific cognitive behavioral interventions are chosen on the basis of the client’s treatment plan. Additional treatment components, such as facilitating self-help participation, increasing social support for abstinence, and addressing employment needs, were also included. In a complex study primarily testing the effects of two medications alone and in combination for alcohol dependence, patients receiving medical management showed better outcomes when also receiving either CBI or naltrexone across several drinking outcomes (Anton et al., 2006). At the time, CBI was unique in incorporating MI both as an active treatment element and as a counseling style for delivery of other treatment components (Moyers & Houck, 2011). Despite a well-defined theoretical rationale, detailed



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manual, and careful therapist selection and training, combining the two approaches was not always seamless. Whereas some of the challenges reflected the demands of conforming to a standardized protocol (e.g., requiring a change plan by the fifth session regardless of patient readiness), treatment-fidelity monitoring revealed that most therapists tended to favor either the clientcentered MI elements or the action-oriented CBT elements throughout, highlighting the need to define decision rules for predictable choice points in approaches that integrate theoretically diverse interventions (Moyers & Houck, 2011). Observing that even the most flexible integrated MI/CBT protocols did not yet allow for the dynamic shifting of styles characteristic of ideal clinical practice, Vidrine et al. (2013) developed Motivation and Problem Solving (MAPS), an integrated MI/CBT treatment for smoking cessation and relapse prevention. In a study of 251 diverse low-income women who quit smoking during pregnancy, abstinence rates among those who received MAPS were 41.9% at 8  weeks postpartum and 22.8% at 26 weeks postpartum, as compared with 27.8% at 8 weeks and 16.5% at 26 weeks among those who received usual care (brief advice and self-help materials). The main effect of treatment reached significance in analyses adjusted for age, race/ethnicity, partner status, education, smoking rate, and smokers in the environment, χ2(1) = 3.79; OR = 1.60, 95% CI [1.00, 2.58]; p = .05 (Reitzel et al., 2010). Unique to MAPS is specification of MI-consistent therapist attention to moment-by-moment shifts in client motivation in the context of providing CBT interventions. This dynamic approach to motivation, with the therapist adjusting their responses based on client change or sustain talk, is likely characteristic of best practices in CBT; MAPS represents an effort to specify guidelines for that process. Anxiety and Related Disorders Some of the greatest empirical support for CBT’s efficacy is in the treatment of anxiety and related disorders (Hofmann et al., 2012). Nevertheless, some anxious clients find CBT challenging, as they are encouraged to reshape beliefs about worry that they have historically viewed as adaptive (Freeston et al., 1994), and they are encouraged to have systematic contact with their worst fears through exposure exercises (Maltby & Tolin, 2005; Randall & McNeil, 2017). As a result, dropout from CBT for anxiety disorders can be higher than CBT for other mental health disorders, such as major depressive disorder (Haby et al., 2006). Henny Westra and her colleagues have developed an impressive line of research examining the combination of MI and CBT for generalized anxiety disorder (GAD), a disorder that has historically been associated with a relatively low rate of clinically significant recovery relative to other anxiety disorders and depression (Hunot et al., 2007). In a preliminary RCT comparing four sessions of MI plus CBT (MI  +  CBT; n = 38) with CBT alone (n = 38; Westra et al., 2009), results indicated that 92% of clients receiving MI  +  CBT were classified as

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recovered (as measured by the Penn State Worry Questionnaire [PSWQ]; T. J. Meyer et al., 1990), compared with 71% of those receiving CBT alone. The benefit of adding MI as a pretreatment intervention was realized specifically in clients who endorsed the most severe levels of pretreatment worry. In addition, the authors achieved a moderate effect size (d = 0.59) in favor of MI  +  CBT clients being rated as completing more CBT homework than those receiving CBT only, and mediation analyses indicated that homework completion explained the greater reduction in worry symptoms in the MI  +  CBT group. Moreover, a subsequent analysis indicated that clients with a high level of worry severity reported a higher receptivity to change when they received MI, relative to those with a high level of worry severity who did not receive MI, which was, in turn, associated with worry reduction (Aviram & Westra, 2011). Additionally, in a recent study, Westra et al. (2016) compared 43 clients with severe GAD who received 15 sessions of CBT alone with 42 clients with severe GAD who received 4 sessions of MI followed by 11 sessions of integrated MI/ CBT. Results indicated that clients who received MI/CBT demonstrated steeper declines in worry and in general distress (as measured by the Depression Anxiety Stress Scales; Lovibond & Lovibond, 1995) than clients in the CBT condition across the course of treatment, and the odds of no longer meeting GAD diagnostic criteria were approximately five times higher in the MI/CBT group than in the group that received CBT alone. Moreover, 23% of clients who were assigned to receive CBT dropped out of treatment, compared with 10% of clients who were assigned to receive MI/CBT. Although Westra’s line of research is the most extensive that has examined the combination of MI and CBT for any mental health disorder aside from addiction, other applications to anxiety have been reported in the literature. For example, McKay and Bouman (2008) reported that MI preceding CBT for hypochondriasis reduced anxiety and depression symptoms in three clients, all of whom had an extensive history of previous psychotherapy. Korte and Schmidt (2013) reported that clients with a high level of anxiety sensitivity (i.e., anxiety about physiological and cognitive symptoms of anxiety) who participated in a motivational enhancement intervention reported a significant reduction in anxiety sensitivity that was mediated by changes in motivation, relative to anxiety-sensitive clients who participated in a psychoeducational control group. Moreover, Barrera et al. (2016) demonstrated that one pretreatment session of MI enhanced treatment initiation and treatment expectancies, although those who received a pretreatment MI session did not demonstrate better outcome than those who received CBT only. OCD can be a particularly challenging anxiety-related disorder to treat, as many clients refuse the “gold standard” CBT, exposure with response prevention (ERP), and others do not respond optimally (Abramowitz et al., 2002). Although ERP is quite efficacious when clients adhere to the protocol (Simpson et al., 2011), many clients find it difficult to do so because of the anticipated anxiety and dread associated with exposure to the feared stimulus while



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resisting engaging in the compulsion that, to that point, had been perceived as the factor that mitigated aversive outcomes. A few studies have examined the impact of MI-inspired interventions on participation and outcome in CBT-based therapy for OCD. For example, Maltby and Tolin (2005) randomized a small sample of 12 OCD clients who had previously refused ERP to a four-session “readiness” preintervention, including two sessions using MI procedures, or to a wait-list control condition. Results indicated that 85% of those in the readiness condition agreed to pursue ERP, compared with only 20% of those assigned to the wait-list condition. Moreover, those who received the readiness intervention and participated in ERP achieved comparable outcomes to clients who had not refused ERP, whereas those who had been assigned to the wait-list condition did not. E. Meyer et al. (2010) reported that MI combined with thought mapping, a psychoeducational intervention to help clients understand the association between thoughts and behavior, was associated with a greater reduction in OCD symptoms at posttreatment and at a 3-month follow-up assessment than CBT without such pretreatment intervention. However, in perhaps the best designed study to examine the inclusion of MI to ERP for OCD, Simpson et al. (2010) found no differences in adherence and outcome in clients who received the combined intervention and clients who received ERP only. Zuckoff et al. (2015) suggested that clients with OCD are quite invested in their obsessions and associated rituals, and an explicit focus on the way in which overcoming OCD will help them live their lives in alignment with their values is essential. Moreover, Zuckoff et al. indicated that clients with OCD are especially fearful of undergoing ERP procedures and that a therapist’s nonjudgmental and empathetic stance about these fears can go far in promoting a therapeutic alliance that will ultimately facilitate change. MI has also been used to increase clients’ readiness for the cognitive behavioral treatment of posttraumatic stress disorder (PTSD). Within the Veterans Affairs (VA) setting in the United States, veterans with PTSD can participate in a seven-session motivational enhancement group in which they identify problematic behaviors associated with their PTSD, make decisions to address those behaviors, and develop plans to do so (Murphy et al., 2002). One RCT compared 60 veterans with PTSD who received the intervention in the 2nd month of a comprehensive cognitive-behaviorally based PTSD treatment program with 54 veterans who participated in a psychoeducational group (Murphy et al., 2009). Results indicated that veterans in the motivational enhancement group demonstrated increased treatment engagement, as observed by selfreported readiness to change, perceptions of the relevance of treatment, and attendance in the program. These results are encouraging but should be extended to patient populations who do not have access to the comprehensive services that are offered in VA settings. In addition, Yusko et al. (2015) noted that MI-based interventions might have particular relevance to patients with PTSD who have comorbid alcohol or drug use problems.

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Suicide Risk Considerable attention has been given to the potential contributions of MI approaches to suicide prevention, the earliest thinking identifying the potential benefits of mitigating substance-related risk by using MI to increase treatment engagement (Conason et al., 2006; Wylie et al., 1996). Researchers then considered the application of MI directly to suicidal thoughts and behavior (Britton et al., 2008; Zerler, 2008, 2009). These approaches were based, in part, on the recognition that suicidal clients were often just as ambivalent about living as clients with substance abuse disorders are about changing their substance use (Kovacs & Beck, 1977), and when their wish to live was equal to or greater than their wish to die, signaling some degree of ambivalence, they made less severe attempts (Kovacs & Beck, 1977) and were less likely to die by suicide (Brown et al., 2005). Later research also indicated that the wish to live may be more malleable to intervention than the wish to die, which may be less likely to change (Bryan et al., 2016). These findings suggest that interventions that target the wish to live, such as MI, may have an important role in suicide prevention. Recognizing that suicidal behavior was often the result of a lifetime of injurious and damaging experiences that required more intensive treatment than a brief treatment can provide, researchers reasoned that MI approaches to suicide prevention should be considered a component of a multifaceted approach to prevention rather than a stand-alone treatment (Britton, 2012; Britton et al., 2011). In addition to targeting treatment engagement and suicidal ideation and behavior, MI has also been considered as an approach to means safety counseling for firearms, the method of suicide attempt with the highest lethality (Britton et al., 2016). These and other approaches have been reviewed elsewhere, if more detail on theoretical underpinnings and possibilities is desired (Hoy et al., 2016). Suicide research is one of the few areas where the subtle differences in practice implied by the transition from the second to third editions of the Miller and Rollnick (2012) text have been considered and may have a salient impact, particularly if the outcome is suicidal thoughts or behavior (Britton, 2015). In the second edition, sessions are often started by exploring the presenting problem, which in the case of substance abusers is a discussion of reasons to reduce substance use. The patient’s response to the opening question “What brings you here?” often is something like “The judge says that I have to quit drinking or I’m going to jail.” Clients who are suicidal who are asked a similar question respond with reasons to attempt suicide or die. Their response, for example, might be something like “The judge is threatening to put me back in prison.” Given the importance of evoking change talk (or in this case “living talk”) and reducing sustain talk or suicide talk, this is problematic as it elicits reasons to die rather than reasons to live. Thus, it seems likely that approaches targeting suicide risk that are based in the third edition are likely to be safer and possibly more effective than those based in the second edition. There is a small but growing literature examining MI-based approaches to suicide prevention, with essentially an equal number of studies in adolescents



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and adults. In a test of MI plus computer administered behavioral activation (MI  +  CBA) versus education plus CBA (E + CBA) administered to adolescents in primary care, adolescents in the MI + CBA group reported fewer depressive episodes, MI + CBA = 4.5% versus E + CBA = 27.4%, χ2(1) =  4.08, p = .04, with a number needed to treat of 4.36, and less hopelessness, χ2(1) = 4.04, p = .04 (Hoek et al., 2011). In a pilot study of adolescents who screened positive for suicide risk who were randomized to MI-based treatment plus personalized feedback or personalized feedback alone, the group that received MI reported increased readiness to seek help (β = 3.16, p = .001) and less stigma toward help seeking (β = −1.07, p = .004; King et al., 2015). In another pilot study by the same group that examined MI-enhanced safety planning, individual and family therapy, and a postdischarge (MI-SafeCope) call versus treatment as usual, the MI-SafeCope group reported higher self-efficacy to not attempt suicide (β = 1.15, p = .030), ability to cope with suicidal ideation (β = 1.56, p = .042), and safety plan usage (β  =  0.25, p  =  .004), and parents in the MI-SafeCope group reported more motivation to encourage safety plan usage (β  =  1.04, p = .031; Czyz et al., 2019). Adult-related research on MI for suicide prevention is also in its infancy, the majority of studies being pilot studies rather than full-scale RCTs. In an open trial, MI to address suicidal ideation (MI-SI) was associated with a significant reduction in the severity of suicidal ideation (Cohen’s d =  1.95; Britton et al., 2012). On the basis of these preliminary findings, a full-scale RCT was conducted but had to address the shift in MI that was viewed as particularly critical for suicidal clients (Britton et al., 2019) , resulting in three conditions: (a) MI-SI based on the second edition of Miller and Rollnick’s text plus treatment as usual (MI-SI + TAU), (b) MI-SI revised (MI-SI-R) based on the third edition plus TAU (MI-SI-R + TAU), and (c) TAU alone. Findings suggested that clients that received either version of MI-SI + TAU were 41% less likely to report suicidal ideation at follow-up than those who received TAU alone. Clients who received MI-SI-R were 50% less likely to report a suicide attempt than clients in TAU, whereas those who received MI-SI were 50% more likely to report a suicide attempt than clients in TAU. For this study, 95% of participants completed a safety plan while on the unit, which has been shown to reduce risk for suicide attempts (Bryan et al., 2017; Stanley et al., 2018), and 76% of participants in TAU completed a minimum of two outpatient therapy sessions in the month following discharge, indicating TAU was robust, possibly explaining the null finding. Nevertheless, these findings support the use of MI-SI-R or other interventions based on the third edition going forward. In another example of MI as part of a multifaceted approach to suicide prevention, MI principles were built into the educational approach in the World Health Organization Brief Intervention and Contact (BIC). When it was compared with TAU in developing countries, BIC, which included an educational session in the emergency department followed by nine in-person or by-telephone sessions, was shown to reduce risk for suicide, BIC = 0.2% versus TAU = 2.2%, ꭓ2(1) = 13.83, p < .001 (Fleischmann et al., 2008). Although many of the findings described in this section are preliminary and did not reach levels of statistical significance, the application of MI to suicide

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prevention in both adolescents and adults is promising, with potential to increase the use of adaptive coping skills, enhance effectiveness of other interventions, and directly reduce risk for suicidal ideation and attempts. This suggests that MI should be considered a component of more intensive treatment rather than a stand-alone treatment. If targeting suicidal ideation or risk for suicide attempts, it is recommended that an approach based on the most current version of MI be used.

MECHANISMS OF CHANGE Although the evidence as a whole points to MI as an effective stand-alone treatment for many target behaviors and as a prelude that can boost the effectiveness of other active treatments, there has been substantial variability in outcomes across studies and even across sites or therapists following the same protocol in well-controlled, closely supervised studies (Ball et al., 2007; Miller & Rollnick, 2012; Project MATCH Research Group, 1998). This variability in outcomes has prompted process research to identify the active ingredients and mechanisms of change in MI in order to increase the effectiveness of clinical delivery, therapist training, and agency implementation (Magill et al., 2018; Miller & Rose, 2009). In fact, process research has already informed updates to the clinical model, supporting the move away from a strategic emphasis on resolution of ambivalence toward an emphasis on eliciting and strengthening motivation and commitment for change. As outlined earlier, researchers have proposed two complementary technical and relational pathways, or hypotheses, to explain MI’s efficacy (Miller & Rose, 2009). The relational hypothesis posits that the therapist’s use of MIconsistent behavior to manifest a “spirit” of partnership, acceptance, compassion, and evocation (Miller & Rollnick, 2012) fosters a therapeutic relationship in which the client feels free to explore change and in which resistance in the form of psychological reactance is minimized; the relationship itself is the change agent (Miller & Rose, 2009). The technical hypothesis posits that skillful use of MI strategies prompts clients to state arguments for change (i.e., change talk) and minimizes the likelihood that patients will express arguments against change (i.e., sustain talk; Miller & Rose, 2009). The technical hypothesis further indicates that subsequent behavior change is dependent on the strength and balance of change and sustain talk evoked in the intervention, statements of commitment to change being of particular importance (Amrhein et al., 2003). As fully developed, the two hypotheses taken together imply 10 testable pathways from therapist training in MI to therapist MI style and techniques to client in-session speech to ultimate client behavior change, including the possibility that therapist MI style and MI-consistent techniques may directly impact client behavior and exert effects on outcome that are mediated by client change talk and commitment (Miller & Rose, 2009). A growing body of literature has begun to test these hypotheses.



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The relational hypothesis is consistent with the substantial literature indicating that therapist empathy and therapeutic alliance are associated with outcome across a wide range of populations and treatment approaches, including MI (Elliott et al., 2011; Horvath & Symonds, 1991; Martin et al., 2000). Furthermore, some studies have found global measures of MI spirit, empathy, or alliance to be predictive of client engagement in sessions, therapeutic alliance, and behavior change (Boardman et al., 2006; Catley et al., 2006; Moyers, Miller, & Hendrickson, 2005), but others have shown no such association (Bertholet et al., 2014; Feldstein & Forcehimes, 2007; Palfai et al., 2016). One recent meta-analysis addressed the association between observer global ratings of therapist empathy and MI spirit and client in-session speech in 19 primary studies (Pace et al., 2017). It found significant positive correlations between both therapist qualities and client change talk (empathy, r  =  .25; MI spirit, r = .25) and between empathy and client sustain talk (r = .18). However, there was no significant association between observer global ratings of therapist empathy and MI spirit and client outcomes, a finding echoed in a larger metaanalysis including 36 primary studies (Magill et al., 2018; Pace et al., 2017). In both cases, the authors noted that because MI process research typically uses samples drawn from highly trained therapists participating in MI clinical trials, restriction of range may prevent observing global therapist effects on client behavior change outcomes. A recent narrative review and two meta-analyses with differing selection and analytic methods have shown support for some aspects of the technical hypothesis (Magill et al., 2018; Pace et al., 2017; Romano & Peters, 2016). Overall, frequency of therapist use of MI-consistent skills such as reflective listening, open questions, or obtaining client permission to give advice was associated with greater frequency of client change talk within the session (r =.17, Pace et al., 2017; r = .55, Magill et al., 2018) as well as greater frequency of client sustain talk (albeit to a lesser degree) within the session (r = .10, Pace et al., 2017; r = .40, Magill et al., 2018). None of the recent reviews found any association between therapist MI-inconsistent skills such as confrontation and direction—which were rare in these samples—with client change talk; a narrative review and one meta-analysis found an association between therapist MI-inconsistent behavior and client sustain talk (r  =  .16, Magill et al., 2018; Romano & Peters, 2016). More fine-grained, sequential analyses have shown that therapist MI-consistent utterances are more likely to be followed by client change talk, whereas therapist MIinconsistent utterances are more likely to be followed by client sustain talk (Moyers & Martin, 2006). Client change talk was not associated with behavior change outcomes in either meta-analysis, but client sustain talk was associated with worse outcomes (r = .19, Magill et al., 2018; r = −.23, Pace et al., 2017). In a surprising finding, one review found a very small but significant direct effect of therapist MI-consistent behavior with poorer client outcomes (r  =  .04, Pace et al., 2017). A possible explanation is that providers found themselves using more MI strategies with more “difficult” clients, consistent

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with research showing the influence of patient utterances on therapist behavior (Borsari et al., 2015; Tollison et al., 2013). One of the limitations of much MI process research to date is the measurement of therapist MI behavior, which typically consists of summary scores collapsed from many subcodes; however, meta-analytic investigation of the individual codes making up the indices did not provide evidence that MIconsistent therapist behaviors are differentially related to the amount of change or sustain talk they predict (Magill et al., 2014; Pace et al., 2017). Another important limitation is that the measures used in the underlying studies—most frequently the Motivational Interviewing Skill Code (MISC; Miller et al., 2008) and Motivational Interviewing Treatment Integrity (MITI) scales (Moyers, Martin, et al., 2005)—mostly address the form of therapist utterances, such as open questions, reflections, and so forth, rather than the “skillful” use of MI-consistent strategies, such as using open questions and reflections strategically to evoke and reinforce change talk (Hilton et al., 2016; Miller & Rollnick, 2012; Miller & Rose, 2009). A few studies have begun to address this complexity, highlighting the importance of more sophisticated skills, such as use of complex reflections, reframing, and focus on commitment (Barnett et al., 2014; Magill et al., 2012; Tollison et al., 2008, 2013), and identifying the role of relational skills in facilitating technical MI implementation (Villarosa-Hurlocker et al., 2019). Others have begun to address the limits of generalizability of MI and its hypothesized mechanisms of change. For example, a recent study found that client change talk mediated the relation between therapist MI-consistent behavior and alcohol use outcome only for more experienced therapists and clients with higher severity alcohol problems (Gaume et al., 2016). Measurement of MI processes has also evolved, with the introduction of methods for sequential analysis of therapist and client speech (Moyers & Martin, 2006) and the update of the widely used MITI to include ratings of strategic eliciting of change talk and minimizing of sustain talk (Moyers et al., 2014). Yet another limitation is that the variety of adaptations of MI and populations that it has been applied to may prevent clear findings from emerging in meta-analyses and reviews of the literature, as suggested by the significant heterogeneity in some of the meta-analyses (Magill et al., 2014, 2018). Taken together, process findings suggest that MI is an approach whose complexity is only beginning to be understood. There is good support for several links in the technical hypothesis, but evidence for the link between client change talk and clinical outcomes remains elusive. The relational hypothesis has not been consistently supported; however, the MI-inconsistent behaviors associated with low MI spirit and empathy, while rare in most studies, appear to be particularly toxic, associated with client sustain talk and worse outcomes. Given that some of the purported mechanisms of change in MI correspond to “general” factors in psychotherapy (Miller & Rollnick, 2012), one take-home message for the clinician, therefore, is “do good psychotherapy”—or, at the very least, avoid doing bad psychotherapy. MI training provides a pathway and a set of tasks to guide clinicians toward having better conversations about



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change (Miller & Moyers, 2006). The emerging research on the importance of relational factors in facilitating the effectiveness of technical factors helps debunk stereotypes of MI as manipulative. The body of research, as a whole, points to the importance of direct observation of both therapist and client speech, via review of one’s own recorded sessions or working with a supervisor or coach, to improve practice. Whereas coding systems used in research are often prohibitively complex and still may not address the finer points distinguishing quantity from quality of practice, therapists can benefit from identifying which of a menu of tasks in learning MI are most relevant to their professional development (e.g., recognizing and responding to change talk) and doing simple monitoring aimed at tracking and improving skill in those areas (Miller & Rollnick, 2012).

DISSEMINATION AND APPLICATIONS FOR DIVERSE POPULATIONS Even before the evidence base—now consisting of hundreds of clinical trials— took shape, MI grew in popularity both within and well beyond its original scope as a means to help people prepare to change addictive behavior. The decision of the founders to eschew a gatekeeping role in favor of encouraging creative adaptation surely played a role in making MI seem simple and “trialable” enough to be a candidate for real-world implementation (E. M. Rogers, 1995). Clinicians across diverse professional roles and settings seem to “recognize” MI, finding it compatible with their experience and values, another key factor in diffusion of innovation (E. M. Rogers, 1995). The Motivational Interviewing Network of Trainers (MINT), an international organization of MI trainers with a mission to promote good practice in the use, research, and training of MI, grew from an informal meeting of trainers trained by Miller and Rollnick in 1997. Now incorporated as a nonprofit charitable organization, the MINT has provided expert trainers’ training to over 3,000 professionals worldwide (Miller & Moyers, 2017). The MINT supports MI trainers with mentoring, online resources for dissemination of best practices, and an annual educational forum for members. It has also sponsored five public International Conferences on Motivational Interviewing since 2008 as well as Oceanic and Scandinavian regional conferences. Miller and Rollnick (2012) pointed to the rapid, worldwide dissemination of MI—including books in at least 27 languages and MI trainers on six continents, speaking at least 50 languages—as evidence of the broad cross-cultural transferability of MI’s core principles. Moreover, the nonjudgmental and collaborative counseling style, with its emphasis on respecting the expertise of the client, has made MI a frequent choice for adaptation for working with underserved ethnic minority groups in the United States (Añez et al., 2008; Santa Ana et al., 2009). Two meta-analyses have found that patient ethnicity is associated with MI effect size. The first found that effect sizes were significantly higher in studies

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with samples predominantly composed of U.S. ethnic minorities than in studies conducted in the United States with mainly White samples, accounting for 19% of the variance in effect sizes (mean dc = 0.79 vs. dc = 0.26; Hettema et al., 2005). A later meta-analysis showed a more complex association among type of comparison group and ethnicity: Studies whose populations included a higher proportion of African American participants showed higher effect sizes when MI was compared with a weak comparison group, whereas a higher proportion of non-White, non-African American U.S. minority groups was associated with greater effect sizes in studies comparing MI to a strong comparison group (Lundahl et al., 2010). Results from a large multisite U.S. study suggest that MI may particularly benefit Native American participants with alcohol use disorders (Villanueva et al., 2007); however, there was no differential benefit of MI for Hispanic participants (Arroyo et al., 2003). It has been suggested that aspects of the characteristic MI communication style may be more culturally consistent for certain U.S. ethnic minority groups or that marginalized groups may differentially benefit from MI’s person-centered, strengths-based approach (Añez et al., 2008; Dickerson et al., 2016; Santa Ana et al., 2009; Venner et al., 2007). This is consistent with Miller and Rollnick’s (2012) observation that MI may benefit from a “contrast effect” relative to what has often been, sadly, harsh or authoritarian treatment. Some authors have noted a potential mismatch between MI’s focus on individual motivation and the more collectivist frame of reference characteristic of some ethnic groups (Oh & Lee, 2016), and cultural adaptations of MI have often included efforts to increase exploration of cultural and social influences on the target behavior and motivation for change. Additional changes to content in cultural adaptations of MI have been inclusion of culture-specific views and concerns regarding health in feedback and educational materials and use of culturally relevant imagery and metaphors, while keeping the main features of MI style intact (Lee et al., 2013; Osilla et al., 2012; Ramos & Alegría, 2014; Venner et al., 2007). Some authors have recommended changes to the MI counseling style to include more self-disclosure during the engagement process to help build rapport with Native American clients (Dickerson et al., 2016; Venner et al., 2007). Although this was not a deliberate cultural adaptation, fidelity ratings in one study showed that Spanish-speaking MI practitioners relied on “fundamental” engagement skills before moving on to the more directive components to a greater extent than English-speaking MI practitioners, perhaps reflecting cultural norms or greater perceived need to build trust among clients in a marginalized minority group (Santa Ana et al., 2009). Cultural adaptations for ethnic minorities have also often included changes to service delivery to ameliorate cultural and systemic barriers to accessing health care (Lee et al., 2013; Manuel et al., 2015; Osilla et al., 2012; Ramos & Alegría, 2014). Although cultural adaptations of MI with U.S. ethnic minority populations have shown promising results, there have been few studies directly comparing cultural adaptations of MI to their “standard” counterparts (Oh & Lee, 2016).



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CLINICAL EXAMPLE In this section, we include an excerpt of clinical dialogue to capture some nuances of MI-based responses in the context of preparing a client for exposure-based CBT for OCD. The client, Jane, has presented for treatment willingly but has expressed ambivalence about participating in exposure and facing her fears. During the first session of therapy following a thorough psychosocial assessment, the therapist began to provide psychoeducation to the client about exposure, its procedures, and its efficacy rate. The following illustrates the conversation that transpired. JANE:

This all sounds good in many ways, but I just don’t think I’m ready for this.

THERAPIST: It’s scary to think about doing this, and yet there are parts of this

that make a lot of sense. [Here, the therapist is making a doublesided reflection that acknowledges sustain talk and, simultaneously, reinforces change talk.] JANE:

Yeah exactly. I’ve been so limited by my condition for so long . . . But facing some of these fears, I just couldn’t forgive myself if I actually did contaminate someone I love.

THERAPIST:

You’re afraid of what will happen if you face these fears. [Here, the therapist again uses a simple reflection to show compassion while providing the client space to grapple with her ambivalence.]

JANE:

I know it’s completely irrational and that I sound crazy.

THERAPIST: You can see that your OCD thoughts are not realistic. Tell me

how you recognize that your thoughts are not realistic. [Here, the therapist reflects upon the client’s change talk, taking care to use language that is more neutral than “irrational” and “crazy.” The therapist then encourages the client’s elaboration on her change talk, eliciting the client’s strengths and motivation.] JANE:

Oh boy, a lot of ways. It takes me forever just to clean one part of the kitchen or bathroom. I get so wrapped up in cleaning that sometimes I even forget appointments that I have, so I’m always late. And my husband .  .  . don’t get me started on his frustration.

THERAPIST: And you don’t want to live this way anymore. It prevents you

from having the relationship you want, or from being the partner you want to be, and you want to make a change. [Here, the therapist makes a complex reflection by continuing the client’s sentence, adding emphasis and guessing at meaning.]

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JANE:

Oh yes, something’s got to give. I just don’t know if I have it in me to do it.

THERAPIST: It’s entirely up to you. You’re in control every step of the way.

[Here, the therapist is respecting the client’s ambivalence and making an explicit statement that she will not be forced to engage in any specific procedure, advancing a sense of collaboration.] JANE:

Really? Because I’ve read articles describing patients whose therapists made them lick the toilet in a public restroom. And there is just no way.

THERAPIST: There is no need to lick toilets. I would never ask you to do any-

thing dangerous, and I couldn’t make you do anything even if I wanted to. Everything we do will ultimately be your choice. I give you my word that we’ll work as a team. But it sounds like you’ve heard some things about exposure. Tell me what you’ve already heard about it. [Here, the therapist continues to reinforce the client’s autonomy and the collaborative nature of CBT. She also asked for elaboration about the client’s perceptions of exposure in order to elicit additional sources of ambivalence that could be resolved through further discussion.] JANE:

Well . . . I’ve heard that it’s the way to go. But, also, my understanding is that it can be very painful. I’m so fragile right now, I feel like anything painful could just break me.

THERAPIST: You’ve done your homework and you’re right; exposure is one

of the best treatments we have. At the same time, you’re really worried about what this will be like and about what will happen. [Here the therapist affirms the work the patient has already put into addressing her OCD and makes a simple reflection.] We’ll work together on this. [Here the therapist, again, assures collaboration and respect for the place at which the client is starting.] Would you like me to share some of my experiences working with other people with similar problems who were also concerned about what would happen? [Here the therapist asks permission before launching into discussion that might be perceived by the client as forcing her to participate in exposure.] JANE:

Oh, that would be really great. [Therapist goes on to discuss examples of successful treatment, highlighting the significant life changes reported posttreatment by clients who participated in exposure and ways in which exposures began with the lower rated items on the exposure hierarchy to accumulate successes, which in turn increased motivation to take on more difficult exposures.]



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THERAPIST: Now that you have these illustrations, what do you think? JANE:

I’m willing to give it a try. I like that you will work at my speed and check in to see how I am doing.

THERAPIST: I really admire your decision. I realize this isn’t easy. We will

absolutely take it one step at a time. [Here, the therapist acknowledges the client’s strength, expresses empathy, and reinforces collaboration.] Jane went on to participate in 24 sessions of exposure-based CBT across the course of 6 months. On many occasions, she remarked that exposure was more manageable than she had anticipated, and she continued to express gratitude that she could work at her own pace. At times, she did not complete her exposure homework in between sessions, so an MI framework was adopted by the therapist to resolve continued ambivalence and to allow space for Jane to recognize her own reasons for change. By the end of treatment, she continued to exhibit some behavioral tendencies consistent with OCD, as often is the case, but she no longer met diagnostic criteria for a full-fledged disorder. Jane reflected fondly on the way in which her relationship with her husband had improved and that she was now able to pursue valued activities with which her OCD had previously interfered.

CONCLUSION AND FUTURE DIRECTIONS The extant literature clearly suggests that the inclusion of MI either before or within a larger cognitive behavioral treatment package is advantageous for a number of reasons, including the increase of motivation for treatment in some cases and the enhancement of outcome in other cases. A theme that pervades this literature, however, is that there is inherent tension between MI and action-oriented treatments like CBT. Specifically, it has been suggested that such treatment approaches utilize very different clinical styles (e.g., client centered and action oriented; Westra et al., 2011). We argue here that this is a false dichotomy and that while CBT is, indeed, an action-oriented treatment, cognitive behavioral therapists would be doing a disservice to clients if they failed to deliver it in a client-centered manner that takes into account clients’ readiness for change. Instead, we suggest that the MI spirit can and should be integrated into the course of CBT, such that the aims of both approaches are achieved simultaneously, and we provide multiple models for doing so in the review. Directions for future research are abundant. The literature on MI processes has shaped the understanding and delivery of MI, and its application to MI/CBT packages would shed much light on optimal ways to deliver a combined intervention package and weave the MI spirit into the delivery of contemporary action-oriented CBT interventions. Although the integration of MI and CBT has been the subject of much scholarly and empirical attention (e.g., Arkowitz

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et al., 2015), much more work is needed to evaluate its application to the wide array of mental health problems seen in clinical practice, such as family discord in clients with psychosis and externalizing problems. Finally, clinicians would benefit from guidance inspired by empirical research on interventions that are optimal matches for clients in various stages of change.

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Palfai, T. P., Cheng, D. M., Bernstein, J. A., Palmisano, J., Lloyd-Travaglini, C. A., Goodness, T., & Saitz, R. (2016). Is the quality of brief motivational interventions for drug use in primary care associated with subsequent drug use? Addictive Behaviors, 56, 8–14. https://doi.org/10.1016/j.addbeh.2015.12.018 Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy: Theory, Research, & Practice, 38(4), 443–448. https://doi.org/10.1037/0033-3204.38.4.443 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 Project MATCH Research Group. (1998). Therapist effects in three treatments for alcohol problems. Psychotherapy Research, 8(4), 455–474. https://doi.org/10.1080/ 10503309812331332527 Ramos, Z., & Alegría, M. (2014). Cultural adaptation and health literacy refinement of a brief depression intervention for Latinos in a low-resource setting. Cultural Diversity & Ethnic Minority Psychology, 20(2), 293–301. https://doi.org/10.1037/a0035021 Randall, C. L., & McNeil, D. W. (2017). Motivational interviewing as an adjunct to cognitive behavior therapy for anxiety disorders: A critical review of the literature. Cognitive and Behavioral Practice, 24(3), 296–311. https://doi.org/10.1016/j.cbpra. 2016.05.003 Reitzel, L. R., Vidrine, J. I., Businelle, M. S., Kendzor, D. E., Costello, T. J., Li, Y., Daza, P., Mullen, P. D., Velasquez, M. M., Cinciripini, P. M., Cofta-Woerpel, L., & Wetter, D. W. (2010). Preventing postpartum smoking relapse among diverse low-income women: A randomized clinical trial. Nicotine & Tobacco Research, 12(4), 326–335. https://doi.org/10.1093/ntr/ntq001 Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. https://doi.org/10.1037/ h0045357 Rogers, E. M. (1995). Diffusion of innovation (5th ed.). Free Press. Romano, M., & Peters, L. (2016). Understanding the process of motivational interviewing: A review of the relational and technical hypotheses. Psychotherapy Research, 26(2), 220–240. https://doi.org/10.1080/10503307.2014.954154 Santa Ana, E. J., Carroll, K. M., Añez, L., Paris, M., Jr., Ball, S. A., Nich, C., Frankforter, T. L., Suarez-Morales, L., Szapocznik, J., & Martino, S. (2009). Evaluating motivational enhancement therapy adherence and competence among Spanish-speaking therapists. Drug and Alcohol Dependence, 103(1–2), 44–51. https://doi.org/10.1016/j. drugalcdep.2009.03.006 Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence predicts outcome from cognitive behavioral therapy in obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 79(2), 247–252. https://doi.org/10.1037/a0022659 Simpson, H. B., & Zuckoff, A. (2011). Using motivational interviewing to enhance treatment outcome in people with obsessive-compulsive disorder. Cognitive and Behavioral Practice, 18(1), 28–37. https://doi.org/10.1016/j.cbpra.2009.06.009 Simpson, H. B., Zuckoff, A., Page, J. R., Franklin, M. E., & Foa, E. B. (2008). Adding motivational interviewing to exposure and ritual prevention for obsessivecompulsive disorder: An open pilot trial. Cognitive Behaviour Therapy, 37(1), 38–49. https://doi.org/10.1080/16506070701743252 Simpson, H. B., Zuckoff, A. M., Maher, M. J., Page, J. R., Franklin, M. E., Foa, E. B., Schmidt, A. B., & Wang, Y. (2010). Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behaviour Research and Therapy, 48(10), 941–948. https://doi.org/10.1016/j.brat.2010.05.026 Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety

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planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/ jamapsychiatry.2018.1776 Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlistcontrolled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27(5), 476–484. https://doi.org/10.1002/da.20673 Stewart, J. S. (2012). A critical appraisal of motivational interviewing within the field of alcohol misuse. Journal of Psychiatric and Mental Health Nursing, 19(10), 933–938. https://doi.org/10.1111/j.1365-2850.2012.01880.x Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts, and emotions. Guilford Press. Tollison, S. J., Lee, C. M., Neighbors, C., Neil, T. A., Olson, N. D., & Larimer, M. E. (2008). Questions and reflections: The use of motivational interviewing microskills in a peer-led brief alcohol intervention for college students. Behavior Therapy, 39(2), 183–194. https://doi.org/10.1016/j.beth.2007.07.001 Tollison, S. J., Mastroleo, N. R., Mallett, K. A., Witkiewitz, K., Lee, C. M., Ray, A. E., & Larimer, M. E. (2013). The relationship between baseline drinking status, peer motivational interviewing microskills, and drinking outcomes in a brief alcohol intervention for matriculating college students: A replication. Behavior Therapy, 44(1), 137–151. https://doi.org/10.1016/j.beth.2012.09.002 Venner, K. L., Feldstein, S. W., & Tafoya, N. (2007). Helping clients feel welcome: Principles of adapting treatment cross-culturally. Alcoholism Treatment Quarterly, 25(4), 11–30. https://doi.org/10.1300/J020v25n04_02 Vidrine, J. I., Reitzel, L. R., Figueroa, P. Y., Velasquez, M. M., Mazas, C. A., Cinciripini, P. M., & Wetter, D. W. (2013). Motivation and problem solving (MAPS): Motivationally based skills training for treating substance use. Cognitive and Behavioral Practice, 20(4), 501–516. https://doi.org/10.1016/j.cbpra.2011.11.001 Villanueva, M., Tonigan, J. S., & Miller, W. R. (2007). Response of Native American clients to three treatment methods for alcohol dependence. Journal of Ethnicity in Substance Abuse, 6(2), 41–48. https://doi.org/10.1300/J233v06n02_04 Villarosa-Hurlocker, M. C., O’Sickey, A. J., Houck, J. M., & Moyers, T. B. (2019). Examining the influence of active ingredients of motivational interviewing on client change talk. Journal of Substance Abuse Treatment, 96(1), 39–45. https://doi.org/10. 1016/j.jsat.2018.10.001 Wenzel, A. (2017). Innovations in cognitive behavioral therapy: Strategic interventions for creative practice. Routledge. https://doi.org/10.4324/9781315771021 Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. American Psychological Association. https://doi.org/ 10.1037/11862-000 Westra, H. A. (2004). Managing resistance in cognitive behavioural therapy: The application of motivational interviewing in mixed anxiety and depression. Cognitive Behaviour Therapy, 33(4), 161–175. https://doi.org/10.1080/16506070410026426 Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. Guilford Press. Westra, H. A., Arkowitz, H., & Dozois, D. J. A. (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 Westra, H. A., Aviram, A., & Doell, F. K. (2011). Extending motivational interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry, 56(11), 643–650. https://doi.org/10.1177/ 070674371105601102 Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety



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disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768–782. https://doi.org/10.1037/ccp0000098 Wylie, K., House, A., Storer, D., Raistrick, D., & Henderson, M. (1996). Deliberate self-harm and substance dependence: The management of patients seen in the general hospital. Journal of Mental Health Administration, 23(2), 246–252. https://doi. org/10.1007/BF02519115 Yusko, D., Drapkin, M. L., & Yeh, R. (2015). Enhancing motivation in individuals with posttraumatic stress disorder and comorbid substance use disorders. In H. Arkowitz, W R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed., pp. 110–135). Guilford Press. Zerler, H. (2008). Motivational interviewing and suicidality. In H. A. Arkowitz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (pp. 173–193). Guilford Press. Zerler, H. (2009). Motivational interviewing in the assessment and management of suicidality. Journal of Clinical Psychology, 65(11), 1207–1217. https://doi.org/10.1002/ jclp.20643 Zuckoff, A., Balán, I. C., & Simpson, H. B. (2015). Enhancing the effectiveness of exposure and response prevention in the treatment of obsessive-compulsive disorder. In H. Arkowitz, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (2nd ed., pp. 58–82). Guilford Press.

12 Regulation of Physiological Arousal and Emotion Holly Hazlett-Stevens and Alan E. Fruzzetti

I

mproved regulation of physiological arousal and emotion appears to be an underlying mechanism of change across many cognitive behavioral interventions. Clinicians teach progressive relaxation and breathing training techniques to reduce their patients’ excessive physiological arousal and to promote adaptive responding to anxiety-provoking cues or triggers. Empirically supported mindfulness-based interventions, originating from ancient Buddhist traditions, lead to improved regulation across multiple physiological systems, including the recruitment of neural circuitry associated with enhanced emotion regulation (e.g., Goldin & Gross, 2010). Dialectical behavior therapy (DBT), an integration of mindfulness and other acceptance skills and interventions into traditional behavior therapy, provides explicit training in multiple emotion-regulation skills wound closely together with mindfulness skills. Patients in DBT, therefore, practice mindfulness as a specific emotionregulation-related skill deployed in the service of adaptive emotional and behavioral response to daily life events. Within Western psychology, the cognitive behavioral techniques of progressive relaxation and breathing retraining developed over the 20th century to treat a wide variety of psychological and behavioral medicine conditions. Psychologists considered these strategies beneficial because they help regulate unnecessary autonomic nervous system (ANS) arousal and reduce physical tension mediated by the central nervous system (CNS). Patients theoretically experience increased bodily relaxation with regular practice of these techniques, which, in turn, reduces excess anxiety and stress reactivity in the course of daily life.

https://doi.org/10.1037/0000218-012 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  349 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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In a concurrent development, mindfulness-based interventions first emerged in the field of medicine in the 1980s, teaching both applied and formal Buddhist meditation practices to help medical patients cope with the stress of chronic pain and illness. Although grounded in ancient Eastern Buddhist traditions, this approach—now known as mindfulness-based stress reduction (MBSR)—taught the essence of mindfulness meditation practices to mainstream American medical patients in a culturally sensitive way free from traditional Buddhist cultural trappings. Jon Kabat-Zinn developed MBSR for the purpose of reducing patients’ automatic stress reactivity and promoting more deliberate and adaptive responding to stress. Placed within a larger self-regulation theoretical framework (e.g., Schwartz, 1984), MBSR reestablishes mind–body connections, thereby supporting an individual’s natural capacity to maintain stability while allowing for optimal adaptability across multiple system feedback loops. Psychologists Zindel Segal, Mark Williams, and John Teasdale later adapted MBSR for the specific purpose of preventing major depressive relapse, integrating this mindfulness meditation approach with Western cognitive therapy to create mindfulness-based cognitive therapy (MBCT). Psychologist Marsha Linehan developed DBT during this time, incorporating Zen-inspired mindfulness training practices taught outside the formal meditation context explicitly to promote emotion-regulation skill development. The theoretical framework of DBT takes a broad view of the skills necessary to manage emotional arousal effectively. Therefore, the DBT literature commonly employs the terms emotion regulation and emotion dysregulation to reflect this theoretical conceptualization of DBT skill development, the clinical change process, and skill deficits targeted with DBT interventions. Placed within a broader cognitive behavioral framework, DBT targets disorders of chronic emotion dysregulation by teaching skills, such as mindfulness, designed to help patients tolerate and/or skillfully modulate difficult or intense emotional experience. In this chapter, we describe a wide range of clinical approaches found across a variety of behavioral and cognitive behavioral therapy (CBT) protocols: progressive relaxation, breathing training, mindfulness-based interventions, and mindfulness skills training within DBT. Although their clinical procedures can differ greatly, all of these interventions share an underlying proposed function: to improve regulation of physiological and emotional arousal. After an overview of the guiding rationale and specific clinical procedures and techniques involved, we examine how each intervention approach may improve regulation across physiological, cognitive, and/or behavioral domains of functioning.1 Although not an exhaustive research literature review, we highlight relevant research providing empirical support for proposed regulation mechanisms and for the clinical effectiveness of these intervention approaches.

PROGRESSIVE RELAXATION Progressive relaxation (PR) is a widely used relaxation method that teaches patients to reduce muscle tension directly. Physiologist Edmund Jacobson developed PR in the early 20th century after observing minimal, or even absent, Clinical examples are disguised to protect patient confidentiality.

1



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startle responses to unexpected loud noise when individuals were physiologically relaxed. His innovative PR method, first published in 1929, detailed specific ways to create and subsequently release physical tension systematically across dozens of muscle groups. Jacobson’s simple physiological rationale advanced the idea that elongated muscle fibers produce physical relaxation, thereby directly opposing the contracted or shortened muscle fibers associated with physical tension and resulting subjective states of anxiety. In the course of intensive training over several weeks or months, patients practiced deliberately tensing and releasing approximately 48 different muscular movements. As a result, they eventually learned to detect even the slightest levels of muscle contraction and, consequently, could voluntarily release any subtle unnecessary muscle tension upon detection. Psychiatrist Joseph Wolpe brought PR into the field of behavior therapy in 1958 when he developed an abbreviated form of PR as part of his systematic desensitization method. Based on his rationale that a state of physical relaxation would serve a counterconditioning function in the context of fear reduction, Wolpe reduced Jacobson’s original PR procedures to include only 16 major muscle groups typically taught over the course of seven training sessions. Wolpe also adapted Jacobson’s original instructions by having the clinician verbalize suggestions about further release at the end of tension-release cycles. In 1966, psychologist Gordon Paul modified Wolpe’s abbreviated PR methods by shortening tension-release cycle times, ensuring that patients practice with all 16 muscle groups in every training session, introducing a “pendulum” analogy to explain the purpose of first creating tension, and increasing the use of elaborate therapist suggestions of relaxation during training sessions. Psychologists Douglas Bernstein and Thomas Borkovec created a manual reflecting Paul’s PR approach (Bernstein & Borkovec, 1973) in an effort to streamline Jacobson’s original PR technique for a variety of behavior-therapy applications. During approximately 10 sessions, patients practice systematic tension and release of 16 muscle groups, eventually combined into seven muscle groups, and then further combined into only four muscle groups. In later sessions, patients practice “recall and counting” procedures to achieve relaxation quickly so they can apply relaxation as a coping response in the course of daily life. This abbreviated PR method, often referred to as abbreviated progressive relaxation training (APRT), appears in an updated manual (Bernstein et al., 2000), and this protocol remains a cornerstone in the professional practice of clinical behavior therapy and stress management. APRT Clinical Procedures APRT begins with the clinician and patient exploring how anxiety and tension may contribute to the patient’s current difficulties and, therefore, how learning to reduce physical tension might be beneficial. In this initial training session, the clinician demonstrates how to produce physical tension in each of the 16 muscle groups, asking the patient to try alongside the clinician to determine if certain movements indeed created discernable tension. The clinician explains

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that the procedure of tensing before releasing different muscle groups theoretically reduces muscle tension below current adaptation levels, as deliberately producing tension in a muscle group creates a “momentum” to enable further release of the tension once released. Beginning with each hand and lower arm, the patient makes a tight fist to create tension throughout the hand, over the knuckles, and across the lower arm. Upper arm muscles are tensed by pushing each elbow down into the arm of the chair, producing tension in the biceps of that arm without disturbing the muscles of the hand and lower arm. Tension instructions for the muscles of the face consist of three facial muscle groups. First, the patient creates tension in the forehead area by lifting the eyebrows up as high as necessary to feel for tension throughout the forehead and into the scalp region. Second, the patient tenses central face region muscles by tightly squinting the eyes while wrinkling the nose to create tension around the eyes and across the upper part of the cheeks. Third, the patient tenses the muscles of the lower part of the cheeks and the jaw by clenching the teeth while pulling the corners of the mouth back. To produce tension in the neck, the patient can pull the chin downward toward the chest while keeping the chin from actually touching the chest, thereby counterposing against the muscles of the back of the neck. To tense the muscles of the chest, shoulders, and upper back, the patient takes a deep breath and holds it while pulling the shoulder blades together as if trying to touch them together. Abdominal muscles are tensed by intentionally making the stomach hard, as if preparing for a hit to the stomach. Tensing instructions end with the muscles of the legs and feet. The patient produces tension in each upper leg by counterposing the large thigh muscle on top with the two smaller muscles underneath. The patient then creates tension in each lower leg by pulling the toes of that foot up toward the head. Finally, the muscles of each foot are tensed by pointing the toes and then turning the foot inward while curling the toes. While instructing the patient to tense each muscle group, the clinician prevents the patient from tensing muscles too hard and limits each tensing period to 5–7 seconds in order to avoid painful cramping. Next, the clinician guides the patient through the first formal relaxation practice during this initial training session, instructing the patient through each specific tension-release cycle while inviting the patient to feel associated physical sensations. To enhance the patient’s ability to focus attention on physical sensations, ideal consulting room features include closed doors and covered windows to minimize outside distractions, dim indirect lighting, and a comfortable chair or couch that provides full body support. If possible, the patient should wear loose and comfortable clothing and remove shoes, watches, glasses, or any other items that create pressure on the body. During the formal relaxation practice, the patient typically will keep the eyes closed. The clinician then directs the patient’s attention to the first muscle group (the muscles of the hand and lower arm on the dominant side), instructs the patient to focus attention on these muscles, reminds the patient how to produce tension in this muscle group, and instructs the patient when to tense with a cue word, such as



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“now.” After holding the tension for 5–7 seconds, the patient is instructed to release all tension and to attend to the sensations of relaxation in the target muscle group for the next 30–40 seconds. During this time, the clinician encourages observation of relaxation sensations with relaxation “patter” comments such as “noticing what it feels like as the muscles become more and more relaxed” (Bernstein et al., 2000, p. 157). This tension-release cycle is repeated, followed by a slightly longer relaxation patter period of 45 to 60 seconds. To ensure the patient has achieved relaxation in these muscles before moving on, the clinician will ask the patient to signal by lifting the little finger of the right hand if the muscles of the dominant hand and lower arm feel completely relaxed. In response, the clinician will either repeat the tension-release cycle a third time or invite the patient to allow these muscles to continue relaxing while shifting attention to the muscles of the dominant upper arm. The guided instructions proceed in this way for the remaining muscle groups, following the same basic sequence: (a) focus full attention on the target muscle group, (b) produce tension in that muscle group, (c) hold the tension for 5 to 7 seconds, (d) release all tension in the muscle group at once when cued, and (e) focus attention on the target muscle group as it relaxes. After completing all 16 muscle groups, the clinician may ask the patient to signal if any slight tension remains anywhere in the body and, if so, guide the patient to tense and release that muscle group again. The patient might remain in this state of relaxation for another minute or so before the clinician ends the practice gently, counting backward from 4 to 1 and inviting the patient to move slightly throughout the body with each count. After the patient’s eyes have opened, the clinician asks about patient experiences and works with the patient to resolve any difficulties. Patients then practice at home, ideally twice per day for 15 to 20 minutes each time, often using a recording of the practice session for guidance. Bernstein et al. (2000) presented a sample rationale script, an outline of initial session information, and specific instructions for creating and releasing tension in each of the 16 muscle groups. Subsequent sessions include review of patient’s home practice experience and review of progress. After the patient reports initial improvement and successful practice, the clinician will guide the patient through an abbreviated formal practice combining the original 16 muscle groups down to 7: (a) dominant hand, forearm, and upper arm; (b) nondominant hand, forearm, and upper arm; (c) all facial muscles; (d) neck; (e) chest, shoulders, upper back, and stomach; (f) dominant upper leg, calf, and foot; and (g) nondominant upper leg, calf, and foot. Once the patient reports some mastery of this abbreviated practice, approximately 2 weeks later, the clinician further combines the seven muscle groups down to just four: (a) the hands, forearms, and upper arms on both sides; (b) the face and neck; (c) chest, shoulders, back, and stomach; and (d) both legs and feet. Eventually the patient will practice “recall” procedures, in which the patient directs attention to a particular muscle group, but instead of producing tension, the patient identifies any tension already present, recalls

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feelings associated with tension release, and deliberately lets go of any tension in these muscles. After the patient achieves some mastery with the recall procedure using four muscle groups, the clinician introduces a “counting” procedure for the patient to apply in daily life situations. Empirical Evidence for PR Proposed Mechanisms of Change Jacobson (1929) originally argued that PR methods reverse habits of chronic residual muscle tension, allowing the body to achieve true physiological rest in place of baseline neuromuscular hypertension and accompanying feelings of restlessness and nervousness. He reported that his PR patients found it impossible to feel negative affect while physically relaxed, and he, therefore, viewed PR as a proprioceptive means of reducing emotional excitability. Building upon Jacobson’s early physiological regulation notions, behavior therapists adapted Jacobson’s original PR procedures for the specific purpose of teaching patients how to regulate ANS arousal and associated emotional reactivity in response to anxiety-provoking or stressful stimuli. Indeed, early laboratory research in the 1970s supported these claims, finding that PR reduced subjective tension and tonic psychophysiological arousal (Paul, 1969), reduced phasic physiological and subjective responses to stressful imagery (Paul & Trimble, 1970), and increased self-control over tonic physiological arousal and subjective tension (Beiman et al., 1978). In 1981, Green et al. found that just two sessions of APRT (Bernstein & Borkovec, 1973) reduced tonic sympathetic nervous system arousal on measures of skin conductance, heart rate, and facial muscle tension (as measured by frontalis electromyography). Electrodermal activity reductions achieved by PR were superior to those exhibited by a self-induced relaxation group. Green et al. also examined phasic responses to fear slides depicting physical wounds, surgical procedures, and burn victims. Participants receiving PR reported lower subjective emotional arousal to highly stressful slides compared with self-relaxation participants, and analysis of skin conductance group means also favored PR. More recent research demonstrated that a single 20-minute APRT session immediately reduced state anxiety, perceived stress, heart rate, and salivary cortisol levels—and increased salivary immunoglobulin A concentration and secretion and subjective relaxation—when compared with a randomly assigned “quiet sitting” control group (Pawlow & Jones, 2005). Dolbier and Rush (2012) extended these findings by measuring heart rate variability (HRV), an index of parasympathetic nervous system activity. Participants were randomized either to practice a 20-minute guided PR procedure while lying down with eyes closed or simply to lie down with eyes closed for 20 minutes in a nondistracting environment without further instruction. PR participants reported increased mental and physical relaxation and exhibited increased normalized high-frequency HRV, coupled with a decreased low- to high-frequency HRV ratio, when compared with control group participants. These results suggest that PR may support adaptive ANS regulation not only by reducing sympathetic activity but also by stimulating parasympathetic activity—the branch of the ANS that calms the



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body to restore homeostasis after an activating event. Small effect sizes were found on additional HRV measures, salivary cortisol, and self-report anxiety measures as well. A brief 25-minute PR session also increased the nociceptive flexion reflex (NFR) threshold compared with a randomized no-treatment control condition (Emery et al., 2008), suggesting that PR may enhance chronic pain management by reducing the sensitivity of this particular muscle withdrawal reflex associated with experienced pain intensity. Taken together, these experimental research studies provide some empirical support for Jacobson’s original assertions that PR both reduces baseline levels of physiological arousal associated with negative emotional states and promotes adaptive regulation of physiological arousal when recovering from emotionally evocative events. Although this laboratory research allowed for direct examination of such hypothesized regulation mechanisms, these studies typically included healthy college students rather than clinical patient populations. PR Applications and Dissemination APRT and similar PR procedures have received extensive empirical support for a wide variety of behavioral medicine and psychological conditions in outcome research effectiveness trials. Clinical benefits of PR, either alone or in combination with other cognitive behavioral components, have been documented for headache, insomnia, cancer, chronic pain, arthritis, irritable bowel syndrome, hypertension, tinnitus, and dysmenorrhea, as well as for most anxiety and depressive disorders (for reviews of this outcome literature, see Bernstein et al., 2000, 2007; McCallie et al., 2006). PR procedures have been widely disseminated to mental health and other health care practitioners to serve their patients, in the form of published therapy manuals (e.g., Bernstein et al., 2000), popular textbooks (e.g., Hazlett-Stevens & Bernstein, 2012), and professional continuing education seminars and workshops. In addition to this diverse array of clinical-setting applications, PR is a leading technique taught in employment settings to reduce work-related stress. For example, Sundram et al. (2016) delivered PR as part of a worksite health-promotion program to assembly-line workers on-site at their respective automobile plant location. When compared with workers at a similar plant receiving only printed pamphlets describing stress reduction, the PR workers reported significant reductions in stress after the five-session PR program. PR procedures are widely available to the general public as well, with numerous worksheets and information pamphlets available online and descriptions of how to practice PR appearing in published self-help books (e.g., Hazlett-Stevens, 2005).

BREATHING TRAINING TECHNIQUES Diaphragmatic breathing (DB) and related breathing training techniques provide another physiological means for improved regulation of emotional arousal. Given the role of increased respiration rate in stress reactivity as well as observed

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associations between hyperventilation and anxiety symptoms, clinicians have developed various methods to teach patients how to regulate emotional arousal by deliberately changing their breathing patterns. Breathing training techniques capitalize on the fact that breathing patterns automatically shift in reaction to changing physiological demands but also can be altered deliberately when under conscious control. Patients therefore learn to monitor their natural breathing patterns in the service of detecting early signs of stress reactivity or anxiety and, if warranted, deliberately slow and deepen breathing patterns to reduce physiological arousal. Patients also may practice regular slow and deep breathing throughout the day to reverse subtle hyperventilation habits, thereby promoting baseline physical relaxation. Such breathing training techniques first became popular in the 1970s. Paced respiration techniques involved slowing one’s breathing rate down to approximately eight breaths per minute to reduce autonomic arousal as a strategy to cope with stress (e.g., Harris et al., 1976). Similar breathing relaxation strategies involved purposefully deepening the breath into the abdomen to limit hyperventilation, also in an effort to reduce physiological arousal and emotional distress (Suess et al., 1980). Clinicians labeled these methods diaphragmatic breathing techniques because patients were encouraged to breathe from the diaphragm muscle located in the abdomen. Psychologists subsequently integrated breathing training procedures into various psychotherapy protocols. In their updated APRT manual, Bernstein et al. (2000) added a description of DB procedures as an alternative relaxation technique. Many CBT protocols for anxiety disorders—especially panic disorder and generalized anxiety disorder (GAD)—include DB procedures (e.g., Borkovec et al., 2002; Craske & Barlow, 2007; Hazlett-Stevens, 2008). In addition, a specific breathing training method for panic disorder known as capnometry-assisted respiratory training (CART; Meuret et al., 2008) systematically targets the hypocapnia (low levels of carbon dioxide) associated with panic. CART involves a 4-week training program using immediate feedback of end-tidal carbon dioxide pressure to teach patients how to raise these levels voluntarily, allowing increased control over the specific respiratory physiology implicated in panic (i.e., pCO2). DB Clinical Procedures The clinician typically begins DB training by drawing a contrast between the physiology of shallow and rapid chest breathing and that of deep and slow abdominal breathing. The clinician explains how the diaphragm is a large curved muscle in the abdomen naturally designed to move as the abdomen moves with each breath, thereby supporting the body to breathe with minimal exertion by the chest. As the patient learns to breathe in this physiologically optimal way—that is, breathing slowly and deeply using the diaphragm muscle of the abdomen—the patient promotes adaptive regulation of physiological arousal by stimulating the parasympathetic branch of the ANS and achieving optimal blood oxygen levels to prevent an imbalance of oxygen and carbon



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dioxide. This pattern of relaxed natural breathing contrasts with that experienced during stress or anxiety, in which diaphragm muscle contraction and reliance on chest muscles for breathing is believed to result in physical discomfort, muscle soreness, and further stimulation of sympathetic ANS activity. Furthermore, such unintended stress-related physical effects may accumulate over time with habitual chest breathing. Patients therefore practice DB as a means of reducing baseline physiological arousal and as a coping response to stressful or anxiety-provoking events. While presenting this DB rationale, the clinician places one hand on their own chest and their other hand on their stomach and shows the patient how breathing from the chest causes only the top hand to move whereas breathing from the abdomen results in a rising and falling of the belly as the bottom hand moves. The patient then tries this exercise by breathing naturally to see how much each hand moves and eventually shifts toward breathing from the abdomen as much as possible. If abdominal breathing feels unfamiliar or difficult, the clinician can advise the patient to relax and expand the abdomen intentionally just before each inhalation. As the patient becomes able to breathe in this way, the clinician may invite the patient to close their eyes and allow the rate of breathing to slow down further, with the eventual aim of breathing in a smooth and fluid manner. Although an optimal breathing rate of 8–10 breaths per minute is recommended in the literature (e.g., Craske & Barlow, 2007), the patient should always be encouraged to breathe at a rate that feels comfortable. After a discussion of the patient’s experience, the clinician offers any suggestions to help the patient engage regular DB practice at home. If the patient reports the common challenge of distraction and experiences difficulty maintaining attention on the breath, the clinician may suggest a focusing strategy. For example, the patient might silently count each inhalation and then silently repeat a word such as “relax” on each exhalation, counting forward to 10, backward to 1, forward to 10 again, and so on for the duration of the practice session (Craske & Barlow 2007). Another method instructs the patient silently to say the syllable “re” on each inhalation and the syllable “lax” on each exhalation (Rygh & Sanderson, 2004). The clinician typically recommends home practice in a quiet and comfortable setting free from interruptions or distractions twice daily, for about 10 minutes per practice session. As the patient reports mastery of DB in this daily formal practice, the patient starts to practice deep abdominal breathing informally throughout the day. Eventually, the patient applies DB as a coping response to internal or external cues of tension, stress, or anxiety by deliberately shifting to slow, fluid, diaphragmatic breathing. Adapted DB Procedures in the Treatment of Panic Craske and Barlow (2007) modified the standard DB procedures described above when treating patients diagnosed with panic disorder or otherwise experiencing recurrent panic attacks. These procedures begin with a voluntary

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hyperventilation exercise in which the patient compares the sensations produced by intentional hyperventilation with those of an unexpected panic attack. After the clinician demonstrates hyperventilation by showing the patient how forcefully to breathe, the patient stands and purposefully breathes quickly and heavily while forcing each exhalation, as if trying to blow up a balloon. The clinician encourages the patient to continue this voluntary hyperventilation for 60 to 90 seconds or for less time if intense sensations develop quickly and the client expresses significant distress. Immediately afterward, the patient sits down and breathes normally as the clinician points out that hyperventilation creates intense but harmless sensations. The patient then closes their eyes and intentionally breathes slowly, pausing after each breath. After the patient confirms returning to a comfortable resting state, the clinician and patient discuss the hyperventilation sensations just experienced and the typical sensations of panic. The clinician helps the patient (a) identify specific sensations experienced during and following the hyperventilation exercise and (b) compare such sensations to the patient’s dominant panic attack sensations. This discussion leads into psychoeducation about the physiology of hyperventilation and how a sudden imbalance of carbon dioxide and oxygen can lead to a harmless constriction of certain blood vessels and slightly reduced blood flow to the brain. Common panic symptoms such as dizziness, light-headedness, and a sense of unreality, as well as increased cardiovascular activity and numbness or tingling in extremities are also typical results of hyperventilation, merely reflecting how the body naturally compensates for increased respiration in the absence of any accompanying physical exertion. Mild hyperventilation and/or subtle overbreathing could lead the patient to take in more oxygen than needed by the body over time, potentially inducing similar hyperventilation-related physiological effects, even for patients who may not normally hyperventilate in the exaggerated fashion just experienced. After presenting this psychoeducation information specific to panic symptoms, the clinician proceeds to teach DB as outlined in the previous section. Proposed Mechanisms of Change, Applications, and Dissemination of DB Techniques One prominent proposed therapeutic mechanism of DB is improved respiratory and physiological regulation, leading to reduced subjective states of anxiety and stress. For example, Fried (1993) argued that hyperventilation and resulting hypoxia (decreased oxygen availability) is a common characteristic of stress reactivity, and therefore, breathing training procedures that restore optimal breathing patterns improve regulation across multiple physiological systems. In his analysis of the physiology of respiration and DB techniques, Fried (2000) identified several respiratory physiological mechanisms implicated in DB: (a) decreased end-tidal CO2 and possible hypometabolism; (b) increased finger temperature, suggesting improved peripheral blood circulation; (c) improved respiratory sinus arrhythmia (RSA) pulse interbeat pattern, indicating resto-



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ration of vagal tone by heart-lung reflexive synchrony; and (d) electroencephalogram activity in which alpha is coherent and predominant and theta is depressed, a profile associated with improved brain blood flow. This line of research is consistent with documented effects of a European medical respiratory retraining method known as whole-body breathing (Dixhoorn, 2007), in which voluntary modification of breathing patterns improves regulation across interconnected respiratory and physiological systems. The polyvagal theory (PVT) of Stephen Porges (2011) also supports the view that DB promotes adaptive regulation of emotional arousal by improving systemic physiological regulation, thereby reducing maladaptive physiological arousal. PVT is based on the premise that threat perception activates the sympathetic branch of the ANS while depressing parasympathetic influence. PVT also suggests that after this reactive fight-or-flight physiology evolved, a later phylogenic stage of development allows mammals faster parasympathetic inhibition of initial fight-or-flight reactivity due to myelinated vagal nerves. Thanks to this later stage of neurological development, humans have a physiological means of quickly overriding sympathetic activation and regulating ANS arousal during times of emotional stress. As DB increases vagal tone, the individual becomes better able to self-regulate nervous system arousal, thereby selfsoothing and promoting relaxation. Research in support of PVT has demonstrated how such vagal tone plays a crucial role in sustained attention, stress resiliency, and the ability to calm down after reacting to stressors, all of which are considered fundamental to effective self-regulation, appropriate social behavior, and emotional stability (see Porges, 2011, for reviews of PVT and relevant research literature). For this reason, DB may be especially therapeutic for chronic anxiety conditions such as GAD. Indeed, detrimental effects of high trait worry and poor emotion regulation on HRV (an index of parasympathetic control of the heart) have been demonstrated among healthy college students (Knepp et al., 2015), and DB appears in leading cognitive behavioral treatment packages for GAD (Borkovec et al., 2002). In clinical effectiveness research, DB typically is included as a component of larger stress management or cognitive behavioral treatment protocols and is rarely evaluated in isolation. However, intensive DB training delivered to IT company employees over 20 sessions in 8 weeks improved sustained attention, improved self-reported affect, and reduced salivary cortisol levels compared with a randomly assigned assessment-only control group (X. Ma et al., 2017). In a relaxation program combining DB with abbreviated PR and mental imagery, Fried (1993) reported improvement on several stress-related psychophysiological indices, leading Fried to recommend this relaxation program for many stress-related symptoms (e.g., chronic shortness of breath, asthmatic breathing, chronic fatigue, sleep difficulties, headache, unexplained pain, impaired concentration or memory, muscle tension, irritability; Fried, 2000). In another investigation (Chiang et al., 2009), a breathing training component was added to a standard self-management intervention for children with moderate-to-severe asthma. Children randomly selected to receive the treatment

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including breathing training experienced reduced anxiety compared with children in the self-management-only condition. In the treatment of anxiety disorders, a number of evidence-based cognitive behavioral protocols integrate DB with other cognitive and behavior therapy procedures, most notably for GAD (e.g., Borkovec et al., 2002) and for panic disorder (e.g. Craske & Barlow, 2007). While the proposed mechanisms of improved physiological regulation discussed above are implicated in these anxiety treatments, DB also might increase subjective states of relaxation and lead to perceptions of greater control over one’s physiology (Garssen et al., 1992). It is, therefore, unclear whether the demonstrated effectiveness of such cognitive behavioral interventions can be attributed solely to physiological regulation mechanisms rather than increased perceptions of control (see Craske & Hazlett-Stevens, 2002, for a discussion of this issue). In sum, DB is an included treatment component of several efficacious cognitive behavioral therapies for anxiety and related disorders, though it rarely has been studied in isolation in clinical trials. DB does appear beneficial on its own for general stress management in nonclinical settings, such as the workplace (X. Ma et al., 2017). Indeed, DB strategies have been widely disseminated to clinicians seeking strategies to help their patients (e.g., Bernstein et al., 2000) and to the general public, appearing in published self-help books (e.g., Hazlett-Stevens, 2005) and countless informational websites online. Nevertheless, some patients may find the application of DB techniques problematic, as reviewed in this next section. Capnometry-Assisted Respiratory Training As mentioned previously, DB has appeared as a component of effective treatment packages for panic disorder. Based on the premise that hypocapnia (low levels of carbon dioxide, or CO2) may contribute to panic symptoms and associated hyperventilation sensations, cognitive behavioral treatment involves teaching patients to reappraise hyperventilation symptoms as harmless while using DB as a coping skill to manage reactivity to such symptoms. However, outcome research on the specific benefits of DB for panic disorder has produced equivocal results, some studies supporting its effectiveness and others yielding null results (Meuret et al., 2003). Furthermore, cognitive behavioral experts have warned clinicians that DB for panic is countertherapeutic if DB becomes a false safety aid and encouraged clinicians to deliver DB procedures in ways that do not undermine exposure therapy efforts (e.g., Craske & Barlow, 2007). Meuret et al. (2003) also questioned the efficacy of DB in reducing hypocapnia, arguing that deliberate deep breathing may result in an overcompensation that inadvertently perpetuates hyperventilation further. In their review of nine panic disorder clinical trials that examined the effects of DB when delivered in isolation, Meuret et al. suggested that outcome findings were mixed because instructing patients to decrease respiration rate without controlling tidal volumes may have exacerbated, rather than corrected, problematic breathing pat-



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terns, potentially leading to hyperventilation-induced hypocapnia. Building upon etiological theories that implicate hypocapnia and related respiratory problems in the development of panic, they designed a specific clinical protocol for respiratory biofeedback breathing training that monitors such physiology throughout treatment and teaches patients to modify respiration rate and tidal volume, thereby regulating pCO2 blood gases and reducing hyperventilation directly (Meuret et al., 2004). Thus, this particular breathing training procedure specifically targets the hypocapnia associated with panic disorder by explicitly teaching patients how to gain voluntary control over and effectively manipulate respiration patterns in the service of regulating pCO2 levels. CART, therefore, was designed to target the hypocapnia believed to contribute to panic disorder symptom development and maintenance. This breathing training intervention employs respiratory biofeedback technology in the form of a handheld portable capnometry device. Patients receive objective physiological feedback as the capnometer continually samples and quantifies CO2 in their expired air and provides respiration rate as well as end-tidal CO2 for individual breaths. These data are stored and downloaded for review in treatment sessions. Over the course of approximately five weekly individual sessions, clinicians educate patients about the role of hypocapnia in the exacerbation of panic symptoms, help patients identify problematic respiratory patterns, and teach patients how to control and correct dysregulated respiration and end-tidal pCO2. Patients practice specific brief exercises between sessions with the portable capnometer twice daily. After a 2-minute baseline recording, patients breathe in synchrony with recorded tones for the next 10 minutes while monitoring pCO2 levels and respiration rate. This exercise concludes with a 5-minute visual feedback period. With practice, patients learn to breathe shallowly and regularly with the tones and to meet the goal of maintaining a pCO2 of 40 ± 3 mmHg (see Meuret et al., 2004, for further description of CART procedures). In randomized controlled clinical trials, CART yielded significant improvements in panic disorder outcome measures and moderate-to-large effect sizes when compared with a delayed-treatment control condition (Meuret et al., 2008), and these clinical improvements following CART were comparable to cognitive training (Meuret et al., 2010). pCO2, but not respiration rate, partially mediated changes in fear of bodily symptoms (i.e., anxiety sensitivity), and although earlier pCO2 levels predicted later levels of anxiety sensitivity, earlier levels of anxiety sensitivity did not predict later levels of pCO2 (Meuret et al., 2009). Only CART—not cognitive training—corrected hypocapnic respiration patterns to normocapnic levels (Meuret et al., 2010). Furthermore, pCO2 preceded changes in symptom appraisal and perceived control, and pCO2 was unidirectionally associated with changes in panic disorder symptom severity among CART patients. Thus, the increased control over dysregulated respiration provided by CART may result in greater perceived control over—and therefore reduced fear of—panic-related sensations, ultimately reducing panic disorder symptoms.

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Clinical Guidelines for Breathing Training Techniques Clinicians have taught breathing training techniques to their patients for decades, providing a means of altering their physiology for improved regulation of emotional arousal. DB strategies target the increased respiration rate associated with stress reactivity and may increase vagal tone, thereby promoting adaptive regulation of ANS physiological arousal. For this reason, DB appears especially helpful for general stress management and for treating the chronic and diffuse anxiety symptoms associated with GAD. However, DB procedures actually may be contraindicated for patients experiencing symptoms of panic, as deliberate slow and deep breathing without controlling tidal volumes could cause an overcompensation that inadvertently perpetuates hyperventilation further. Thus, DB has the potential to exacerbate, instead of correct, problematic breathing patterns, ultimately leading to hyperventilation-induced hypocapnia or low levels of carbon dioxide. When addressing breathing patterns with anxious patients, clinicians can assess for any signs that DB methods are inadvertently inducing hyperventilation and, if so, encourage patients to return to normal and comfortable breathing patterns. In the treatment of panic, clinicians may choose to induce hyperventilation deliberately for interoceptive exposure in the context of cognitive behavioral treatment, but CART procedures offer a hyperventilation-reducing alternative for the treatment of panic disorder. CART utilizes respiratory biofeedback technology in a handheld portable capnometry device to target the hypocapnia believed to contribute to panic disorder symptom development and maintenance. CART procedures therefore provide patients objective physiological feedback to establish an optimal regulation of their respiratory physiology.

MINDFULNESS MEDITATION INTERVENTIONS Mindfulness first became an English word when the term sati was translated from the ancient language of Pali. Pali was the original language of Buddhism, comprising a wide array of cultural practices and teachings dating back to more than 2,500 years ago in present-day Nepal (Thera, 1965). Buddhist teachings offer practitioners specific meditation instructions intended to train the mind toward the qualities of awareness captured by the term sati. Authorities from present-day Buddhist traditions have defined sati as “the clear and single-minded awareness of what actually happens to us and in us, at the successive moments of perception” (Thera, 1965, p. 30); “keeping one’s consciousness alive to the present reality” (Nhất Hạnh, 1975 p. 11); and a “special mode of perception” to cultivate a “special way of seeing life” that contrasts with our usual tendency to “see life through a screen of thoughts and concepts, and we mistake those mental objects for reality” (Gunaratana, 1992, p. 37). After such mindfulness meditation practices entered the field of Western medicine in the 20th century, Western scholars have defined mindfulness as “the awareness that emerges



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through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment” (Kabat-Zinn, 2003, p. 145); “keeping one’s complete attention to the experience on a moment-to-moment basis” (Marlatt & Kristeller, 1999, p. 68); “the nonjudgmental observation of the ongoing stream of internal and external stimuli as they arise” (Baer, 2003, p. 125); and “to consciously attend in a caring, open, discerning way” (Shapiro & Carlson, 2009, p. 13). As evident from the plethora of available definitions, mindfulness does not lend itself to a precise verbal definition because this term refers to a nonverbal and nonconceptual phenomenological experience of awareness. Nevertheless, common themes across these definitions emerge. After reviewing use of the term mindfulness across Western clinical and Buddhist literatures, Germer (2005, p. 7) concluded that definitions of mindfulness tend to include the following three basic elements: (a) awareness, (b) of present experience, (c) with acceptance. In its original Buddhist meditation context, mindfulness is cultivated to alleviate the suffering inherent to the human condition. From the perspective of Buddhism, we all suffer a chronic form of dissatisfaction that inevitably results when the human mind wants to experience something other than what actually exists in any given moment. Importantly, we can reduce, or even cease, such suffering by relinquishing this habitual struggle against present-moment reality (see Follette & Hazlett-Stevens, 2016, and Hazlett-Stevens, 2017, for further discussion of the Buddhist origins of mindfulness and mindfulness meditation practice). As Buddhist meditation teachings became available in America in the 1970s, Jon Kabat-Zinn, a Buddhist meditation practitioner and medical researcher trained in molecular biology, brought mindfulness meditation practices into a Western medical setting. In 1979, he opened a stress-reduction clinic at the University of Massachusetts (UMass) Medical School to teach mindfulness meditation to medical patients in an attempt to relieve the mental suffering associated with chronic pain and illness. Kabat-Zinn developed an 8-week stress-reduction class curriculum to teach the essence of Buddhist meditation practice in a secular manner tailored to the needs of American medical patients; this public health education intervention eventually became known as mindfulness-based stress reduction (MBSR). Since that time, dozens of clinical research trials have established its efficacy for a variety of clinical indications, and a proliferation of MBSR programs have emerged in medical centers worldwide. In addition, clinicians adapted the original MBSR protocol to target specific populations. Within the field of clinical psychology, cognitive therapy researchers Zindel Segal, Mark Williams, and John Teasdale modified Kabat-Zinn’s MBSR curriculum with the aim of preventing future relapse among patients recovered from recurrent major depressive episodes. Mindfulness-based cognitive therapy (MBCT) has since become a leading evidence-based group-therapy approach in the treatment of depression and anxiety (Segal et al., 2013).

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MBSR Curriculum Procedures MBSR consists of eight weekly group sessions lasting 2.5–3 hours each. In addition, an all-day (7-hour) silent meditation practice retreat occurs during a Saturday or Sunday of the 6th week (see Kabat-Zinn, 2013, for an updated description of MBSR procedures). Weekly sessions begin with 45 to 90 minutes of guided formal mindfulness practice, followed by group discussion of participants’ experiences with the practices and didactic presentation of educational material. Participants practice formal daily assignments at home, guided by a recording of practice instructions. An initial formal MBSR practice consists of a 45-minute body scan meditation, in which participants systematically move attention throughout each area of the body. Formal sitting meditation practices begin with instructions to focus awareness on the breath, and eventually this practice is expanded to include other objects of attention such as body sensations, sound, and thoughts and emotions. In later sessions, participants practice a formal sitting meditation characterized as “choiceless awareness.” In this open-monitoring form of meditation practice, present-time experience itself becomes the object of attention, allowing participants to observe the interplay between sensory, bodily, and cognitive-affective experiences that naturally arise and cease during the meditation period. In addition to these formal meditation practices conducted in stillness, mindful movement practices include formal walking meditation and gentle hatha yoga stretches. Throughout the 8 weeks, participants also engage in informal mindfulness practice assignments, such as eating and completing everyday activities mindfully, recording experiences with pleasant and unpleasant events that naturally occur during the day, and bringing mindful awareness to stressful events in daily life. MBSR instructors present educational material each session in a didactic yet interactive format. Specific didactic material presented each week addresses the role of perception in stress, the difference between automatic stress reactivity and intentional response to stress, and how mindfulness can allow automatic habitual patterns of stress reactivity to shift toward more skillful response in times of stress. MBSR instructors consistently embody the accepting and allowing qualities of mindfulness as they interact with participants throughout the 8-week program. Instructors carefully respond to all participant reactions expressed during sessions in a welcoming, inclusive, open, nonjudgmental, and unassuming way. Thus, as instructors encourage participants to respond to their private intrapersonal experiences by welcoming and allowing all experience, regardless of how pleasant or unpleasant, and without trying to fix it or to change it, instructors also relate to participants in this same inclusive fashion interpersonally. The value of turning toward all experience, rather than rejecting unpleasant or difficult experience, is conveyed with the Sufi poet Rumi’s “The Guest House,” in which readers are invited to treat each experiential phenomenon, whether sorrow, shame, malice, or joy, as a welcome guest who visits their home. Given the emphasis on the instructor’s own therapeutic presence and embodiment of these mindfulness qualities, instructors are expected to maintain their own rigorous mindfulness meditation personal practice to enable them to teach MBSR from their own direct experience.



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Empirical Evidence for MBSR’s Proposed Mechanisms of Change In his early explanations for how training in mindfulness could lead to stress reduction, Kabat-Zinn (2013) claimed that mindfulness does not reduce the occurrence of stressful events but instead changes participants’ relationship to such events when they do occur. When participants become aware of their habitual patterns of cognitive and behavioral reactivity, they realize the opportunity to respond deliberately and thoughtfully to stressful events rather than feeling caught up in automatic reactivity. Kabat-Zinn (2013) argued that such deliberate “mindfulness-mediated stress responses” become possible when essential mind–body connections become reestablished. Placed within the larger self-regulation theory of Gary Schwartz (1984), Kabat-Zinn conceptualized health as an organism’s capacity to maintain stability, while allowing for adaptability, through natural self-regulation processes via various systemic feedback loops. From this theoretical perspective, conscious attention allows for greater and deeper connectedness between mind–body subsystems, reflecting an innate human potential for conscious self-regulation. Thus, deliberately bringing attention to one’s current mind–body state reestablishes this mind– body connection, which increases self-regulation, eventually restores order to the system, and ultimately improves physical/emotional health. Subsequent research identified ways in which mindfulness meditation training might improve emotion regulation specifically within such larger selfregulation frameworks. For example, patients with social anxiety disorder exhibited decreased negative emotion, reduced amygdala activation, and increased activity in regions important for deployment of attention during a breath-focused attention laboratory task following MBSR (Goldin & Gross, 2010). MBSR also reduced negative emotion when faced with negative selfbeliefs during a receptive awareness attention-regulation task (Goldin et al., 2013), and associated neural responses characterized by increased activation in attention-related parietal cortex regions suggested improved attentional regulation. MBSR also may improve emotion regulation by increasing one’s focus on momentary direct experience rather than a self-referential narrative. Farb et al. (2007) reported reduced activity in medial prefrontal cortex (mPFC) regions as well as increased activity in lateral PFC and viscerosomatic areas (such as the insula) during an experiential attention-focus task among participants who completed MBSR. In addition, the functional connectivity between the right insula and the mPFC found in nonmeditators was uncoupled in the MBSR group, suggesting that the self-referential narrative focus mode is distinct from the experiential present-moment focus mode and that MBSR might teach individuals to uncouple these two forms of self-awareness. Mindfulness-Based Program Applications and Dissemination Early outcome research demonstrated that MBSR improved chronic pain management (Kabat-Zinn, 1982; Kabat-Zinn et al., 1985) and reduced anxiety and depression symptoms among patients diagnosed with various anxiety disorders (Kabat-Zinn et al., 1992; Miller et al., 1995). Subsequent clinical trials established

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the efficacy and effectiveness of MBSR for a host of behavioral medicine and psychological conditions, including chronic pain (e.g., Morone et al., 2008); anxiety, depression, and psychological distress associated with cancer (Ledesma and Kumano, 2009); chronic medical diseases (Bohlmeijer et al., 2010); anxiety disorders (e.g., Vøllestad et al., 2011); and other mental health conditions (Biegel et al., 2009). In a meta-analysis of 20 MBSR studies, Hofmann et al. (2010) reported MBSR Hedges’s g effect sizes of 0.49 for depression symptom measures and 0.55 for anxiety symptom measures, indicating effective anxiety and depression symptom improvement across a wide range of medical and psychiatric conditions. Similarly, Fjorback et al. (2011) reported medium effect sizes for mental health symptom outcomes following MBSR in their meta-analysis. A Campbell Systematic Review (de Vibe et al., 2012) that identified 26 randomized controlled trials of MBSR (1,456 participants) reported postintervention Hedges’s g effect sizes of 0.53 for anxiety, 0.54 for depression, and 0.56 for stress/distress, with a combined mental health effect size of 0.53 and a somatic health effect size of 0.31. MBSR now appears in the Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP) as an intervention evaluated in comparative effectiveness research studies. MBSR also appears effective when applied in a variety of nonclinical contexts, reducing stress and/or improving health among employees in the workplace, psychotherapists in training, health care providers, medical students, and community volunteers (see Shapiro & Carlson, 2009, for a review). The dissemination of MBSR has increased dramatically since its inception at the UMass Medical School in 1979. As the benefits of MBSR became known across medical communities, Kabat-Zinn and other leaders of the original UMass Stress Reduction Clinic created the UMass Center for Mindfulness in Medicine, Health Care, and Society to promote the dissemination and delivery of mindfulness-based programs. In addition to providing MBSR and MBCT frequently and regularly to the local community, the UMass Center for Mindfulness also offers live interactive online programs, 5-day residential retreat programs at retreat centers around the world, and a MBSR self-guided video program. Other self-guided materials include published self-help books, such as A Mindfulness-Based Stress Reduction Workbook by authors Bob Stahl and Elisha Goldstein published by New Harbinger Publications in 2010. The UMass Center for Mindfulness website (https://www.umassmed.edu/cfm) offers a wealth of information about mindfulness meditation practice and connects a global online meditation community. This organization also delivered MBSR to correctional facility inmates (Samuelson et al., 2007) and to low income, multiracial, and multicultural individuals in Spanish as well as in English at their inner-city clinic (Kabat-Zinn et al., 2016). As health care and mental health professionals increasingly sought training in the delivery of MBSR, Kabat-Zinn and his colleagues also developed professional teacher training programs for the larger professional community. The UMass Center for Mindfulness created a professional education organization, the Oasis Institute, that regularly offers mindfulness-based professional educa-



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tion programs worldwide. The Oasis Institute also oversees and provides MBSR teacher certification, and the UMass Center for Mindfulness website currently lists 135 certified MBSR teachers in the United States alone. In sum, these various dissemination and professional training efforts have made mindfulnessbased practices available to almost anyone seeking them out worldwide. Other Mindfulness-Based Interventions As MBSR gained recognition within the emerging field of mind–body medicine, clinicians from other disciplines began to adapt the MBSR curriculum to target specific clinical indications. MBCT is a leading example, in which cognitive therapy researchers Zindel Segal, Mark Williams, and John Teasdale developed a protocol that included the formal practices and overall session structure of MBSR while incorporating specific psychoeducational components describing the nature of automatic thoughts and emotions in depression. Group discussions consider the self-referential nature of thoughts, how automatic ruminative thought patterns can lead to depression, how cognitive tendencies to make negative interpretations of events impact emotion, and how mood, in turn, can influence thoughts and behavior. MBCT teaches a specific informal mindfulness practice called the “3-minute breathing space” to deploy in the course of daily life, whereby patients practice stepping out of “autopilot” mode and expanding attention to present-moment experience. In their initial randomized controlled clinical trial, which compared MBCT to treatment as usual (Teasdale et al., 2000), MBCT significantly reduced the risk of subsequent depressive relapse among patients with three or more previous depressive episodes. Subsequent research replicated these findings (e.g., S. H. Ma & Teasdale, 2004), and one meta-analysis including six randomized control investigations of MBCT found that MBCT significantly reduced the risk of depressive relapse by 35%, though this reduction rate increased to 44% for patients with three or more past episodes (Piet & Hougaard, 2011). MBCT also reduced anxiety and depression symptoms among patients diagnosed with GAD, panic disorder, and/or social anxiety disorder (Craigie et al., 2008; Evans et al., 2008; B. Kim et al., 2010; Y. W. Kim et al., 2009; Piet et al., 2010). MBCT has been endorsed as an evidence-based therapy by the United Kingdom’s highly respected National Institute for Health and Clinical Excellence (NICE). Several other examples of mindfulness-based adaptations of MBSR, such as mindfulness-based eating-awareness therapy (MB-EAT; Kristeller et al., 2006) and mindfulness-based relapse prevention for substance use (MB-RP; Witkiewitz & Marlatt, 2004), also have emerged in the literature. In addition, some individual psychotherapies integrate mindfulness practices with CBT, such as the acceptance-based behavior therapy for GAD developed by Roemer et al. (2008). A large comprehensive meta-analysis (Khoury et al., 2013) reported moderate effect sizes for mindfulness-based therapies in pre-post comparisons (Hedges’s g = 0.55), when compared with wait-list controls (Hedges’s g = 0.53) and compared with other active treatments (Hedges’s g = 0.33), although

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mindfulness-based therapies did not yield differences in measured outcomes when compared with traditional cognitive behavioral or behavior therapies or with pharmacological treatment.

COMBINING PR, DB, AND MINDFULNESS-BASED APPROACHES: A CASE EXAMPLE Given the various advantages of these three approaches reviewed thus far, many clinicians will teach relaxation skills, breathing training, and mindfulness practices to the same client over the course of CBT in the hopes of maximizing benefits. Below is a hypothetical case example based on the first author’s private practice experience combining these approaches to treat anxiety. Margaret, a 32-year-old married White woman, presented for psychotherapy with symptoms of generalized anxiety, worry, and occasional panic attacks. Although she identified herself as a “worrier” for most of her life, symptoms of chronic muscle tension, an inability to relax, trouble falling asleep at night, and feeling like her worry had escalated out of control significantly worsened after the birth of her second child 3 months ago. Since then, she also experienced unexpected brief and acute rushes of fear, in which she felt her heart pounding with an accelerated heart rate, approximately once per month. Margaret earned her law degree in her 20s and had worked as an attorney until the birth of her first child 3 years ago. At that time, she left her career temporarily to stay at home and care for her daughter while her husband financially supported their family with his full-time professional salary. Margaret described that she felt able to manage anxiety while caring for her daughter over the past 3 years, but after giving birth to her son 3 months ago, her anxiety had “spiraled out of control.” An extensive diagnostic interview yielded a current diagnosis of GAD and ruled out a comorbid diagnosis of panic disorder, as Margaret did not endorse severe apprehension or worry about her occasional limited-symptom panic attacks. Margaret and her therapist agreed to a 16-session course of CBT for generalized anxiety. Initial therapy sessions would begin with psychoeducation and anxiety spiral self-monitoring. Next, the therapist would teach Margaret relaxation strategies and mindfulness practices to address chronic muscle tension and enhance awareness of her idiosyncratic anxiety-enhancing cognitive and behavioral habit patterns. Cognitive restructuring strategies for automatic anxious thoughts and interpretations of ambiguous events would promote additional coping in response to anxious cues. Later therapy sessions would examine underlying metacognitive and core beliefs and address any specific worry safety behaviors and passive avoidance behaviors maintaining anxious habit patterns. See Hazlett-Stevens (2008) for in-depth theoretical rationale and detailed therapy procedures. In the first therapy session after initial evaluation and diagnostic assessment, the therapist presented Margaret with a cognitive behavioral model of worry,



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anxiety, and fear. Fear is considered a basic emotion we all experience in the face of immediate danger, and the “flight-or-fight response” is the natural physiology that occurs during fear. Panic attacks are simply false alarms that some people are vulnerable to experience, particularly during times of high stress. In contrast, anxiety is experienced when a perceived threat is anticipated in the future rather than immediately present. Anxiety also is considered a normal human phenomenon that even can enhance performance at the right time. The therapist further explained the adaptive origins of worry (i.e., thinking ahead into the future to anticipate upcoming threats) in cases where real concrete threats are likely and specific constructive action can be taken. Thus, the goal of treatment is not to rid Margaret of all anxiety. Rather, treatment aims to increase her awareness of moment-to-moment reactions that currently lead to excessive perceptions of threat, uncontrollable worry, and associated somatic anxiety symptoms. Such increased awareness will allow Margaret to intervene with an adaptive coping response whenever she notices this anxiety process building. During this session, Margaret described a specific recent anxiety episode, and the therapist used her example to illustrate how anxiety is a process comprising a sequence of thoughts, physical sensations and subjective feelings, and behavioral responses and urges. Like many other overrehearsed behavioral habits, these “anxiety spirals” often occur completely out of awareness. Near the end of the session, the therapist introduced Margaret to anxiety-monitoring procedures using a printed Anxiety Diary form that would prompt her to stop and rate her current anxiety on a scale of 0 to 100 four times per day. With each anxiety rating, Margaret also was instructed to identify any associated specific thoughts, physical sensations, behavior, and environmental triggers. This self-monitoring process between sessions was intended to (a) help Margaret identify the moment-to-moment sequence of reactions that make up anxiety episodes and (b) promote present-moment awareness. Relaxation training and mindfulness practice began in the second therapy session, beginning with mindfulness of breathing practice. After complying with the therapist’s request that she begin self-monitoring between sessions, Margaret returned to this session with initial insight into how worry about her baby’s health often triggered the clenching of her jaw and eventually led to shallow breathing. The therapist described the physiology of deep stomach breathing, similar to traditional DB procedures, and encouraged Margaret to explore sensations of breathing by placing one hand on her chest, placing the other hand on her stomach, and breathing naturally. However, rather than instructing Margaret to isolate her breathing to her stomach and breathe more deeply, the therapist simply asked Margaret to close her eyes and focus all her attention on the sensations of breathing as they naturally occur in the present moment. Each time she noticed her mind wandering away from sensations of breath, she could practice gently bringing her mind back to the present moment without judgment. At first, Margaret found that her attention was swept away from sensations and caught up with thoughts almost constantly, which she found quite frustrating. Therefore, the therapist further instructed her to count

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each breath, starting with 1, silently counting breaths up to 10, back down to 1, and so on. The therapist next explained how PR procedures might directly address Margaret’s complaints of excessive chronic muscle tension. However, in order to prevent a paradoxical increase in anxiety caused by trying hard to relax, the therapist emphasized that the aim of PR procedures was for Margaret to feel sensations of muscle tension and relaxation as they naturally occurred during PR procedures rather than to relax as quickly as possible. As the therapist guided Margaret through the formal 16-muscle-group PR initial practice procedures described above, the therapist carefully chose wording to encourage bodily awareness of sensations produced by muscle tension-and-release cycles and avoided suggestions that Margaret should feel relaxed. In addition to continued self-monitoring with the Anxiety Diary form, the therapist asked Margaret to conduct a daily formal practice at home, where she could retreat to a quiet place and practice undisturbed. After 10 minutes of mindfulness of breathing while counting her breaths, Margaret would play back the therapist’s guided PR practice instructions and practice the 16-muscle-group procedure. Margaret practiced mindfulness of breathing and PR formal procedures in between sessions on a daily basis largely as instructed. During her first week of practice, she noted a couple of instances of relaxation-induced anxiety, in which she felt deep physical relaxation followed by a sudden moment of fear and having to “catch her breath.” However, she remembered the therapist mentioning that such experiences sometimes happen when relaxation sensations are unfamiliar, and she was able to notice that this anxiety passed away quickly. Although her mind still wandered with thoughts from time to time during her practice sessions, she noted that her ability to focus attention on her breath or her body as directed was slowly improving. The subsequent three sessions were spent reviewing Margaret’s self-monitoring forms and identifying sequences of momentary reactions that composed her anxiety spirals, practicing mindfulness of breathing by focusing attention on the breath with Margaret no longer needing to count breaths, and formally practicing the seven- and four-muscle-group PR practice. During the subsequent therapy sessions, the therapist encouraged Margaret to continue daily formal practice of mindfulness of breathing and to check in with her breathing throughout the day to increase her awareness of anxiety cues as they naturally arise in the course of daily life. The therapist worked with Margaret during the second and third months of treatment to help her apply these relaxation and awareness skills in response to anxious thoughts, bodily sensations, and other anxiety spiral experiences as she noticed them occurring in the course of daily life. During one of these therapy sessions, the therapist guided Margaret through the formal MBSR body scan practice. With repeated home practice using a recording for guidance, Margaret reported that her body scan practice greatly increased her comfort with and tolerance of a wide range of sensations throughout her body. The therapist also incorporated cognitive therapy components during these sessions. By the fourth month of treatment, the therapist worked with Margaret to identify subtle behavior changes she



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could make to improve her quality of life and to challenge underlying anxious beliefs. After approximately 4 months of weekly CBT, Margaret felt ready to continue working with anxiety cues on her own without further therapy sessions. The therapist agreed that she had made considerable progress in therapy and no longer met diagnostic criteria for any anxiety disorder. The mutually agreedupon end of the therapy followed a final session devoted to reviewing Margaret’s progress and suggestions for continued progress and relapse prevention.

A DIALECTICAL APPROACH TO EMOTION REGULATION: ACCEPTANCE AND CHANGE DBT was developed by Marsha Linehan and her colleagues to treat multiproblem, chronically suicidal and self-harming people typically considered to meet diagnostic criteria for borderline personality disorder (BPD) and related problems (Linehan, 1993). The DBT model maintains that BPD is a disorder of emotion dysregulation and that BPD is simply a severe example of problems related to emotion dysregulation (Fruzzetti et al., 2005). This understanding of BPD also highlights the fact that people with BPD typically also meet criteria for multiple other disorders. Thus, emotion dysregulation is understood as a transdiagnostic process, one that connects and makes sense of the various problems that are common among people with BPD. Because DBT was developed for people with severe problems with emotion dysregulation, its focus has been more on understanding emotion dysregulation (rather than on emotion regulation per se) and how to help people become more emotionally regulated. Although early DBT studies focused on BPD and suicidality, in the past couple of decades, DBT has been applied transdiagnostically not only with patients with BPD and suicidality (along with multiple other co-occurring disorders or problems) but also with clients with a variety of problems related to severe and chronic emotion dysregulation, including posttraumatic stress disorder (Bohus et al., 2020), depression (e.g., Lothes et al., 2014; Lynch et al., 2003), substance use problems (e.g., Axelrod et al., 2011), eating disorders (e.g., Haynos et al., 2016; Safer & Jo, 2010; Telch et al., 2001), domestic violence (Iverson et al., 2009), chronic pain (e.g., Linton & Fruzzetti, 2014), and a host of others. Although beyond the scope of this chapter to describe fully, DBT has been shown to be effective for children, adolescents, adults, and older adults and across the full range of mental health service settings, including outpatient, intensive outpatient, residential, and inpatient services. Moreover, although DBT is a multicomponent treatment with multiple functions, psychological skills are at the core of the treatment, including the following: (a) mindfulness, (b) distress tolerance, (c) interpersonal effectiveness, and (d) emotion regulation. Although the definition of mindfulness in DBT is consistent with Kabat-Zinn’s (2003) definition and others’ (i.e., paying attention, on purpose, in the present moment, without judgments), Linehan (2015) utilized Thích Nhất Hạnh’s (1975) seminal work in The Miracle of Mindfulness to deconstruct mindfulness

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into its psychological components or activities. She then described both what we do when we are being mindful and how we do it as psychological skills. What we do includes either observing/noticing something, describing it (i.e., using only descriptive words), or participating in it (i.e., throwing ourselves into the experience). The idea is that we can do only one of these (i.e., observing, describing, participating) at a time, although we can go back and forth among these activities rather quickly. How we do things mindfully includes staying nonjudgmental (i.e., things are neither right/wrong nor good/bad), one-mindful (i.e., staying in the present moment, doing one thing at a time with purposeful attention), and effective (i.e., whatever we do must be in the service of our authentic goals and values), simultaneously. Mindfulness, of course, is central to emotion regulation and is considered the core skill in DBT because no other skills can be employed effectively without mindfulness first orienting the person to the situation and the need for additional skills and then allowing the person to engage in those skills purposefully and mindfully. When a person becomes sufficiently distressed or emotionally dysregulated, “escaping” from that emotional state can become urgent and automatic. Being able to tolerate that distress keeps the person from engaging in behaviors or activities that might have a short-term benefit (e.g., pain or arousal reduction) and incurs a longer term cost to the emotion regulation system, important outcomes, self-regard, or important relationships. Substance use, self-harm, and suicide attempts are extreme versions of these kinds of escape behaviors. Briefly tolerating distress delays these urges to engage in dysregulated actions and provides momentary relief from the frequent “chain reaction” of a person having a lot of painful emotions about their emotions. Instead, one’s attention is placed elsewhere, allowing for arousal to slow down or begin to go down and, eventually, for thinking and problem solving to become possible again. There are many skills in DBT that are designed to help a person tolerate distress for a while, until other skills can become possible. Distress tolerance skills include purposeful distraction, self-soothing, engaging in intense physiological activities (e.g., running up and down stairs), use of extreme temperatures (e.g., ice cubes or an ice dive, a hot shower), and a variety of other skills both simple and complex. Relationships, and other people, are often the source of distress, as well as a source of connection and joy. Being able to build close, reliable, and reciprocal relationships and to balance practical or material objectives, relationship objectives, and self-respect are the key interpersonal effectiveness skills taught here. Being mindful of one’s goals in relationships and being able to be mindful of others’ experiences are at the foundation of these skills. By improving relationships, people reduce negative interpersonal events and increase positive ones and build supportive and validating social networks. Similarly, by titrating time with people who are critical or invalidating, or even ending those kinds of relationships, we reduce antecedents for emotional distress and vulnerabilities to dysregulated emotion. Although all the other skills noted also play key roles in regulating emotion, emotion-regulation skills address emotions directly. Although not exhaustive,



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emotion-regulation skills include understanding emotions, accurately identifying and labeling emotional experiences, discriminating between primary and secondary emotions, connecting emotions to events, accurately expressing emotions, building positive emotional experiences to buffer against negative ones, reducing biological vulnerabilities to distress and dysregulation (e.g., improved sleep, balanced eating, taking care of medical problems, getting exercise), learning how simply to allow emotions to come and go without trying to push them away (or hold on to them), and learning how to use exposure to reduce painful emotions that are not serving the person well (called “opposite action” in DBT). Unlike most forms of psychotherapy, DBT has multiple components designed to meet five functions of treatment to accomplish these tasks: (a) skill acquisition (i.e., learning psychological and social skills, as noted above), (b) skill generalization (i.e., practicing these skills in increasingly natural situations until competent to use them in the person’s most challenging situations), (c) motivation (i.e., replacing dysfunctional thoughts/judgments and reactions with skillful alternatives, aided by careful analysis with and support and validation from the therapist; Fruzzetti & Ruork, 2018; Rizvi & Ritschel, 2014), (d) interventions in the client’s social environment (e.g., family interventions, both to reduce difficult or invalidating responses from others and to help clients improve their social relationships in general; Fruzzetti et al., in press), and (e) a therapist consultation team (to help therapists improve their own treatment skills and their motivation and reduce their burnout; Sayrs, 2017). In a DBT framework, emotion dysregulation occurs when a person’s high negative emotional arousal (or anticipation thereof) disrupts effective selfmanagement of cognition, relationships, and/or overt behavior and thus interferes with the person attaining their goals (Fruzzetti et al., 2009; Linehan, 1993). A person can have a lot of negative emotion and be very upset but still remain emotionally regulated. Disruption occurs when the emotional distress, or anticipation of impending distress, is so intense that the person ceases attending to other activities and longer term goals and instead focuses on reducing, escaping, or avoiding immediate painful arousal. In such situations, the individual may engage in behaviors that “work” (or function) to reduce or escape negative emotions but that also maintain or exacerbate life problems and increase vulnerabilities for further emotion dysregulation, as unintended consequences. Out-of-control behaviors might include self-harm, substance use, binge eating, or verbal aggression, and out-of-control cognitions might include polarized or judgmental thinking, brief distortions of reality, or severe misappraisals. Furthermore, of course, out-of-control relationship behaviors include either attacking or withdrawing from people the person wants to be close to. Thus, in this model, emotion regulation leads to cognitive, relationship, and overt behavioral dysregulation, which typically feeds back to maintain the person’s vulnerabilities to become emotionally dysregulated again and again. Pervasive emotion dysregulation is understood to result from an ongoing transaction between a person with certain vulnerabilities and an invalidating

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social and family environment (Fruzzetti et al., 2005). The person’s vulnerabilities may be present from birth or may develop over time, and these ongoing transactions exacerbate both the individual’s vulnerabilities to become dysregulated and the social environment’s tendency to invalidate the individual. Invalidating responses may be overt and critical, but even well-intended, loving responses may invalidate the person’s experience, emotions, desires, thoughts, and overt and other behaviors. Invalidating responses have an immediate impact on others, including increasing their negative emotional arousal; conversely, validating responses soothe others’ arousal and bring their negative emotions down (Shenk & Fruzzetti, 2011). In DBT, emotion regulation includes a variety of steps that all begin with a public event (i.e., external events that elicit emotional reactions) or a private one (i.e., thoughts, memories sensations). To stay “regulated” (or simply to manage ongoing emotions effectively), the person must discriminate those sensations associated with primary emotions in response to those events and have some awareness of the link between the event and the subsequent experience. Of course, simply allowing this experience to unfold, at least initially, is also part of managing emotions and requires mindfulness of sensations, cognitions, action urges, and emotions and their connection to the antecedent event(s). The person may also have certain vulnerabilities to becoming dysregulated that influence the experience of emotion. These might include being tired, being hungry, feeling sluggish from not getting much exercise, having physical pain or discomfort from an illness, or possessing other biological factors that can influence the “discomfort” or “undesirability” of negative emotions, likely making them more unpleasant (and their converse might provide a buffer to dysregulation). Similarly, managing emotions effectively requires awareness of these vulnerability factors (mindfulness), which in turn allows more specific emotion regulation skills to be utilized. In addition, the person may be more vulnerable to dysregulation simply due to a high baseline at that time, resulting from recent previous events. Cognitive activities that help maintain regulated emotion include forming accurate appraisals (mindfulness in the current moment), simply describing the events and reactions, bringing interest to these events and reactions (versus judgments, inaccurate appraisals, and negative thoughts about the reactions themselves), and acknowledging or validating one’s own experience. Rather than allowing the experience, having negative secondary emotional reactions to primary emotional reactions significantly increases the likelihood of dysregulated emotions; high vulnerabilities and a judgmental or self-invalidating cognitive style (e.g., “I shouldn’t feel this way,” “I’m a bad person,” or “That should not have happened”) can easily create secondary emotional reactions. This last point is central to understanding the close relation between mindfulness and both distress tolerance and emotion-regulation abilities (or skills), as emotion dysregulation in DBT is understood to occur largely when people lose mindful awareness (e.g., acceptance) of their primary emotions and instead jump to or escape to secondary emotions via judgments or conditioning. Thus,



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dysregulation typically includes negative emotional reactions to already existing unpleasant emotions. After becoming aware of when this process of “reacting to reactions” begins (mindfulness), the person may use a distress-tolerance skill to interrupt actions that exacerbate the pattern. Once negative emotional arousal stops escalating, the person can become aware of their primary emotions and connect them to recent emotionally relevant event(s) (mindfulness) and then utilize one or more emotion regulation skills to modulate or manage emotional arousal effectively and authentically. Thus, as emotional reactions become apparent, a person with good “skills” to manage emotion can engage effectively in both acceptance-oriented behaviors and change-oriented behaviors vis-à-vis emotional experiences or do both, dialectically. Acceptance-oriented skills include allowing the emotional experience: observing sensations, thoughts, desires, urges, and so on; tolerating emotional distress; and perhaps observing, describing, or participating in the situation or experience of the situation. Self-validating and moving toward authentic and desired goals are also accepting. Conversely, change-oriented skills include problem solving the situation to improve it; engaging in a variety of activities proactively to improve emotion management (e.g., increasing enjoyable activities and emotions, building healthy and satisfying relationships, planning ahead for how to handle difficult situations); or directly attempting to change undesired emotions or their intensity in ways that promote, rather than thwart, long-term goals, such as doing exposure, taking a break from a situation (and coming back, thus neither avoiding nor escaping), or doing self-soothing activities. Finally, there are social responses that are quite relevant to emotions staying regulated. For example, being invalidated results in a dramatic increase in negative emotional arousal, whereas being validated has a soothing impact on negative emotional arousal even while negative events or stressors continue (Shenk & Fruzzetti, 2011). Thus, expressing one’s experience in an accurate manner and being validated can help the person stay regulated and manage even painful negative emotional arousal. However, it is well documented that when negative emotion becomes high enough, it is common for people to become rather binary in their thinking and unable to perform complex cognitive tasks, all based on the Yerkes-Dodson law (Yerkes & Dodson, 1908). Thus, under high states of negative emotional arousal, people easily stop being “accurate” and descriptive about what is happening and about their primary emotional reactions and instead can easily become judgmental in their communication, inaccurately and ineffectively blaming, criticizing (self or others), and so on. This makes their experiences difficult to understand and commonly results in being invalidated. Of course, even accurate expression can be invalidated, resulting in significantly increased negative emotion and risks for dysregulation. Thus, socially, managing emotion includes building satisfying and primarily validating relationships and seeking validation and support as needed. Overall, then, emotion regulation includes managing one’s life to be able create many events that are satisfying; managing emotions well even when they are

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not satisfying; and effectively building social relationships that are meaningful, genuine, and primarily validating, while being able to tolerate being invalidated. DBT is designed to help people learn to regulate their own emotions by learning skills matched to each step noted above, which in turn facilitates their self-management of cognition, overt behavior, and relationships. Thus, DBT at its core is about helping people learn psychological and social skills to regulate their emotions effectively, in the service of their genuine goals, and learning key mindfulness and emotion-regulation skills are considered the primary mechanisms of change in DBT. The key skills in DBT (mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness; Linehan, 2015) at first glance may appear distinct, but they form a nearly complete set of overlapping skills designed to help a person manage attention, emotion, cognition, relationships, and overt behavior in daily life. Increased skill use and mastery have been shown to have a significant impact on reducing emotion dysregulation, and DBT skills use has been shown to fully mediate decreases in suicide attempts and depression and increases in control of anger as outcomes (Neacsiu et al., 2010). In addition, Mancke et al. (2018) found that DBT (more than treatment as usual) increased gray matter volume of particular brain regions that are thought to be central to emotion regulation and higher order functions.

CONCLUSION The intervention approaches reviewed in this chapter, including PR, DB, CART, midfulness-based interventions, and DBT, provide a variety of interventions to help people regulate their emotions and associated physiological arousal. Each of these sits in commonality with the others in some ways yet also provides distinct theoretical and practical advantages in certain situations or with particular patients. PR procedures guide the systematic tensing and releasing of specific muscle groups throughout the body to induce physical muscle relaxation directly. DB procedures also aim to regulate unnecessary physiological arousal directly. However, DB techniques target improved physiological regulation by teaching the deliberate slowing and deepening of increasingly even and steady breathing patterns. CART procedures offer an important alternative to DB techniques because, for some individuals suffering from hyperventilation, deliberate deep breathing may result in an overcompensation that inadvertently perpetuates hyperventilation even further. Instead, CART procedures directly improve physiological regulation by correcting dysregulated respiration patterns of hyperventilation, thereby improving the regulation of fear and anxiety-related emotional states. Mindfulness-based interventions teach ancient Buddhist mindfulness meditation practices in a modern-day, secular fashion. These practices theoretically promote full mind–body system regulation, allowing for adaptive mindful responding to external and internal stressors as well as disengagement from dysregulating mental phenomena, such as



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depressive rumination and worry. In DBT, mindfulness and emotion regulation skills in particular (along with distress tolerance and interpersonal skills) allow one to interrupt quickly rising negative emotional arousal purposefully and effectively before becoming dysregulated and then manage (i.e., allow/accept or modulate) ordinary or primary emotional reactions in the service of longterm goals.

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women with borderline personality disorder. Journal of Psychiatry & Neuroscience, 43(3), 171–181. https://doi.org/10.1503/jpn.170132 Marlatt, G., & Kristeller, J. (1999). Mindfulness and meditation. In W. R. Miller (Ed.), Integrating spirituality into treatment: Resources for practitioners (pp. 67–84). American Psychological Association. https://doi.org/10.1037/10327-004 McCallie, M. S., Blum, C. M., & Hood, C. J. (2006). Progressive muscle relaxation. Journal of Human Behavior in the Social Environment, 13(3), 51–66. https://doi.org/ 10.1300/J137v13n03_04 Meuret, A. E., Rosenfield, D., Hofmann, S. G., Suvak, M. K., & Roth, W. T. (2009). Changes in respiration mediate changes in fear of bodily sensations in panic disorder. Journal of Psychiatric Research, 43(6), 634–641. https://doi.org/10.1016/j. jpsychires.2008.08.003 Meuret, A. E., Rosenfield, D., Seidel, A., Bhaskara, L., & Hofmann, S. G. (2010). Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity. Journal of Consulting and Clinical Psychology, 78(5), 691–704. https://doi.org/10.1037/a0019552 Meuret, A. E., Wilhelm, F. H., Ritz, T., & Roth, W. T. (2003). Breathing training for treating panic disorder: Useful intervention or impediment? Behavior Modification, 27(5), 731–754. https://doi.org/10.1177/0145445503256324 Meuret, A. E., Wilhelm, F. H., Ritz, T., & Roth, W. T. (2008). Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder. Journal of Psychiatric Research, 42(7), 560– 568. https://doi.org/10.1016/j.jpsychires.2007.06.005 Meuret, A. E., Wilhelm, F. H., & Roth, W. T. (2004). Respiratory feedback for treating panic disorder. Journal of Clinical Psychology, 60(2), 197–207. https://doi.org/10.1002/ jclp.10245 Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17(3), 192–200. https:// doi.org/10.1016/0163-8343(95)00025-M Morone, N. E., Greco, C. M., & Weiner, D. K. (2008). Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain, 134(3), 310–319. https://doi.org/10.1016/j.pain.2007.04.038 Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832–839. https://doi.org/10.1016/j.brat.2010. 05.017 Nhất Hạnh, T. (1975). The miracle of mindfulness: A manual on meditation. Beacon Press. Paul, G. L. (1966). Insight vs. desensitization in psychotherapy. Stanford University Press. Paul, G. L. (1969). Physiological effects of relaxation training and hypnotic suggestion. Journal of Abnormal Psychology, 74(4), 425–437. https://doi.org/10.1037/h0027746 Paul, G. L., & Trimble, R. W. (1970). Recorded versus “live” relaxation training and hypnotic suggestion: Comparative effectiveness for reducing physiological arousal and inhibiting stress response. Behavior Therapy, 1(3), 285–302. https://doi.org/10. 1016/S0005-7894(70)80108-3 Pawlow, L. A., & Jones, G. E. (2005). The impact of abbreviated progressive muscle relaxation on salivary cortisol and salivary immunoglobulin A (sIgA). Applied Psychophysiology and Biofeedback, 30(4), 375–387. https://doi.org/10.1007/s10484005-8423-2 Piet, J., & Hougaard, E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 31(6), 1032–1040. https://doi.org/10. 1016/j.cpr.2011.05.002

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13 Relapse Prevention John Ludgate

C

ognitive behavioral therapy (CBT) is an efficacious treatment and is considered a first-line treatment for many psychological disorders in both research trials (Butler et al., 2006; Hofmann et al., 2012) and clinical practice (Stewart & Chambless, 2009). Short-term outcomes have consistently demonstrated favorable results, and CBT packages have, in some cases, demonstrated durability in that recovery is sustained over time. However, an important need remains in CBT implementation: how to go beyond basic methods to enhance and optimize long-term outcome and prevent relapse. This is a significant challenge for CBT moving forward, but there are encouraging signs of progress on this front, which are reviewed in this chapter. The literature on predictors of relapse in CBT, theoretical models, and clinical insights from practitioners in this field will be integrated in this chapter to provide methods and procedures that can optimize long-term outcomes and reduce relapse risk.1

HISTORY In psychotherapy research in general, a paucity of attention has been paid to the problem of relapse, which is common after psychotherapy in substance abuse, recurrent depression, and chronic conditions. A good deal of research has been done on dropouts from, attrition from, and nonresponse to acute Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-013 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  385 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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therapy, but the literature on the important issue of relapse prevention has been sparse from a research perspective and regarding the development of theoretical perspectives and clinical procedures to help prevent relapse and recurrence after successful treatment. Although these observations are probably accurate concerning psychotherapy in general, literature on cognitive behavioral relapse prevention is beginning to accumulate. Because of the well-documented high incidence of relapse in the areas of addictions and depression, there was an early focus in CBT on how to prevent this in the treatment literature in these fields. Relapse-prevention strategies were described in early protocols for depression (A. T. Beck et al., 1979). Also, the earliest trials of cognitive therapy (CT) for depression included systematic follow-ups of 1 to 2 years (Blackburn et al., 1986; Evans et al., 1992; Kovacs et al., 1981; Simons et al., 1986) to examine CT’s efficacy in sustaining recovery/ remission. In the field of substance abuse, considerable attention was given to relapse prevention by CBT researchers and practitioners, culminating in Marlatt and Gordon’s (1985) seminal edited volume titled Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. Also, there was considerable emphasis on the problem of relapse and how to target this therapeutically in early treatment guides for the treatment of sex offenders (Laws, 1989). The growing interest in this issue was seen in the emergence of an edited book titled Principles and Practice of Relapse Prevention (Wilson, 1992), with chapters on depression, eating disorders, schizophrenia, pain, marital distress, and several anxiety disorders. In recent years, there has been even greater emphasis on this topic, as evidenced by Antony et al.’s (2005) edited book entirely dedicated to this topic entitled Improving Outcomes and Preventing Relapse and the emergence of several specific guides on how to maximize relapse prevention in adult depression and anxiety (Ludgate, 2009), depression in children and adolescents (Kennard et al., 2016), substance abuse (Bowen & Chawla, 2011; Daley & Douaihy, 2015), posttraumatic stress disorder (PTSD; Duckworth & Follette, 2012), and sex offenders (Laws et al., 2000). Strategies that can augment relapse prevention and sustained recovery in depression, such as mindfulness (Segal et al., 2002) and maintenance CBT (Jarrett et al., 2001), have been also described in seminal articles.

DEFINITION OF TERMS Klerman (1978) suggested that relapse refers to a return of symptoms within 6 to 9 months after remission (i.e., a reemergence of symptoms of the original episode), whereas recurrence refers to a return of symptoms after a period of 6 to 12 months of remaining symptom free (i.e., a new episode). This distinction has the benefit of helping avoid confusion when different studies define these terms differently and so facilitates the interpretation of the literature. In addition, Brownell et al. (1986) pointed out that there are two definitions of the word relapse, each reflecting a bias concerning its nature and severity. The first



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is “a recurrence of symptoms of a disease after a period of improvement” (p. 765), which refers to a specific outcome and implies dichotomous categories of well versus ill. The second definition is “the act or instance of backsliding, worsening or subsiding” (p. 765), which refers to a process rather than an outcome and implies that something less serious (e.g., a slip, mistake, or regression) has occurred, which in turn may or may not lead to a full relapse. Whether the process or outcome definition of relapse is chosen has obvious implications for the conceptualization, prevention, and treatment of relapse. Viewing relapse as a process and not as an outcome implies that there are choice points in the process where the therapist and patient can intervene. Therefore, the initial stage may involve a lapse, which might mean the reemergence of a previous habit or set of symptoms. This stage may or may not lead to a full relapse. Whether this occurs is related to the degree to which corrective action is taken and how successful this action is. Put simply, the patient’s response to the initial lapse will determine whether relapse will occur. The definition of relapse as a process is consistent with the theoretical underpinnings of cognitive behavioral approaches, which focus on the acquisition of selfmanagement skills so that the relapse can be prevented or attenuated. In contrast, the definition of relapse as a recurrence of a disease is more consistent with a medical model of emotional disorder.

UNDERLYING THEORY Marlatt’s model, initially proposed in 1985 by Marlatt and Gordon and developed further by Marlatt and Donovan (2005), has been very influential. It proposes that a number of variables interact significantly in the relapse process. Some variables are intrapersonal (e.g., negative emotional states, motivation, coping, outcome expectancies, craving, self-efficacy), and others are interpersonal (e.g., social pressure, exposure to substance cues, interpersonal conflict). According to this model, several cognitive factors interact in this process of relapse, including self-efficacy, outcome expectancies (i.e., prediction of the outcome of certain acts or behaviors), and attributions of causality (i.e., the patient’s view of whether the substance misuse behavior was seen as due to internal factors, such as behavioral choices or coping efforts, or external factors, such as disease or environment). In this model, an abstinent patient who encounters a negative emotional state (e.g., loneliness), has an interpersonal conflict, or experiences social pressure to use is called upon to use their coping skills. If they succeed, perceived control and self-efficacy increase; conversely, if they fail, there is a decrease in self-efficacy, which in turn increases the probability of relapse. Individuals’ reactions to a slip and their attributions regarding why this occurs are determining factors in the escalation of a slip into a full relapse. Following this model, therapy is focused on teaching patients selfmanagement, which includes identifying unique risk factors and rehearsing coping and managing those factors.

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Marlatt and Gordon (1985) also posited the “abstinence violation effect,” which involves giving up on the pursuit of behavior change in the face of a setback. Marlatt and colleagues proposed seeing the lapse as the first stage, with the possibility of either prolapse (i.e., moving forward) or relapse (i.e., further slipping back into a full-blown return of problems/addictive behaviors). Instead of viewing a slip as an irreparable failure, patients (and therapists) can see these slips as learning experiences that are expected and can ultimately improve their maintenance efforts and outcomes. A similar phenomenon can be seen in patients with emotional disorders who relapse and have negative cognitions concerning the setback or themselves for having the setback that exacerbated their relapse. This has important treatment practice implications. It is believed by researchers and practitioners following this theoretical model that one danger in using the term “relapse” is the implication that there are only two states regarding maintaining change—namely, success and failure. The alternative view is that change may involve a series of ebbs and flows, so patients can normalize and work with these effectively and not perceive it as failure. This model has been adapted by Wilson (1992) as an approach to depressive relapse, by Ludgate (1994) for relapse prevention in depression and anxiety, and by Emmelkamp et al. (1992) for relapse prevention in obsessive-compulsive disorder (OCD). Shiffman (1989), also in the field of substance abuse, posited three factors as being important in relapse: (a) enduring personal characteristics (e.g., coping style, personality), (b) background variables (e.g., life events), and (c) precipitants (e.g., thoughts and feelings related to a particular relapse episode). He suggested that all need to be assessed and their interaction charted. Ludgate (1994) adapted this model for understanding depressive relapse. In addition to monitoring the three factors above, it was suggested that measures of selfefficacy and skill in coping should be assessed early in treatment and a comprehensive risk analysis carried out. The patient’s previous history of depression plus their cognitive vulnerability (e.g., dysfunctional attitudes and attributional style) and motivation to change would also be important to assess during treatment. Therapy could then be tailored to what is required for the particular patient with their risk of relapse established. Decisions may be made regarding length of treatment, advisability of maintenance or continuation CBT, the need for motivational interviewing (MI) to increase motivation, the emphasis on dysfunctional beliefs or attributional style, and efforts to increase self-efficacy. In his consideration of depressive relapse, A. T. Beck (1976) in his early writings suggested that because dysfunctional attitudes may predispose individuals to both initial and subsequent episodes of major depressive disorder, CT (now generally referred to as CBT), which targets these, should be expected to reduce relapse. Blackburn et al. (1986) argued that because CBT involves the acquisition of self-regulatory skills, it would be expected to prevent recurrence. Patients who have undergone successful CBT will have learned skills (e.g., thought identification and modification) that can be applied to new episodes of mood disturbance after treatment ends, which gives them some form of protec-



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tion from relapse. Empirical evidence suggests that many skills acquired in CBT indeed reduce relapse risk, including CBT-based coping skills and evidence of clients’ intentions to implement these skills in their lives (Strunk et al., 2007) and decentering (i.e., the ability to observe internal states as temporary events in one’s mind rather than reality; Fresco et al., 2007). Segal et al. (2002) introduced the idea of mindfulness as an important adjunct to CBT, as it creates a metacognitive skill that would likely reduce the risk of relapse in depressed patients in recovery because they would be more aware of negative thoughts and feelings of dysphoria at times of potential relapse and, crucially, respond to them in ways that allow them to disengage from ruminative or catastrophic processing involving overgeneralized memories, black-and-white thinking, and other thinking styles. In essence, this decentering approach of not engaging with negative thoughts should help patients avoid hopeless and negative thinking about their prodromal symptoms, which can then result in further escalation of depressive symptoms. Research, which is reviewed later, has clearly demonstrated the efficacy of using mindfulness in addition to CBT in reducing relapse potential or risk.

DESCRIPTION OF MAIN PROCEDURES As has been noted previously, there has been a great deal of emphasis on relapse prevention in the clinical literature on addictions (Marlatt & Gordon, 1985). In addition, a number of scholars have described how maintenance and relapse prevention can be built into a comprehensive treatment of depression (Kennard et al., 2016; Rowa et al., 2005) and anxiety (McCabe & Antony, 2005; Waters & Craske, 2005). The distinctive features of maintenance treatment, including the need for increased patient responsibility in the maintenance phase (Shiffman, 1992), have been described. Some concrete suggestions for improving longer term outcome, incorporating into clinical practice data related to research on predictors of relapse, are now available (Jarrett et al., 2001; Rowa et al., 2005; Segal et al., 2002). Attempts to describe specific strategies for maintenance and relapse prevention in anxiety disorders have been sporadic and few in the early history of CBT (e.g., Öst, 1989). However, in recent years, there have been several accounts of how CBT can incorporate a more specific relapse-prevention focus in panic disorder (McCabe & Antony, 2005), social anxiety disorder (Ledley & Heimberg, 2005), generalized anxiety disorder (Waters & Craske, 2005), OCD (Franklin et al., 2005), and PTSD (Feeny & Foa, 2005). Knowledge of predictors of relapse or sustained recovery can guide good clinical practice in terms of relapse prevention. For example, studies done on dysfunctional attitudes and relapse (Jarrett et al., 2012) suggest that unless patients’ maladaptive attitudes or beliefs are identified and modified in therapy, patients who have improved symptomatically may still be at risk for relapse after treatment, especially if they are experiencing a temporary negative mood state (Segal et al., 2006). It may be that psychotherapy that produces symptom

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relief only is less than adequate treatment in terms of long-term outcome. Although no studies have addressed this issue empirically, it seems likely that inadequate conceptualization and the application of CBT in a rigid, overtechnical manner is associated with a higher relapse. The literature shows that the following factors may be important in the relapse process and should be targeted for intervention in a comprehensive treatment approach: (a) the patient’s personal resources and skills and their perception of these resources and skills; (b) external resources, including support systems such as family, friends, community, and professional help, and the perception of these resources; (c) life events/stressors and the patient’s perceptions of these events; (d) residual symptomatology at the end of treatment; and (e) residual or continuing cognitive deficits or distortions, such as dysfunctional beliefs, biased information processing, or negative attributional style at conclusion of treatment (Ludgate, 2009). In the case of depression, it has been found that the following are predictors of relapse: (a) higher levels of residual depression, (b) hopelessness, (c) dysfunctional attitudes, (d) global and external attributional style, (e) lack of self-efficacy or belief that one has skills to deal with future problems, (f) more environmental stress/negative life events following therapy, (g) less satisfaction with life roles, and (h) less social support (Ludgate, 2009). The implications of these findings in terms of maintenance and relapse prevention are as follows: • Before termination, therapy should be focused on correcting those cognitive distortions (including dysfunctional attitudes and attributional style) that predispose to relapse after therapy. • Residual depressive symptoms and hopelessness should be addressed before therapy is terminated. • General problem-solving skills should be taught and practiced regularly. • Self-efficacy and perception of ability to use self-control methods should be fostered. • Future life stressors should be anticipated and planned for where possible. • Significant others should be involved in treatment, if possible, and support systems set up before therapy ends. • Therapy should be focused on life roles and lifestyle and promote change in these areas, where necessary. Although there are no studies addressing the issue of the effects of MI (Miller & Rollnick, 2012) in producing sustained recovery, it might be expected that, given that CBT augmented by MI during the early stages of therapy has been found to enhance short-term outcome in anxious and other patients (Miller & Rollnick, 2012; Westra, 2012), the addition of MI at various stages of treatment or when motivational difficulties arise might also benefit long-term outcome regarding maintenance and relapse prevention.



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It is probable that patients will do better over the long term if they either have fewer stressful life events or deal better with them, so treatment should focus on modifying behaviors to make these less likely or increase the patient’s perception that they are in possession of coping skills that will help in dealing with the challenges produced by stressors. This would involve training patients in metacognitive skills: the ability to reflect on one’s own thinking, to evaluate the accuracy of specific thoughts, and to generate alternatives that can be logically or empirically tested. The learning of specific coping responses is likely to give patients a sense of control over their depression. This may, in turn, help prevent the “depression about depression,” which often occurs when patients experience some mild recurrence of symptoms after treatment. Negative life events have also been implicated in the long-term outcome of patients treated for anxiety disorders; factors in the interpersonal domain (e.g., rejection, loss, marital conflict) and physical/health area (e.g., childbirth, surgery, loss of health) have also been cited as important in the long-term outcome of anxiety disorders (Waters & Craske, 2005). Rapee (1991) hypothesized that information-processing deficits are implicated in the maintenance of anxiety disorders. For example, patients with generalized anxiety disorder are hypothesized to be particularly likely to associate various stimulus information with threat. In addition, threat-sensitive patients also have been found to have a perception of uncontrollability over threatening events. According to the cognitive model, the interaction of these two factors may predispose individuals to experience clinically significant levels of anxiety. As a consequence, psychotherapy that aims to prevent relapse should focus on identifying and correcting faulty beliefs regarding the presence of threat and uncontrollability. Predictors of poorer long-term outcome include residual avoidance behavior after treatment, comorbidity with depression, and attributional style (Ledley & Heimberg, 2005; McCabe & Antony, 2005). One predictor of positive longer term outcome in panic disorder is changes in anxiety sensitivity, or the degree to which individuals are fearful of sensations associated with panic attacks, during therapy (McCabe & Antony, 2005). Essentially, the implication of the above is that, in the treatment of anxiety disorders, procedures that target the crucial cognitive vulnerabilities, associated marital or interpersonal issues, and remaining behavioral issues (avoidance) that maintain the anxiety are likely to reduce the risk of relapse.

PRACTICAL STRATEGIES FOR RELAPSE PREVENTION Some specific relapse-prevention strategies in the different stages of CBT are described here. They are applicable to patients with emotional disorders. Patients with other disorders such as substance abuse may also benefit from disorder-specific interventions, such as urge-surfing (Bowen & Chawla, 2011; Daley & Douaihy, 2015).

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In the early stages of therapy, the therapist should • utilize MI as appropriate to address issues of commitment, readiness, and self-efficacy regarding change; • foster the idea that CBT involves a skills-training approach, which will aid patients in “becoming their own therapist”; • emphasize the importance of collaboration and patient activity in the therapy process, as well as the notion that between-session assignments are vital in practicing skills that will arm patients for future episodes; and • assess the relapse risk for each patient and make decisions concerning the content and duration of sessions plus the need for maintenance or continuation CBT. Throughout therapy, there should be an emphasis on • learning to manage negative emotions and dysfunctional thoughts in a skill-building manner, • monitoring patient progress collaboratively, • creating internal attributions regarding change or progress, • regularly reviewing skills and the patient’s perception of their skills, • facilitating the generalization of skills, and • increasing the emphasis on between-session practice and a more active patient role in sessions. In the later stages of therapy, the following strategies are important: • identifying and preparing for the management of high-risk situations • recognizing and managing early warning signals of lapse/relapse • rehearsing and practicing an emergency plan • working on vulnerability factors (dysfunctional attitudes and maladaptive schemas) • managing lifestyle imbalance – It should be noted that although this focus in the later phase of therapy is advisable for all CBT patients, when the risk of relapse is considered high, these procedures (i.e., recognizing early warning signs, identifying high-risk situations, and practicing an emergency plan) become critical. • introducing mindfulness and giving a rationale for its importance in preventing relapse – The rationale given may include the fact that research has found that patients who have a history of recurring depression who learn and utilize mindfulness practice are less prone to recurrence of their depression.



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Because mindfulness trains individuals in how to pay attention to what is happening in the present moment without judgement and evaluation (Kabat-Zinn, 2013), it increases awareness of when emotions/feelings or symptoms are changing, perhaps getting worse, without creating judgmental or hopeless, negative thoughts such as “I am weak” or “I am going to end up severely depressed again,” which, in turn, can increase depression and interfere with constructive action to reduce depressive symptoms. A good description of mindfulness-based cognitive therapy (MBCT) for patients can be found in Williams et al. (2007). • creating a sound support system • rehearsing an action plan to deal with possible future negative life events/ stressors Although research has not been carried out in identifying which elements of the array of procedures described above are critical for relapse prevention, on the basis of clinical experience and in line with suggestions in the literature, it is suggested that the following have considerable merit and should be a regular part of relapse-prevention therapeutic efforts: • reviewing progress and skills, prompting internal attribution for change, discussing generalization of skills to new situations, and fostering an increased sense of self-efficacy • identifying early warning signs, socializing the patient to the idea of relapse and recurrence as a process, and setting up a monitoring system • anticipating high-risk situations, developing a plan to deal with these, and rehearsing cognitive and behavioral responses to setbacks (i.e., “emotional fire drill”) In clinical practice, the metaphor of recovery as a road or journey can be helpful to illustrate to patients the fluid application of skills and techniques outlined previously (Ludgate, 2009). For example, the therapist might say to the patient, If you think of the process of sustained recovery as being like a long journey, this will help you realize that, although recovery or maintenance may take time and effort, you will eventually get to your destination. Now, just like on a journey, the first thing to be decided is your destination. Similarly, in terms of your emotional health or problems, what do you ultimately want to achieve? On a long journey, you may have to plan several stages, such as places you would stop overnight or take a break. What are your shorter term goals? Where do you want to be in 1 month, 3 months, or 1 year? Setting out on a journey, you have a departure point, for example, home, overnight stop, and so on. From where are you starting? Where are you in terms of solving the problems you have? On a car journey, you would probably check that you had the right tools for the journey, such as a jack to change a tire, a flashlight, and so forth. What are the tools or skills that you bring with you on your journey? When you are driving, there are certain things to look out for that warn you that you might break down, such as the oil light, fuel light, knocking noise from the engine, and so on.

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What are early warning signs suggesting that you are slipping back emotionally to which you need to pay attention? On a road journey, there are a number of possible hazards that you need to be aware of and then take appropriate corrective action, such as other drivers’ behavior or bad road conditions that prompt you to slow down and be more vigilant. Likewise, there are certain high-risk situations in terms of relapse for which you need to recognize and prepare. What are these situations for you? Lastly, it is possible on a journey that your car may break down or you may take a wrong turn. At this point, you need to be a problem solver rather than become upset and incapacitated; for example, you might call someone to help rather than angrily kick the stranded car. Though you may never have to use it, it will be helpful for you to have a plan if you have some recurrence of symptoms or problems. What is your emergency plan in the event of a lapse that will get you back on your journey?

This extended metaphor can be adapted or elaborated for certain formats or patient populations. Other appropriate analogies or metaphors pertaining to relapse and recovery can also be incorporated into relapse-prevention work at different stages of therapy (Marlatt & Gordon, 1985). An additional strategy, which can be of therapeutic benefit, is helping the patient plan continuing self-therapy. In addition to the specific plans generated to deal with setbacks, patients should also be asked, “How can you continue to use the skills you have learned in therapy in your everyday life?” They should be encouraged to write down ways of practicing the skills they have learned and instructed to record a step by-step self-therapy plan. For example, an anxious patient might develop the following list of activities to be continued after therapy: (a) do breathing exercises once a day, (b) write down and respond to thoughts when I am anxious, (c) read over old therapy notes once a month, and (d) do one thing I really enjoy every day. Among other therapy activities that the patient can continue doing might be filling out thought records, listing accomplishments, setting specific goals, making plans to reduce avoidance, partaking in graded exposure tasks, identifying costs and benefits of behaviors, selfmonitoring, activity scheduling, and posting reminders containing revised beliefs or adaptive cognitions. The costs and benefits of such efforts can be examined with the patient. The advantages of making self-therapy a priority, even when feeling well, need to be stressed. The analogous situation of medical patients stopping necessary long-term medication when feeling better can be used to underscore this point. Also, the evidence that old habits tend to return if replacement habits are not practiced regularly can be cited. To formalize these maintenance efforts, patients can set a daily or weekly appointment with themselves, modeled on their actual therapy sessions. They can put aside 30–60 minutes for these sessions on a regular basis, such as every day, week, or month. The act of making this time available tends, by itself, to make the patient’s emotional state a priority. During self-therapy, in line with recommendations made by J.  S. Beck (2011), the patient can be encouraged to structure sessions in the following manner: (a) set an agenda (i.e., “What do I need to think about?”), (b) review any homework (i.e., “What have I learned?”), (c) review the week (i.e., “What positive/negative things happened? How could I have handled things better?



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What tools did I use?”), (d) engage in self-monitoring (i.e., “How am I doing with depression, anxiety, or specific symptoms or problems?”), and (e) target problems (i.e., “What problems do I need to work on? What exactly is going on? What are the triggers, my thoughts, and feelings? What can I do?”). In the later phase of active therapy, the therapist can fade therapy sessions so that the sessions become less frequent or of shorter duration. The reduction in frequency and/or duration of therapy sessions encourages the patient to increase their coping efforts and take more responsibility for solving problems or dealing with emotional distress. Following the end of the acute phase of therapy, the patient and therapist may decide collaboratively to set up booster sessions for a specified or as-needed follow-up period. Research studies have demonstrated superior clinical outcome with the use of continuation CBT (e.g., Jarrett et al., 2001). There are many advantages to conducting regular booster sessions. If booster sessions are spaced out less frequently than therapy sessions, patients may be encouraged to cope with difficulties on their own first, but with the knowledge that they can discuss these efforts in the next booster session and receive suggestions and feedback. Booster sessions give some continuity to treatment, and they also reinforce the concept of recovery as being a long-term process of coping and dealing with problems as they arise. With booster sessions, patients may be more likely to continue maintenance efforts because of their increased accountability as well as the reinforcement ensuing from therapist contact. Booster sessions allow the therapist an opportunity to monitor the patient’s progress and to take action, if necessary (e.g., increase the frequency of sessions, consider medication changes). A sound rationale needs to be given to the patient for booster sessions that incorporates some of these stated advantages. Booster sessions can be carried out face-to-face (in individual or group formats) or by telephone. If other preferred methods are impossible, the patient and therapist in unusual circumstances might even use email, phone calls, texting, tapes, or letters to continue contact in the aftercare phase. In addition to booster sessions, some continued contact by the therapist with significant others (with the patient’s permission) might be used to monitor the patient’s progress. In some cases, it may be important to stress the importance of booster sessions to the patient, even if they may not think it is necessary. Even when the patient is feeling well, they can be encouraged to see these sessions as a preventive measure in the way that a medical checkup (wellness visit) or car maintenance is helpful. To maximize the benefits to patients, it is important that booster sessions be well structured and that the patient actively prepare for the session. Patients can be given some guidelines before therapy ends about how to maximize the value of these sessions. They can be encouraged to develop a plan for booster sessions and to bring items for the agenda and to write them down so they will not forget in the longer intervals between these sessions. Following the suggestions made in some cognitive therapy practice guides (J. S. Beck, 2011; Wilson, 1992), patients can be encouraged to ask themselves

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the following questions in advance in an effort to prepare for and maximize the effectiveness of these booster sessions: • What has gone well for me since the last booster session? • What problems have arisen recently, and how did I handle them? • How could I have coped better? • What problems could arise in the near future or before my next booster session? • What have I done to maintain my progress after therapy? • What gets in the way of maintaining my skills? • What else might I do? • What goals do I have for myself? • What specific plans do I have to achieve these? • What issues do I want to discuss with my therapist over and above the problems I have identified here? As alluded to previously, research has revealed that, especially with patients who have residual symptoms of depression at the end of treatment, who have unstable remission, or who have a history of recurrence, a continuation phase of CBT can help reduce the risk of relapse relative to ending treatment after the acute symptoms have responded in the short term (Jarrett et al., 2001). It has been recommended that, in this phase of therapy, the emphasis should be solidly on maintenance and relapse prevention and on promoting general skills and self-efficacy. In addition, residual symptoms and cognitive vulnerabilities can be targeted, rather than discrete problems encountered. In a sense, the therapist is more of a consultant at this point. The patient should be very active in this phase of therapy, working both on developing plans for applications of intervention skills to future situations and on modifying remaining unhelpful beliefs, which may predispose the individual to future problems. In essence, these sessions may be quite similar to booster sessions and may be held at regular intervals, though somewhat less often than during the acute treatment phase to facilitate self-maintenance efforts. One difference may be in the content of these sessions; in the case of continuation therapy, it may be quite different from acute phase CBT, whereas in booster sessions it may be more similar, with some greater emphasis on the patient planning the content and frequency of the sessions. Continuation or maintenance CBT may often be used in conjunction with maintenance medication (i.e., continuing medication well beyond the point of remission in patients with a history of recurrence or relapse), in line with research suggesting that both can be efficacious in preventing relapse. When this is the aftercare plan, psychotherapy can address issues related to medication compliance and beliefs about continuing to take medication, in addition to the other issues outlined above.



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It may be important to outline helpful strategies with a patient who returns to active therapy following a relapse (Ludgate, 2009). The therapist’s task here is to conceptualize and help the patient understand the relapse process. Other important objectives are to help restructure the meaning of the relapse, to encourage the patient to apply all of their coping skills appropriately, to determine the need for more therapy sessions or medication, and, most importantly, to reinstall a sense of self-efficacy in the patient who is discouraged and demoralized. Often such patients will need cognitive interventions to reappraise slipping back or experiencing some symptom recurrence so that they do not react very negatively to this experience. Informing patients that relapse is not infrequent after termination, especially in inpatients or outpatients who have been in therapy for a long time, may be useful in getting patients to put this in perspective. It will also be helpful to provide an explanation of how this lapse occurred in the patient’s case, particularly if this explanation stresses external factors rather than personal deficits in the patient. Patients who relapse are often discouraged and experiencing a loss of morale. In such cases, the therapist should carefully explore the patient’s cognitions and expectations regarding recovery and relapse. Patients may have unrealistic expectations, such as “I am now over my depression and will never feel bad again” or “It shouldn’t be this hard.” Patients who expect their progress to be linear may become self-pitying, angry, or discouraged when negative feelings recur and, thus, may become unable to problem solve. Some patients will also expect that negative thoughts will not reemerge after therapy or that they will always be able to combat them quickly and effectively. A win-win situation can be set up by the therapist by giving the patient the following message: Old habits, such as certain negative thoughts or behaviors, are likely to recur. If you can deal with them successfully, this is the best outcome. But if you cannot, this will also be helpful, as it will give some useful information on the kind of thinking or actions that keep you depressed, which can then be worked on in booster sessions or at other times when you are less distressed.

The therapist should be alert for perfectionist or defeatist attitudes in patients who respond to the reemergence of negative thoughts or unpleasant affect states with either hopelessness or anger (often toward themselves). Such patients can be shown how self-defeating these responses are in contrast to a problem-solving approach. A cost-benefit analysis that contrasts continuing to work on one’s problems versus giving up can be carried out at this point in an attempt to get the patient to actively decide to continue their maintenance work rather than give up. It is also necessary to prepare the patient for situations like the above by letting them know that the ability to reduce negative feelings and to answer negative thoughts will take time and a good deal of practice. The analogy can be made with other skills familiar to the patient, such as learning to drive or play a sport. The patient can be told the following: When you first try [this particular skill/activity], you have to work very hard in a self-conscious way to avoid making mistakes. You may get temporarily distressed by anything difficult or unusual at this point. Later, with practice, you

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will be able to deal more easily with harder situations, and you will also find that your responses become more automatic. The difficulties and mistakes made earlier are actually a chance to practice and learn.

Some patients, in addition to having somewhat unrealistic expectations about the course of their disorder or recovery, will see related situations in a black-and-white or all-or-nothing way. If they experience some symptom recurrence, they may have cognitions such as “I’m just back to square one” with the resultant belief that “I can now do nothing except go back to the clinic or hospital.” All-or-nothing thinking, in combination with an external attributional style regarding change, is particularly destructive in terms of hopelessness. The belief that any lapse constitutes complete failure leads patients to cease any efforts to help themselves and to resign themselves to a deteriorating course predicted by the belief system. The therapist should actively intervene and help patients reshape this dichotomous thinking and encourage patients to recognize small and subtle changes. In the event of a setback, it is important to encourage patients to examine exactly how far they have slipped back relative to the start of treatment and to see what was in any way positive in their response (e.g., “I didn’t run from the store this time”), as well as what was negative in their response (e.g., “I had a severe panic attack”). Lastly, for such patients, a key element in getting them back on track is helping them see relapse not as a single event but as a process with choice points where they, with the therapist’s help, can intervene successfully. It is also helpful for therapists working with patients who have relapsed to consider the following: (a) avoid labeling or stereotyping the patient; (b) persist with the model, even when relapse/setbacks occur; (c) identify and deal with any therapist dysfunctional cognitions (e.g., “It’s my fault or the patient’s fault”); (d) be realistic in expectations, as relapse is common even with good therapy; and (e) seek support or advice from colleagues, as necessary.

OUTCOME DATA Standard CBT In a comprehensive review of the literature, Hollon et al. (2006) concluded that (a) CBT appears to have an enduring effect in the treatment of depression and anxiety disorders and reduces the risk for subsequent symptom return; (b) there is clear documentation of reduced risk relative to medication for depression, panic disorder, social phobia, and OCD; and (c) there is also evidence of stability of gains for several other anxiety disorders. It is first helpful to consider naturalistic studies of depression before examining the data on long-term outcome in CBT. Depression has been found to be a condition in which recovery following treatment is common, but recurrence is also common. Depression has an inherently chronic and recurrent nature. Individuals who recover fully have a 40% to 50% likelihood of having a second episode, and for those with a history of two or more episodes, relapse rates as high as 60% to 70% are frequently observed (Solomon et al., 2000).



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Major depression is often experienced in multiple phases: an acute phase, treatment response, episode relapse, and episode recurrent (Frank et al., 1991). Recovery rates of 40% to 50% are seen initially, but the relapse is significant even when maintenance medication is utilized—relapse rates are closer to 50% with maintenance medication versus approximately 70% with short-term medication. This context can help one evaluate relapse rates associated with CBT, which has been found to be efficacious with approximately 50%–70% of patients in the short term (which is roughly equivalent to antidepressant medication effects) and to reduce the relapse risk by approximately 50% in the longer term. (Hollon et al., 2006; Ludgate, 2009). Although standard CBT is designed to offset the risk of relapse that occurs in approximately 30% of CBT patients in remission following a course of CBT, treatments that are more targeted to the risk of relapse including MBCT (Segal et al., 2002) and maintenance or continuation CBT (Jarrett et al., 2001) may reduce this risk even further. The empirical support for these approaches is reviewed in the next section. In their review of outcome studies on CT and CBT, Hollon and DeRubeis (2018) concluded that whereas CBT and medication are equally as efficacious in the short term, and both superior to pill placebo (DeRubeis et al., 2005), CBT has an enduring effect not found for medications, with patients receiving CBT about half as likely to relapse. In a systematic review, this effect was seen in seven of the eight trials in which CT was evaluated as a treatment for depression (Cuijpers et al., 2013). Hollon and DeRubeis cautioned, however, that this enduring effect has not been observed so far when combining CT and medication, which is a common practice. Specifically, Hollon et al. (2014) found that adding CBT to medication enhanced rates of recovery and continued remission for nonchronic patients, who were more severe, but had little effect on patients who were chronic but nonsevere. It is noteworthy that exposure to CBT when patients are receiving medication does not necessarily prevent recurrences (i.e., new episodes of depression; DeRubeis, 2014). Hollon and DeRubeis argued that providing CBT in combination with active medications may inhibit the acquisition of learned resilience in these patients. More research on the mechanism involved is clearly needed. Behavioral activation (BA; Jacobsen et al., 2001) and interpersonal psychotherapy (IPT; Klerman et al.,1984) have also demonstrated reduced relapse risk in depressed patients. Dobson et al. (2008) reviewed studies that followed depressed patients treated with BA and found low relapse rates. In a multicenter National Institute of Mental Health trial follow-up (Shea et al., 1992), relapse rates at 18 months were 36% for CT, 33% for IPT, and 50% for imipramine. The rate of return to therapy was significantly lower for patients who received CT compared with patients who were assigned to the other groups. CBT for patients with bipolar disorder is also associated with a significant reduction in relapse. For example, 1-year relapse rates for CBT with medication and for medication alone were 44% and 75%, respectively. Not only were gains maintained in a second follow-up year, but those receiving CBT with medication were less likely than those receiving medication alone to

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specifically experience a depressive relapse (Lam et al., 2003, 2005). Similar results were reported by Scott et al. (2001). Miklowitz et al. (2007) compared family-focused therapy, IPT, and CBT with a control condition, in which patients were also receiving medication. Over the long term, CBT in addition to medication led to the most positive outcome. Moreover, a study examining the role of CBT in the reduction of suicide risk demonstrated that patients receiving CBT were 50% less likely to repeat suicide attempts in 18-month follow-up compared with patients receiving treatment as usual (Brown et al., 2005). A similar finding was reported in a military setting (Rudd et al., 2015), where it was reported that over a 2-year follow-up, CBT-treated patients were 60% less likely to repeat suicide attempts compared with patients who received treatment as usual. Long-term outcome studies of CBT for anxiety disorders have demonstrated sustained recovery and low relapse risk. In a longer term follow-up of CT for panic disorder, Clark et al. (1994) found CT to be superior to either imipramine or applied relaxation. Nearly 90% of the CT patients were panic free 9 months later, compared with 50% panic free in the imipramine and applied-relaxation groups. For patients with generalized anxiety disorder, Dugas et al. (2003) and Wells et al. (2010) have shown CBT approaches (which also included a focus on tolerance for uncertainty in the former study and metacognition in the latter) to be superior to behavioral approaches and to result in longer lasting and more enduring effects. In a meta-analysis of 37 randomized controlled trials, Öst et al. (2015) found that 65% of patients with OCD who received CBT reported a substantial reduction in symptoms, which was maintained at an average of 15 months follow-up. Examinations of CBT for PTSD have found that relapse is uncommon in the first year posttreatment with either exposure or CBT (Tarrier et al., 1999). Moreover, at a 5-year follow-up (Tarrier & Sommerfield, 2004), CBT demonstrated superiority in that 0% of those subjects met criteria for PTSD, relative to 29% of those who received imaginal exposure. Chard (2005) found only 6% met criteria for PTSD in a 1-year follow-up of cognitive processing therapy (CPT), and Resick et al. (2012) found that 5 to 10 years after treatment, no differences were found between prolonged exposure and CPT, both maintaining the positive outcome found at the end of treatment. Examining CBT for substance abuse, Magill and Ray (2009) conducted a meta-analysis indicating that 58% of patients treated with CBT fared better than patients in other treatment comparison groups and that 79% did better than those who received no treatment in the short term. However, they also found that the effects of CBT diminished over time, with lesser effects at the 6- to 9-month follow-up points and even more diminished effects at the 1-year follow-up point. Epstein et al. (2003) showed that, even though CBT was initially less efficacious than contingency management in the treatment of substance abuse, it had more durable effects 1-year posttreatment. Moreover, with patients with internet gaming disorder, K. S. Young (2013) reported that 78% maintained gains longer term after being treated with CBT.



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Several studies have examined long-term outcome following CBT for personality disorders. For example, Svartberg et al. (2004) studied a mixed group of personality-disordered patients after 40 sessions of CT and found that, at 2-year follow-up, 42% were recovered on symptom measures and 40% showed improvements in interpersonal and personal functioning. Bamelis et al. (2014) compared 50 sessions of schema therapy (J. Young et al., 2006) to other treatments and found an 80% recovery rate at 3-year follow-up. Moreover, Davidson et al. (2010) showed that 50% of patients with borderline personality disorder treated for 1 year with CT were in remission 6 years later. CBT With a Specific Relapse-Prevention Focus The relapse-prevention therapy approach, following Marlatt and Gordon’s model, named relapse-prevention therapy (RP) has received considerable empirical support. In a review of RP studies, Carroll (1996) found that it was more effective than no treatment and equal to other treatments in improving substance abuse treatment outcomes. She found that RP had sustained effects, suggesting that it may provide continued improvement over a longer period of time, termed the delayed emergence effect that has been found in subsequent studies. It was demonstrated in this review that RP could also reduce the intensity of relapse episodes. A meta-analysis conducted by Irvin et al. (1999) found RP to be efficacious both in the short and long term in treating alcohol abuse, smoking, and polysubstance abuse. Moreover, RP has also been shown to be efficacious for depression (Katon et al., 2001), sexual offending (Laws et al., 2000), bipolar disorder (Lam et al., 2003), and panic disorder (Bruce et al., 1999). A series of important studies done by Robin Jarret and her colleagues examined relapse rates following remission in depressed patients treated with CBT. In a study that has important implications for clinical practice, Jarrett et al. (2001) found that adding 10 sessions of continuation CT, with a focus on generalization of skills and relapse prevention, over an 8-month period after remission reduced relapse rates from 31% to 18% over a 2-year follow-up. Vittengl et al. (2009) also showed that when patients who received this continuation therapy were compared with controls at a 16-month follow-up, remission rates improved from 88% to 97% and recovery rates from 60% to 84%. They also noted that most patients who remitted or recovered did not relapse subsequently. Vittengl et al. (2014) examined patients with a high risk of relapse who responded to acute phase CT and were assigned randomly to continuation CT, medication, or pill placebo and followed up with them 24 months later. During the continuation phase, the CT and medication group had lower mean depressive symptoms and were not significantly different. Vittengl et al. (2007), in a comparative meta-analysis of 28 studies that focused on CBT and relapse in major depressive disorder, found that (a) after discontinuation of acute-phase treatment, many responders to CT relapsed (29% within 1 year and 54% within 2 years) and (b) continuation-phase CT treatment reduced relapse by

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21% at end of treatment and by 29% at follow-up compared with acute-phase CT with assessment only after treatment. Another important series of studies has empirically tested the efficacy of MBCT (Segal et al., 2002) in preventing relapse. This treatment combines mindfulness-based stress reduction (MBSR; Kabat-Zinn, 2013), usually administered in groups, with standard CBT treatment for depression. The results have indicated a significant effect on relapse using this approach. For example, Ma and Teasdale (2004) showed that MBCT reduced the relapse risk by half compared with treatment as usual. It was particularly striking in this study that the difference in the risk of relapse was 36% to 37% for the MBCT group versus 67% to 78% for the treatment-as-usual group in patients with three or more previous episodes of depression. In a subsequent study (Segal et al., 2010), patients in remission were assigned to continuation medications, MBCT, or placebo and outcomes were compared in two separate groups: (a) stable remitters (i.e., no symptom flurries during treatment) and (b) unstable remitters (i.e., symptom flurries or symptom fluctuations during treatment). Relapse rates were no different across treatment groups for stable remitters, but in unstable remitters, maintenance medication with a 27% relapse rate and MBCT with a 28% relapse rate were both significantly lower than in the placebo group. It can be concluded that MBCT may confer a particular benefit over time, regarding relapse prevention and sustained recovery in both unstable remitters and in those with a history of several previous episodes of depression. This has important implications for treatment planning in the cognitive behavioral treatment of depression. There are a number of other studies showing that the MBCT approach can reduce relapse in anxiety disorders, which are reviewed by Segal and Ferguson (2018).

DISSEMINATION CBT, in general, has somewhat lagged behind addictions treatment in the past with regard to focusing on the relapse-prevention phase of therapy and in identifying what works and how well it does. However, more recently (i.e., in the last two decades) this situation has improved considerably, as evidenced by the increase in published research in this area, by the emergence of articles and books detailing how to optimize relapse prevention in a number of different disorders that CBT treats, and perhaps most importantly, by the fact that this important clinical topic is better represented now in postgraduate education in evidence-based psychotherapies in general and in CBT training workshops in particular.

CLINICAL EXAMPLE George is a middle-aged man who has a history of depressive episodes. He has had 12 sessions of CBT with this therapist. Sessions have now been spaced out



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to every few weeks, as the client’s depression is largely remitted, and the therapist is now targeting relapse prevention. The following is an exchange that occurred during Session 13. THERAPIST: As part of our agenda for today, I wonder how you would feel

about us reviewing what you have learned and discussing how to keep this going into the future, given that you are now doing better, and also preparing you in case you run into any setbacks later on. How does that sound? GEORGE:

I think that would be helpful because I am a bit anxious moving forward, now that we are meeting less often. Can we also talk about what I can do regarding having more frequent meetings again, if things get a little tough?

THERAPIST:

Absolutely; that will be a part of our planning ahead for preventing relapse or dealing with setbacks effectively. Since there is some anxiety, as you said, our discussion, which will include an action plan, will also help with some worrisome thoughts you might be having as well.

GEORGE:

It will be good to focus on these thoughts, as they come up from time to time, and I don’t want to shut them out. But I also want to have a way to counteract them, so I don’t end up being dragged down by worries about the future or that I might slip up, when I am doing well now. And you and I have worked in here on this mindfulness idea and being in the present, so maybe that’s important.

THERAPIST: That’s an excellent point, George, about the worry about the

future having the potential to interfere with feeling pretty good right now. So, let’s talk about what those thoughts are and when they come to you. GEORGE:

They haven’t come too often recently, maybe once or twice a week. Like a few nights ago, I was trying to get to sleep, and I thought, “What if I get really depressed again like I did last fall? That would be really awful. Maybe I’d end up back in the hospital, and my wife would have to take charge of everything again.”

THERAPIST: So, you thought about the possibility of falling back into depres-

sion, similar to last fall. How did you feel when you had that thought? GEORGE:

Pretty upset, scared, I guess. It was hard to get to sleep after it.

THERAPIST: So, what we are going to do today can help you to have a way of

responding to such thoughts. Then, if they occur moving forward, you can be mindful of them, as we have talked about. Not

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trying to suppress them, but also reminding yourself of a plan, which we will go over in this session. How does that sound? GEORGE:

Good.

THERAPIST:

So, rather than the idea that the depression might reemerge, let’s look at what would let you know that your mood is going down again, particularly anything you might notice early on. Think about the scenario in which your car is running low on gas, and the yellow light comes on somewhere in your dashboard to warn you, which in turn leads you to take action. Similarly, we need to be aware of the warning signs of distress developing, so we can take action sooner rather than later. Does that make sense to you?

GEORGE:

I can see the analogy. In either case (driving or getting depressed again), you need to be alert to what is going on so you don’t wait too long and end up in bad situation, like running out of gas or getting severely depressed.

THERAPIST: That’s exactly right. Now in your case, what are warning signs

that you might be getting a bit depressed again or slipping back? GEORGE:

Maybe not sleeping well and being easily annoyed?

THERAPIST: Those have occurred before when you were slipping back into

depression, right? Anything else you can recall that comes early on? GEORGE:

Well, I just realized that losing my sense of humor is part of it, too. I generally laugh a lot, but when I begin to get depressed, I don’t see the funny side of things. Oh, and also losing interest in hobbies and not enjoying things.

THERAPIST: That’s excellent George. So now you have a few things: poor

sleep, getting frustrated easily, not laughing or having a sense of humor, and losing interest or not enjoying things. These symptoms seem to show up early on when you are starting to feel depressed. Did I get that right? GEORGE:

Yes.

THERAPIST:

On this sheet here where it says Early Warning Signs, let’s write these down. Also, let’s make it very specific . . . so can you elaborate a bit? Not sleeping (how exactly would your sleep not be good?), getting easily frustrated (at what?), not laughing (at what?), not being as interested in or enjoying things (what activities?).

Together, the therapist and George generate a list of early warning signs.



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THERAPIST: Now we have this personal list. I am also giving you a general list

of possible signs of relapse in depression. It may be helpful to get both these sheets out and check anything that you have observed day to day as a way of reviewing how you are doing. Do you think that sounds like a good idea, and if so, when and how often do you think it would be good to do this? GEORGE:

I can see the benefit of keeping an eye on this. I would imagine once a week, maybe say on a Sunday evening I could do this.

THERAPIST: Great, let’s plan for that. Maybe you can put it on your calendar

or on your phone. Now, just like noticing that your gas is low and noticing that light on leads to the action of stopping to get gas, let’s talk about what you can do if you notice the signs we talked about, which might be early signals of developing depression. Maybe we could think about this in two ways. First, what skills have you learned in therapy that seemed to work well for you in helping with the depression? Second, are there additional skills that have helped improve your mood, even if you and I never talked about them in session? GEORGE:

I remember the recognizing and correcting the distortions or traps in my thinking—I think that’s what it was called—was a big help.

THERAPIST: Okay, noticing and correcting the distortions. Anything else? GEORGE:

Yes, also structuring my time, planning things, both things I needed to do and fun things too, was good in improving my mood because I start to do less and less when I get down in mood.

THERAPIST: So scheduling activities, which we called behavioral activation if

you recall, was helpful. Anything else? GEORGE:

I think those two, especially but also using the mindfulness idea . . . being in the moment just observing and not judging things or myself helped with my tendency to beat up on myself.

THERAPIST:

It’s terrific that you remember mindfulness as being helpful from our sessions and also from your practice in between sessions. So, we have those three things then—working on distortions, keeping your time structured, and being mindful—all of which might help moving forward. Is that right?

GEORGE:

Yes.

THERAPIST:

Let’s write those down here on this form, which you see has four categories: Things I Can Do on My Own, Things I Can Do With Others, People I Can Reach Out To, and Professional Help. Which category should those three go into to?

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GEORGE:

The first one, the Things I Can Do on My Own category.

THERAPIST: Right. Can you think of anything else in that category that has

ever helped you feel better? GEORGE:

Exercise, reading something uplifting, music of a certain sort, and maybe prayer or something spiritual. Oh, and being in nature.

THERAPIST: Okay, so several more things to write in there then. Good job.

What about the second category, Things I Can Do With Others. Any ideas there? GEORGE:

Let’s see. Maybe a walk around the golf course with my wife. A beer with, or even just phone call to, my friend Carl. He always makes me laugh. I think also I could watch a funny Disney movie with my kids. They’d love that too, in addition to what it would do to improve my mood.

THERAPIST: Great. Let’s add in those ideas here in Section 2. Now the next

one is whom you could reach out to if still feeling bad after doing some of these things and, also, what you might say to that person. Anybody come to mind to reach out to? GEORGE:

My long-time friend Vic. He’s had depression, too, and we have each talked about it when we’ve struggled in the past.

THERAPIST: Great. What might you say to Vic initially? Thinking about how

you did it before, how would you bring it up? GEORGE:

Oh, we don’t ever beat around the bush. I’d come right out and say, “I’m not doing too well now, I am pretty down. Can I talk to you about it?”

THERAPIST: So, Vic would be the go-to person there. Anyone else, in case he

wasn’t reachable? GEORGE:

My wife for sure.

THERAPIST: Okay, so let’s write in your friend Vic and Caroline, your wife,

here in Section 3. GEORGE:

Okay. This list is getting longer, which I guess is a good thing.

THERAPIST: It is, George, because if one thing doesn’t help, something else

might. It’s good to have a range of resources or options available. Now what about professional resources? GEORGE:

Well you, obviously; I have your office number and a number for after hours too.

THERAPIST: Yes, we will go over the logistics of calling, as well as identify

signs that it is time to call me, in a minute. Or, to get back to



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something you brought up earlier, it would be fine to reach out if you felt that we needed to talk on the phone or that you wanted to bring your next session forward in time. Once you notice things are slipping, and these other steps don’t seem to be helping, then call me. Is there anyone else who would go in this category, professional help? GEORGE:

Actually, my psychiatrist is fine with me calling too, which is great. She gave me a number to reach her outside of office hours. Also, I could call my minister. He knows my story, and I reached out to him before I went to the hospital a few years ago.

THERAPIST: Excellent. So, three professionals to put in that section. Can you

write them in there, and later we will add their contact information? . . . Now, George, we will review this list and make it even more specific, where needed, like putting in telephone numbers and concretely what you will actually do in each case. For example, how exactly would you make sure you were being mindful or were recognizing your distortions? GEORGE:

I’d make sure to do the mindful practice daily, if I wasn’t already, or remind myself with a stick-it note to take the mindful pause we talked about when I’m upset. I’d have that list of distortions close by, on my nightstand or workspace for when I notice negative thinking coming back. Actually, I think I lost that list. Can I get another one?

THERAPIST: Sure. I will give you another before we finish today. Those are

great ideas as to how to make sure you practice what potentially will prevent a major slip back. So now we will elaborate a bit on what’s on the list we have generated so far. Then, as homework, perhaps you could review this form along with the warning signs we talked about earlier and see if anything can be added on? The idea is that you will also use this on your own, since we are now meeting only every few weeks, to keep an eye on how you are doing and to take action as needed. How does that sound? GEORGE:

Good. Actually, you know what, this brings down the worry I was telling you about earlier on . . . the anxiety I have been having about the future.

THERAPIST: I am glad it helps with that. I am curious how exactly it has

helped. GEORGE:

I guess because I realize that it’s not wise to spend a lot of time worrying about what might happen, when I am doing well now. I should enjoy it. Also, it helps to know, first, that it might not happen and, second, if it does, I have a plan ready to go.

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THERAPIST: You nailed it there. Sounds like you are saying something like

you will embrace the present moment, which is good for preventing depression, and you will realize that the future could go in different ways, but that you have a good plan to put into operation if you need to. Is that right? GEORGE:

Yes. I never had that in my past struggles with depression, so I feel more prepared now, rather than before just hoping and praying nothing bad happens but worrying that it might.

THERAPIST: Good. You did really good work today. GEORGE:

Thank you.

CONCLUSION AND FUTURE DIRECTIONS Although cognitive behavioral approaches with or without a specific relapseprevention focus appear to have reduced the relapse rates in emotional disorders, substance abuse, and other disorders as shown previously, a significant percentage of patients (approximately 20%–35%) with depression and anxiety still experience a recurrence of symptoms (Ludgate, 2009). Also, research in the field of addictive behaviors, including cocaine dependence (McKay, 1999), smoking (Piasecki et al., 2000), and alcohol misuse (Hester & Miller, 2003), demonstrate that more than 50% of these patients do not maintain behavior change over time. This may be an even more significant problem in clinical practice, as usually patients treated in clinical practice will have more severe psychopathology than patients meeting the inclusionary criteria for research studies. Thus, it behooves clinicians and researchers to continue to develop methods to further reduce the significant problem of relapse in patients successfully treated with CBT. Dismantling studies are needed to examine which components of a relapseprevention package as described earlier are most critical or lead to the most successful outcomes. Also, research needs to be carried out on the effectiveness of relapse-prevention approaches with other populations. Outside of substance abuse and depression, there is a paucity of empirical data on the incidence and predictors of relapse in CBT-treated patients and how relapse can be reduced or curtailed. Predictors of sustained recovery or relapse need to be identified that can aid clinical practice, and further research on factors such as self-efficacy, cognitive vulnerability, and motivation for change, which can be targeted in therapy, needs to be carried out. In addition, dissemination of information on relapse prevention has generally been poor, with a developing but still meager number of resources to aid clinicians in the clinical application of relapse prevention within CBT practice. Workshops and training events in the area of relapse prevention at national and international conferences are often notable by their absence. Training



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programs at graduate and postgraduate levels should address the issues of relapse and maximize the acquisition of skills to prevent relapse and ensure maintenance of treatment effects. “Staying well” should be prioritized as much as “getting well” has been within the field of CBT.

REFERENCES Antony, M. M., Ledley, D. R., & Heimberg, R. (Eds.). (2005). Improving outcomes and preventing relapse in cognitive behavior therapy. Guilford Press. Bamelis, L. L. M., Evers, S. M. A. A., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171, 305–322. https://doi.org/10.1176/appi.ajp.2013.12040518 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press. Blackburn, I.-M., Eunson, K. M., & Bishop, S. (1986). A two-year naturalistic followup of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. Journal of Affective Disorders, 10, 67–75. https://doi.org/10.101 6/0165-0327(86)90050-9 Bowen, S., & Chawla, N. (2011). Mindfulness-based relapse prevention for addictive behaviors. Guilford Press. Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294, 563–570. https://doi. org/10.1001/jama.294.5.563 Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986). Understanding and preventing relapse. American Psychologist, 41, 765–782. https://doi.org/10.1037/ 0003-066X.41.7.765 Bruce, T. J., Speigel, D., & Hegel, M. (1999). Cognitive-behavioral therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation: A long-term follow-up of the Peoria and Dartmouth studies. Journal of Consulting and Clinical Psychology, 67(1), 151–156. https://doi.org/10.1037/0022006X.67.1.151 Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. https://doi.org/10.1016/j.cpr.2005.07.003 Carroll, K. M. (1996). Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology, 4(1), 46–54. https://doi.org/10.1037/1064-1297.4.1.46 Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965–971. https://doi.org/10.1037/0022006X.73.5.965 Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759–769. https://doi.org/10.1192/bjp.164.6.759

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III PSYCHOTHERAPY PACKAGES

14 Cognitive Therapy Amanda Fernandez, Keith Dobson, and Nikolaos Kazantzis

T

he term cognitive behavioral therapies (CBTs) describes a family of interventions that use techniques to promote the modification of cognitive content and patterns (A. T. Beck, 1970; Frank & Frank, 1961; see Kazantzis, Reinecke, & Freeman, 2010). This said, CBTs vary in terms of the way they focus on thoughts and behaviors within therapeutic intervention and the treatment processes they target. Some CBTs focus on acceptance and decentering of cognition (e.g., mindfulness-based cognitive therapy; Dimidjian et al., 2010); others focus on changing relationships with the environment and activation (e.g., behavioral activation therapy; Martell et al., 2010); and yet others focus directly on the reality-based evaluation of thought content and the information processing that contribute to the maintenance of that content (e.g., A. T. Beck’s cognitive therapy; A. T. Beck, 1964). Although the theoretical structure of cognitive-based therapies was influenced, in part, by the writings of several psychological and philosophical individuals, Aaron T. Beck is known and broadly recognized as the “founder” of cognitive theory and therapy. A. T. Beck’s early writings suggested that emotional disorders resulted and maintained from underlying distortions in cognition (A. T. Beck, 1964, 1967; A. T. Beck et al., 1979), which laid the foundation for many therapies within the CBT family. In a narrower definition, A. T. Beck’s traditional approach to cognitive therapy (CT), which was established in the 1970s, can be defined as a therapeutic intervention that focuses on the premise, assumption, and attitude underlying an individual’s cognitions (A. T. Beck, 1970). As such, CT is based on the notion that psychological disorders are

https://doi.org/10.1037/0000218-014 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  417 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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associated with the personal meaning that one attaches to an event or an experience, rather than the event itself, and that these meanings are formed by core beliefs developed over time (J. S. Beck & Tompkins, 2007; Dobson & Dobson, 2017). This chapter focuses on A. T. Beck’s CT through a consideration of its historical development, theoretical foundations and growth, and therapeutic procedures. In addition, this chapter provides an overview of the empirical support of CT and its dissemination.

HISTORY The beginning of CT can be traced back to Aaron T. Beck’s seminal work conducted in the late 1960s and first crystallized in an article that described the relation between behavior therapy and cognitive therapy (A. T. Beck, 1970). During this time, psychodynamic therapy and behavior therapy were the two widely accepted models of psychotherapy. Although A. T. Beck was a practicing psychoanalyst, like the behaviorists of his time, he believed in the importance and necessity of empirical support for theory and psychotherapy. He believed that a validated psychotherapy paradigm had three prerequisites: a comprehensive theory, empirical support for the theory, and credible research to demonstrate treatment efficacy (A. T. Beck, 1991). As a result, he spent much of his career revolutionizing the field of mental health in a pursuit to provide the medical community with a psychotherapy that met his formulation of empiricist quality. A. T. Beck began his career with a psychoanalytic practice. During a study in which he attempted to validate Freudian dream theory, he began to observe trends in the day- and dream-state content of his depressed patients. Specifically, he noted the patients would verbalize thoughts that fit with particular themes related to a negative view of the present, past, and future (A. T. Beck, 1991). These thoughts were seemingly automatic, repetitive, and highly plausible to the client, and they were often followed by negative affect (A. T. Beck, 1964, 1991). A. T. Beck began to develop a therapy that drew from his psychoanalytic background but addressed the conscious patterns of cognition he identified in his studies. Psychoanalytic therapeutic concepts within CT included examining the meaning within an individual’s experiences, identifying themes that arose across thoughts and behaviors, and connecting present and past experiences to understand the origin of the current issues (A. T. Beck, 2005). However, the focus of the developing model was on conscious rather than unconscious experiences and was predominately present focused. Given A. T. Beck’s empiricist proclivity, he noted the influences of the common practices of behavior therapy within CT. Specifically, he described that although cognitive theory aligned with the psychoanalytic focus on internal processes within the individual, CT aligned with the behavioral practice of examining and altering these internal processes through overt and concrete strategies (A. T. Beck, 2005). Structure taken from the behavior therapy



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approach included increasing the role of the therapist, operationalizing procedures, setting goals, assigning homework, and measuring or evaluating outcome (A. T. Beck, 2005; A. T. Beck et al., 1979). A. T. Beck also believed in the agency of the individual. His model was founded on a type of therapeutic interaction that was grounded in collaboration with the therapist regarding the focus and direction of therapy, ultimately empowering the individual take charge of the therapy. Again, reflecting the behavioral influence, the active role for the individual was deemed crucial in order for the transfer of practical skills to the everyday situations and relationships in which their problems exist. A. T. Beck also expected that the individual would adopt the scientific method, or empiricism for their subjective experiences, and that, ultimately, the individual would internalize the questions used by the therapist to scrutinize their thoughts, emotions, physiology, and behavioral responses. Thus, collaboration, empiricism, and Socratic dialogue, which is the strategy of involving the client in the therapeutic process through the use of systematic questioning, represent the three distinctive elements of the therapeutic interaction in CT (A. T. Beck et al., 1979; Kazantzis et al., 2017; Rutter & Friedberg, 1999).

UNDERLYING THEORY A. T. Beck’s Cognitive Model A. T. Beck’s introduction of the cognitive model (A. T. Beck, 1964, 1970) was extremely influential, as it significantly contributed to a paradigm shift within the approach to psychotherapy from a behavioral to cognitive framework. This model was based on information-processing theories and was originally formulated in the context of depression. Specifically, Beck examined depression in terms of how an individual processes information could contribute to the development and persistence of depressive symptomology, as well as provide a key point of intervention. This model has since been adapted for many psychopathologies (e.g., A. T. Beck, 1988; A. T. Beck et al., 1974, 1985). According to the cognitive model, an individual can process external or internal events and stimuli in a biased fashion. This bias then systematically distorts the individual’s perception of their experiences, which can lead to a variety of errors in their cognitions, coined by A. T. Beck (2005) as cognitive distortions. These errors or distortions in cognition, although made automatically and without conscious effort, are postulated to occur due to underlying cognitive structures that contain dysfunctional beliefs (A. T. Beck, 2005). Such underlying structures are referred to by A. T. Beck as schemas, or cognitive structure that are used to screen, code, and evaluate external and internal stimuli but that incorporate an emotion and behavioral expression (A. T. Beck, 1964). Schemas are the mode used by the brain to break down and organize an individual’s environment into psychologically relevant factors and categorize their experiences in an emotionally meaningful way (A. T. Beck, 1964).

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Thus, schemas are stable cognitive structures that shape thought processes. A. T. Beck (1964) provided an example of the way in which a schema may distort an individual’s perceptions. If an individual is anxious when approached by a dog, they may think “It’s going to bite me,” regardless of whether the dog is friendly or aggressive. It can be ascertained that the individual’s assumption regarding the dog may be “All dogs that come near me are dangerous and might bite me,” and that person’s core beliefs may be “I am vulnerable,” “the world is a dangerous place,” and “the future is uncertain.” When the individual recognizes an approaching dog, the cognitive process is experienced as a compressed event that may seemingly arise automatically to form the automatic thought (a prediction) “It will bite me” (A. T. Beck, 1964). In this regard, if the schema is skewed and associated with marked emotion (i.e., fear) and a problematic behavioral response (i.e., avoidance of all dogs), then the conclusion that ensues will also be flawed. Stereotyped or repetitive themes and patterns of conceptualizing events are indications of how the individual’s schemas may manifest (A. T. Beck, 1964), which then offer insight into potential points of intervention. One of the main tenets of the cognitive model is that certain beliefs, or cognitive structures, constitute a vulnerability to psychopathology (A. T. Beck, 2005). This hypothesis, referred to as the diathesis-stress model, purports that maladaptive schemas develop early in life and remain dormant until triggered by a later stressful event (A. T. Beck, 1967). This model explains how schemas influence the interpretation of events throughout the lifetime (Riskind & Alloy, 2006). Individuals who have underlying maladaptive schemas carry a cognitive vulnerability for psychopathology. Biased beliefs associated with these schemas are postulated to occur on a continuum; when a belief becomes exceedingly biased, the individual increases their probability of experiencing psychopathology (A. T. Beck & Haigh, 2014). In addition to the interplay of schemas and unbalanced (or distorted) thought patterns, the cognitive model highlights the continuity of thought and affect and indicates that the type and magnitude of affect is typically congruent with the content of the thought (A. T. Beck, 1964). Dysfunctional beliefs make an individual vulnerable to developing psychopathology due to an increased impact of negative life events based on the individual’s beliefs. For example, in the context of depression, if an individual believes “I am a failure if I don’t succeed,” then perceived failures will activate the negative cognitive triad and result in the belief about the self “I am a failure” (A. T. Beck, 2005). This outcome, in turn, increases the likelihood of further distorted thoughts, which increases the risk of psychopathological symptomology. Although negative thoughts are a central focus of cognitive theory, many other factors play an important role in an individual’s mental health, including life events, social interactions, and biological factors. However, although these factors may initiate the mental health difficulties and psychopathology in general, cognitive theory puts forth the way in which cognition may play a pivotal role in its maintenance (Freeman, 2004). This theoretical model has important clinical implications, as each component of the model is postulated to connect



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and offer a point of intervention that will influence other components. The cognitive model informs therapy by advising interventions to focus on the content of thought and cognition and, thereby, to evoke changes in thought patterns and subsequent schema activation (A. T. Beck & Haigh, 2014). Cognitive Specificity Cognitive theory is traditionally adapted to fit with disorder-specific presentations, which arose from the content-specificity hypothesis (A. T. Beck, 1991). According to this model, each emotional disorder can be characterized by specific and unique cognitive content related to that disorder (A. T. Beck, 2005). For example, the typical maladaptive cognitions associated with anxiety disorders focus on the future possibility of danger or threat and/or uncontrollability of specific stimuli, situations, or experiences, whereas cognitions associated with depression are often associated with themes of self-debasement (A. T. Beck, 1970; Hofmann et al., 2010). Although CT was first introduced as a theoretical account and intervention for depression (A. T. Beck, 1964, 1967), its theory and treatment have since been applied to a number of other disorders and presentations, including, but not limited to, suicide (e.g., cognitive processes associated with suicidal acts; A. T. Beck et al., 1974; Wenzel & Beck, 2008), social phobia (e.g., increased perception of the danger of being negatively evaluated by others; Clark, 2005), panic disorder (e.g., catastrophic misinterpretation of the experience of physical sensations; A. T. Beck, 1988), bipolar disorder (e.g., change in thought content related to new interests and less inhibition; Basco & Rush, 2005), personality disorders (e.g., continual schema activation and the way they position themselves in relations to others; A. T. Beck et al., 2015), anger (e.g., others and aversive events are dichotomously categorized as “the enemy,” A. T. Beck, 1999), and substance abuse (e.g., drug-related beliefs, such as anticipatory beliefs, permissive beliefs, and relief-oriented beliefs; Wright et al., 1993). Generic Cognitive Model In recent years, A. T. Beck and Haigh (2014) proposed the generic cognitive model (GCM), which sought to provide a theoretical framework that would still identify unique features of specific psychological disorders but also improve our understanding of cognitive processes observed in psychopathology in general. The GCM’s main goal was to describe how common cognitive processes become pathological and how these common processes differentiate into different disorders. The expansion of the traditional cognitive model to the GCM is helpful within therapeutic practice, as it clearly elaborates on how adaptive cognitive processes can become maladaptive, which can be integral to case formulation and selection of therapeutic techniques used for remediation. The GCM expands on the original cognitive model (A. T. Beck, 1964, 1970) by highlighting that psychological problems and clinical disorders are extensions

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of normal or adaptive functioning. Adaptive functioning involves the ability of an individual to employ cognitive, affective, and behavioral strategies to help cope with distress or attain goals. These systems can be activated during inappropriate life events and/or used inappropriately, in which case they become maladaptive. Maladaptive functioning is suggested to result from an exaggeration of negative and positive biases found in normal processing. A negative bias is defined as an exaggeration of a threat or challenge, and a positive bias is defined as an exaggeration of a perceived reward. The GCM proposes that the main mechanism that transforms normal functioning to maladaptive functioning is how an individual processes information. Specifically, when information processing provides inaccurate information, subsequent cognitions, emotions, and behaviors are maladaptive. These maladaptive responses may involve other cognitive biases in interpretation, memory, and attention, as well as inappropriate affect and behaviors. The inclusion of information about the continuity between adaptive and maladaptive functioning is important within therapeutic application, as it outlines how various psychopathological disorders share common underlying cognitive processes yet can be distinguished based on content. Specifically, this model aids the clinician in determining how an individual’s thought content may be biased and what an individual’s thought content should reflect when they adopt and exhibit nonpathological cognitions. The GCM also was expanded to incorporate the idea that cognitive schemas influence and control the way in which an individual processes information. Broadly, when a schema is activated, the meaning it holds interacts with cognitive, emotional, and behavioral systems through two interacting subsystems— the automatic processing subsystem and the reflective processing subsystem. Initially, information is processed crudely through the automatic system where environmental and subjective information is divided into simple categories consistent with the overarching schemas. Thereafter, the information and subsequent interpretations of the experience are refined and reappraised to promote goal achievement. The addition of automatic and refined processes provides the clinician with information regarding how distortions and maladaptation in cognitive processes can occur at early and later stages of processes and how these stages can influence and maintain distortions. Another addition of the GCM is the influence of personal goals and obligations on adaptive and maladaptive presentations. These modes represent the consolidation of schemas into belief systems, rules adhered to, and concepts such as self-esteem. They reflect aspects of an individual’s personality through two dimensions—the self-expansive mode and the self-protective mode. The self-expansive mode is primarily concerned with increasing personal value, whereas the self-protective mode is primarily concerned with early detection of danger signals, to mobilize when threat is encountered. For example, an increased self-expansive mode is theorized to relate to symptoms of excitement and mania, whereas a decrease in this mode can lead to withdrawal and depression. Further, an enhanced self-protective mode can be manifested in either



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paranoia or anxiety. The integration of these modes into the cognitive model increases the clinical utility of cognitive case formulation for psychopathological presentations such as manic episodes and endogenous depression. In summary, A. T. Beck and Haigh’s (2014) GCM includes theoretical adaptations of A. T. Beck’s original cognitive model that improve clinical application. Beck’s original cognitive model lacked clarity on factors such as the association between adaptive and maladaptive functioning, schema activation, and the role of personal goals. The GCM offers additional information about how schemas and modes can impact information processing and therefore transform normal adaptive responses into disorders. This elaboration of the cognitive model can aid in the case conceptualization and treatment of both the precipitants and maintenance factors associated with the client’s psychopathology, as underlying cognitive processes are hypothesized to be similar across disorders with the content of belief, focus, and behavior as an indication of the disorderspecific presentation.

DESCRIPTION OF MAIN PROCEDURES Given the theoretical principles of the cognitive model, CT contains a host of techniques and procedures that were developed to alter the content and structure of distorted thoughts and maladaptive schemas. The major assumption of CT is that the client has acquired a pattern of maladaptive reactions that can be unlearned, without requiring information about the origin of the symptoms (A. T. Beck, 1970). Therefore, CT initially involves a systematic and structured therapeutic interview to gain a detailed description of the client’s current problems. The therapist then formulates the patient’s presenting symptoms using the cognitive model. CT necessitates that although theory is necessary, an idiographic case conceptualization is essential for proper therapeutic application. Case conceptualization is a foundational procedure of CT (Bieling & Kuyken, 2003; Kuyken et al., 2008), as it provides a description of the client’s specific problem areas, explanatory hypotheses about etiology and maintenance of presenting problems, and insight into techniques and timing relevant for intervention (Kuyken, 2006; Persons & Davidson, 2010). The case conceptualization helps the therapist collaborate with the client to design a specific set of strategies to help tackle the client’s defined problem areas. In other words, case conceptualization is a tool that is used to describe client presentations in a way that is meaningful to the idiosyncrasies of the client and that facilitates an effective intervention (Kuyken et al, 2008). CT can be defined as goal oriented, as it seeks to obtain remission from the client’s presenting problem and prevent future relapse (A. T. Beck, 1970; J. S. Beck & Tompkins, 2007). Following case conceptualization, the therapist works with the client to coach them to learn and develop appropriate and helpful strategies. CT sessions are structured. An agenda is collaboratively set at the beginning of each session that focuses on discussing client problems and teaching therapeutic skills related

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to the identified problem (J. S. Beck & Tompkins, 2007). The techniques ameliorate overt symptoms or problems presented with a specific focus on their maladaptive thought processes (A. T. Beck, 1970), but they include strategies related to regulating emotion and modifying behavior (J. S. Beck & Tompkins, 2007). CT often is administered using a scaffolding approach to treatment, which infers that although the therapist may begin by teaching the client therapeutic strategies, the client eventually is expected to develop the ability and competence to conduct their own strategies. In part due to this process of building the client’s self-efficacy, CT is also a time-limited therapy.

Therapeutic Techniques CT uses techniques that emphasize change in maladaptive cognitions (A. T. Beck, 1970). One of the main cognitive procedures was originally defined by A. T. Beck (1963) as the recognition of idiosyncratic cognitions. These idiosyncratic cognitions, or automatic thoughts (A. T. Beck, 1963), refer to internalized statements that are specific to the client and that reflect faulty appraisals about themselves, the world, and their future (A. T. Beck, 1963, 1970). It is common for an individual to report a connection between a specific event and unpleasant emotion but lack the ability to explicate the way in which the event and the emotion are related (A. T. Beck, 1970). Within CT, it is particularly important to motivate and train clients to attend to their automatic thoughts to help them better understand the source of their distress. The abilities to understand how their cognitive patterns precede distressing emotions and reactions and to accurately identify distorted cognitions are central to the client’s ability to apply further corrective strategies. Once clients can identify their automatic thoughts, they are helped to observe their thoughts objectively. Distancing is the term used by A. T. Beck (1970) to describe this process. According to the premises underlying CT, an independent “real world” exists, and our beliefs cause us to misinterpret or misperceive this reality (K. S. Dobson, 2013; Dobson & Dobson, 2017). The ability to discern inference from reality is a key skill necessary to help evaluate and restructure our understanding of events, feelings, and behaviors to shift thought content to align with real-world alternatives. The ability to scrutinize a belief allows an individual to gradually generate different views that may be less distorted or more helpful. It is postulated that the mechanism behind such techniques involves the attenuation of preexisting cognitive biases that derive the reaction of emotional distress (DeRubeis et al., 2010). The final procedure involves the correction of cognitive distortions, as the client can use the recognition of their faulty thought processes to help make the appropriate corrections (A. T. Beck, 1970). There are many strategies that can be implemented to help the client achieve mastery in the preceding skills. The remainder of this section elaborates the most common techniques used.



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Thought Records The abilities to identify and reshape automatic thoughts are a central component of CT. To this end, thought records are widely used as a self-monitoring tool to help the client observe and track their thoughts. Self-monitoring contains two components: Frst the client must observe the target behavior, thought, or emotion; then they must document this information on a record (Korotitsch & Nelson-Gray, 1999). In general, a thought record contains columns associated with the key aspects of the cognitive model (DeRubeis et al., 2010). The client records the antecedent situation, the negative emotional response, and the cognitions or automatic thoughts that explain the connection between these elements (Freeman, 2004). Columns that require the identification of a “rational response” (also referred to as “restructured thought,” “alternative response,” or “adaptive response”) and the monitoring of outcomes are also important for the client’s ability to self-monitor and reshape thoughts (Freeman, 2004). Questions such as “What is the evidence for and against the belief?” and “What are the alternative interpretations of the event?” can be taught to clients to facilitate alternative thoughts and the reshaping of thoughts (DeRubeis et al., 2010; Dobson & Dobson, 2017). Identify Cognitive Errors The identification and labeling of cognitive distortions is another technique that is often implemented during CT. Categorizing thought processes into simple groupings helps provide heuristics that the client can easily memorize and use as a template to discern how their thinking may be distorted. Having identified and labeled distorted thinking, clients can often more easily implement strategies to question, contradict, and restructure the identified thoughts. Common cognitive errors include the following (A. T. Beck et al., 1979): • All-or-nothing thinking (black-or-white thinking): all experiences fall on either extreme end of a spectrum (e.g., “If I don’t do well at this task then I am a complete failure.”) • Overgeneralization: generalizing an experience and using it to infer that all experiences will be the same (e.g., “Because my last relationship ended horribly, all my relationships will end horribly.”) • Discounting the positives: discounting the good things that have happened as either not being important or somehow being negative (e.g., “They were only trying to make me feel better when they said I did a good job.”) • Jumping to conclusions: only considering one piece of information when attempting to discern an explanation for a situation (e.g., “She didn’t smile at me, so that must mean she hates me.”) • Mind reading: the belief that one knows what another person is thinking (e.g., “My boss thinks I’m inept.”)

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• Fortune telling: only considering one possibility for a future outcome and believing it to be true (e.g., “I’m going to get fired from my job.”) • Magnification (catastrophizing)/minimization: when one perceives a negative event to be more important than it really is or a positive event to be less important than it really is (e.g., “I forgot to send the attachment with that email so now everyone at work thinks I’m incompetent.”) • Emotional reasoning: basing a conclusion on the intensity of one’s emotional reaction (e.g., “I feel guilty; therefore, I must have done something really bad.”) • “Should” statements: the use of critical words like “should” or “ought” when determining how to act or think (e.g., “I should have known better.”) • Labeling: prescribing an all-or-nothing label to describe a behavior and then internalizing that label (e.g., “That was a dumb thing to do; I’m so dumb.”) • Inappropriate blaming: blaming oneself for a negative outcome and ignoring all other factors that may have contributed to that outcome (e.g., “It’s all my fault that my spouse and I fought.”) Many of these errors are not mutually exclusive and, to some extent, may be expected in the absence of psychopathology. Thus, care must be exercised by the practitioner to use such a list to facilitate recognition but not to pathologize a given pattern of thinking. Some cognitive processes may be socially or culturally sanctioned or expected. Downward Arrow Whereas the thought record involves reality testing and recognizing distortions within identified thoughts, the downward arrow technique encourages the client to consider the broader meaning(s) attached to a given thought. Specifically, when an important automatic thought is identified, questions such as “What would it mean if this thought were true?” or “What does this mean to you?” can help to elicit the more basic belief that underlies the surface-level thought and subsequent emotion. This strategy can help identify the centrally distressing thought in situations, assumptions, and rules, as well as the core beliefs the individual may have regarding themselves, others, and the world (i.e., usually with the variation “What does this mean about you?”). It should be noted that the identification of core beliefs is often distressing, and the specific content of the cognition may be outside the client’s conscious awareness. Thus, identification of core beliefs is ideally a strategy employed early in a session so that there can be reappraisal. Collaborative Empiricism, Socratic Questioning, and Guided Discovery To be collaborative and empirical are two of the main principles of CT (Kazantzis et al., 2017), and it is important to consider the way this may manifest in the



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therapeutic interventions chosen to be applied. Although change in distorted thoughts or beliefs are the desired primary outcome in CT, cognitive therapists want to maximize their ability to work collaboratively with the client in order to seek empirical evidence for or against the thoughts or beliefs the client currently holds rather than simply lead them to the answer. Collaborative empiricism is viewed within CT as a key element in providing the client with skills needed to gain long-term benefits in reshaping their thoughts. The collaborative process of seeking evidence and evaluating thought processes allows the client to learn skills related to processing thoughts and to gain self-efficacy in the use of this approach. Simply put, CT involves not simply fixing a problem but rather teaching a way to find solutions and make more adaptive choices (Padesky, 1993). To this end, Socratic questioning offers a modality to guide this discovery without leading, as it incorporates questions to understand the client’s point of view rather than simply change the client’s mind (Padesky, 1993). Padesky (1993) offered a definition of Socratic questioning that involves (a)  asking the client questions to which they have the answer, (b) drawing attention to concrete and relevant information pertaining to the discussion that may be outside the client’s focus, and (c) asking questions that then move from the concrete to the abstract in order to allow the client to apply the new information to help reevaluate a previous conclusion or construct a new idea. It is important to question in a way that promotes guided discovery in a collaborative way (Kazantzis & Stuckey, 2018). Guided discovery is defined as a broad strategy in which the therapist facilitates critical examination and questioning, rather than lecturing, debating, or “cross-examining,” to help guide clients to observe a new perspective by coming to their own conclusions regarding potential errors in their beliefs (Young & Beck, 1980). Strategies that the therapist can use to facilitate guided discovery include examining evidence that contradicts beliefs, gathering additional information to help make hypotheses, and looking for alternative consideration. Padesky (1993) highlighted stages that compose the guided discovery process to increase the likelihood that the therapist’s line of questioning leads to discovery as well as the likelihood that the client can apply this information to their life. The first stage involves asking informational questions that follow the guidelines for Socratic questioning outlined above. The second stage requires listening. Although this stage may seem intuitive, guided discovery involves listening to the client’s responses and responding with openness and a willingness to consider unexpected or unanticipated answers rather than deeming answers as irrelevant and not aligning with the “direction” in which the therapist is attempting to go. The third stage involves the summarization of new information that was learned during Socratic questioning. Providing a summary of what was discussed is important, as it not only gives the therapist and client a chance to ensure they are understanding what was said in similar ways but also, most importantly, allows the client to look at the new information rather than single pieces of information. Summarizing what was discovered during Socratic questioning can and should be done throughout the session.

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The fourth and final stage involves the therapist asking a synthesizing question that connects the new information to the client’s original belief or thought and that ties everything together in a meaningful way and facilitates new learning (Padesky, 1993; see also Kazantzis et al., 2017). Behavioral Self-Monitoring Although CT mainly focuses on the remediation of distortions or errors in cognition, it includes behavioral strategies related to behavioral self-monitoring. As with the self-monitoring techniques utilized in the cognitive strategies described previously, the client must observe target behaviors and document this information on a record along with additional information relevant to the target goals of therapy (Korotitsch & Nelson-Gray, 1999). Traditionally, behavioral methods have been used by behavior therapists to decondition maladaptive learned behavioral responses to stimuli. In CT, behavioral self-monitoring provides an opportunity for the individual to identify how thoughts may manifest in a certain setting, test hypothesis regarding those thoughts, and facilitate the formation of new thoughts through hypothesis testing (DeRubeis et al., 2010). Self-monitoring of behaviors is, therefore, an important component of CT to assist in the desired cognitive change. More specifically, behavioral self-monitoring in CT usually involves the client carefully maintaining a record of their hourly activities throughout the day. The client may also provide information about emotional experiences preceding, during, or following an activity or behavior (DeRubeis et al., 2010). These aspects of self-monitoring allow the therapist to observe the client’s range of behaviors and the client to observe and reflect on antecedents, behaviors, and consequences of those behaviors. These insights into daily activities and behaviors can be powerful for several different reasons. Instead of relying on memory, which can be affected and altered by cognitive biases and emotions (Mathews & MacLeod, 2005; Matt et al., 1992), the client can more objectively record information and debate evidence for or against alternative hypotheses obtained through objectively monitoring their thoughts and beliefs (DeRubeis et al., 2010). Further, the therapist may use this record to monitor positive or negative events in the client’s life that may be relevant to discuss during session, or the client may use the record to reflect on which activities or behaviors are worth continuing or altering depending on their antecedents and consequences (DeRubeis et al., 2010). Importance of Therapeutic Interaction CT highlights that the therapeutic relationship is essential for collaborating effectively and is, therefore, postulated to be a necessary component in producing therapeutic effects (A. T. Beck et al., 1979; Freeman, 2004). The relationship between the therapist and client is viewed as a strong contributor to an environment that helps the client attain therapeutic goals (Cronin et al., 2015). Therapeutic relationships involve listening, expressed empathy, and positive



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regard, as well as collaboration and a strong working alliance (Markin, 2014; Cronin et al., 2015). The components of collaboration, empathy, and positive regard that encompass therapeutic relationships have all been empirically supported as important for therapeutic change (Castonguay & Beutler, 2006; Kazantzis et al., 2017; Norcross & Lambert, 2011). Specifically, within CT, the therapeutic relationship is defined as a collaborative bond and agreement on the goals of therapy and tasks to attain those goals (Bordin, 1979; Cronin et al., 2015). In fact, the agreement and collaboration of therapeutic goals and tasks between the client and therapist within CT has been observed to positively impact symptom change (Webb et al., 2011). Importance of Homework Homework is integral to CT, and it helps ensure that skills are being practiced between sessions and generalized broadly. Homework facilitates faster recovery and relapse delay (J. S. Beck & Tompkins, 2007; Kazantzis, Whittington, & Dattilio, 2010; Kazantzis et al., 2000, 2005, 2016). Homework development within CT differs between clients, as strategies and skills taught during therapy are guided by the conceptualization of the client’s difficulties and collaboratively determined in session. The main goals of homework within CT are to (a) implement strategies that provide solutions to problems discussed in session; (b)  increase self-awareness to antecedents, thoughts, behaviors, and consequences; (c) practice and reinforce cognitive and behavioral strategies learned in session; (d) evaluate and test cognitions and beliefs; and (e) offer practice for the preparation for and prevention of potential relapse (J. S. Beck & Tompkins, 2007).

OUTCOME DATA One of the cornerstones of CT is the importance of empirical support for theory and therapy (A. T. Beck, 2005). Given the nearly 50 years since the development of CT, a wealth of empirical studies have been conducted. The following section outlines a brief selection of this research. Perhaps one of the most influential studies was the Treatment of Depression Collaborative Research Project (TDCRP; Elkin et al., 1989). This seminal study compared the efficacy of CT, interpersonal psychotherapy (IPT), and pharmacotherapy for depression. Equivalent outcomes for CT and IPT were observed, and, perhaps most importantly, no evidence was found to support that psychotherapy was either less efficacious or more efficacious than pharmacotherapy (Elkin et al., 1989). When the patient sample was dichotomized according to depressive severity, pharmacotherapy was most effective for severely depressed and functionally impaired patients. IPT was also found to be effective for severely depressed patients relative to pill placebo (Elkin et al., 1989). In a follow-up study that examined the efficacy of CT and psychodynamic-interpersonal

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psychotherapy for depression, both treatments were found to be equally efficacious regardless of depressive severity or duration of treatment (D. A. Shapiro et al., 1994). There has been strong support for the use of CT in a range of different psychological and disorder presentations. CT has been found to be superior or equivalent to untreated controls, wait-list controls, behavior therapy, and non-evidence-based therapies for the treatment of depression (Gloaguen et al., 1998; Wampold et al., 2002). Specifically, meta-analyses have observed that CT is more effective than no-treatment or wait-list control (d = −0.58 to −7.24) and that, overall, CT clients did better than 98% of control clients (K. S. Dobson, 1989). CT was also found to be more effective than behavior therapies and pharmacotherapy (d = 0.33 to −1.03 and d = 0.42 to −1.74, respectively), with 67% and 70% of CT clients achieving better outcomes, respectively (K. S. Dobson, 1989). Additional meta-analyses also confirm that CT was found to be superior to antidepressants (d+ = −0.38), waiting list or placebo (d+ = −0.82), and other psychotherapies (e.g., psychodynamic, IPT, nondirective; d+ = −0.24; Gloaguen et al. 1998). They also found that CT was equal to behavior therapy (d+ = 0.05; Gloaguen et al., 1998). However, when decreasing the heterogeneity of “other therapies” by comparing CT with “bona fide” and “non-bona fide” treatment, CT was found to be roughly as effective as other “bona fide” therapies for depression (d+  =  0.03) and superior to “non-bona fide” therapies (d+ = 0.49; Wampold et al., 2002). Additionally, CT and pharmacotherapy are equally effective in treating acute depression (d = 0.16; DeRubeis et al., 2005). Other evidence suggests the longterm effects are greater for CT than antidepressant medication, as relapse rate of CT patients was lower than those who discontinued antidepressants (29.5%– 30.8% vs. 60.0%–76.2%; Gloaguen et al., 1998; Hollon et al., 2005) but equal to those who remained on antidepressants at 1-year follow-up (30.8% vs. 47.2%; Hollon et al., 2005). There is also evidence to suggest a combination of the two may be more effective than either one alone in treating severe depression (see Segal et al., 2002, for a review). When examining the effects of CT on depressive cognition, research has found that mean scores on cognitive content variables such as hopelessness, dysfunctional attitudes, attributional style, and learned resourcefulness improved from pre- to post-CT (d = 0.77–0.99), and individuals scoring in the “healthy range” of depressive cognition increased significantly on hopelessness, dysfunctional attitudes, and learned resourcefulness scores from pre-CT (22%– 48%) to post-CT (63%–84%; Vittengl et al., 2014). Moreover, an increase in cognitive coping strategies to deal with distressing events and thoughts (e.g., generating alternative explanations, development of concrete problem-solving plans) has also been observed pre- to post-CT (d = 1.04, Barber & DeRubeis, 2001). With regard to anxiety disorders, there are mixed findings in regard to the efficacy of CT strategies for specific and social anxiety alone compared with wait-list controls (e.g., d = 0.98, Wolitzky-Taylor et al., 2008; also see Choy et al., 2007, for a review), as well as these strategies when combined with in vivo



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exposure (e.g., for reviews see Choy et al., 2007; Rodebaugh et al., 2004; Rowa & Antony, 2005). The use of CT with generalized anxiety disorder is associated with an overall reduction in levels of worry following treatment compared with control conditions, which were maintained at 12-month follow-up (d = 1.81; Hanrahan et al., 2013). CT was also found to have significantly better recovery rates 12 months posttreatment than no therapy and non-CT interventions (57% vs. 14.8% vs. 26.2%, respectively; Hanrahan et al., 2013). The efficacy of CT with other clinical presentations include the use of strategies to modify distorted beliefs about delusions and hallucinations in schizophrenia and psychosis. CT for psychosis was found to successfully reduce psychotic symptoms and continued to improve over time (d = 0.65 and d = 0.93; Gould et al., 2001). CT strategies also produced larger effect sizes than wait-list controls for the treatment effects on chronic pain (d = 0.50), and CT strategies for pain were found to produce greater changes in regard to pain experience and cognitive coping and appraisal (Morley et al., 1999). CT was also found to be helpful in the suppression of anger for those who experience difficulties with anger (d = 0.82, Del Vecchio & O’Leary, 2004). Given this chapter’s focus on CT and not CBT, only a description of studies examining CT have been described. However, it should be noted that therapy comprising CT and behavioral components (i.e., CBT) has strong empirical support beyond what is highlighted here (for examples, see, for social anxiety, Rodebaugh et al., 2004; panic disorder, Landon & Barlow, 2004; Mitte, 2005; obsessive compulsive disorder, Eddy et al., & 2004; insomnia, Wang et al., 2005; and bulimia nervosa, J. R. Shapiro et al., 2007).

MECHANISM OF CHANGE DATA Despite the efficacy of CT, relatively few studies have examined the mechanism of change and the degree to which symptom changes are due to specific CT components rather than general therapeutic approaches (Crits-Christoph et al., 2017; Gibbons et al., 2009). In general, the cognitive model assumes that the key mechanism of change that is critical to recovery or symptom reduction is a change in cognition. Various theories have been proposed to describe how therapeutic change occurs explicitly in the context of CT (Crits-Cristoph et al., 2017). For example, some hypotheses suggest that core cognitions (i.e., schemas) are simply modified to decrease distortions and become more adaptive or that individuals learn compensatory skills to help suppress maladaptive cognitions (Hollon et al., 1990). However, changes within these cognitions can be indicative of both the modification and suppression of core cognitions. Therefore, it is quite difficult, if not impossible, to differentiate evidence for one model over the other (Garratt et al., 2007). Further, although there are a number of approaches that can be used to study the relation between cognitions and cognitive change (e.g., cognitive change and symptom change during or posttreatment), it is difficult to determine which change (i.e., symptom or cognitive)

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preceded the other or whether they occur concurrently (Kazdin, 2007). In summary, it is difficult at this time to conclude that cognitive change, as the cognitive model suggests, is the mediator of therapeutic change (Kazdin, 2007). Empirical research has found improvement on cognitive content variables after participating in CT. For example, hopelessness, dysfunctional attitudes, attributional style, and learned resourcefulness were moderately to highly correlated with improvements in depressive symptoms (r = .33–.64; Vittengl et al., 2014; for a review, see Garratt et al., 2007). However, disparity can be observed in regard to the effects of cognitive change on therapeutic outcome. For example, attributional style (r = .54), hopelessness (r = .55), and dysfunctional attitudes (r = .51) that occur within the first 6 weeks of treatment predict depressive symptom change at 12 weeks, although change in negative automatic thoughts does not (DeRubeis et al., 1990). Conversely, in a more recent study, cognitive contents’ (i.e., hopelessness, dysfunctional attitudes, attributional style, and learned resourcefulness) mediation on symptom reduction was found to be limited (r = −.06 to .15; Vittengl et al., 2014). Moreover, research has observed that therapeutic change can occur without changes in cognitions (e.g., Burns & Spangler, 2001). Additionally, research has examined whether CT may produce therapeutic change by facilitating more skillful use of positive cognitive compensatory strategies or cognitive coping skills (e.g., generating alternative explanations, development of concrete problem-solving plans). Such positive compensatory skills have been associated with decreased depression posttreatment (r = −.54; Barber & DeRubeis, 2001), although it should be noted that this observation cannot speak to whether skill change is causing symptom reduction or vice versa. However, improvements in the use of adaptive compensatory strategies are associated with improvement of symptoms at 6-month follow-up, which could indicate that the use of adaptive compensatory strategies is producing symptom change (Gibbons et al., 2009). Indeed, therapist adherence to skills that help patients engage in adaptive compensatory strategies (e.g., reevaluating thoughts) was observed to predict depression symptom improvement (r = .44; Strunk et al., 2007); however, it should be noted that evidence suggests CT does not differ from psychodynamic therapy in terms of improvement in adaptive compensatory skills or the correlation between skill change and symptom reduction (Gibbons et al., 2009). Therefore, research has also examined the degree that depression-related cognitions change in response to CT compared with control groups and other psychotherapies. A recent meta-analysis on CT and depression concluded that CT was associated with a greater change in dysfunctional thinking than control groups both at posttest (g = 0.51) and follow-up (g = 0.46, Cristea et al., 2015); however, no significant differences were found in comparison to other psychotherapies (g = 0.17) or pharmacotherapy (g = 0.04, Cristea et al., 2015). Further, patients treated with CT and IPT exhibited a similar degree of improvement on mediator variables (e.g., dysfunctional cognitions) across



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both treatments (difference in improvement effect sizes: d = −0.19 to 0.30, Lemmens et al., 2017). Thus, factors hypothesized to play a key role in mechanism of change within CT may not be unique or specific. Specifically, cognitive change may occur through both direct and indirect pathways. Using IPT as an example, although altering thought processes is not a core component of IPT, cognition and distorted thought may be addressed within an interpersonal context, and an adjustment of cognitions could occur following changes to interpersonal functioning (Lemmens et al., 2017). Therefore, the potential that cognitive change is not unique to CT does not mean CT is ineffective; it may only suggest that cognitive change may be achieved through a number of different modalities. Literature has begun to shift away from content of thought and instead focus on thought processes, as researchers posit that perhaps it is not the change in content of thoughts that produces therapeutic change but instead the way information is processed. For example, research has highlighted that CT has led to a reduction in dichotomous thinking and that this change in thought form, rather than thought content, mediates the effects of CT on preventing relapse (15% of those with low-dichotomous thinking vs. 42% of those with high-dichotomous thinking relapsed; Teasdale et al., 2001). Other studies have found that unhelpful cognitive processes, like ruminative cognition styles, prolong intensity of a negative mood, whereas attitudinal changes associated with acceptance reduce the intensity of a negative mood (15% vs. 65% recovered from an induced sad mood; Singer & Dobson, 2007). Research that has examined rumination has found that focusing on ruminative thought processes improved chronic depressive disorders (71% showed symptom reduction and 50% achieved remission; Watkins et al., 2007). Furthermore, the concept of decentering, which is the ability to observe thoughts and feelings as temporary events rather than true reflections of the self (Fresco et al., 2011; Safran & Segal, 1990), is often thought of as the first step to cognitive restructuring and, therefore, to minimizing suffering (A. T. Beck et al., 1985; Dalai Lama & Beck, 2005; Fresco et al., 2011; Herbert & Forman, 2011). However, recent literature suggests that decentering is one factor that produces change in CT, as high levels of decentering and low cognitive reactivity at posttest were associated with the lowest rates of relapse in an 18-month follow-up (34% relapse compared with 59%; Fresco et al., 2011; Teasdale et al., 2002). It should be noted that cognitive change can occur even when therapeutic techniques do not explicitly target maladaptive cognitions. In other words, cognitive restructuring can occur even when this process is not explicitly addressed in treatment (Hofmann, 2008; Hofmann et al., 2010). Overall, promising headway is being made on understanding the complexities of how CT leads to therapeutic change. More research is required to adequately assess the mechanism of change related to whether thought content is modified, deactivated, or suppressed or whether the mechanism of change is related more to a function in altered thought process.

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DISSEMINATION A key issue for evidence-based interventions is their dissemination, as results from research studies are sometimes relevant to only a particular population and stringent treatment parameters that do not always reflect real-world practice. Recent efforts have been made within the health care system to adequately disseminate evidence-based treatment including CT to practitioners and community providers. In this regard, several organizations have created credentialing systems for therapists trained in CT, including the Academy of Cognitive Therapy and the Canadian Association of Cognitive-Behavioural Therapy among others (although these organizations do not only credential CT-trained therapists, as they cover the field of CBT more generally). The Beck Institute for Cognitive Behavior Therapy is a private organization created by Aaron T. Beck that is dedicated to the training of CBT. The goals of the institute pertain to the training, advancement of knowledge, and advocacy of CT techniques in the context of CBT. In addition, the institute aims to provide resources and connect consumers with CBT services. It offers workshops and online training opportunities for individual health care professionals as well as organizations. Beginning in 2019, it will also provide accreditation to organizations and certification to individuals who have completed the necessary training and demonstrated excellence in CBT practice in order to set a standard of practice for skilled cognitive behavioral therapists. The institute’s involvement in the training, connection of consumers, and dissemination of CBT research aims to decrease the gap between science and practice in professional psychology. The wider dissemination of CT is now underway with the implementation of the Beck Initiative Training Program in Cognitive Therapy (Stirman et al., 2009), which is a partnership between researchers and clinicians at the University of Pennsylvania Department of Behavioral Health and Mental Retardation Services in Philadelphia, their behavioral managed care organization Community Behavioral Health, and their providers. The hallmark of the program is to provide intensive training and consultation in CT as well as quality assurance and support and to promote innovative methods to implement CT within community mental health care systems in the United States (Stirman et al., 2009). The Beck Initiative also works with providers to develop training programs that will meet the specific needs of each agency. Workshops focus on core CT concepts and intervention strategies for a range of clinical presentations. Following training, clinicians receive consultation during which they can submit recorded therapy sessions and are provided with weekly feedback. Preliminary program evaluation has provided evidence that these efforts successfully provide relevant training options to the community, as those who have received training indicated high satisfaction and demonstrated the ability to implement CT with skill and fidelity (Stirman et al., 2009).



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APPLICATION TO DIVERSE POPULATIONS The role of culture and diversity has become an increasing topic of consideration in clinical practice. CT was developed in the United States, and most extant research uses predominately Western samples. Western cultures emphasize individualism and autonomy. The concepts of independence, selfactualization, self-expression, and explicit communication are all readily observed as values that underlie CT (Hodge, 2008). Indeed, it is important to contemplate the potential effects on treatment outcomes related to both overall outcomes and therapeutic alliance. Unfortunately, this is an understudied area, and more research is needed to examine the effects of CT in diverse contexts. In general, efforts to culturally adapt CT should include the systematic modification of therapy to account for language, culture, and context in a way that is consistent with the client’s cultural patterns, meanings, and values (Bernal et al., 2009). Adaptations could include making material available in languages other than English, providing content that is specific to the client’s culture, conferring with clients in their first language, and training clinicians to be culturally sensitive to communication styles. Specific examples can be seen in work with low-income ethnic minorities (Miranda et al., 2003), Latinas (Gelman et al., 2006; Lara et al., 2003), and elderly Chinese Americans (Dai et al., 1999). Most adaptations included the inclusion of topics sensitive to the population being treated, adjustment of the manual to align with reading level and language, and adjustment of the language in which the therapy was provided. It should be noted there was no control group to account for effects of these modifications on efficacy (for a review, see Horrell, 2008). However, culturally adapted strategies can be associated with better treatment outcomes and lower dropout rates (Kohn et al., 2002; Miranda et al., 2003). For example, in addition to offering CBT sessions, the inclusion of supplemental case management that used the CBT model and included additional services to address and set goals to help manage issues related to low-income populations observed higher attendance rates (10.5 ± 4.6 compared with 8.4 ± 4.7, as measured by attendance to sessions) and fewer depressive symptoms compared with those who received CBT alone (22.0–22.5 vs. 19.0–23.5, as measured on the BDI; Miranda et al., 2003). Overall, some research supports the notion that cultural adaptations of CBT can lead to better outcomes than unadapted CBT and that these adaptations result in positive outcomes (e.g., Kohn et al., 2002; Miranda et al., 2003; Rosselló & Bernal, 1999). Another area for development is spiritually modified CTs. Similar to traditional CT, identifying unhelpful thoughts that underlie and contribute to current difficulties and learning strategies to alter thought content and processes are at the core of therapeutic goals. Spiritually modified CT uses spiritual principles derived from clients’ current beliefs to help foster this change (Hodge, 2006). Research in this area is sparse but generally shows that similar symptom outcomes can be achieved (for review, see Hodge, 2006). Although cultural and

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spiritual considerations are beginning to come about in efficacy studies and the development of treatment manuals, more research is still needed to fully understand the effects of CT within diverse populations and whether there are direct increases to treatment outcomes due to such modifications.

CONCLUSION In summary, the development of CT is credited to Dr. Aaron T. Beck, who developed a model of psychopathology that postulates certain beliefs or schemas constitute a vulnerability to psychopathology by systematically distorting the individual’s perception of their experiences and leading to a negative view of the past, present, and future (A. T. Beck, 1991, 2005). The development of CT was influenced substantially by psychodynamic and behavioral models of the 1950s and 1960s, but CT is a unique model for examining meaning and identifying themes across thoughts and behaviors. The CT model also employs behavioral interventions and focused, concrete, and goal-specific therapeutic strategies. Although cognitive theory has been updated to coincide with recent empirical findings and questions regarding normal adaptation, mechanism of activation and deactivation of schemas, and the role of personal goals within cognitive process, the overall theory and hypothesized mechanism regarding the importance of cognition on psychopathology has remained largely consistent over time. The first step of CT in clinical practice is to gather a detailed description of the client’s current problems and histories and then to formulate a conceptualization of the client’s presentation using the cognitive model. Case conceptualization is an integral step, as it allows the therapist and client to collaboratively develop an understanding of the client’s current difficulties, the factors that may precipitate or maintain the difficulties, and relevant intervention strategies. Strategies involved in CT are predominately cognitively based, including the use of thought records; the identification of cognitive errors; and the utilization of downward arrow, collaborative empiricism, Socratic questioning, and guided discovery techniques. Select behavioral methods, such as self-monitoring, are used to provide an opportunity for the client to observe, test, and modify cognitions. Practice of the cognitive strategies implemented and learned during session is considered integral to CT outcomes and is a significant aspect of the therapeutic intervention. There is a large body of empirical support for CT across symptom presentations and disorders. In addition, research has highlighted the efficacy of CT in comparison to pharmacotherapy and other psychological interventions for some disorders. Moreover, there is an even larger body of literature that demonstrates the efficacy of CT used in tandem with behavioral interventions and in the larger family of CBT, although this literature is not in the scope of the current chapter. Although limited efforts have been made to study the effects of cultural and spiritual adaptations of CT with diverse population, effects have



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appeared promising. In addition, despite the large body of research highlighting CT as a highly efficacious intervention, scant literature exists on the mechanism for these therapeutic outcomes. Literature has been mixed regarding whether therapeutic change occurs due to the modification of content of thought or whether compensatory strategies are learned that suppress maladaptive cognitions. An interesting development in the research related to the mechanism of change is the focus on thought process rather than thought content. Research in this area is promising, although much more is needed to explicate the mechanism of change in CT. CT is one of the best supported and widely used therapeutic interventions in the mental health community. There is often a disconnect between research and practice, which has been at the forefront of the minds of CT researchers. Efforts have been made to increase knowledge translation and disseminate training in CT interventions. Institutions and accreditation/certification efforts have been made to ensure adequate training in CT and that consumers are informed on where to locate services. In addition, recent efforts have been made with the implementation of the Beck Initiative to provide intensive training and consultation services to community mental health care systems. These services show promise with regard to disseminating CT and increasing evidence-based therapeutic training and service delivery within the community. Although these initiatives show promise at increasing evidence-based training, future efforts are needed to improve access to CT services.

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DeRubeis, R. J., Evans, M. D., Hollon, S. D., Garvey, M. J., Grove, W. M., & Tuason, V. B. (1990). How does cognitive therapy work? Cognitive change and symptom change in cognitive therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology, 58, 862–869. https://doi.org/10.1037/0022-006X. 58.6.862 DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., O’Reardon, J. P., Lovett, M. L., Gladis, M. M., Brown, L. L., & Gallop, R. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62, 409–416. https://doi.org/10.1001/ archpsyc.62.4.409 DeRubeis, R. J., Webb, C. A., Tang, T. Z., & Beck, A. T. (2010). Cognitive therapy. In K. S. Dobson (Ed.), Handbook of cognitive behavioural therapies (pp. 277–316). Guilford Press. Dimidjian, S., Kleiber, B. V., & Segal, Z. V. (2010). Mindfulness-based cognitive therapy. In N. Kazantzis, M. A. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp. 307–331). Guilford Press. Dobson, D., & Dobson, K. S. (2017). Evidence-based practice of cognitive-behavioral therapy (2nd ed.). Guilford Press. Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57(3), 414–419. https://doi.org/10. 1037/0022-006X.57.3.414 Dobson, K. S. (2013). The science of CBT: Toward a metacognitive model of change? Behavior Therapy, 44(2), 224–227. https://doi.org/10.1016/j.beth.2009.08.003 Eddy, K. T., Dutra, L., Bradley, R., & Westen, D. (2004). A multidimensional metaanalysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24, 1011–1030. https://doi.org/10.1016/j.cpr.2004.08.004 Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R., Pilkonis, P. A., Leber, W. R., Docherty, J. P., Fiester, S. J., & Parloff, M. B. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46(11), 971– 982. https://doi.org/10.1001/archpsyc.1989.01810110013002 Frank, J. D., & Frank, J. B. (1961). Persuasion and healing: A comprehensive study of psychotherapy. Johns Hopkins University Press. Freeman, A. (2004). Clinical applications of cognitive therapy. Springer Science & Business Media. https://doi.org/10.1007/978-1-4419-8905-5 Fresco, D. M., Flynn, J. J., Mennin, D. S., & Haigh, E. A. P. (2011). Mindfulness-Based cognitive therapy. In J. D. Herbert & E. M. Forman (Eds.), Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies (pp. 57–82). John Wiley & Sons. https://doi.org/10.1002/9781118001851.ch3 Garratt, G., Ingram, R. E., Rand, K. L., & Sawalani, G. (2007). Cognitive processes in cognitive therapy: Evaluation of the mechanisms of change in the treatment of depression. Clinical Psychology: Science and Practice, 14(3), 224–239. https://doi.org/10. 1111/j.1468-2850.2007.00081.x Gelman, C. R., López, M., & Foster, R. P. (2006). Evaluating the impact of a cognitivebehavioral intervention with depressed Latinas: A preliminary report. Social Work in Mental Health, 4(2), 1–16. https://doi.org/10.1300/J200v04n02_01 Gibbons, M. B. C., Crits-Christoph, P., Barber, J. P., Wiltsey Stirman, S., Gallop, R., Goldstein, L. A., Temes, C. M., & Ring-Kurtz, S. (2009). Unique and common mechanisms of change across cognitive and dynamic psychotherapies. Journal of Consulting and Clinical Psychology, 77(5), 801–813. https://doi.org/10.1037/ a0016596 Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59–72. https://doi.org/10.1016/S0165-0327(97)00199-7

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Gould, R. A., Mueser, K. T., Bolton, E., Mays, V., & Goff, D. (2001). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335– 342. https://doi.org/10.1016/S0920-9964(00)00145-6 Hanrahan, F., Field, A. P., Jones, F. W., & Davey, G. C. (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33(1), 120–132. https://doi.org/10.1016/j.cpr.2012.10.008 Herbert, J. D., & Forman, E. M. (Eds.). (2011). Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies. John Wiley & Sons. https://doi.org/10.1002/9781118001851 Hodge, D. R. (2006). Spiritually modified cognitive therapy: A review of the literature. Social Work, 51(2), 157–166. https://doi.org/10.1093/sw/51.2.157 Hodge, D. R. (2008). Constructing spiritually modified interventions: Cognitive therapy with diverse populations. International Social Work, 51(2), 178–192. https://doi.org/ 10.1177/0020872807085857 Hofmann, S. G., Sawyer, A. T., & Fang, A. (2010). The empirical status of the “new wave” of cognitive behavioral therapy. Psychiatric Clinics of North America, 33(3), 701– 710. https://doi.org/10.1016/j.psc.2010.04.006 Hofmann, S. G. (2008). Common misconceptions about cognitive mediation of treatment change: A commentary to Longmore and Worrell (2007). Clinical Psychology Review, 28(1), 67–70. https://doi.org/10.1016/j.cpr.2007.03.003 Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D., Salomon, R. M., O’Reardon, J. P., Lovett, M. L., Young, P. R., Haman, K. L., Freeman, B. B., & Gallop, R. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives of General Psychiatry, 62(4), 417–422. https://doi.org/10.1001/archpsyc.62.4.417 Hollon, S. D., Evans, M. D., & DeRubeis, R. J. (1990). Cognitive mediation of relapse prevention following treatment for depression: Implications of differential risk. In R. E. Ingram (Ed.), Contemporary psychological approaches to depression: Theory, research, and treatment (pp. 117–136). Plenum Press. https://doi.org/10.1007/978-1-4613-06498_8 Horrell, S. C. V. (2008). Effectiveness of cognitive-behavioral therapy with adult ethnic minority clients: A review. Professional Psychology, Research and Practice, 39(2), 160– 168. https://doi.org/10.1037/0735-7028.39.2.160 Kazantzis, N., Dattilio, F., & Dobson, K. S. (2017). The therapeutic relationship in cognitivebehavioral therapy: A clinician’s guide. Guilford Press. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189–202. https://doi.org/10.1093/clipsy.7.2.189 Kazantzis, N., Deane, F. P., Ronan, K. R., & L’Abate, L. (2005). Using homework assignments in cognitive behaviour therapy. Routledge. https://doi.org/10.4324/ 9780203499825 Kazantzis, N., Reinecke, M. A., & Freeman, A. (Eds.). (2010). Cognitive and behavior theories in clinical practice. Guilford Press. Kazantzis, N., & Stuckey, M. E. (2018). Inception of a discovery: Re-defining the use of Socratic dialogue in cognitive behavioral therapy. International Journal of Cognitive Therapy, 11(2), 117–123. https://doi.org/10.1007/s41811-018-0015-z Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755– 772. https://doi.org/10.1016/j.beth.2016.05.002 Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144–156. https://doi.org/c67ctx



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Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. https://doi.org/10.1146/annurev.clinpsy. 3.022806.091432 Kohn, L. P., Oden, T., Muñoz, R. F., Robinson, A., & Leavitt, D. (2002). Adapted cognitive behavioral group therapy for depressed low-income African American women. Community Mental Health Journal, 38(6), 497–504. https://doi.org/10.1023/ A:1020884202677 Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in assessment and treatment. Psychological Assessment, 11(4), 415–425. https://doi.org/10.1037/1040-3590.11.4.415 Kuyken, W. (2006). Evidence-based case formulation: Is the emperor clothed? In N. Tarrier (Ed.), Case formulation in cognitive behaviour therapy: The treatment of challenging and complex cases (pp. 12–35). Routledge. Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https:// doi.org/10.1017/S1352465808004815 Landon, T. M., & Barlow, D. H. (2004). Cognitive-behavioral treatment for panic disorder: Current status. Journal of Psychiatric Practice, 10(4), 211–226. https://doi. org/10.1097/00131746-200407000-00002 Lara, M. A., Navarro, C., Rubí, N. A., & Mondragón, L. (2003). Outcome results of two levels of intervention in low-income women with depressive symptoms. American Journal of Orthopsychiatry, 73(1), 35–43. https://doi.org/10.1037/0002-9432.73.1.35 Lemmens, L. H. J. M., Galindo-Garre, F., Arntz, A., Peeters, F., Hollon, S. D., DeRubeis, R. J., & Huibers, M. J. H. (2017). Exploring mechanisms of change in cognitive therapy and interpersonal psychotherapy for adult depression. Behaviour Research and Therapy, 94, 81–92. https://doi.org/10.1016/j.brat.2017.05.005 Markin, R. D. (2014). Toward a common identity for relationally oriented clinicians: A place to hang one’s hat. Psychotherapy: Theory, Research, & Practice, 51(3), 327–333. https://doi.org/10.1037/a0037093 Martell, C. R., Dimidjian, S., & Lewinsohn, P. M. (2010). Behavioral activation therapy. In N. Kazantzis, M. A. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp. 193–217). Guilford Press. Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology, 1, 167–195. https://doi.org/10.1146/annurev. clinpsy.1.102803.143916 Matt, G. E., Vázquez, C., & Campbell, W. K. (1992). Mood-congruent recall of affectively toned stimuli: A meta-analytic review. Clinical Psychology Review, 12(2), 227– 255. https://doi.org/10.1016/0272-7358(92)90116-P Miranda, J., Azocar, F., Organista, K. C., Dwyer, E., & Areane, P. (2003). Treatment of depression among impoverished primary care patients from ethnic minority groups. Psychiatric Services, 54(2), 219–225. https://doi.org/10.1176/appi.ps.54.2.219 Mitte, K. (2005). A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. Journal of Affective Disorders, 88, 27–45. https://doi.org/10.1016/j.jad.2005.05.003 Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80(1), 1–13. https:// doi.org/bhzv7n Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy: Theory, Research, & Practice, 48(1), 4–8. https://doi.org/10.1037/a0022180 Padesky, C. A. (1993, September). Socratic questioning: Changing minds or guiding discovery? [Keynote address]. European Congress of Behavioural and Cognitive Therapies, London, United Kingdom.

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Persons, J. B., & Davidson, J. (2010). Cognitive-behavioural case formulation. In K. S. Dobson (Ed.), Handbook of cognitive behavioural therapies (3rd ed., pp. 172–193). Guilford Press. Riskind, J. H., & Alloy, L. B. (2006). Cognitive vulnerability to emotional disorders: Theory and research design/methodology. In L. B. Alloy & J. H. Riskind (Eds.), Cognitive vulnerability to emotional disorders (pp. 1–29). Erlbaum. Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review, 24, 883–908. https://doi.org/10.1016/j. cpr.2004.07.007 Rosselló, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734–745. https://doi.org/10.1037/0022-006X.67.5.734 Rowa, K., & Antony, M. M. (2005). Psychological treatments for social phobia. Canadian Journal of Psychiatry, 50(6), 308–316. https://doi.org/10.1177/ 070674370505000603 Rutter, J. G., & Friedberg, R. D. (1999). Guidelines for the effective use of Socratic dialogue in cognitive therapy. Innovations in Clinical Practice: A Source Book, 17, 481– 490. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Basic Books. Segal, Z., Vincent, P., & Levitt, A. (2002). Efficacy of combined, sequential and crossover psychotherapy and pharmacotherapy in improving outcomes in depression. Journal of Psychiatry & Neuroscience, 27(4), 281–290. Shapiro, D. A., Barkham, M., Rees, A., Hardy, G. E., Reynolds, S., & Startup, M. (1994). Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. Journal of Consulting and Clinical Psychology, 62(3), 522–534. https://doi.org/10.1037/0022006X.62.3.522 Shapiro, J. R., Berkman, N. D., Brownley, K. A., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Bulimia nervosa treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 321–336. https://doi.org/ 10.1002/eat.20372 Singer, A. R., & Dobson, K. S. (2007). An experimental investigation of the cognitive vulnerability to depression. Behaviour Research and Therapy, 45(3), 563–575. https:// doi.org/10.1016/j.brat.2006.05.007 Stirman, S. W., Buchhofer, R., McLaulin, J. B., Evans, A. C., & Beck, A. T. (2009). Publicacademic partnerships: The Beck Initiative: A partnership to implement cognitive therapy in a community behavioral health system. Psychiatric Services, 60(10), 1302– 1304. https://doi.org/10.1176/ps.2009.60.10.1302 Strunk, D. R., DeRubeis, R. J., Chiu, A. W., & Alvarez, J. (2007). Patients’ competence in and performance of cognitive therapy skills: Relation to the reduction of relapse risk following treatment for depression. Journal of Consulting and Clinical Psychology, 75(4), 523. https://doi.org/10.1037/0022-006X.75.4.523 Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275–287. https://doi.org/10. 1037/0022-006X.70.2.275 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 Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2014). Are improvements in cognitive content and depressive symptoms correlates or mediators during acute-



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phase cognitive therapy for recurrent major depressive disorder? International Journal of Cognitive Therapy, 7(3), 251–271. https://doi.org/10.1521/ijct.2014.7.3.251 Wampold, B. E., Minami, T., Baskin, T. W., & Callen Tierney, S. (2002). A meta(re)analysis of the effects of cognitive therapy versus “other therapies” for depression. Journal of Affective Disorders, 68(2–3), 159–165. https://doi.org/ck2wd6 Wang, M. Y., Wang, S. Y., & Tsai, P. S. (2005). Cognitive behavioural therapy for primary insomnia: A systematic review. Journal of Advanced Nursing, 50(5), 553–564. https://doi.org/10.1111/j.1365-2648.2005.03433.x Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., Kennell-Webb, S., Moulds, M., & Malliaris, Y. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45(9), 2144–2154. https://doi.org/10.1016/j.brat.2006.09.018 Webb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S. (2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom change. Journal of Consulting and Clinical Psychology, 79(3), 279–283. https://doi.org/10.1037/a0023252 Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied & Preventive Psychology, 12(4), 189–201. https://doi.org/10.1016/j. appsy.2008.05.001 Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021–1037. https://doi.org/10.1016/j.cpr.2008.02.007 Wright, F. D., Beck, A. T., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse: Theoretical rationale. NIDA Research Monograph, 137, 123–146. Young, J., & Beck, A. T. (1980). Cognitive therapy scale: Rating manual [Unpublished manuscript].

15 Rational Emotive Behavior Therapy Debbie Joffe Ellis

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n the 1950s, the status quo in the world of psychotherapy began to have its position challenged. The psychoanalytic approach, which dominated the field at that time, was confronted by one that was active-directive, pragmatic, no-nonsense, philosophical, and imbued with compassion—an approach that would herald in the cognitive revolution in psychotherapy. The groundbreaking humanist Dr. Albert Ellis created that approach, now known as rational emotive behavior therapy (REBT). Cognitive approaches that followed, including cognitive therapy, cognitive behavioral therapy (CBT), acceptance and commitment therapy, dialectical behavior therapy, multimodal therapy, positive psychology, some types of life coaching, and others, stand on the shoulders of the immense body of work by Ellis, whose influence can easily be recognized in such modalities. Some of the originators of approaches that followed Ellis’s, including Aaron T. Beck, the late Arnold Lazarus, and Martin E. Seligman, have given credit to Ellis for his influence and inspiration. Others have not. It is lamentable that, as time moves along since the passing of Ellis in 2007, it appears some writers and teachers of the history of psychology and psychotherapy and of the various psychotherapeutic approaches are not recognizing his enormous contributions and do not give Ellis and REBT their rightful acknowledgment. This author is a professor at Columbia University in New York City and also gives lectures, workshops, and seminars to students at various other colleges within the United States, in addition to REBT workshops and courses in other countries. I regret to say that I have heard from a significant https://doi.org/10.1037/0000218-015 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  445 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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number of those students, particularly those outside the United States, that they have not heard much about Ellis in their graduate courses or that they thought that REBT was an offshoot of CBT developed after CBT had already been well established. Many of them shared with me that, before attending my REBT presentations, they did not know that REBT had played such a significant part in the creation of CBT. This chapter of the Handbook of Cognitive Behavioral Therapy contains discussion of REBT’s unique history and development, along with descriptions of its theory, techniques, and change mechanisms; its application to and efficacy for various and diverse populations; its unique elements; its evaluation; and final comments.1 It is hoped that in addition to reading this chapter, readers will go on to read articles and books by Ellis himself. There are at least 2,000 published articles, over 85 published books, and countless individual chapters by Ellis contained in books written or edited by other authors. In addition to providing stimulating and powerful material that can both enhance the individual lives of readers, doing so can increase the efficacy of our care of, and work with, others. Therapists in almost any modality, including traditional and nontraditional cognitive behavioral practitioners, may find elements and techniques of REBT that enhance their existing practices. So let us begin this relatively brief, but substantial, consideration of REBT.

HISTORY AND DEVELOPMENT Albert Ellis was born in Pittsburgh, Pennsylvania, on September 27, 1913, to Hettie and Henry Ellis. His beloved brother Paul was born around 18 months later, followed in time by the birth of their sister Janet. When Ellis was about 3 years old, the family moved to live in New York City, which was to be his home base for the rest of his life. Born with remarkable intelligence, Ellis was extraordinary in many ways. When he was around 3 years of age, he learned to read with the help of a 5-year-old neighbor who would read out loud to him, sitting on the stoop of their apartment building. From infancy and throughout his childhood, Ellis was often very ill and, over those years, spent long months in hospital. Some of the illnesses included nephritis, terrible migraine headaches, and painful bloating and stomach problems. His mother, busy tending to his younger siblings and participating in various community activities, rarely visited him, nor did his father, who was frequently away on business trips. Understandably, young Al felt very sad, yet his response to the neglect and sadness that he felt was highly unusual for a child of such a young age. He did not like feeling sad and he did not want to feel sad, so he became proactive in order to reduce his melancholy. He read books from the hospital’s children’s library; he made up games to play during the day; he talked to fellow patients and their visitors; he fell in love with his nurses; he daydreamed about baseball heroes and other people he admired; he used his Clinical examples are disguised to protect patient confidentiality.

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imagination to think about what he would do when he grew up; and he invented games (some of which were considered rather naughty at the time), that he and the other children in his ward could play after “lights out.” These actions helped him focus on things other than his sadness and the neglect by his parents and were fine examples of the benefits of cognitive distraction—which became, and is, a technique of REBT. It is important to point out here, as seen in these examples, that a large component of the formation and development of REBT was the creative and constructive ability that Ellis displayed, starting at a remarkably young age, to find practical ways to endure, cope with, and reduce his own emotional suffering. He successfully applied ideas and actions that were to become part of REBT well before he could even imagine being a therapist (Ellis, 2010). This is unusual in the development of a therapeutic approach, which more often than not begins with a hypothesis or some hypotheses that their creator sets out to prove, or disprove, and research. The fact that such an immense body of the REBT approach was born from Ellis’s suffering and his successful efforts to reduce and, at times, remove it lends to its humanistic manner, its power, its effectiveness, its relatability, and its no-nonsense yet immensely compassionate nature. In college, as a youth leader of a radical political group, Ellis had a severe phobia about public speaking and avoided giving speeches until he read of the early work of John B. Watson and the success of employing gradual exposure and in vivo desensitization with young children to help them overcome their intense fears of animals. Ellis decided “if it’s good enough for the little kiddies, it’s good enough for me!” and he forced himself, despite his discomfort, to speak often in public. Within weeks, he overcame his phobia and discomfort to such a degree that he discovered that he actually enjoyed public speaking greatly, and he proved to be most effective at doing so. He would often say in workshops and lectures when recalling that time, “I completely got over my phobia, and now you can’t keep me away from the public speaking platform!”2 Concurrently, there was an additional challenge for him to address. He experienced great social anxiety along with a strong fear of talking to women. This was highly inconvenient as, to quote him, “I fell in love with 110 out of 100 women but was too afraid to start a conversation with them.” He realized that if he wanted to date women, he would need to overcome that fear, and he again used gradual exposure and in vivo desensitization to overcome this obstacle that was preventing the attainment of one of his most ardent goals. Throughout his professional life, students, professionals, and members of the general public would both be inspired and heartily laugh when he would talk about his strivings to overcome this phobia and describe the homework activity he gave himself over the month of August that year of sitting next to at least 100 women on park benches in the Bronx Botanical Gardens and starting conversations with them. Although he made only one date, and she did not show up, he overcame At times quotes by Ellis are presented in this chapter without citations. Such quotes were heard (many times!) firsthand by the author of this chapter, Dr. Debbie Joffe Ellis, who was his wife and who worked with him in all areas of his work.

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his fear of approaching women. These practices of gradual exposure and in vivo desensitization became, and remain, frequently used techniques in REBT. When Ellis was around 24 years of age, he was madly in love with an energetic and vivacious 19-year-old named Karyl. They spoke of living together forever and of their great love for one another often, yet Karyl would at times be unpredictable. One night after Ellis and Karyl shared a particularly romantic time at her parent’s home while they were out, she walked him to the door and said that she thought they should break up. This was totally unexpected, and he felt devastated. Though it was late at night, Ellis walked to the nearby Bronx Botanical Gardens and circled the lake therein, deep in contemplation. He would recount that after hearing those words from Karyl, he shed tears—one of the few times in his life in which he did so. At first, he thought that he could never be happy without her, that his life held no meaning if he could not be with her, that she should not go back on her promises to love him forever, that she should be as loyal to him as he was to her, that he would never love anyone as much as he loved her, and that he should not be treated this way, and he felt deeply depressed. However, then he had an epiphany—one that contributed to changing the world of psychotherapy forever. He realized that in fact it was not Karyl’s rejection of him that was creating his misery but rather what he was telling himself about it that caused the emotional pain. He thought things through. He questioned some of his premises. He disputed those that had no logic or evidence to back them up. For example, he realized that there was no evidence that he could “never” be happy without her, and even if—worst case scenario—he ended up not feeling as happy as he had felt during his times with her, there were still things in life that could bring him some measure of satisfaction. He loved writing, reading, and helping people. He contemplated that just because she promised something, there was no evidence or law of nature that said that she could not or should not change her mind, even though he wished she had not done so. He saw that just because he acted a certain way and held loyalty as an important standard to live by, there was no evidence or reason that Karyl was obliged to hold that belief or to act accordingly. He thought to himself that even though he preferred strongly that she would not treat him in that way, there was no reason that she should not. Having recently read works by neo-Freudian Karen Horney that describe the “tyranny of the shoulds,” Ellis realized that he had allowed himself to fall victim to such tyranny. Furthermore, he resolved to stop that tendency and to think wisely and rationally in ways that would prevent such deep ache and allow him to live a productive life. This awareness of the importance of ceasing demandingness—the shoulds, musts, and oughts—in order to live a happier life is paramount in the theory of REBT. As will be seen later in this chapter, although preferences and strong desires and goals are encouraged in REBT, demands can, more often than not, lead to unhealthy and debilitating emotions if that which is sought after is not attained. Thus, REBT teaches the “how-to’s” of identifying demanding and irrational ideas and of disputing them with precision.



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Having witnessed Ellis overcome his shyness and relationship angst, many of Ellis’s friends gravitated to him when they wanted relationship advice and help. He found that he enjoyed and was effective at helping them. He decided that even though a goal of his was to write the “great American novel,” he wanted to become a therapist and help people. During the depression, he and his brother helped their father with business activities, but as soon as he could afford to, he started his master’s and PhD programs at Columbia University Teachers College in New York City, and he excelled. Ellis read avidly, and elements of REBT can be recognized as having been influenced by some of the wise sages and philosophers he enjoyed. Ellis regularly gave credit to those who influenced and inspired elements of his work, and he did not take credit for, or pretend to be inventing, any “wheels” that his predecessors had so ably invented. As was touched upon early in this chapter, it is sad to observe that the contributions of Ellis and other inspiring pioneers and great thinkers who are no longer alive are being neglected in the writings and teachings of some people who devise new and appealing titles for their approaches yet are including elements of their predecessors, works without giving them due credit. Some of the people, philosophies, and practices that Ellis acknowledged as being influential in his work included Gautama Buddha, Zen Buddhists, certain meditation practices, and even aspects of the ancient Hebrew and Christian philosophies (despite the position taken for most of his life as a “probabilistic atheist”). He was particularly taken by Ellis with Greek and Roman philosophers and Stoic philosophy, including the works of Epicurus, Epictetus, and Marcus Aurelius. During the period in the early 1940s in which Ellis worked as a clinical sexologist, he followed works of Havelock Ellis, W. F. Robie, and others, who were physicians and practiced what could be called cognitive behavior sex therapy. Ellis was inspired by writings of the general semanticist Alfred Korzybski and those of philosophers including Bertrand Russell, Paul Dubois, and Emile Coue (the latter two used persuasive forms of psychotherapy). He enjoyed the works of Alexander Herzberg (who included homework assignments in his work) and the works of existential philosophers of his time, such as Kierkegaard, Heidegger, Sartre, and Tillich. Though Ellis was trained in and practiced liberal psychoanalysis, he thought of himself as more of an existential analyst. His psychoanalytic influences at that time included Erich Fromm, Karen Horney, Harry Stack Sullivan, and Alfred Adler. Ellis created the LAMP (Love and Marriage Problems) Institute in his apartment in the Parc Vendome building on West 56th Street in New York and helped many people using knowledge he had learned from his studies, copious research, and personal experience. He was a founder of the Society for the Scientific Study of Sexuality (Quad S), which had its first meetings in that very same apartment. Quad S has continued to grow and flourishes to this very day. Ellis was a contributing figure to the sexual revolution in America in the 20th century, writing and speaking about sexuality in the 1940s and throughout his

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life. He was one of very few to vigorously advocate for equal rights for gay people and for women’s rights in the 1950s and onward. He was a pioneering feminist and particularly taught women how they could choose to be assertive rather than passive or aggressive. Following the acquisition of his PhD, Ellis saw patients for therapy under supervision, the requirement for attaining his license. Ellis increasingly found that the psychoanalytic approach in which he had been trained was too passive, inefficient, and lacking in educational and behavioral elements. His dissatisfaction led to his becoming more active and directive with his clients, and he abandoned psychoanalysis in 1953, developing the approach now known as REBT. He observed in sessions that although most of his patients felt better following their sessions due to their talking and venting, they were not improving. They were continuing to think in self-defeating ways and perpetuating their creation of unhealthy emotions and unnecessary misery. He gave clients homework activities to do between sessions and taught them that they were responsible for their own emotional destinies. He taught that it was not their circumstances that created their emotional disturbances but their beliefs about the circumstances that did so. He mindfully continued to monitor his clients’ progress as he used his active-directive approach, seeing significant improvement in most of them, and continued to develop his rational approach. He continued his research and writing, and articles he wrote were published in 1945. In each year following that one, published articles and books were produced until the year of his death in 2007. A substantial bibliography of his works can be seen in the appendix of his autobiography (A. Ellis, 2010). REBT was first called rational therapy (RT), then in the early 1960s, rational emotive therapy (RET). In 1993, it became known as rational emotive behavior therapy (REBT) to reflect its holistic nature. Along with heralding in the cognitive revolution in psychotherapy, REBT was recognized as being a most humanistic approach and profoundly changed the world and practice of psychotherapy (A. Ellis, 1973). Ellis first presented his approach to his peers and colleagues at the annual convention of the American Psychological Association in 1956, with a response of jeers, criticism, and damning remarks. His approach was accused of being superficial and simplistic. Ellis did not allow those critiques to mar his efforts to help more people become emotionally healthy using his no-nonsense, activedirective, encouraging, and compassionate approach, and he persisted to research, write, and present about it. By the 1960s, growing numbers of therapists embraced his approach. He had purchased a building in 1959 that was to become the nonprofit Institute of Rational Therapy, later known as the Albert Ellis Institute. This haven for those wanting to learn, enhance, sharpen, and expand their knowledge and practice of REBT thrived. Albert Ellis and other REBT therapists saw individual clients there. He also conducted eight weekly group therapy sessions. He provided trainings, REBT certification, and practicums for professionals. He offered regular workshops on specific issues of everyday life for members of the general



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public, (including his famous Friday Night Workshops, which ran for 47 years, open to professionals and nonprofessionals), in which he demonstrated the REBT approach with volunteers from the attending audiences. Intensive workshops were held there. For years in the 1970s, the institute was the home of the Living School, in which children learned the principles of REBT. Postgraduate and doctoral students from within the United States strove to do internships at the institute, and many went on to do fellowship programs. Annual postdoctoral fellowship programs were provided for international therapists to encourage the presence of REBT in countries around the world. At the same time, as the institute continued to thrive and touch the lives of countless people, Ellis would also tirelessly present lectures, seminars, and workshops at colleges and conferences throughout the United States and in countries all over the globe. This author’s friendship with Ellis began in the 1980s, and as the years rolled along, it progressed into intimacy and marriage. In his final decade of life in our work together, we began to present workshops on REBT and Buddhism. We would give much focus to, and emphasis on, the REBT tenets of unconditional acceptance. These formed part of REBT from its inception, yet in the climate of growing fears of terrorism in that first decade of the new century, we focused more frequently upon them than Ellis might have done at times in the past. During the final years of Ellis’s remarkable life, some unanticipated and heart-wrenching events took place. The original mission statement for his institute that he had created around 1959 had been changed without his knowledge, he was dismissed from duties, he was no longer permitted to do any work or teaching within the institute, and he was ousted from the board of which he had been president. He did what he could in his fight for justice. There were two lawsuits, the outcome of one being that he was reinstated to the board, with the judge saying that the behavior of those who had ousted him was disingenuous. Yet after the reinstatement, he had no practical power within the board, and not long thereafter, he succumbed to pneumonia. He made exhausting efforts to regain health and strength for the 15 months that followed, but despite his superhuman efforts, he passed on July 24, 2007. He died before the second lawsuit could be completed. Those final years contained the greatest sadness he had ever experienced—he felt shocked and deeply sad at what had happened in his institute. The master of REBT was being tested, and he passed the test with distinction. He practiced what he preached until his end. Despite his disdain for the actions of the people involved, he hated only what they did; he did not hate them. He felt compassion for them. In consoling me one day when I felt deeply sad following an action against him that I considered cruel and appalling from some of the people, he said to me, “Debbie—you are forgetting to practice REBT now. You are such a good teacher and therapist—but now you are not applying it to yourself. Accept, accept, accept—they have to do what they are doing when they think the way that they are thinking. Accept.” He applied REBT's attitudes and actions, through practically every jolt and nasty situation. Accepting did not mean inaction. We did what we could to

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bring about change, and we did not allow ourselves to give up striving for justice and our mission to teach REBT to as many people as possible. We continued teaching and presenting in a very large rented room in the building next door. Accepting what is does not mean not striving and acting to change it. In accepting, there is the probability of feeling less rage, depression, and anxiety and of experiencing, instead, a healthy concentrated, determined, and motivated drive to affect change, while also feeling disappointment, sadness, and concern, which do not debilitate but may motivate and facilitate productive actions. During the final months of Ellis’s life, when it was clear that his health was rapidly declining and not likely to improve and that it was unlikely that in his lifetime he would witness the justice that he sought, we continued to practice what he preached. Despite our deep sadness, ache, and disappointment (and on top of that, his great physical pain much of the time), we focused on what was good in our lives. That was our profound love. Each day we would hold and hug one another. If he was in too much pain for our lying together in his hospital bed, I would stroke his head and hands, and we felt deeply grateful that we had one another, that we were together, and for our rare and profound love—despite and including the bitter circumstances we were facing and enduring. In the work I have done and continue to do since my husband’s passing in 2007, I give great emphasis in my teaching and writing to the importance and benefit of striving to experience and practice unconditional acceptance, gratitude, compassion, kindness, awe, and wonder in one’s daily life (Ellis & Ellis, 2019; D. J. Ellis, 2015). These are not new components of the REBT philosophy, but some I choose to focus on and magnify during these times of increasing random and brutal violence and political divisiveness and unrest.

UNDERLYING THEORY Many people believe that one of the marks of genius is the ability to translate complex and/or copious numbers of ideas into simple and clear form. There is no doubt that Ellis was a genius in this way, among many other ways. As indicated earlier in this chapter, in addition to incorporating select aspects of Stoic, Eastern, and contemporary philosophers’ works, along with a few aspects of Alfred Adler’s individual psychology, Karen Horney’s neopsychoanalytic work, and others, Ellis constructed the theory and methods of REBT to a significant extent from his own experiences of coping with various adversities throughout his life and from his intellect, wisdom, and constructive, creative, and visionary abilities. His books were easily understood by both professionals and nonprofessionals. Some were primarily targeted toward professional readers and others for the broad population of individuals. One of his great contributions was being the first author of self-help books, which over the decades has become one of the most popular genres for readers. His goal was to help as many people



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as possible who did not require intensive help to get better, not just feel better, and to learn the ways to keep themselves in good mental and emotional shape without needing to rely on regular therapy. Moreover, for those who did benefit from longer term therapy, Ellis believed that the simplicity of REBT enhanced their therapeutic processes. REBT is psychoeducational in nature and, with precision, teaches people how to distinguish between rational and irrational thinking and between healthy and unhealthy negative emotions. Let us now look at the main aspects of REBT: • It is not an event or adversity that creates our emotions but our perception of, and beliefs about, the events/adversities that create our consequent emotional experience. • When we think in rational ways in response to activating events or adversity (e.g., not getting what we want, getting what we do not want, experiencing intense loss), we create healthy negative emotions. When we think in irrational ways in response to such activating events, we create unhealthy and debilitating emotions. The word “negative” used here is not to imply “bad” in any way. It indicates that the emotions may not be pleasant, but they may or may not be healthy. • The unhealthy negative emotions include (a) anxiety, panic, and extreme fear; (b) depression, despondency, and hopelessness; (c) rage; and (d) shame and guilt. The healthy negative emotions include (a) concern; (b) sadness, disappointment, and grief; (c) healthy anger and annoyance; and (d) regret. • The elements of irrational thinking include (a) demands, shoulds, musts, and oughts; (b) rigid thinking; (c) blowing things out of proportion, lack of realistic perspective, taking things too seriously, and an absence of humor; (d) catastrophizing and awfulizing; (e) overgeneralizing, absolutistic thinking, and stereotyping; (f) low frustration tolerance (i.e., “I can’t stand it!”); and (g) damning oneself, others, and life when things do not go the way one thinks they “should.” The three core irrational beliefs from which countless others sprout include (a) “I must do well and be liked/loved/approved of by everyone,” (b) “You must treat me well and act the way I think you should,” and (c) “Life should be fair and just.” • The elements of rational thinking include (a) preferences, desires, wishes, and wants (REBT encourages us to experience intense and passionate intentions and emotions that are life enhancing, rather than demands that can lead to restrictive and debilitating emotions); (b) flexible thinking; (c) realistic view and perspective of events; (d) adoption of humor and a humorous view of events; (e) avoidance of catastrophizing and awfulizing; (f) avoidance of overgeneralizing, absolutistic thinking, and stereotyping; (g) high frustration tolerance (i.e., remembering that we can stand what we do not like—we just do not like it); and (h) unconditional acceptance, including unconditional self-acceptance, unconditional other acceptance, and unconditional life acceptance.

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• With awareness, we have choice. REBT can aptly be described as the original contemporary mindfulness psychotherapy. It reminds us to “think about our thinking,” to identify any irrational beliefs, to thoroughly dispute them, and to then replace them with rational beliefs. That, too, sets REBT apart from other approaches—rather than simply asserting that we had best replace irrational and distorted beliefs with rational ones, as many other approaches do, it vigorously encourages us to first dispute the life out of the irrational ones before we replace them. • Clients in REBT are encouraged to create and maintain healthy change and are taught and reminded that doing so requires ongoing effort. • REBT is not simply an effective therapeutic approach; it is also a way of life for those who adopt it as such. In articles that were published in 2003 and 2005, authors Ellis, Aaron T. Beck (known as the father of CBT), and prominent CBT authority Christine Padesky agreed that REBT is the most philosophical of the two approaches (A. Ellis, 2003, 2005; Padesky & Beck, 2003). • REBT does not suggest to its practitioners that a key to making healthy thinking a habitual mode of thinking is to simply replace the irrational beliefs with rational ones. It asserts that, before doing so, it is important to dispute each of the irrational beliefs, to “zap” their hold and any mistaken ideas of their veracity, and to consequentially create rational beliefs. This is a unique feature of REBT, relative to other cognitively based therapies. This promotes the creation of a habitual tendency to attend to irrational beliefs as soon as they are recognized by “nipping them in the bud” through thorough and precise disputing, and then applying repetitive reflection on the rational beliefs that replace them. REBT encourages us to apply three forms of disputing: (a) realistic disputing, in which facts and evidence are sought that would either support or refute the irrational beliefs; (b) logical disputing, which involves identifying the presence or absence of logic and whether or not resultant accurate inferences are being made; and (c) pragmatic disputing, in which one considers whether continuing to think in the irrational ways is practical and whether it is helpful or harmful to do so. The precision and immediacy of disputing that REBT encourages is another of its factors that sets it apart from other cognitive approaches. • General semantics, a system of linguistic philosophy developed and founded by Albert Korzybski (1933), plays a significant part in the theory and practice of REBT, which reminds us to be aware of the impact of words and the meanings we attribute to them. REBT also cautions us against overgeneralizing, stereotyping, and absolutist thinking. • REBT encourages multimodality. As already mentioned, certain elements of the writings of the Stoic and Eastern philosophers and of Alfred Adler were incorporated into it. Furthermore, REBT can be a beneficial adjunct to other modalities, including those that may be less active-directive in nature, such as Rogerian client-centered psychotherapy.



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• REBT is humanistic to the core, demonstrated in many ways including its focus more on human elements than environmental ones that contribute to emotional well-being, its deeply philosophical nature, and its hefty encouragement of expressing and experiencing compassion and acceptance. While attending to cognition and behavior, REBT gives great attention to the emotional element of therapy and well-being (its “E”). One of the myths perpetuated over the years has been that REBT neglects to do so. For many years Ellis and Fritz Perls carried on a feud and debated strongly following the accusation by Perls that REBT was too intellectual and ignored any emotional element. Other writers who credited Ellis for highlighting the cognitive element neglected, and still fail to recognize, the fact that he equally highlighted the emotive aspect. Unlike others who combine unpleasant and painful emotions into one category, Ellis clearly distinguished between what he called healthy and unhealthy negative emotions (referred to earlier in this chapter). REBT encourages us to embrace healthy negative emotions rather than to avoid or eliminate them. It actively teaches the difference between healthy negative emotions and debilitating unhealthy ones, along with the process of creating the healthy ones. In addition, REBT urges therapists to practice what they preach. Many REBT therapists may not do so or may do so to a limited extent, yet may still be effective in helping clients due to REBT’s clear structure, framework, theory, methods, and elegance. However, Ellis asserted, as this author continues to do, that therapists may be even more effective when practicing it in their own daily lives. The reasons for this include the following: (a) they may display an added component of greater authenticity, which can create stronger empathy and rapport in the client–therapist relationship; (b) they are seen as credible models of the approach; and (c) they make an ongoing effort to keep themselves stable, steady, and not upset during challenging times in their own lives, which in all probability, can enable them to remain focused and effective during even the most challenging of sessions. In all, the manner and essential attitude of REBT is one of realistic optimism. It can also be described as a no-nonsense, evidence-based, effective, efficient, and scientific approach that is imbued with compassion.

DESCRIPTION OF MAIN PROCEDURES One of the most effective tools offered in REBT, which is incorporated in part or whole by other approaches and modalities that followed REBT, is the ABCDE self-help approach for emotional disturbance. Through this remarkably simple yet strongly effective framework, one clarifies the connection between an activating event and its consequences by identifying the irrational beliefs involved and then provides the means for replacing irrational beliefs with rational ones through disputation and the creation of effective new beliefs. It has contributed to empowerment and healthy change in

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countless numbers of people who have utilized it. The ACBDE procedure is as follows: • A (Activating Event): Describe, as objectively as possible, the event or circumstance that seemed to create the resultant emotion and/or self-defeating behavior. • C (Consequences: Emotion and/or Behavior): Describe the unhealthy negative emotion one would like to change and, if applicable, any self-defeating behavior. • B (Beliefs): Identify the irrational beliefs (as many as possible) that followed the A (in this framework, B follows C). • D (Disputing): Disputeg each of the irrational beliefs through (a) realistic disputing, asking “Where is it written? Where is the evidence?”; (b) logical disputing, asking “Does it follow that . . . ?”; and (c) pragmatic disputing, asking “Where will it get me to maintain this irrational belief?” • E (Effective New Philosophies): These are healthy, functional, and realistic beliefs that replace the former irrational ones as a consequence of thorough disputing, and for lasting change, it is important to go over them often and regularly. Techniques and tools suggested by a therapist, or those selected for practice by an individual doing self-help, can be chosen from a variety of cognitive, emotive, and behavioral techniques and tools. They include the following3: • Cognitive: the ABCDE self-help procedure, vigorous disputing, doing a cost/ benefit analysis, distraction activities, modeling, psychoeducation, bibliotherapy, and audiotherapy and video therapy • Emotive: rational emotive imagery (e.g., imagining a challenging situation that evokes a disturbing or debilitating emotion to immerse oneself in the sensation and experience of that emotion and then to lessen the intensity of or to eliminate that emotion by changing one’s former thoughts and beliefs about the activating situation); shame-attacking exercises (e.g., doing something quirky or unusual, not dangerous, that attracts attention from people nearby, while forcefully reminding oneself all the while that the thoughts and opinions of others don’t in any way define one’s worth and that one doesn’t need approval from others); creating and repeating strong coping statements; role playing; and forcefully disputing one’s irrational beliefs that one has recorded or written • Behavioral: risk-taking (safe), in vivo desensitization, staying temporarily in a difficult situation (when safe to do so) to develop frustration tolerance, skill training, relapse prevention, reinforcement, use of humor, and rational Detailed descriptions of these techniques can be found in many of the scores of books by Albert Ellis and in A. Ellis and Ellis (2019).

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emotive songs (the goal of these songs is to allow the singer to reflect on and laugh about their human fallibility and self-defeating tendencies) Ellis wrote hundreds of lyrics to tunes of songs from the Great American Songbook, and often participants in workshops that he and this author presented would gleefully sing a small selection of them. One of the songs that evoked much laughter and recognition from its singers is the following: Glory Glory Hallelujah (Tune: Battle Hymn of the Republic, by Julia Ward Howe) Mine eyes have seen the glory of relationships that glow And then falter by the wayside as love passions come—and go! Oh, I’ve heard of great romances Where there is no slightest lull— But I am skeptical! Glory glory Hallelujah! People love ya till they screw ya! If you’d lessen how they do ya— Then don’t expect they won’t! Glory glory Hallelujah! People cheer ya—then pooh-pooh ya! If you’d soften how they screw ya! Then don’t expect they won’t!

As mentioned earlier, REBT strongly emphasizes the importance of the practices of three forms of unconditional acceptance, namely (a) unconditional self-acceptance, (b) unconditional other acceptance, and (c) unconditional life acceptance. Unconditional other acceptance has been controversial. Some people argue that it is foolish and unrealistic to expect people to unconditionally accept others who have acted in brutal and cruel ways against them. REBT reminds us that unconditionally accepting that a person has worth, despite and including any flaws and misdeeds, does not mean that we accept their rotten behavior. Certainly, REBT is all for seeking justice, but its theory asserts that justice may be more aptly attained when coming from a place of emotional stability than from rage and damnation of others—and that it is achievable. We can remind ourselves of many people (some reported in the media, others who we may know in our personal lives) who have succeeded in experiencing unconditional other acceptance and genuinely applied forgiveness of a person or people who assaulted them, though not necessarily the bad deeds. REBT invites us to consider that if we had the backgrounds of those who act in despicable ways, had their biological and genetic profiles, and had been thinking the thoughts they had thought when doing their evil actions, then in all probability, we might have acted in similar ways. This “walking a mile in the other’s shoes” begets empathy and is enriching for the receiver—and perhaps even more so for the giver. Unconditional self-acceptance can be hard to experience in those who, for years, have never examined their view of themselves and who consider their self-downing automatic thoughts and attitudes to be true. REBT beautifully, patiently, and persistently reminds us to be vigilant in the quest to make unconditional self-acceptance the norm. It is achievable when one is

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aware that one is not experiencing it and makes the choice to change that status quo. One client, “Steve,” had not considered the presence or lack of unconditional self-acceptance in his life until he came across REBT. He sought therapy for help with depression, hopelessness, and inertia. He had also recently been contemplating suicide, though had not yet attempted it. He realized early on in our therapy sessions that he had always tended to put himself down, he never believed that he was good enough, he damned himself for severe errors and bad choices he had made in his past, and he felt extreme guilt and shame about the emotional suffering those close to him had gone through as a result of his past foolish actions. On reflection, he believed that he would never and, furthermore, that he did not deserve, to feel any sense of self-worth and “okayness” about himself. It was known to me that Steve loved animals and plants and was active in supporting groups dedicated to saving the environment. In particular, he was working with a group bringing awareness to people about the irresponsible burning of huge areas of forest growth around the Amazon River. So, homing in on his love of nature, I asked him about an impressive tree growing in a small area surrounded by grass in the footpath in front of the building we were in. That majestic tree could be clearly seen from the window of the room in which we were working. It was huge, very old, somewhat gnarled, inhabited by a variety of plant parasites, and had had some letters engraved in it by starry-eyed teens years prior. I drew his attention to the tree and asked what he thought of it. He immediately replied that he thought it was magnificent. I answered that I thought that perhaps he had not noticed that it was old, gnarled, had parasites, and had been engraved into. His reply: “So what?” I went on to say that, perhaps, it would be best for the city council to remove it and replace it with a young fresh tree. He vehemently disagreed, saying that it was magnificent just the way it was and despite those flaws that I had mentioned. I thought to myself, “Great!”; that was just the type of response I had been hoping for. I then expressed words to him along the lines of “Steve, are you any less a part of nature than that tree?” “No, of course not,” he said, and then he got my intended message, and tears flowed down his face. He realized that though he had been accepting (easily was able to accept) unconditionally the worth of that tree despite its many imperfections, he had not been doing that to himself. We talked about this, and he embraced the fact that with effort he could choose to dispute his former harsh and self-downing ideas about himself, he could replace them with realistic and compassionate ones, and he could repeat and repeat the latter until, over time, he felt convinced of their veracity. He realized that by accepting that he was a fallible human prone to making mistakes just like other humans, he could allow himself to regret and learn from past failings in order to prevent repeating them, without damning himself for having made them in his past. He made a diligent effort and, in a relatively short time, no longer felt burdened by the weight of guilt, shame, and self-



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loathing. He felt liberated and tranquil, and various areas in his life, including his relationships with some significant people, improved. In the years since that time, he has become a therapist, working mainly with troubled youth, sharing with them some of the profound REBT insights and techniques that he had employed to turn his life around.

THERAPEUTIC CHANGE In REBT, the first part of the therapeutic process is the clarification of therapeutic goals, and this is done in collaboration with the client. The approach is immensely psychoeducational; the therapist will explain the principles of REBT to clients very early in treatment and, when appropriate, will recommend reading and video materials to assist in their learning and understanding of the approach. The therapist may also suggest materials of other approaches or philosophies if deemed helpful; hence, REBT is truly multimodal, as indicated earlier in this chapter. The effective therapist also stays abreast of current news, with focus on inspiring stories in particular, and of popular books and movies that support themes being worked on in therapy that can be recommended to clients. The effective REBT therapist encourages clients to self-reflect and identify their beliefs and philosophy of life and encourages them to make ongoing efforts to challenge self-defeating ideas, dispute them, and replace them. REBT does not recommend simply removing or placating symptoms, but it aims to facilitate profound and lasting beneficial changes in the thinking, emotional, and active life of the client. REBT takes into account the tendency that we all can have to relapse into previous dysfunctional states and thus has built into it relapse-prevention methods. These methods include regular self-monitoring, vigorous application of the disputing methods that have been helpful in the past, and perhaps most importantly, the practice of unconditional selfacceptance despite and including any relapses. An important aspect of the REBT therapist is to motivate clients to persist in their efforts to reduce emotional misery and maximize joy and tranquility, and this can include straightforwardly encouraging the client to consider the consequences of maintaining irrational thoughts and self-defeating attitudes, to avoid the arresting of efforts to change. It also may include helping the client to envision the fruits of continuing to make efforts and choices that enhance their lives. The effective REBT therapist models unconditional other acceptance when there are relapses in the client’s progress, warmly recognizes and talks about progress the client is making on their therapeutic journey, and encourages ongoing forward movement. The therapist also makes an effort to develop rapport with the client. A gross misconception about REBT is that REBT asserts that rapport and the demonstration of empathy does not matter very much in the therapeutic process. This is false, and it is a distortion of REBT’s encouragement to therapists to avoid

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allowing the client to depend on the therapist to “make them feel better.” Instead, REBT helps clients work on removing any excessive and inappropriate need to feel accepted by the therapist and to work toward being emotionally self-sufficient and self-accepting without needing approval from others. REBT therapists encourage clients to take responsibility for their emotions; however, they also recognize the benefit of creating rapport in the client–therapist relationship. A possible reason for the misconception referred to above was the criticism some people expressed about the vigorous style and manner of Albert Ellis when he conducted his demonstrations and sessions. His direct approach, his no-nonsense style, and his frequent use of colorful language led to some people wrongly inferring that his style was the only recommended REBT style and led to the false assumption that his manner prevented rapport and demonstrated an absence of empathy. There is no doubting that his manner was not embraced by everyone, but it did not mar the progress of countless others. Massive amounts of letters and verbal feedback he received indicated the opposite. The letters and feedback from these people described their experience and belief that he truly understood them and that they appreciated his direct and honest communication. They felt that he genuinely cared about them and their well-being. Ellis did not suggest that other practitioners copy his style and manner. The effective REBT practitioner applies the tenets, theory, methods, and philosophy of REBT, but in their own unique ways, style, and manner. A good number of prominent writers, teachers, and practitioners whose lives he helped, some of whom do not even practice REBT in their professional work, have also expressed such appreciation. Therapeutic change does not depend on the effectiveness of the REBT therapist alone. A strong part of any therapeutic change is the willingness clients have to make effort, to be mindful, to regularly reflect on their thinking, and to take appropriate life-enhancing actions. Awareness is a key element in change and is highlighted and encouraged. To that end, in addition to any one or some of the techniques described earlier, some clients are encouraged to learn and practice forms of meditation and relaxation. It is also beneficial for clients to hold realistic expectations about their personal growth, change, and healing— including the fact that change may not happen overnight or as quickly as they want. As a result, patience, high frustration tolerance, and endurance are encouraged. REBT, in the form of brief therapy, is sufficient for some, but for those with deeper issues and disturbances, longer term REBT is helpful. Those requiring brief therapy can experience significant changes within five to 12 sessions (for some, in even fewer sessions). Achieving productive results through brief therapy depends on the ability and willingness of the clients to take responsibility for constructing their emotional well-being, learning the tenets of REBT, and applying them on a frequent and regular basis. Clients with severe emotional disturbances, greater endogenous disturbances, co-occurring conditions, or poor learning skills benefit from longer term



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REBT. Although sessions of individual therapy are recommended, over time some such clients may benefit from both individual and group therapy. As their progress continues, they may simply then attend group therapy as a means of reinforcement, enhancement, and maintenance of their therapeutic gains. Such clients are welcomed to return for individual therapy if or when they may benefit from direct one-to-one refresher sessions, particularly if they have experienced any relapses. A detailed description of the application of REBT to various and specific conditions that may require long-term REBT, such as perfectionism, obsessivecompulsive disorder, borderline personality disorder, addiction, the co-occurring disorders, severe emotional disturbances and self-defeating behaviors, would turn this chapter into a book. Hence, readers are strongly encouraged to read about such applications in one or many of the books by Ellis, particularly in A. Ellis (2001) and in A. Ellis and Ellis (2019).

APPLICATION TO DIVERSE POPULATIONS The effective REBT therapist educates themself about aspects of their client’s culture, religious (or nonreligious) background, gender, and so forth. In so doing, the therapist can be better equipped to form rapport through understanding clients’ unique culture and cultural elements that affect their lives and by choosing respectful ways of communicating that are less likely to be dismissed or misinterpreted by clients from different cultural backgrounds. The therapist asks questions about relevant aspects of clients’ beliefs if they have not informed themselves about them before seeing the client. REBT does not challenge or dispute any aspect of the client’s belief systems or religions, and instead, it focuses on clients’ own beliefs (including those related to their culture/religion, and so on) that contribute to the disturbing emotions and/or behaviors that the clients want to work on.

OUTCOME DATA Despite the resistance to REBT from many psychologists when Ellis first presented his theory to them, there were outcome studies and evidence that REBT worked, and these contributed to changing the views of the psychologists who had previously favored the psychoanalytic approach. A recent meta-analysis demonstrated REBT’s effectiveness currently and over past decades, regardless of clinical status, age of sample, and delivery format. However, the authors asserted that more studies need to be conducted and more psychometrically sound instruments need to be used to uniformly measure REBT mechanisms of change (David et al., 2018). A significant reason that more studies were not done in Ellis’s lifetime is that his institute had been primarily a training institute without the funding and facilities for conducting as much research as academic

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research institutes could do. Although there was research done there, Ellis was disappointed that more had not been done. Nonetheless, there is a good amount of evidence-based research demonstrating the efficacy of REBT, and hundreds of studies validate the major theoretical hypotheses of REBT (A. Ellis & Whitely, 1979). The vast body of CBT research also supports the premises and efficacy of the REBT approach. REBT found support from the comprehensive survey of meta-analyses that offer empirical validation for CBT in various clinical applications (Butler et al., 2006), which is not surprising because CBT has at its roots many of REBT’s tenets. Many psychiatrists, licensed psychologists, mental health counselors, and coaches incorporate the REBT approach into their therapy practices. Sadly, it appears that a number of people who were trained by Ellis are now teaching a blend of CBT and REBT, and this contributes to REBT being watered down and marginalized. Others continue to teach REBT in its essential form, including this author. At present, REBT workshops and continuing education programs are presented throughout the United States and in other countries. A full-semester REBT course is taught at Columbia University Teachers College (which is the college from which Albert Ellis earned his MA and PhD). Seton Hall University has lecture series highlighting REBT, and other universities include REBT as part of other courses such as comparative psychotherapies and CBT. For nonprofessionals, the REBT approach is presented clearly and simply in Ellis’s books and has been successfully applied by great numbers of people as a self-help process.

CONCLUSION One chapter, such as this one on the powerful and empowering approach of REBT, the modality that changed the world of psychotherapy in the 20th century and is as relevant (if not more so) in this day and age, can only spotlight a selection of its main elements and contributions. REBT’s theory, philosophy, tools, and techniques are imbued with compassion and care, all the while encouraging each and every one of us to take productive and practical actions in order to effect beneficial change. REBT is more than simply an effective evidence-based theory and psychotherapeutic modality—which it is par excellence. It is also indubitably a most holistic approach and a way of life for those who use it as such. Its creator, Albert Ellis, dedicated his life to helping as many people as possible accept and embrace that each one of us is responsible for creating our own emotional destiny according to the way we think. REBT’s holism, effectiveness, and elegance continue to benefit countless people who strive to embrace life, cherish their moments, minimize suffering, and maximize joy.



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REFERENCES Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. https://doi.org/10.1016/j.cpr.2005.07.003 David, D., Cotet, C., Matu, S., Mogoase, C., & Stefan, S. (2018). 50 years of rationalemotive and cognitive-behavioral therapy: A systematic review and meta-analysis. Journal of Clinical Psychology, 74, 304–318. https://doi.org/10.1002/jclp.22514 Ellis, A. (1973). Humanistic psychotherapy. McGraw-Hill. Ellis, A. (2001). Overcoming destructive beliefs, feelings and behaviors. Prometheus Books. Ellis, A. (2003). Similarities and differences between rational emotive behavior therapy and cognitive therapy. Journal of Cognitive Psychotherapy, 17(3), 225–240. https://doi. org/10.1891/jcop.17.3.225.52535 Ellis, A. (2005). Discussion of Christine A. Padesky & Aaron T. Beck, “Science and philosophy: Comparison of cognitive therapy and rational emotive behavior therapy.” Journal of Cognitive Psychotherapy, 19(2), 181–185. https://doi.org/10.1891/ jcop.19.2.181.66789 Ellis, A. (with Ellis, D. J.) (2010). All out: An autobiography. Prometheus Books. Ellis, A., & Ellis, D. J. (2019). Rational emotive behavior therapy (2nd ed.). American Psychological Association. Ellis, A., & Whitely, J. (Eds.). (1979). Theoretical and empirical foundations of rational emotive therapy. Wadsworth. Ellis, D. J. (2015). Reflections: The profound impact of gratitude in times of ease and times of challenge. Spirituality in Clinical Practice, 2(1), 96–100. https://doi.org/10. 1037/scp0000051 Korzybski, A. (1933). Science and sanity. International Society for General Semantics. Padesky, C. A., & Beck, A. T. (2003). Science and philosophy: Comparison of cognitive therapy and rational emotive behavior therapy. Journal of Cognitive Psychotherapy, 17(3), 211–224. https://doi.org/10.1891/jcop.17.3.211.52536

16 Emotion-Centered Problem-Solving Therapy Arthur M. Nezu and Christine Maguth Nezu

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e begin this chapter by asking you, the reader, to “solve” the following problem: Mr. Hardy was washing windows on a high-rise office building when he slipped and fell off a 60-foot ladder onto the concrete sidewalk below. Incredibly, he did not injure himself in any way. How is this possible? The answer is in a footnote before the references. Note that the answer does not involve a supernatural explanation, such as “Mr. Hardy is a superhero with the ability to fly.” If you are having difficulty, try visualizing the scenario. Such problems have often been the focus of inquiry within the fields of experimental and cognitive psychology. Within this context, the construct of problem solving has, traditionally, been conceptualized as a major component of executive functioning involving higher order mental or cognitive processes. As such, this area of psychological inquiry generally addresses the question of how humans solve problems of a cognitive or intellectual nature, such as that provided above. Now consider the following problem: Janice P., a 42-year-old female teacher, feels more and more stressed these days.1 Teachers in her school district have not had a raise or contract for the past 3 years, and her ex-husband recently was laid off from his factory job. Thus, he can no longer afford to provide child support funding to help Janice maintain a household that includes a 7th grade boy and a 4-year-old girl. Having very little savings, she is scared that she will no longer be able to pay for childcare for her daughter. She is thinking about getting a second job to increase incoming monies, but last night she calculated that additional childcare would cost more than any second job could pay. What should Janice do? Clinical examples have been disguised to ensure patient confidentiality.

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https://doi.org/10.1037/0000218-016 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  465 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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Obviously, this is a different type of problem from the one noted above it. As we have argued previously (A. M. Nezu et al., 2016), math, logic, and insight problems do not reflect the complexity of dilemmas that people like Janice face in the real world. In essence, “real-life” problems are different in that they are (a) often stressful, (b) caused by or engender emotional difficulties, (c) frequently involve other individuals, (d) have real-life consequences, and (e) usually have more than one “correct” solution. In addition, due to differential goals, values, and individual person variables, whether a given solution to a real-life problem is successful depends heavily on the people involved and the specific nature of the circumstances characterizing the problem.

REAL-LIFE PROBLEMS We have previously defined real-life problems as those life situations that require (a) adaptive responses in order to prevent potential negative sequalae but in which (b) possible solutions are not immediately obvious or available to those people actually experiencing the problem (A. M. Nezu et al., 2013). Problems can occur externally within a person’s social or physical environment, as for example, a conflict with a family member or poor living conditions. They can also originate internally or intrapersonally, as for instance, a goal to obtain a higher paying job or confusion regarding one’s life goals. Situations become problems for individuals when various obstacles exist that are difficult to overcome during attempts to reach a desired goal. Such barriers often include multiple factors, such as (a) experiencing something novel (e.g., beginning of a new romantic relationship), (b) feeling confused (e.g., uncertainty about how to obtain a mortgage), (c) being unable to predict the future (e.g., lack of control over one’s job stability), (d) experiencing conflicting goals (e.g., differences between spouses/partners with regard to child-rearing practices), (e) having various performance skills deficits (e.g., difficulties communicating), (f) having limited resources (e.g., lack of finances), and (g) experiencing significant emotional arousal (e.g., prolonged grief over the loss of a loved one). Individuals may recognize that a problem exists almost immediately based on their reactions to the situation. Such reactions can involve physical symptoms (e.g., headaches), negative thoughts (e.g., thoughts of incompetence), or negative emotions (e.g., urge to aggress against someone). Alternatively, people may identify the problem only after repeated initial attempts to cope with the situation have failed. However, for some individuals, not labeling such situations “as a problem” can serve to inhibit their ability to effectively solve them. Problems can be a single event (e.g., losing one’s car keys, being late for an important appointment); a series of related events (e.g., continued disagreements between friends, not having a job that pays well); or a chronic, ongoing situation (e.g., a serious medical illness, persistent depressive symptoms). Problems should not be considered solely the result of either people’s environment or the individuals themselves. Rather, problems represent an interac-



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tion between individuals and their environment, which is characterized by real or perceived disparities between what the situation requires and people’s ability to cope with the situation. Problems, therefore, are by definition idiographic and can vary in difficulty or significance over time as a function of variations among individuals, their environment, or both. Thus, what is perceived as a problem for one person is not necessarily a problem for someone else even if the superficial characteristics appear very similar. For example, two people experiencing financial problems may be doing so for vastly different reasons. Moreover, what is perceived as a problem for a certain person at one point in time may not be considered a problem for this same person at a later point.

REAL-LIFE SOLUTIONS Solutions within real-world contexts involve situation-specific coping responses that are geared to mitigate the problem. However, solutions vary in their ability to successfully achieve an optimal problem-solving goal. Thus, differences between effective and ineffective solutions need to be defined. An effective solution is one that not only successfully attains a person’s desired objective(s) but simultaneously further maximizes positive consequences and attenuates negative outcomes. Alternatively, ineffective solutions are characterized as attempts that either (a) do not reach one’s desired goal(s) as a function of being unable to overcome various obstacles, (b) focus on addressing inappropriate (e.g., avoidance of the problem) or ill-defined goals, and/or (c) create more negative consequences than positive ones. Consequences include the various effects on oneself and others, as well as short- and long-term outcomes. Note that individuals can differ in their evaluation of the efficacy of a given solution as a function of varying norms, values, and goals. It was not until the second half of the 20th century that research began to focus on those factors that impact one’s ability to successfully solve the types of problems that are typically experienced in everyday life (D’Zurilla & Nezu, 2007). This form of problem solving was referred to as social problem solving to differentiate it from the more traditional processes involved in addressing logic, math, or purely cognitive problems (D’Zurilla & Nezu, 1982).

SOCIAL PROBLEM SOLVING We previously defined social problem solving (SPS) as the process by which individuals attempt to identify, discover, or create adaptive means of coping with a wide variety of stressful problems, both acute and chronic, encountered during the course of living (D’Zurilla & Nezu, 2007). It represents the process whereby people direct their coping efforts at (a) changing the nature of the situation that made it a problem in the first place, (b) altering their maladaptive reactions to such problems, or (c) both. Instead of being defined by a single type of coping

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behavior or activity, SPS represents “the multidimensional metaprocess of ideographically identifying and selecting various coping responses to implement in order to adequately match the unique features of a given problematic situation at a given time” (Nezu & Nezu, 2019, p. 14). To minimize confusion often contained in the literature, we suggest that the construct of social problem solving should be differentiated from that of problem-focused coping. Coping involves both the cognitive and behavioral activities that individuals engage in when attempting to manage stress. Lazarus & Folkman (1984) have described two types of coping: problem-focused and emotion-focused coping. Problem-focused coping involves activities aimed at altering the stressful situation so that it no longer is a problem. Alternatively, emotion-focused coping includes activities geared to better manage associated negative emotions. SPS has often been misrepresented as being one type of problem-focused coping, suggesting that SPS only involves attempts to control the environment. However, we define SPS as being a broader, more versatile coping process that can include both problem-focused and emotion-focused objectives (A. M. Nezu, 2004). Regardless of whether the objective is articulated as problem focused or emotion focused, the ultimate goal of SPS is to attenuate the negative effects of stressful life events on individuals’ well-being. We suggest that stressful problems are likely to necessitate identifying both problem-focused and emotionfocused activities to be successfully resolved.

A MULTIDIMENSIONAL MODEL OF SOCIAL PROBLEM SOLVING On the basis of our research, we identified that SPS is composed of two general, but partially independent, dimensions: (a) problem orientation and (b) problem-solving style (D’Zurilla et al., 2004). Problem orientation includes various generalized beliefs, attitudes, and emotional reactions about real-life problems, as well as perceptions about one’s ability to successfully cope with such problems. Whereas our original model suggested that there are two types of problem orientations and that they represent opposite ends of the same continuum (e.g., D’Zurilla & Nezu, 1999), subsequent research suggests that they operate somewhat independent of each other and are only minimally correlated (A. M. Nezu, 2004). We refer to these two dimensions as positive problem orientation and negative problem orientation. A positive problem orientation involves the tendency of people to (a) perceive problems as challenges rather than major threats to one’s well-being, (b) be optimistic in believing that problems are solvable, (c) have a strong sense of self-efficacy regarding their ability to handle difficult problems, (d) believe that successful problem solving usually involves time and effort, and (e) view negative emotions as important sources of information necessary for effective problem solving (e.g., “something is occurring that requires my attention”; A. M.



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Nezu et al., 2013). A negative problem orientation is the tendency of individuals to (a) view problems as major threats to one’s well-being, (b) generally perceive problems to be unsolvable, (c) maintain doubts about their ability to cope with problems successfully, and (d) become particularly frustrated and upset when faced with problems or when they experience negative emotions (A. M. Nezu et al., 2013). The importance of the problem-orientation dimension is its potential impact on subsequent problem-solving activities. For example, a strong positive problem orientation can influence a person’s level of motivation to be persistent in continuing to cope with stressful problems. Thus, it becomes essential clinically to evaluate and attend to a client’s dominant orientation to be able to adequately teach people to become more effective problem solvers. Unfortunately, some researchers have included only “rational or logical” problem-solving skills when applying such concepts to psychotherapeutic applications and have de-emphasized or ignored problem-orientation variables. In doing so, there is a risk that training is less effective (A. M. Nezu, 2004). Consistent with this view, two meta-analyses of randomized clinical trials (RCTs) of problem-solving training programs have found that not specifically addressing the role of problem-orientation variables consistently engenders significantly less effective outcome when compared with programs that do include such a focus (A. C. Bell & D’Zurilla, 2009; Malouff et al., 2007). In fact, A. M. Nezu and Perri (1989) conducted a dismantling study to assess the relative efficacy of such differing protocols in reducing clinical depression and found evidence that confirmed this principle directly. Problem-solving style is the second major dimension of SPS. This refers to the various cognitive-behavioral activities that people engage in when attempting to solve problems that occur in real life (A. M. Nezu, 2004). Three styles have been empirically identified (D’Zurilla et al., 2002, 2004): planful or rational problem solving, impulsive-careless problem solving, and avoidant problem solving. Planful problem solving represents the adaptive process of systematically and planfully applying a set of specific tasks aimed at solving the problem. These include the following four major activities (A. M. Nezu, 2004): • Defining the problem: describing the problem in clear and understandable language, articulating a realistic set of goals, and identifying extant barriers that serve as the reason(s) why the situation is a problem (i.e., prohibits one from reaching the goals) • Brainstorming solutions: thinking of various potential alternative ideas aimed at solving the problem by virtue of overcoming the obstacles identified previously • Developing a solution plan: identifying and predicting the likely consequences of such alternatives, conducting an analysis regarding the overall quality of each alternative, and deciding which ones to include in a solution plan

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• Carrying out the solution plan and evaluating the actual outcome: implementing the plan, monitoring the outcome, assessing whether the plan effectively achieved the problem-solving goal, and determining whether additional problem-solving efforts are required The other two problem-solving styles generally engender unsuccessful results (D’Zurilla et al., 2002, 2004). The first maladaptive style involves being impulsive or careless when attempting to cope with real-life problems. This approach represents people’s tendency to be impulsive, hurried, and careless. The second maladaptive style, avoidant problem solving, represents an approach to problem solving characterized by procrastination, passivity, and overdependence on others to resolve stressful difficulties. In addition to likely resulting in ineffective coping, use of either approach is likely to also worsen extant problems and possibly engender new ones. Multiple studies, including various age groups and ethnic minority samples, have provided validation of this multidimensional model of SPS (D’Zurilla & Nezu, 2007). However, we are not positing that these specific dimensions represent “personality traits,” whereby people are represented by a certain type of orientation or problem-solving style. Instead, we suggest that each dimension represents strong leanings toward either viewing and/or reacting to stressful problems in a particular manner as a function of one’s learning experiences and the nature of the problem. To support this notion, in a study we conducted with college students, participants were found to be more effective in their problemsolving activities when dealing with an academic or work problem as compared with when attempting to cope with a relationship problem (Stern et al., 2013).

SOCIAL PROBLEM SOLVING AND PSYCHOPATHOLOGY The relevance of ineffective SPS as a potential target of psychotherapy interventions is strongly underscored by decades of research that has consistently identified significant associations between SPS and various measures of psychopathology and emotional distress. One research venue has focused, for example, on differences between “effective” versus “ineffective” problem solvers across a variety of psychological distress parameters. Such research has included participants of varying age groups, populations, and cultures. It has also incorporated different measures of SPS. Collectively, ineffective or poor problem solvers, for instance, have been found to report a greater number of problems in living, more negative health and physical symptoms, higher levels of anxiety and depression, and greater degrees of maladjustment when compared with effective problem solvers (D’Zurilla & Nezu, 2007; A. M. Nezu et al., 2004, 2013). In addition, significant correlations have been routinely identified between a negative problem orientation and negative moods, worry, pessimism, and depression (A.  M. Nezu, 2004). Further, SPS deficits have been found to be significantly predictive of poor self-esteem, feelings of hopeless-



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ness, suicidal risk, anger proneness, substance use difficulties, and physical health problems (D’Zurilla & Nezu, 2007). Previously, we have presented a diathesis-stress model of psychopathology that describes the interactional relationships between SPS and various biological, psychological, and sociocultural variables as a means of demonstrating how individuals respond to life stressors and what the outcome of this process might be (see A. M. Nezu et al., 2013, for additional details regarding this model, particularly the distal, proximal, and immediate roles that various neurobiological, immune, and brain chemistry factors play in this process). According to this model, various early life experiences collectively serve to engender vulnerabilities that can further make people susceptible to negative health and behavioral health outcomes later in life. For example, genetic predispositions, in combination with early life stress, have been shown to produce a biological vulnerability to experiencing depression as an adult (Nugent et al., 2011). A psychosocial susceptibility can also develop due to a lack of opportunities to learn effective SPS skills (Wilhelm et al., 2007). Further, research has also documented how experiencing major negative life events and chronic daily problems can lead to the initial onset of and/or the fostering of preexisting psychopathology, such as depression and posttraumatic stress disorder (Arnsten et al., 2015; Provencal & Binder, 2015), in addition to heart disease and diabetes (Pandey et al., 2011). In addition to the presence of stress as a contributor to psychopathology, there may be important biological, developmental, sociodemographic, and psychological factors that play a role in how individuals respond to stressors. For example, not effectively coping with stress can actually lead to increased levels of both stress and distress. This is known as stress generation. People who have experienced higher levels of early life stress and/or possess a genetic vulnerability, within the context of this stress generation process, become particularly susceptible to negative outcomes (e.g., Monroe et al., 2006), such as suicide (Zatti et al., 2017). Within this model, we have argued that SPS is a key component of successful coping (A.  M. Nezu et al., 2013). Thus, problem solving functions as an important moderator of the stress-distress association. In other words, how individuals cope with stress influences the probability of subsequently experiencing acute and/or long-term psychological difficulties. Research has basically supported this notion. For example, effective problem solvers have been found to experience significantly lower levels of distress as compared with their ineffective problem-solver counterparts, even when both groups experience similar levels of high stress (Londahl et al., 2005; A.  M. Nezu & Ronan, 1988; Ranjbar et al., 2013). Our model further posits that people are also likely to experience negative health outcomes and psychological distress if their SPS is inadequate in coping with life stress. This might occur as a function of preexisting SPS deficits (e.g., difficulties in creatively identifying possible solutions) or an attenuation in problem-solving efficacy related to the overwhelming nature of the stress (e.g., experiencing combat or rape). Moreover, poor outcomes can produce further

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life stress, as well as continuously undermine one’s further problem-solving attempts. This reciprocal downward spiral of stress-distress generation can thus lead to long-term clinical disorders. In light of this association between SPS and psychopathology and well-being, the next logical question is whether individuals can be trained to become better problem solvers to attenuate emotional difficulties and enhance their overall quality of life. It was from this context that problem-solving therapy (originally referred to as social problem-solving therapy) was developed (e.g., A. M. Nezu, 1986, 2004).

(EMOTION-CENTERED) PROBLEM-SOLVING THERAPY Problem-solving therapy (PST) is a psychotherapy approach that emanates from a social learning framework and is based on a diathesis-stress model of abnormal behavior (A. M. Nezu et al., 2013). The major goal of PST is to train people to apply a set of skills aimed at enhancing their ability to cope successfully with various life stressors. Such stressors include (a) major negative life events (e.g., the death of a significant other, the onset of a chronic illness), (b) chronic daily problems (e.g., repeated arguments with coworkers, marital difficulties), and (c) traumatic events (e.g., severe car accident, rape). A basic assumption of PST suggests that psychopathology, behavioral difficulties, and emotional problems are essentially the consequences of repeated ineffective coping with life stress. Within this context, we posit that training people to become better problem solvers can lead to a reduction in extant behavioral health difficulties. Therefore, PST aims to foster the following two key objectives: • “successful adoption of adaptive problem-solving attitudes (e.g., optimism, enhanced self-efficacy, recognition and appreciation of the notion that problems are a normal aspect of living)” (A. M. Nezu & Nezu, 2019, p. 6) • “effective implementation of certain behaviors (e.g., emotional regulation, planful problem solving) as a means of coping with life stress and thereby attenuating the negative effects of stress on physical and mental well-being” (A. M. Nezu & Nezu, 2019, p. 6) The origins of PST from a cognitive and behavioral framework go back to an article by Tom D’Zurilla and Marvin Goldfried (1971). On the basis of a review of multiple areas of psychology and education, these psychologists created a prescriptive model of problem-solving training. Their approach sought to enhance people’s overall social competence and help them more effectively manage daily problems in living. Social competence involved the following components: “the ability to use a variety of alternative pathways or behavioral responses in order to reach a given goal . . . the ability to use a variety of social systems and resources within society . . . [and] effective reality testing” (D’Zurilla & Nezu, 1999, pp. 6–7).



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As a graduate student mentored by Dr. D’Zurilla during this time, one of us (A. M. Nezu) became interested in applying this model to clinical populations and developed a clinical intervention protocol to treat adults diagnosed with major depressive disorder (e.g., A. M. Nezu, 1986; A. M. Nezu et al., 1989). Initial clinical trials labeled this intervention “social problem-solving therapy,” although the “social” label eventually was dropped. Since that time, a multitude of successful applications of this model have occurred and have focused on a wide range of psychological disorders and medical patient populations (A. M. Nezu et al., 2013). Moreover, researchers have successfully used different modes of implementing PST, including individual therapy, group therapy, therapy by telephone, and therapy over the internet. An additional use of PST has involved enhancing people’s adherence to other front-line interventions, such as medical prescriptions (A. M. Nezu et al., 2006). As new research improves our understanding of the association between problem solving and stress, we have endeavored to revise and update this approach using research from various literature bases, including the fields of affective neuroscience, cognitive psychology, and clinical psychology. In particular, given advances in our understanding of the important role that stressrelated negative emotional arousal plays in engendering psychological difficulties, we refer to the most recent iteration of our approach as emotion-centered problem-solving therapy (EC-PST) to underscore the need to focus on minimizing the impact of such arousal on individuals’ ability to apply planful problem-solving strategies (A. M. Nezu et al., 2019). As noted previously, problem-solving-based interventions that have included training in various orientation factors have been shown to be more efficacious than those focused solely on training individuals in rational problem-solving skills. EC-PST takes this approach one major step forward by focusing heavily on training those types of skills that foster one’s ability to engage in effective emotion regulation. A recent study we conducted provides indirect support for this focus. More specifically, use of effective SPS skills has been found to moderate negative emotion reactivity to stress in predicting suicidal ideation among U.S. military veterans (A. M. Nezu et al., 2017).

EFFICACY OF PROBLEM-SOLVING THERAPY INTERVENTIONS During the past decade, several meta-analytic reviews of PST-based clinical trials have been conducted that affirm the overall effectiveness of this intervention. The first meta-analysis, conducted by Malouff et al. (2007), included 32 investigations involving close to 3,000 participants. These researchers focused on studies that assessed the efficacy of PST across a range of mental and physical health problems. On the basis of their analysis, these researchers came to several conclusions. First, they found PST to be equally as efficacious as other psychosocial treatments (d  =  0.22). Second, PST was significantly more effective than various control conditions (d values ranged

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between 0.56 and 1.37). Last, these researchers found that including problem-orientation training engendered larger effect sizes concerning treatment outcome. During that same year, Cuijpers et al. (2007) published a meta-analytic review of clinical trials evaluating PST as a treatment specifically for depression. Their analysis of 13 RCTs, which had a combined sample of over 1,100 participants, led them to conclude that, whereas this group of studies was characterized by significant variability in outcome, “there is no doubt that PST can be an effective treatment for depression” (d = 0.83; Cuijpers et al., 2007, p. 9). Given the finding of the Malouff et al. (2007) analysis concerning differences in outcome as a function of including problem-orientation training, it is possible that this variability identified by Cuijpers et al. can be explained by differences in the treatment protocols, although this was not directly addressed. A. C. Bell and D’Zurilla (2009) also focused specifically on RCTs of PST for the treatment of depression. In addition to 12 studies included in the Cuijpers et al. (2007) analysis, they identified and included seven additional studies. Based on this larger sample, a similar conclusion was made. Specifically, PST was equal in effectiveness as compared with other psychosocial therapies, as well as antidepressant medication (d = 0.17). Moreover, PST was more efficacious than supportive therapy and attention-control conditions (d = 0.45). Last, similar to the Malouff et al. (2007) analysis, it was found that those clinical protocols that included training in problem-orientation variables engendered better outcomes than those that did not. In addition to systematic reviews that focused specifically on PST RCTs, other meta-analyses provide additional support for its efficacy. For example, Cape et al. (2010) conducted a systematic review of trials that focused on brief psychotherapies, including PST, for the treatment of adult primary care patients who suffered from depression, anxiety, or a mixture of various behavioral health symptoms. Their investigation included 34 studies with a combined sample of close to 4,000 patients. In focusing specifically on brief PST, the resulting mean effect size of d = 0.21 was found to be significant. Nieuwsma et al. (2012) conducted a meta-analysis that evaluated the comparative efficacy of various forms of brief psychotherapy (eight or fewer sessions), including PST, for the treatment of depression. A mean significant effect size of d = 0.26 also supported the efficacy of PST. Barth et al. (2013) conducted a meta-analysis that assessed several differing psychotherapies for adult depression and further underscored the efficacy of PST (d = 0.74). A more recent meta-analysis of RCTs exclusively of PST trials for the treatment of depression was conducted by Cuijpers et al. (2018) as an update to their 2007 investigation described previously. For this review, they included 30 RCTs that had a combined sample of 3,530 patients. These studies compared PST with other psychotherapies and pharmacological interventions, as well as various control conditions. Overall, these researchers concluded that PST is an effective treatment for depression with comparable effects to other treatments of depression.



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In sum, these seven meta-analytic reviews offer significant evidence to support the contention that PST-based interventions are efficacious for treating depression, as well as other psychological difficulties.

PROBLEM-SOLVING THERAPY AS A TRANSDIAGNOSTIC INTERVENTION In light of the wide range of targeted problems and clinical populations for which PST has been shown to be efficacious, it can be considered a transdiagnostic intervention, especially as life stress frequently plays a significant role in engendering and/or exacerbating psychological difficulties and PST is geared to foster individuals’ ability to cope with such stress. To illustrate this wide range of applications, Table 16.1 provides a listing of populations and clinical problems that have been the target of PST-based interventions. In addition to being implemented as a means of reducing psychological symptomatology, PST has also been applied as an adjunctive intervention to enhance the efficacy of other interventions (A. M. Nezu et al., 2006). In addition, PST has been conducted effectively in a variety of ways, including on an individual basis (e.g., A. M. Nezu et al., 2003), in groups (e.g., A. M. Nezu & Perri, 1989), over the telephone (e.g., K. R. Bell et al. 2017), using the internet (e.g., Choi et al., 2014), via an interactive media protocol (e.g., Sandoval et al., 2017), and as a collaborative care model (e.g., Unützer et al., 2002).

DESCRIPTION OF MAIN PROCEDURES Our current set of clinical guidelines is based on the idea that four barriers can exist across individuals when they are confronted with various life stressors. These include (a) poor problem solving, (b) “brain overload,” (c) hopelessness, and (d) emotional dysregulation (A. M. Nezu & Nezu, 2019). These obstacles are then viewed as potential treatment targets, whereby EC-PST provides training in four skill sets aimed at helping people overcome these barriers. The four “toolkits” include (a) Planful Problem Solving; (b) Problem-Solving Multitasking; (c) Enhanding Motivation for Action; and (d) Stop and Slow Down. We wish to emphasize that the order in which the toolkits are listed and described below represents the sequence of components that would be administered in a research setting where there is the need to standardize treatment implementation, as, for example, in an RCT. In real-life clinical settings, however, we advocate that therapists develop a case formulation to better determine individual client needs and tailor EC-PST accordingly. For example, if certain clients appear to be suffering from significant emotional distress, such as clinical depression or anxiety, it is likely that initially teaching them a systematic approach to solving real-life problems can easily be impeded by their negative emotional arousal. Therefore, it may be important to focus at the beginning

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TABLE 16.1. Brief List of Studies That Have Applied PST-Based Interventions Across a Range of Clinical Populations and Disorders Reference

Clinical population/disorder

Azrin et al. (2001)

Adolescents with conduct disorder and substance abuse problems

Alexopoulos et al. (2011)

Older adults with major depression and executive dysfunction

Berry et al. (2012)

Caregivers of children with autism spectrum disorder

Buntrock et al. (2016)

Subthreshold depression (to prevent major depression)

Ell et al. (2008)

Latino adults with cancer

Erdley et al. (2014)

Hemodialysis patients

Garand et al. (2014)

Caregivers of patients with dementia

García-Vera et al. (1997)

Adults with hypertension

Gellis et al. (2014)

Depressed geriatric homecare patients

Grant et al. (2002)

Caregivers of stroke patients

Gustavson et al. (2016)

Depressed older adults with executive dysfunction and suicidal ideation

Hadidi et al. (2015)

Depressed stroke patients

Harpole et al. (2005)

Depressed medical patients

Hatcher et al. (2011)

Adults who previously attempted suicide

Hirai et al. (2012)

Distressed early stage breast cancer patients

Katon et al. (2004)

Adults with Type 2 diabetes

Kleiboer et al. (2015)

Adults with depression and anxiety

Langdon et al. (2013)

Young offenders with intellectual disabilities

Law et al. (2017)

Parents of children with idiopathic chronic pain conditions

A. M. Nezu et al. (2003)

Distressed cancer patients

C. M. Nezu et al. (1991)

Adults with intellectual disabilities and comorbid psychiatric diagnoses

Pech & O’Kearney (2013)

Insomnia

Rees et al. (2017)

Adults with diabetic retinopathy and diabetes-specific distress

Rivera et al. (2008)

Caregivers of patients with traumatic brain injuries

Robinson et al. (2017)

Prevention of poststroke mortality

Rovner et al. (2013)

Vision-impaired adults

Tenhula et al. (2014)

Distressed military veterans

van den Hout et al. (2003) Adults with lower back pain Vuletic et al. (2016)

Military service members with traumatic brain injury

Wade et al. (2015)

Children with traumatic brain injury

of treatment on the Stop and Slow Down toolkit, which is geared to foster people’s ability to better manage negative emotionality. Once they are able to better manage their negative emotional reactions, they can take advantage of other toolkits.



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This case formulation can be based on both qualitative (e.g., clinical interview) and quantitative (e.g., questionnaires) information. One method of ascertaining individuals’ problem-solving abilities is the Social Problem-Solving Inventory–Revised (SPSI-R; D’Zurilla et al., 2002). There are two versions: a long form, which includes 52 items, and a short form, which involves 25 items. Both are self-report inventories that have been found to be both reliable and valid across multiple populations. The SPSI-R has also been translated to Spanish as well as other languages. It has a total score, as well as five scale scores that represent the five problem-solving dimensions previously described: Positive Problem Orientation, Negative Problem Orientation, Rational Problem-Solving Style, Impulsive/Careless Problem-Solving Style, and Avoidant Problem-Solving. Because there are norms for both sexes, across a wide range of ages, and regarding multiple patient and “normal” samples, the SPSI-R can offer important comparative information regarding people’s problem-solving abilities. Within this context, a client’s specific problem-solving strengths and weaknesses can be used to assess which aspects of EC-PST should be provided. Note that not all materials across all four toolkits are required across all individuals. In other words, the EC-PST therapist should employ both assessment and outcome information to help determine the inclusion and emphasis of particular EC-PST treatment activities. Planful Problem-Solving Toolkit: Fostering Effective Problem Solving The first toolkit aims to enhance individuals’ ability to use a systematic and planful approach when confronted with problems in living. This toolkit, referred to as planful problem solving, entails four specific tasks that individuals should engage in to more effectively handle or cope with life stress. The first task, Problem Definition and Formulation, involves directing people to describe the problem in such a way as to increase its accuracy and clarity. Specifically, individuals are taught to differentiate between “facts” and “assumptions” when describing a problem, articulate a set of realistic and attainable problem-solving objectives, and determine which factors about the problem serve as barriers preventing them from reaching such goals at the present time. Given that not all problems are “solvable” (e.g., the loss of a loved one), it is imperative to distinguish between problem-focused goals (i.e., objectives geared to modify the situation such that it no longer is a problem to the individual) and emotion-focused objectives (i.e., goals aimed at changing an individual’s negative reactions to problems that cannot be changed). For the latter type of goal, potential methods to achieve such objectives can include relaxation training to reduce negative physical arousal, as well as accepting that the circumstances cannot be revised. The second task, referred to as Generating Alternative Solutions, teaches individuals to creatively brainstorm various ideas aimed at overcoming the previously identified obstacles as a means of achieving the problem-solving goal(s). Several basic principles are emphasized to foster people’s ability to brainstorm,

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including “quantity leads to quality” (i.e., the more ideas produced, the greater the probability that effective ones would be created), “defer judgment” (i.e., it is important to inhibit the tendency to automatically evaluate each idea generated as that inhibits creativity), and “think of variety” (i.e., creativity is enhanced when one understands that there are multiple ways to reach a goal). After generating a list of possible solution ideas, individuals are directed to engage in the third planful problem-solving activity, that of decision making. This entails predicting the possible positive and negative consequences of the various solutions if they were implemented. On the basis of this prediction, individuals are then taught to conduct a cost-benefit analysis to better understand the potential effectiveness of the various alternatives using various decision criteria, including both personal and social consequences as well as immediate and long-term effects. After deciding which ideas appear to be ones that are more likely to reach the problem-solving goals and lead to positive outcomes, people are then directed to develop a “solution plan,” which can include several alternatives to maximize goal attainment. The final task, Solution Implementation and Verification, first involves having people implement the chosen solution plan. To maximize its success, individuals are directed to behaviorally or imaginarily rehearse carrying out this plan. After implementing the plan, they are taught to monitor and assess the actual outcomes. On the basis of these “data,” they are then directed to consider whether their problem-solving efforts have been successful or whether they need to identify which aspect of the problem-solving process needs to be revisited and revised (e.g., “Was the problem accurately defined? Were quality alternatives generated?”). Problem-Solving Multitasking Toolkit: Overcoming Brain Overload This second toolkit is geared to aid individuals to overcome a common human limitation when confronted with stressful real-life problems: “brain or cognitive overload” (Rogers & Monsell, 1995). People in general are unable to handle large amounts of information when attempting to solve complex problems or make effective decisions, especially when under stress. Moreover, they cannot engage in several activities at the same time without potentially decreasing the accuracy or effectiveness of such tasks. That is why we are all encouraged not to text or talk on the phone while driving. To help people become better multitaskers, EC-PST teaches people to frequently apply three skills especially when confronted with stressful problems. The first skill, externalization, entails having people “take information out of their heads and display it externally.” For example, individuals are encouraged to make lists, write ideas down in a journal, draw diagrams, or audiotape ideas. In this manner, people are less vulnerable to stimulus overload and more able to concentrate on the task at hand. Individuals are also taught to use the second skill, visual imagery, to help overcome brain overload. For example, when people are having difficulty describing the problem, they can visualize the situation



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to identify more information. They can also use imaginal rehearsal to increase the frequency of practicing various activities, such as carrying out a solution plan. Individuals are also taught to use visualization as a form of guided imagery (e.g., going on a beach vacation) to reduce negative arousal. The third multitasking skill is simplification, which entails breaking down problems to make them more manageable. For example, large, long-term goals can be broken down into a series of smaller objectives. Enhancing Motivation for Action Toolkit: Overcoming Reduced Motivation and Feelings of Hopelessness Oftentimes, clients experience reduced motivation to continue working on solving a problem or are hopeless about the concern that their efforts will be unsuccessful. This third EC-PST toolkit aims to help individuals overcome such roadblocks to goal attainment. For example, one tool in this skill set is geared for individuals who are hesitant to implement their action plan. Individuals are directed to identify various positive and negative consequences that might occur (a) if no action plan is carried out and (b) if the plan is carried out and is successful. Evaluating and comparing such outcomes can engender increases in motivation to continue in the problem-solving process. Moreover, developing such lists can potentially help identify possible weaknesses in the action plan that may require efforts to modify the plan. A second task entails the use of visualization, in this case as a means of fostering motivation and reducing hopelessness. This visualization task is different from those included in the previous toolkit. Here, individuals are taught to “use their mind’s eye” to imaginarily create a scenario in the future where a problem has already been solved and to experience how it “feels” to overcome the barriers. Our goal here is to assist clients “to see the light at the end of the tunnel” and experience vicariously a variety of positive consequences. The focus in this visualization is on the feelings associated with a problem solved and not on how to solve it. Stop and Slow Down Toolkit: Overcoming Emotional Dysregulation The fourth EC-PST toolkit addresses the barrier of emotional dysregulation by helping individuals to more effectively manage their affective reactions to life stressors. Negative affect, according to our conceptual model, is the outcome of significant life stress that has not been effectively handled. Moreover, it can also engender additional stress, potentially leading to an increasingly overwhelming situation. Thus, EC-PST can help distressed individuals on two levels: (a) enhancing their ability to effectively cope with life stress that potentially creates negative affect and (b) decreasing clinically significant emotional distress directly. This toolkit teaches individuals to apply a series of tasks aimed at fostering their ability to manage negative emotional arousal, in contrast to the goal of never experiencing such feelings again. We emphasize the notion that negative

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affect can serve as an important signal or cue that problems exist; thus, our goal is not to eradicate negative emotions but rather to minimize the negative impact they might have on one’s ability to be an effective problem solver. Being able to modulate stress-related negative arousal can help people be more effective in their use of the various planful problem-solving tools, as well as successfully inhibiting the tendency to be impulsive or avoidant. The first step involves having individuals become more “emotionally mindful” or aware of and attentive to when and how they experience negative emotions. This entails paying attention to changes in physical (e.g., headache, fatigue), mood (e.g., sadness, anger), cognitive (e.g., worry, rumination), and behavioral (e.g., yelling, crying) responses. They are then directed to stop and focus on what they are experiencing with the objective of becoming aware of the actual stimulus-response association (i.e., what created the arousal). They are taught several ways to behaviorally stop: shout out loud, raise one’s hands, or hold up a stop sign. Stopping derails the likelihood that the initial negative arousal has the opportunity to lead to an even more intense reaction. This is followed by having individuals engage in various slow down techniques, which helps further decrease the potential acceleration of the negative reactivity. These include counting down from 10 to 1, controlled breathing, deliberate yawning, guided imagery, visualization, meditation, exercise, talking to appropriate others, and prayer (if appropriate to a given individual). To provide for an easy way to conceptualize the overall EC-PST process, we offer the following acronym: SSTA. The “SS” refers to stop and slow down, whereas the “T” and “A” letters refer to thinking and acting (i.e., the planful problem-solving tools). In this manner, we posit that only when people are able to initially stop and slow down are they then able to effectively think and act when attempting to cope with the stressful problems that initially engendered the negative emotions. Guided Practice The majority of EC-PST sessions involves teaching the four toolkits to individuals and providing meaningful feedback regarding how effective they are in applying the toolkits to their personal problems. It is emphasized throughout the therapy to practice applying the tools as frequently as possible. Toward the end of treatment, clients are encouraged to look to the future to identify potential stressful situations as a means of developing problem-solving action plans that can minimize possible life stress.

CLINICAL EXAMPLE The following is a brief description of how EC-PST can be applied to a patient who enters treatment being depressed, anxious, and at an elevated risk for suicide.



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Background Ronald was a 39-year-old man who was referred by a coworker and colleague from a university medical center. He was a White male who described himself as Catholic and ethnically Irish. Ronald was a neurologist who was a U.S. Navy medical officer and was on active duty at a major military medical center. His colleague and coworker, a civilian psychiatrist, experienced a growing concern that Ronald was depressed, was isolated, and had made statements that suggested increased suicidal risk. Although he had been previously avoidant of seeking psychotherapeutic treatment, Ronald relented in response to his friend’s supportive suggestions. Almost 1 year before Ronald entered treatment, his father committed suicide by suffocation. Ronald blamed himself for this tragedy, stating that he knew that his father was increasingly depressed and had a long history of threatening to kill himself. As a result, this patient expressed a strong sense of guilt, stating, “I knew it was coming and should have done something to save him.” Ronald’s first session indicated that he was extremely depressed and hopeless. Although he was viewed by others as a successful physician and surgeon, Ronald disclosed a history of hiding an often painful inner life with periods of intense anxiety and significant depression. He described a challenging childhood and the trauma of “knowing” that his father was chronically depressed and suicidal. Ronald was raised in a mid-Atlantic state and was home schooled. He is the oldest of four children and described his nuclear family as extremely closed off emotionally, stating that they never discussed in any meaningful way the loss of their father or any other family problems that occurred over the years. Ronald was married and had recently become a parent. His wife, who was trained as a nurse, was currently at home to care for their baby son. Despite his successful career, Ronald’s distress continued to interfere with his work as a physician. His anxiety regarding his nuclear family was ever present, and his guilt and self-blame for his father’s death was continuously painful. Moreover, he recently experienced a growing belief that his wife was disappointed in him, wondering if she had married him primarily to have access to his income as a physician. Although not at immediate risk of a suicide attempt, it appeared that Ronald at times thought of developing a plan. His increased risk was exacerbated by the anniversary of his father’s death that would occur in approximately 6 weeks.

Assessment and Case Formulation An assessment protocol was first conducted aimed at developing an initial case formulation that could help create a treatment plan specific to Ronald. This included both quantitative (e.g., self-report questionnaires) and qualitative (e.g., interview questions, use of visualization exercises) strategies. In addition to confirming elevated levels of clinical depression, anxiety, and suicidal ideation, it was also determined that, in part based on his responses to both the

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SPSI-R previously described and clinical inquiries, Ronald had a strong negative problem orientation related to his personal life. However, this negativity was beginning to impact his view of his work activities and future, which made him particularly concerned and increasingly more depressed and hopeless. In addition, it appeared that whereas his planful problem-solving abilities were sufficiently effective in helping him achieve a meaningful career as a physician in the military, he did not apply such skills to problems encountered in his personal life. Moreover, he engaged in avoidant problem-solving strategies—developed during his childhood and adolescent upbringing—as a major means of coping with difficult situations, particularly involving his nuclear family and wife. As a standard part of EC-PST, the case formulation was shared with Ronald, noting that his emotional learning history was particularly stressful, as it was characterized by having a depressed father, a family that avoided open discussions about emotions, and prioritizing academic and career goals to the exclusion of a balance with relationship and personal goals as a means of emotional regulation. These stressors collectively led to his current (and lifelong) depression and inability to handle stressful personal problems. Normal current stress emanating from his work as a physician, as well as being anxious about the possibility of becoming an ineffective dad to his recently born son, further exacerbated such difficulties. Alternatively, it appeared that a major strength characterizing Ronald was his ability to be sufficiently effective in his work environment, which included positive relationships with coworkers, supervisors, and patients. Avoidance and suppression of his negative orientation and emotions, particularly with regard to his father’s suicide and his subsequent guilt, while serving him well in one area of his life, simultaneously led to increasing difficulties outside work. For example, it was conveyed to Ronald that he appeared to be the “proverbial” individual whom everyone at work perceived to be “friendly and self-confident” but who would come home only to reveal a low threshold for any perceived criticism. For example, whereas the majority of his negative affect involved depression, he frequently became angry at his wife when she teased him playfully about a minor flaw. On the basis of numerous discussions with his therapist, Ronald defined his major goals as (a) decreasing depression, (b) reducing guilt related to his father’s suicide, and (c) improving his relationship with his wife. The goal of improving his relationships with his siblings was initially “put on hold” as he was doubtful if this could ever happen.

Initial Treatment Plan From the initial assessment, it would appear that a tailored EC-PST protocol for Ronald should initially include the following clinical components and in the following order: 1. Emotion-regulation training. Despite his ability to function successfully in his work environment, Ronald has significant difficulty in understanding



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and regulating negative emotions pertaining in his personal life. Therefore, it would appear more fruitful to initially focus on teaching and helping Ronald to apply the Stop and Slow Down tools in order to provide him with skills to better manage his reactions to both interoceptive and external cues that serve as triggers for negative emotions. 2. Overcoming feelings of hopelessness. The toolkit involving the use of visualization to overcome hopelessness should be provided to Ronald simultaneously with emotion-regulation training as he has frequently lapsed into guilt and despair. This would help him be more hopeful that learning emotion regulation tools can ultimately lead to goal achievement. 3. Planful problem solving. A more formal training in these skills should follow the above approaches, with specific focus on demonstrating how such an approach can be helpful to achieve his specified goals, as well as across other life problems and not only specific to academic and career arenas. It is possible that as treatment continues, the original goals can be revised or new ones articulated. For example, it was mutually decided to set a more immediate goal to better emotionally manage an upcoming family visit on the anniversary of his father’s death. 4. Overcoming brain overload. Training in this module should be closely tied to the emotion-regulation training. In the past, when Ronald has felt overwhelmed with stressful stimuli, he has tended to become sad, angry, anxious, and flooded with negative memories, rather than attempting to stop and slow down and engage in more adaptive ways of coping. EC-PST for Ronald would entail the above sequence of clinical components with the focus on those problems (e.g., guilt, anxiety about being a good father) that have engendered the greatest feelings of depression. As therapy would continue, additional problems across areas of his life could then be addressed. A heavy emphasis would be placed on having Ronald practice both in and between sessions in order to foster skill acquisition and application. The use of analogies and metaphors to enhance his understanding would occur throughout the course of treatment (e.g., “similar to the need to practice surgical skills in order to be competent and even expert, it is important to view the need to practice these problem-solving skills as well in order to more effectively achieve your desired life goals”). Even though Ronald has an above-average intellectual ability, all EC-PST clients receive numerous handouts to enhance learning with the suggestion that such information (which would include various training worksheets) should be kept in order to refer to them in the future. Monitoring of change should occur throughout the course of treatment, focusing on both symptom reduction and improvements in the various skill sets that were the focus of treatment. Due to Ronald’s elevated suicidal risk, particular attention should be paid to changes in this area over time. If sufficient change does not occur within a reasonable period of time, the therapist should review the initial case formulation to determine what needs to be revised. We encourage therapists to view themselves as clinical “problem solvers” applying many of the

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same problem-solving principles described earlier, viewing their goal in this context as “how can I best help this person achieve their goals?” (see C. M. Nezu et al., 2016). Before ending treatment, an additional focus would be to help Ronald better predict future stressful circumstances in order to be better prepared to cope with them.

MECHANISMS OF CHANGE DATA Theoretically, we have posited that PST-based interventions lead to behavioral and emotional change as a function of changes in people’s ability to better handle stressful problems. Simply put, learning to become a better social problem solver, for example, should result in reduced emotional distress and enhanced well-being. Several studies assessing the correlation between improvements in SPS and reductions in depression found them to be significantly associated, providing indirect evidence of viewing problem-solving ability as a mechanism of action for PST (Alexopoulos et al., 2003; Areán et al, 1993; A. M. Nezu, 1986; A. M. Nezu & Perri, 1989). Warmerdam et al. (2010) conducted a more direct assessment of this question in a study that compared online cognitive behavior therapy (CBT) with online PST in treating depression among Dutch adults. They tested whether four treatment-specific variables served as treatment mediators: (a) dysfunctional attitudes, (b) worry, (c) problem-solving skills, and (d) perceived control. Initial results indicated that both online interventions led to significantly less depression, higher levels of control beliefs, and lower levels of worry and negative problem orientation as compared with a control group. However, no differences were identified between CBT and PST regarding all four potential mediators. This suggests that (a) these variables play a mediating role in both CBT and PST and (b) the psychosocial processes important for inducing symptom reduction are comparable across two different therapies.

DISSEMINATION A significant effort to disseminate PST-based programs has been conducted by the Department of Veterans Affairs (VA). Specifically, we developed a program that was focused on building resilience and reducing emotional distress among U.S. veterans based on principles of PST. This adaptation, entitled Moving Forward, comprises four sessions. The dissemination plan involved having us train various VA therapists (e.g., psychologists, psychiatrists, social workers, counselors) to conduct Moving Forward groups, some of whom would eventually be further trained as consultants who would aid in training future therapists. A smaller group of these consultants would subsequently serve as “master trainers,” that is, training future therapists on their own. Such a plan helps foster a larger number of trained Moving Forward therapists along with greater client accessibility across various VA medical centers and hospitals.



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An initial evaluation of the first 3 years of the program (2010–2012) involved an assessment of 479 veterans (out of an initial 621 enrollees) representing 155 different groups (Tenhula et al., 2014). Qualitative results indicated that the program was feasible and well received by veterans. Quantitatively, analyses found that Moving Forward yielded statistically significant improvements in social problem solving, resilience, depression, and interpersonal functioning. Exploratory analyses further showed that changes in problem solving were significantly correlated with changes in depression, functioning, and resilience.

APPLICATION TO DIVERSE POPULATIONS Similar to all other psychosocial interventions, much research is needed to determine whether PST/EC-PST is efficacious for various ethnically diverse populations. However, those studies that have been conducted with this question in mind have generally found problem-solving-based approaches to be effective across groups. For example, Reynolds et al. (2014) conducted a study that included 90 Blacks in a participant sample of 247 older adults. Their study was geared toward preventing major depression among individuals experiencing subsyndromal depressive symptoms. Results indicated that PST was effective in preventing major depression in this population. No differences were found between Whites and Blacks. In addition, Areán et al. (2005) conducted subgroup analyses regarding the outcome of PST administered within a collaborative care model for certain minority groups. Of a sample of 1,801 older adults, 138 were Latino. Results of a subgroup evaluation indicated that such individuals experienced significant decreases in depression and health-related functional impairment as compared with usual care participants. In a study by Dwight-Johnson et al. (2005), depressed Latina cancer patients randomized to active treatment were initially provided the option of undergoing pharmacotherapy or PST. At 8 months postbaseline, PST participants were found to experience 4.5 times greater reduction in depression than women in a usual care condition. Additional studies demonstrating the efficacy of PST as part of a larger collaborative care model for reducing depression with Latino populations include Ell et al. (2008), which focused on low-income, depressed Latina women with cancer; Ell et al. (2010), which treated low-income, depressed Hispanic diabetic patients; and, more recently, Wu et al. (2018), which included depressed Latina women with diabetes in primary care, safety-net systems.

CONCLUSION This chapter provided an overview of PST and a justification for its recent evolutionary revision: EC-PST. We initially noted how solving logical and intellectual problems are different from coping with problems in living and, thus, require a different set of skills. We further described a multidimensional model

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of SPS, the process involved in addressing real-world problems. Next, we discussed how social problem solving is etiologically associated with psychopathology and stressful problems. A series of meta-analyses provided for significant justification for describing PST as an evidenced-based intervention. A brief overview further delineated the clinical guidelines of EC-PST, and a clinical case illustrated their application. Last, we briefly addressed three additional issues: mechanisms of change, dissemination, and applications to diverse populations.2

REFERENCES Alexopoulos, G. S., Raue, P., & Areán, P. (2003). Problem-solving therapy versus supportive therapy in geriatric major depression with executive dysfunction. American Journal of Geriatric Psychiatry, 11(1), 46–52. https://doi.org/10.1097/ 00019442-200301000-00007 Alexopoulos, G. S., Raue, P. J., Kiosses, D. N., Mackin, R. S., Kanellopoulos, D., McCulloch, C., & Areán, P. A. (2011). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction: Effect on disability. Archives of General Psychiatry, 68(1), 33–41. https://doi.org/10.1001/ archgenpsychiatry.2010.177 Areán, P. A., Ayalon, L., Hunkeler, E., Lin, E. H., Tang, L., Harpole, L., Hendrie, H., Williams, J. W., Jr., Unützer, J., & the IMPACT Investigators. (2005). Improving depression care for older, minority patients in primary care. Medical Care, 43(4), 381– 390. https://doi.org/cp7zgb Areán, P. A., Perri, M. G., Nezu, A. M., Schein, R. L., Christopher, F., & Joseph, T. X. (1993). Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. Journal of Consulting and Clinical Psychology, 61(6), 1003–1010. https://doi.org/10.1037/0022-006X.61.6.1003 Arnsten, A. F., Raskind, M. A., Taylor, F. B., & Connor, D. F. (2015). The effects of stress exposure on prefrontal cortex: Translating basic research into successful treatments for post-traumatic stress disorder. Neurobiology of Stress, 1, 89–99. https://doi.org/10. 1016/j.ynstr.2014.10.002 Azrin, N. H. D., Donohue, B., Teichner, G. A., Crum, T., Howell, J., & DeCato, L. A. (2001). A controlled evaluation and description of individual-cognitive problem solving and family-behavior therapies in dually-diagnosed conduct-disordered and substance-dependent youth. Journal of Child & Adolescent Substance Abuse, 11(1), 1– 43. https://doi.org/10.1300/J029v11n01_01 Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., Jüni, P., & Cuijpers, P. (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: A network meta-analysis. PLOS Medicine, 10(5), e1001454. https:// doi.org/10.1371/journal.pmed.1001454 Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A metaanalysis. Clinical Psychology Review, 29(4), 348–353. https://doi.org/10.1016/j.cpr. 2009.02.003 Bell, K. R., Fann, J. R., Brockway, J. A., Cole, W. R., Bush, N. E., Dikmen, S., Hart, T., Lang, A. J., Grant, G., Gahm, G., Reger, M. A., St De Lore, J., Machamer, J., Ernstrom, K., Raman, R., Jain, S., Stein, M. B., & Temkin, N. (2017). Telephone problem solving for service members with mild traumatic brain injury: A randomized, clinical trial. Journal of Neurotrauma, 34(2), 313–321. https://doi.org/10.1089/ neu.2016.4444 Answer: Mr. Hardy was on the lowest rung of the ladder when he fell off.

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Tenhula, W. N., Nezu, A. M., Nezu, C. M., Stewart, M. O., Miller, S. A., Steele, J., & Karlin, B. E. (2014). Moving Forward: A Problem-solving training program to foster Veteran resilience. Professional Psychology, Research and Practice, 45(6), 416–424. https://doi.org/10.1037/a0037150 Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., Langston, C., & the IMPACT Investigators. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288(22), 2836– 2845. https://doi.org/10.1001/jama.288.22.2836 van den Hout, J. H. C., Vlaeyen, J. W. S., Heuts, P. H. T., Zijlema, J. H. L., & Wijnen, J. A. (2003). Secondary prevention of work-related disability in nonspecific low back pain: Does problem-solving therapy help? A randomized clinical trial. Clinical Journal of Pain, 19(2), 87–96. https://doi.org/dqz7q3 Vuletic, S., Bell, K. R., Jain, S., Bush, N., Temkin, N., Fann, J. R., Stanfill, K. E., Dikmen, S., Brockway, J. A., He, F., Ernstrom, K., Raman, R., Grant, G., Stein, M. B., Gahm, G. A., & the CONTACT Investigators. (2016). Telephone problem-solving treatment improves sleep quality in service members with combat-related mild traumatic brain injury: Results from a randomized clinical trial. Journal of Head Trauma Rehabilitation, 31(2), 147–157. https://doi.org/fg75 Wade, S. L., Kurowski, B. G., Kirkwood, M. W., Zhang, N., Cassedy, A., Brown, T. M., Nielsen, B., Stancin, T., & Taylor, H. G. (2015). Online problem-solving therapy after traumatic brain injury: A randomized controlled trial. Pediatrics, 135(2), e487–e495. https://doi.org/10.1542/peds.2014-1386 Warmerdam, L., van Straten, A., Jongsma, J., Twisk, J., & Cuijpers, P. (2010). Online cognitive behavioral therapy and problem-solving therapy for depressive symptoms: Exploring mechanisms of change. Journal of Behavior Therapy and Experimental Psychiatry, 41(1), 64–70. https://doi.org/10.1016/j.jbtep.2009.10.003 Wilhelm, K., Siegel, J. E., Finch, A. W., Hadzi-Pavlovic, D., Mitchell, P. B., Parker, G., & Schofield, P. R. (2007). The long and the short of it: Associations between 5-HTT genotypes and coping with stress. Psychosomatic Medicine, 69, 614–620. https://doi. org/10.1097/PSY.0b013e31814cec64 Wu, S., Ell, K., Jin, H., Vidyanti, I., Chou, C. P., Lee, P. J., Gross-Schulman, S., Sklaroff, L. M., Belson, D., Nezu, A. M., Hay, J., Wang, C. J., Scheib, G., Di Capua, P., Hawkins, C., Liu, P., Ramirez, M., Wu, B. W., Richman, M., . . . Guterman, J. (2018). Comparative effectiveness of a technology-facilitated depression care management model in safety-net primary care patients with Type 2 diabetes: 6-month outcomes of a large clinical trial. Journal of Medical Internet Research, 20(4), e147. https://doi.org/10.2196/jmir.7692 Zatti, C., Rosa, V., Barros, A., Valdivia, L., Calegaro, V. C., Freitas, L. H., Ceresér, K. M. M., Rocha, N. S. D., Bastos, A. G., & Schuch, F. B. (2017). Childhood trauma and suicide attempt: A meta-analysis of longitudinal studies from the last decade. Psychiatry Research, 256, 353–358. https://doi.org/10.1016/j.psychres.2017.06.082

17 Schema Therapy Eva Fassbinder and Arnoud Arntz

O

ver the last 2 decades, schema therapy (ST), developed by Jeffrey Young (Young et al., 2003), evolved as one of the major current treatments for patients with personality disorders (PDs) and chronic mental health problems. ST has its roots in cognitive behavioral therapy (CBT) but also integrates ideas and techniques of other theoretical orientations (e.g., attachment theory, psychodynamic and experiential therapies). Practitioners of ST assume that traumatization in childhood and frustration of basic childhood needs lead to the development of early maladaptive schemas (i.e., basic mental representations of the self, the relationship to others and the world) and dysfunctional schema modes (i.e., negative emotional-cognitive-behavioral states), which cause psychological problems in adult life. Thus, a strong emphasis in treatment is placed on early development. In addition to cognitive and behavior-oriented techniques, ST extensively uses experiential techniques to process memories of aversive childhood experiences. The therapeutic relationship is conceptualized as limited reparenting, meaning that the therapist, within the boundaries of a professional therapy relationship, behaves like a “good parent” toward the patient. ST is basically a transdiagnostic approach. However, it also comprises disorderspecific models for most PDs. A number of studies demonstrate effectiveness for treatment based on these models, especially for borderline personality disorder (BPD; Dickhaut & Arntz, 2013; Farrell et al., 2009; Fassbinder, Schuetze, et al., 2016; Giesen-Bloo et al., 2006; Nadort et al., 2009) and Cluster C PDs (i.e., avoidant, dependent, and obsessive-compulsive PD; Bamelis et al., 2014). In https://doi.org/10.1037/0000218-017 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  493 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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this chapter, we provide an overview of the background, underlying theory, practical application, and outcome data of ST. Case formulation and therapeutic techniques will be illustrated with case examples of a patient with BPD and a patient with chronic depression and avoidant PD.1

HISTORY AND DEVELOPMENT OF SCHEMA THERAPY In the 1980s, Young developed ST as an extension of Beck’s cognitive therapy for patients who did not respond fully to treatment (Young et al., 2003). These patients showed very complex, pervasive, enduring psychological problems (called “characterological problems” by Young) and dysfunctional behavioral patterns, which in most cases could be followed back into their childhood. In many of these patients, a PD was evident. The characterological problems also lead to problems in psychotherapy and often interfere with the therapeutic process. In order to develop helpful treatment strategies, Young tried to understand the characteristics of these patients and potential pitfalls of CBT techniques. Major aspects were the following (Young et al., 2003): • Patients learned early in life to suppress and avoid emotions and other inner experiences as a coping strategy that they developed in response to adverse experiences. Thus, they had problems and showed resistance to expressing emotions or thoughts. This caused problems for CBT, as sufficient access to and willingness and ability to report thoughts and emotions are usually needed to ensure success in therapy. Consequences could be that patients avoided doing their homework or rejected trying techniques the therapist proposed. This often led therapists to doubt patients’ compliance. • Patients had difficulties in forming a collaborative relationship with the therapist, such that they remained distant, mistrustful, or hostile. Other patients, on the contrary, became too reliant on the therapist. These interpersonal problems were often mirroring the problems patients had in their relationships in everyday life. • Patients’ complaints were often vague and hard to capture, whereas standard CBT aims for clarity and focuses on clear, measurable treatment goals. • The belief system of these patients and their coping strategies were very rigid. Thus, even if they committed to trying CBT techniques, their patterns of thinking and feeling seemed to be deeply rooted and were very resistant to change. To address these problems, Young enriched CBT techniques with elements and insights from attachment, interpersonal, and object relation theory and integrated experiential techniques from gestalt and emotion-focused therapy. This integration led to the following distinctive features of ST, which distinguish ST from other CBT approaches: Case examples are disguised to protect patient confidentiality.

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• A strong emphasis is placed on the patient’s early development. The patient’s current problems are brought into context and explained from adverse childhood experiences and frustration of basic childhood needs. • Experiential techniques are used extensively. They aim at processing aversive childhood memories and experiencing emotions and needs in a safe way and bringing them in a healing process by emotional restructuring. Through the use of these techniques, coping strategies (such as experiential avoidance) are reduced, and dysfunctional schemas and the dysfunctional meaning of emotions and needs are changed. • The therapeutic relationship serves as an antidote to adverse interpersonal experiences and is conceptualized as limited reparenting. This means that within professional boundaries the therapist creates an active, caring, parent-like relationship with the patient. At the same time—as good parents would do with their child—the therapist empathically confronts the patient with the problematic consequences of their behavior and the need to change and promotes change. • The major goal in ST is helping patients understand their emotional core needs and learn adaptive ways of getting needs met better. This requires breaking through long-standing emotional, cognitive, and behavioral patterns, meaning change of dysfunctional schemas, coping strategies, and schema modes.

UNDERLYING THEORY Early Maladaptive Schemas A central assumption of ST is that aversive experiences and frustration of basic childhood needs lead, in interaction with biological and cultural factors, to the development of early maladaptive schemas. Young et al. (2003) defined early maladaptive schemas as broad pervasive life themes or patterns of information processing composed of memories, emotions, cognitions, bodily sensations, and attention preferences. Schemas strongly influence individuals’ views of themselves (e.g., “I am a terrible person”), their relationships to others (e.g., “Others will leave me anyway”), and the world as a whole (e.g., “The world is a dangerous place”). Besides explicit and verbal knowledge accessible to consciousness, schemas also contain implicit and nonverbal knowledge. Schemas are developed during childhood or adolescence and elaborate throughout one’s lifetime. They act as filters of incoming information and have a self-sustaining character, as information is processed in a way that fits the schema. Thus, they are very stable and resistant to change. It is important to consider that everybody develops schemas in childhood and that there are maladaptive and adaptive schemas. Adaptive (healthy) schemas develop when core emotional needs are met in childhood. This enables children to develop positive pictures about themselves and their connection to other

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people. That there is a relation between the development of maladaptive schemas and negative childhood experiences and that these schemas mediate the association between childhood experiences and personality disorders, is supported by research (Carr & Francis, 2010; Specht et al., 2009; Thimm, 2010). Basic emotional needs of children include the following (Arntz & van Genderen, 2009; Young et al., 2003): (a) secure attachment, stability, and care; (b) protection from harm and abuse; (c) connection to other people and social inclusion; (d) love, nurturing, and attention; (e) acceptance and praise; (f)  autonomy, competence, and identity; (g) expression and validation of emotions, needs, and opinions; (h) realistic limits; and (i) play and spontaneity. Young et al. (2003) described 18 maladaptive schemas, grouped into five domains, each domain reflecting a theme of frustrated needs (e.g., disconnection and rejection; see Table 17.1). The 18 maladaptive schemas were derived from clinical experience. Psychometric research with the Young Schema Questionnaire, which assesses the presence or absence of 16 core maladaptive schemas, has shown stable factor structure in clinical samples (Baranoff et al., 2006). Early maladaptive schemas are activated automatically by internal or external triggers, especially if triggers show parallels with the situations that have led to the development of the schema. Activation of the maladaptive schema leads to psychological distress associated with painful emotions. In order to deal with this psychological distress, an individual may use one of the following three coping styles: (a) surrender (i.e., giving in to one’s schema), (b) avoidance (i.e., avoiding full activation and awareness of one’s schemas), and (c) overcompensation (i.e., fighting one’s schema by believing and doing the opposite of the schema). TABLE 17.1. Early Maladaptive Schemas and Schema Domains Identified by Young et al. (2003) Schema domain

Schemas

Disconnection and rejection

• • • • •

Abandonment/instability Mistrust/abuse Emotional deprivation Defectiveness/shame Social isolation/alienation

Impaired autonomy and achievement

• • • •

Dependency/incompetence Vulnerability to harm and illness Enmeshment/undeveloped self Failure

Impaired limits

• Entitlement/grandiosity • Insufficient self-control

Other-directedness

• Subjugation • Self-sacrifice • Approval seeking

Overvigilance and inhibition

• • • •

Negativity/pessimism Emotional inhibition Unrelenting standards Punitiveness



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For example, patients with a mistrust/abuse schema are convinced that others will betray, abuse, humiliate, cheat, lie to, or manipulate them intentionally. These expectations reflect their experiences in childhood, when they experienced that it is not advantageous to trust others. Patients with this schema often experienced severe abuse in childhood, including sexual, physical, and emotional (including verbal) abuse. If the schema is activated, which often occurs in interpersonal situations, patients experience strong anxiety, threat, and a sense of mistrust. The three ways of schema coping are as follows: • If patients surrender to their mistrust schema, they might choose relationships with abusive partners and allow others to mistreat them; thus, they repeat history from childhood. Although this leads to emotional pain, it might somehow feel familiar for these patients. Often, these patients do not see any alternative to the schema, or they believe that it would cause even more pain and is hopeless for them to try an alternative. Thus they give in and stay in abusive relationships. • If patients avoid their mistrust schema, they might avoid relationships entirely, or they will not show themselves to be vulnerable, and they will not disclose personal information or trust other people. This way they cannot be hurt; thus, painful emotions do not arise in the short run. In the long run, these patients experience loneliness without close relationships. They do not provide themselves with opportunities to experience corrective experiences, and their schema stays stable. • If patients overcompensate their mistrust schema, they might abuse and mistreat others. This way they are in control, they feel strong and powerful instead of weak, and they cannot be hurt by others (e.g., “If I beat them first, they cannot beat me”). The schema is often not conscious to the overcompensating patients, or they deny it; thus, the emotional pain is not felt directly. However, overcompensating behavior also causes problems in relationships. Corrective experiences are impossible, and the underlying schema remains uncorrected. Coping strategies typically develop in childhood as attempts to adapt to a distressing environment. As such, they have an adaptive value and can help the child attenuate painful emotions. However, they often become very rigid, inflexible, and automatically triggered over time and impair adaptive interpersonal and self-regulatory behavior, leading to many difficulties in essential life areas. Rigid coping prevents the needs that were frustrated in childhood from being fulfilled in adult life and serves to maintain the maladaptive schema.

Schema Modes While working with BPD patients (as well as with other patients with severe personality pathology), Young discovered that many competing schemas were apparent and that these patients manage these schemas with different coping

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strategies. The plurality of possibilities (18 schemas × 3 coping styles = 54 possibilities) leads to a high level of complexity, which makes it hard to maintain an overview for both patient and therapist. Moreover, the schema concept was not optimal to explain and work with the quick mood and behavior changes of these patients. Thus, Young extended the schema theory with the mode model approach, a major development in the evolution of ST. Young et al. (2003) developed the schema mode approach first specifically for BPD, then for narcissistic PD. Later, the schema mode approach was further developed and empirically tested for most other PDs (Bamelis et al., 2011; Lobbestael et al., 2008, 2010). A schema mode (“mode” to simplify) is a combination of an activated schema and a coping strategy and describes the momentary emotional-cognitive-behavioral state that is active at a given time point. Patients can flip from one mode to another mode very quickly, whereas a schema is rigid and enduring (i.e., schema = trait, mode = state; Young et al., 2003). It is, therefore, a convenient concept in clinical practice, as it helps patients and therapists track and explain the frequent and sometimes sudden shifts in emotion, cognition, and behavior. Also, specific treatment strategies and goals for each dysfunctional mode have been developed, which help patients learn healthier ways of coping with them. Most outcome studies on ST are based on the mode model (Jacob & Arntz, 2013), and modern ST works almost exclusively with the mode model. Thus, in this chapter we focus on the mode model. It is, however, important to keep in mind that schema modes are related to schemas, in the sense that the activation of a schema leads to a way of coping with the activation, which results in a schema mode: activated schema → coping → schema mode

This model has received empirical support in two studies so far (Rijkeboer & Lobbestael, 2012; van Wijk-Herbrink et al., 2017). Interestingly, the ST model predicts that the same schema can underlie very different types of modes, depending on the way the individual coped with the schema activation therefore, both externalizing and internalizing psychopathology can be based on the very same schema. For instance, the activation of a mistrust/abuse schema can lead to depression and anxiety (via surrender type of coping, resulting in a vulnerable child mode activation) or to aggression (via overcompensating type of coping, resulting in an angry-enraged child mode activation; see van WijkHerbrink et al., 2017, for an empirical test). This implies that when a schema mode is addressed in treatment, the associated schema is automatically addressed. In the basic approach of the mode-model there are four broad categories of modes (see Figure 17.1, modified from Arntz & Jacob, 2012): • Dysfunctional child modes develop when major emotional needs were frustrated in childhood. In these modes, patients experience intense aversive emotions, such as fear or abandonment, loneliness, helplessness, and sadness or mistrust (vulnerable child modes), but also anger, rage, impulsivity, or lack of discipline (angry/enraged/impulsive/undisciplined child modes).



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• Dysfunctional parent modes (punitive, demanding) are characterized by internalized negative beliefs about the self, which the patient has acquired in childhood due to the behavior and reactions of significant others (e.g., parents, teachers, peers). They are associated with self-devaluation and a sense of self-hatred, guilt, shame, or extremely high standards. • Dysfunctional coping modes serve to reduce the emotional pain and distress of child and parent modes and describe the excessive use of the coping strategies of surrender (e.g., compliant surrender mode), avoidance (e.g., detached protector mode or self-soother mode), or overcompensation (e.g., self-aggrandizer mode or bully-and-attack mode). These modes are usually acquired early in childhood to protect the child from further harm and are therefore considered as “survival strategies.” • The healthy modes of the healthy adult mode and the happy child mode represent functional states. In the healthy adult mode, people can deal with emotions, care for their needs, solve problems, and create healthy relationships. In this mode, people are aware of their needs, possibilities, and limitations and act in accordance with their values, needs, and goals. The happy child mode is associated with joy, fun, play, and spontaneity. In severe psychopathology, the healthy modes are usually weak at the beginning of therapy. Table 17.2 displays the most important modes in more detail and specifies for each mode the PD that is typical. For more information and a detailed description of all modes, see Arntz and Jacob (2012).

FIGURE 17.1. Basic Structure of the Mode Model

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Modes can be assessed by self-report with the Schema Mode Inventory (SMI), though there are limitations in the degree to which patients can report their modes, due to lack of insight, strategic reporting, or unwillingness to report (Lobbestael et al., 2010). We later address other ways to assess modes during treatment.

TABLE 17.2. Schema Modes Child modes

Vulnerability

Lonely child mode Feels like a lonely child that only gets attention and love if they do everything that is expected by the parents or other important persons. Core emotional needs are not met; thus, the child has a sense of being alone, socially unaccepted, unloved, and unlovable. Typical mode in narcissistic and obsessive-compulsive PD (however, often denied and not conscious in the beginning of treatment) as well as in avoidant PD (especially in combination with a sense of inferiority). Abandoned, abused child mode Has a sense of being abandoned, sad, anxious, helpless, hopeless, and threatened; has extreme fears of being left alone, mistreated or neglected; appears fragile, vulnerable, needy like a child, looking for a parent figure that helps. Typical child mode in BPD and dependent, avoidant, and histrionic PD.

Happiness

Lack of discipline

Anger

Dependent child mode Has a sense of being like a helpless child, incapable and overwhelmed by adult responsibilities; searches urgently for someone for help and to take over responsibility. Typical child mode in dependent PD. Angry/enraged child mode Feels angry, enraged, frustrated, and inpatient because core emotional (or physical) needs of the vulnerable child are not being met; expresses anger in inappropriate ways (e.g., by making demands that seem entitled or spoiled, shouting, or even being physically aggressive). With the enraged child mode, there is loss of control not only over the feeling of anger and its verbal expression but also over aggressive behavior. Thus, there is severe aggression in a “hot” emotional state. Typical child mode in BPD as well as antisocial and histrionic PD. Impulsive child mode Acts impulsively to get needs and desires met, without thinking about long-term consequences or taking care of others; often has difficulty delaying short-term gratification to concentrate on long-term goals. Typical child mode in BPD as well as antisocial; and histrionic PD. Undisciplined child mode Has difficulties with rules, discipline, and finishing routine or boring tasks; is frustrated quickly and gives up soon. Typical child mode in antisocial and histrionic PD. Happy child mode Feels happy and contented because core emotional needs are met; has a sense of being loved, connected to others, valued, understood, hopeful, resilient, optimistic, and spontaneous.



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TABLE 17.2. Schema Modes (Continued)

Punishment

Punitive parent mode Reflects internalized punitive messages of significant others (e.g., parents, teachers, siblings, or peers); shows in self-devaluation, self-contempt, self-hatred, shame, and guilt. Patients think they are bad, stupid, lazy, ugly, or invalid; punish themselves or do not allow space to take care of themselves or to do something good for themselves; and believe that they must be punished for expression of needs or emotions and for any mistake. Present in all PDs; however, often denied or not conscious to patients with strong overcompensating modes, such as narcissistic, histrionic, obsessive-compulsive, and antisocial PD.

Criticism

Dysfunctional parent modes

Demanding parent mode Has extremely high standards and pushes patient to do everything perfect, without mistake, to be effective and efficient, not to lose time, to strive for the high achievement, to be modest, and/or to put others’ needs before one’s own. The patient feels that it is wrong to express feelings or to be spontaneous. In patients with narcissistic and obsessive-compulsive PD, there is often a demanding parent mode with focus on achievement, while in dependent and avoidant PD, the demanding parent mode focuses more on social behavior and the needs of other persons.

Surrender

Maladaptive coping modes Compliant surrender mode Acts in a passive, submissive, reassurance-seeking way without caring for their own interests to avoid conflicts, disharmony, or rejection by others; behaves as they think others wish them to behave, allows others to take over the control of their life and to mistreat them, and stays in invalidating, sometimes even violent, relationships. Major coping mode in dependent PD.

Avoidance

Detached protector mode Distances themself from other persons and emotions by shutting off all emotions (e.g., by consuming drugs or alcohol, through dissociation or distraction), withdrawing from relationships, and keeping others at a distance. Major coping mode in patients with BPD. Avoidant protector mode Uses situational avoidance as the primary coping strategy; avoids social contacts, challenging situations, and conflicts as well as emotions in general, intensive sensations, or activities that are in any way arousing. Major coping mode in patients with avoidant PD. Angry protector mode Keeps others at a distance with cynism, irritation, or angry behavior often found in BPD patients. Detached self-soother mode Shut off their emotions by engaging in activities that will somehow soothe, stimulate, or distract them from feelings (e.g., addictive or compulsive behaviors such as workaholism, gambling, dangerous sports, eating, watching TV all day, engaging in fantasies, promiscuous sex, drug abuse). Typically found in narcissistic patients. (continues)

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TABLE 17.2. Schema Modes (Continued)

Overcompensation

Self-aggrandizer mode Behaves in a grandiose, over-self-confident manner; is very competitive, arrogant; highlights own strengths and achievement; points at others’ mistakes or weaknesses; shows little empathy for others’ needs or feelings; expects to be treated as special. One of the main coping modes in narcissistic and obsessive-compulsive PD. Attention- and approval-seeking mode Tries to get other people’s attention and approval by extravagant, inappropriate, and exaggerated behavior. Usually compensates for underlying loneliness. Major coping mode of histrionic PD. Perfectionistic overcontroller mode Attempts to protect themself from making mistakes or a perceived or real threat by focusing attention, ruminating, worrying, increased planning, and controlling Focus lies on perfectionistic behavior to prevent criticism, misfortune, mistakes, or guilt and to prove capability. Major coping mode of obsessive-compulsive PD. Suspicious overcontroller mode Attempts to protect themself from threat by being vigilant, scanning other people for signs of malevolence, and controlling others’ behavior out of suspiciousness. Major coping mode of paranoid PD. Bully and attack mode Bullies and intimidates others, behaves aggressively toward others, and threatens others and tries to frighten others in order to have the control and not be harmed by others. Major coping mode of antisocial PD. Healthy adult mode Performs appropriate adult functions, such as working, parenting, taking responsibility, and committing; pursues pleasurable adult activities such as sex; intellectual, esthetical, and cultural interests; health maintenance; and athletic activities. Has functional attitudes toward emotions and needs and uses appropriate assertiveness when functional. Note. BPD = borderline personality disorder; PD = personality disorder. From Schema Therapy in Practice: An Introductory Guide to the Schema Mode Approach (p. 42–46), by A. Arntz and G. A. Jacob, 2012, Wiley. Copyright 2012 by Wiley. Adapted with permission.

Treatment Goals of Schema Therapy The ultimate goal of ST is helping patients find adaptive ways to get their needs better met in their everyday life and helping them deal with the frustration if their needs cannot be met in a certain situation. This requires changing maladaptive schemas, coping styles, and modes that underlie patients’ symptoms and problems. With respect to the mode model, there are mode-specific goals for each mode providing a central “red thread” to follow at each point of therapy. These goals are connected with specific therapeutic tasks for each mode (see Figure 17.2):



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• Child modes are healed and corrected. The patient should get in contact with their vulnerable core and become aware of their emotions and frustrated needs. Needs and emotions are validated and taken care of to foster emotional processing of childhood maltreatment and enable corrective experiences. This way, early maladaptive schemas can be healed. In the angry, impulsive child mode, patients need to learn adequate ways to deal with their anger and desires; sometimes this also requires setting limits to these modes. The major aim, however, is to reach and soothe the vulnerable child mode, which is underneath the angry child mode. Memories of childhood experiences related to child modes are emotionally processed mainly by experiential techniques such as imagery rescripting, multiple chair, and drama techniques, as is done with trauma processing. • Parent modes are abolished as much as possible. The therapist “fights” the punitive and demanding parent modes and helps the patient learn healthier views of themself and develop more self-compassion. • Coping modes are made less necessary by replacing them with healthier, more flexible strategies. However, because these modes have functioned as “survival strategies” to protect the vulnerable child mode, first their adaptive value needs to be accordingly honored. Their reduction is to take place gradually as the healthy adult mode has to develop more functional ways of coping. • The healthy adult mode should become the dominant mode so that the patient can take over all the above-named tasks by themself and become able to create healthy relationships more and more. Thus, the therapist is not needed anymore at the end of treatment. The happy child is also enhanced. Joy and spontaneity should get more space in patients’ lives and protect them from psychological distress. FIGURE 17.2. Mode-Specific Therapeutic Tasks

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The mode-specific goals are achieved by means of cognitive-oriented, experiential, and behavior-oriented techniques and through the work with the therapeutic relationship. Each set of techniques is explained in the following passage in more detail.

FOCI OF TREATMENT AND CHANNELS OF CHANGE ST has three general areas on which the treatment focuses: • childhood experiences, which lie at the root of the development of the problems • the therapeutic relationship, to offer corrective experiences and to address issues that become apparent in this relationship • present problems and the future, to address the problems the patient struggles with outside the therapy The focus on the etiology of the problems in ST is a distinctive feature compared with other forms of CBT, with the exception of trauma-focused CBT for posttraumatic stress disorder (PTSD) related to childhood trauma. The reason for the focus on the childhood experiences that contributed to the development of the current disorder is that emotionally processing the memories of these experiences leads to a change in their (implicational) meaning, which, in turn, causes a change in the related schemas. Thus, successful processing of memories of abandonment experiences in childhood leads to a reduction of the abandonment schema (and thus the abandoned child mode), which in turn, is associated with a reduction of the associated problems in the present (e.g., abandonment fears and dysfunctional attempts to prevent or cope with these fears). Moreover, understanding the relation between childhood experiences and present problems helps the patient understand the present problems and promotes a metacognitive grip on them (Tan et al., 2017). A second distinctive feature is the focus on the therapeutic relationship. Personality pathology has a strong interpersonal aspect and will, therefore, also become manifest in the therapeutic relationship. This offers the chance for the therapist to directly offer corrective experiences (i.e., the expression of negative emotions, including anger toward the therapist, is followed not by rejection from the therapist but by empathy and support). Schema therapists are warm and more personable to foster a safe and corrective experience, but at the same time, they are also directive (especially at start of treatment), as warm and personal directiveness matches the needs of the patient that has missed this form of care in childhood. This concept of limited reparenting, such that the therapist tries to meet the needs that were not adequately met in childhood, within professional boundaries, is further discussed later. The third focus is on problems outside the therapy room, in the present and future. ST shares this focus with most (other) CBT approaches. However, when



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indicated, the therapist might more actively put issues on the agenda like (dys) functional partner choice, choice of education and work, or hobbies to prevent patients from remaining caught in a repletion of dysfunctional choices and to promote their future well-being. In addition to the three foci, ST integrates three channels of change: • Experiential: changing by experiential techniques • Cognitive: changing by thinking (reasoning, information) techniques • Behavioral: changing by behaving differently Experiential techniques are generally inspired by techniques used in experiential therapies like gestalt therapy, and an important reason to use them is that they are so powerful in getting emotions activated and in bringing about a change that goes further than cognitive insight (i.e., a change on a felt level). This is, in particular, important in the treatment of personality problems, as these patients often report, after the use of cognitive therapy techniques, that they see what is meant but do not feel it. Experiential techniques also allow one to go back to the developmental level of the child that experienced the negative events that contributed to the problems and offer corrective experiences and information on a developmentally appropriate level, so that these are better integrated in the memory representations of these events. The cognitive techniques used in ST not only are those that are common in traditional CBT (dominated by a Socratic dialogue approach and challenging negative thoughts) but also involve extensive psychoeducation about universal emotional needs and emotions, the etiology of psychological problems, the effects of abuse and neglect, and the intergenerational transmission of psychopathology. The behavioral techniques can involve most of those known in CBT. One specific technique to emphasize is behavioral pattern breaking, which usually takes place at the end of treatment if dysfunctional patterns are still apparent. It occurs when patients are stimulated to change the way they behave and make choices to stop with dysfunctional patterns and start with trying out more functional options. All ST techniques are explained in detail in the following section.

DESCRIPTION OF MAIN PROCEDURES Main Treatment Plan After assessing current problems, symptoms, important relationships, and the developmental history of the patient, an individual case conceptualization with the mode model (see below) is worked out. This normally happens within the first five sessions. In the following treatment process, all occurring problems and interpersonal disturbances are put into context, explained, and worked with in this individual mode model. This means that for each situation or problem, the patient and therapist find out which modes are involved and how their interplay contributes to the problem, and then they intervene according to the above-named mode-specific goals.

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First, a rule of thumb, coping modes must be addressed and reduced because they block access to the vulnerable child mode and the associated schemas, often from the first domain. It is important for therapists to keep in mind that these modes have served as a “protective shield” for many years; thus, they have to proceed with caution. Patients will only reduce their coping modes if they feel safe enough in the therapeutic relationship and if the adaptive function of these modes has been acknowledged sufficiently. At the same time, patients also need to understand the disadvantages these modes cause in their current life and why it would be important to learn healthier strategies. The therapist, thus, motivates the patient to reduce their coping mode stepwise, first in the therapeutic relationship and later in other situations outside the therapy room. Second, once there is access to the vulnerable core of the patient, the therapist aims at validating needs and emotions of the child modes and helps heal the deeply rooted and long-standing emotional pain by means of experiential methods and through the therapeutic relationship. Simultaneously, dysfunctional parent modes are reduced, and their influence in the patient’s life is weakened. Implicitly, the patient builds healthier schemas (e.g., “I am a loveable person,” “I can trust others”). Throughout the whole therapy process, the healthy adult mode is strengthened and the patient takes over more and more responsibility by themself. Only very general information about the duration of treatment can be provided because ST is used with very different patients and settings. For patients with severe PD, a length of at least 1.5 years with weekly individual sessions is recommended. For patients with less severe PDs, around 30 weekly sessions followed by five monthly booster sessions is recommended as a minimum. In less severely ill patients or in self-therapy of therapists, only a few sessions might already lead to pronounced changes. In the following section, we present a case conceptualization as well as cognitive-oriented, experiential, behavior-oriented, and therapy relationship techniques and illustrate them with two patient examples. We have chosen a patient with BPD and a patient with a Cluster C PD to demonstrate the variety of ST techniques and the adjustment of ST to the specific patient group and the individual patient. These PDs are quite common and have been studied in randomized controlled trials of ST, which are described later in the chapter. All techniques are presented in line with the original manuals for ST in general (Arntz & Jacob, 2012; Young et al., 2003) and for the treatment of BPD (Arntz & van Genderen, 2009), which we recommend for further reading. Case Conceptualization With the Mode Model At the start of treatment, an individual case conceptualization with the mode model is developed through interaction with the patient. Major current symptoms and interpersonal and emotional problems of the patient are conceptualized within the relevant modes and put into context with their developmental background.



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In most patients with PDs, a specific pattern of dysfunctional modes can be observed. These patterns are summarized as disorder-specific mode models. Such specific models exist and have been empirically tested for most PDs (all but schizotypal and schizoid PD) and forensic patients (Bamelis et al., 2011; Lobbestael et al., 2008, 2010). These disorder-specific mode models provide therapists with a rough frame for case conceptualization in the respective PD. However they always have to be adapted to the individual patient, their symptoms, and their history. The disorder-specific approach can be extended by adding additional modes to capture all major problems easily. Thus, even in very complex patients with high comorbidity rates and many problems, it is possible to work with one clear, plausible model. When there is no disorder-specific mode model available, such as for patients with chronic depression or other Axis I disorders, the therapist uses the general mode approach (as shown in Figure 17.1 and Table 17.2) and chooses the relevant modes for the patient. It is the therapist’s responsibility to concentrate on the most relevant modes and to keep the model as simple as possible. Thus, it is recommended to work with four to six problematic modes so that patient and therapist do not get lost and so they can focus on essential problems. To reduce the complexity of the model, one can often chunk modes with similar functions, such as combining the angry and the impulsive child modes into one mode. We now present two case examples to explain the way in which an idiosyncratic case conceptualization is developed. The examples are partly based on German publications and DVD sets on ST and chair dialogues (Fassbinder, Erkens, & Jacob, 2016; Fassbinder & Jacob, 2014; Jacob & Seebauer, 2013). Case Example 1: Patient With Borderline Personality Disorder Linda, age 23 years, comes to treatment because she is afraid to lose her boyfriend: I just can’t trust him; although he does not give me any reason. I just can’t believe that he really loves me as horrible as I am. I am always afraid that he might cheat on me and will leave me for another woman. When he is out and I am alone at home, I freak out and call him several times. If he does not answer I check his Facebook account and emails. We had so many fights. I am totally out of control then. I shout and throw things at him. I even beat him. If he then withdraws from me, it even gets worse.

Asked for other symptoms, she says that she smokes cannabis or drinks alcohol at least three times a week and that she has binge eating attacks several times a week. “This happens mostly when I am alone and feel sad. I can’t bear that. I always try to have something to do. If this does not work out, I smoke pot, drink alcohol, or eat . . . and I am already fat enough.” Besides the relationship to her boyfriend, she has one close friend, “Steph.” Steph has been very reliable and supporting in the past, so the therapist values that relationship as a healthy one. From other people, Linda withdraws herself totally. She even keeps Steph at a distance most of the time.

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With regard to her developmental history, it becomes clear that circumstances in her childhood were very chaotic: Both parents had an alcohol dependency; her father was in jail several times. At a young age, she was often left alone at home and did not know when, if, and how her parents would come back. She felt very anxious and lonely and did not know what to do. Both of her parents had several affairs and were lying to and cheating on each other very often. She often witnessed their arguments connected with physical assaults. Her parents were also violent toward Linda; most of the times, she did not understand for what she was being punished. Harsh insults and devaluation took place every day. As a young child, she often tried to protect herself by hiding under her bed or by saying nothing. Later, she fought back, mostly without success. To soothe herself, she dreamed about another family that loved her and would come to rescue her; in fact, going into fantasy world is something she still does today. At the age of 10 years she drank alcohol for the first time; by age 13, she consumed it daily and had begun to smoke cannabis. Figure 17.3 shows Linda’s mode model that her therapist has worked out in collaboration with her. As usual in ST, Linda chose individual names for each mode. Linda shows the BPD-typical mode combination, such that the vulnerable child mode is named “little abandoned Linda” and is connected with her anxiety of being abandoned and her feelings of loneliness, sadness, and mistrust. Linda’s rage attacks and fights with her boyfriend and associated controlling behavior (e.g., calling him several times, checking his emails) are conceptualized in the angry, impulsive child mode “little wild Linda.” These modes developed because major childhood needs have been frustrated and circumstances have been so chaotic. Verbal and physical abuse by her parents fueled the development of Linda’s strong punitive parent mode, called her FIGURE 17.3. Linda‘s Mode Model



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“punitive side.” This mode consists of self-devaluating messages, feelings of self-hatred, shame, and guilt. Additionally, Linda has two coping modes. In the “detached protector mode” called “the wall,” she avoids contact with other people and distracts herself from painful emotions by smoking cannabis, drinking alcohol, binge eating, or having something to do. The “detached self-soother mode” (i.e., “the soother”) helps Linda soothe herself, when she feels lonely and sad, by going into fantasy world, smoking cannabis, or eating. It can be seen that smoking cannabis and eating are present in both modes because they have both a detaching and soothing function. Linda developed both coping modes at young age because these strategies helped her soothe herself when nobody took care of her and protected herself from further emotional pain by hiding. “Grown-up Linda” is her healthy adult mode and shows in Linda’s commitment in therapy and her friendship with Steph. After developing the mode model, Linda is very relieved. She says that the mode model is like an inner “road map” for her and that it helps her understand her “inner chaos.” Case Example 2: Chronically Depressed Patient With an Avoidant Personality Disorder George is 43 years old, single, and working as a teacher. He comes to treatment because he feels overworked and exhausted. Apart from his job, he is active in his church community and organizes the church choir. He reports slowly with many breaks and without eye contact: I can’t take it anymore. It is too much. I thought about going to my doctor and asking him for sick leave, but then my colleagues will have to do all the work. I am inferior anyway and they will be angry at me, if they have to do my work. That’s not possible.

During the conversation, it becomes clear that George has strong fears of being rejected and criticized by others. He often takes over unpleasant tasks and has problems saying no if someone asks him to do something. Many times, others have used him because of this. George prepares his lessons for school, often very detailed, until late at night to run as little risk as possible to get attacked by his pupils. The pupils laugh at him nevertheless, which reinforces his sense of inferiority and shame. Outside school and church, he has no personal contacts and feels very lonely. He has never had a romantic relationship and feels very ashamed for that. Asked for his information about his childhood, he reports that both parents have been strict Catholics. They were both very demanding and emotionally distant. His mother was suffering from a chronic inflammatory gut disease but nevertheless was very engaged in the church community. At home, she often blamed George for not supporting her enough. George’s central emotions toward her were guilt and anxiety that her disease might get worse. His father was very rigid and demanded obedience without questioning. If George failed to fulfill his demands, he punished him hard and criticized him harshly.

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George’s mode model is shown in Figure 17.4. George also chooses names for each mode. In the case conceptualization, the therapist uses the disorderspecific mode model for avoidant PD as an orientation and detects the respective modes: • A lonely/inferior and an abandoned/abused child mode. To simplify George’s case conceptualization, the therapist decides to bring both modes into one vulnerable child mode with George (“little George”). • A punitive parent mode, which in George’s case was strongly influenced by the father. The mother gave more emotionally demanding messages, and thus a demanding parent mode is also apparent in George. Again, to keep a better overview, the therapist decides to work with only one parent mode (“the guilt inducer”). • An avoidant and detached protector mode as avoiding coping modes (“the avoider”)—always strongly present in avoidant PD—and compliant surrender as surrendering coping mode (“the surrenderer”), also a frequent mode in avoidant PD, although not seen as regularly as the avoiding coping modes. George also shows some traits of obsessive-compulsive PD and, in line with this, has a perfectionistic overcontroller mode (“the perfectionist”), which is not typical for avoidant PD but the major coping mode in obsessive-compulsive PD. • A healthy adult mode (“grown-up George”).

FIGURE 17.4. George’s Mode Model



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Cognitive Techniques On the cognitive level, psychoeducation on schemas, coping styles, modes, needs, emotions, and the normal development of children takes place especially in the beginning of treatment. Moreover, all CBT techniques can be used (see Exhibit 17.1). These techniques are always adapted to the frame of the mode-model and follow the typical ST goals. EXHIBIT 17.1

Cognitive Techniques Psychoeducation on schema, modes, coping styles, needs, emotions, interpersonal reactions, and normal development of children • Increasing awareness of modes by working out typical trigger situations and moderelated cognitions, body reactions, emotions, and behaviors • Working out development and function of specific modes and schemas in the light of traumatic experiences and frustration of basic childhood needs • Testing the validity of schemas and modes using evidence from all periods of life • Identifying and reappraising of schemas and mode-related distortions (e.g., identify “I am a loser!” as a cognition from the punitive mode, restructuring from the healthy adult mode perspective) • Reviewing pros and cons, especially for coping modes • Considering long-term consequences, such as from the impulsive child mode or staying in the coping modes • Using flashcards for relevant mode and schemas that helps patients remind themselves of healthy views and behaviors in difficult situations • Analyzing problematic situations in light of the mode model • Writing schema or mode diaries to increase mode awareness and mode change • Analyzing selective awareness processes • Shifting attention to other perspectives (e.g., to the vulnerable child mode or the healthy side) • Looking up and considering relevant information, such as about the emotional needs of children and their importance for childhood development or about the rights of children to receive care and love • Investigating the assumed causal relation between two concepts (e.g., between work achievement and being liked by others) with the two-dimensional drawing technique, such that the x-axis represents the assumed cause, the y-axis the effect, and the diagonal the assumed relationship; persons varying in achievement success and in being (dis) liked are placed in the two-dimensional space, and the relationship is reconsidered given where these people are placed (see Arntz & van Genderen, 2009) • Pie chart drawing with all factors given a part to investigate the degree to which one is responsible or guilty (see Arntz & van Genderen, 2009) • Reducing dichotomous thinking by using visual analogue scales (see Arntz & van Genderen, 2009) • Countering one-dimensional evaluation by evaluating on multiple dimensions (see Arntz & van Genderen, 2009)

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Continuation of Case Example 1: Use of Cognitive Techniques For Linda, it was, first of all, important to understand her symptoms and interpersonal problems in light of the mode model and to see how they originated, as an important focus of treatment would be on the origins of the problems. It was central to recognize that her rage attacks and impulsive acts in the “little wild Linda” mode were preceded by fears of abandonment, helplessness, and mistrust in her vulnerable child mode. This mode was quite pronounced because Linda had often experienced loneliness and abandonment and had lacked secure attachment and other major core needs in childhood. Moreover, her parents’ relationship model was characterized by cheating on and lying to each other; thus, Linda expected relationships to be like that. Although Linda understood the origins and developed good awareness to recognize “little wild Linda,” it was hard for her to deactivate this mode and focus on long-term consequences. The therapist and Linda worked on these aims with many interventions, including the following flashcard that Linda wrote for her angry impulsive child mode:

Hello little wild Linda, you are going wild and out of control again. Stop right now, and breathe two times. If you call John right now, you make it even worse. Remember, you want to trust him. I know that this is hard for you because of your previous experiences and your mistrust and abandonment schemas. However, you can trust John. He is different from your father. He has said that he loves you and has shown it to you often enough. He will come back to you. If you can’t stand being alone right now, call Steph.

Continuation of Case Example 2: Use of Cognitive Techniques A central cognitive technique is reviewing advantages and disadvantages, especially in the work with coping modes. Table 17.3 shows the advantagesdisadvantages list of George’s compliant surrender mode, which he developed with his therapist. Therapeutic Relationship Techniques Because early maladaptive schemas develop in particular through early interpersonal traumatization by significant others, especially parents, the work with the therapeutic relationship is a central focus of ST throughout the whole therapy process. The therapeutic relationship has been conceptualized to serve as an antidote to these adverse experiences in childhood and is an important source of corrective interpersonal and emotional experiences, and through this,



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TABLE 17.3. Pros and Cons of George’s Compliant Surrender Mode Advantages of “surrender” • Others are thankful when I take over unpleasant things from them; I get at least some attention. • I do not have such strong feelings of guilt and do not feel so egoistic. • Fewer arguments and less criticism. • More harmony, leading to less anxiety. • If I take care for others, I have something to do, which gives me the sense of being worthwhile and decreases the sense of inferiority and shame.

Disadvantages of “surrender” • I have a lot of work, and because of that I feel exhausted and depressed. • My needs are not important and do not get fulfilled, which detracts from quality of life. • No awareness of my limits and borders. • Other people use me. • The fear of doing something wrong persists, and I go on with a sense of being inferior and unloved, which does not allow for corrective experiences in relationships (creating a vicious circle). • Some other people do not like my submissive behavior.

it aims to change early maladaptive schemas. The two major techniques are limited reparenting and empathic confrontation, which have been described as the “two central pillars” of ST by Young (Young et al., 2003). Limited Reparenting Limited reparenting means that the therapist behaves toward patients as if the therapist were a “good” parent figure and determines the central therapeutic attitude at any time of the therapy process. The therapist, of course, respects the limits of a professional therapy relationship. It is a limited and “as if” takeover of the parent role, in which the therapist models appropriate parental responses and behaviors, helping patients become aware of their needs and emotions and express them. The therapist validates them and fulfills, to a limited extent, the needs that were frustrated in childhood. At the same time, the therapist also set limits and helps patients process the frustration that might result from limitations of the therapist. On the one hand, limited reparenting is characterized by support, warmth, empathy, attention, praise, and providing secure attachment. On the other hand, a therapist practicing limited reparenting also might set appropriate limits or encourage or push patients toward autonomy and growth. These needs might also have been frustrated and have to be fulfilled. The therapist adjusts their relational style to the specific frustrated needs, schemas, and modes of the individual patient. Thus, they always behave a little bit different with each patient. It might be that they react differently to the very same behavior in two different patients (e.g., being late for session with a patient with obsessivecompulsive PD affords a different reaction than in a patient with antisocial PD). The two case examples serve to illustrate this individual adjustment to each patient in more detail. With each individual patient, the therapist adjusts their relational style to each mode in line with the mode-specific goals of ST, which we demonstrate in Figure 17.5 for Linda’s case.

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Continuation of Case Example 1: Design of the therapeutic relationship In her childhood, Linda experienced much chaos, unreliability, and violence, and she received little love, praise, and support. For these reasons, it is particularly important that the therapist offer a reliable, warm-hearted, and caring relationship. She needs self-soothing skills to apply in times of difficulty and to reinforce herself for even the slightest progress. At the same time, due to the chaotic circumstances in her childhood, Linda needs a reliable structure and clear limits, especially when she is in her angry, impulsive child mode. Figure 17.5 illustrates the mode-specific design of the therapeutic relationship. Continuation of Case Example 2: Design of the therapeutic relationship In contrast to Linda, George comes from a very structured, authoritarian, and emotionally cold family environment. His parents placed precise requirements on him regarding how he should behave, feel, and think. If he did not fulfill these requirements, expressed his own needs, or verbalized an “unsuitable” opinion, he was punished. His mother induced feelings of guilt in little George by being disappointed or sad in him or by accusing him of being selfish. His father produced massive shame and a sense of inferiority through devaluation. As an antidote, George’s therapist offers a very warm, open, caring, and supportive relationship. She promotes the expression of needs and emotions and validates them. She shows interest in George’s opinions and judgments and helps him deal with situations in which there are different opinions. The therapist encourages George to sense and verbalize his own limits and reduce feelings of guilt when he does so or expresses his own needs. She praises him for progress, shows him that it is not bad if something does not work out right away, and promotes his autonomy. FIGURE 17.5. Mode-Specific Work With the Therapeutic Relationship in the Case

of Linda



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Empathetic Confrontation In empathic confrontation, on the one hand, the therapist empathizes with the intentions and emotions underlying problematic behavior or views of the patient, explicitly connecting them with the patient’s modes and schemas as well as with the childhood origins. On the other hand, the therapist confronts the patient with the consequences of their behavior and the need for change. The therapist does that in a friendly but very clear manner. It is important that therapists also address their own emotions that were evoked through the patient’s behavior, after checking that their reactions are not connected with their own dysfunctional schemas. By doing so, the therapist always makes clear that the patient’s behavior and not the patient themself is meant and checks the emotional reaction of the patient (careful self-disclosure). Continuation of Case Example 2: Empathetic confrontation with George’s avoidant coping mode George is, in the beginning of treatment, very often distant and silent. He only answers with a few sentences and tries to avoid eye contact. THERAPIST: George, I recognize that it is hard for you to talk to me and that

you are very silent. I think this is your avoider-mode. Remember, this was the mode that came to protect you. When I think back, what you told me about your father and his harsh criticism, it was very important that you developed this mode to protect you. There was nothing that you could do right in the eyes of your father. I think the “avoider” was the only solution for little George and protected him from feeling even more ashamed. Does this make sense to you? [George nods, but still avoids looking at the therapist and seems to be very ashamed. Thus, the therapist goes on validating George.] THERAPIST: I have the impression that your vulnerable child mode still feels

that shame and anxiety and hears these punitive voices, even here in therapy. I can imagine that that is awful. GEORGE:

[nodding more] Yes, it is always like that. I always feel shame and have so many fears about doing something wrong.

The therapist supports George opening up by looking at him in a friendly manner and with compassion (as with children, nonverbal behavior is sometimes even more important than verbal behavior). She makes a connection between the schema and the coping mode.

THERAPIST: [with warm voice] Yes, that is your shame/inferiority schema

that you feel with all that pain . . . and the ‘avoider’ still comes to rescue. [Then she starts softly with the confrontation part.] At

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the same time, the avoider does not allow little George to get in contact with other people, and little George continues to feel lonely and sad and does not get what he really needs. Also, he can’t learn other things about himself and these feeling of shame and inferiority stay with him. What do you think about that? GEORGE:

Hmm, I never looked at it this way, but I guess that is true. I really feel lonely and have looked at myself as inferior for all my life, but it is true others can’t get in contact with me when the avoiding side is always there.

THERAPIST: Yes, and here in therapy, the same happens: The avoider also

puts me at a distance, and I can’t reach little George. I think that little George would need my support, connection, and someone he can talk to so that he does not feel so lonely .  .  . but the avoider blocks me out. GEORGE:

Oh, I really do not want to block you away, but this happens automatically.

THERAPIST: Yes, I understand. See, good thing is that we can change that

automatic pattern together and that you can practice here with me in a safe environment. GEORGE:

That sounds good, but what should I do?

THERAPIST: Pretty much, what you did today. Try to tell me what you are

thinking and feeling. I am really interested in that because I get to know you better. There is nothing that you can do wrong. Let’s just give it a try. It can be seen that the therapeutic relationship in ST provides a safe haven with much validation, caring, and support, while being a source of change, such as by offering the patient the possibility to try new interpersonal behavior in the safe environment of the therapeutic relationship. One major aim of the relational work in ST is that patients internalize the reactions toward their needs and emotions modeled by the therapist in their healthy adult mode, and through these new experiences, they are able to fulfill their needs themselves without support of the therapist. Limited reparenting is very dynamic and flexible. Besides adjustment to the frustrated needs and schemas of the patients, the therapist also adjusts their relational style to the patient’s skills as well as to the phase of treatment: Normally, the therapist is very active and caring at the start of treatment, and as treatment proceeds they step back more and more and foster the patient’s autonomy and independence—again showing the parallels with real parenthood. Experiential Techniques Experiential techniques, including emotional processing of aversive childhood memories as well as work on current emotional problems, are of high signifi-



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cance in ST, which is an important difference from traditional CBT. Often, patients reach an intellectual understanding of their problems quite quickly; however, strong emotions connected to dysfunctional schemas or modes still remain (e.g., “I know it from my head, but I can’t feel it in my gut”). Experiential techniques aim at changing how the patient feels, or the emotional core of the schema, which is often not stored verbally and is more deeply rooted. The major experiential techniques are chair dialogues, imagery work (especially imagery rescripting), and historical role play. Chair Dialogues In this technique, different chairs are used to express different sides of a patient, emotions, or perspectives of other persons (see overview in Kellogg, 2014). In ST, most often the chairs symbolize the different modes and dialogues between them that are initiated. The patient changes chairs and expresses in each chair the perspective of the respective mode as well as connected needs and emotions. If a new mode emerges, the therapist normally asks the patient to switch to a new chair, which represents the new mode (e.g., “That sounds pretty much like your punitive side; would you please switch chairs to this chair, which stands for your ‘guilt inducer,’ and tell me what he is saying?”). The therapist can also demonstrate the interplay of the modes, such as by helping the patient to see the effect one mode has on another (e.g., “These were very harsh messages from your ‘guilt inducer.’ Could you please sit here in the chair for ‘little George’ and tell me how he feels when he gets these messages?”). The therapist helps patients express their emotions and needs, and if patients have difficulties doing so, the therapist might also model expression of the emotions and needs (e.g., “I see that it is very difficult for you to tell me what ‘little George’ feels. Is it okay with you if I sit down in ‘little George’s’ chair and tell you what I feel as him?”) The therapist addresses the modes in line with the mode-specific goals (see Figure 17.2) and adjusts content, tone of voice, and other nonverbal behaviors to the respective mode. Continuation of Case Example 1: A chair dialogue with “little wild Linda” Linda becomes very upset in “little wild Linda” mode in the session. She is very angry at her partner and thinks, again, that he is having an affair. She speaks very loudly and quickly and urges the therapist to call John: “You need to tell him that he has to tell me the truth and that he must come here immediately.” The therapist says clear and loud, “Stop,” to limit Linda. She asks Linda to hand over her cellphone to make clear that they will not call John in the “wild Linda” mode. Finally, she can bring Linda to do a chair dialogue with her. Here, Linda first sits on the chair for “wild Linda” and expresses her anger and her intentions: “I am so angry. I want to go to John, crash the door, and see if another woman is there with him. I have a right to know that.” The therapist stops “wild Linda” and asks Linda to sit down in the chair for “grown-up Linda.” Linda sits in the chair with some resistance. The therapist places herself next to Linda and encourages her to inhale and exhale twice to regulate her tension. Linda does so a bit reluctantly. The therapist praises Linda for every step

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in the right direction. She guides in small steps and remains active throughout the process. In the next step, the therapist helps Linda look at the situation from the perspective of the healthy adult mode. While doing so, emotions of “little abandoned Linda” come to light; thus, the therapist takes a new chair for the vulnerable child mode. She helps Linda express her sense of anxiety, despair, and powerlessness and validates these experiences in light of Linda’s childhood experiences. She soothes “little abandoned Linda” and expresses her care and support. Afterward, the ideas of “wild Linda” are reflected upon again from the healthy adult mode. “Grown-up Linda” recognizes that these proposals will lead to even more problems in the long run and that she might actually lose John if she follows “wild Linda.” Together with the therapist, “grown-upLinda” thinks about how she might bridge the time until John will call her and how she can best take care for the needs of “little abandoned Linda.” She recognizes that being alone is currently too difficult and therefore decides to contact Steph after the session. Imagery Work Imagery exercises can be used for diagnostic reasons (diagnostic imagery) or to foster change of early maladaptive schemas and the meaning of adverse childhood events (especially imagery rescripting). Diagnostic imagery exercises are usually performed at the start of treatment and serve to clarify the origin of dysfunctional emotional and behavioral patterns. Most often, diagnostic imagery exercises start from a current situation, which is emotionally disturbing for the patient. The patient is asked to imagine that situation with eyes closed, as if it is currently happening, and to describe the scene in present tense. While patients describe what they or other persons in the image are doing, thinking, and feeling, emotions become more vivid and intense. The therapist focuses on the emotions and asks the patient where in the body they can feel the emotion. When the emotion is clear enough, the therapist asks the patient to let go of the current situation but to stay with the feeling (i.e., affect bridge) and “float back” to childhood and see whether an image that is somehow associated with their feelings has been activated. The childhood image is, then, considered in the same way, and the patient is prompted to express their feelings and needs. Continuation of Case Example 2: Diagnostic imagery with George George reports that he often oversteps his boundaries at work. He has problems with saying no if someone asks him for something at work. His therapist suggests doing an imagery exercise to better understand that pattern. George agrees, and they imagine a situation that George has experienced—the last day with a female colleague, who was asking him to do some copy work for her lesson. This copy work is normally done by the secretary, but George perceived that he could not say no. THERAPIST: What do you think? GEORGE:

[with eyes closed] I have to do it. She has so much to do, and I am on break now. She needs my help.



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THERAPIST: What do you feel? GEORGE:

I feel pressure to help her. It is egoistic that I want to have my break. I am an awful and lazy person.

THERAPIST: How does that feel emotionally? GEORGE:

Pretty much under pressure. I feel ashamed and guilty. I need to help her.

THERAPIST: Can you feel that in your body? GEORGE:

Yes, there is pressure on my shoulders and a peak behind my sternum.

THERAPIST: Okay, George, could you please wipe out that current image as if

you see a black television screen, but stay with the emotions and the feeling in your body, and perhaps also enlarge them a bit. And now travel back to your childhood and see if an image pops up that is somehow connected. Do not force yourself, just take your time and see if something comes up. GEORGE:

Hmm, that is strange. I have a picture of me with my mother.

THERAPIST: Very good. How old are you in that picture? GEORGE:

I must be 8 or 9.

THERAPIST: What happens in the image? Please tell me what you see when

you look out of little George’s eyes. GEORGE:

I am with my mum in the living room. She is lying on the sofa and she looks as if she has pains.

THERAPIST: What do you feel? GEORGE:

I am anxious that she might get worse again. But I am also looking forward since James, a classmate, has said he would come around to play soccer with me. I am so excited because nobody has asked me before. I think nobody is interested in me in school . . . but I feel bad because my mother is so ill and I have to stay with her.

James rings the doorbell, but little George is too afraid to open. He asks his mother cautiously if he can go out to play. His mother reacts in a disappointed manner and accuses George by saying, “Oh, George, I have such strong pains; how can you even think about going to play soccer?” George feels ashamed, guilty, and selfish, and he is also sad that he cannot go out and play with James.

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In the debrief of that imagery exercise, George and the therapist examine the parallels between his current situation and the childhood images and focus on their connection within the mode model. The desire for play and connection with other children and relaxation in his current situation are normalized, as are his sadness when these needs get frustrated (in the vulnerable child mode). His mother’s demanding messages and behaviors are connected with George’s profound guilt and shame, “guilt-inducing mode” being activated by the demand of his colleague in the current situation. Thus, the compliant surrender mode emerged immediately to reduce these feelings of guilt and followed the demands of the parent mode.

Diagnostic imagery exercises can also be performed without an affect bridge, such as by imagining memories with both parents or other significant people. Diagnostic imagery serves to gain an emotional understanding of schemas and modes and does not involve emotional processing by changing the memory, unlike imagery rescripting (described next). Sometimes, especially in severely traumatized patients, this leaves the patients with strong, overwhelming emotions, which they are not able to regulate themselves at the start of treatment. Thus, in some groups of patients, such as patients with BPD, diagnostic imagery alone (without rescripting) is not recommend or should be performed with caution. In imagery rescripting (Arntz & Weertman, 1999), an emotionally disturbing situation, usually an unpleasant memory, is imagined in a way in which the course of the event is changed to a positive outcome. Imagery rescripting is a flexible, creative technique, and it is hard to predict the exact course. However, for imagery rescripting in ST, there is a structured guideline leading the therapist and patient step by step through the emotional process. Imagery rescripting incorporates two phases: (a) Phase 1, imagery of the unpleasant situation, and (b) Phase 2, the rescripting part, changing of the situation to have a better ending. In Phase 1, patients select a focus for the exercise, most often an aversive childhood memory with a strong association with the patient’s maladaptive schema. Such memories can be found through affect bridges, as explained previously, or can be directly taken from patient report. The therapist instructs the patient to describe the situation from the perspective of the child using “I” and present tense and then asks for the sensory experiences, emotions, cognitions, and needs of the child. When the traumatic memory is sufficiently activated, and the patient clearly feels the related emotions and needs, Phase 2, the rescripting part, is started. In Phase 2, a helping figure is introduced in the image and modifies the situation into a more pleasant ending for the child, in which the needs of the child are better met. The helping figure can be the patient themself in their healthy



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adult mode, if they are already strong enough. For patients with a PD, this is often not the case in the beginning of therapy. Thus, the therapist is initially the helping figure. The helping figure first creates safety for the child, then stops the perpetrator and confronts them. Then the helping figure takes care of the other needs of the child, comforts the child, and soothes the child. The child is encouraged to express all emotional needs. Besides fulfillment of these needs, the child receives explanation and corrective information on needs and emotions suited to children, which often relieves aversive emotions such as anxiety, loneliness, helplessness, shame, or guilt, while a sense of safety, secure attachment, warmth, love, joy, and other pleasant emotions is promoted. The aim of this exercise is not to suppress aversive emotions but to bring them in a functional emotional process, to promote awareness, and fulfill the connected need. For example, in the case of sadness, it is important that this feeling can be fully experienced (i.e., as a “mourning process”) and that the patient is helped to regulate it. To meet a central need associated with sadness, the therapist ensures that the patient is soothed and comforted. To deepen the feelings of safety and connection and to foster other pleasant emotions like happiness and fun, the therapist can decide to proceed with a pleasant situation (e.g., going to the cinema, playing together with a dog) if this is suitable for the situation and matches the patient’s needs. Unlike in typical CBT, the aim of imagery rescripting is not habituation and extinction as a primary goal. Instead, the primary goal of ST is changing maladaptive schemas and the original meaning of the trauma, including the meaning of emotions and needs, through emotional processing. Thus, from an ST perspective, it is not necessary that the patient relive the entire trauma in detail in imagery rescripting. Continuation of Case Example 1: Imagery rescripting with Linda Through an imagery rescripting exercise, Linda and her therapist work on Linda’s mistrust schema. Linda imagines herself as a 10-year-old girl. She received a bad grade in math; she is afraid to get punished by her father; and she, thus, decides to talk first to her mother. Her mother promises not to tell her father. When her father comes home, he is drunk and starts a fight with her mother. Her mother tells him about Linda’s bad grade to distract his attention away from her to Linda. The father starts shouting at Linda and wants to hit her. The therapist enters the image because Linda is frightened, and she does not want her to relive the full trauma. She steps between her father and Linda to protect Linda and says, “Stop immediately. You are not allowed to hit Linda and say those awful things. It’s a shame how you treat Linda. That is not what children need.” Linda’s father is very aggressive and wants to hit the therapist too. In response, the therapist creates a wall of bulletproof glass between Linda and her and her father and calls the police. Linda sees that four policemen arrest the father, but she is still upset by her mother’s behavior. The therapist confronts her mother by saying, “Your behavior was unfair. If you give a promise, you must keep it, and you need to protect Linda. Children need someone to rely

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on.” Her mother apologizes to Linda and says that she was so frightened, indicating that she did not think that her father would not attack Linda. The therapist explains that Linda needs a safe and warm place to live and reliable people around her and that her mother at the moment is not able to provide these needs for Linda. Her mother says that she wants to work on these problems and to take better care. Because Linda wants to stay with her mother, the therapist organizes that the two of them move to a mother-children residential establishment. Here, the mother receives support for her emotional problems and learns adaptive parenting skills, and Linda is cared for as well. The therapist promises that she will visit Linda twice a week to check how she is doing. Continuation of Case Example 2: Imagery rescripting with George In the diagnostic imagery description presented previously, George had strong emotions of shame, guilt, and sadness; thus, his therapist suggests that they rescript his memory in a later session. The therapist recreates the picture with little George and his mother lying on the sofa and inducing guilty feelings in little George. After a short search for an adequate helping figure, the former family doctor, Dr. Miller, is introduced, as George trusted Dr. Miller very much, and Dr. Miller’s opinion was even accepted by George’s mother. Dr. Miller rebukes the mother and states, “Mrs. Smith, I see that you have pain. However, it is not okay that George has to take over the responsibility for that. He is just a child. He has a right to play and have fun. That does not make him a bad boy. That is just normal and healthy. I will take care of your pain now, and George can go out and play with James.” George is relieved and happy. He opens the door and runs out with James and the others to play soccer. Historical Role Play Historical role play (Arntz & Weertman, 1999) originates from drama therapy. The therapist and patient examine an adverse childhood memory together as a role play. The patient switches roles by playing their own role (most often as a child) in the first round and the role of the other person (most often a parent) in the second. This structure helps the patient experience both their own feelings and needs as a child and the perspective of the other person. The insight from the perspective of the other person can especially help the patient understand the motivation and causes for the perpetrator’s behavior and, thereby, the meaning of the situation. Continuation of Case Example 2: Historical role play The therapist and George identify a situation in which George has been criticized by his father after he had dropped the candles on the floor at a church service for his first holy communion. In the first round (George playing himself as a child and the therapist playing the father), George views himself as inferior, unloved, and a disappointment for his father, as his father posed very high demands on him and was criticizing him harshly. In the second round, George plays the father, while the therapist takes over the role of little George. By adopting the perspective of the



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father, George can see that the father posed high demands on himself also and that he does so because he has learned that from his father, who also put high demands on him. He sees that his father was very much under pressure because church was so important for him, and he wanted to protect George from behaving in a way that would be embarrassing. Through this exercise, George can understand that it is not him being inferior or unlovable but that the experiences his father has experienced in the past have contributed to his father’s actions. For all experiential interventions, therapists should keep in mind that intense unpleasant emotions can be activated in patients. Especially at the beginning of treatment, patients have intense fears of emotions, as they often believe that they cannot control emotions and will be overwhelmed by them, and, as a result, they demonstrate a great deal of experiential avoidance. Therefore, the aim for this exercise is that patients experience emotions in a safe way without being overwhelmed. The therapist adapts the intensity of emotions to the individual patient and the phase of treatment. They set up emotional work in small steps and balance emotional activation by means of the therapeutic relationship. Despite the strong activation of emotions, ST shows very low dropout rates and a high degree of acceptance in patients (de Klerk et al., 2017; Jacob & Arntz, 2013). Behavioral Techniques Behavioral techniques aim at breaking through behavioral patterns displayed as a function of unhelpful coping modes and spending more time in the healthy adult mode. All techniques from behavior therapy to learn new behavior can be applied, such as role play, homework, behavioral experiments, skill training, behavioral activation, problem solving, and relaxation. All techniques are adjusted to the mode model and follow mode-specific aims (see Figure 17.2). Therapists are encouraged to consider that, at the beginning of treatment, behavior change is quite challenging for patients due to maladaptive schemas and the resultant coping mechanisms that have become habitual and rigid over time. Thus, these techniques assume greater focus in the later stages of treatment and are prepared by the other ST techniques. Continuation of Case 1: Example of Behavior-Oriented Technique After 1 year of treatment, Linda and her therapist work on Linda’s educational aspirations. For homework, the therapist encourages Linda to inform herself about possible educations in the job center and to do some career-related internet research. In the next session, Linda has completed her homework in a thorough manner and reports that she wants to complete an education as a carpenter. She has already found three joineries where she would like to apply for an internship, but she is afraid to call there. THERAPIST: First of all, I must say I am very proud on you. You did all that

research and decided to do an internship first, which will help

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you to see if you really like that job. It’s terrific that you looked into places where you can do that internship. [Linda smiles.] Very good job, Linda. LINDA:

Yes, but I did not call there because I did not know what to say.

THERAPIST: That is quite normal. This is the first time you have applied for

an internship, and nobody has ever showed you how one does something like that. Typically, parents or teachers show you how to do those things. LINDA:

Really. I thought I was stupid and a scaredy cat because I do not know what to say.

THERAPIST:

That is your punitive side speaking. You are definitely not stupid. This is quite normal, feeling afraid and not knowing what to say. You know what is funny: My daughter was in the same situation last month. She wanted to do an internship in a kindergarten and was also afraid to call.

LINDA:

Really, but what did she do then?

THERAPIST: We prepared the call, then did a role play together, and then she

called. [Therapist smiles.] And we can do it here the same way, if you want. LINDA:

[smiling] Okay, if you think that works also for me.

THERAPIST: I am sure. Okay, let’s start. What do you want to say when you

call? And remember, Linda, like always, no answer is wrong. We will just give it a try. LINDA:

Okay. I guess, I will say hello and my name and that I want to do an internship.

THERAPIST: Great. Please use direct speech. LINDA:

Hello. My name is Linda Myers. I am very interested to do an internship in your joinery and would like to ask you if this is possible.

THERAPIST: Okay. Very, very good. This is grown-up Linda! We can directly

jump into the role play. I am the boss of the joinery now, okay? [Linda nods.] THERAPIST: [with deep voice, imitating to speak in a phone] Hello, Miss

Myers. Thank you for your interest. Indeed, we are looking for an intern at the moment. But in our company interns stay for at least 3 months. Is this possible for you? LINDA:

Yes, I would like to stay 3 months or even longer.

THERAPIST: Okay, that is good. Do you have any experience as carpenter?



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LINDA:

[getting unsecure, shaking a bit] No, aehm . . . not really. . . . Oh gosh, I am a complete failure! No one will ever give me a job.

THERAPIST: [uses normal therapist voice, leans over to Linda] Okay, Linda,

that is not a problem. Most people who want to do an internship do not have experience. Breathe two times and let go of the punitive voices. [Linda breathes and relaxes herself.] Very good, Linda. Please sit upright, so that your body helps you to get back in contact with grown-up Linda again. . . . Very good. Okay, I will ask that question again, and you go back to your healthy side and answer. You can just say “No, I don’t have experience, but I am very interested” or you can express why you want to do the internship. Okay? [Linda nods.] Okay, what do you want to say? LINDA:

I can say that I would like to do training to become a carpenter, and maybe that I like to work with woods and with my hands.

THERAPIST: Great. That sounds very good. Can we restart the role play so

that you can say these things? [Linda nods.] Good, so I am the boss again. [Therapist speaks again with deep voice, imitating speaking on a phone.] Do you have any experience as carpenter? LINDA:

No, I have no experience, but I would like to do the training to become a carpenter, and that is why I want to do the internship first to gain experience. Yes, and I like to work with woods and my hands. And I have good manual skills and spatial imagination.

THERAPIST: [as carpenter] That sounds good. Why don’t you write me a

short application, and then we’ll meet and get to know each other to determine whether this will be a good match. LINDA:

Yes, that would be great. I will send you my application in the next few days. Should I, then, call again that we can make an appointment?

THERAPIST: I will give a call then. LINDA:

Okay, that is great. Do you need anything else from me?

THERAPIST: Please include your résumé, and then I will give you a call. LINDA:

Yes, I will do that. Thank you.

THERAPIST: Thank you. Hope to see you soon. LINDA:

Yes, me too.

THERAPIST: Goodbye. LINDA:

Okay, goodbye.

THERAPIST:

[stops role play, in therapist voice] You did a great job. How was it for you?

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LINDA:

Not as hard as I expected. I just need to ignore the punitive mode, then it seems to play out . . .

THERAPIST: Yes, you did a very good job. And it is true the punitive side

doesn’t help you; it blocks you. It worked out fine to let it go and to shift into grown-up Linda, didn’t it? LINDA:

Yes, that is true. . . . I hope he will be as nice as you.

THERAPIST: [smiling] Of course, we do not have a guarantee that the person

you are calling will react nicely. However, most of the time, people are at least cordial on those occasions, and the most important thing is that you call and give it a try. Only who dares, wins, and there are three chances because you found three joineries. LINDA:

Yes, that is true. Nothing to lose.

THERAPIST: Great, so when will you make the calls? LINDA:

Directly after the session.

THERAPIST: Great. I cross my fingers for you.

Directly after the session Linda calls a joinery and receives a good answer. While working out her CV, the punitive voice comes again, and thus, in the next session Linda and the therapist do some chair work, where grown-up Linda finally throws the chair of the punitive side out of the therapy room. As homework the therapist prompts Linda to send her CV and make an appointment for a job interview. Continuation of Case 2: Example of Behavior-Oriented Technique After 15 sessions, George reports that he is interested in pursuing a romantic relationship and that he does not want his parent and avoiding modes to keep him away from that anymore. A new female teacher has started at school, and George thinks that she is very attractive and nice. After all these years in his coping mode, he feels insecure and does not know how he should show that he is interested. The therapist uses problem solving to help George identify steps for initiating a romantic relationship and acquire relevant interpersonal skills. The therapist recognized that, in George’s case, it is also important for him to learn to be aware of his nonverbal behavior (e.g., body language and friendly mimics). George and his therapist do work in a café so that George can learn to maintain eye contact with people, to smile at them, and to engage in small talk. Finally, George’s therapist initiates a role play so that George can practice asking the new teacher out on a date.

POPULATIONS TO WHICH ST IS APPLICABLE ST is particularly suitable for patients with long-standing maladaptive emotional, interpersonal patterns and complex chronic problems. It was primarily



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developed not to treat a specific disorder but rather as a universal approach to treat a variety of problem constellations that are related to characterological factors. Thus, ST is a transdiagnostic approach. However, through the evolution of ST, prototypical models for case conceptualization and treatment of most PDs have been developed and elaborated (Arntz & Jacob, 2012; Bamelis et al., 2011; Lobbestael et al., 2005, 2008; Young et al., 2003). Thus, ST comprises both a transdiagnostic and a disorder-specific approach for most PDs. Randomized controlled trials (RCTs) demonstrate good treatment effects for ST in PD, especially in BPD and Cluster C PDs (Bamelis et al., 2014; Jacob & Arntz, 2013; Sempertegui et al., 2013; see also the section on outcome data below). Thus, ST can be seen as a treatment of first choice for PDs. There are also encouraging data for various syndromal disorders, such as chronic depression, eating disorders, complex PTSD, and complex obsessive-compulsive disorder (Malogiannis et al., 2014; Renner et al., 2016; Simpson et al., 2010; Thiel et al., 2016). ST should not be used in patients with an acute, circumscribed, and/or simple problem that is not a part of a persistent pattern. Such disorders should be treated with a less complex treatment method. As with all psychotherapies, limited efficacy is to be expected in states that prevent emotional learning, such as severe medical or neurological diseases, pronounced substance abuse, or low body mass index in anorexia nervosa. Treatment-disabling psychosocial circumstances (e.g., dependency of a perpetrator) must also be considered. These states, however, are not to be regarded as absolute contraindications. The degree to which psychosis and (untreated) bipolar disorder are contraindicated is not known yet.

OUTCOME DATA Most studies into efficacy and effectiveness of ST were done for the treatment of BPD. Two RCTs (Farrell et al., 2009; Giesen-Bloo et al., 2006), one case series (Nordahl & Nysaeter, 2005), five open pilot studies, and one implementation study (Dickhaut & Arntz, 2013; Fassbinder, Schuetze, et al., 2016; Nadort et al., 2009; Reiss et al., 2014) demonstrated large improvements in reduction of all nine BPD symptoms, general psychiatric symptoms, and quality of life as well as low treatment dropout. In the first RCT, a Dutch multicenter trial (N = 86), ST was compared with transference-focused therapy (TFP). Both treatments consisted of two individual sessions per week over the course of 3 years. Both groups improved significantly regarding all Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition [DSM-IV]; American Psychiatric Association, 1994) BPD-criteria, borderline-typical and general psychopathological symptoms, and quality of life. ST was superior to TFP in all measures. Moreover ST led to fewer and later dropouts (over 3 years, 27% in ST vs. 50% in TFP), higher remission rates (46% in ST vs. 24% in TFP), and higher rates of reliable change (66% in ST vs. 43% in TFP; Giesen-Bloo et al., 2006). In addition, ST was more cost-effective (van Asselt et al., 2008). A pre-post comparison

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demonstrated successful implementation of individual ST for patients with BPD in general clinical practice and showed comparably good effects (pre-post effect size of reduction of borderline typical symptoms = 1.55, recovery rate after 1.5 years = 42%) with a reduced frequency and duration of therapy (first year, two sessions per week; in the second year, frequency of sessions was gradually decreased; Nadort et al., 2009). Aiming at a more efficient use of resources, a group format (group schema therapy [GST]) was developed by Farrell and Shaw (2012) and tested in an RCT in the United States. In this study, 32 women with BPD either received treatment as usual (TAU) alone or underwent a GST treatment involving 30 ST group sessions added to TAU. The GST group showed no dropout (0% vs .25% in the TAU alone), high remission rates of BPD (94% vs. 15% in TAU only), and significant reductions in BPD-typical and general psychiatric symptoms as well as improvements in psychosocial functioning with large effect sizes after only 8 months (Farrell et al., 2009). Two outpatient pilot studies on GST in the Netherlands (Dickhaut & Arntz, 2013) and in Germany (Fassbinder, Schuetze, et al., 2016) using GST combined with individual ST also found large improvements in BPD symptoms (pre-post effect sizes of 2.7 in the Dutch study and 1.8 in the German study), general psychopathology, schema and mode measures, quality of life, and happiness. An inpatient GST treatment model was developed and tested in three pilot studies, as well (Reiss et al., 2014). These studies suggest that specific group factors may catalyze effects of ST, as effects were large and attained in a comparably short time (8–16 months). Thus, group ST may be particularly effective and lead to savings in treatment costs. To systematically investigate the clinical effectiveness and cost-effectiveness of GST for BPD and to test different formats of GST (GST only vs. a combination of GST with individual ST), a large international multicenter RCT on GST for BPD was commenced and is underway now (Wetzelaer et al., 2014). A metaanalysis from 2013 (including all published outpatient studies at the time, which are all above mentioned except Fassbinder, Schuetze, et al., 2016, and Reiss et al., 2014) revealed an overall effect size of 2.38 of pre-post changes and an overall dropout rate of 10% for ST in BPD patients in the first year (Jacob & Arntz, 2013). This is a very low dropout rate compared with the average dropout rate of 25% for BPD patients for interventions of at least 12 months’ duration (Barnicot et al., 2011; Reiss et al., 2014). A Dutch multicenter RCT examined the clinical effectiveness of ST also for patients with other PDs than BPD (Cluster C, paranoid, and narcissistic) with a majority of Cluster C PD patients. Patients (N= 323) were randomly assigned to ST, clarification-oriented psychotherapy (COP; which is a contemporary form of client-centered therapy adjusted for PD patients) or TAU. Both ST and COP were delivered weekly according to a standardized protocol. ST patients received 40 sessions in the first year and 10 booster sessions in the second year, whereas COP was open-ended. TAU did not follow a standardized protocol; patients received the optimal treatment that was available at the treatment center. Therapists in this condition were expected to follow the clinical



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guidelines for the treatment of PD in the Netherlands. ST was superior to both conditions in recovery from PD (ST, 81% vs. COP, 60% vs. TAU, 52%) and depression. Also ST patients showed less dropout (ST, 15% vs. COP, 21% vs. TAU, 41%) and higher general and social functioning at follow-up (Bamelis et al., 2014). In addition, ST was more cost-effective than the other treatments (Bamelis et al., 2015). A qualitative study on patients’ and therapists’ perspectives on ST revealed that both value highly the therapeutic relationship, the transparent and clear theoretical model, and the specific ST techniques, imagery in particular. However, unhelpful aspects of the ST protocol were also found, as several patients and some therapists perceived length of treatment with 50 sessions as too short, some patients lacked clear advance information about the possibility that strong emotions might occur while working with ST, and some patients wished for clear practical targets in the final phase of treatment. These unhelpful aspects must be taken into account in the further development of ST (de Klerk et al., 2017). Lastly, a RCT compared ST to usual psychotherapy (both part of a treatment package) in a high-security hospital sample of forensic patients with PDs (half of them meeting criteria for psychopathy) and found modest positive effects of ST on most outcomes and treatment retention (Bernstein, 2016) Three reviews summarize the data on ST for BPD, PD, and ST in general (Jacob & Arntz, 2013; Masley et al., 2012; Sempertegui et al., 2013). In the case of depression, an RCT with 100 depressed patients comparing CBT and ST found both treatments to be of comparable efficacy on all key outcomes. In a Greek single-baseline case series, 12 female patients with chronic depression received 60 sessions of individual ST. The mean score of the Hamilton Rating Scale for Depression (HRSD) dropped from 21 at baseline to 10 at the end of treatment, 42% of the patients fully remitted (remission was defined as a score of lower on the HRSD), and another 17% responded satisfactorily (response was defined as a 50% drop in the HRSD). Gains of treatment were maintained over a follow-up period of 6 months (Malogiannis et al., 2014). In a Dutch multiple-baseline case series study, 25 patients with chronic depression first received a 6- to 24-week baseline phase as a no-treatment control condition, then a 12-week exploration phase functioning as an attention control condition, and then finally received up to 65 sessions of individual ST. ST had a significant, large effect on depressive symptoms when compared with the baseline control (effect size of 1.3). Forty percent of the patients showed good response to treatment (defined as a 50% drop in the Beck Depression Inventory), 35% reached remission (defined as a score of lower than 6 on the Quick Inventory of Depressive Symptomatology), and 6% recovered (recovery was defined as the absence of a DSM-IV depression diagnosis assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders at posttreatment; Renner et al., 2016). These three studies support the use of ST as an effective treatment for (chronic) depression. Pilot studies also report promising results for other types of mental health disorders. For example, an Australian study investigated a group program that

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included ST for veterans with PTSD and found that posttraumatic stress symptoms, anxiety, depression, and the strength of maladaptive schemas decreased significantly after treatment (Cockram et al., 2010). In a case series of eight patients with eating disorders, a group ST program led to reductions in eating disorder severity, global schema severity, shame, and anxiety levels (Simpson et al., 2010). For patients with obsessive-compulsive disorder who did not respond to CBT, a 12-month inpatient treatment augmenting exposure techniques with ST was developed and piloted with 10 patients. Results showed significant reductions of obsessive-compulsive symptoms and depression, with large pre-post effect sizes ranging from 1.48 to 2.25 (Thiel et al., 2016).

MECHANISM OF CHANGE DATA Research on mechanisms of change is in its infancy in ST. The importance of limited reparenting is underpinned by an examination of the therapeutic alliance in the first RCT on BPD. Compared with TFP, scores of the therapeutic alliance both of patients and therapists were higher in ST. Low ratings at early treatment predicted dropout, whereas positive ratings of patients predicted clinical improvement (Spinhoven et al., 2007). Thus, the therapeutic alliance in ST may serve to facilitate change processes underlying clinical improvement in patients with BPD. Other indications of mechanisms of change come from the non-BPD trial (Bamelis et al., 2014): Therapists in this trial were trained differently, the first cohort of therapists being trained by mainly lecture and watching video tapes and the second cohort of therapists being trained mainly by practicing in role plays. Therapists of the second cohort stated afterward that they felt better equipped for the treatment (de Klerk et al., 2017). These therapists had significantly less dropout and better treatment effects than the first cohort of therapists. Because independent raters, blind for condition and cohort, detected a higher use of ST techniques in recordings of sessions of the second cohort of therapists than in the first cohort, the better treatment effects of the second cohort were most likely achieved by their more intensive use of ST techniques. Moreover, a mediation analysis found that a reduction of the vulnerable child mode especially and an increase in the healthy adult mode preceded reductions in PD severity and improvement in general and social/ societal functioning, whereas there was no reversed time effect on these two modes. This indicates that changes in these two modes are essential for treatment success and that therapists should always focus on these modes (Yakin et al., 2020). With regard to imagery rescripting, there are several studies demonstrating its effectiveness as a stand-alone technique in a broad range of psychiatric disorders, including posttraumatic stress disorder (Arntz et al., 2007; Grunert et al., 2007; Raabe et al., 2015), social phobia (Brewin et al., 2009; Frets et al., 2014; Nilsson et al., 2012; Wild & Clark, 2011; Wild et al., 2008), and depression (Brewin et al., 2009; Wheatley et al., 2007; review in Arntz, 2012). A



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recent meta-analysis showed large effect sizes in reducing psychological complaints due to aversive memories in diverse psychiatric disorders in a small number of sessions (Morina et al., 2017). This meta-analysis supports the use of imagery rescripting as a transdiagnostic tool in the treatment of aversive memories. Therapeutic techniques using imagery instead of verbalization probably have greater impact on emotions (Holmes et al., 2009). Imagery rescripting can, therefore, be considered as an empirically supported technique that contributes to the effectiveness of ST. This is supported by qualitative studies into views of patients and therapists that received ST in two different RCTs, as both stakeholders reported finding experiential techniques, especially imagery rescripting, to be powerful and leading to important changes (de Klerk et al., 2017; Tan et al., 2017). Other techniques used in ST, such as chair dialogues or historical role play, call for further investigation, although one study compared the (short-term) effects of experiential techniques focusing on the past to the more traditional present-focused CBT techniques and detected no significant differences in the treatment of nonborderline PDs (Weertman & Arntz, 2007). An RCT demonstrating strong effects of art therapy provided in an ST framework is important to mention, as the treatment heavily relied on experiential methods and led to strong improvements compared with a wait-list control group (Haeyen et al., 2018). Lastly, it should be noted that because of its integrative nature, ST incorporates many CBT techniques whose mechanisms of change are discussed elsewhere. Component analysis in which the respective techniques and elements of ST are tested could shed further light on the mechanism of change (e.g., ST with experiential techniques vs. ST without experiential techniques; ST with only chair dialogues vs. ST with only imagery rescripting vs. normal ST including all techniques). Another helpful approach would be to test the effects of a single technique in experimental designs, such as testing the (short-term) effectiveness of the empty chair technique to fight the punitive parent mode by comparing this technique to exploring the mode (attention control) or to using a traditional cognitive technique.

DISSEMINATION In the last decade, ST has been disseminated throughout the world after publication of the first RCT on BPD (Giesen-Bloo et al., 2006). The International Society for Schema Therapy (ISST; https://www.schematherapysociety.org) is growing quickly and has members all over the world. Moreover, ST has been accepted by most CBT organizations as an advanced development for chronic complex problems, which facilitates dissemination. Dissemination has been supported by the availability of theory and protocol books (e.g., Arntz & van Genderen, 2009; Arntz & Jacob, 2012; Young et al., 2003), many of which have been translated into various languages. DVDs with examples of techniques have been produced that help therapist understand the specific techniques

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(e.g., Jacob & Seebauer, 2013; van der Wijngaart & Bernstein, 2010; van der Wijngaart & Sijbers, 2016). ST was originally developed for an individual setting; however, as development continues, it has been adapted successfully to the group setting (Farrell & Shaw, 2012; Farrell et al., 2014), with very promising results in the treatment of BPD (Dickhaut & Arntz, 2013; Farrell et al., 2009; Fassbinder, Schuetze, et al., 2016; Reiss et al., 2014). ST is used also in couples therapy and self-therapy for therapists. Originally developed as outpatient treatment programs, ST is now offered as day treatment or inpatient treatment, for various patient groups, including forensic patients. Moreover, online treatment programs that combine face-to-face ST with an online tool have been developed (Fassbinder et al., 2015). A detailed overview on the wide range of patient populations and settings in which ST is applied can be gained through the handbook by van Vreeswijk et al. (2012).

APPLICATION TO DIVERSE POPULATIONS There is a dearth of research in the application of ST to different races/ethnicities, sexual orientations, ages, and other diverse populations. We shortly summarize the information we have thus far. Heilemann et al. (2011) tested an adapted version of ST in low-income, second-generation Latinas living in the United States and suffering from depression, with good results. Videler et al. (2018) piloted ST as treatment for Cluster C PDs in a multiple-baseline case series design in a sample of older patients (mean age 69 years old), with good results (i.e., large effect sizes). Lastly, applications of ST for youths with PDs in development or with a criminal development have been designed and will probably be tested in the near future. Two preparatory small-scale case series studies reported promising results (Roelofs et al., 2016; van Wijk-Herbrink et al., 2017). As can be seen, future research on ST needs to address how it can be applied with these populations.

CONCLUSION AND FUTURE DIRECTIONS ST is one of the major recent psychotherapeutic developments in the treatment for patients with PD and chronic psychopathological problems, especially in the treatment of BPD and Cluster C PDs. Besides large effect sizes in symptom reduction and increases in quality of life, ST is characterized by high acceptance from patients and therefore low dropout rates. ST was also demonstrated to be a cost-effective treatment. In principle, ST is a transdiagnostic model, but it also encompasses disorder-specific models for most PDs. The mode model provides a clear structure for case conceptualization and guides the treatment, as there are specific tasks for each mode, and the therapy techniques are chosen based on the active mode in the therapy situation. Besides cognitive and behavior-



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oriented techniques, there is a special emphasis on experiential techniques and the therapeutic relationship. Psychotherapy research has focused so far mainly on BPD and Cluster C PDs. Future research should, of course, address other disorders like antisocial, narcissistic, and histrionic PDs and/or chronic Axis I disorders such as eating disorders, substance use disorders, or PTSD, but it should also deepen the evidence base for BPD and Cluster C PDs. More information is needed especially on treatment duration, frequency of sessions, group/individual or combined treatment, and the optimal setting and application. ST has been directly compared with TFP in patients with BPD; however, studies comparing ST with other major evidence-based treatments like dialectical behavior therapy and mentalization-based therapy are still warranted. STs for adolescents and couples, which are already often applied, need to be explored by systematic studies. Moreover, ST uses a variety of techniques and features. Currently it is impossible to say which are the most relevant for treatment success. Dismantling studies are necessary to reveal the most important features.

REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical trials, basic studies, and research agenda. Journal of Experimental Psychopathology, 3(2), 189–208. https://doi.org/10.5127/jep.024211 Arntz, A., & Jacob, G. A. (2012). Schema therapy in practice: An introductory guide to the schema mode approach. Wiley. Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 345–370. https://doi.org/10.1016/j.jbtep.2007.10. 006 Arntz, A., & van Genderen, H. (2009). Schema therapy for borderline personality disorder. Wiley. Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37(8), 715–740. https://doi.org/cxxnch Bamelis, L. L., Arntz, A., Wetzelaer, P., Verdoorn, R., & Evers, S. M. (2015). Economic evaluation of schema therapy and clarification-oriented psychotherapy for personality disorders: A multicenter, randomized controlled trial. Journal of Clinical Psychiatry, 76(11), e1432–e1440. https://doi.org/10.4088/JCP.14m09412 Bamelis, L. L., Evers, S. M., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171(3), 305–322. https://doi.org/ 10.1176/appi.ajp.2013.12040518 Bamelis, L. L., Renner, F., Heidkamp, D., & Arntz, A. (2011). Extended schema mode conceptualizations for specific personality disorders: An empirical study. Journal of Personality Disorders, 25(1), 41–58. https://doi.org/10.1521/pedi.2011.25.1.41 Baranoff, J., Oei, T. P., Cho, S. H., & Kwon, S. M. (2006). Factor structure and internal consistency of the Young Schema Questionnaire (Short Form) in Korean and Australian samples. Journal of Affective Disorders, 93(1–3), 133–140. https://doi.org/ 10.1016/j.jad.2006.03.003

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Grunert, B. K., Weis, J. M., Smucker, M. R., & Christianson, H. F. (2007). Imagery rescripting and reprocessing therapy after failed prolonged exposure for posttraumatic stress disorder following industrial injury. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 317–328. https://doi.org/10.1016/j.jbtep.2007.10.005 Haeyen, S., van Hooren, S., van der Veld, W., & Hutschemaekers, G. (2018). Efficacy of Art Therapy in Individuals With Personality Disorders Cluster B/C: A Randomized Controlled Trial. Journal of Personality Disorders, 32(4), 527–542. https://doi.org/10. 1521/pedi_2017_31_312 Heilemann, M. V., Pieters, H. C., Kehoe, P., & Yang, Q. (2011). Schema therapy, motivational interviewing, and collaborative-mapping as treatment for depression among low income, second generation Latinas. Journal of Behavior Therapy and Experimental Psychiatry, 42(4), 473–480. https://doi.org/10.1016/j.jbtep.2011.05.001 Holmes, E. A., Lang, T. J., & Shah, D. M. (2009). Developing interpretation bias modification as a “cognitive vaccine” for depressed mood: Imagining positive events makes you feel better than thinking about them verbally. Journal of Abnormal Psychology, 118(1), 76–88. https://psycnet.apa.org/doi/10.1037/a0012590 Jacob, G. A., & Arntz, A. (2013). Schema therapy for personality disorders: A review. International Journal of Cognitive Therapy, 6(2), 171–185. https://doi.org/10.1521/ijct. 2013.6.2.171 Jacob, G. A., & Seebauer, L. (2013). Schematherapie: Fallvideos zu Persönlichkeitsstörungen und Suizidalität (English title: Schema therapy for personality disorders and suicidality). Beltz. Kellogg, S. (2014). Transformational chairwork: Using psychotheraputic dialogues in clinical practice. Rowman & Littlefield. Lobbestael, J., Arntz, A., & Sieswerda, S. (2005). Schema modes and childhood abuse in borderline and antisocial personality disorders. Journal of Behavior Therapy and Experimental Psychiatry, 36(3), 240–253. Lobbestael, J., van Vreeswijk, M., Spinhoven, P., Schouten, E., & Arntz, A. (2010). Reliability and validity of the short Schema Mode Inventory (SMI). Behavioural and Cognitive Psychotherapy, 38(4), 437–458. https://doi.org/10.1017/S1352465810000226 Lobbestael, J., van Vreeswijk, M. F., & Arntz, A. (2008). An empirical test of schema mode conceptualizations in personality disorders. Behaviour Research and Therapy, 46(7), 854–860. https://doi.org/10.1016/j.brat.2008.03.006 Malogiannis, I. A., Arntz, A., Spyropoulou, A., Tsartsara, E., Aggeli, A., Karveli, S., Vlavianou, M., Pehlivanidis, A., Papadimitriou, G., & Zervas, I. (2014). Schema therapy for patients with chronic depression: A single case series study. Journal of Behavior Therapy and Experimental Psychiatry, 45(3), 319–329. https://doi.org/10.1016/ j.jbtep.2014.02.003 Masley, S. A., Gillanders, D. T., Simpson, S. G., & Taylor, M. A. (2012). A systematic review of the evidence base for Schema Therapy. Cognitive Behaviour Therapy, 41(3), 185–202. https://doi.org/10.1080/16506073.2011.614274 Morina, N., Lancee, J., & Arntz, A. (2017). Imagery rescripting as a clinical intervention for aversive memories: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 55, 6–15. https://doi.org/10.1016/j.jbtep.2016.11.003 Nadort, M., Arntz, A., Smit, J. H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., van Asselt, T., Wensing, M., & van Dyck, R. (2009). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: A randomized trial. Behaviour Research and Therapy, 47(11), 961–973. https://doi.org/10.1016/j.brat.2009.07.013 Nilsson, J. E., Lundh, L. G., & Viborg, G. (2012). Imagery rescripting of early memories in social anxiety disorder: An experimental study. Behaviour Research and Therapy, 50(6), 387–392. https://doi.org/10.1007/s11920-020-1139-4

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Nordahl, H. M., & Nysaeter, T. E. (2005). Schema therapy for patients with borderline personality disorder: A single case series. Journal of Behavior Therapy and Experimental Psychiatry, 36(3), 254–264. https://doi.org/10.1016/j.jbtep.2005.05.007 Raabe, S., Ehring, T., Marquenie, L., Olff, M., & Kindt, M. (2015). Imagery rescripting as stand-alone treatment for posttraumatic stress disorder related to childhood abuse. Journal of Behavior Therapy and Experimental Psychiatry, 48, 170–176. https:// doi.org/10.1016/j.jbtep.2015.03.013 Reiss, N., Lieb, K., Arntz, A., Shaw, I. A., & Farrell, J. (2014). Responding to the treatment challenge of patients with severe BPD: Results of three pilot studies of inpatient schema therapy. Behavioural and Cognitive Psychotherapy, 42(3), 355–367. Renner, F., Arntz, A., Peeters, F. P., Lobbestael, J., & Huibers, M. J. (2016). Schema therapy for chronic depression: Results of a multiple single case series. Journal of Behavior Therapy and Experimental Psychiatry, 51, 66–73. https://doi.org/10.1016/j. jbtep.2015.12.001 Rijkeboer, M. M., & Lobbestael, J. (2012, May 17–19). The relationships between early maladaptive schemas, schema modes, and coping styles: An empirical study. In M. M. Rijkeboer (Chair), Assessment of schema concepts and their interrelationships [Symposium]. International Society of Schema Therapy, ISST-Conference, NY, United States. Roelofs, J., Muris, P., van Wesemael, D., Broers, N. J., Shaw, I., & Farrell, J. (2016). GroupSchematherapy for Adolescents: Results from a Naturalistic Multiple Case Study. Journal of Child Family Studies, 25, 2246–2257. https://doi.org/10.1007/s10826-0160391-z Sempertegui, G. A., Karreman, A., Arntz, A., & Bekker, M. H. (2013). Schema therapy for borderline personality disorder: A comprehensive review of its empirical foundations, effectiveness and implementation possibilities. Clinical Psychology Review, 33(3), 426–447. https://doi.org/10.1016/j.cpr.2012.11.006 Simpson, S. G., Morrow, E., van, V. M., & Reid, C. (2010). Group schema therapy for eating disorders: A pilot study. Frontiers in Psychology, 1, 182. https://doi.org/10.3389/ fpsyg.2010.00182 Specht, M. W., Chapman, A., & Cellucci, T. (2009). Schemas and Borderline Personality Disorder symptoms in incarcerated women. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 256–264. https://doi.org/10.1016/j.jbtep.2008.12.005 Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooiman, K., & Arntz, A. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75(1), 104–115. https://doi.org/10.1037/0022-006X.75.1.104 Tan, Y. M., Lee, C. W., Averbeck, L. E., Brand-de Wilde, O., Farrell, J., Fassbinder, E., Jacob, G., Martius, D., Wastiaux, S., Zarbock, G., & Arntz, A. (2018). Schema therapy for borderline personality disorder: A qualitative study of patients’ perceptions. PLOS ONE, 13(11), e0206039. https://doi.org/10.1371/journal.pone.0206039 Thiel, N., Jacob, G. A., Tuschen-Caffier, B., Herbst, N., Kulz, A. K., Hertenstein, E., Nissen, C., & Voderholzer, U. (2016). Schema therapy augmented exposure and response prevention in patients with obsessive-compulsive disorder: Feasibility and efficacy of a pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 52, 59–67. https://doi.org/10.1016/j.jbtep.2016.03.006 Thimm, J. C. (2010). Mediation of early maladaptive schemas between perceptions of parental rearing style and personality disorder symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 41(1), 52–59. https://doi.org/10.1016/j.jbtep.2009.10.001 van Asselt, A. D., Dirksen, C. D., Arntz, A., Giesen-Bloo, J. H., van Dyck, R., Spinhoven, P., van Tilburg, W., Kremers, I., Nordot, M., & Severens, J. (2008). Out-patient psychotherapy for borderline personality disorder: Cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. British Journal of Psychiatry, 192(6), 450–457. https://doi.org/10.1192/bjp.bp.106.033597



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van Wijk-Herbrink, M. F., Bernstein, D. P., Broers, N. J., Roelofs, J., Rijkeboer, M. M., & Arntz, A. (2018). Internalizing and externalizing behaviors share a common predictor: The effects of early maladaptive schemas are mediated by coping responses and schema modes. Journal of Abnormal Child Psychology, 46(5), 907–920. https://doi.org/10.1007/s10802-017-0386-2 van der Wijngaart, R., & Bernstein, D. (2010). Schema therapy: Working with modes. Science Vision. van der Wijngaart, R. & Sijbers, G. (2016). Schema therapy: Avoidant, dependent and obsessive compulsive personality disorder. Science Vision. van Vreeswijk, M., Broersen, J., & Nadort, M. (Eds.). (2012). The Wiley-Blackwell handbook of schema therapy. Theory, research, and practice. Wiley. Videler, A.C., Alphen, S.P.J. Rita J.J. van Royen, R.J.J., van der Feltz-Cornelis, C.M., Rossi, G. & Arntz, A. (2018). Schema therapy for personality disorders in older adults: a multiple-baseline case series study. Aging and Mental Health, 22(6), 738–747. https://doi.org/fh5s Weertman, A., & Arntz, A. (2007). Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: A controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behaviour Research and Therapy, 45(9), 2133–2143. https://doi.org/10.1016/j.brat.2007.02.013 Wetzelaer, P., Farrell, J., Evers, S., Jacob, G. A., Lee, C. W., Brand, O. van Breukelen, G., Fassbinder, E., Fretwell, H., Harper, R. P., Lavender, A., Lockwood, G., Malogiannia, I. A., Schweiger, U., Startup, H., Stevenson, T., Zarbock, G., & Arntz, A. (2014). Design of an international multicentre RCT on group schema therapy for borderline personality disorder. BMC Psychiatry, 14(1), 319. Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S. (2007). “I’ll believe it when I can see it”: Imagery rescripting of intrusive sensory memories in depression. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 371–385. https://doi.org/10.1016/j.jbtep.2007.08.005 Wild, J. & Clark, D. M. (2011). Imagery rescripting of early traumatic memories in social phobia. Cognitive and Behavioral Practice, 18(4), 433–443. https://doi.org/10. 1016/j.cbpra.2011.03.002 Wild, J., Hackmann, A., & Clark, D. M. (2008). Rescripting early memories linked to negative images in social phobia: A pilot study. Behavior Therapy, 39(1), 47–56. https://doi.org/10.1016/j.beth.2007.04.003 Yakin, D., Grasman, R., & Arntz, A. (2020). Schema modes as a common mechanism of change in personality pathology and functioning: Results from a randomized controlled trial. Behavior Research and Therapy, 126, 103553. https://doi.org/10.1016/j. brat.2020.103553 Young, J. E., Klosko, S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.

18 Dialectical Behavior Therapy Hollie F. Granato, Amy R. Sewart, Meghan Vinograd, and Lynn McFarr

D

ialectical behavior therapy (DBT) is a transdiagnostic, comprehensive, multimodal treatment developed by Marsha Linehan to treat individuals experiencing severe emotion dysregulation (Linehan, 1993). Since the time of its development, research has consistently supported DBT as an efficacious treatment for emotion dysregulation broadly, as well as specifically for high suicidality and symptoms related to borderline personality disorder (BPD; for a review, see Panos et al., 2014). This chapter seeks to provide a broad overview of DBT, ranging from a description of how the treatment is structured to a review of the state of research supporting the efficacy and effectiveness of DBT at the time of writing. In particular, this chapter focuses in on five separate areas related to DBT: (a) a brief review of the history and theory underlying the treatment, (b) a description of the treatment modalities and structure of DBT, (c) a discussion of the current research supporting DBT and the various populations for which it may be useful, (d) suggested mechanisms of change, and finally (e) the current status and future directions toward dissemination of this treatment.1

HISTORY AND DIALECTICS DBT was initially developed as a cognitive behavioral therapy (CBT) based on the principles of behaviorism (Bandura, 1986) and social learning theory Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-018 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  539 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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(Staats, 1975) and grounded in biosocial theory (Shearin & Linehan, 1994). While the earliest practice of DBT focused on reducing suicidal behaviors and helping individuals build a “life worth living,” the initial clinical trials required grant funding for treatment outcome research focused on a specific mental disorder diagnosis rather than the behavior of suicide. This led to DBT’s early association with BPD, a diagnosis often associated with suicidal behavior, as participants in these trials were recruited both for chronic suicidality and for meeting criteria for BPD (Leichsenring et al., 2011). BPD can be a debilitating disorder and is often associated with instability in affect, relationships, and behaviors, as well as suicide and nonsuicidal self-injury (Klonsky, 2007; Lieb et al., 2004). In fact, between 65% and 80% of clients diagnosed with BPD report engaging in self-injury without the intent to die (Brickman et al., 2014; Soloff et al., 1994). Therefore, an interesting historical element of DBT is that it was initially developed broadly for individuals experiencing chronic suicidal behavior and severe emotion dysregulation and not just those who met criteria for BPD. Existing research has demonstrated that individuals with a wide range of diagnoses associated with emotion dysregulation, and not just those with diagnoses of BPD, show improvements following DBT treatment and perhaps presaged the current move toward processes rather than diagnostic targets for cognitive and behavioral treatment (Barlow et al. 2011; Hayes & Hofmann, 2018). Due to the life-threating nature of chronic suicidality, the early focus of DBT was primarily on problem-solving strategies and helping clients facilitate change in their lives. However, as has been the experience among treatment professionals working with suicidal clients for many years, Linehan found that a primary focus on problem solving resulted in clients often feeling invalidated and frustrated. At times, this led clients to end treatment early, without implementing the change strategies emphasized in therapy (Linehan, 1993). Likewise, an emphasis on cognitive strategies that targeted distorted and unrealistic thinking also prompted invalidation and a sense from clients, “see, I am the problem.” Subsequently, DBT developers began to shift toward an approach focused on validation, warmth, and acceptance of the client’s presenting problems, often drawing from principles found in Zen practice. With this shift, however, DBT therapists as well as the early DBT clients found that the clients’ problems were not being resolved. It became clear that this need for both change and acceptance was one of the early dialectics, defined as a style of arguing in which two seemingly opposing truths are determined to be equally valid, resulting in the exploration of a synthesis that honors both (Linehan, 1995; Shearin & Linehan, 1989). In treating high-risk clients, therapists found themselves stuck between two poles or truths, one of needing to accept the client and one of needing to change the client. Neither the change nor the acceptance strategy alone was enough to comprehensively address the complex pain of chronically suicidal clients’ lives as they were currently being lived, yet each was profoundly important in treatment. Therefore, it was at this time that Linehan (1993) attempted a synthesis between these two different elements through the inclusion of a dialectical



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philosophy. Dialectics is a philosophy and study of inquiry that suggests that there can be truth in two opposing concepts (e.g., there is truth in change and there is truth in acceptance). Drawing from the philosophy of dialectics, the goal is to come to a synthesis of the opposing positions, which honors the truth in each perspective. Interestingly, this is ultimately a cognitive process that requires flexible thinking. Thus, DBT rests on three frames: behavioral science, Zen practice, and a dialectical philosophy. The spirit of these three pillars is synthesized in four different aspects of treatment: (a) the technology of change and technology of acceptance; (b) a spaciousness of the therapist’s mind as they “dance” with the client’s behavior in session using movement, speed, and flow; (c) the therapist’s radical acceptance of the client exactly as they are, as well as the fact that progress may be slow and episodic with a constant suicide risk; and finally (d) the therapist’s humility to conceptualize the transactional nature between themselves and the client. By synthesizing these four aspects in treatment, Linehan began to develop DBT as a treatment that at its core balanced the essential dialectic between encouraging change among clients while facilitating an accepting environment for the client by validating their experience (Linehan, 1995). It was also through this dialectical synthesis that the nature of how clients develop chronic and severe emotion dysregulation was conceptualized, and a focus on facilitating the client’s acceptance of themself while committing to change was manifested in DBT treatment.

BIOSOCIAL MODEL AND UNDERLYING THEORY The dialectical synthesis gave rise to a model for understanding emotion dysregulation among clients diagnosed with BPD. This model, known as the biosocial model of emotion dysregulation, seeks to synthesize the relationship between a client’s biological vulnerabilities for emotion dysregulation and their environmental learning history (Linehan, 1987; Shearin & Linehan, 1994). In terms of biological vulnerabilities, it is possible that a biological disposition for sensitivity to emotions, disproportionate emotional reactions, and a slow return to baseline following an emotional experience may contribute to an individual developing later emotion-regulation difficulties. However, these biological vulnerabilities alone are not enough for a client to develop emotion dysregulation, in part because the way in which an individual’s environment responds to these experiences may vary. For clients with severe emotion dysregulation, such as those who develop chronic suicidality and BPD, it is the transaction between these biologically driven experiences and an invalidating environment. This theory specifically posits that when individuals with this biological vulnerability express emotions, an invalidating environment (a) ignores emotional expression, (b) oversimplifies problem solving, and (c) intermittently reinforces emotional expression that may be extreme or ineffective (Linehan, 1993). At the extreme end, severe invalidation also encompasses abuse and neglect experiences. For a more in-depth discussion of the biosocial theory, see Linehan (1993).

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The nature of this invalidation can range from severe childhood abuse to a mismatch with a family that has lower or higher emotional reactivity than the individual (Linehan, 1993; Sauer & Baer, 2010). This invalidation of people’s emotional experiences can lead them to discount their own emotions, learning over time that they cannot trust their emotional experience. Ultimately, individuals learn to escalate their expression of emotions in order to communicate to the environment the seriousness of what they are experiencing. The environment then is likely to intermittently reinforce the escalation, which increases the likelihood of further communication behaviors. In terms of emotion dysregulation, this may begin with self-invalidation and ultimately lead the individual to engage in suicidal behavior as an attempt to problem solve emotional experiences that the environment has told the individual are invalid and which the environment has failed to educate the individual about how to regulate. This dialectic highlights the polarized transaction that can pit an individual’s biological experience of emotions against the environment and that contributes to the synthesis in DBT focusing on both increasing the client’s skills for managing their biological vulnerability to emotions and helping the client learn to navigate an invalidating environment (Linehan, 1993; Robins, 2002). This requires acceptance on the part of both the therapist and the client around the client’s predisposition for emotional reactivity and an environment that may respond ineffectively to this predisposition. It also requires problem solving with skills that can help clients both change their emotional experiences and intervene to shape this transaction with the environment over time such that they can foster a life worth living. This is accomplished through a skills-based approach to treatment that is behaviorally targeted and emphasizes consultation to both the client and the therapist.

OVERVIEW OF TREATMENT DBT consists of four major treatment components, referred to as modes of treatment: individual therapy (which functions to improve clients’ motivation), skills group (which functions to enhance clients’ capabilities), between-session phone coaching (which functions to ensure generalization to each client’s environment), and consultation team for the therapist (which functions to enhance therapists’ capabilities and motivation to treat clients effectively). The client participates in the first three treatment modes, and the therapist participates in all four treatment modes. DBT is also divided into multiple stages including (a) pretreatment, involving four sessions where a client commits to treatment; (b) Stage 1 treatment, often involving a 1-year commitment from clients, which targets behavioral dysregulation by focusing on stability and behavioral control; (c) Stage 2 treatment, which often addresses comorbid diagnoses using a time-limited evidence-based treatment and targets “quiet desperation” by focusing on normative emotional experiencing and expression; (d) Stage 3 treatment, which targets problems in living by focusing on ordinary happiness



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and unhappiness; and (e) Stage 4 treatment, which targets incompleteness by focusing on the client developing a capacity for sustained joy and freedom. “Standard DBT” typically refers to pretreatment and Stage 1 treatment. For the purpose of this chapter, we provide an overview of Stage 1 of DBT treatment. However, it is important to note that after clients have completed Stage 1 treatment, they may engage in another empirically supported treatment based on the goals of the client and their comorbid diagnoses, such as CBT for social anxiety disorder. During this time, the client may continue aspects of DBT treatment, such as the diary card (described later); sessions during later stages of DBT treatment often resemble prototypical CBT sessions. Individual Therapy Individual therapy sessions in the outpatient setting typically occur on a weekly basis and last between 45 and 60 minutes. It may be appropriate for some clients to have sessions more than once per week or meet for longer sessions, between 90 and 120 minutes, depending on the goals of the session (see Linehan, 1993). Individual therapy begins with pretreatment, which is typically four sessions in duration. There are several goals of pretreatment. One of the most important is assessing and building the client’s commitment to entering DBT. Given that most clients commit to completing at least 6 months of DBT, and because DBT is relatively intensive due to its multiple components, it is important to conduct a thorough assessment of the client’s readiness for treatment. Clients can present for treatment with varying levels of commitment, from those who report a belief that they do not need treatment to those who are eager to begin. For individuals who demonstrate a relatively low level of commitment during pretreatment, various commitment strategies may be used. These strategies include playing devil’s advocate, foot in the door, door in the face, and freedom to choose/ absence of alternatives (Linehan, 1993). In playing devil’s advocate, for example, the therapist takes an opposing side to what they are asking the client to do. The therapist might argue against treatment commitment, asking the client why they are choosing to engage in a highly intense and involved treatment, or if they have the energy and motivation to go through with this commitment. Other goals of pretreatment include a thorough explanation of the components of DBT, an explanation of the biosocial model of BPD (if applicable), a collaborative discussion about the client’s treatment goals, and rapport building between the therapist and client. Starting in the first session, the therapist must begin to establish a solid relationship with the client. A positive therapist–client relationship is crucial because the therapist may be the only reinforcer that can help a client change their behavior (Linehan, 1993, p. 98). For individuals who are actively suicidal or engaging in self-harm behaviors, pretreatment will also focus on harm reduction and on building clients’ commitment to stay alive. Before Stage 1 treatment can begin, both the client and therapist must agree to several treatment agreements. This can be done orally, but a written treatment

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contract may also be used. Client agreements include a 1-year therapy agreement, an attendance agreement, a suicidal behaviors agreement, a therapyinterfering behaviors agreement, and a skills training agreement. The 1-year therapy agreement states that the client and therapist will typically work together for at least 1 year (although recent studies suggest that, for some clients, 6 months may be sufficient; Rizvi et al., 2017; Stanley et al., 2007) and renew their commitment to working together on a yearly basis or until the client has met their treatment goals. Additionally, the client agrees that termination of treatment will occur after four consecutive misses of either individual therapy sessions or skills group meetings. Under this agreement, the client also agrees that the therapist can terminate treatment with the client in the event that the therapist believes that they can no longer help the client, possibly because they have been pushed beyond their limits. It is, however, the responsibility of the therapist to alert the client before termination occurs in order to give the client a chance to alter their behavior. The attendance agreement states that the client will attend all scheduled individual therapy and skills group sessions. The suicidal behaviors agreement consists of the client agreeing to work toward solving their problems using means other than suicidal or self-harm behaviors. Similarly, the therapy-interfering behaviors and skills training agreements consist of the client agreeing to address any therapy-interfering behaviors that may arise during treatment and to make efforts to learn the DBT skills through attendance at a skills group. Therapist agreements include an every-reasonable-effort agreement, an ethics agreement, a personal contact agreement, a respect-for-client agreement, a confidentiality agreement, and a consultation agreement. The every-reasonableeffort agreement states that the therapist will exert maximal effort in helping the client learn new skills for handling their problems effectively, while acknowledging that the therapist cannot solve the client’s problems. The ethics agreement states that the therapist will follow standard ethical guidelines in the treatment of the client. The personal contact agreement consists of the therapist agreeing to come to every scheduled session and to reschedule as needed, as well as be available for phone coaching during a predetermined timeframe. The respect-for-client agreement states that the therapist will respect the rights of the client. The confidentiality agreement states that the therapist will only discuss the content of the client’s treatment within the DBT consultation team, while noting that confidentiality may be broken in the event that the client may be a danger to themself, a danger to others, or under mandated reporting circumstances. Finally, under the consultation agreement, the therapist agrees to seek consultation from other members of the DBT consultation team as needed in order to provide the best possible care for the client. After the goals of pretreatment have been met, Stage 1 treatment commences. Treatment sessions begin with the therapist reviewing the client’s diary card from the previous week. On the diary card, the client tracks their emotions, urges, use of skills, and occurrence of target behaviors since the previous individual therapy session. Target behaviors are behaviors that the client would



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like to either increase or decrease based on their treatment goals. These targets are highly individualized to the client’s goals and case conceptualization. For example, one client may focus on tracking the number of times they engaged in binge eating each day, whereas another client may focus on time spent looking at an ex-romantic partner’s social media account. Importantly, the diary card also asks clients to track suicidal and self-injury behaviors to aid the therapist in structuring the therapy session. Upon reviewing the diary card, the therapist sets an agenda for the session. Sessions are structured around a treatment hierarchy, with information from the diary card used to guide which level of the hierarchy needs to be addressed to begin the session. First, life-interfering behaviors, including suicide attempts, suicidal ideation, and self-injury, are addressed. Second, therapyinterfering behaviors are addressed. These behaviors can include missing individual therapy sessions or skills group meetings, arriving late to appointments, and not having completed their diary card or skills group homework. Interpersonal difficulties between the client and therapist can also be addressed as therapy-interfering behaviors, as are therapy-interfering behaviors of the therapist (e.g., being late to session, not returning phone calls). Third, quality-oflife interfering behaviors are addressed. These behaviors are typically, though not always, related to the target behaviors tracked on the diary card. The fourth and final treatment target is the consolidation of skills as learned in skills group. The rationale for this treatment hierarchy is that above all else, clients must remain alive in order to receive treatment (Level 1 of the hierarchy addressing life-threatening behaviors), and following that, a client must remain actively involved in treatment in order for treatment to work (Level 2 of the hierarchy addressing therapy-interfering behaviors) before the client and therapist can begin addressing targets that are meaningful to and impacting the client’s current symptoms (Level 3 of the hierarchy addressing quality-of-life interfering behaviors) and then finally they can focus on consolidating and practicing skills use (the final treatment target). After the hierarchy is used to select a specific behavior, the therapist and client complete a functional analysis of a specific behavior (hereafter referred to as a chain analysis) in order to gain a thorough understanding of the antecedents and consequences of the behavior in question. The chain analysis includes a step-by-step account of the thoughts, emotions, and physical sensations that led to the occurrence of a (typically) problematic behavior, as well as the explicit identification of its consequences in order to determine whether these consequences are possibly reinforcing the behavior. After the completion of a chain analysis, a solution analysis is used to determine at which point in the chain of events preceding and following the problematic behavior the client may have been able to use skills to reduce the likelihood of the problematic behavior occurring, either at the time that the event occurred or in the future. The therapist then guides the client in developing a specific plan to avoid the problem behavior in the future, troubleshoots the plan, and works to obtain a commitment from the client to enact the plan. It is important to note that case

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management, which functions to help clients structure their environment, is also targeted in individual therapy. Often, the environment’s impact is considered within the chain analysis, and the therapist strives to apply dialectical strategies, including acceptance and problem solving, to consult with clients on changing their environment. It is rare that a DBT therapist would directly intervene on a client’s behalf unless absolutely necessary. In addition to the target behaviors included on the diary card, secondary targets also help guide the therapist in conceptualizing the client’s symptoms in Stage 1 of DBT treatment. Secondary targets are dialectical dilemmas that clients with severe emotion dysregulation often find themselves experiencing (Linehan, 1993). These dialectical dilemmas can help both the therapist and client conceptualize the client’s target behaviors. The secondary targets specifically include three dialectical dilemmas: (a) the dilemma between the behavior of a person with high emotional vulnerability and engagement in selfinvalidation, (b) the dilemma between having a life with unrelenting crisis and experiencing inhibited grieving, and finally (c) the dilemma between “apparent competence” and active passivity. During treatment, the therapist and client may begin to conceptualize the client’s target behaviors as a reaction to being stuck in these common dilemmas related to emotion dysregulation. For example, within the first dilemma, clients may struggle to regulate their emotions while also telling themselves statements like “I should be able to do this” or “This isn’t a big deal; I shouldn’t be so upset.” Clients may switch back and forth between feeling high emotions and invalidating their experience, leaving them feeling stuck and unable to change. Likewise, clients may experience multiple significant life stressors (unrelenting chaos) that exacerbate each other (e.g., boyfriend stole wallet, therefore no gas to get to work, risks losing job, gets overwhelmed, uses drugs), which prompts intense emotions that decrease problem-solving capabilities, often resulting in more experiential avoidance and chaos. While in the midst of chaos, there is little time or few resources to process emotions or loss. The “flip side” of this dialectical dilemma is inhibited grieving, in which the client suppresses and blunts intense emotions related to difficult or even traumatic events. In apparent competence, clients overestimate their capabilities and ability to problem solve. As a result, both the client and the environment have unrealistic expectations. The flip side of apparent competence is active passivity, in which clients work hard to get the environment to regulate them, insisting and believing that they are not capable at all. When the therapist is able to highlight these dilemmas, clients can begin to manifest a dialectical approach in which they practice using skills to manage high emotional vulnerability while validating themselves when their emotions remain challenging and are painful, or seeking a “middle path” view of their capabilities. The goal of addressing these dialectical dilemmas is for the therapist to assist clients in understanding how their target behaviors make sense given the dilemma with which they are currently faced, while also assisting them to “walk a middle path” for each dilemma by using DBT skills.



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Skills Group Skills group is the second mode of DBT treatment. Whereas individual therapy in DBT is principle based in its focus on the treatment hierarchy, the skills group is a protocol-based component of DBT. Thus, with these two modes, DBT also strives to balance the dialectic between a treatment based on principles with a treatment based on a specific protocol. After clients have completed pretreatment, they join a skills group. Skills groups meet on a weekly basis and are typically co-led by two DBT therapists. Skills groups vary in their duration, but 1.5 to 2.5 hours (with a break) is typically sufficient for homework review and the presentation of new material. Groups can also vary in the number of clients; a group only needs two members to be conducted. Clients who cannot attend a skills group often complete individual skills training, either with the individual therapist or, preferably, with another DBT therapist. Of note, there are currently no studies on the effectiveness of individual skills training in a one-on-one format; however, it is routine practice in many settings to provide skills training in an individual format instead of the standard group format. There are four modules taught in skills group: Mindfulness, Emotion Regulation, Distress Tolerance, and Interpersonal Effectiveness. For an overview of the structure and content of skills groups, see the DBT Skills Training Manual (Linehan, 2014).

Phone Coaching Phone coaching is the third component of DBT treatment. As a part of DBT, the therapist makes themself available to the client for phone contact between sessions. There is a wide range of clinician availability, such that therapists range from 24/7 access to a set number of predetermined hours based on their own limits. Most clinical trials described in the literature offered 24/7 access to clinicians. There are three primary goals of phone coaching. The first goal of between-session phone coaching is to reinforce the client asking for help effectively. The second goal of phone coaching is to facilitate the generalization of skills to everyday life. Finally, the third goal of coaching calls is to address instances in which the client is feeling alienated from the therapist in order to reduce the likelihood of treatment dropout. After clients have attended a reasonable number of skills group sessions, they are instructed to attempt to use relevant skills before contacting the therapist for phone coaching. Phone coaching calls are highly targeted and focused on brief assessment and incorporation of a skill the client will use to address the situation, and they last approximately 10 to 15 minutes on average. It is crucial that clients are oriented to the function of phone coaching. Furthermore, phone coaching calls are always addressed in the next in-person individual therapy session. Any inappropriate use of phone coaching, such as calling the therapist but expressing willfulness around refusal to use skills, should be addressed in individual therapy as a therapy-interfering behavior.

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Consultation Team Consultation team, held on a weekly basis, is the fourth major component of DBT. Consultation team is meant to function as “therapy for the therapist” in light of the stress that can be associated with working with DBT clients, especially those who present with suicidal or self-injurious behaviors. Consultation team can be structured based on the specific needs of the therapists involved and centers on several agreements, including a dialectical agreement, a consultation-to-the-client agreement, a consistency agreement, an observing limits agreement, a phenomenological empathy agreement, and a fallibility agreement. It can be helpful to select one of these agreements to read aloud at the start of the consultation team meeting as a reminder. The dialectical agreement posits that members of the consultation team will seek to search for a synthesis when two opposing truths arise during consultation team meetings. The consultation-to-the-client agreement centers on the idea that therapists should guide clients in using skillful behavior in interacting with other members of their treatment team (e.g., a skills group leader) when issues arise, rather than the treating therapists discussing the issue amongst themselves. The consistency agreement states that inconsistencies in treatment delivery may arise within the DBT treatment team. The observing-limits agreement centers on the idea that each therapist is allowed to set their own limits as a therapist and that therapists will not judge one another about these limits. The phenomenological empathy agreement states that consultation team members will make nonpejorative interpretations of clients’ behavior. Finally, the fallibility agreement posits that all therapists are fallible and that problematic behaviors on the part of the therapist will be addressed using a balance of problem-solving strategies and validation within the consultation team. The primary function of team is not just to provide consultation for therapists on complex client conceptualizations but also, specifically, to increase motivation and willingness to treat high-risk clients. Therefore, therapists on the team are encouraged to help each other identify their own feelings related to a consultation question rather than tell the therapist what to do with a client. DBT Style Overarching all modes of DBT treatment is the style in which DBT is delivered. As DBT is a principle-based treatment, therapists are encouraged to find their own style with which to deliver it. There are, however, common stylistic approaches with which all DBT therapists are suggested to approach treatment. Ultimately, the goal of these stylistic strategies is to assist therapists in manifesting a balance between both change and acceptance strategies for clients, so that they are inherently dialectical. Specific examples of stylistic strategies used in DBT include irreverence, radical genuineness, validation, metaphors, paradoxical position, extension of the client’s position, and devil’s advocate. For example, irreverence might be strategically employed when a therapist reminds a client, “If you kill yourself, we can’t meet for treatment next week.” The inten-



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tion of using this strategy is to shift clients toward a different perspective when they may be feeling stuck or willful. Another example of a stylistic strategy in DBT may be when a therapist uses a metaphor of the client’s engagement with treatment while suffering being akin to climbing out of hell. The use of metaphors in DBT can facilitate the goal of teaching while allowing clients to have a readily available example to later conceptualize their symptoms or situation. Throughout treatment, therapists seek to provide validation to clients while pushing the client to change. Linehan published an expanded chapter on validation in Empathy Reconsidered: New Directions for Psychotherapy that may be useful for therapists in working toward manifesting the dialectic between both validation and problem solving in therapy (Bohart & Greenberg, 1997). Additionally, video material of expert therapists conducting DBT can be found on the Behavioral Tech website (https://behavioraltech.org/training/streaming/) and can provide helpful modeling for DBT stylistic strategies.

EFFICACY AND EFFECTIVENESS The specific outcomes emphasized in this chapter strive to represent outcomes ranging across the treatment hierarchy (i.e., life-threatening, therapy-interfering, and quality-of-life-related behaviors). It should be noted that although the majority of studies use the term “parasuicidal behaviors,” as mentioned earlier, among DBT therapists the term “nonsuicidal self-injury” (NSSI) is preferred, as NSSI does not assume intent of self-harm behaviors. For the purposes of remaining consistent with the research literature, we will use the broader term parasuicidal behaviors, herein defined as any deliberate, acute self-injurious behaviors, with or without suicidal intent, which may range from nonsuicidal self-injuring behaviors (e.g., cutting, burning, headbanging) to suicide attempts (Linehan et al., 1991), when it is consistent with the verbiage used by the authors a of particular randomized controlled trial (RCT). RCTs To date, there have been currently 21 RCTs conducted in eight different countries in support of standard DBT, supporting DBT’s efficacy in the treatment of BPD, BPD traits, NSSI, bipolar disorder, substance use disorders (SUD), eating disorders, depression, and PTSD (Courbasson et al., 2012; Harned et al., 2014; Safer et al., 2011; Van Dijk et al., 2013). In the first, an RCT of chronically suicidal women diagnosed with BPD, standard, 12-month DBT (n = 24) outperformed community-based treatment as usual (TAU; n  =  23) in reducing the likelihood of any parasuicidal behavior, lowering the medical risk of parasuicide attempts, and decreasing the number of medically treated parasuicide attempts observed during the treatment period (Linehan et al., 1991). Although treatment conditions did not differ in the amount of NSSI episodes observed, which may have consisted of either a single parasuicidal act or a cluster of acts

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that are repetitive or close in time (e.g., engaging in cutting multiple times during the course of one evening), those with parasuicidal behavior randomized to DBT had significantly fewer acts per year than those randomized to TAU. In addition, significantly more individuals in DBT maintained therapy with the same therapist for the entire year of treatment when compared with those in TAU. Demonstrating superior treatment retention, those in DBT stayed in individual therapy longer as compared with those individuals in TAU who received a new therapist at the beginning of the treatment, with a significant difference emerging at the 8-month time point. Those in TAU had more psychiatric days hospitalized per person than clients in DBT (mean days per year: DBT = 8.46, TAU = 38.86) and a higher number of admissions per person. No significant difference was found between the DBT and TAU conditions in the likelihood of being admitted for inpatient hospitalization at least once (36% and 55%, respectively). With regard to quality-of-life (QOL) outcomes, both groups were observed to have significant improvements from pretreatment to 12 months on measures of depression, hopelessness, reasons for living, and suicidal ideation, and no between-group differences were observed. A subsample of individuals who engaged in at least two instances of parasuicidal behavior within the 5 years before study recruitment and one instance within 8 weeks before study recruitment were later reanalyzed (DBT n = 13, TAU n = 13; Linehan et al., 1994). Within this subsample, individuals in DBT reported greater reductions in trait anger and more significant improvement in social and global functioning when compared with individuals in the TAU condition. Similar outcomes were replicated over the course of treatment and through the year-long follow-up period in a RCT comparing standard DBT (DBT— replication; DBT-R; n  =  52) with community treatment by selected experts (CTBE, n = 49) in chronically suicidal and self-injurious women diagnosed with BPD (Linehan et al., 2006). Therapists providing treatment in the CTBE condition were nominated by community mental health leaders, and the content of CTBE was not controlled by the research study. The observed rate of suicide attempts over the 2-year treatment and follow-up period for DBT-R was half that of CTBE (23.1% vs. 46%). In addition, the observed rate of suicide attempts carried out with the intent to die for DBT-R was half that of CTBE (5.8% vs. 13.3%). Furthermore, the mean proportion of individuals who attempted suicide for DBT-R (6.2%) was again half that of CTBE (12.2%). Both DBT-R and CTBE were effective in reducing the frequency of NSSI, and no between-group differences in rate of change was observed. The medical risk of suicide attempts or instances of intentional self-injury was significantly lower for DBT-R than CTBE, F(1,156) = 3.2, p = .04. Regarding therapeutic maintenance outcomes, the risk of dropping the first-assigned therapist and dropping out of therapy was significantly higher for CTBE than DBT-R. During the course of treatment, 42.9% of CTBE clients and 19.2% of DBT-R clients dropped out of therapy. In addition, individuals in DBT-R were admitted to psychiatric hospitalization for any reason (Year 1: 19.6% of individuals in DBT-R had at least 1 admission vs. 48.9% in CTBE, and Year 2: 23.4% in DBT-R vs. 23.7% in CTBE; F[1,92] = 6.0, p = .007) and specifically for suicidal ideation (Year 1: 9.8% of individuals in



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DBT-R had at least 1 admission vs. 35.6% in CTBE, and Year 2: 14.9% in DBT-R vs. 18.4% of CTBE subjects; F[1,92] = 7.3, p =.004) significantly less than those in CTBE. Similar to findings from Linehan et al. (1991), both treatment conditions had significant reductions in QOL measures, and no between-group differences emerged for self-reported depression, suicidal ideation, or reasons for living. Later, a study conducted by Sunseri (2004) found that engagement in DBT reduced overall hospitalizations for adolescent clients, an outcome with great financial implications for high-risk populations. Uncontrolled Trials Outcomes of DBT therapy programs conducted in uncontrolled, “real world” settings have been evaluated and also reflect notable treatment success. Currently, there have been 15 uncontrolled published studies in support of DBT, along with numerous other quasi-experimental and observational studies(see  https://behavioraltech.org/wp-content/uploads/2018/04/Non-RCTsResearch-Data-to-Date-2013.12-new-logo.pdf for a complete list). Comtois et al. (2007) examined the effectiveness of a comprehensive DBT program in a community mental health setting, Harborview Mental Health Services (HMHS DBT), that possessed minor modifications for this population (e.g., case and medication management). HMHS DBT was provided to individuals (96% women) who chronically self-injured or had a history of treatment failure. When compared with the year before treatment, significant reductions in number of medically treated self-injuries, psychiatric-related emergency room visits, median number of psychiatric inclient days, and number of crisis services engaged were observed at posttreatment. Notably, reduction in crisis service utilization resulted in a reduction of inclient charges from a median of $12,850 to $0. Findings from this study were compared with outcomes of RCTs, including the aforementioned Linehan et al. (1991; DBT) and Linehan et al. (2006; DBT-R) treatment trials. Within the initial treatment year, the percentage of individuals attempting suicide was highest for CTBE (46%), followed by HMHS DBT (41.7%), and DBT-R (23%). Similarly, the percentage of individuals who engaged in self-inflicted injury was highest for TAU (95.5%), followed by HMHS DBT (66.7%), and DBT (63.6%). In terms of psychiatric inclient hospitalization, 25% of individuals in HMHS DBT were hospitalized during the course of treatment, compared with 55% in TAU, 49% in CTBE, 36% in DBT, and 20% in DBT-R. In addition, the dropout rate for HMHS DBT was 24%, which outperformed TAU (58%) and CTBE (43%) and was similar to that of DBT (17%) and DBT-R (19%). Overall, these results speak favorably to DBT’s effectiveness outside a controlled research context. Summary For individuals diagnosed with BPD, DBT has consistently demonstrated significant, long-term reductions in NSSI behaviors and in frequency and

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duration of inclient hospitalizations during the course of and following treatment in both controlled and uncontrolled settings. These rate reductions more often than not significantly outperform TAU conditions. In addition, DBT consistently demonstrates superior therapeutic retention rates. Although DBT has also been uniformly successful in improving QOL outcomes, such as global and social functioning, anger, and drug use, whether or not these rates outperform TAU is inconsistent across studies. Overall, outcomes for DBT reflect a high level of efficacy, effectiveness, and promise for clients presenting with BPD and related symptomology (see https://behavioraltech.org for a comprehensive account of outcomes).

DBT AS A TRANSDIAGNOSTIC TREATMENT DBT is characterized as a transdiagnostic treatment, meaning that it is an approach that has significant positive outcomes across a wide variety of clinical presentations linked to emotion dysregulation, rather than only being a stand-alone treatment for BPD (Neacsiu et al., 2014; Ritschel et al., 2015). RCTs have found efficacy for chronically depressed older adults as well as evidence that DBT reduces overall depression and hopelessness in addition to NSSI and suicide attempts for an array of clinical conditions (for review see Robins & Chapman, 2004). At its core, DBT targets ineffective problem solving related to emotion dysregulation, which subsequently has resulted in a wide variety of clinical populations for whom DBT has been found to be an efficacious treatment (Miller, 2015). BPD and Comorbid Substance Use Individuals diagnosed with BPD frequently engage in problematic substance use, a significant QOL-interfering behavior, with some studies reporting that as many as 50.7% of individuals diagnosed with BPD report being diagnosed with a comorbid SUD diagnosis in the past 12 months (Grant et al., 2008; Trull et al., 2000). Psychotherapeutic treatments specifically targeting substance use such as alcohol use and prescription drug abuse have demonstrated worse outcomes in individuals with co-occurring BPD when compared with those without this additional diagnosis (e.g., Kosten et al., 1989). In one RCT, DBT adapted to address substance use in women with BPD (S-DBT, n = 12) was compared with community substance abuse or mental health counseling TAU (S-TAU, n = 15; Linehan et al., 1999). Those in S-DBT experienced a significantly higher proportion of abstinence days and clean urinalyses than S-TAU at most treatment and follow-up assessments. Although dropout rates were high for both conditions, discontinuing treatment was found to be higher for S-TAU than S-DBT. No between-group differences were observed pre- to posttreatment in parasuicidal episodes or in types and amounts of medical and inpatient psychiatric care. Of note, base rates for parasuicide in this study were low, and overall,



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participants demonstrated significant reductions in NSSI behavior over the course of the study. At the 16-month follow-up, however, individuals in S-DBT reported better QOL as measured by global and social functioning measures when compared with those in the S-TAU condition. Eating Disorders DBT has substantial research supporting its efficacy for eating disorders, with several RCTs showing significant improvement for individuals randomized to DBT compared with TAU for binge eating, bulimia nervosa, and purging (Hill et al., 2011; Safer et al., 2001, 2010; Telch et al., 2001). Additionally, Safer et al. (2017) have published a manual specifically focused on the adaptation of DBT for eating disorders and have found evidence in support of full-model DBT using these skills as an efficacious treatment for eating disorders (Chen et al., 2008). This treatment includes specific considerations about modifying the diary card as well as how skills could be tailored for the treatment of eating disorders. This research has highlighted that, related to the transdiagnostic use of DBT for disorders characterized by emotion dysregulation, DBT is particularly efficacious for eating disorders that coincide with more emotional dyscontrol such as binge eating disorder and bulimia nervosa (Safer et al., 2001; Telch et al., 2001). BPD and Comorbid PTSD Among individuals with BPD, there are extremely high rates of PTSD (Pagura et al., 2010), with rates of comorbid PTSD among individuals diagnosed with BPD ranging from 25% to 58% across studies (Scheiderer et al., 2015). Although DBT as a stand-alone treatment has not been shown to decrease PTSD symptom severity, increased use of DBT skills has been linked to increased functioning among those diagnosed with comorbid BPD and PTSD (Harned et al., 2014). One of the factors facing therapists in determining whether a client is ready for PTSD treatment is the client’s ability to tolerate challenging emotions. For individuals who are referred for DBT, the challenge may be that their PTSD symptoms could be driving their emotion dysregulation, and DBT alone may not be enough to address these underlying factors. Similarly, PTSD treatment alone may result in increased risk for suicidal behaviors due to heightened emotion dysregulation that can occur as a result of PTSD treatment. In response to this need, Harned et al. (2010) have developed a modification of DBT protocol for individuals who meet comorbid criteria for severe emotion dysregulation and PTSD. This protocol combines standard DBT with prolonged exposure (PE; Foa et al., 2007), a treatment with an extensive research base that has been consistently shown to reduce symptoms in individuals with PTSD (Powers et al., 2010). To date, among suicidal women with co-occurring BPD and PTSD, this protocol has demonstrated efficacy at reducing NSSI, suicidal behavior, and posttraumatic stress symptoms (Harned et al., 2012, 2014).

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Adolescents A growing area of research within the DBT literature is the efficacy of DBT for adolescents, with an adapted version of the DBT skills manual that has been published for use with teens (Rathus & Miller, 2014). To date, three RCTs have supported DBT’s efficacy for the treatment of suicidal as well as bipolar adolescents (Goldstein et al., 2015; Mehlum et al., 2014, 2016). Quasi-experimental studies have also consistently found significant positive outcomes in the implementation of DBT for this age group in inpatient, residential, and forensic settings (McCann et al., 2000). Additionally, several other RCTs are currently underway to further ascertain the efficacy of DBT with adolescents, as well as the efficacy of DBT for preadolescent children (Perepletchikova et al., 2017). Other Areas of Research In addition to the research mentioned in this section, studies have also suggested that DBT could be an efficacious treatment for incarcerated individuals (Bradley & Follingstad, 2003; McCann et al., 2000), individuals diagnosed with attention-deficit/hyperactivity disorder (Fleming et al., 2015; Hirvikoski et al., 2011), individuals with treatment-resistant depression (Harley at al., 2008), and university students with emotion dysregulation (Uliaszek et al., 2016). Specifically in support of DBT as a transdiagnostic treatment, Neacsiu et al., (2014) have found pilot RCT support for DBT’s efficacy for mixed anxious and depressed individuals exhibiting emotion dysregulation. As the field of research continues to grow, undoubtedly this list will expand, and we provide only brief insight into the mounting field of DBT research for other diagnoses and as a transdiagnostic treatment.

APPLICATION TO DIVERSE POPULATIONS To date, DBT is being implemented in over 25 countries on six different continents (Behavioral Tech, 2017). Additionally, although DBT was developed in the United States, at the time of the writing of this chapter, 12 RCTs have been conducted in other countries including Canada, the Netherlands, Australia, Great Britain, Spain, Germany, Sweden, and Norway. Specifically in studies conducted in Norway, Great Britain, Australia, and the Netherlands, DBT has been found to outperform TAU (Carter et al., 2010; Feigenbaum et al., 2011; Mehlum et al., 2014; Priebe et al., 2012; Verheul et al., 2003). However, much more research is needed to evaluate DBT cross-culturally, and there is currently a push within the research community to increase the evaluation of DBT not only among different cultural groups worldwide but also among diverse populations within the United States. Additionally, new research pathways have suggested the importance of studying DBT with transgender and gender-minority individuals (Sloan et al., 2017), and future research is needed in order to study the efficacy of DBT with other marginalized groups and diverse cultural groups



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within the United States. Although there is promising preliminary support for DBT’s effectiveness cross-culturally, empirical questions remain about potential cultural considerations in the translation and implementation of this treatment.

MECHANISMS OF CHANGE Due to the large and continually growing research base supporting the efficacy of DBT, researchers have now begun to turn their attention to the mechanisms of change within DBT that account for its efficacy. Mechanisms of change are defined as variables that mediate, or account for, the relation between a treatment and the outcomes it has for clients. Additionally, it is important that mechanisms of change be framed within a larger scientific knowledge base (Kazdin & Nock, 2003). To date, although numerous studies have evaluated the efficacy of DBT, few have focused specifically on the components within the treatment that facilitate change. This is a common phenomenon among evidence-based treatments and one for which there has been a call to action to address among preeminent researchers in the field. A review by Rudge et al. (2020) has produced one of the most comprehensive attempts to date to summarize the current state of outcomes research on DBT. Identifying 12 empirical studies on DBT meeting their criteria for outcomes research on mechanisms of change, they found that three broad themes emerged in the current outcomes literature: (a) emotional regulation/selfcontrol, (b) skills use, and (c) therapeutic alliance/investment in treatment. Lynch et al. (2006) have further proposed several mechanisms of change by which DBT exerts its impact on outcomes on the basis of biosocial theory of BPD proposed by Linehan (1993). These mechanisms relate to the reduction of ineffective action tendencies that are linked with emotion dysregulation (Chapman, 2006). Specifically, researchers have raised the possibility that the primary mechanism of change within DBT is related to the client increasing their engagement in functional and effective behavior, even when strong emotions are occurring (Linehan et al., 2007). In support of this proposition, two RCTs have found that skills group alone might be effective for symptom reduction and partially mediate treatment outcomes (McMain et al., 2017; Neacsiu et al., 2010; Soler et al., 2009). Therefore, although much more research is needed to clarify which mechanisms impact symptoms among individuals receiving DBT, there is preliminary evidence to suggest that emotion regulation/self-control as well as increased skill usage may be key mechanisms of change unique to DBT, in support of the biosocial theory (Linehan, 1993 Lynch et al., 2006). It will be important for future research to home in on the skills that are most strongly associated with improvement in outcomes of interest, as well as the unique role that both dialectics and validation strategies have on treatment outcomes. Additionally, although research has found therapeutic alliance and investment in treatment to be common factors across therapy modalities (Horvath & Luborsky, 1993),

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the review by Rudge et al. (2020) further emphasizes the importance this may serve in DBT as a potential mechanism of change. It will be important for future research to assess what skills map onto changes in emotion dysregulation and self-control, as well as the way in which DBT style could uniquely relate to therapeutic alliance. Although it is clear at this time that DBT has shown great efficacy and effectiveness in treating a variety of diagnoses, it will be imperative for the field to understand the process by which this happens in order to more strategically refine symptom reduction across problems associated with emotion dysregulation.

DISSEMINATION AND TRAINING IN DBT Because of the demonstrated efficacy of DBT in controlled research settings, there is an increased emphasis on the dissemination and implementation of DBT into different clinical settings. To date, however, only six studies have been published specifically on the dissemination of DBT (Behavioral Tech, 2017). The American Psychological Association (2006) has outlined that clinical utility specifically includes ease of dissemination, and as a complex and time-intensive treatment for clients enrolled in DBT, it is equally a complex and time-intensive commitment for students endeavoring to gain competency in the treatment. Whereas protocol-based treatments may be quickly adapted via session-bysession guide, the principle-based nature of DBT necessitates a depth of understanding in the model in order to achieve competency. The current DBT certification process offered within the United States suggests allotting up to 2 years of training time in order to meet the current standard for certification in this treatment (Behavioral Tech, 2017). Additionally, this may be further complicated by the diverse theoretical background clinicians may have coming into learning about DBT. Promisingly, an early study conducted by Hawkins and Sinha (1998) found that frontline clinicians from diverse backgrounds (e.g., social work, psychology, medical fields) demonstrated acquisition of mastery in DBT through a community mental health setting. Since that time, research has found further support for the training of medical residents in DBT, as well as evidence for positive training outcomes when using tech-based trainings for DBT (Brodsky et al., 2017). The current implementation research on DBT also lends itself to understanding the needs of DBT dissemination. A study conducted by Swales et al. (2012) found support for the sustainability of a DBT training to therapists, and qualitative research has highlighted the need for administrative support and organizational investment in DBT in order to foster successful implementation within community settings. Additionally, as training is time intensive, a time commitment is required on the part of therapists to obtain adequate training, supervision, consultation, and a supportive environment of the clinical team to support therapists (Carmel et al., 2014). Although more research is needed into the most cost-effective and efficient way to train therapists and support new



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DBT teams, clinicians can currently seek DBT certification through DBT-LBC (Behavioral Tech, 2017), an organization started by Linehan to foster and support the dissemination of DBT. Additionally, resources for obtaining training in DBT are available through this organization. Although preliminary research has suggested that DBT is, in fact, a treatment to be implemented in a wide variety of settings and with clinicians from varied backgrounds, there is still much for us to learn about the next steps in disseminating DBT across professions and settings. Additionally, as DBT continues to extend to a global population, it will be necessary to examine the most effective way to disseminate as well as culturally translate DBT across cultures.

CASE EXAMPLE Presenting Problems Jane, the client example used in this case study, is a female-identified, European American, cisgender, heterosexual individual in her late 20s. She was referred to the clinic after recent suicidal behavior during which she took an overdose of her prescribed psychiatric medication and presented to the emergency room. At the time of her intake, she was assessed for BPD using the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD; First et al., 2016) and endorsed eight of the nine criteria for BPD. Jane expressed an interest in receiving treatment for her emotional dysregulation at this time, and pretreatment commenced. Biosocial Model and Relevant History Jane was oriented to the biosocial model during pretreatment and endorsed biological vulnerability including (a) experiencing strong emotional reactions throughout her life that (b) were easily prompted by a variety of stimuli and (c)  were slow to return to baseline. Related to an invalidating environment during childhood, she reported that she was sexually abused when she was approximately 11 years old by a distant family relative who was staying in her family home for a short time while the relative was homeless. She noted that her family did not believe her when she told them and that they have never discussed or addressed her abuse, a significant example of emotional expression being directly invalidated and ignored. Additionally, Jane described that her parents as well as her older brother would frequently tell her that she was “too sensitive” and “needed to toughen up” when she expressed a strong emotional reaction, reporting that she became tearful easily as a child and was frequently asked why she could not be more like her brother. This example described by the client characterizes oversimplification of problem solving. She further noted that the only time she felt any care from her parents was when she was hospitalized in college for her first suicide attempt, an example of her emotional expression only being responded to in a more severe form (intermittent reinforcement).

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Treatment Individual Jane identified in pretreatment that her life-worth-living goal is to have a community she can rely on, a career she enjoys, confidence in herself, and a stable romantic relationship. Stemming from this overarching life-worth-living goal, the treatment hierarchy was applied to the client’s treatment goals. The client’s life-threatening behaviors were the first target of treatment, including current self-harming behavior of scratching her arm with her fingernail when she was distressed (approximately once per day) and high urges to die (client rating urges to die a 4 on a 0- to 5-point Likert scale, with 0 being lowest urges) on the diary card approximately once per week. It was determined via functional analysis over the course of treatment that vulnerability factors for Jane included alcohol use, specific prompting events were situations where she interpreted that she was being socially rejected, and consequences of the scratching and suicidal thoughts (which increased overall suicidal urges) were relief from shame. Therapy-interfering behaviors, the second hierarchy target of treatment, were identified as the client avoiding skills group when her homework was incomplete, not participating in group, and not calling the therapist for phone coaching when distressed. It was determined via functional analysis over the course of treatment that these behaviors also served the function of avoidance of shame. For the third hierarchy level of treatment, QOL-interfering behaviors, she identified reducing substance use (alcohol and marijuana), decreasing avoidance symptoms related to social anxiety, and decreasing acting on angry urges during interpersonal situations. Further assessment determined that she met criteria for social anxiety disorder. Therefore, once the first two levels of the treatment hierarchy had been addressed, she engaged in a manualized CBT protocol for social anxiety within the context of DBT treatment. Phone Coaching Initially, Jane did not contact the therapist for phone coaching within the first month of treatment. Using a chain analysis during individual therapy, it was determined that calling the therapist to ask for help prompted shame for her. She practiced skills to soften her shame in order to increase contacting the therapist, and she engaged in a practice phone call once during the week when she was not in distress, initially texting the therapist to call her when she needed coaching. After approximately 3 months, the client was calling the therapist for phone coaching once per week on average and reported that her shame around phone coaching had decreased completely. The client primarily called when she was in high distress related to situations in which she interpreted that she was being socially rejected. Examples included not receiving interest from potential dating partners in which she expressed interest on a dating application, not being invited to a work happy hour with several of her coworkers, and being reprimanded for a mistake in a meeting at work. During the final 2 months of treatment, she and her therapist collaboratively identified ways to decrease phone coaching, such as by consulting a list of skills she could use during an upsetting situation and later sharing her success in individual



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therapy. The function of this intervention was to shape her toward increasing her practice of using skills independently without prompting from the therapist as she ended treatment. Group Jane completed 1 year of skills group and successfully “graduated.” Twice during treatment, she was close to missing four consecutive therapy meetings via not attending skills group (see the earlier “Individual Therapy” section for description of treatment agreements). This behavior was targeted in individual therapy, as well as by having the group leaders contact her to connect with her and problem solve group attendance. It was determined in consultation team (see below) that the client’s avoidance of shame was impacting group attendance. As shame related to group was strategically targeted in individual therapy over the course of treatment, group attendance improved. Additionally, group leaders targeted shame in group by increasing their attempts to build rapport with the client (e.g., engaging her in conversation briefly after group, commenting on how happy they are to have her in group), by engaging her in group by asking her specific questions and validating her, and by shaping her attendance through initially reinforcing her for engaging in opposite action to shame when she attended group without her homework. Consultation Team The consultation team facilitated discussion around developing a collaborative contingency plan for the group leaders and the individual therapist related to the function of Jane’s behaviors in both individual therapy and skills group. For example, the group leaders identified in consultation team that they observed a tendency to “fragilize” the client (i.e., treating the client as not capable of handling their emotions or problems) by not calling on her to answer a question and not asking her what got in the way of her doing her homework when she did not have it with her. With the team’s support, the group leaders committed to acting in a way that was opposite to their urges by asking Jane about her homework weekly and calling on her throughout group. Further, the individual therapist received consultation on targeting shame in session, through both encouraging emotional experiencing of shame as nonthreatening and teaching Jane to act opposite to her emotion of shame in public (e.g., making eye contact with others, engaging with others). The therapist also received consultation on examining her own therapy-interfering behavior of providing reassurance to Jane when reassurance seeking served as one of Jane’s primary avoidance strategies. Finally, the team assisted the therapist in conceptualizing secondary targets for Jane, including the way in which shame related to the dialectic between apparent competence and active passivity for Jane both in session and in group. Treatment Progress By the end of standard yearlong DBT treatment, not only did Jane no longer meet criteria for BPD or social anxiety disorder, she also reported an 8-month

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abstinence from self-harming and 6 months with no urges to die. Additionally, at the end of treatment, she was enrolled in college courses and had commenced a relationship with a new romantic partner.

CONCLUSION DBT is a comprehensive, multimodal, structured transdiagnostic treatment with strong research support. This chapter reviews the history of DBT, spanning from its initial focus on the treatment of chronic suicidality to a theoretical conceptualization of emotion dysregulation. This chapter also seeks to provide a broad overview of the multimodal and hierarchal approach to treatment within DBT as well as to highlight the role of dialectics in treatment. An overview of outcomes research was presented, as well as a brief review of other populations for which DBT has shown efficacy and current endeavors into understanding how best to implement and disseminate this complex evidenced-based treatment. Finally, we presented a case to illustrate the treatment. The primary goal of this chapter is to provide a broad introduction to this continually developing literature base and give readers a foundational understanding of this treatment. Although DBT has taken a stronghold in the field, the literature is still nascent in its understanding of the wide scope of the utility of DBT. Additionally, as highlighted, more research is needed in order to understand how best to disseminate and implement DBT in a wide range of clinical settings as well as crossculturally.

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19 Acceptance and Commitment Therapy Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin

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his chapter provides a basic overview of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2011), with the aim of allowing professionals to learn the basics of ACT and providing guidance on how to more fully “dig in” to learn more. We first discus the historical context in which ACT was developed and its theoretical foundations. We then introduce ACT concepts and familiarize the reader with some of ACT’s vernacular. A case example is used to illustrate the practical use of these concepts in a treatment setting.1 Finally, we provide a brief review of the literature, describing areas and populations in which ACT might be best utilized and where mental health professionals can find further information.

BRIEF HISTORY ACT is a modern cognitive behavioral therapy (CBT), sometimes referred to as contextual CBT, to recognize its emphasis on the context in which behavior occurs for conceptualizing and treating psychological problems (Hayes, Villatte, et al., 2011), or as a “third-wave CBT” to recognize its differences from more traditional CBT (Hayes, 2004). Before presenting the key features of ACT and its clinical application, we briefly review the history of ACT’s development to contextualize its defining features and points of departure from traditional CBT (see Zettle, 2005, for a more in-depth review). Clinical examples are disguised to protect patient confidentiality.

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https://doi.org/10.1037/0000218-019 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  567 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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Early development of ACT began in the 1970s–1980s with research by Dr. Steven C. Hayes and his colleagues on rule-governed behavior and verbal behavior (e.g., Hayes et al., 1986; Zettle & Hayes, 1983). This research was consistent with the growing interest in cognitive phenomena in understanding and treating psychological concerns but sought to pursue this aim from a behavior analytic framework emphasizing the context and contingencies that govern the impact of thoughts on behavior. Examples included a behavioral interpretation and empirical analysis of coping self-statements (Zettle & Hayes, 1983) and the impact of verbal rules on behavior (Hayes et al., 1986). This early body of literature led to research evaluating whether the cognitive distancing component of cognitive therapy, reducing the literal functions of cognition by noticing thoughts as just thoughts, was effective relative to full cognitive therapy in treating depression (Zettle & Hayes, 1986). Referred to as comprehensive distancing, this was the precursor of ACT, representing a behavior analytic interpretation of the way in which cognition affects behavior and a proposed explanation for the way in which cognitive therapy improves mental health. This line of scholarship resulted in a refined intervention focused on targeting the functions of thoughts by altering the context in which they occur. In other words, ACT shared the interests of other so-called second-wave CBTs in understanding the role of cognitive processes, but it sought to do so using the “first-wave” paradigm of behavior therapy and behavior analysis (Hayes, 2004). Although early development and evaluation of ACT occurred in the 1980s, subsequent randomized controlled trials (RCTs) and broader implementation efforts did not start until the mid to late 1990s. During this second period of ACT development between the mid-1980s and 1999 (Zettle, 2005), a heavy emphasis was placed on developing a more adequate behavioral account of language and cognition to provide a stronger theoretical and basic scientific foundation for ACT. The most notable development during this period was relational frame theory (RFT; see Hayes et al., 2001, for the first book-length publication), which provided a modern behavioral account of these verbal processes. This work was essential for clarifying the way in which verbal processes influence behavior and alter the effects of direct learning histories, providing the basic principles upon which to develop contemporary ACT theory and intervention strategies. This emphasis on such connections to basic behavioral research is a defining feature of ACT and some other third-wave CBTs that seek to include complex human behavior and phenomena such as cognition and affect in their models, but using the contextual framework developed in earlier behavioral approaches. Following this period of basic research and theoretical refinement, the first book-length description of ACT was published in 1999 (Hayes et al., 1999), which has led into a subsequent period of rapid development, research, and dissemination of ACT that continues today. For example, the third RCT on ACT was published in 2000 (Bond & Bunce, 2000), and the number of RCTs has increased exponentially, with over 200 RCTs published to date and approximately 28 published in 2017 alone. ACT is now recognized on various empirically supported/evidence-based treatment lists, such as the American



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Psychological Association’s Division 12, the Society of Clinical Psychology. The Association for Contextual Behavioral Science (ACBS) was founded in 2005, providing an organization for ACT, RFT, and other modern behavioral approaches, and has a current membership of over 7,000 members internationally. This rapid growth in research and dissemination of ACT is due in part to the early, careful theoretical and basic research done before 2000, which provided a strong philosophical, basic science, and theoretical basis for subsequent development and evaluation of ACT (Hayes et al., 2013). The next section of this chapter considers the philosophy of science and basic behavioral principles that inform the ACT model of psychopathology and intervention. ACT is defined more by a set of theoretical pathological processes and processes of change rather than by specific techniques. Thus, understanding the basic philosophy and principles underlying the ACT model can help one understand how they are then flexibly applied in practice.

THEORETICAL FOUNDATIONS Functional Contextualism ACT is founded in the philosophy of functional contextualism (Hayes et al. 2013). Functional contextualism advances the idea that the truth criterion for analysis should be defined by what is effective in predicting and influencing behavior. In other words, an account is true insofar as it is successful in identifying the conditions under which a behavior occurs and can be changed. This pragmatic approach provides the foundation for the scientific strategy and approach to theory used in ACT (Hayes et al., 2013) and echoes into clinical practice. One result of adopting a functional contextualist viewpoint is a heavy emphasis on what works for clients being defined by their own experiences and goals. Although this is common across many therapies, ACT places a particularly strong focus on identifying clients’ values and evaluating what works in relation to moving toward these values (including case conceptualization, treatment plan, current coping strategies, and therapeutic methods). In other words, what is true is what works for clients in living the life they want to live. Another result is the stance that behavior is only understood in context. ACT emphasizes the contexts that govern the relations between thoughts, feelings, and behavior because these contexts are where a therapist would intervene. For example, understanding that a depressed thought leads to withdrawal does not directly identify how to change this pattern, whereas understanding the external conditions that lead to this depressed thought or the impact of the thought on behavior would (i.e., what could be changed to make the thought less likely or what would make the thought not lead to this behavior). Behavior Analysis and RFT Behavior analysis and RFT offer the analytical lenses for functional contextualism through which the interactions between behavior (including cognition)

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and context can be understood for prediction and influence. ACT can be understood as part of behavior analysis, with behavior analysis sharing the same functional contextual roots as ACT. Behavior analysis provides the foundation and basic research for understanding the way in which context influences behavior to either increase or decrease the probability of that behavior recurring in the future. As noted in the previous section on history, however, traditional behavior analytic accounts of human behavior did not adequately address complex human behaviors relevant to cognition that are of critical importance for some applied domains, including psychotherapy (Zettle, 2005). RFT, as a modern behavior analytic account of cognition (Hayes et al., 2001), thus provides a second analytic lens to explain the way in which cognition might influence behavior and the impact of context on behavior in ways that go beyond direct learning histories accounted for by traditional behavior analytic principles. In other words, RFT offers a framework for applying behavior analytic principles to more complex human behavior and phenomena. Let us take a brief example of how RFT expands the ability to account for complex behaviors, difficult to understand just with reference to direct learning experiences. Suppose an individual receives the message that people who cry are “weak” and relates the behavior of crying to feeling sad. In turn, the individual may attempt to avoid or suppress feelings of sadness to also avoid the notion of being a “weak person.” In the absence of any direct learning history (i.e., being punished by others for crying), crying has become something important to avoid through these verbal relations. Behavior analysis and RFT provide the foundation for ACT’s theoretical model. For example, practitioners of ACT posit that a key process that contributes to psychopathology is experiential avoidance, in which individuals engage in rigid patterns of behavior to avoid, escape, or otherwise change internal experiences (e.g., thoughts, feelings). RFT provides the basic principles for understanding why individuals might experience an expanded set of stimuli as aversive experiences to be avoided at all costs. From an RFT perspective, a core aspect of cognition is the ability to arbitrarily relate any stimulus to any other stimulus and to derive further relations beyond those directly learned (Hayes et al., 2001). For example, someone could learn that the symbols “C-A-T” are the same as the audible utterance “cat” and that the utterance “cat” is the same as an actual live cat in the room. A unique aspect of this relational behavior is that the person can automatically derive that the actual live cat is the same as the symbols “C-A-T” despite this not being directly learned. Furthermore, if that person then gets scratched by the actual live cat, they might avoid going to a house they are told “has a cat” despite a lack of any direct history. This process of arbitrarily applying and deriving relations and the transformation of functions due to these relations could quickly lead to avoiding a whole host of situations that are now associated with potential cats. As another example with more complex/abstract phenomena, a person might learn to relate social rejection to ugliness and sadness to social rejection, and they may derive a relation between sadness and “ugliness” and may also relate sadness to rejection and



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ugliness to rejection in the absence of direct training of these relations (Figure 19.1). They may, in turn, avoid expressing feelings of sadness in their relationship to avoid being perceived as “ugly” and being rejected, as the function of sadness has been transformed. In turn, this may impede their ability to connect authentically in their relationships in the presence of sad emotions. Thus, RFT provides a framework for understanding how humans can come to contact an expanded array of aversive experiences and engage in broad patterns of avoidance despite the negative consequences of doing so. Another pathological process identified in the ACT model that is closely connected to RFT is cognitive fusion, in which people’s behavior is rigidly controlled by verbal rules and cognitions rather than direct contingencies or personal values (Tórneke et al., 2008). For instance, say the person above derives a rule that “crying results in being rejected.” This person may later have problems effectively expressing negative affect, even when it may be appropriate to do so (e.g., at a funeral, upon hearing another person’s loss). This rule unnecessarily restricts the person’s actions by reducing their sensitivity to immediate cues, such as others crying or displaying sadness, and it may interfere with other potentially adaptive behaviors, such as expressing empathy. In turn, following this rule detracts from the person’s ability to engage effectively in their relationships with others, which may have negative consequences. RFT provides a framework for understanding how someone’s behavior can be more strongly affected by a verbal rule (e.g., how things should work and what one should do) than direct learning history (e.g., what actually happens when one follows this rule). In summary, RFT allows for the application of behavior analytic principles to a functional contextual understanding of psychopathology within ACT. Due to the ability to arbitrarily relate internal events via relational framing, internal experiences (e.g., thoughts, emotions, memories) can acquire the function of promoting avoidant behavior in the absence of an immediate threat or previous learning history. This avoidant behavior can inappropriately generalize to a FIGURE 19.1. Direct and Derived Relational Associations Rejection

Sadness

“Ugly” Direct Relation Derived Relation

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wide range of situations, including contexts in which sensitivity to external or social cues would support more effective responses. This rigidity ultimately impedes the individual’s ability to choose behavior that would support living a vital life, resulting in further distress and diminished life quality. Within ACT, this behavioral rigidity is often described as psychological inflexibility, referring to behavior that is rigidly under the control of internal experiences, or efforts to avoid such experiences, at the expense of living consistently with one’s personal values. ACT attempts to build psychological flexibility as a way to help clients engage in values-consistent behavior while being mindful of the present and accepting whatever internal experiences arise. ACT aims to alter the context in which internal experiences occur, changing how an individual relates to these experiences (i.e., their function) to increase their capacity to engage in effective, valued actions. With the previous example of someone for whom sadness impinges on relationship values, ACT would help clients respond more flexibly to sadness and rules about vulnerability, such that they could be vulnerable with their partner when it is effective or meaningful to do so. In other words, ACT would involve helping clients choose behaviors based on what would be effective or meaningful in the moment, rather than based on inflexible verbal rules or avoiding unwanted thoughts and feelings. The ACT Model The ACT theoretical model consists of six relational and behavioral processes thought to support psychological flexibility (Hayes, Strosahl, & Wilson, 2011; see Figure 19.2). Each process is defined functionally, meaning that it describes how people respond to their experiences instead of the specific contents of those experiences. Each process is described in terms of the pathological process that contributes to psychological inflexibility and the opposing therapeutic process that increases flexibility. These processes are further explored through a case example. Cognitive fusion refers to responding to one’s thoughts as if they are literally true, such that they dominate one’s experiences and actions. This process reduces an individual’s flexibility by restricting their available choices of behavior in the presence of specific thoughts. For example, someone fused with the thought “I’m too shy for public speaking” may avoid public speaking whenever they feel shy; hence, they are limited by this thought. Conversely, defusion refers to the process of responding to thoughts in a nonliteral way and choosing one’s behavior despite the thoughts that arise. Defusion is practiced by relating to cognitions in ways that do not support their literal meaning, such as by repeating a thought over and over until it loses its meaning, or acknowledging one’s thoughts with the preface “I’m having the thought that . . .” Experiential avoidance refers to excessive efforts to avoid or control unwanted thoughts, feelings, or other internal experiences. As noted previously, this is defined functionally such that just about any action could be done in the service of moving away from unwanted inner experiences (e.g., thought suppres-



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FIGURE 19.2. The Acceptance and Commitment Therapy Process of Change

sion, mindfulness, substance use, exercise, seeking reassurance, procrastinating, working). In contrast, acceptance refers to the process of choosing to respond to unwanted feelings by openly experiencing them instead of trying to control, avoid, or otherwise react to them. The practice of acceptance involves the active choice to have an internal experience to its full extent, without changing one’s behavior to suppress or change it. This includes valued actions typically avoided due to unwanted thoughts and feelings, while allowing whatever internal experiences arise to naturally come and go. In this way, acceptance is often framed in the context of being in the service of moving toward one’s values (i.e., doing it because it works to help you do what matters) rather than for its own sake. Loss of contact with the present refers to when an individual’s experience is dominated largely by thoughts about the past and future. This reduces a person’s ability to respond flexibly to what is happening in the present and to choose to move toward values based on the immediate situation. Contact with the present moment refers to the process of choosing to actively attend to the present moment. This skill is practiced by making the conscious choice to notice and participate in what one is doing while redirecting one’s mind from thoughts about the past or future. The practice of being in the present moment increases the ability to respond flexibly and adaptively to one’s changing experiences, such that it supports valued living. Self-as-content describes an experience of self that is dominated by conceptual evaluations and labels based on the contents of one’s experiences. This experience

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can reduce flexibility by unnecessarily restricting a person’s contact with experiences and choices that do not fit the contents associated with one’s “self.” As an example, a person may apply the label of “failed student” when feeling frustrated with their academic performance and may later behave in ways that confirm this label (e.g., by dropping out of classes or school altogether). On the other hand, self-as-context involves connecting with an experience of the self as the observer of one’s changing internal and external experiences. The practice of self-as-context involves, first, acknowledging the presence of an observing perspective and, second, looking through this perspective at the contents of one’s experience. An important component of self-as-context is the awareness that although the contents of one’s experience change and are included by the “self,” the observer point of view is content free. This component of ACT increases people’s flexibility to respond in values-consistent ways to their changing experience, without attachment to the changing thoughts, emotions, and memories that comprise this experience or the need to adhere to selfevaluations or labels derived from one’s history. A lack of values clarity can contribute to excesses in avoidant behavior and limited contact with rewarding experiences. Specifically, in the absence of guiding principles for living a vital life, changing internal experiences or rigid rules come to dominate one’s behavioral choices. On the other hand, values are verbally derived qualities of behavior that serve to increase one’s engagement in that behavior and one’s sense of meaning. Values focus on what is deeply meaningful about how one does things and what one wants one’s actions stand for, rather than the specific outcomes and goals one achieves. In this way, values are focused more on the day-to-day process of doing what matters, providing an ongoing motivator and guide for behavior. The practice of values involves identifying what qualities of action are important and noticing whether one’s behavior moves toward the qualities about which one cares. Returning to the functional contextual roots of ACT, values provide the criterion against which clients can determine what works for them. Inaction refers to problems choosing or persisting in behavior that is aligned with one’s values. Deficient valued action will restrict a person’s opportunities to connect with rewarding aspects of pursuing a values-consistent behavior and may diminish flexibility and persistence in the presence of barriers to valued pursuits. Committed action refers to ongoing engagement in behavior that is valued. The practice of committed action involves choosing overt behavior that reflects one’s values, such as through setting goals and monitoring one’s progress in aspects of life that are important. Committed action helps the client sustain contact with rewarding contingencies on a regular basis and replaces behavior that is mostly about unwanted thoughts, feelings, and other internal experiences. Each of these processes is targeted through a variety of ACT interventions, in a way that matches the client’s unique presentation and needs. This model allows clinicians to flexibly engage with ACT, in a way that matches the kind of flexibility that is encouraged for clients engaged in the intervention. Consistent with the ACT’s emphasis on flexibility, implementation of ACT can vary consid-



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erably depending on the needs of the situation. It can, and often does, take the form of traditional eight to twelve 1-hour sessions of therapy protocols, but treatment can be lengthened or shortened depending on client and logistical needs. Additionally, although ACT traditionally employs many metaphors to help illustrate concepts to clients, a more straightforward and didactic approach can also be successful, again depending on the needs of the client. Finally, the order in which ACT concepts are presented might vary a great deal based on client needs. For example, imagine a client who is psychologically minded, is not overly fused with internal content, and has some ability to be open to this content but is still struggling to find meaning in their life. In this case, the therapist might emphasize processes like values and committed action over others at the beginning of treatment. Ultimately, practitioners of ACT meet clients where they are and promote psychological flexibility in the service of living more rich and meaningful lives. Doing so requires clinicians to practice and exemplify psychological behavior in session with clients as well as in their treatment planning. In the next section, we provide a case example of a more typical session-bysession ACT structure that would meet the needs of the client; however, alterations should be considered on a case-by-case basis.

CASE EXAMPLE We present a case example in order to illustrate a common structure for ACT over multiple sessions. It should be noted, however, that although the examples provided clearly target a specific process, in practice, ACT should be employed in a flexible manner. Often, this involves dynamically targeting multiple processes within session in an attempt to foster psychological flexibility and ultimately valued action. As depicted in the diagram of what has become known as the hexaflex (see Figure 19.2), each of the six processes targeted in ACT is interconnected. Thus, affecting one is likely to have an impact on the others as well. For example, increasing one’s ability to make space for difficult thoughts and emotions (acceptance) might also assist in not overidentifying with them (self-as-context), not believing them to be necessarily important (defusion), and increasing willingness to make and keep behavioral commitments (committed action). We present snippets of treatment over multiple sessions using the following case example. Jamie is a 40-year-old single woman seeking help for anxiety. She was recently promoted to an upper managerial position at her job. Although she was happy for the promotion, Jamie reports that she feels overwhelmed with her new duties and is not performing well at her job. She experiences what she calls “anxiety attacks” in which her anxiety becomes “unbearable” and causes her to “shut down.” She states that her mind is constantly racing and planning how to perform her job well, although she spends little time engaged in meaningful activities that would accomplish her work goals. Jamie says that she would experience “extreme anxiety” if she did not constantly review and make plans about her work because she may not be fully prepared and then make

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mistakes. Since her job promotion, her racing thoughts and planning behaviors have increased in intensity and frequency. She says that her anxiety has negatively impacted her relationships with her coworkers whom she cares about, largely because she avoids contact except when absolutely necessary. Additionally, Jamie indicates that she spends so much time on work that she does not have time to do other activities she wants to do. Creative Hopelessness: Challenging the Change Agenda We will assume that a general assessment and introduction to therapy have been conducted. Because ACT emphasizes increasing valued living and deemphasizes the reduction of symptoms (e.g., anxiety, depression, pain) it is important to get the client on board with this agenda and make sure they understand what the priorities of the treatment are going to be. Thus, ACT usually begins with some form of a procedure called creative hopelessness. This procedure sets the stage for the rest of treatment. In a nutshell, creative hopelessness is a process of helping clients recognize that their attempts to control inner experiences ultimately fall short and often get in the way of engaging in valued behaviors. No matter how hard they have worked and no matter how many strategies they have tried, here they are, still stuck with the same thoughts, emotions, memories, and urges as before. Often a metaphor is used to illustrate this situation, such as in the following example. THERAPIST : What else have you tried to control your anxiety? JAMIE :

Well, I make plans in my head of all the things I need to accomplish at work and how I can get them done in the best way.

THERAPIST : And how does that work for you? JAMIE :

It helps me get organized .  .  . to make sure things are done properly.

THERAPIST : And the anxiety? JAMIE :

I mean, I feel better for a bit, but then my mind is off again, racing, worried about different plans.

THERAPIST : So, it sounds like in the long run you are right back where you

started? JAMIE :

Yes! And you know the real irony of it all is that all of this planning and worry just make me feel worse at the end of the day when I realize that I didn’t actually get anything done.

This conversation continues and covers other ways that she tries to control her anxiety.



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THERAPIST : It sounds to me that you aren’t the type of person to just give up

on something difficult. You are a hard worker and have clearly spent years working on this anxiety problem. Yet here you are. Still with essentially the same problems. JAMIE :

I know. . . . If anything, they are worse. I still can’t get over this worry and, on top of that, I feel like a failure. I am just so sick and tired of doing this.

THERAPIST : So what now? Is there some strategy you haven’t tried that

would finally beat this thing? JAMIE :

I sure don’t have one. I was hoping you might. I guess that’s why I’m here.

THERAPIST : Absolutely. Because there has just got to be something that

would beat this anxiety for good, right? But at the same time, you know your experience better than anyone and, from what I understand, you’ve tried everything. What if this whole thing, this whole strategy of beating this anxiety, is actually part of the problem? It reminds me of a tug-of-war match. A rope is stretched out over a vast pit, with you on one end and your opponent on the other. You have become very familiar with this opponent—it is a huge, strong, smelly, monster. A monster we could perhaps name anxiety. And for years you have put great effort into this match. You’ve developed new ways to pull on the rope, maybe you’ve put gloves on to help you grip, you’ve even invited friends to come help you pull for a while. But every time you seem to make any progress the monster just grunts and pulls back even harder than before. You tell me that you are exhausted, but you fear that if you don’t keep fighting, that you will be pulled into the pit and be done for. In the situation you are in, the difficult thing to see is that perhaps your job is not to win this fight. Perhaps your job is to simply drop the rope. JAMIE :

How do I drop the rope? What would that look like?

THERAPIST : These are excellent questions, but first it is important to just

understand that this tug-of-war match cannot be won and that it doesn’t need to be. Despite the name, the goal of this process is not to change the sense of hopelessness in the client. The only thing hopeless about this process is the client’s control strategy, not her prospects for a meaningful life. In fact, it can be a liberating process of letting go of an often lifetime long struggle coupled with a creative energy of trying something truly new. By letting go of a strategy of control, space is made for an alternative way of engaging with inner experiences.

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Of note, the creative hopelessness process is key to getting clients on board and willing to embrace a new paradigm with regard to how they interact with their internal experiences. Therefore, it is not unusual for this process to take multiple sessions. We provide only the briefest version of this process here. Control as the Problem and Acceptance Now that Jamie’s change agenda has been challenged, we will continue to reinforce this by further exposing the paradoxical nature of attempting to control her anxiety. Moreover, we will introduce an alternative paradigm—acceptance or willingness. Many practitioners of ACT tend to favor the word “willingness,” as it conveys the idea of being open to experiences without some of the verbal baggage of the word “acceptance” that can invoke concepts such as tolerance and resignation that are counter to our goals. During this phase of treatment, the client is introduced to what is referred to as control as the problem before formally introducing the concept of willingness. Control as the problem highlights the negative impact that constantly avoiding or trying to reduce unwanted internal experiences has on one’s quality of life. This runs counter to our experiences in the physical world where, when a problem arises, the solution is to work, work, work at it until it is solved. Too often, we use this same strategy on our unwanted internal experiences and find ourselves caught in a struggle that cannot be won and that simply makes the matter worse than it was before we started. There are many exercises that can illustrate this process. The following is just one example. THERAPIST : Imagine that I had a million dollars in a suitcase with your name

on it. I am prepared to give it to you if you do just one simple thing for me. Now imagine the large sports arena near here. The next time that there is an event, and all of the seats in the stadium are full, I want you to walk out to the middle of the arena and sing the national anthem to the tens of thousands of fans. That’s it. Do that and you are an instant millionaire. What do you think? Would you do it? JAMIE :

I hate to sing! I would get booed off the stage.

THERAPIST : Doesn’t matter. You just have to do it. Believe me for just a min-

ute. Imagine this is real. JAMIE :

Well, if it doesn’t matter how well I do, I guess I would. I mean, that’s a lot of money.

THERAPIST : Exactly! You may even hate every moment of it, but it would be

worth it, right? Now, I want to do the same thing—same million dollars, same arena, same song—but this time there is one other small criterion. You aren’t allowed to feel anxious while you do it. And I am going to attach a magical device to your wrist that



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will detect if you get anxious. You can’t fake it; it will know if you feel even a bit of anxiety. What about now? Could you do it? JAMIE :

Of course not! I’d be a wreck the whole time.

THERAPIST : Not even for a million dollars though? Isn’t there something you

could do? JAMIE :

If there is, I haven’t found it. I mean, I’d be anxious about trying not to be anxious!

THERAPIST : Right. And how often do you find yourself in a similar situa-

tion—not for a million dollars, but for your own well-being— where you tell yourself that you have to not feel a certain way before you can accomplish things that are important to you? If I said I’d give you that same million dollars to complete a task at work, I’d imagine you’d find a way. But if I said you couldn’t feel anxiety while you did it, I’m pretty confident I’d be keeping my money. Once Jamie recognizes the problem with her control strategies, we introduce acceptance or willingness as an alternative. Exercises are often useful to illustrate the benefits of willingness over more traditional control strategies. As in the tug-of-war metaphor, dropping the rope (i.e., practicing willingness) changes the relationships one has with internal experiences. They are not defeated, however. There is just no longer any struggle with one’s thoughts and feelings, which can reduce their impact. Additionally, all the effort that was previously put into the fight can be asserted elsewhere toward behaviors that are personally meaningful. Another useful exercise is to have clients write their unwanted experience on a card. In this case, Jamie would write “anxiety” or “worry.” The therapist would then place the card in her hand and ask her to push the card away as it approaches her. Much like the tug-of-war match, this requires a fair amount of focus and effort and ultimately does not result in the card going away. Subsequently, Jamie would be asked to simply lay the card on her lap and notice the experience of letting the card sit with her without struggling with it, but also without changing or removing it. This is acceptance. Perhaps Jamie’s experiences of anxiety do not have to go away before she can accomplish work that is meaningful to her. Defusion and Self as Context We will cover these processes together, as they complement one another. Jamie now better understands the concept of willingness and has had a chance to practice it between sessions. She might say something like, I like the idea of being more willing to just have my anxiety, but it is so hard to make space for something so scary. I’m just such an anxious person that I don’t know if I can do this. It feels like that if I truly “let go of the rope,” that anxiety monster is going to come over here and throw me in the pit!

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We can see that her feelings of anxiety are not only uncomfortable but also intimidating and frightening. This is where the processes of defusion and self-as-context might be useful. As previously stated, defusion is responding to thoughts in a nonliteral way. In more clinically appropriate words, it is the process of making space between a person and their internal experiences and noticing those for what they are: internal experiences, and nothing more. Similarly, self-as-context is a process that describes defusing from internal experiences that we identify as part of what makes up our “self” and noticing that we are not made up of these internal experiences. Rather, we are simply a vessel through which these experiences pass (just as the sky is a vessel that contains passing clouds and weather). So often we “buy into” the thoughts our mind gives us (e.g., “I’m not good enough”) and the emotions we feel (e.g., “I am depressed”) and treat them as important and true, without any consideration. In session, ACT therapists often use defused language to set an example for how we can engage with our internal experiences in a different manner. Thus, when a client says that he “is not good enough,” the therapist may simply ask him to notice that thought and to thank his mind for it. Or if a client states that she “is worthless,” the therapist might rephrase it as “You are having the thought that you are worthless. And what other thoughts, feelings, or experiences come with this thought?” In the case of Jamie, her therapist would say that she is fused with her thoughts and feelings that come with the experience that she calls anxiety. In addition, she identifies as an “anxious person.” Thus, anxiety is not just something that she experiences; it is a part of who she is. In other words, she does not recognize that she is the context in which these experiences occur; rather, the experiences define her. Like before, exercises and metaphors can be powerful tools to illustrate these concepts. The following is an example of what one could do in Jamie’s situation. THERAPIST : Let’s imagine that you are the driver of a bus. And like any bus

driver, you make stops along the way when there are passengers who need to get on or off the bus. Except in this scenario, these passengers are your thoughts, emotions, urges, and memories— the stuff inside your skin. Some of the passengers are quiet and just sit in the back until it is time to for them to get off—you hardly notice these ones. Some are talkative and friendly—you don’t usually mind having them on board. And some are downright scary. They are disruptive, they yell, they make demands, they may even carry weapons and threaten you. What might you name some of these passengers on your bus? JAMIE :

Anxiety for sure. Worry. Fear of failure. And guilt.

THERAPIST : Right. And you’ve described them as scary before. And we’ve

talked about how they can push you around. And we’ve discussed all of the ways that you have tried to get them off your



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bus. In this story, it is like you have pulled over and said, “That’s enough! Get off my bus!” and tried pushing them out. And as commendable as your hard work has been, how has that worked out for you? JAMIE :

It’s like we talked about. The harder I fight, the more passengers there seem to be. It’s like they are climbing through the windows as I push them out the door.

THERAPIST : Hmm . . . and another thing to notice in this scenario. When you

pull your bus over to fight, notice that you aren’t driving anywhere. You aren’t getting to where you want to go. JAMIE :

Yeah. It really does stop me in my tracks sometimes.

THERAPIST : And over time, I see another thing happen. You get sick and

tired of fighting, so you make a deal with these passengers. You say, “Anxiety, I’ll do what you say if you will just sit in the back of the bus where I don’t have to see you as much. You just tell me when to turn and I will. I just don’t want to deal with you anymore.” And off you go, back to driving your bus. But now the anxiety passenger is in charge. It says where to go and when to do it, and in exchange, you don’t have to look at it as much. Does this sound familiar? Have you ever made a deal like this before? JAMIE :

It’s weird to think of it that way, but yeah, I guess so. When I shut down and skip work or avoid my coworkers, it feels a lot like what you said. The anxiety is in charge. I feel a bit better for the day and it hides in the back for a bit.

THERAPIST : Okay. Now the thing about this whole scenario is—it’s a trick.

The real threat that these thought, emotion, and urge passengers offer is as simple as this: they say, “If you don’t do what we say, we aren’t going to hide in the back and we will come up here and make you look at us.” That’s it. They may claim that they will hurt you if you don’t listen, but this has never actually happened. These passengers, our thoughts, our emotions, our inside stuff, have no real power to control—except for that which you give them.

Contact With the Present Moment At this point, we would like for Jamie to be actively practicing making space for her anxiety and noticing her anxiety thoughts and symptoms as “passengers on her bus” and nothing more. Treatment would have also incorporated teaching Jamie how to better contact the present moment. The ability to be present, and

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to notice one’s experiences as they occur, can have a powerful impact on behavior. Being present allows one to attend to and learn from direct contingencies as they occur. Moreover, this skill can help facilitate the development of other processes. Contacting the present moment in ACT allows for the simple recognition of one’s current experiences and fosters an environment in which to practice acceptance and defusion skills. In the case of Jamie, she reports having near-constant racing thoughts about tasks that need to be completed. Thus, she is rarely focused on the present and instead places much of her energy in a future that she cannot actually engage with. It is as if she feels that she must sort out her thoughts and worry before she can effectively engage in the present moment. However, this quickly turns into another tug-of-war match where she spends her life engaged with this struggle instead of living in the present and disengaging with the monsters in her mind. Some exercises that foster present moment awareness may be familiar to readers who integrate mindfulness practice into their treatment (e.g., placing thoughts on leaves on a stream or noticing one’s breath). These formal exercises can be a great way for clients to practice being present each day. However, in addition to these types of exercises, the process of present moment awareness should be demonstrated by the therapist throughout treatment. This can be done by simply describing present moment experiences in an accepting and defused way (e.g., “When you say that, I notice my mind tell me to rescue you and say that everything will be alright”). More often, the therapist will ask the client to practice being present to facilitate objective awareness of a sensation (e.g., “How would you describe the physical qualities of that emotion? What is its color, texture, weight, and form?”) or to better understand the function of their current behavior (“You just said, ‘I don’t want to talk about that.’ What passenger on your bus are you frightened will show up if you do?”). In the case of Jamie, fostering the ability to be present will be of crucial importance as she practices making space for anxiety symptoms and while she moves toward a more meaningful quality of life.

Values and Committed Action Because ACT’s primary aim is to increase meaningful, values-directed behavior, it is crucial that clients understand what that means for them. Once clients have fostered psychological flexibility through the aforementioned processes, they should be freer to engage in any chosen behavior, regardless of what internal experiences they might have. If clients are spending less time dealing with their anxiety, urges, depression, and so on, they should be spending more time engaged in behavior that improves their quality of life. Clients’ values serve as a guide for which behaviors to engage in to meet this goal. Values are identified by asking the question, “What do I want my life to be about?” Moreover, values are self-chosen patterns of behaving that provide a sense of meaning to one’s life. They are generally defined as broad domains (e.g., family, education, community, spirituality) that are not readily achieved, but rather give direction to



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smaller, achievable goals along a valued path. There are many ways to explore a client’s values. We present a brief version of a values exercise with Jamie next. THERAPIST : Close your eyes and simply follow my voice as we engage in this

exercise. Now imagine that we have traveled far into the future, to your 80th birthday. You have lived a long, meaningful life, and you are having a party to celebrate. Imagine who you would want to be at this party. It doesn’t matter if it makes sense, just who you would want to be there. Family, friends, people you care about. Now pick just one of these people, someone you care a great deal about. Imagine that they stand up in front of everyone and offer a toast to you, to your life, to the things you’ve accomplished, to the type of person you are. Imagine for a minute what you would like for them to say about you and the life you’ve lived. What has your life been about? Not what you think your life will be, but what you want for it to be. Time would be given to allow Jamie to imagine what would be said. This would then be repeated with one or two other party guests; the exercise would then conclude.

THERAPIST : What did people say about you that stood out to you? JAMIE :

They said so many nice things. That I was always kind and easygoing, but at the same time, that I accomplished a lot in my life. And that I was a dependable friend to everyone. That I wasn’t worried all the time. That I was there for people—I was present—I listened.

THERAPIST : You’ve spoken about wanting to excel in your career. Are these

qualities that you would like to see in your job performance? JAMIE :

Absolutely. I want to get out of my head and be a better boss, a better coworker, a better friend. I want to be dependable.

THERAPIST : Those are great examples of ways to move closer to your value

of excelling at your career. It sounds to me like this would be a great sign to hang on the front of your bus as you go to work each day. Do you think that you could make space for all of the passengers on your bus while driving toward this value? In this example, we briefly considered one values domain. However, there are likely other areas of Jamie’s life that she would like to pursue and that would be examined. Once Jamie’s values have been clarified, goals can be set along the path toward these values. Committed action is the process of setting these goals, making a clear plan to achieving them, and taking action to do so

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with full knowledge that it may be difficult or that failure is a possibility. Thus, practitioners of ACT help their clients make commitments in which they are willing to fully engage. This has been likened to committing to jump off something. No matter the height, whether it is something very high or something as low as a piece of paper, the commitment is the same— “I will jump.” Not “I will think about jumping,” not “I will try to jump,” but “I will jump.” In the case of Jamie, this might be a commitment as large as completing a difficult task or project over the next week or as small as practicing being present while eating lunch with coworkers. Each week, the previous commitments should be followed up on, and new commitments should be made. These commitments provide opportunities to pull together all that the client has learned to build increasingly large patterns of valued living, while practicing acceptance, defusion, and mindfulness with barriers that arise. Thus, this last phase often serves to support solidifying and generalizing gains made in therapy as final steps for ending treatment. This case example and introduction to ACT processes is very brief. However, we hope that it has provided a starting point to understanding this type of treatment. For readers interested in learning more, there are many widely available resources for learning more about ACT, with some key resources noted in the dissemination section below.

EFFICACY AND EFFECTIVENESS ACT has been applied across a wide range of populations and settings for a variety of presenting concerns. ACT is intended as a transdiagnostic intervention, meaning that the intervention model is applicable to a range of symptom categories and is not designed for a specific disorder. The primary goal of treatment across disorders is engagement in effective, valued patterns of activity (e.g., quality of life, psychosocial functioning, valued action), rather than symptoms reduction. In other words, ACT seeks to increase valued living irrespective of levels or types of internal distressing symptoms, rather than focus on reducing internal symptoms themselves. However, studies of ACT across various populations nevertheless have found reductions in symptoms that are consistent with those found using other evidence-based interventions, concurrent with changes in psychological (in)flexibility. Applications in Mental and Behavioral Health Meta-analytic evidence supports the use of ACT as a transdiagnostic intervention for a range of adult mental health problems. The broadest meta-analysis to date was conducted by A-Tjak et al. (2015) and included trials of ACT for anxiety disorders, depression, somatic health problems, and addiction. The metaanalysis found medium to large effect sizes for ACT as compared with placebo (Hedges’s g = 0.51), wait-list (g = 0.82), and active control (g = 0.64) conditions



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for primary outcomes as well as for quality-of-life (g = 0.37) and process measures (g = 0.56). Although meta-analyses lend support for a transdiagnostic application of ACT, certain mental health problems seem especially well suited. ACT has strong potential as an intervention for chronic pain and related conditions, as it emphasizes valued living despite unwanted inner experiences (e.g., pain) and reduces the need to control these experiences (McCracken & Vowles, 2014). Similarly, ACT’s focus on building flexibility around inner experiences may be well suited to obsessive-compulsive and anxiety disorders (Bluett et al., 2014). A number of other problem-specific applications of ACT have or are gaining increasing empirical support, including ACT for depression, smoking cessation and other addictions, psychosis, weight management, eating disorders, and coping with medical conditions (e.g., cancer, diabetes, tinnitus). Altogether, these studies point to the application of ACT for chronic conditions as well as conditions associated with problematic efforts to control or avoid distress. Several authors have attempted to compare ACT with established treatments. A-Tjak et al. (2015) and Ruiz (2012) compared ACT with established treatments for a variety of diverse mental health problems and found few overall differences among these treatments. The Ruiz analysis of mediation results suggested that ACT was more efficacious at targeting its putative mechanisms of change, as compared with CBT (ACT: g = 0.38; CBT: g = 0.05). However, in another meta-analysis comparing ACT and traditional CBT for anxiety disorders, results suggested that the approaches produce equivalent positive effects on psychological flexibility (Bluett et al., 2014). Altogether, ACT appears to be equivalent to best practices for a wide range of mental health and behavioral health problems in adults. ACT has received less attention as an intervention for childhood and adolescent emotional and behavioral problems. For children, parents are trained to respond flexibly to the child’s experience, such as by validating emotions instead of instructing the child to control or suppress their feelings. This approach has been successfully applied to anxiety disorders, chronic pain, and pediatric health conditions; however, trials evaluating these conditions tend to include small sample sizes (Coyne et al., 2011; Murrell & Scherbarth, 2006). For adolescents, ACT has been applied both with and without parental involvement to address stress, depression, eating disorders, and chronic pain (Coyne et al., 2011; Wicksell et al., 2011). Altogether, ACT has support for applications with a range of childhood problems, although this research is still in its infancy. A common theme in extant studies is that parents can support the application of ACT principles with children and that ACT principles can be applied with children and adolescents if they are sufficiently adapted to the client’s developmental levels. At least one study suggests that the mechanisms in ACT for children and adolescents are comparable to those involved in ACT for adults (Wicksell et al., 2011). Summarily, ACT has received research support for a wide range of applications to problems among adult clients, with burgeoning support for pediatric

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concerns. ACT may be especially well suited to working with problems that consist of distressing internal experiences that are difficult to control (e.g., obsessions, chronic pain, psychosis, addictions). Research on the application of ACT to new problem areas is ongoing, while extant findings suggest that the ACT model can be flexibly applied to a variety of problems. Broad Applications ACT has been applied outside the context of treating psychological and behavioral health problems as a preventive intervention with populations at risk for poor mental health or to enhance positive functioning. Such applications have focused on enhancing psychological flexibility in a group of people with common stressors or challenges. In these contexts, the acronym “ACT” refers to acceptance and commitment training, wherein the primary goal is to enhance life quality or satisfaction instead of working with extant symptoms (Flaxman & Bond, 2010). The most common, broad applications of ACT have been in workplace and educational settings. Workplace applications of ACT have spanned a range of populations, including nursing staff (Frögéli et al., 2016), intellectual disability staff (Bethay et al., 2013), drug and alcohol counselors (Varra et al., 2008), people in management and leadership positions (Moran, 2011), employees of government organizations (Flaxman & Bond, 2010), social workers (Brinkborg et al., 2011), and psychological practitioners (Luoma & Vilardaga, 2013). Outcome data from this research suggest that moderate effects on workplace satisfaction, performance, and stress can be obtained with a relatively brief ACT intervention (Bethay et al., 2013; Brinkborg et al., 2011; Flaxman & Bond, 2010). ACT has also been shown to increase adherence to best practices for mental health care and may support clinicians in developing and sustaining proficiency in mental health interventions (Luoma & Vilardaga, 2013; Varra et al., 2008). The outcomes of ACT in workplace settings appear to be moderated by participants’ use of ACT skills (Bethay et al., 2013); therefore, employees may benefit most if provided with ongoing support to use the target skills. ACT has been applied in educational settings with school-age and college populations to manage stress (Pahnke et al., 2014), reduce procrastination (Scent & Boes, 2014), and reduce prejudice (Lillis & Hayes, 2007). In addition, ACT has been applied as an online preventive intervention for college students to address a range of mental health outcomes (Levin, Pistorello, et al., 2014). In educational settings, briefer workshop interventions (e.g., Lillis & Hayes, 2007) have tended to produce small to moderate immediate effects, with some sustained effects at follow-up. Longer interventions with regular contact (e.g., Pahnke et al., 2014) have demonstrated more sustained outcomes. Altogether, ACT has preliminary support as a preventive intervention in workplace and educational settings for students and employees at risk for poor psychological and educational outcomes. Broad applications of ACT appear to be most effective when participants are provided with additional contact or support following the initial intervention. These findings are consistent with



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the notion that ACT skills are broadly applicable, with benefits for people with and without significant psychological distress. Transdiagnostic Potential of ACT The ACT model is intended as a transdiagnostic intervention on the basis of the notion of psychological inflexibility as a pervasive process across mental health problems. Psychological inflexibility is related to a broad range of mental health symptoms (Levin, MacLane, et al., 2014) as well as to poor adaptive functioning (Hayes et al., 2013). ACT interventions have demonstrated medium to large effects on psychological inflexibility in recent meta-analyses (A-Tjak et al., 2015; Ruiz, 2012), and changes in psychological inflexibility appear to mediate outcomes in ACT trials (Hayes et al., 2013). A large body of evidence thus supports a central role of psychological inflexibility in psychological suffering. Very few studies have examined fully transdiagnostic applications of ACT. However, studies of ACT as applied across broad diagnostic categories lend support for the flexibility of the ACT model. Such studies have included outpatient clients with heterogeneous anxiety disorders (e.g., Arch et al., 2012); psychiatric hospital clients with mood, anxiety, personality, substance use, and painrelated disorders (Pinto et al., 2017); and college students with diverse mental health symptoms (Levin, Pistorello, et al., 2014; Räsänen et al., 2016). These studies indicate that although ACT resulted in overall improvements in psychological inflexibility as well as symptoms across samples, the effectiveness of ACT varied across clients (e.g., Pinto et al., 2017) and treatment modalities (e.g., Levin, Pistorello, et al., 2014). Further research on what conditions moderate the effectiveness of ACT will be necessary for fully evaluating its transdiagnostic effectiveness. The notion of psychological inflexibility as a transdiagnostic process can inform whether ACT is appropriate for a given client. Although there is insufficient evidence to suggest that psychological inflexibility is a central component across all mental health problems, extant evidence supports that targeting this process in a range of concerns can be effective. Thus, for many clients and presenting problems, clinicians may benefit from assessing psychological inflexibility as a constellation of problematic behavioral responses to symptoms. Based on this assessment, and in relation to the client’s unique goals, the clinician may then decide whether ACT is an appropriate treatment approach. When working with children or adolescents, the clinician may determine whether concurrent work with the child and their caregiver(s) on psychological inflexibility is warranted.

MECHANISMS OF ACTION Mediation studies also provide support for the use of psychological inflexibility as a transdiagnostic intervention target. Mediation analysis is used to test whether an intervention produces changes in a target mechanism or process

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(e.g., psychological inflexibility) and whether changes in the target mechanism or process result in changes in intervention outcomes (e.g., quality of life). Changes in psychological inflexibility have been shown to mediate outcomes in studies of ACT for depression (Zettle et al., 2011), mixed anxiety disorders (Arch et al., 2012), chronic pain (Wicksell et al., 2011), and various other mental health conditions (Hayes et al., 2013). This evidence suggests that reductions in psychologically inflexible behavior are associated with improvements in a variety of psychological problems.

DISSEMINATION Association for Contextual Behavioral Sciences ACT is disseminated in much the same way as other CBTs. There is a central organization, the Association for Contextual and Behavioral Sciences (ACBS) and ancillary ones such as the Association for Behavioral and Cognitive Therapies and the Association for Behavior Analysis International. ACBS was officially formed in 2005 after a couple of years of smaller conferences on ACT. In 2005, interested individuals agreed that an organization should be formed for the dissemination of contextual behavioral science ideas rooted in functional contextualism and associated areas including behavior analysis, RFT, and ACT, among many others. Many of the principles of ACBS focus on cooperation and a linear (as opposed to hierarchical) structure of membership. The idea that the group will succeed if as many people as possible have opportunities has always been central to ACBS. When the organization started, dues were “values based,” meaning that people gave what they thought they were getting out of the organization. Eventually, the base rate was matched to what it costs the organization to have a member, but that rate was still below 10 USD. Most pay much more, as the values-based rate still exits. The ACBS website is a wiki site; therefore, all pages (except the home page) may be edited by any member. This has resulted in impressive sharing of materials by members. For example, there are lengthy pages of manuals, measures, and client handouts available to any member to download and use. By allowing all members to participate freely, the wealth of knowledge quickly grows. In 2012, ACBS started a journal, the Journal of Contextual Behavior Science (JCBS). In 2021 this journal is on its 10th volume (i.e., 10th year), publishing four issues per year. Although the majority of the work published in this journal is not on ACT, it all is related to contextual behavioral science in some way. Thus, there are studies on ACT, studies on ACT processes of change, and translational research on contextual behavioral science topics. There is a yearly conference organized by ACBS that attracts approximately 1,000 professionals. As a means to increase dissemination, the conference alternates between North America and elsewhere. In addition, there are many special interest groups and chapters that hold their own conferences throughout the world. Some of the larger chapter conferences occur in Australia, New Zealand, the United Kingdom, and Scandinavia.



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Although there are many training workshops immediately before the ACBS conferences, ACT is also trained in single- or multiday trainings. A calendar for ACT trainings exists on the ACBS website (https://contextualscience.org). It should also be noted that ACBS allows for individuals who deliver trainings in ACT to be “peer reviewed.” This process is not accreditation, but rather, it allows trainers to be assessed for quality by their peers. A listing of trainers who have been evaluated as acceptable at training ACT by their peers is also available on the ACBS website. Resources Like most forms of well-developed psychotherapy, ACT has a large library of books on theoretical and applied issues. Interestingly, because ACT is the application of behavioral principles, it is utilized in many ways other than psychotherapy, including in sports, business, industrial organizational safety, curriculum design, and so on. There are also many books on the use of ACT with most diagnosable conditions. Although a variety of publishers of ACT research exist, New Harbinger is the leading publisher of ACT material. A noteworthy line of work is the testing of self-help books to treat psychological issues. To our knowledge there are at least eight randomized trials of bibliotherapy from a self-help book on ACT (including intervention with teachers and staff, foreign college students, anxiety disorders, depression, chronic pain, weight self-stigma, and problematic pornography use). The results of a recent meta-analysis (French et al., 2017) suggest that bibliotherapy alone or with the addition of support, either via phone or internet, demonstrates small, statistically significant effects compared with active control conditions (depression: Hedges’s g = 0.34; anxiety: g = 0.35; psychological flexibility: g = 0.42). The same meta-analysis shows supportive data on the use of ACT-based applications for smoking cessation with small to medium effects over control conditions (g  =  0.26–0.54; French et al., 2017). Work has also been done using applications for depression and anxiety in clients in therapy, health behaviors, and general mental health (e.g., Krafft et al., 2019; Levin et al., 2017). Similar support exists for ACT websites (French et al., 2017; Levin, Pistorello, et al., 2014). Finally, web-based technologies have also been used to disseminate ACT to professionals.

APPLICATION TO DIVERSE POPULATIONS There are many levels to consider when thinking about the application of a therapy to diverse populations. Cross-cultural psychology focuses on human actions as they are influenced by culture and society. How large or small one wants to go in this study depends on one’s goals. As this book will largely be utilized by individuals in North America, we might focus on the effects of cultures within North America and how that might affect the practices of a therapist in North America. Another view of culture as it pertains to psychology is

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cross-national research, which focuses on behavior of a larger sampling of individuals within a country. While not all within a nation share the same culture, there are elements that may be shared. Thus, whenever considering the role of culture in behavior and the corresponding use of psychotherapy with an individual, there are many cultural levels to which one should attend. Major cultural variables such as gender, sexual orientation, race, country of origin or residence, religion, and acculturation, though major variables, do not represent all the variables that are important to consider when conceptualizing a case and planning intervention. Although much of the preliminary development of ACT has occurred within North America by white cisgender men (who are mostly of high socioeconomic status) there has also been regard for cultural and national adaptions of ACT, as well as a notable amount of research on the applicability of ACT across cultural groups. The brief review in this chapter illustrates the positive steps forward that have been made by contextual behavioral science researchers, and the concluding paragraph of this section describes where greater advancements need to occur. The main measure of psychological inflexibility is the Acceptance and Action Questionnaire (AAQ). The original version was published in English in 2004 (Hayes et al., 2004) and was updated in 2011 (AAQ-II; Bond et al., 2011).Over time, the translation and validation of the AAQ has occurred in many languages. The ACBS website offers AAQs in 23 different languages as well as validation work in many of them. Countries where ACT is more established (e.g., Italy, Spain, Sweden) offer translated versions of many ACT measures. Rates are similar for books on ACT that are either translated from English or authored by native speakers of those languages. A review of ACBS membership as well as publications suggests that there is ACT work occurring in most countries, suggesting that experts in particular countries can adapt ACT to their cultures. The ultimate validity and success have been demonstrated in some, but not all, countries. Still, a key issue is the multicultural or cross-cultural adaption of ACT within North America. North America has a large amount of diversity, and this is where most of the early ACT development occurred; however, it was developed by, and researched on, rather homogeneous samples. A somewhat dated review showed that the majority of the research on ACT utilized White participants (Woidneck et al., 2012). A handful of studies had notable minority samples, and a couple of studies administered treatment through an interpreter. Thus, much more emphasis needs to occur at the research end on the use of ACT with particular diverse populations. Theoretical work has occurred on the use of ACT with particular diverse groups. An edited book focuses on cultural competency and the use of acceptance and mindfulness approaches (Masuda, 2014). There is writing on cultural adaptions of ACT, but much of the writing focuses on the use of ACT to promote cultural competency and undermine prejudice, stigma, and self-stigma (Krafft et al., 2017; Lillis & Hayes, 2007).



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CONCLUSION In summary, ACT is a modern contextual CBT with promising to strong empirical support for a wide range of psychological and behavioral health challenges. Research indicates that focusing on psychological flexibility processes specified in ACT with methods such as those covered in the case example can lead to meaningful improvements in psychosocial functioning, valued action, and psychological symptoms. ACT has become widely disseminated internationally and with an increasing emphasis on how to successfully implement this treatment in diverse populations and refine its procedures for specific problem areas. The success of ACT may be attributable to its unique development history and strategy, focused on carefully progressing and connecting the philosophy of functional contextualism, basic research in behavior analysis and RFT, and therapeutic processes of change specified in the psychological flexibility model.

REFERENCES A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. https://doi.org/10.1159/000365764 Arch, J. J., Eifert, G. H., Davies, C., Plumb Vilardaga, J. C., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750–765. https://doi.org/10.1037/a0028310 Bethay, J. S., Wilson, K. G., Schnetzer, L. W., Nassar, S. L., & Bordieri, M. J. (2013). A controlled pilot evaluation of acceptance and commitment training for intellectual disability staff. Mindfulness, 4(2), 113–121. https://doi.org/10.1007/s12671-0120103-8 Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. https://doi.org/10. 1016/j.janxdis.2014.06.008 Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5(1), 156–163. https://doi.org/10.1037/1076-8998.5.1.156 Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. https:// doi.org/10.1016/j.beth.2011.03.007 Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour Research and Therapy, 49(6–7), 389–398. https://doi. org/10.1016/j.brat.2011.03.009 Coyne, L. W., McHugh, L., & Martinez, E. R. (2011). Acceptance and commitment therapy (ACT): Advances and applications with children, adolescents, and families.

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Child and Adolescent Psychiatric Clinics of North America, 20(2), 379–399. https://doi.org/ 10.1016/j.chc.2011.01.010 Flaxman, P. E., & Bond, F. W. (2010). A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training. Behaviour Research and Therapy, 48(8), 816–820. https://doi.org/10.1016/j.brat.2010.05.004 French, K., Golijani-Moghaddam, N., & Schröder, T. (2017). What is the evidence for the efficacy of self-help acceptance and commitment therapy? A systematic review and meta-analysis. Journal of Contextual Behavioral Science, 6, 360–374. https://doi. org/10.1016/j.jcbs.2017.08.002 Frögéli, E., Djordjevic, A., Rudman, A., Livheim, F., & Gustavsson, P. (2016). A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses. Anxiety, Stress, and Coping, 29(2), 202–218. https://doi.org/f3m48s Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639– 665. https://doi.org/drnft9 Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. Kluwer Academic/Plenum Publishers. https://doi.org/10.1007/b108413 Hayes, S. C., Brownstein, A. J., Haas, J. R., & Greenway, D. E. (1986). Instructions, multiple schedules, and extinction: Distinguishing rule-governed from schedulecontrolled behavior. Journal of the Experimental Analysis of Behavior, 46(2), 137–147. https://doi.org/10.1901/jeab.1986.46-137 Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180–198. https://doi.org/10.1016/j.beth.2009.08.002 Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M. A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., Forsyth, J. P., Karekla, M., & McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54(4), 553–578. https://doi.org/10.1007/BF03395492 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press. Hayes, S. C., Villatte, M., Levin, M., & Hildebrandt, M. (2011). Open, aware, and active: Contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annual Review of Clinical Psychology, 7, 141–168. https://doi.org/10.1146/ annurev-clinpsy-032210-104449 Krafft, J., Ferrell, J., Levin, M. E., & Twohig, M. P. (2017). Psychological inflexibility and stigma: A meta-analytic review. Journal of Contextual Behavioral Science, 7, 15–28. https://doi.org/10.1016/j.jcbs.2017.11.002 Krafft, J., Potts, S., Schoendorff, B., & Levin, M. E. (2019). A randomized controlled trial of multiple versions of an acceptance and commitment therapy matrix app for well-being. Behavior Modification, 43, 246–272. https://doi.org/10.1177/ 0145445517748561 Levin, M. E., Haeger, J., Pierce, B., & Cruz, R. A. (2017). Evaluating an adjunctive mobile app to enhance psychological flexibility in acceptance and commitment therapy. Behavior Modification, 41(6), 846–867. https://doi.org/10.1177/ 0145445517719661 Levin, M. E., MacLane, C., Daflos, S., Seeley, J., Hayes, S. C., Biglan, A., & Pistorello, J. (2014). Examining psychological inflexibility as a transdiagnostic process across



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psychological disorders. Journal of Contextual Behavioral Science, 3(3), 155–163. https://doi.org/10.1016/j.jcbs.2014.06.003 Levin, M. E., Pistorello, J., Seeley, J. R., & Hayes, S. C. (2014). Feasibility of a prototype web-based acceptance and commitment therapy prevention program for college students. Journal of American College Health, 62(1), 20–30. https://doi.org/fjkb Lillis, J., & Hayes, S. C. (2007). Applying acceptance, mindfulness, and values to the reduction of prejudice: A pilot study. Behavior Modification, 31(4), 389–411. https:// doi.org/10.1177/0145445506298413 Luoma, J. B., & Vilardaga, J. P. (2013). Improving therapist psychological flexibility while training acceptance and commitment therapy: A pilot study. Cognitive Behaviour Therapy, 42(1), 1–8. https://doi.org/ggd6k4 Masuda, A. (2014). Mindfulness and acceptance in multicultural competency: A contextual approach to sociocultural diversity in theory and practice. New Harbinger Publications. McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178–187. https://doi.org/10.1037/a0035623 Moran, D. J. (2011). ACT for leadership: Using acceptance and commitment training to develop crisis-resilient change managers. International Journal of Behavioral and Consultation Therapy, 7(1), 66–75. https://doi.org/10.1037/h0100928 Murrell, A. R., & Scherbarth, A. J. (2006). State of the research & literature address: ACT with children, adolescents and parents. International Journal of Behavioral and Consultation Therapy, 2(4), 531–543. https://doi.org/10.1037/h0101005 Pahnke, J., Lundgren, T., Hursti, T., & Hirvikoski, T. (2014). Outcomes of an acceptance and commitment therapy-based skills training group for students with highfunctioning autism spectrum disorder: A quasi-experimental pilot study. Autism, 18(8), 953–964. https://doi.org/10.1177/1362361313501091 Pinto, R. A., Kienhuis, M., Slevison, M., Chester, A., Sloss, A., & Yap, K. (2017). The effectiveness of an outpatient acceptance and commitment therapy group programme for a transdiagnostic population. Clinical Psychologist, 21(1), 33–43. https:// doi.org/10.1111/cp.12057 Räsänen, P., Lappalainen, P., Muotka, J., Tolvanen, A., & Lappalainen, R. (2016). An online guided ACT intervention for enhancing the psychological wellbeing of university students: A randomized controlled clinical trial. Behaviour Research and Therapy, 78, 30–42. https://doi.org/10.1016/j.brat.2016.01.001 Ruiz, F. J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta-analysis of current empirical evidence. International Journal of Psychology & Psychological Therapy, 12(3), 333–357. Scent, C. L., & Boes, S. R. (2014). Acceptance and commitment training: A brief intervention to reduce procrastination among college students. Journal of College Student Psychotherapy, 28(2), 144–156. https://doi.org/10.1080/87568225.2014. 883887 Tórneke, N., Luciano, C., & Salas, S. V. (2008). Rule-governed behavior and psychological problems. International Journal of Psychology & Psychological Therapy, 8(2), 141–156. Varra, A. A., Hayes, S. C., Roget, N., & Fisher, G. (2008). A randomized control trial examining the effect of acceptance and commitment training on clinician willingness to use evidence-based pharmacotherapy. Journal of Consulting and Clinical Psychology, 76(3), 449–458. https://doi.org/fczgrs Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (2011). Mediators of change in acceptance and commitment therapy for pediatric chronic pain. Pain, 152(12), 2792–2801. https://doi.org/10.1016/j.pain.2011.09.003 Woidneck, M. R., Pratt, K. M., Gundy, J. M., Nelson, C. R., & Twohig, M. P. (2012). Exploring cultural competence in acceptance and commitment therapy outcomes. Professional Psychology: Research and Practice, 43(3), 227.

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Zettle, R. D. (2005). The evolution of a contextual approach to therapy: From comprehensive distancing to ACT. International Journal of Behavioral and Consultation Therapy, 1(2), 77–89. https://doi.org/10.1037/h0100736 Zettle, R. D., & Hayes, S. C. (1983). Effect of social context on the impact of coping self-statements. Psychological Reports, 52(2), 391–401. https://doi.org/10.2466/pr0. 1983.52.2.391 Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason-giving. Analysis of Verbal Behavior, 4(1), 30–38. https://doi.org/ 10.1007/BF03392813 Zettle, R. D., Rains, J. C., & Hayes, S. C. (2011). Processes of change in acceptance and commitment therapy and cognitive therapy for depression: A mediation reanalysis of Zettle and Rains. Behavior Modification, 35(3), 265–283. https://doi.org/10.1177/ 0145445511398344

20 Mindfulness-Based Cognitive Therapy Amanda Ferguson, Lê-Anh Dinh-Williams, and Zindel Segal

D

epression continues to be one of the leading causes of disability worldwide for both men and women, despite the availability of efficacious pharmacological and psychotherapeutic treatments (World Health Organization, 2012). Global prevalence rates for major depressive disorder (MDD) range from 3% to 13% (Gelenberg, 2010; Richards, 2011), and lifetime risk of MDD in the U.S. is estimated at 17% to 19% (Kessler et al., 1994). The chronic and recurrent nature of depression presents a unique set of challenges for treatment developers. Individuals who have recovered from a major depressive episode are 40% to 50% more likely to experience a second episode, and for those with two or more episodes, relapse rates are as high as 60% to 70% (Judd, 1997; Solomon et al., 2000). MDD is often characterized by its multiple phases, including an acute phase, treatment response, episode relapse, and episode recurrent (Frank et al., 1991). Thus, contemporary approaches have emphasized the utility of sequential treatment algorithms in which the effective management of MDD utilizes treatment strategies that are specific to each phase. An interesting corollary of this strategy is that interventions used to attain treatment response and remission may not resemble those put in place to sustain recovery (Guidi et al., 2016). At present, antidepressant medication (ADM) and psychotherapy (e.g., cognitive behavioral therapy [CBT]) have proven to be the most effective treatments for the acute phase of depressive illness, each demonstrating approximately 40% to 50% recovery rates (Hollon et al., 2006). Until recently, the most widely supported approach for prevention of relapse/recurrence in formerly depressed patients has been https://doi.org/10.1037/0000218-020 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  595 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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maintenance antidepressant medication (mADM; Geddes et al., 2003), although CBT for the acute phase of depression has also been shown to provide patients with protective benefits that endure beyond the point at which therapy is terminated (Hollon et al., 2005). One of the limitations of relying solely on ADM for preventing relapse/ recurrence in depression is that the rates of treatment compliance for long-term use tend to be low (Samples & Mojtabai, 2015). Patients may view themselves as “well” following symptom remission and may believe that long-term mADM is unnecessary in light of the costs and/or high side effect burden associated with persistent use. Moreover, it is possible that the efficacy of the drug eventually fades over time or that pregnancy concerns in women may preclude them from being candidates for mADM. Taken together, these factors may leave many formerly depressed patients “uncovered” during a period where their risk of relapse/recurrence is quite high. It was against this backdrop that Segal et al. (2002, 2013) sought to develop a maintenance version of CBT that could offer a psychotherapeutic alternative to mADM for the prevention of depression. Treatment development was informed by Beck’s model of cognitive vulnerability, which postulated that depressogenic thinking patterns (e.g., negative views of the self, others, and future) could be retriggered in recovered patients when they experienced transient setbacks or dysphoric moods (Beck, 1976). It was argued that this pattern of cognitive reactivity could promote the return of depressive symptoms if left unaddressed. Indeed, experimental tests of Beck’s formulation have shown that triggering mild dysphoria in formerly depressed patients activates thinking patterns similar to those previously present during the acute phase of a depressive episode, whereas never-depressed control subjects do not change their thinking style when triggered (Ingram et al., 2011). The experimental literature on mood-related cognitive changes in remitted depressed patients provided further support for this idea (Segal et al., 1996; Teasdale et al., 1995). Indeed, there is now good evidence that the negative thinking patterns activated by dysphoric mood in formerly depressed individuals intensifies the dysphoric state by escalating self-perpetuating cycles of ruminative cognitive-affective processing (Teasdale, 1988), increasing the risk of subsequent relapse. Segal et al. (2006) reported that patients with increased mood-linked cognitive reactivity had a 69% relapse rate, compared with those with minimal or decreased reactivity, who had relapse rates of 30% and 32%, respectively, over an 18-month follow-up (Segal et al., 2006). These data illustrate the importance of addressing mood-linked changes in cognitive processing among formerly depressed patients to reduce their risk of relapse/recurrence. In line with this work, Segal et al. (2002, 2013) sought to develop an intervention that helped build metacognitive skills in formerly depressed patients in order to preempt the establishment of such dysfunctional processing cycles. Metacognitive skills refer to the ability to be acutely aware of patterns of thinking in the moment and to observe rather than identify with these internal experiences; this ability is believed to play a pivotal role in adaptive responses to stressors and emotion regulation more generally (Farb et al., 2017; Teasdale et



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al., 2002). Applied to relapse prevention, it was proposed that the risk of relapse and recurrence would be reduced if previously depressed patients could learn, first, to be more aware of negative thoughts and feelings when they arise (e.g., “I can’t do anything right”) and, second, to view these thoughts and feelings as mental events, allowing them to disengage from ruminative depressive thinking and feelings (Nolen-Hoeksema, 1991; Williams et al., 2000). Mindfulness based cognitive therapy (MBCT) was designed to achieve these aims through the practice of traditional contemplative practices such as mindfulness meditation (Segal et al., 2002, 2013; Teasdale et al., 1995).

MBCT COMPONENTS AND STRUCTURE The MBCT program combines elements of Jon Kabat-Zinn’s (1990) Mindfulnessbased stress reduction (MBSR) program and standard cognitive techniques for relapse prevention. These components are described in this section. Mindfulness Training Mindfulness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to things as they are” (Williams et al., 2007, p. 47). The mindfulness training in MBCT was drawn largely from MBSR and includes both formal and informal meditative practices to help cultivate metacognitive awareness and mindfulness (see Table 20.1 for full descriptions of each meditative practice taught in MBCT). Formal meditations refer to practices that typically require an extended commitment of time (e.g., from 20 minutes to several hours) and focus on one feature of present-moment experience, such as the breath, an aspect of sensation, stillness, or the body as a whole. Examples of formal mindfulness practices in MBSR and MBCT include sitting meditation, walking meditation, body scan meditation, and gentle yoga practices. During informal meditations, participants are asked to mindfully approach daily activities that might otherwise be completed on “automatic pilot,” that is, performed without conscious intention or awareness. For instance, participants may be asked to pay attention with purpose to the features of an everyday activity, such as washing the dishes, that are often overlooked, such as noticing the water (e.g., its texture and warmth; see Table 20.1). The MBCT program also teaches the 3-minute breathing space as a strategy for dealing with everyday stress. The 3-minute breathing space is designed to facilitate present-moment awareness of the thoughts, emotions, sensations, or behaviors that arise during times of emotional challenge (Segal et al., 2002, 2013). In sum, these brief informal meditations consist of practicing mindfulness in the context of one’s everyday life. Different formal and information meditations are assigned to specific sessions and designed to introduce participants to a variety of practices (see Table  20.1). Ultimately, the hope is that these practices will help increase

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TABLE 20.1. Descriptions of Formal and Informal Meditative Practices in Mindfulness-Based Cognitive Therapy Meditation Mindful eating (raisin exercise)

Type Formal

Body scan

Formal

Mindful stretching (Hatha yoga)

Formal

Walking meditation

Formal

Sitting meditaFormal tion (focused attention)

Sitting meditation (open monitoring)

Formal

Mindfulness of daily activities

Informal

3-minute breathing space

Informal

Session Description number Exploring an often overlooked experience (e.g., 1 eating a raisin) with all of your senses. Individuals will often start by observing the raisin visually, followed by observing the smell, sound, touch, and taste. During this time, participants are encouraged to observe any thoughts or judgments that arise during the experience of mindful eating. Practicing the ability to pay attention with 1, 2, 8 purpose to one body part at the time. Participants will typically start by paying attention to sensations in their toes and gradually move their attention with guidance to various areas of the body. Following a sequence of gentle stretching 3 exercises and yoga poses to help loosen the body and cultivate greater flexibility and strength, all while noticing the breath and sensations in the body as they arise. Moving slowly and noticing the different 3 sensations associated with the experience of walking, such as those that arise at the bottom of their feet as their weight shifts, the contact of their feet on the ground, sensations in the legs while lifting feet gently off the ground, etc. Bringing attention to the breath, noticing the 3–6 quality of each in breath and out breath. When the mind wanders, meditators are to briefly notice what it is that took the mind away, then gently bring the attention back to breathing. In open monitoring meditation, there is no 7 object in the internal or external environment. Rather, the aim is to remaining attentive to any experience that may arise, without selecting, judging, or focusing on any particular object. Mindfully approaching daily activities that 1–8 might otherwise be completed on “automatic pilot.” For instance, participants may be asked to pay attention with purpose to the features of an everyday activity that are often overlooked, such as noticing the water, its texture and warmth, while washing the dishes. Briefly practicing mindfulness to help step away 3 from being in automatic pilot and shift attention to internal present-moment experiences by noticing mental content (e.g., current thoughts and feelings, “what is going through your mind?”), followed by the breath and body.



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TABLE 20.1. Descriptions of Formal and Informal Meditative Practices in Mindfulness-Based Cognitive Therapy (Continued) Meditation Brief mindfulness of seeing and/ or hearing

Type Informal

3-minute coping Informal space

Description Paying attention to sights, such as the shape, pattern, movement, and color of common objects in the current environment. Paying attention to sounds in the room and letting go of usual categories used to make sense of what is heard, concentrating on the patterns of pitch, tone, and volume. Similar to the 3-minute breathing space; noticing unpleasant thoughts and feelings, and redirecting your attention to the breath and sensations in the body.

Session number 3

5

mindfulness skills over time and that participants will be able to identify at least one practice they are likely to continue following treatment. Mindfulness training is viewed as an essential therapeutic ingredient of MBCT and relapse prevention through the cultivation of (a) focused attention, which includes the ability to observe the moment-by-moment structure and content of one’s internal experience, notice when the mind wanders, and bring one’s attention back to the defined target of attention (e.g., the breath), and (b) a nonjudgmental attitude, marked by an openness, curiosity, kindness, and flexibility during present-moment experiences. Focused attention is invaluable for metacognition, or the ability to guide attention toward the ongoing monitoring of thoughts, feelings, and sensations as they arise. This has the potential for creating distance between events and automatic/habitual responses that may tend to spiral downward into ruminative thinking, depressogenic cognitions, and low mood. Approaching present-moment experiences in a nonjudgmental, curious manner adds a layer of protection against relapse vulnerability because it encourages individuals to simply observe thoughts and feelings as mental events. These strategies cultivate the understanding that thoughts and feelings are not facts but momentary events in the mind. Cognitive Behavioral Training The CBT components of the MBCT program include psychoeducation about automatic thoughts and depressive thinking patterns. Automatic thoughts refer to the thoughts, interpretations, images, or judgments that arise almost instantaneously in response to an event. Building awareness of automatic thoughts when they arise and the ways in which they influence depressive thinking patterns is viewed as a key therapeutic ingredient in MBCT. Midway through the program, participants are introduced to the concept of automatic thoughts, types of negative thinking patterns, and automatic thoughts associated with depression, with the aim of recognizing the ways in which automatic thoughts can be affected by situations and moods. The importance of noticing these thought patterns in the moment and the ways in which participants can

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question automatic thoughts are discussed as a group. In addition to depressive thoughts, participants are encouraged to identify their unique depressive behaviors and “relapse signature” and set in place an action plan for use when experiencing low mood. For example, some individuals may notice that they are waking up earlier in the morning than usual or turning down social invitations and preferring to stay home by themselves. These changes would be highlighted as harbingers of a relapse; participants could recognize them sooner as possible symptoms and take action to prevent them from building momentum toward a full depressive episode. Participants are also encouraged to identify people who can provide emotional support, as well as activities over which they feel a sense of mastery or pleasure. Taken together, the skills taught in the MBCT program are designed to help participants differentiate their experience of depression from their conception of the self (e.g., viewing thoughts as passing mental events rather than facts or truths). Participants are encouraged to relate to the change and flux of bodily sensations, feelings, and thoughts with a nonjudgmental, compassionate, and accepting attitude. These skills reduce the risk of ruminative cognitive-affective cycles that tend to follow low mood and promote conditions of vulnerability for the return of depression. Ultimately, the goal of this program is to provide formerly depressed patients with a “relapse toolkit” to be used during periods of vulnerability. Assessment and Eligibility MBCT was specifically designed and evaluated for the prevention of relapse to depression. Because of the demands of the MBCT program (e.g., in terms of patience, time commitment), individual eligibility should be determined in an initial assessment interview. First, depression status and symptom severity are usually measured by a brief self-report scale such as the Beck Depression Inventory-II (BDI-II; Beck et al., 1996) or the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001). Second, the extent to which an individual is able meet the demands of the program must be determined. For example, the time demand for patients can run to 45 minutes of home practice each day. From a diagnostic perspective, individuals who are actively suicidal, currently abusing substances, have untreated trauma, or carry a diagnosis of borderline personality disorder (BPD), should be directed to seek alternate care. Although there have been some recent studies examining its potential for the treatment of various disorders, including disorders associated with trauma, there is no evidence yet to suggest that MBCT is more efficacious than CBT or dialectical behavior therapy (DBT) for the treatment of these active clinical conditions. For instance, King et al. (2013) noted that MBCT was more efficacious than treatment-as-usual for the relief of posttraumatic symptoms in a sample of combat veterans, suggesting that it is potentially therapeutic and does not result in further harm. The issue is that there is no clear understanding of whether these gains are inferior, equal, or better than what would be observed following



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current gold standards of care (e.g., cognitive processing therapy, a specific cognitive behavior for the treatment of posttraumatic stress disorder). Moreover, although mindfulness training is a core component of DBT, it is not viewed as the sole therapeutic ingredient of DBT, nor is it provided in a similar format; mindfulness practices as they are taught in DBT are generally informal and brief in comparison to those in MBCT, and individuals engaged in DBT are not expected to practice formal meditations on a daily basis as they are in MBCT. Training in distress tolerance, emotion regulation, and interpersonal effectiveness, in addition to mindfulness, are considered essential to DBT’s effectiveness. MBCT does not explicitly address these additional components and, thus, may not be adequately suited for the treatment of emotion dysregulation and the BPD clinical presentation as compared with DBT, although this has yet to be formerly examined. Instructor Qualification Instructors of MBCT are required to work within dual domains of guiding mindfulness meditation and delivering CBT techniques. This balance requires particular training and skills. In recognition of this need, a standardized set of training experiences are outlined in the MBCT Training Pathway (Segal et al., 2016) including the following: (a) training as a mental health professional, including experience with evidence-based treatments for depression; (b) attending an intensive, week-long MBCT teacher development course; (c) experiencing as a participant observer in an MBCT group; (d) leading MBCT groups and receiving supervision; and (e) most importantly, an ongoing personal practice of mindfulness meditation. Session Structure MBCT comprises eight group sessions of approximately 2 to 2.5 hours’ duration, with each focusing on a different core theme. See Table 20.2 for a description of each session’s theme and its possible overlap with concepts from CBT. Fundamental to the MBCT program is its group-based inquiry process, wherein participants’ thoughts, emotions, sensations, and other observations that arose during the meditative practice are elicited and probed by the group facilitator following each practice to enhance the observation of mental contents. As such, MBCT in its formal structure is not offered on an individual basis, though certain elements of MBCT are easily transferable to an individual treatment setting. For example, an experienced clinician can lead a short meditation during an individual session and discuss the experience afterward with the client. Similarly, the psychoeducational and cognitive components of MBCT (e.g., creating a relapse prevention plan) are easily adaptable to an individual treatment context. Session 1 is largely devoted to introductions and a review of the administrative issues (e.g., confidentiality). A mindful eating exercise is introduced, as is

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TABLE 20.2. Provisional Mapping of Mindfulness-Based Cognitive Therapy (MBCT) Session Themes Onto Related Cognitive Behavioral Therapy Concepts MBCT session

MBCT core theme

Possible overlap with cognitive behavioral therapy

1

Awareness and automatic pilot

How automatic thoughts and automatic information processing affect mood

2

Living in our heads

Psychoeducation with respect to the Action-Belief-Consequence (ABC) model of situation-thought-feeling

3

Gathering the scattered mind

Building awareness through the first three columns of the thought record

4

Recognizing the territory of aversion

Becoming familiar with depressive symptoms and thought patterns

5

Allowing/letting be

Using these skills during situations that carry an emotional charge

6

Thoughts are not facts

Treating thoughts as ideas or hypotheses to be tested

7

How can I best take care of myself?

Understanding behavioral routines and constructing a relapse prevention plan

8

Maintaining and extending new learning

Emphasizing continued practice of therapy skills once the program has ended

the body scan (see Table 20.1 for description of meditative practices). The remaining sessions follow a consistent format. The sessions begin with a meditation exercise (e.g., body scan, sitting meditation) to facilitate the transition from daily life to present moment awareness. Next, the instructor facilitates a group discussion of the meditative experience. The previous week’s homework is reviewed, and content related to recognizing and regulating pleasant/ unpleasant experiences, including thoughts and emotions, is presented. Toward the end of each session, new home practice is assigned. Similarities and Differences Between MBCT and CBT MBCT, like CBT, emphasizes the importance of recognizing symptoms of depression as they develop. In both treatment modalities, individuals are taught to identify the experience of automatic negative thoughts and to monitor their thoughts and feelings during unpleasant events. In MBCT, these strategies are intended to help the individual stay aware in the moment and ultimately allow for the identification of deteriorating mood. In CBT, individuals are taught to create an action plan for self-care during times of stress and negative mood. Both CBT and MBCT stress the importance of experiential learning outside of the therapy hour or group, and likewise emphasize the utility of homework. There is good evidence demonstrating a relation between homework compli-



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ance and outcome following CBT, such that individuals who report high level of homework compliance also demonstrate more positive treatment outcomes (e.g., Kazantzis et al., 2000). The effects of homework in MBCT are still being investigated. There are studies documenting clinical gains associated with the practice frequency of mindfulness meditation (Crane et al., 2014), but some studies have also failed to find this association (MacCoon et al., 2012). An important difference between CBT and MBCT is the relative locus of change. The target of CBT is negative thinking (i.e., the thoughts themselves), and the goal is to change the contents of those thoughts. MBCT uses an acceptance/willingness-based approach in which negative thoughts need not be changed but simply acknowledged and observed. Whereas the mechanism underlying CBT is change-based, the MBCT approach utilizes metacognitive skills (e.g., observing thoughts in a nonjudgmental and nonreactive fashion) and “letting be” so that negative thoughts can be noticed and accepted as passing events occurring in the mind, rather than permanent facts about the self, others, and the future. Further differences between MBCT and CBT include the latter’s method of purposefully exposing individuals to problematic situations or conducting behavioral experiments. In MBCT, individuals do not complete specific exposure assignments, but they are invited to attend to and examine positive or negative experiences as arise throughout the day. The intention here is to develop the capacity to generate curiosity, rather than judgment, toward all manner of experience regardless of valance.

OUTCOME DATA Early trials of MBCT established this approach as an efficacious prophylactic treatment for depressive relapse (Ma & Teasdale, 2004; Teasdale et al., 2000). In the initial multicenter trial by Teasdale et al. (2000), individuals were randomized into either MBCT or treatment-as-usual (TAU) conditions (N = 145). Participants were in remission from depression, but they had a history of at least two previous episodes. Those in the TAU condition were instructed to seek support from their physician or community sources as they normally would. Those in the MBCT condition participated in eight weekly group sessions, plus four follow-up sessions scheduled at 1-, 2-, 3-, and 4-month intervals. Both groups were followed for a total of 60 weeks. Severity of depressive symptoms and relapse were evaluated with the Structured Clinical Interview for DSM Disorders (SCID; First et al., 1996), and the primary outcome measure was whether and when participants experienced relapse (i.e., met criteria for a major depressive episode according to the Diagnostic and Statistical Manual of Mental Disorders [DSM]). In each condition, participants were stratified according to the number of previous episodes (two vs. three or more) they had experienced. Results revealed differential treatment outcomes as a function of the number of prior depressive episodes participants had experienced. For individuals who had two or fewer past episodes, there were no differences between

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MBCT and TAU in terms of relapse rates at 15 months. However, in the sample of individuals with three or more previous episodes (77% of the overall sample), there was a significant benefit of MBCT. Using intention-to-treat (ITT) analyses, relapse was observed in only 34% of the MBCT group, whereas relapse was observed in 66% of those in the TAU condition. These findings were replicated in a smaller single-site trial (N = 75; Ma & Teasdale, 2004). It is still unclear what the cardinal differences are between these two past-episode defined groups, other than recognizing that they may come from populations with different risk profiles and that the more vulnerable patients showed greater treatment gains. What also is still unclear is the extent to which this vulnerability is driven by psychological factors such as higher rumination, childhood maltreatment (Williams et al., 2014), and/or genetic and neurobiological factors associated with mood disorders in general. Segal et al. (2010) conducted a randomized controlled trial (RCT) comparing MBCT with mADM and a placebo medication. Participants in this trial had been on an ADM regimen for the previous 8 months. Of the original sample (N = 165), 84 individuals achieved remission and were assigned to one of the study conditions. Participants were further categorized according to the “stability” of their remission states during the acute phase of treatment for depression, as determined by symptom elevations on the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960). Unstable remitters (51% of the sample), compared with stable remitters (49% of the sample), were those who experienced “symptom flurries,” or occasional, transient symptom elevations on the HRSD. Stable remitters (49% of the sample) had no such elevations. For stable remitters, ITT analyses demonstrated no difference in relapse rates across treatments. For unstable remitters, ITT results revealed comparable rates of relapse in the MBCT condition (28%) and the mADM condition (27%), but a much higher rate in the placebo condition (71%). The authors concluded that the MBCT provided protective benefits for remitted individuals consistent with those conferred by maintenance pharmacotherapy, and that these treatments were particularly effective for individuals with a history of unstable remission. More recently, Farb et al. (2017) reported results of the first study to directly compare relapse prophylaxis following MBCT and CBT. The authors evaluated rates of relapse in remitted depressed patients (N = 166) receiving MBCT and CBT with a well-being focus (CBT-WB; Fava et al., 1998). Participants were followed for 24 months, with process markers measured every 3 months. ITT analyses indicated no differences between MBCT and CBT-WB in either rates of relapse to MDD or time to relapse across follow-up. Decentering (i.e., putting space between one’s concept of self and their emotional experience) and dysfunctional attitudes were also assessed as treatment-specific process markers. Individuals in both the MBCT group and the CBT-WB group reported significant increases in decentering, and participants in CBT-WB reported greater reductions in dysfunctional attitudes. Within both treatments, participants who relapsed reported lower decentering scores than those who stayed well over the follow-up period. The lack of group differences between MBCT and CBTWB reported in Farb et al. (2017) supports the view that both interventions are



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efficacious and that increases in decentering achieved via either treatment are associated with greater protection. Several independent trials have found further support for the efficacy of MBCT in preventing relapse. Beneficial outcomes, such as longer periods of wellness between episodes of depression, reduced residual depressive symptoms, and lowered rates of relapse (in the range of 50%), have been observed in MBCT treatment groups (Bondolfi et al., 2010; Geschwind et al., 2011; Godfrin & van Heeringen, 2010; Kuyken et al., 2008, 2010, 2015). A recent meta-analysis examined the efficacy of MBCT in preventing relapse to depression when compared with active treatments, including TAU (Kuyken et al., 2016). The authors examined individual patient-level data for nine RCTs (N = 1,329) conducted by different research groups and using a range of European and North American participants. Compared with those enrolled in other depression treatments, individuals who completed MBCT had a significantly reduced risk of depressive relapse over a 60-week follow-up period (hazard ratio = 0.69, 95%CI [0.58, 0.82]). When compared with ADM treatment alone (N = 637), MBCT reduced the risk of relapse (hazard ratio = 9.7, 95%CI [0.60, 0.98]). Importantly, the treatment effect of MBCT on risk of relapse was larger in participants who reported more severe depression at baseline, as compared with participants with more severe depression in non-MBCT conditions. Consistent with the findings of Teasdale et al. (2000), these results suggest that MBCT may be particularly helpful for individuals with higher levels of residual depressive symptoms. Although MBCT was specifically designed for individuals in remission for depression, it has been applied to the treatment of several other disorders with hypothetically similar underlying mechanisms. For example, it can be argued that anxiety and pain disorders are maintained by rumination, avoidance, and hypervigilance to body sensations, all of which are targeted by MBCT. A recent RCT (N = 182) compared a modified version of MBCT with CBT-based psychoeducation and TAU in the treatment of generalized anxiety disorder (GAD; Wong et al., 2016; see also Evans et al., 2008). Modifications to the MBCT protocol (specifically the CBT components therein) were undertaken to make the intervention particularly suitable for people with anxiety disorders (e.g., discussing automatic thoughts related to anxiety, developing action plans to prevent avoidance and symptom return). Results revealed significant benefits of both the MBCT and psychoeducational treatments when compared with TAU in symptom reduction (i.e., anxiety level, worry). Similar results have been demonstrated for the treatment of health anxiety/hypochondriasis (McManus et al., 2012) and perinatal depression (Dimidjian et al., 2016). For example, in a recent RCT (N = 74) that compared MBCT for hypochondriasis to TAU, participants who completed MBCT were significantly less likely to meet criteria for the diagnosis of hypochondriasis than those in the TAU condition (McManus et al., 2012). This was true immediately following treatment (50.0% vs. 78.9%) and at a 1-year follow-up (36.1% vs. 76.3%). The authors concluded that MBCT was an acceptable and beneficial treatment for patients with health anxiety.

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MECHANISMS OF CHANGE Van der Velden et al. (2015) published a systematic review summarizing the findings of 23 studies examining the mechanisms of change underlying MBCT. The authors reviewed whether changes in certain psychological processes (i.e., those that are theoretically understood as the therapeutic ingredients of MBCT) were related to the return of depressive symptoms following treatment, including (a) increases in mindfulness and metacognitive skills (e.g., meta-awareness and decentering) and (b) reductions in depressogenic cognitions (e.g., tendency to engage in rumination, worry, low self-compassion, or suppression of negative emotions/thoughts) and the degree of cognitive reactivity to stressors or low mood. Moreover, this review highlighted evidence for additional areas of change that may similarly influence the risk of relapse following treatment, such as (a) the quality of memory formations and retrieval, which tend to be overly general and negative in those vulnerable to depression; (b) attention regulation; (c) specificity of life goals and goal attainment; and (d) the frequency and quality of negative and positive emotions. In line with the theoretical predicted mechanisms of change, this review concluded that there was significant evidence that changes in mindfulness, metacognitive skills, and depressogenic cognitions predicted or mediated the effects of MBCT on treatment outcome. More specifically, 12 studies found evidence for these mechanisms of change on subsequent relapse risk or depressive symptoms at posttreatment, whereas only two studies reported no significant effects. Differences between these findings may reflect differences in the measures utilized to capture these psychological processes, as well as differences in participant inclusion criteria. For example, in a study by Williams et al. (2014), training in mindfulness appeared to be important for reducing the risk of relapse, but only for those most vulnerable to chronic depression. More specifically, the authors of this study conducted a large dismantling trial comparing MBCT with TAU and a cognitive psychoeducation program (CPE) that was matched to MBCT on key nonspecific and specific factors but excluded training in mindfulness meditation. The aim here was to isolate the contribution of one of MBCT’s hypothesized therapeutic ingredients—training in mindfulness meditation—on treatment outcomes. This study did not find any significant advantages of MBCT over CPE or TAU, suggesting that mindfulness skills may not provide any additional protection against relapse. However, the authors reported the interesting finding that, for individuals with a history of childhood trauma, MBCT (and mindfulness training) was significantly more effective at curbing this risk of relapse than CPE and TAU. These results suggest that changes in mindfulness and metacognitive skills following MBCT may be mechanisms of change that are particularly crucial for populations that are most at risk of reexperiencing depression (e.g., individuals with a history of three or more episodes, patients with a history of childhood trauma). With regard to cognitive reactivity, Kuyken et al. (2010) investigated whether changes in cognitive reactivity, measured by assessing the degree of



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depressive cognitions following a dysphoric mood induction, mediated the effects of MBCT on subsequent relapse risk. MBCT was compared with a control group composed of participants on a regime of mADM. Contrary to expectations, this study found that MBCT participants demonstrated greater cognitive reactivity posttreatment compared with the mADM group. However, cognitive reactivity predicted poorer outcome only for the mADM group and not for the MBCT group. This pattern of results suggests that MBCT may not reduce the automatic nature of cognitive reactivity in formerly depressed patients, but it may help prevent these depressogenic cognitions from escalating into a selfperpetuating cycle of dysfunctional ruminative cognitive-affective processing that promotes a persistent vulnerability to depression. Indeed, the authors found that increases in self-compassion “nullified” the relation between increased cognitive reactivity and relapse risk in the MBCT group. In other words, it appears that MBCT may help to prevent the return of depressive symptoms by enabling patients to greet the onset of negative events, thoughts, and feelings with self-compassion and acceptance rather than identifying and ruminating over the content of these negative experiences. The review by van der Velden et al. (2015) reported that eight studies demonstrated changes in memory specificity, goal achievement, attention regulation, emotional reactivity, and momentary positive and negative affect following MBCT and that these changes may provide protection against the return of depressive symptoms. Williams et al. (2000) demonstrated that MBCT was associated with a decrease in overgeneral autobiographical memory and an increase in memory specificity, wherein autobiographical information was richer in detail compared with a TAU control group. Crane et al. (2012) found that MBCT helped increase the specificity of life goals and belief that these goals were attainable—an optimistic outlook that is associated with resilience and reduced risk of relapse (Crane et al., 2012). Bostanov et al. (2012) found that MBCT improved the ability to deploy and maintain attention on a specific task despite feeling sad and being distracted by task-irrelevant auditory stimuli, which may be indicative of improvements in the ability to disengage from the habitual pull of sad mood. Indeed, De Raedt et al. (2012) noted that participants showed reduced facilitation of attention for negative information and reduced inhibition of attention for positive information following MBCT, compared with a control group that received no therapeutic care. Similarly, Britton et al. (2012) found that MBCT was associated with lower stress responses and anxiety symptoms following a social-stress test compared with a wait-list control group. Another proposed mechanism of change is related to the effect of MBCT on quality and frequency of positive affect in everyday life. By increasing one’s ability to generate positive affect from pleasant daily life events, MBCT may build resilience in the face of negativity. For example, Geschwind et al. (2011) demonstrated that MBCT was associated with reports of increased experience of momentary positive emotions and enhanced responsiveness to pleasant daily-life activities. These results remained significant after controlling for

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alterations in depressive symptoms, negative emotion, rumination, and worry. Interestingly, Batink et al. (2013) demonstrated that for patients with three or more previous depressive episodes, changes in positive and negative affect predominantly mediated the effect of MBCT on posttreatment symptoms of depression. In sum, these studies suggest that MBCT may help prevent the return of depression by improving patients’ ability to pay attention to present moment experiences without the need to judge or evaluate those experiences, to observe thoughts as passing mental events rather than facts, and to replace habitual and automatic responses to negative events (e.g., rumination, worry). There is some evidence that improvements in memory, attention, goal attainment, and frequency of positive emotions follow MBCT; however, whether these changes help prevent the return of depressive symptoms in the long term has yet to be formally examined.

DISSEMINATION OF MBCT Although MBCT has considerable empirical support, it faces several practical challenges to dissemination. At the very least, access to a trained practitioner is required. In rural areas, or for those with inflexible schedules and other obligations, access may be an important impediment to treatment. Beyond physical access, service costs and waiting lists may be prohibitive for those interested in treatment (Wang et al., 2003). Internet-based treatments can offer an alternative that addresses several of these challenges (e.g., Clarke et al., 2005; Proudfoot et al., 2004; Warmerdam et al., 2010). In one example of an internet-based treatment, Mindful Mood Balance (MMB; Dimidjian et al., 2014) was developed to digitize the content of in-person MBCT into an eight-session, self-guided online program. MMB closely follows the session structure of MBCT, but it utilizes a variety of learning modalities (e.g., video, audio). To simulate the group-based inquiry component of MBCT, videos of selected portions of an in-person MBCT group are provided. A quasi-experimental investigation demonstrated that MMB significantly reduced residual depression symptom severity, which was sustained over 6 months, and was associated with improvement in measures of rumination and mindfulness (Dimidjian et al., 2014). A qualitative study of MMB has also yielded positive results. In their exit interview, participants reported that they had developed affect-regulation skills and identified several advantages to the online format of MMB, including flexibility, reduced cost, and time commitment (Boggs et al., 2014). Together, these results suggest that MMB represents a feasible, credible, and effective method for increasing access to prevention treatment. As with other digital therapeutics, the larger questions of where programs such as MMB are hosted, the nature of their financial support, and how they are promoted have yet to be definitively addressed.



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APPLICATION TO DIVERSE POPULATIONS To our knowledge, no study to date has explicitly examined the role of culture in outcomes following MBCT. A meta-analysis by Fuchs et al. (2013) investigating outcomes following acceptance- and mindfulness-based interventions for underserved populations (i.e., those from nondominant cultural and/or marginalized backgrounds) reported small to large effect sizes following these interventions, which varied by study design. Given the diversity of mental health issues and interventions included in this meta-analysis, however, it is not possible to translate these findings directly to MBCT. Indeed, some have argued that mindfulness training, despite being secularized in interventions such as MBCT and MBSR, may be biased toward a view of suffering rooted in habits of mind and constructions of the self, ignoring the importance of culture in these views of self, as well as the suffering that arises from poverty, inequality, and structural violence (Kirmayer, 2015). In this respect, the mindfulness and cognitive behavioral features of MBCT may not be adequately sensitive to the importance of social belief systems and stressors in the return of depressive symptoms. More research is needed for an accurate discussion of the role of culture in MBCT’s effects on relapse prevention.

FUTURE DIRECTIONS FOR RESEARCH Although its evidence base is steadily growing, exactly how MBCT exerts its preventive effect is not fully understood. Recent investigation has suggested that the cultivation of decentering plays an important role in one’s outcome following MBCT (Farb et al., 2017), but it is still possible that MBCT may work for multiple reasons. Indeed, questions related to mechanisms of change are a challenge facing researchers of evidence-based psychotherapies in general (Kazdin, 2009), and MBCT would benefit from further research into the psychological and neurological mechanisms that may be underlying its efficacy. The original MBCT efficacy trials compared MBCT with TAU (Ma & Teasdale, 2004; Teasdale et al., 2000). In the time since those trials, several studies have compared MBCT to an active control condition. Although MBCT demonstrated efficacy when compared with TAU, it may not be superior to control groups intended to be structurally equivalent (e.g., the Health Enhancement Program [HEP]; MacCoon et al., 2012). For example, with a moderately sized sample of 92 participants, Shallcross et al. (2015) demonstrated that MBCT was not superior to HEP on primary or secondary outcome variables, including rate of depression relapse, symptom reduction, and life satisfaction. Conversely, a study by Meadows et al. (2014) has suggested a more positive result when comparing MBCT to an active control condition. In a sample of 200 nondepressed individuals with a history of three or more depressive episodes, MBCT combined with depression-relapse active monitoring (DRAM) was superior to

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DRAM alone in reducing depressive relapse/recurrence over 2 years of follow-up. Another important area of inquiry concerns the role of homework in outcome following MBCT. In MBCT, participants are required to maintain a daily at-home meditation practice (with each daily guided meditation lasting approximately 30–45 minutes), as well as complete homework exercises similar to those assigned in CBT. Given the importance of meditative practice in the cultivation of mindfulness, and the demonstrated role of homework compliance in treatment outcomes following CBT (Kazantzis et al., 2000), the extent to which one engages and completes the homework (i.e., meditative practice) during MBCT may be an important factor in eliciting its preventative effects.

CONCLUSION MBCT was developed to prevent depression relapse among individuals with recurrent depression. Segal, Williams, and Teasdale were all trained as cognitive behavioral therapists and clinical scientists before they ventured into treatment development. The influence of their training can be seen in MBCT’s theoretical background and their views of how patients can learn to disengage from depressogenic patterns of thinking. Research from numerous RCTs supports the efficacy of MBCT, and preliminary research evidences novel extensions of MBCT. A primary goal of MBCT is to teach participants to identify vulnerability-inducing habits of thinking, with the goal of relating to them through a metacognitive, present-moment orientation. MBCT is firmly rooted in the view of mindfulness as a form of attentional training that first requires familiarity with the automatic or mindless modes of cognitive processing before consistent practice can acquaint patients with new modes that provide flexibility in the midst of possible relapse triggers and, more widely, with life’s ever-present challenges and opportunities.

REFERENCES Batink, T., Peeters, F., Geschwind, N., van Os, J., & Wichers, M. (2013). How does MBCT for depression work? Studying cognitive and affective mediation pathways. PLOS ONE, 8(8), e72778. https://doi.org/10.1371/journal.pone.0072778 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press, Inc. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II. Psychological Corporation. Boggs, J. M., Beck, A., Felder, J. N., Dimidjian, S., Metcalf, C. A., & Segal, Z. V. (2014). Web-based intervention in mindfulness meditation for reducing residual depressive symptoms and relapse prophylaxis: A qualitative study. Journal of Medical Internet Research, 16(3), e87. https://doi.org/10.2196/jmir.3129 Bondolfi, G., Jermann, F., der Linden, M. V., Gex-Fabry, M., Bizzini, L., Rouget, B. W., Myers-Arrazola, L., Gonzalez, C., Segal, Z., Aubry, J. M., & Bertschy, G. (2010).



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depression: A translational research study with 2-year follow-up. Australian and New Zealand Journal of Psychiatry, 48(8), 743–755. https://doi.org/10.1177/ 0004867414525841 Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569–582. https://doi. org/10.1037/0021-843X.100.4.569 Proudfoot, J., Ryden, C., Everitt, B., Shapiro, D. A., Goldberg, D., Mann, A., Tylee, A., Marks, I., & Gray, J. A. (2004). Clinical efficacy of computerised cognitivebehavioural therapy for anxiety and depression in primary care: Randomised controlled trial. British Journal of Psychiatry, 185(1), 46–54. https://doi.org/10.1192/ bjp.185.1.46 Richards, D. (2011). Prevalence and clinical course of depression: A review. Clinical Psychology Review, 31(7), 1117–1125. https://doi.org/10.1016/j.cpr.2011.07.004 Samples, H., & Mojtabai, R. (2015). Antidepressant self-discontinuation: Results from the collaborative psychiatric epidemiology surveys. Psychiatric Services, 66(5), 455– 462. https://doi.org/10.1176/appi.ps.201400021 Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., Bloch, R., & Levitan, R. D. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256–1264. https://doi. org/10.1001/archgenpsychiatry.2010.168 Segal, Z. V., Kennedy, S., Gemar, M., Hood, K., Pedersen, R., & Buis, T. (2006). Cognitive reactivity to sad mood provocation and the prediction of depressive relapse. Archives of General Psychiatry, 63(7), 749–755. https://doi.org/10.1001/ archpsyc.63.7.749 Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse (1st ed.). Guilford Press. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach for preventing relapse (2nd ed.). Guilford Press. Segal, Z. V., Williams, J. M. G., Teasdale, J. D., Crane, R., Dimidjian, S., Ma, H., Woods, S., & Kuyken, W. (2016). Mindfulness Based Cognitive Therapy Training Pathway. http:// mbct.com/training/mbct-training-pathway/ Segal, Z. V., Williams, J. M. G., Teasdale, J. D., & Gemar, M. (1996). A cognitive science perspective on kindling and episode sensitization in recurrent affective disorder. Psychological Medicine, 26(2), 371–380. https://doi.org/10.1017/S0033291700034760 Shallcross, A. J., Gross, J. J., Visvanathan, P. D., Kumar, N., Palfrey, A., Ford, B. Q., Dimidjian, S., Shirk, S., Holm-Denoma, J., Goode, K. M., Cox, E., Chaplin, W., & Mauss, I. B. (2015). Relapse prevention in major depressive disorder: Mindfulnessbased cognitive therapy versus an active control condition. Journal of Consulting and Clinical Psychology, 83(5), 964–975. https://doi.org/10.1037/ccp0000050 Solomon, D. A., Keller, M. B., Leon, A. C., Mueller, T. I., Lavori, P. W., Shea, M. T., Coryell, W., Warshaw, M., Turvey, C., Maser, J. D., & Endicott, J. (2000). Multiple recurrences of major depressive disorder. American Journal of Psychiatry, 157(2), 229–233. https://doi.org/10.1176/appi.ajp.157.2.229 Teasdale, J. D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2(3), 247–274. https://doi.org/10.1080/02699938808410927 Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275–287. https://doi. org/10.1037/0022-006X.70.2.275 Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness)



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21 Metacognitive Therapy Peter L. Fisher

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his chapter provides an overview of metacognitive therapy (MCT), which has its origins in experimental studies of attentional processes and the recognition of psychological processes commonly observed in patients attending therapy. The development of the theoretical model upon which MCT is based is described and provides an introductory account of its core feature, namely metacognitive beliefs and processes. Metacognition refers to beliefs people hold about their thinking or cognition, such as “I have a poor memory,” “I am unable to control my worry,” or “Rumination will help me to solve problems.” A key focus of therapy is helping patients to achieve metacognitive change or to recognize that their beliefs about their thinking are erroneous and lead to the prolongation of metacognitive processes like worry and rumination, which in turn maintain and exacerbate emotional distress. Illustration of some of the main therapeutic techniques are presented, followed by a brief account of the hypothesized mechanisms of change that alleviate emotional distress in patients. The chapter concludes with treatment outcome data and the future directions required for MCT to become an empirically supported intervention across multiple clinical populations.

HISTORY MCT is an empirically supported psychological intervention developed from an information processing model of psychopathology called the self-regulatory executive function (S-REF) model (Wells & Matthews, 1994, 1996). Experimental https://doi.org/10.1037/0000218-021 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  617 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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studies demonstrated that self-focused attention, or attention focused on one’s thoughts or emotions, was associated with anxiety and worry and limited the effectiveness of strategies used to alleviate distress (Matthews & Wells, 1988; Wells, 1985). Clinical observation suggested that patients frequently describe engaging in perseverative thinking, most commonly worry and rumination, as an attempt to deal with unpleasant emotions or negative thoughts but that such attempts “backfire” and intensify levels of distress. Prior experimental studies indicated that attentional processes were not fully automatic and were under at least partial control of individuals (e.g., Norman & Shallice, 1980; Shiffrin and Schneider, 1977). Moreover, in the field of learning and memory, there was clear evidence of strategic control of attention (e.g., Nelson & Narens, 1990). People have control over their response to incoming stimuli in the form of unwanted thoughts and, therefore, can choose how to respond to unwanted negative thoughts. In other words, people can decide how to think about thoughts, guide the content of what they think about, and try to suppress thoughts using a broad variety of strategies (e.g., thought suppression by bringing positive thoughts and images to mind, trying to simply push thoughts out of one’s mind, distraction). To alleviate emotional disorders and emotional distress, an understanding of why people select a particular response to negative and unwanted thoughts was required. Existing psychological theories did not explain how transitory thoughts became significant events in the mind and, in turn, produced a wide array of unhelpful coping strategies. Negative thoughts are ubiquitous, but psychological disorders are not. The advancement of the efficacy of psychological interventions for emotional disorders required identification of the psychological mechanisms that accounted for the continued processing of negative thoughts. The first step in the evolution of MCT was the recognition that there were three core psychological processes involved in the development and maintenance of emotional distress: perseverative thinking, attentional biases, and self-focused attention. The development of models with clinical utility that can be translated into efficacious interventions is a cornerstone of clinical psychology; a model that incorporated each of the above components had the potential to be a viable alternative to traditional cognitive models of emotional distress. The earliest work that contributed to the S-REF model was the identification that level of private self-consciousness or self-focused attention was associated with anxiety (Wells, 1985). Subsequently, this led to the hypothesis that modification of attentional processes would alleviate anxiety symptoms. To test this hypothesis, Adrian Wells developed a treatment strategy called the attention training technique (ATT; Wells, 1990), which was specifically designed to reduce self-focused attention and to enable execution of greater control over perseverative thinking. In a single case study, a patient with panic disorder was treated with ATT and no longer experienced panic attacks, and the treatment effects were sustained over the 12-month follow-up period.



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It is important to note that schema theory and cognitive therapy (Beck, 1967, 1976) directly and indirectly influenced the development of MCT. In cognitive therapy, schemas refer to core beliefs that an individual holds about the world, the self, and others. For example, a schema about the self may be “I’m useless.” Schemas are considered stable structures that influence the way in which an individual interprets events or the occurrence of negative thoughts. However, it is not specified how schemas guide the essential components the S-REF model, namely perseverative thinking and active deployment of attentional strategies. The basic structure of MCT sessions would be instantly recognizable to cognitive behavioral therapists because agenda setting, case formulations, Socratic dialogue, verbal and behavioral reattribution methods, homework setting, and relapse prevention are all included in MCT. However, the practice of MCT is distinctive from CBT in that it focuses on metacognitive rather than cognitive content change. Wells (2000) specified that schema theory proposes that information stored in long-term memory affects the interpretation of thoughts and feelings, but that it does not specify how schemas guide information processing and lead to persistent emotional distress. For psychological therapy to progress, a conceptual framework is required that specifies how self-knowledge regulates cognitive-emotional processing. The S-REF model, a multilevel model of psychopathology, provided an answer. The S-REF model underpins metacognitive disorder-specific models and treatments. Initially, the metacognitive model of generalized anxiety disorder (GAD; Wells, 1995) was developed. This model highlights that metacognitive beliefs are integral to the maintenance of worry, the key feature of GAD. More specifically, patients with GAD hold both positive and negative metacognitive beliefs about worry. Examples of positive beliefs are “Worry helps me to cope” and “Worry ensures that I am prepared and avoid problems.” Negative beliefs predominately focus on the uncontrollability and dangerousness of worry, such as “Worry is uncontrollable” and “Worry could make me lose control of my mind.” If a person holds the belief that worry is uncontrollable, it exacerbates distress as the person believes worry will last forever and nothing can stop worry. Further disorder-specific models and corresponding metacognitive treatment protocols followed and included interventions for posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), depression, and bulimia nervosa (Wells, 2009). Because the metacognitive approach is a transdiagnostic model, it offers the opportunity to provide a single treatment that can be efficacious across disorders in diverse populations (Wells, 2009). The potential clinical utility of the transdiagnostic model is being examined in people with physical health conditions and experiencing clinical levels of emotional distress. In addition, treatment development work in physical health populations is underway (see section on application to diverse populations).

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UNDERLYING THEORY The theoretical basis for MCT is the S-REF (Wells, 2000, 2008; Wells & Matthews, 1994), which includes three levels of cognition that interact to produce an information processing model of psychopathology. The first is a low-level form of processing in which intrusive thoughts function as the incoming stimuli, and this level of processing operates with very limited awareness and with no intent to influence the way in which it operates. The second level is online processing, which is under an individual’s active control and regulation. It is also the level that influences and guides the way in which intrusive thoughts are assessed, appraised, and acted upon. The final level, or the top-down processing level, is composed of metacognitive knowledge, which is stored in long-term memory. Metacognitive knowledge, or metacognition, means cognition applied to cognition. It is that aspect of information processing that monitors, controls, appraises, and organizes cognition (Flavell, 1979). The idea that cognition can be monitored and controlled by another dimension of cognition implies the existence of multiple levels of cognition (Nelson & Narens, 1990; Wells, 2009). MCT directs treatment to working at the metacognitive level. The online level of processing includes (a) perseveration (i.e., worry, rumination, overanalyzing, doubting), (b) focused attention on sources of threat both internal (e.g., negative automatic thoughts, memories, obsessions) and external (e.g., monitoring for sounds or smells as in PTSD), and (c) unhelpful coping strategies (e.g., avoidance, drinking excessively, thought suppression, repeated checking). Collectively, these three components are termed the cognitive attentional syndrome (CAS). The CAS backfires, as it impairs self-regulation and prevents change in knowledge about how the cognitive system operates. Many of the coping strategies are metacognitive in nature in that they are intended implicitly or explicitly to alter the status of cognition. For example, the depressed patient often reduces their activity levels to provide more time to analyze the reasons underlying personal failure and sadness. In the metacognitive model, what and how an individual thinks is controlled and modified by metacognition, and so if an individual dwells on their own sense of inadequacy, it is because metacognition leads to sustained analysis of inadequacy and what can be done to overcome the sense of inadequacy. Almost everyone has negative thoughts and emotions, but as mentioned previously, most people do not have anxiety or depressive disorders. Metacognitive beliefs can lead to processing styles that result in negative thoughts being overanalyzed and questioned. In other words, metacognitive beliefs activate and perpetuate the CAS. The principle factor leading to extended and sustained negative (threat-related) experiences is the CAS are the higher order metacognitive beliefs that are of central importance in MCT. The CAS can also be thought of as the mechanism by which people try to return to a state of homeostasis, such as not feeling anxious or depressed. For example, in OCD, an intrusion pushes into consciousness, which activates a plan for processing how to respond to the intrusion. One goal might be to remove the intrusion from consciousness, and, therefore, the person will engage in coping strategies such as



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forming an alternative image to the intrusion or checking. In this way, the person can (temporarily) alleviate distress and return to a state of homeostasis. There are multiple forms of metacognitive knowledge in the S-REF model. However, such knowledge is often dichotomized into two broad subtypes of metacognitive beliefs: (a) positive beliefs and (b) negative beliefs. The nature of these two types of belief can help to answer the question as to why people engage in sustained thinking, threat monitoring, or coping responses that have deleterious effects. Specifically, positive metacognitive beliefs (PMBs) concern the benefit or value of engaging in each aspect of the CAS (e.g., “Worry and/or rumination will help me to cope” or “Focusing on possible signs of threat keeps me safe”). Some PMBs are common to all disorders, whereas others are most closely associated with specific disorders. For example, PMBs in OCD concern the need to control thoughts and remove thoughts from consciousness, and these may support different forms of coping such as forming a positive image to replace an obsessional thought. A common PMB in PTSD is “I must fill any gaps in my trauma memory before I can move on.” In depression, PMBs focus on the benefits of understanding the causes and meaning of symptoms through rumination, such as “Rumination will help me discover the root cause of my depression,” with the goal of overcoming depression. Negative metacognitive beliefs (NMBs) focus on the significance and importance of cognition, including intrusions, negative automatic thoughts, memories, impulses, and perseverative thinking. In general, NMBs can be conceptually divided into beliefs about the uncontrollable nature of worry and rumination (e.g., “My worry is out of control”) and beliefs about the danger/significance of thoughts and mental events and the consequences of thinking in a particular manner. As with PMBs, some NMBs are most closely tied to specific disorders. For example, OCD is characterized by negative metacognitive fusion beliefs about intrusions. These take three forms, including (a) thought-event fusion, or the belief that thoughts can influence events (e.g., “If I think about a crime, then it actually happened”); (b) thought-action fusion, or the belief that thoughts will lead to commission of action (e.g., “If I think of hurting my child, it will make me do it”); and (c) thought-object fusion, or the belief that thoughts, feelings, and/or memories can be transferred into objects (e.g., “My guilty thoughts can infect my books”). Also, patients with OCD sometimes express beliefs regarding the uncontrollability of their rituals. NMBs in depression primarily focus on the uncontrollable nature of rumination, although some patients hold NMBs about the interpersonal implications of excessive rumination. The same types of uncontrollability beliefs about rumination/worry are seen in PTSD and GAD, together with beliefs about the dangers of worrying (e.g., “Worrying could make me lost control of mind”). Recent work on emotional distress in adolescent survivors of cancer (Fisher et al., 2018) has illustrated that very similar metacognitive beliefs are held by people with physical health issues experiencing persistent emotional distress. Holding beliefs about the uncontrollable nature of perseverative thinking means that patients generally make infrequent attempts to bring worry and rumination under control. Also, if people believe that certain types of thoughts are highly significant or dangerous, they often

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engage in thought monitoring and thought control. However, the counterproductive nature of such strategies is readily evident, as searching or monitoring for signs of threat generates more unwanted thoughts.

DESCRIPTION OF MAIN PROCEDURES Although there is a broad range of treatment techniques within the MCT armory, it is essential to recognize that MCT is not simply a collection of techniques. Each treatment technique has multiple goals and should be implemented with the aim of maximizing metacognitive change. MCT concentrates on changing the way in which the patient thinks by modifying beliefs about cognition. Conducting MCT requires working at the metacognitive level and avoiding the pitfall of working at the cognitive-content level, as typically practiced in CBT. It is imperative that the metacognitive therapist focuses on the three components of the CAS: perseverative thinking (e.g., worry, ruminating, overanalyzing, questioning, doubting), maladaptive internal and external attentional strategies, and unhelpful coping strategies that maintain metacognitive beliefs and processes. In developing a case formulation, the metacognitive therapist should elicit each aspect of the CAS and the broad range of metacognitive beliefs that perpetuate the CAS and prevent its modification. In MCT, a negative automatic thought is either a trigger for perseverative thinking, a thought that occurs during perseveration, or a thought that occurs at the end of a perseverative chain of thinking. PMBs direct the person to select perseveration and other aspects of the CAS to aid in coping or finding solutions to their ongoing issues. Unfortunately, the selection of the CAS broadens the sense of threat and maintains emotional distress. NMBs about the uncontrollability of worry/rumination increase the likelihood that the individual will not attempt to interrupt the CAS, thereby maintaining these beliefs. The noninterruption of the CAS can also exacerbate distress by maintaining and prolonging psychopathology because if one believes the CAS cannot be brought under control and is harmful (e.g., “I will lose control of my mind if I don’t stop worrying”), it will elevate distress levels. The modification of both types of metacognitive beliefs plays a central role in treatment and enables patients to increase the awareness that thoughts are transitory events in the mind that do not require any form of further conceptual processing. Outlined below are a few of the main techniques that can be used by the metacognitive therapist to promote change in metacognitive beliefs and processes (Wells, 2009). Modification of NMBs NMBs about thoughts or perseverative thinking can be subdivided into beliefs about worry/rumination being uncontrollable and beliefs about the danger of this thinking style. Typical uncontrollability beliefs are that worrying/ruminat-



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ing is beyond control, whereas examples of danger-related beliefs include, “Worrying could make me go crazy” and “People will reject me if they knew how much time I spent dwelling on my situation.” During episodes of perseverative thinking, these negative beliefs are activated, leading to extended thinking and negative appraisals of worrying and ruminating, which exacerbate anxiety, depressive affect, and other manifestations of emotional distress. Modifying Uncontrollability Beliefs About Worry/Rumination In MCT for depression and for GAD, the case formulation and socialization processes highlight the importance of uncontrollability beliefs in maintaining the patient’s clinical problem. Modification of uncontrollability beliefs about worry or rumination begins with verbal reattribution by reviewing the evidence for and against uncontrollability beliefs. Questions to be posed include, “If worry is completely uncontrollable, how can worry ever stop?” and “What happens to your worry when you become focused on a difficult task?” Typically, patients reply that worry stops. However, sometimes patients answer that worry is all consuming and is continuous. The therapist can then introduce a worry/rumination postponement exercise as a behavioral experiment, which can be conducted in session and then set as a homework task. Patients are helped to identify a typical trigger for a worry or rumination and then to rapidly start and stop the worry/rumination. Patients are then asked, “If you can start and stop worrying, how uncontrollable is worry?” The main worry/rumination postponement strategy is a homework task (described later in this section) that is a fundamental component of MCT and is a highly effective strategy in reducing conviction in uncontrollability beliefs. Worry/rumination postponement is only one way of modifying uncontrollability beliefs. The metacognitive therapist could implement loss of control experiments, in which patients are asked to try and lose control of their worrying by worrying as hard as they can; in other words, they are asked to push worry beyond their normal limits. This can also be done in session or as a homework task. There is a paradoxical effect when patients conduct this experiment, as they view their worrying as more controllable, thus demonstrating that loss of control is not possible. Modifying Danger Metacognitive Beliefs About Worry/Rumination Individuals hold NMBs about the dangers of perseverative thinking. Typical beliefs include, “Worrying is harmful for my body and could damage my heart,” “I’d end up alone if I revealed how many hours I spend thinking about my problems,” “Worrying could make me lose control of my mind,” and “Doubting all the time will make me go mad.” All danger-related metacognitive beliefs are modified through verbal and behavioral reattribution methods. Verbal reattribution often begins by questioning the mechanism, such as asking, “How will worry damage your heart?” or “How can worry make you lose control of your mind?” The next step may be to review evidence and counterevidence that worry/rumination is harmful. It is also important to help patients recognize

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that worry, rumination, and doubting are all common processes, which helps to normalize their experiences. Behavioral experiments almost always follow verbal reattribution methods to further reduce conviction in metacognitive beliefs. As mentioned previously, the “loss of control” experiment (Wells, 1997) can be used to directly target danger-related metacognitive beliefs. The patient is asked to try and make the feared event come true by worrying as much as possible during a worry period of the treatment session or as a component of detached mindfulness (DM) and worry postponement as part of a homework task (i.e., during the postponed worry period patients are asked to push their worry). Loss of control experiments are further reinforced by requesting that patients worry as hard as they possible can when they next notice a “what if” question/worry intrude into consciousness in daily life. Loss of control experiments can help to modify both metacognitive belief about the danger of worry and also the metacognitive belief that worry is uncontrollable. Explicitly targeting NMBs about the uncontrollability and danger of perseverative thinking is a feature unique to MCT. Although all aspects of MCT are focused on metacognitive change, helping patients to shift from utilizing the CAS to assuming a state of DM is central to achieving successful treatment outcomes. Methods for implementing DM and worry/postponement are illustrated below. Detached Mindfulness and Worry/Rumination Postponement DM refers to an objective awareness of negative unwanted thoughts and emotions, but it is without any form of conceptual analysis and does not aim to provide answers. It is the antithesis of the CAS and helps patients to increase their awareness of the CAS while simultaneously reducing conceptual processing. Patients are initially helped to differentiate between a spontaneous negative thought (trigger) and subsequent rumination/worry. The therapist also emphasizes that the patient can decide how to respond to their commonly occurring negative thoughts. Patients are helped to experience DM using a variety of tasks and discussion. Metacognitive therapists often introduce DM by discussing the natural flow and decay of emotionally neutral thoughts over the course of a typical day. The therapist facilitates the discussion by asking questions such as “What happens to the majority of your everyday thoughts?” “Where do these thoughts go?” “How many thoughts do you have each day?” “How many of those thoughts do you pay attention to?” and “What would happen if you did nothing with all of your thoughts, including the ones you currently find unpleasant?” Patients realize that with most thoughts, DM is the natural information processing state and that they are deciding to engage the negative thoughts with a variety of elements of the CAS, predominately perseveration. Several specific tasks can be used to facilitate DM. Outlined below are two of the most commonly used tasks (i.e., the free association task and the tiger task) to demonstrate DM, followed by a description of worry/rumination and how it should be used in combination with DM. The free association task is introduced by giving the following instructions:



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In a moment I am going to say a list of common words, and I would like you to let your mind roam freely in response to the words. It’s important that you do not attempt to control your mind or your response to the words. I would like you just to notice what happens in your mind when I say the words. For some people, not much happens, whereas other people find that pictures or images come into their mind and some people also report feelings or sensations. I’m now going to say the list of common words: orange, pen, table, tiger, trees, glasses, breeze, and statue. What did you notice when you just watched your mind? (Wells & Fisher, 2015, p. 305)

Patients often report noticed an image associated with each word and generally each image replaced the previous one. Sometimes images merge together; for example, the pen may be seen on the table. The essential aspect of this task is that whatever happens (e.g., one image replaces another, images merge, there is a nonoccurrence of images), all processing must happen spontaneously. Therapists must carefully check that patients are not attempting to influence what happens in their mind in any way, including trying to connect or remember the images. Patients can then be asked what happened to the first image as the list was read out. Patients typically reply that the first image simply vanished. The therapist follows up this answer by asking whether the patient could do the same thing with intrusive thoughts, as this will be the subsequent task when patients implement DM for homework. It is useful to repeat DM with the goal of enhancing detachment by asking patients to be aware that they are a separate observer of their thoughts. Assuming correct application of the task, the free association task can then be extended by interspersing emotionally salient words (specified by the patient) with emotionally neutral words. This procedure helps patients to recognize that thoughts have a life of their own, and that they can be aware of thoughts and not engage in effortful coping responses. The tiger task can be also be used to help patients experience and understand DM. Patients are asked to bring an image of a tiger to mind and to watch the image without doing anything with the image. The therapist guides the patient through the task as below:

In order to get a feel for using detached mindfulness, I’d like you to begin by bringing an image of a tiger to mind. I don’t want you to try and influence the image, so don’t try to change the tiger’s behavior or change anything about it. The image might be in black and white or color; it doesn’t matter, just notice the tiger. The tiger might move, but don’t make it move; just watch how the image develops over time, but do not try to influence it. Simply watch the image of the tiger in a passive way. (Fisher & Wells, 2009, p. 96)

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Both tasks can be used to help consolidate the application of DM and foster metacognitive awareness. DM is most frequently delivered in combination with worry/rumination postponement. The therapist introduces rumination postponement by explaining that rather than responding to negative thoughts with extended thinking, the patient should apply DM each time they notice a typical negative thought that acts as the trigger for worry or rumination and postpone any response until a time later in the day. Worry/rumination postponement for a depressed patient was presented in the following manner:

When you notice thoughts such as “I’m a bad mother” or “I can’t cope,” I’d like you to say to yourself, “There’s a negative thought. I’m not going to do anything with it now, and if I want to, I’ll think about it later.” All I want you to do is to allow the thought to exist without trying to influence it at all, so that means not analyzing, not trying to push it out of your mind, and not trying to purposely distract yourself. All I’d like you to do is carry on with whatever it was you were doing without engaging with the thought in any way. However, this does not mean you can’t ruminate about it later in the day. I’d like you to postpone your rumination until a convenient time later in the day, perhaps 8 p.m., and then if you think that you must ruminate about the negative thoughts that have popped into your head during the day, then you can ruminate about them for a maximum of 15 minutes. You do not need to use this rumination time; in fact, most people decide not to use the rumination time. However, it would be helpful, if you do decide to use your rumination time, to make a brief note of the reasons you decided to use it. (Wells & Fisher, 2015, p. 306)

DM and worry/rumination postponement are introduced as an experiment to provide an experience that ultimately alters the metacognitive belief about uncontrollability. This phase of treatment requires the therapist to monitor the frequency with which DM and postponement are practiced and the proportion of negative thoughts to which they are applied. Conviction in PMBs can lessen after practicing DM and worry/rumination postponement as the patient is not worrying or ruminating as a coping strategy and, therefore, knowledge about the usefulness of perseverative thinking is modified. Modification of PMBs Reducing conviction in PMBs is an important component of MCT because PMBs perpetuate conceptual processing. If patients believe that using the CAS will enable them to cope more effectively or to alleviate distress, then they will continue to use their unhelpful strategies. Examples of common PMBs include “Worry makes me less distressed,” “Checking my mind for unwanted thought means I can remove them more quickly,” and “Ruminating will help me find the cause of my depression.” As with the modification of NMBs, verbal reattri-



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bution is the first method used by the metacognitive therapist to reduce conviction in PMBs. Using a depressed patient as an exemplar, the metacognitive therapist might begin verbal reattribution by conducting an advantages– disadvantages analysis of engaging in worry or rumination, which typically yields more disadvantages than advantages. Advantages are then evaluated, with the aim of helping patients to recognize that there may be more appropriate and helpful ways of achieving the advantages than via rumination. Direct questions can be asked, such as “If rumination is helpful, why do you continue to have difficulties with low mood? What does this tell you about the usefulness of rumination?” or “How many new solutions to overcome your depression have you found this week?” These forms of question can be followed up by presenting a paradoxical question to the patient, such as “You might be right that rumination is helpful; maybe the problem is that you haven’t spent enough time ruminating about your problems; would it be a good idea to spend more time ruminating over the forthcoming week?” Patients typically find it easy to recognize that extending the time spent ruminating would not be helpful and that ruminating is contributing to their depressive symptoms. Other verbal reattribution strategies to modify rumination include questioning the mechanism, such as “How does rumination help you to find solutions?” or “What happens to how you feel when you spend time dwelling?” The therapist uses Socratic dialogue to illustrate that dwelling and ruminating exacerbate distress, do not yield solutions, and increase levels of hopelessness and helplessness. The worry/rumination experiment is a behavioral experiment that can be used to modify the belief that rumination helps to solve problems (Wells, 2000). Patients are asked to ruminate on one day, followed by minimal or no rumination the next day, and to record the number of solutions that were obtained each day. Patients typically report that no more solutions were found on the rumination day and that they were more distressed. Turning to the patient who worries extensively, PMBs about the function of worry can be modified through “mismatch strategies” (Wells, 1997). This strategy requires the patient to write down all the worries contained within a single worry episode and to compare these worries with what actually happened in that event. Initially, this can be completed in session by asking about a past event and comparing the worry chain and the actual outcomes. The method can also be applied prospectively as a behavioral experiment, in which the patient is asked to worry about a forthcoming event. Together with the therapist, the chain of worries is recorded. Between sessions, the patient faces the feared situation, and in the next therapy session, the actual events and the negative predictions in the worry chain are compared. As one would expect, both the predicted number and severity of worries are typically greater than the actual events.

Attention Training Technique A primary goal of MCT is to reduce self-focused processing and enhance metacognitive control, which can be achieved through a specific strategy called the attention training technique (ATT; Wells, 1990). ATT comprises three externally

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focused auditory attentional tasks: (a) selective attention, (b) attention switching, and (c) divided attention tasks. These are conducted sequentially during a 10- to 15-minute ATT session. Selective attention to different sounds in different locations is practiced for approximately 5 minutes before the next step of rapid attention switching between the sounds for 5 minutes. The final step of the ATT is a 2-minutes divided attention component, in which the patient is instructed to listen to all of the sounds simultaneously. This is a guided technique, and the patient is reminded that if any negative thoughts or feelings occur to carry on with the tasks as instructed and not attempt to respond to the thoughts. ATT is introduced using socialization of the patient into treatment to demonstrate the role of self-focused attention and rumination in maintaining and exacerbating depressive symptoms. The case formulation provides the patient with an overview of the association between self-focused attention and symptomatology. For example, when socializing a patient to the model, it is illustrated how focusing attention on one’s physical symptoms (e.g. increased heart rate) or cognitive symptoms (e.g., negative thoughts) exacerbates the severity of symptoms. The next step is to assess the extent of self-focused attention compared with externally focused attention using a seven-point rating scale; the rating scale ranges from –3 (entirely externally focused) to +3 (entirely self-focused), which is repeated after the within-session ATT. Typically, a 2-point change in level of self-focus (toward being externally focused) is targeted. If this level of change in self-focused attention does not occur, then the therapist examines with the patient why they remained self-focused. The most common reason for continued self-focus is incorrect application of the strategy, which can be remedied through further psychoeducation, application to the patient’s symptoms, and practice. After practicing ATT, the theorist reviews the procedure with the patient and plans how it will be implemented for homework. Patients are asked to complete ATT at least once per day for 15 minutes but are reminded that it should not be used as a coping strategy, such as to distract themselves from unwanted thoughts and feelings.

TREATMENT OUTCOME DATA The evaluation of the efficacy of MCT has followed a well-developed framework for evaluating new treatments. Tests of the potential efficacy of MCT began with single case series studies, which examined whether MCT could alleviate anxiety and depression in mental health populations and in cancer patients. Single case methodology has an important role in establishing the potential efficacy of a psychological intervention and its contribution to evidence-based practice, it is a necessary step in developing empirically supported treatments. One meta-analysis examined data on the efficacy of MCT from single case series studies (Rochat et al., 2018). Although traditional meta-analyses often report both between-group and within-group changes, a



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meta-analysis on single case designs focuses only on within-group changes. Across 14 studies (53 patients), approximately 75% of treated patients achieved recovery. The authors used a data analytic procedure developed by Shadish et al. (2014), which facilitates comparison with reports of effect sizes obtained from amalgamating outcomes from randomized controlled trials. The effect sizes obtained were comparable to those obtained in traditional meta-analyses, reported later. Two meta-analyses have examined the efficacy of MCT in the context of randomized controlled trials; both were conducted by Normann and colleagues (Normann et al., 2014; Normann & Morina, 2018). In the first meta-analysis on anxiety and depression treatment trials in mental health populations, MCT was more efficacious than wait-list control conditions (effect size of 1.81) and brief CBT (effect size of 0.97), indicating that MCT is a highly promising psychological intervention (Normann et al., 2014). Comparable results were obtained in the subsequent meta-analysis (Normann & Morina, 2018), which obtained a large within-group effect size (2.06) from pre- to posttreatment on the primary outcome measures for anxiety and depression. When MCT was compared with CBT, the pooled effect size (Hedges’s g) favored MCT at posttreatment and at follow-up (0.69 and 0.37, respectively). There were also substantial reductions in a range of dysfunctional metacognitive beliefs over the course of treatment. In relation to the metacognitive model, NMBs about uncontrollability and danger of thinking have both an indirect and direct effect on psychopathology (Wells, 2000). The within-group effect sizes for NMBs were 1.31 and 1.28 from pre- to posttreatment and from pretreatment to follow-up, respectively. The reductions in NMBs suggest that modifications of these beliefs play an important role in the alleviation of anxiety and depression. However, it should be noted this is a speculative interpretation of the results and would require corroboration from other forms of analyses, such as mediation analysis in the context of randomized controlled trials or from experimental manipulations (see section on mechanisms of change). In addition, MCT has been adapted for more specific clinical presentations and age ranges. For example, initial studies have supported the feasibility and potential efficacy of MCT in cancer survivors. Clinically significant reductions in anxiety and depression were observed in an open trial of MCT for emotional distress in adolescent and young cancer survivors (Fisher et al., 2015) and in a case series and open trial in adult cancer survivors (Fisher et al., 2017, 2019). The translation of MCT to children and adolescents is in its infancy, but evidence from small-scale studies suggests that MCT is a promising intervention for children and adolescents with OCD (Simons et al., 2006). Moreover, in an open trial of group MCT that included 40 children aged 7 to 13 with GAD, approximately 80% of the sample no longer met diagnostic criteria following the intervention, and treatment gains were largely maintained through to the 6-month follow-up (Esbjørn et al., 2018). However, controlled evaluations in OCD, GAD, and other anxiety and mood conditions are required to verify these initial findings.

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Beyond determining the efficacy of MCT, there should be consideration of the degree to which it is a cost-effective intervention. The treatment effects described previously are obtained within six to twelve 1-hour treatment sessions, and treatment effects generally are sustained through to 6- and 12-month follow-ups. Longer term follow-up is necessary to determine the durability of treatment gains and to offer insight into resilience against adverse life events, such as when one experiences levels of anxiety and low mood but without the persistence that significantly compromises quality of life. MCT has predominately been developed and applied to adults with anxiety and mood disorders; however, as the S-REF model is a transdiagnostic model of psychopathology, it should be applicable to all forms of emotional distress in most populations. One argument is that MCT may be more applicable than traditional cognitive therapy to people with physical health conditions experiencing clinically significant levels of distress, as it does not focus on the content of people’s cognition, but the metacognitive processes that maintain distress. For example, it has been argued that in cancer survivors, many of the negative thoughts experienced (e.g., “My cancer may return”) are realistic thoughts and are not especially amenable to the logical disputation that occurs in traditional CBT. Therefore, it is possible that through targeting metacognitive beliefs and processes rather than cognitive content, MCT enables patients to disengage worry and rumination and thereby experience the potential for greater efficacy (Fisher et al., 2019; McNicol et al., 2013). Evidence for the potential breadth of clinical application of MCT comes from the first step in translating psychological treatments. The Medical Research Council U.K. (Craig et al., 2008) specifies that the translation of complex interventions requires supporting evidence of the model in a new population, followed by small-scale treatment outcome studies and then large-scale randomized controlled trials. Tests of the central predictions of the metacognitive model in “new” populations have been encouraging. Support has been obtained for the role of metacognitive beliefs and processes in psychological distress across an increasing range of physical health conditions, including cancer (Cook et al., 2015; Thewes et al., 2013), Parkinson’s disease (Allott et al., 2005; Brown & Fernie, 2015), epilepsy (Fisher & Noble, 2017), chronic fatigue syndrome (Maher-Edwards et al., 2011, 2012), fibromyalgia (Kollmann et al., 2016), diabetes (Purewal & Fisher, 2018), and multiple sclerosis (Heffer-Rahn & Fisher, 2018).

MECHANISMS OF CHANGE Several lines of investigation have explored the mechanisms of change in MCT. However, in comparison with the number of research studies on treatment outcomes for MCT, there have been comparatively few tests of how MCT effects change. A central hypothesis of the metacognitive model is that excessive and inflexible self-focused attention underpins the CAS (Wells, 1990; Wells & Matthews, 1994, 1996). Accordingly, numerous studies of the mechanisms of treat-



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ment change through ATT have been conducted (Fergus & Bardeen, 2016; Knowles et al., 2016). These studies illustrate that ATT leads to a reduction in anxiety but not that ATT causally reduces self-focused attention. Comparable results were obtained in experimental studies on the role of self-focused attention in social phobia, whereby modifying self-focused attention resulted in greater symptom reduction than control conditions (e.g. Vogel et al., 2016; Wells & Papageorgiou, 2001). However, more recently, Fergus and Wheless (2018) demonstrated that ATT causally leads to a reduction in self-focused attention and worry as predicted by the metacognitive model. A related finding on the role of reducing self-focused attention and increasing executive control through a single session of ATT was demonstrated by Knowles and Wells (2018) in a neurophysiological experimental study. After the single session, there was increased activity in the frontotemporal networks, which is linked to greater executive control. Two experimental studies targeting OCD have yielded results that speak to the mechanisms of change at work in MCT. In Fisher and Wells (2005), patients with OCD were asked to listen to a loop tape of their obsession for 5 minutes under two conditions. In the first condition, patients were given a habituation rationale, and in the second metacognitive condition, patients were given a rationale that focused on metacognitive beliefs about obsessions. The metacognitive condition produced significantly greater reductions in distress, desire to use neutralizing strategies, and the belief about the importance of obsessional thoughts. In another study on patients with OCD, Solem et al. (2009) found that change in metacognitive beliefs over the course of exposure and response prevention was associated with greater symptom reduction than the change in cognitive belief domains. There are several criticisms of such studies, most specifically that these noted changes occur between subjects and do not focus on within-subject change. However, an intriguing study by Hoffart et al. (2018) illustrated that during a clinical trial of CBT versus MCT, there were greater changes in both NMBs and PMBs in MCT than in CBT. More importantly, these reductions occurred on a week-to-week basis, indicating that modification of metacognitive beliefs results in treatment outcomes in treatment-resistant anxiety conditions.

APPLICATION TO DIVERSE POPULATIONS It is evident from the treatment outcome data presented in the section above that MCT can be used for people with physical health conditions who experience levels of distress that warrant treatment. There are several studies that have started to examine if MCT can be successfully modified to be applicable to children (e.g., Simons & Kursawe, 2019). In both routine clinical practice and in research settings, MCT has been applied to people from a range of ethnic and religious backgrounds. Research is beginning to examine if MCT can be successfully applied to older adults and if it will be efficacious when delivering MCT via a translator.

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DISSEMINATION Efforts in the dissemination of empirically supported interventions face multiple barriers, including scientific credibility within the profession, reluctance to change to a new therapeutic approach, and limited funding for specialist training (Andrews & Titov, 2009; Chorpita & Regan, 2009). Furthermore, MCT is based on a theoretically consistent model that should not be integrated with other models and interventions, which may limit dissemination because integrative practice has become the most common therapeutic approach of psychotherapists in the U.S. (Norcross & Goldfried, 2005). Training in MCT adheres to the specific metacognitive model, and therapists should receive appropriate training and supervision by highly experienced and qualified therapists. It is possible that without such training, the efficacy and scientific validity of MCT could be diluted (Byrne et al., 2018, Wells & Fisher, 2015; see also Metacognitive Therapy Institute at https://www.mct-institute.co.uk/). To this end, specialist training should be sought, and therapists of all approaches should avail themselves of appropriate training to ensure effective delivery.

CONCLUSION AND FUTURE DIRECTIONS There is substantial support for the clinical utility of the metacognitive model in anxiety and depressive disorders in both mental health and physical health populations. The efficacy of MCT is supported in randomized controlled trials, with evidence of the potential efficacy of MCT from open trials and single case studies across disorders and populations. The ever-growing evidence base highlights the ongoing successful translation of MCT from a well-specified model of psychopathology to an efficacious psychological intervention. Beyond evidence derived from clinical trials, the benefits of qualitative work should not be overlooked. Qualitative methods provide information on patients’ understanding and experience of therapy and the degree to which modifications to the therapy and its delivery are needed (O’Cathain et al., 2013). According to the U.K. Medical Research Council, qualitative methods should be used in addition to early clinical trials to help in development, delivery, and evaluation of emerging interventions. A major benefit of qualitative analysis in the recent open trial of adult survivors of cancer experiencing clinical levels of emotional distress (Fisher et al., 2019) illustrated that being challenged by the therapists early in therapy was a key ingredient to their engagement with therapy, irrespective of the nature of patients’ presenting psychopathology (Cherry et al., 2019).

REFERENCES Allott, R., Wells, A., Morrison, A., & Walker, R. (2005). Distress in Parkinson’s disease: Contributions of disease factors and metacognitive style. British Journal of Psychiatry, 187(2), 182–183. https://doi.org/10.1192/bjp.187.2.182



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Andrews, G., & Titov, N. (2009). Hit and miss: Innovation and the dissemination of evidence based psychological treatments. Behaviour Research and Therapy, 47(11), 974–979. https://doi.org/10.1016/j.brat.2009.07.007 Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. Harper and Row. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press, Inc. Brown, R. G., & Fernie, B. A. (2015). Metacognitions, anxiety, and distress related to motor fluctuations in Parkinson’s disease. Journal of Psychosomatic Research, 78(2), 143– 148. https://doi.org/10.1016/j.jpsychores.2014.09.021 Byrne, A., Salmon, P., Fisher, P. (2018). A case study of the challenges for an integrative practitioner learning a new psychological therapy. Counselling and Psychotherapy Research, 18(4), 369–376. https://doi.org/10.1002/capr.12185 Cherry, M. G., Salmon, P., Byrne, A., Ullmer, H., Abbey, G., & Fisher, P. L. (2019). Qualitative evaluation of cancer survivors’ experiences of metacognitive therapy: A new perspective on psychotherapy in cancer care. Frontiers in Psychology, 10, 949. https://doi.org/10.3389/fpsyg.2019.00949 Chorpita, B. F., & Regan, J. (2009). Dissemination of effective mental health treatment procedures: Maximizing the return on a significant investment. Behaviour Research and Therapy, 47(11), 990–993. https://doi.org/10.1016/j.brat.2009.07.002 Cook, S. A., Salmon, P., Dunn, G., Holcombe, C., Cornford, P., & Fisher, P. (2015). A prospective study of the association of metacognitive beliefs and processes with persistent emotional distress after diagnosis of cancer. Cognitive Therapy and Research, 39, 51–60. https://doi.org/10.1007/s10608-014-9640-x Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., Petticrew, M., & Medical Research Council (2008). Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ, 29(337), a1655. https://doi.org/10. 1136/bmj.a1655 Esbjørn, B. H., Normann, N., Christiansen, B. M., & Reinholdt-Dunne, M. L. (2018). The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: An open trial. Journal of Anxiety Disorders, 53, 16–21. https://doi. org/10.1016/j.janxdis.2017.11.002 Fergus, T. A., & Bardeen, J. R. (2016). The attention training technique: A review of a neurobehavioral therapy for emotional disorders. Cognitive and Behavioral Practice, 23(4), 502–516. https://doi.org/10.1016/j.cbpra.2015.11.001 Fergus, T. A., & Wheless, N. E. (2018). The attention training technique causally reduces self-focus following worry provocation and reduces cognitive anxiety among self-focused individuals. Journal of Behavior Therapy and Experimental Psychiatry, 61, 66–71. https://doi.org/10.1016/j.jbtep.2018.06.006 Fisher, P. L., Byrne, A., Fairburn, L., Ullmer, H., Abbey, G., & Salmon, P. (2019). Brief Metacognitive therapy for emotional distress in adult cancer survivors. Frontiers in Psychology, 10, 162. https://doi.org/10.3389/fpsyg.2019.00162 Fisher, P. L., Byrne, A., & Salmon, P. (2017). Metacognitive therapy for emotional distress in adult cancer survivors: A case series. Cognitive Therapy and Research, 41(6), 891–901. https://doi.org/10.1007/s10608-017-9862-9 Fisher, P. L., McNicol, K., Cherry, M. G., Young, B., Smith, E., Abbey, G., & Salmon, P. (2018). The association of metacognitive beliefs with emotional distress and trauma symptoms in adolescent and young adult survivors of cancer. Journal of Psychosocial Oncology, 36(5), 545–556. https://doi.org/10.1080/07347332.2018.1440276 Fisher, P. L., McNicol, K., Young, B., Smith, E., & Salmon, P. (2015). Alleviating emotional distress in adolescent and young adult cancer survivors: An open trial of metacognitive therapy. Journal of Adolescent and Young Adult Oncology, 4(2), 64–69. https://doi.org/10.1089/jayao.2014.0046 Fisher, P. L., & Noble, A. J. (2017). Anxiety and depression in people with epilepsy: The contribution of metacognitive beliefs. Seizure, 50, 153–159. https://doi.org/10.1016/j. seizure.2017.06.012

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Fisher, P. L., & Wells, A. (2005). Experimental modification of beliefs in obsessivecompulsive disorder: A test of the metacognitive model. Behaviour Research and Therapy, 43(6), 821–829. https://doi.org/10.1016/j.brat.2004.09.002 Fisher, P. L., & Wells, A. (2009). Metacognitive therapy: Distinctive features. Routledge. Flavell, J. H. (1979). Metacognition and metacognitive monitoring: A new area of cognitive-developmental inquiry. American Psychologist, 34(10), 906–911. https://doi. org/10.1037/0003-066X.34.10.906 Heffer-Rahn, P., & Fisher, P. L. (2018). The clinical utility of metacognitive beliefs and processes in emotional distress in people with multiple sclerosis. Journal of Psychosomatic Research, 104, 88–94. https://doi.org/10.1016/j.jpsychores.2017.11.014 Hoffart, A., Johnson, S. U., Nordahl, H. M., & Wells, A. (2018). Mechanisms of change in metacognitive and cognitive behavioral therapy for treatment-resistant anxiety: The role of metacognitive beliefs and coping strategies. Journal of Experimental Psychopathology, 9(3), https://doi.org/10.1177/2043808718787414 Kollmann, J., Gollwitzer, M., Spada, M. M., & Fernie, B. A. (2016). The association between metacognitions and the impact of Fibromyalgia in a German sample. Journal of Psychosomatic Research, 83, 1–9. https://doi.org/10.1016/j.jpsychores. 2016.02.002 Knowles, M. M., Foden, P., El-Deredy, W., & Wells, A. (2016). A systematic review of the efficacy of the attention training technique in clinical and nonclinical samples. Journal of Clinical Psychology, 72(10), 999–1025. https://doi.org/10.1002/jclp.22312 Knowles, M. M., & Wells, A. (2018). Single dose of the attention training technique increases resting alpha and beta-oscillations in frontoparietal brain networks: A randomized controlled comparison. Frontiers in Psychology, 9, 1768. https://doi.org/ 10.3389/fpsyg.2018.01768 Maher-Edwards, L., Fernie, B. A., Murphy, G., Nikcevic, A. V., & Spada, M. M. (2012). Metacognitive factors in chronic fatigue syndrome. Clinical Psychology & Psychotherapy, 19(6), 552–557. https://doi.org/10.1002/cpp.757 Maher-Edwards, L., Fernie, B. A., Murphy, G., Wells, A., & Spada, M. M. (2011). Metacognitions and negative emotions as predictors of symptom severity in chronic fatigue syndrome. Journal of Psychosomatic Research, 70(4), 311–317. Matthews, G., & Wells, A. (1988). Relationships between anxiety, self-consciousness and cognitive failure. Cognition and Emotion, 2(2), 123–132. https://doi.org/10.1080/ 02699938808408069 McNicol, K., Salmon, P., Young, B., & Fisher, P. (2013). Alleviating emotional distress in a young adult survivor of adolescent cancer: A case study illustrating a new application of metacognitive therapy. Clinical Case Studies, 12(1), 22–38. https://doi. org/10.1177/1534650112461298 Nelson, T. O., & Narens, L. (1990). Metamemory: A theoretical framework and some new findings. In G. H. Bower (Ed.), The psychology of learning and motivation (pp. 125– 173). Academic Press. Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration (2nd ed.). Oxford University Press. Norman, D. A., & Shallice, T. (1980). Attention to action: Willed and automatic control of behavior (CHIP Report 99). University of California. Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A systematic review and meta-analysis. Frontiers in Psychology, 9, Article 2211. https://doi.org/10. 3389/fpsyg.2018.02211 Normann, N., van Emmerik, A. A., & Morina, N. (2014). The efficacy of metacognitive therapy for anxiety and depression: A meta-analytic review. Depression and Anxiety, 31(5), 402–411. https://doi.org/10.1002/da.22273 O’Cathain, A., Thomas, K. J., Drabble, S. J., Rudolph, A., & Hewison, J. (2013). What can qualitative research do for randomised controlled trials? A systematic mapping review. BMJ Open, 3, e002889. https://doi.org/10.1136/bmjopen-2013-002889



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Purewal, R., & Fisher, P. L. (2018). The contribution of illness perceptions and metacognitive beliefs to anxiety and depression in adults with diabetes. Diabetes Research and Clinical Practice, 136, 16–22. https://doi.org/10.1016/j.diabres.2017.11.029 Rochat, L., Manolov, R., & Billieux, J. (2018). Efficacy of metacognitive therapy in improving mental health: A meta-analysis of single-case studies. Journal of Clinical Psychology, 74(6), 896–915. https://doi.org/10.1002/jclp.22567 Shadish, W. R., Hedges, L. V., & Pustejovsky, J. E. (2014). Analysis and meta-analysis of single-case designs with a standardized mean difference statistic: A primer and applications. Journal of school psychology, 52(2), 123–147. https://doi.org/10.1016/j. jsp.2013.11.005 Shiffrin, R. M., & Schneider, W. (1977). Controlled and automatic human information processing: II. Perceptual learning, automatic attending, and a general theory. Psychological Review, 84(2), 127–190. https://doi.org/10.1037/0033-295X.84.2.127 Simons, M., & Kursawe, A.-L. (2019). Metacognitive therapy for posttraumatic stress disorder in youth: A feasibility study. Frontiers in Psychology, 10, Article 264. https:// doi.org/10.3389/fpsyg.2019.00264 Simons, M., Schneider, S., & Herpertz-Dahlmann, B. (2006). Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. A case series with randomized allocation. Psychotherapy and Psychosomatics, 75(4), 257–264. https://doi.org/10.1159/000092897 Solem, S., Håland, A. T., Vogel, P. A., Hansen, B., & Wells, A. (2009). Change in metacognitions predicts outcome in obsessive-compulsive disorder patients undergoing treatment with exposure and response prevention. Behaviour Research and Therapy, 47(4), 301–307. https://doi.org/10.1016/j.brat.2009.01.003 Thewes, B., Bell, M. L., & Butow, P. (2013). Fear of cancer recurrence in young early-stage breast cancer survivors: The role of metacognitive style and diseaserelated factors. Psycho-Oncology, 22(9), 2059–2063. https://doi.org/10.1002/pon. 3252 Vogel, P. A., Hagen, R., Hjemdal, O., Solem, S., Smeby, M. C. B., Strand, E. R., Fisher, P., Nordahl, H. M., & Wells, A. (2016). Metacognitive therapy applications in social anxiety disorder: An exploratory study of the individual and combined effects of the attention training technique and situational attentional refocusing. Journal of Experimental Psychopathology, 7(4), 608–618. https://doi.org/10.5127/jep.054716 Wells, A. (1985). Relationship between private self-consciousness and anxiety scores in threatening situations. Psychological Reports, 57(3 Suppl.), 1063–1066. https://doi.org/ 10.2466/pr0.1985.57.3f.1063 Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attention training approach to treatment. Behavior Therapy, 21(3), 273–280. https:// doi.org/10.1016/S0005-7894(05)80330-2 Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23(3), 301–320. https://doi.org/10. 1017/S1352465800015897 Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Wiley. Wells, A. (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Wiley. Wells, A. (2008). Metacognitive therapy: Cognition applied to regulating cognition. Behavioural and Cognitive Psychotherapy, 36(6), 651–658. https://doi.org/10.1017/ S1352465808004803 Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford Press. Wells, A., & Fisher, P. L. (Eds.). (2015). Treating depression: MCT, CBT, and third wave therapies. Wiley-Blackwell. Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Erlbaum.

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Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy, 34(11–12), 881–888. https://doi.org/ 10.1016/S0005-7967(96)00050-2 Wells, A., & Papageorgiou, C. (2001). Brief cognitive therapy for social phobia: A case series. Behavior Research and Therapy, 39(6), 713–720. https://doi.org/10.1016/S00057967(00)00036-X

22 Applied Behavior Analysis Raymond G. Miltenberger, Diego Valbuena, and Sindy Sanchez

T

he term applied behavior analysis (ABA) was introduced by Baer et al. (1968) to describe the application of basic behavioral principles to understand and improve behavior. In their article, Baer et al. outlined a set of characteristics of ABA, which include (a) a focus on behavior that is socially significant, (b) clear demonstration of a functional relationship between behavior and its environment, (c) procedures that are clearly identified and described, (d) direct relation to the basic principles of behavior, (e) focus on socially meaningful behavior, and (f) enduring behavior change. Although ABA comprises a set of assessment and intervention procedures focusing on manipulation of environmental events to change behavior, ABA procedures are based on a set of basic behavioral principles that are also the foundation for the behavioral components of most of the other cognitive behavior therapy (CBT) procedures. ABA focuses on observable, measurable, and objectively defined behavior that may occur in excess or not frequently enough (behavioral deficit). Behavioral assessment is used to identify functional relationships between these behaviors and relevant stimuli to design interventions that help people modify their behavior. One important feature of ABA is the reliance on frequent data analysis to accurately assess changes in behavior and modify interventions as needed. Finally, ABA emphasizes a thorough understanding of recent environmental events to understand the causes of behavior. ABA has been used successfully to help individuals in all walks of life, including children and adults

https://doi.org/10.1037/0000218-022 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  637 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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with disabilities and mental illnesses, teachers and students in school settings, and people in settings such as businesses, sports, health-related fields, and gerontology, among others (e.g., Cooper et al., 2007; Fisher et al., 2011; Miltenberger, 2016; Roane et al., 2015). In this chapter, we present an overview of the field of ABA, including discussion of behavioral assessment and research design, basic principles of behavior, procedures for establishing new behavior, and the functional approach to assessment and intervention for problem behavior.

USING DATA IN APPLIED BEHAVIOR ANALYSIS In ABA, behavior is observed, recorded, and displayed graphically before and after intervention is implemented to monitor behavior change and guide treatment decisions. Although ABA focuses on such direct measures, indirect measures are also utilized.

Indirect Assessment Indirect assessments include interviews, questionnaires, and rating scales used to gather information retrospectively regarding a target behavior and related environmental events. These can be completed by the person engaging in the behavior or someone (e.g., teacher, parent) who regularly observes the behavior (e.g., Hanley et al., 2014; O’Neill et al., 1997). Information gathered through indirect measures may not be as accurate as more objective information gathered through direct measures because the former relies on recall of information by people who are not typically trained on observing the target behavior (Miltenberger, 2016). However, indirect measures may be valuable for planning direct observation recording, as they can provide information about the time and contexts in which the behavior is likely to occur (e.g., Hanley et al., 2014). One other form of indirect assessment is permanent product recording of tangible products that can result from a behavior (e.g., Noell et al., 2005). Permanent product recording has the advantage of not requiring an observer to record occurrences of the behavior, which is useful in situations where observing the behavior would be impractical. For example, product recording could be used to record the number of items recycled in an office setting, number of units assembled by a factory worker, weight for a person participating in a weight-loss program, or correct answers in a homework assignment. Although permanent product recording is convenient, because the behavior is not being directly observed, it may be difficult to determine who engaged in the behavior. Due to the limitations associated with indirect assessments, ABA focuses on direct observation and recording of behavior. The remainder of this chapter will focus on direct measures of behavior.



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Observing and Recording A defining feature of ABA is the objective measurement of behavior accomplished through directly observing and recording the behavior as it occurs. Direct assessment is carried out in the following steps (Miltenberger, 2016). Defining The initial step in observing and recording behavior is to define the target behavior. When deciding which behavior to target, it is important to consider the social importance of the behavior (Baer et al., 1968; Schwartz & Baer, 1991; Wolf, 1978). Target behaviors include behavioral excesses and behavioral deficits. A behavior that a client wants to reduce is called a behavioral excess. Inversely, a behavior that a client wants to increase is called a behavioral deficit. Definitions of target behaviors should include active verbs that describe the behavior in objective and unambiguous terms. Two observers familiar with the definition observing the same behavior should agree on whether the target behavior occurred. Logistics of Recording After the target behavior is defined, the next step is to determine when, where, and by whom the target behavior will be observed. The observer, who can be a caregiver, therapist, or researcher, should be someone who is in the environment when the target behavior occurs. When it is not possible for others to observe the behavior (e.g., if it occurs at very low rates or only when others are not present), the person engaging in the behavior can be the observer (i.e. self-monitoring). The observation period should be a time when the target behavior is likely to occur in the environment where it typically occurs. Recording Method After the logistics of recording are decided, the next step is to choose a recording method. There are three categories of recording methods: continuous recording, interval recording, and time sample recording. In continuous recording, the observer observes the client directly throughout the entire observation period while recording every occurrence of the target behavior; thus, it should be clear when an instance of the behavior begins and ends (e.g., Miltenberger et al., 1999). When conducting continuous recording, a person can measure one or more dimensions of the behavior: (a) frequency (the number of times it occurs), (b) duration (the time from the onset to the offset of the behavior), (c) intensity (the amount of force, energy, or exertion), or (d) latency (time from some stimulus event until the start of the behavior). Interval recording is conducted by dividing the observation period into smaller intervals and recording whether the behavior occurred at any point during each interval (partial interval recording) or throughout the entire interval (whole-interval recording; e.g., LeBlanc et al., 2016; Northup et al., 1991). The number of intervals with the target behavior is divided by the total number of

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intervals and multiplied by 100 to report a percentage of intervals in which the behavior occurred. One can also collect frequency-within-interval data by recording the number of times the target behavior occurs within each interval. Time sample recording is conducted by dividing the observation period into intervals but only recording the behavior during part of each interval. In other words, periods of observation are separated by periods without observation (LeBlanc et al., 2016). For example, a person may divide the observation period into 10-s intervals but record the occurrence of a behavior only at the end of each 10-s interval (also called momentary time sample). As another example, a person might divide the observation period into 1-minute intervals, but only observe and record the behavior in the last 10 seconds of each interval. Time sample recording has the advantage of only requiring the observer to attend to the behavior during a specific time of the interval, making it less cumbersome for the observer. Recording Instrument The last step in observing and recording a target behavior is to select a recording instrument, that is, what the observer will use to record the occurrence of the target behavior. Data sheets are the most common recording instrument; an observer marks the occurrence of the target behavior on the data sheet immediately after it occurs. Data sheets should be designed for clarity and convenience to increase accuracy and minimize response effort when observing and recording the target behavior. Other recording devices include handheld or wrist-worn counters for frequency recording, stopwatches for duration recording, and laptop computers, tablets, or smartphones with apps for frequency, duration, or interval recording. When deciding on which instrument to use, one should consider the practicality and ease of use for the observer in the environment where the behavior is occurring. Reactivity Reactivity refers to a change in behavior as a result of being observed (e.g., Codding et al., 2008; Wright & Miltenberger, 1987). For example, a staff member in a group home may implement a treatment with high accuracy when there is a supervisor present observing their performance and much less accurately when they are not being observed (e.g., Mowery et al., 2010). Reactivity can be problematic because the behavior recorded is not representative of the levels of the behavior in the absence of the observer. To minimize reactivity, one can wait for the person being observed to get used to the observer, or one can observe the behavior discreetly (e.g., hidden camera, one-way mirror, or confederate observers). Reactivity also occurs when self-monitoring, with individuals’ behavior changing when they record their own behavior. Interobserver Agreement Interobserver agreement (IOA) is assessed to ensure that observers are reliably recording the target behavior as outlined in the definition. To measure IOA,



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two observers independently but simultaneously record the target behavior. The recordings of the two observers are then compared, and a percentage agreement on the occurrence of the target behavior is calculated. Because the methods to calculate IOA vary depending on the recording method being used, the reader is referred to Miltenberger (2016), Miltenberger and Weil (2013), or Cooper et al. (2007) for specific details on assessing IOA. Data Display and Research Design In ABA, data are displayed visually in graphs. Most commonly, data are graphed in line graphs or time series, where the level of the behavior is on the vertical or y-axis, and the time when the behavior occurred is on the horizontal or x-axis. Data are collected and graphed prior to intervention (baseline phase) and after intervention is put in place. This allows for the visual comparison of the level of the behavior across phases. Monitoring the behavior change relative to baseline informs the implementer as to whether intervention is producing clinically significant behavior change and whether the implementer needs to modify the intervention. In ABA research, within-subject or time-series research designs are used to demonstrate a functional relationship between an intervention and the change in behavior. A functional relationship is a demonstration that behavior changed as a result of the intervention (and only the intervention), through replication of the intervention and repeated demonstration of behavior change. There are several within-subject research designs that can be employed to demonstrate a functional relationship, including reversal designs, multiple baseline designs, alternating treatments designs, and changing criterion designs. For details, see Miltenberger (2016), Kazdin (2011), or Bailey and Burch (2018).

MECHANISMS OF CHANGE—BASIC PRINCIPLES At the core of ABA is a set of basic principles. These principles describe the kinds of functional relationships that exist between environmental events and behavior—the classes of environmental events that influence behavior. These basic principles, including reinforcement, extinction, punishment, stimulus control, and respondent conditioning, are the mechanisms of change underlying behavior analytic procedures. Reinforcement Reinforcement is the process by which the consequence of a behavior increases the future probability of that behavior. The consequence that follows the behavior is called a reinforcer, and behavior that is strengthened by a reinforcer is called operant behavior. Reinforcement is a fundamental behavioral principle that is utilized in many behavioral procedures.

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There are two forms of reinforcement: positive and negative. Positive reinforcement is defined as the addition of a stimulus (positive reinforcer) following a behavior that increases the future likelihood of that behavior. Conversely, negative reinforcement is defined as the removal of a stimulus (aversive stimulus) following a behavior that increases the future likelihood of that behavior. It is important to note that both positive and negative reinforcement strengthen the future probability of the behavior. Reinforcing consequences can be socially mediated, or they can arise from direct contact with the environment. The former is referred to as social reinforcement, and the latter is referred to as automatic reinforcement. Several factors can influence the effectiveness of reinforcement: immediacy, contingency, motivating operations, individual differences, and magnitude (Miltenberger, 2016). Immediacy refers to the time between the occurrence of a behavior and the reinforcing consequence. Consequences that occur immediately after a behavior are likely to be more effective as reinforcers. Contingency refers to the consistency with which a consequence follows a behavior. That is, every time a behavior occurs, it produces the same consequence, and in turn, that consequence does not occur unless it is preceded by the behavior. Motivating operations (MOs) are antecedent events that alter the value of a stimulus as a reinforcer and influence the probability of any behavior that results in that reinforcer (Laraway et al., 2003, 2014). There are two types of MOs: (a) establishing operations and (b) abolishing operations. Establishing operations increase the value of a reinforcer and increase the probability of any response that will contact that reinforcer. For example, deprivation of human interaction (being alone) will likely make attention a more potent reinforcer and increase the likelihood of any behavior that will produce attention as a consequence. In contrast, abolishing operations decrease the value of a reinforcer and decrease the probability of any behavior that will contact that reinforcer. For example, listening to music for several hours may leave a person satiated, making music a less potent reinforcer and decreasing the likelihood of any behavior that will produce access to music. Consequences that serve as reinforcers vary depending on individual differences and preferences. These differences should be evaluated prior to the beginning of treatment. The last influencing factor is magnitude, which refers to the amount or intensity of a reinforcer. Generally, a higher magnitude stimulus is likely to serve as a more effective reinforcer. Extinction Extinction occurs when a behavior that was previously reinforced is no longer followed by the reinforcing consequence and, as a result, the behavior decreases and eventually ceases to occur (Cooper et al., 2007). The process of extinction is used to weaken operant behavior. Once behavior is no longer reinforced and stops occurring, it is referred to as a behavior that is extinguished or that has undergone extinction. A behavior maintained by positive reinforcement undergoes extinction when it is no longer followed by the positive reinforcer. A



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behavior maintained by negative reinforcement undergoes extinction when it is no longer followed by the removal of an aversive stimulus. In both cases, the behavior weakens and stops occurring. A phenomenon that occurs with extinction is the extinction burst. An extinction burst is characterized by (a) a brief increase in the behavior’s frequency, intensity, or duration and (b) the occurrence of novel or emotional responses (Lerman, Iwata, & Wallace, 1999). For example, a child who typically gets candy at the grocery store when they cry will likely engage in more intense behaviors when they do not receive candy for crying. Although extinction may temporarily increase the variability or persistence of a target behavior, the behavior will eventually cease to occur if the reinforcing consequence continues to be withheld (Miltenberger, 2016). It is important to note that during extinction, reinforcement is withheld, rather than removed, following the target behavior. In the previous example, the candy was not removed from the crying child; rather, candy was simply not delivered when the child cried. The removal of a reinforcer following a behavior is called negative punishment and is discussed in the section below. Another characteristic of extinction is the reoccurrence of the behavior once it has been extinguished for some time, a phenomenon called spontaneous recovery (Lerman, Kelley, et al., 1999). Spontaneous recovery is more likely to occur in conditions similar to those present when the behavior was reinforced, relative to conditions that are dissimilar. If an extinction procedure is still in place when the behavior occurs during spontaneous recovery, then the behavior may very briefly persist and then stop. However, if behavior is reinforced following spontaneous recovery, the behavior may continue to occur. The process of extinction is influenced by two factors. The first is the reinforcement schedule of the target behavior before extinction. Behavior that is reinforced continuously will become extinguished faster than behavior that is intermittently reinforced. This occurs because the difference between continuous reinforcement and extinction is much more salient, leading to faster discrimination of the consequence that follows the behavior. The second factor is reinforcement during the process of extinction. Accidental reinforcement of behavior undergoing extinction is the same as intermittent reinforcement, which will delay the process and make the behavior more likely to resist extinction (Miltenberger, 2016). Punishment Punishment is another process by which the consequence of an operant behavior decreases the future probability of that behavior. The consequence that follows the behavior is called a punisher. There are two forms of punishment: positive and negative. Positive punishment is defined as the addition of an aversive stimulus (punisher) following a behavior that decreases the likelihood of that behavior at a later time. Conversely, negative punishment is defined as the removal of a reinforcing stimulus

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following a behavior which decreases the likelihood of that behavior at a later time. It is important to note that both positive and negative punishment weaken the future probability of the behavior. Although the definitions of punishment and reinforcement are similar, punishment always weakens a behavior and reinforcement always strengthens a behavior—this is the key difference (Cooper et al., 2007; Miltenberger, 2016). Punishment is influenced by the same factors that influence reinforcement, including immediacy, contingency, MOs, individual differences, and magnitude. Punishment is most effective when the consequence occurs immediately and repeatedly contingent on the behavior. Just as with reinforcement, MOs alter the value of the consequence and influence the immediate probability of behavior that will come in contact with the consequence. Punishers will also differ from one person to another, and generally, a higher magnitude stimulus is likely to serve as a more effective punisher. For further discussion on punishment, please refer to Lerman and Vorndran (2002) and Vollmer (2002). Stimulus Control As discussed above, reinforcement, extinction, and punishment are basic principles of behavior that determine whether a behavior will continue to occur. The effects of these basic principles are situation-specific in that a behavior is more or less likely to occur in situations in which it has been reinforced, extinguished, or punished in the past. Situations or stimuli that are present when the behavior occurs are referred to as antecedents. When a behavior is more likely to occur in the presence of specific antecedents, it is said to be under stimulus control (e.g., Tiger & Hanley, 2004). Stimulus control develops through stimulus discrimination training (also referred to as discrimination training), in which the behavior is only reinforced when it occurs in the presence of a particular stimulus (discriminative stimulus [SD]) and not in the presence of any other stimulus (S-delta; Miltenberger, 2016). As result of stimulus discrimination training, the behavior is more likely to occur when the SD is present and less likely to occur when an S-delta is present. Although discriminative stimuli do not increase the future probability of a behavior, an SD does evoke the behavior that has been reinforced in its presence. An SD will have stimulus control over a behavior as long as the behavior continues to be reinforced in its presence. For example, a child is more likely to tantrum with their teacher because the teacher always responds with attention, and they are less likely to tantrum with their father because their father does not provide attention. In this example, the teacher is the SD as the tantrum is reinforced in their presence. The father is the S-delta, as the child’s tantrum in his presence does not result in reinforcement. Sometimes following stimulus discrimination training, a behavior occurs in the presence of stimuli that share properties with the SD. The more similar stimuli are to the SD, the more likely they are to evoke the behavior that was reinforced in the presence of the SD. Generalization is the process by which a behavior



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is likely to occur in the presence of stimuli that are similar to the SD. In the example described above, generalization occurs if the child has a tantrum in the presence of another teacher at their school. Respondent Conditioning Reinforcement, extinction, punishment, and stimulus control are principles of operant conditioning. As operant behavior is controlled by its consequences, operant conditioning involves manipulating these consequences to either strengthen (reinforcement) or weaken (extinction or punishment) a behavior. Respondent behavior is controlled (elicited) by antecedent stimuli; therefore, respondent conditioning involves manipulating antecedents. In respondent (also referred to as classical or Pavlovian) conditioning, a previously neutral stimulus (NS) is paired with an unconditioned stimulus (US). The US naturally elicits an unconditioned response (UR), and as a result of being paired with the US, the NS then elicits a response similar to the UR. The NS is then referred to as a conditioned stimulus (CS), and the response it elicits is referred to as a conditioned response (CR). The UR and CR are called respondent behavior (Miltenberger, 2016). Although basic behavioral principles include operant and respondent conditioning, the principles of operant conditioning form the basis for most ABA procedures used to help people change their behavior. The rest of this chapter focuses on procedures to establish new behaviors and procedures to understand and decrease problem behaviors.

PROCEDURES TO ESTABLISH NEW BEHAVIORS As previously discussed, reinforcement is used to strengthen an operant behavior that is already occurring. However, when the desired behavior is not in the person’s repertoire, the target behavior must be evoked before it can be reinforced. The basic teaching paradigm in ABA involves the use of prompts to evoke the behavior in the presence of the SD, the use of reinforcement to strengthen the behavior in the presence of the SD, and removal of the prompts to transfer stimulus control as the behavior continues to occur in the presence of the SD. The following behavioral procedures are used to teach desirable behaviors. Preference Assessments Preference assessments are used in conjunction with behavior acquisition procedures to identify stimuli that may serve as reinforcers during teaching procedures. Preference can be identified via client or caregiver interviews, direct observations, and single or multiple stimulus tests. For a more detailed description of preference assessments please refer to Cooper et al. (2007) and Cannella et al. (2005).

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Prompting A prompt is a stimulus that is delivered to evoke the behavior in the presence of the SD so the behavior can be reinforced. The two main categories of prompts are response prompts and stimulus prompts. Response Prompts If the behavior of another person is the stimulus that evokes the target behavior, the prompt is considered a response prompt. The four types of response prompts are verbal, gestural, modeling, and physical. When something another person says evokes the target behavior, it is considered a verbal prompt. An example of a verbal prompt is a therapist saying the word “dog” while showing a child a picture of a dog when teaching the child to identify a picture of a dog. The therapist saying the word made it more likely the child would engage in the target behavior of saying “dog” when shown a picture of a dog, allowing the therapist to deliver reinforcement for the target behavior. When physical movements or gestures from another person makes the target behavior more likely to occur, it is considered a gestural prompt. An example of a gestural prompt is a therapist pointing to the picture of a dog out of an array of different animal pictures when asking the child to “grab the picture of the dog.” The therapist pointing to the picture made it more likely that the child would grab the correct picture, allowing the therapist to reinforce the target behavior. When another person demonstrates the target behavior by performing it correctly, making the target behavior more likely to occur, it is considered a modeling prompt. An example of a modeling prompt is a coach demonstrating a correct golf swing. The coach modeling the target behavior of the correct golf swing made it more likely that the client would engage in the target behavior, allowing the coach to deliver reinforcement for the target behavior. When another person physically helps the client engage in the target behavior, making the target behavior more likely to occur, it is considered a physical prompt. Physical prompts include the use of hand-over-hand or other physical guidance to help the client engage in part or all of the behavior. An example of a physical prompt is a coach physically guiding a client to engage in the correct golf swing. The physical guidance from the coach made it more likely that the client would engage in the correct golf swing, allowing the coach to reinforce the target behavior. Because response prompts involve the behavior of another person influencing the behavior of the client, they are considered intrusive. Verbal, gestural, modeling, and physical prompts are considered less to more intrusive in that order. When using prompting to teach a new behavior, the implementer should generally use less intrusive prompts first and move to more intrusive response prompts if less intrusive ones are not effective.



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Stimulus Prompts Stimulus prompts are changes to stimuli, or the addition of stimuli, that make the behavior more likely to occur. Stimulus prompts fall into two main categories: within-stimulus prompts and extrastimulus prompts. Within-stimulus prompts are changes in the position or some other dimension (i.e., size, shape, color, or intensity) of the SD that make the target behavior more likely to occur. For example, a therapist teaching a child to select a picture of a dog out of an array of animal pictures may move the picture of the dog closer to the child than the other animal pictures or make the picture of the dog larger than the other animal pictures. Extrastimulus prompts are the addition of stimuli that make the target behavior more likely to occur. In the previous example of teaching a child to select the picture of the dog, the therapist could add an arrow pointing to the picture of the dog or add a red border around the picture of the dog to make the child more likely to select the correct picture when instructed to do so. Prompt Fading and Delay When using prompts to evoke a target behavior, the prompts must eventually be removed so that the client engages in the correct behavior in the presence of the SD without the assistance of prompts. Removing prompts as the behavior occurs in the presence of the SD is called transferring stimulus control. Two ways to transfer stimulus control to the SD are prompt fading and prompt delay. Response Prompt Fading When using response prompts, one way to transfer stimulus control to the SD is the use of prompt fading. Response prompt fading involves the gradual removal of response prompts across learning opportunities as the correct behavior continues to occur in the presence of the SD. For example, when fading the verbal prompt of saying “dog” when teaching a child to name a picture of a dog, the therapist could gradually remove the prompt by first saying “dog” then “do” then “d” and finally no prompt. In the case of the coach using physical prompting to teach a golf swing, the coach can gradually remove the prompt by at first physically guiding the learner through the entire golf swing, then only the first half of the swing, and so on, until the learner engages in the swing correctly without the response prompt. Stimulus Prompt Fading Similarly, stimulus prompts can be gradually removed across learning trials to transfer stimulus control to the SD. For example, in the case of placing the picture of the dog closer to the learner than other pictures in the array, stimulus prompt fading would involve gradually moving the picture further from the learner until it is in line with all of the other pictures in the array. In the case of the extrastimulus prompts of an arrow pointing at the correct picture, the

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arrow could be made smaller and smaller until it is removed; In the case of the red border around the picture, the border could be made thinner and thinner until it is not there, or the color red could be faded to lighter tones until it is not there. Prompt Delay Another strategy to transfer stimulus control from prompts to the SD is to delay the presentation of the prompts. This strategy, called prompt delay, involves introducing a delay from the presentation of the SD to the presentation of the prompt. At first, the prompt is delivered immediately after the SD (0-s delay). The delay is then introduced in subsequent learning trials. The delay in presenting the prompt allows the learner the opportunity to respond to the SD before the prompt is delivered, resulting in transfer of stimulus control. Chaining Another behavioral procedure used to teach new behaviors is chaining. A behavioral chain is a complex behavior that is comprised of several component responses that occur in sequence (Miltenberger, 2016). For example, drinking a sip of water from a water bottle involves several stimulus-response components to complete the behavioral chain. The sequence of stimulus-response components can be analyzed by its individual components, a process called a task analysis. For example, a task analysis for drinking a sip of water would outline the individual stimulus-response components as follows: SD1 (Water bottle on table) → R1 (Reach for water bottle) SD2 (Hand on water bottle) → R2 (Lift water bottle) SD3 (Water bottle in hand) → R3 (Remove cap) SD4 (Water bottle in hand with cap off) → R4 (bring bottle to mouth) → Reinforcer (drink water) After developing a task analysis for a complex behavior, behavioral chaining procedures are used to teach the learner the behavior chain. Forward Chaining Forward chaining procedures involve teaching one stimulus-response component at a time, beginning with the first component and then chaining (combining) the next component once the previous component has been mastered (e.g., Shrestha et al., 2013; Slocum & Tiger, 2011). In the example of drinking from the water bottle, forward chaining would involve the use of prompting and fading to teach the first component (reaching for the water bottle in response to the water bottle on the table). After the learner masters the first component, the second component is taught together with the first (chained), and so on until all of the components are mastered. Because only the final



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component involves access to the natural reinforcer (drinking water), other reinforcers are used to teach the prior components. Backward Chaining In backward chaining procedures, prompting and fading are used to teach one stimulus-response component at a time; however, the final component is trained first. Once it is mastered, the trainer uses prompting and fading to teach the previous component and then the last two components occur together. This process is continued until all components are learned (e.g., Hagopian et al., 1996; Jerome et al., 2007). Backward chaining has the advantage that by starting with the final component, all trials will result in completion of the behavior chain and therefore produce the natural reinforcer. In the example of teaching to drink from the water bottle, the final component of bringing the open water bottle to the mouth would be taught first. Once mastered, the trainer would combine (chain) the previous component (removing the cap and bringing the bottle to the mouth), and so on until all components are mastered. Total Task Presentation Unlike forward and backward chaining, which teach one stimulus-response component at a time before combining other components, total task presentation teaches the entire behavior chain as a single unit (all components at once; Miltenberger, 2016). The trainer uses physical prompting and fading as necessary to get the learner to engage in the entire behavior chain correctly. As the learner starts to engage in any of the behaviors in the chain, the trainer fades physical guidance, and if the learner fails to engage in any of the behaviors, the trainer resumes physical guidance. Over trials, the prompting is faded to shadowing, and eventually the prompts are eliminated in a process called graduated guidance. Behavioral Skills Training Behavioral skills training (BST) is the use of instructions, modeling, rehearsal, and feedback to teach a new behavior. BST has been used to teach skills to children and adults in a number of areas such as social skills, safety skills, and skills staff need to work effectively with clients. (e.g., Himle, Miltenberger, Gatheridge, & Flessner, 2004; Miltenberger et al., 2017; Sanchez & Miltenberger, 2015). Instructions and Modeling Instructions and modeling are used to evoke the correct behavior. Instructions consist of describing the target behavior and the circumstances in which the target behavior should occur. The person delivering the instructions should be someone with credibility to the learner, and the instructions should be clear and use language that the learner can comprehend. Instructions can be delivered in person or through audio/video recordings. Modeling is demonstrating the target behavior in the proper context while the learner observes. Modeling

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can be done in person by a person in authority or a person with similarity to the client or through video, animation, or even through a small-scale model (Maxfield et al., 2019). Rehearsal and Feedback Rehearsal is practicing the target behavior after receiving instructions and observing a model. This is a critical component of BST, as it allows the trainer to observe the learner engaging in the target behavior and provide feedback. Rehearsal of the target behavior should be immediately followed by feedback (e.g., Himle, Miltenberger, Flessner, & Gatheridge, 2004). Feedback consists of descriptive praise for correct performance in the rehearsal and further instruction for improvement when errors occur during the rehearsal. Rehearsal of the target behavior with feedback should take place in the scenario in which it is expected to occur or in a role-play that simulates the scenario. Rehearsal and feedback should continue until the learner demonstrates the target behavior correctly a few consecutive times. Rehearsal and immediate feedback appear to be critical components of BST. Studies comparing BST versus programs that only provided instructions and models of safety skills found that instructions and modeling alone are insufficient to teach children safety skills (Beck & Miltenberger, 2009; Gatheridge et al., 2004; Miltenberger et al., 2013). Although research shows that BST is more effective than instructional programs that do not include rehearsal and feedback, BST is not always effective; that is, the skills do not always generalize to the natural environment. In such situations, research shows that in situ training can promote generalization (e.g., Gatheridge et al., 2004; Miltenberger et al., 2015).

In Situ Training In situ training starts with the trainer arranging an assessment in the natural environment without the learner’s knowledge (in situ assessment; e.g., Miltenberger et al., 2005). If the learner fails to perform the target behavior correctly, the trainer enters the situation and immediately conducts an in situ training session. The training consists of the same components as BST; however, they are delivered in the natural setting immediately following a failed in situ assessment to facilitate generalization of the skills to the natural setting.

Shaping Shaping is another strategy used to teach new behaviors. Shaping consists of reinforcing successive approximations of the target behavior (Miltenberger, 2016) and includes the following steps: 1. Define the target behavior. The first step is to define the target behavior that will be accomplished through shaping.



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2. Determine the appropriateness of using shaping. The next step is to determine whether shaping is the most appropriate procedure to use to teach the target behavior. If more efficient strategies such as prompting, modeling, or instructions can be used to teach the target behavior, shaping may not be necessary. 3. Identify the shaping steps. The first approximation is a behavior in which the client already engages and that is relevant to the target behavior. Each subsequent step or approximation should be closer to the target behavior than the previous one (successive approximations). 4. Select the reinforcer to use in the shaping procedure. It is important to choose a consequence that will function as a reinforcer for the client. Because they are less sensitive to satiation effects, conditioned reinforcers such as tokens or praise are commonly used in shaping procedures. 5. Differentially reinforce each shaping step. Each step is reinforced until it is mastered, beginning with the first approximation. Once a step is mastered, reinforcement is no longer delivered for that approximation (it is put on extinction), and the trainer delivers reinforcement for the next shaping step. This process (differential reinforcement of successive approximations) continues until the client masters the final approximation, which is the target behavior. 6. Move though the shaping steps at an appropriate pace. It is important to ensure that each step is mastered (performed correctly a few consecutive times) prior to moving to the next shaping step. However, reinforcing one step too many times may make it more difficult for the learner to engage in the next step, as they may continue to engage in the step that has been repeatedly reinforced. Providing instructions, cues, or prompts that the next shaping step is required for reinforcement may make progression to the next step easier.

FUNCTIONAL APPROACH TO ASSESSMENT AND INTERVENTION Thus far, this chapter has discussed several procedures for establishing new behaviors. A second major application of ABA is to help clients change existing behaviors. To modify existing behavior, the behavior analyst must first understand why it occurs. A functional approach to assessment and intervention begins with a functional assessment to identify the antecedents and consequences that evoke and maintain the target behavior. Interventions that specifically address these variables are called functional interventions. Functional interventions include extinction, differential reinforcement, and antecedent control procedures. Functional Approach to Assessment Functional assessment is the process of gathering information to identify the antecedents that evoke the problem behavior and the reinforcing consequences

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that maintain the behavior. A functional assessment is completed once sufficient data have been gathered to generate a hypothesis about the function (reinforcing consequences) of the behavior and the antecedents that evoke the behavior (Miltenberger, 2016; Miltenberger et al., 2016). The reinforcement contingencies that maintain behavior can be categorized as social (when delivered by another person) or automatic (when resulting from the behavior itself). Three methods of conducting functional assessments are indirect assessment, direct observation assessment, and functional analysis. Indirect Assessment When conducting indirect assessments, information is gathered from individuals who are familiar with the client and the target behavior. Ways of conducting indirect assessments involve interviews, questionnaires, checklists, and rating scales. Indirect assessments can also be referred to as informant assessments because an informant is answering questions regarding the behavior and its antecedents and consequences (Lennox & Miltenberger, 1989). The goal of indirect assessments is to gather enough information to formulate a hypothesis about the environmental events that evoke and maintain the problem behavior and use this information to tailor subsequent assessments. Indirect assessments are frequently used because they are easy, time efficient, and readily available (Durand & Crimmins, 1989; Hanley et al., 2014; Iwata et al., 2013). The limitation of an indirect assessment is that it relies on informant recall, which may yield erroneous or biased information. Direct Observation Assessment When conducting direct observation assessments, an observer records the behavior in the natural environment. The goal of these assessments is to accurately capture the antecedents and consequences associated with the target behavior. When conducting a direct observation assessment, it may help to observe discreetly to reduce possible reactivity. Observations typically occur across a number of sessions until sufficient data have been gathered to identify a clear pattern in the antecedent and consequences associated with the target behavior. Direct observation assessments involve descriptive ABC (i.e., antecedent, behavior, consequence) recording or checklists (e.g., Bijou et al., 1968). When using descriptive ABC recording, the observer clearly and objectively documents exactly what happens before and after the target behavior. When using a checklist, the observer designs a three-column checklist with a predetermined set of antecedents, behaviors, and consequences. The observer then places a checkmark in the appropriate space to record each behavior of interest, along with corresponding antecedents and consequences. Both descriptive ABC recordings and checklists can be used to collect data on one or several target behaviors at a time.



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Direct observation assessments eliminate mistakes associated with informant recall and produce objective, and likely more accurate, data (Miltenberger, 2016). However, a limitation of this assessment is that it requires more time and effort, as several observations are typically needed and the observer needs to be available in situations when the target behavior is most likely to occur (e.g., bedtime, early morning routine, car ride). Functional Analysis Functional analyses are a type of functional assessment involving direct manipulation of antecedents and consequences to identify their influence on the target behavior. The purpose of functional analyses is to demonstrate a functional relationship between particular environmental events and the behavior of interest (e.g., Iwata et al., 1994). A functional analysis consists of one or more test and control conditions. In a test condition, the behavior analyst arranges a putative establishing operation to evoke the behavior and delivers a putative reinforcer following the behavior. In a control condition, the behavior analyst delivers an abolishing operation and does not deliver any consequences for the problem behavior. If the behavior is higher in one of the test conditions than in the control condition, the results suggest the consequence delivered in the test condition is the reinforcer for the problem behavior (Miltenberger, 2016; Miltenberger et al., 2016). For example, when evaluating attention as a possible reinforcer for the problem behavior, the test condition would involve providing no attention to the child (EO) and providing attention only contingent on the problem behavior. A control condition would involve delivering noncontingent attention (AO) throughout the session but delivering no attention following the problem behavior. If attention is the reinforcer for the problem behavior, the problem behavior should occur at a high rate in the test condition and not in the control condition. Functional analyses can be used to evaluate a number of possible reinforcers for a target behavior. If this is the case, several test conditions may be considered in the functional analysis. These typically include attention, escape, and access to tangible reinforcers to test for socially mediated functions or an alone or ignore condition to test automatic reinforcement. Functional analyses can also be used to evaluate a specific hypothesis, which involves manipulating one specific reinforcer in one test condition. For example, to test whether escape serves as a reinforcer for a specific target behavior, one would alternate between conditions in which demands are placed on the client and escape follows the target behavior (test) and conditions in which no demands are placed on the client and escape is not provided for the problem behavior (control). A functional analysis demonstrates a functional relationship between antecedents and consequences and the target behavior. However, some limitations include the need for greater expertise understanding and conducting these assessments and temporarily reinforcing problematic behavior in an attempt to identify the reinforcer for the behavior.

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Functional Approach to Intervention Extinction Extinction is both a basic principle (as described above) and a procedure used to decrease the frequency of a target behavior. To use extinction as a behavior reduction procedure, it is necessary to first conduct a functional assessment to identify the reinforcer maintaining the problem behavior. Once the reinforcer is identified, extinction entails withholding the reinforcer after every instance of the behavior (e.g., Iwata et al., 1990). If a behavior is not reinforced, it will eventually cease to occur or extinguish. To use extinction safely and effectively in clinical practice, consider the following (Miltenberger, 2016): 1. Have you accurately identified the maintaining reinforcer? The effectiveness of extinction directly depends on eliminating the reinforcer for the problem behavior. Therefore, conducting a functional assessment prior to the use of extinction is critical to the effectiveness of extinction. 2. Can you eliminate the reinforcer? If the person implementing extinction cannot control access to the reinforcer, extinction cannot be used. This may be the case when you cannot directly influence the individuals that reinforce the problem behavior or when the behavior is maintained by automatic reinforcement. 3. Is extinction safe to use? In some cases, particularly with clients who engage in aggression or self-injury, the intensity of the behavior may be such that extinction could result in harm to the individual or others. In these cases, you could choose a different procedure. 4. Can the individuals implementing extinction manage an extinction burst? In most cases, extinction results in a sudden increase in intensity, duration, and frequency of the target behavior, novel behaviors, and/or emotional responses before the behavior decreases (e.g., Lerman, Iwata, & Wallace, 1999). It is important to train change agents before beginning an extinction procedure so they are prepared for an extinction burst and do not accidentally reinforce a more intense topography of the problem behavior that might occur during an extinction burst. 5. Can consistency be maintained? When using extinction, the reinforcer must be withheld following every single instance of the problem behavior. Accidentally reinforcing the problem behavior is equivalent to intermittent reinforcement, which will likely make the behavior persist or worsen and make the behavior more resistant to the effects of extinction. In clinical practice, extinction should be used in conjunction with a reinforcement procedure that strengthens an alternative replacement behavior. Antecedent manipulation procedures should also be used to eliminate antecedents that evoke the problem behavior and introduce antecedents that evoke the new, appropriate response.



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Differential Reinforcement Differential reinforcement involves the simultaneous use of reinforcement to increase a desirable behavior and extinction to decrease a problem behavior (Hanley & Tiger, 2011). Three types of differential reinforcement are differential reinforcement of alternative behavior (DRA), differential reinforcement of other behavior (DRO), and differential reinforcement of low rates of behavior (DRL). Differential reinforcement can also be used in behavioral contracts and token economies to encourage desirable behaviors. When extinction is not possible, differential reinforcement can still be used, but there must be very clear differentiation between the magnitude and quality of reinforcement following the problem behavior and the appropriate behavior (Athens & Vollmer, 2010). For example, if high intensity self-injurious behavior is maintained by attention and complete extinction is not possible because it would result in harm to the individual, the clinician can still provide low quality attention (e.g., block self-injury attempts, instructions to stop while minimizing conversation and eye contact) and give high quality attention (e.g., enthusiastic praise with eye contact) when the individual appropriately requests attention in the absence of self-injurious behavior. Differential Reinforcement of Alternative Behavior DRA entails reinforcing instances of desirable behavior and using extinction (when possible) to eliminate problem behavior. The goal of DRA is to completely extinguish an undesirable behavior and strengthen a new, desirable behavior (e.g., Petscher et al., 2009). To use DRA, the desirable behavior must already be in the individual’s repertoire and occurring at least occasionally, so that it can be reinforced. In addition, there must also be access to a known reinforcer that can be delivered consistently following each instance of the desired behavior. If the desired behavior is not already occurring and/or there is no access to an appropriate reinforcer, DRA by itself is not the optimal procedure. DRA can involve either positive or negative reinforcement. In either case, the fundamentals of the procedure remain the same—appropriate behavior is reinforced, problem behavior is not (or is minimally reinforced if extinction is not possible). For example, if a problem behavior is maintained by attention, DRA would involve delivering attention following a desirable response and withholding attention following an undesirable response. If a problem behavior is maintained by escape, DRA would involve allowing escape contingent on a desirable response and withholding escape contingent on the undesirable response. In one variation of DRA, reinforcement is delivered for a behavior that is incompatible with the problem behavior, making it impossible for both behaviors to occur simultaneously. For example, if the problem behavior is biting one’s nails, an incompatible behavior may be placing hands on the lap or in pockets. One cannot bite nails if their hands are occupied doing something else. Another variation of DRA is differential reinforcement of communication or functional communication training (FCT; Carr & Durand, 1985). FCT involves

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reinforcing a communication response that is functionally equivalent to the problem behavior. For example, if a problem behavior is maintained by escape from aversive tasks, FCT would involve reinforcing instances of asking for a break and extinguishing instances of the problem behavior. Differential Reinforcement of Other Behavior In DRO, reinforcement is delivered contingent on a specified interval of time without problem behavior. If the problem behavior occurs, the reinforcer is not delivered (extinction) and the reinforcement interval is reset (e.g., Vollmer et al., 1993). As the DRO interval increases and reinforcement follows longer periods of time without problem behavior, the opportunities for appropriate behavior naturally increase. It is important to note that although the name of this procedure suggests that reinforcement follows some other behavior, in DRO reinforcement only follows the absence of the target behavior. With this in mind, DRO can be considered reinforcement of zero rates of the target behavior (Miltenberger, 2016). To use DRO, first, a functional assessment must be conducted to identify the reinforcer maintaining the problem behavior. As extinction is a component of DRO, knowing the correct reinforcer is crucial for the success of this procedure. Second, the reinforcer to be delivered contingent on the absence of problem behavior is selected. Generally, the reinforcer used is the same one responsible for maintaining the problem behavior. Finally, the initial DRO interval (time without problem behavior) for delivering reinforcement is identified. The initial DRO interval is based on the baseline rate for problem behavior. For example, if a problem behavior occurs five times in 5 minutes, the average time between responses is 1 minute; therefore, the initial DRO interval should be set for 1 minute or less. Differential Reinforcement of Low Rates of Behavior In DRL, reinforcement is delivered contingent on lower rates of a target behavior. DRL is used when a target behavior is only problematic because of the high rate at which it occurs or when lower rates of the problem behavior can be tolerated (Miltenberger, 2016). For example, DRL would be an appropriate procedure for decreasing the number of times a student answers questions in class, but it would not be an appropriate procedure when a student engages in high intensity self-injurious behavior. To use DRL, the implementer tells the client which level of the behavior is acceptable during a specified period of time and delivers a reinforcer if the level is achieved after the time has elapsed. This is called full-session DRL. The procedure can be enhanced by having a visual aid or allowing the client to keep track of how often the behavior is occurring. Once the DRL interval is elapsed, reinforcement is delivered if the client engaged fewer than the specified number of responses during that interval (e.g., Dietz & Repp, 1973). Another variation of DRL is called spaced-responding DRL. In space-responding DRL, reinforcement is delivered for a response if a certain amount of time since



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the last response has passed (Anglesea et al., 2008; Singh et al., 1981). If the behavior occurs before the end of the interval, the reinforcer is not delivered, and the interval is reset. The objective of this variation of DRL is to pace the behavior. It is important to note that spaced-responding DRL is not the same as DRO. In DRO, reinforcement follows the absence of the target behavior; in spaced-responding DRL, reinforcement follows the occurrence of the target behavior after an interval of time has passed. The purpose of DRO is to eliminate a problem behavior; the purpose of spaced-responding DRL is to decrease a behavior that is occurring too often. Antecedent Control Strategies Thus far, we have discussed extinction and differential reinforcement, or consequent strategies for increasing or decreasing the occurrence of behavior. Antecedent control strategies manipulate antecedent stimuli to evoke desirable behaviors and make undesirable behaviors less likely to occur. These strategies involve manipulating SDs, EOs, and response effort. Antecedent control strategies for increasing desirable behavior entail presenting relevant SDs and EOs and decreasing response effort. SDs evoke a desirable behavior because the behavior has a history of reinforcement in the presence of the SD. For example, a person who wants to drink more water is more likely to drink water if there is a pitcher of water on the counter. Creating an EO also evokes desirable behavior, as EOs increase the value of a reinforcer and increase the probability of behavior that will produce that reinforcer. For example, a person is more likely to drink water after they have just engaged in vigorous exercise. Finally, minimizing response effort decreases the exertion needed for a specific response. In general, behaviors that require less effort are more likely to occur than behaviors that require more response effort, given the same amount and quality of reinforcement (Piazza et al., 2002). For example, a person is more likely to drink water than soda if water is readily available and access to soda requires a trip to the grocery store. Antecedent control strategies for decreasing problematic behavior entail removing SDs and EOs and increasing response effort. A problematic behavior is less likely to occur in the absence of an SD that signals that reinforcement is available. For example, drinking soda is less likely to occur if soda is not available. Removing an EO also decreases the value of the reinforcing stimulus and decreases the probability of behavior that produces that reinforcer. For example, if a person is thirsty and drinks a glass of water, they will be less likely to drink soda, even if the soda is readily available. Finally, increasing response effort decreases the probability of problematic behavior and makes it more likely that a person will choose a less effortful, functionally equivalent (desirable) response, given the same amount and quality of reinforcement (e.g., Zhou et al., 2000). For example, a person is less likely to drink soda if they have to drive to the store to buy it and more likely to drink water if it is readily available in their kitchen.

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To effectively use antecedent control strategies, one must first identify relevant antecedents through a functional assessment. For more information on how these strategies are used to treat problem behaviors maintained by both positive and negative reinforcement, please refer to Miltenberger (2016). Using Punishment There are a number of ways in which punishment procedures can be implemented to decrease a behavioral excess. However, it is important to note that punishment procedures should only be used after nonpunishment procedures (functional interventions—antecedent control, extinction, and differential reinforcement) have been exhausted (i.e., they have been implemented and found to be ineffective or inappropriate). Punishment procedures should never be the first choice of treatment. When punishment is used, it is commonly negative punishment in the form of time-out or response cost; therefore, only these procedures are described here. When using punishment to decrease a behavioral excess, one should also use reinforcement procedures to increase an appropriate replacement behavior (Miltenberger, 2016). Time-Out One way in which negative punishment is implemented to decrease a target behavior is time-out (i.e., time-out from positive reinforcement). Time-out consists of removing the individual from access to positive reinforcement contingent on a problem behavior, resulting in a decrease in the future likelihood of that behavior. Time-out procedures are categorized as either exclusionary or nonexclusionary. In exclusionary time-out, when the individual engages in the problem behavior, they are removed from the room where the behavior occurred and taken to another room without access to the reinforcers available in the environment where the behavior occurred (e.g., Clark et al., 1973). In nonexclusionary time-out, when the individual engages in the problem behavior, they remain in the room but are removed from the activity or location where access to the reinforcers was available (e.g., Foxx & Shapiro, 1978). Nonexclusionary time-out can be used in situations in which (a) it is possible and practical to withhold access to the reinforcers that were available while the individual stays in the room and (b) the individual staying in the room would not be a disturbance to the remaining people in the room. In situations in which either of these two criteria cannot be met, exclusionary time-out may be more appropriate. When implementing time-out, there are several factors to consider that may influence its effectiveness (Miltenberger, 2016): 1. The function of the problem behavior. Time-out is the correct procedure to use when the problem behavior is maintained by social positive reinforcement (attention or tangibles). Time-out is not appropriate for behaviors maintained by escape because it would negatively reinforce the behavior (e.g., if a student engages in a behavior to escape academic demands, implementing



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time-out would remove them from the demand situation, reinforcing the behavior). It would also not be appropriate for behaviors maintained by automatic reinforcement, as the client would have access to the reinforcer maintaining the behavior regardless of the environment. 2. The practicality of time-out. It is important to consider whether the person implementing the time-out is physically capable of implementing the procedures. If the client resists being taken to the time-out environment, particularly if they are stronger than the implementer, time-out may not be possible. The second factor to consider is the availability of an appropriate time-out environment. No opportunities for tangible or social reinforcement should be available in the time-out environment. 3. The safety of time-out. The time-out environment should be clear of any potentially dangerous items (i.e., sharp, heavy, or breakable items), be well lit, and be clear of any potentially reinforcing items. It is also important that the implementers observe the client in time-out throughout the entire duration so they can intervene if the client engages in any dangerous behaviors. Because minimizing interactions is important for the effectiveness of time-out procedures, the implementer should observe surreptitiously or, when possible, through a camera or one-way observation window. 4. The time-out period is brief. Time-out consists of a brief removal from access to positive reinforcers contingent on the problem behavior. It is important to return the client to the time-in environment as quickly as possible and not extend time-out for long periods of time. Typically, time-out periods range from 1 to 10 minutes. If the client is engaging in the target behavior at the end of the time-out period, the time-out period should be briefly extended (contingent delay) until the client is not engaging in the target behavior. 5. Escape from time-out must be prevented. When implementing time-out, the client may attempt to escape the time-out environment. For time-out to be effective, the implementer should be able to ensure the client stays in time-out (either physically redirecting them back to the area or holding the door to prevent escape if using a safe time-out room). It is important to avoid a struggle which results in attention for the client and may inadvertently reinforce their behavior. 6. Interactions must be avoided. When using time-out procedures, the implementer should remain calm and limit interactions as much as possible. It is important to avoid reprimands or explanations while taking the client to the time-out area or during the time the client is in time-out. If the client attempts to leave the area, the implementer can physically redirect them back into the time-out area without saying anything. 7. Time-out is acceptable. Prior to implementing time-out procedures, the implementer must ensure that this is an acceptable procedure for the given client. In the case of children, the parents must ultimately accept time-out as a

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treatment because they will be the ones implementing the procedure. When the client is an individual with disabilities, it is important to adhere to rules and regulations regarding the use of time-out or other punishment procedures and seek approval prior to implementing as needed. Response Cost Another form of negative punishment to decrease a target behavior is response cost. Response cost involves the removal of a specific amount of a reinforcer contingent on a target behavior, resulting in a decrease in the future likelihood of the behavior (e.g., Conyers et al., 2004; Falcomata et al., 2004). Unlike time-out, which involves removing the client from the reinforcing environment, response cost involves the loss of a reinforcer that the individual already possesses. An example of response cost is removing a child’s favorite toy for the day contingent on aggressive behavior toward their sibling. As is the case when using any punishment procedure, one should use differential reinforcement procedures to increase a replacement behavior when using response cost to reduce a target behavior.

OTHER REINFORCEMENT-BASED BEHAVIOR CHANGE PROCEDURES Token Economy A procedure that can be used to manage reinforcement contingencies in a systematic manner is a token economy. A token economy is a system that uses conditioned reinforcers, or “tokens,” to increase desirable behavior (e.g., Filcheck et al., 2004; Kazdin & Bootzin, 1972). In a token economy, tokens are delivered immediately after the client engages in the target behavior, and later the client can exchange the tokens for backup reinforcers. Implementing a token economy consists of the following steps (Miltenberger, 2016): 1. Define the target behaviors to increase. Operationally define the target behavior. Often multiple behaviors are targeted for increasing. 2. Select items to use as tokens. Tokens should be tangible items that are convenient for the implementer to carry so they can be delivered to the client immediately after the target behavior. It is important that the tokens are not something that the client can easily reproduce or access through other means. Items that are commonly used as tokens include poker chips, raffle tickets, fake money, and points. Another simple strategy is to add tally marks or stickers to a chart while ensuring that the client cannot modify the chart. 3. Select backup reinforcers. For a token economy to be effective, the tokens must act as conditioned reinforcers. It is important to identify what consumables, tangible items, or activities are potential reinforcers for each individual. This can be accomplished through formal preference assessments or through interviews with the individuals when appropriate. Once backup reinforcers are identified, their access should be limited to the client outside of the token economy to increase the value of the reinforcers.



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4. Determine the schedule of reinforcement. The next step is to determine the schedule of reinforcement for the token system. It is common to use continuous reinforcement when first implementing token systems (i.e., every time the client engages in the target behavior, a token is immediately delivered). After some time, token delivery can be faded, with a token delivered after every few instances of the target behavior. In some token economies, different numbers of tokens are delivered for different behaviors, with more tokens being delivered for more important or effortful behaviors. 5. Determine the token exchange rate. The next step is to determine the price in tokens that the backup reinforcers will cost. The number of tokens required to earn a particular reinforcer should reflect the magnitude and value of the reinforcer (more costly or valuable reinforcers should require more tokens). It is important to ensure that the token exchange rate results in the client earning sufficient tokens to earn backup reinforcers. It is also important to ensure that the token exchange rate does not result in the client earning so many tokens that they become satiated to the backup reinforcers. The token exchange rate should be adjusted as necessary to ensure that the client is earning an appropriate number of tokens. 6. Determine a time and place for token exchange. Token exchange can be scheduled to occur at a particular time every day or on only certain days of the week. After the time and place for token exchange are determined, they should be made clear to the clients, and these times should be kept consistent. 7. Consider the need for response cost. The final consideration when implementing a token economy is whether there is a need to include a response cost component. If the intent of the token economy is increasing appropriate behaviors, there is no need to include this component. However, if problem behaviors are competing with the appropriate behaviors, and the problem behaviors do not decrease with the use of the reinforcement-based token economy, adding response cost to the token economy may be considered. The addition of response cost would consist of the client losing a predetermined number of tokens contingent on engaging in the defined problem behavior. Behaviors targeted for reduction with response cost should be clearly defined, and the implementer should determine the rate at which tokens will be lost. This should be made clear to the client.

Behavioral Contract A behavioral contract is another procedure that can be used to manage reinforcement (and punishment) contingencies in a systematic manner. Behavioral contracts (also called contingency contracts) are written agreements between two individuals, such that one of the individuals agrees to engage in a target behavior at a particular level during a specified time period, and the other agrees to deliver a consequence contingent on the target behavior (e.g., Allen et al., 1993; Ruth, 1996). Behavioral contracts include the level of the behavior in

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which the client must engage and the consequences that will be mediated by the implementer if the client engages (or fails to engage) in the target behavior at the specified levels. There are five main components to include in a behavioral contract (Miltenberger, 2016): 1. Define the target behavior. Operationally define the target behavior so it is clear to the client and contract manager. 2. State how the target behavior will be measured. The client and the implementer must agree on how the target behavior will be measured, as it must be done in a way that provides the implementer objective evidence of the occurrence of the behavior. When possible, the implementer can directly observe and record whether the client engaged in the target behavior. In situations when the implementer cannot observe the client directly but another third party can, the third party can record the occurrence of the behavior. Finally, in cases in which the behavior produces a permanent product (e.g., completed homework assignment or cleaned room), permanent product is an acceptable method to use. 3. State when the individual should engage in the behavior. The behavioral contract should specify the time period in which the target behavior should occur (or not occur) for the outlined consequences to take place. The contract should clearly outline the expected level of the behavior (e.g., frequency, magnitude, duration) within the specified time period. 4. Describe the reinforcement or punishment contingencies. The next step is to determine the consequences for engaging in the specified level of the target behavior during the time outlined in the contract. These are the reinforcement and punishment contingencies. If the specified level of the behavior occurs (or does not occur) within the specified time frame, the consequences for gain or loss of reinforcers are clearly outlined. 5. Establish who will implement the contingencies. The final step is to determine who will deliver the consequence for engaging (or not engaging) in the behavior specified in the behavior contract. In one-party contracts, the behavior of one individual is tied to the outlined contingency while another party (contingency manager) delivers the consequences outlined in the contract. In two-party contracts, the behavior of two individuals is tied to the outlined contingencies, and the contract manager or the parties involved in the contract may be responsible for delivering the consequences outlined in the contract. Promoting Generalization Generalization is the occurrence of the target behavior in the presence of stimuli that are similar to the SD that was present during training (see section on stimulus control). When behavioral interventions are implemented, it is important that the change in the target behavior occurs in all relevant situa-



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tions in the natural environment. For example, if teaching shopping skills during therapy sessions to a young adult with autism, generalization would involve the individual engaging in shopping skills in actual stores. There are seven strategies for promoting generalization (Miltenberger, 2016): 1. Reinforce instances of generalization. Following training, instances of the target behavior in the natural setting are reinforced. In the example of teaching the young adult shopping skills, if they are observed engaging in the skills in a real shop, praise or other reinforcement is provided. 2. Train skills that are likely to contact reinforcement in the natural environment. Teach relevant skills that will likely produce reinforcement from people who are unfamiliar with the client. In the example of teaching the young adult shopping skills, this means that one would teach greetings and interactions that are likely to be reinforced by a wide range of merchants that they could approach. 3. Modify contingencies of reinforcement/punishment in the natural environment. In the case of teaching the young adult shopping skills, this may consist of initially telling the cashiers at the stores to praise them if they do everything correctly, or to allow them more time to respond than a typical consumer, to ensure they contact the natural reinforcement of receiving the item they purchased. 4. Incorporate a large variety of stimuli during training. The more relevant stimuli that are present during training, the more likely it is that the behavior will generalize following training. In the example of teaching shopping skills to the young adult, one would include a variety of different stimuli, such as different types of store fronts, different goods being bought, and different types of bills or paying methods. 5. Incorporate common stimuli. In addition to including a wide range of stimuli, the stimuli should be selected from the generalization (natural) environment. In the example of shopping skills, stimuli from a variety of local shops that the individual is likely to encounter when out in the community should be included in training. 6. Train functionally equivalent responses. This means that one should teach a variety of responses that can produce the same reinforcer or outcome. In the example of shopping skills, this means teaching a variety of greetings, responses, and methods of paying that would all result in the same outcome (receiving the purchased good). 7. Include self-generated mediators of generalization. A self-generated mediator of generalization is a “stimulus that is maintained and transported by the client as part of treatment” (Stokes & Osnes, 1989, p. 349). An example could be a physical stimulus (in the example of shopping skills, it could be a notecard with reminders of the steps that the client needs to engage in [greet, ask price, count money, pay cashier]). Another example could be the behavior of the client (in the example of the shopping skills, it could be the young adult telling themselves the steps outlined in the card).

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The promotion of generalization is an extremely important component of behavioral interventions as it increases the likelihood that the targeted skills will occur in the contexts where they are needed most, the client’s everyday life.

OUTCOMES AND DISSEMINATION One major clinical application for ABA is in the area of autism spectrum disorder (ASD). Behavioral interventions for the treatment of ASD were first proposed by Lovaas (1981) and involved a comprehensive, intensive approach encompassing a set of procedures based on the principles of ABA to teach adaptive skills to young children (Reichow, 2012). Some key features of behavioral interventions for the treatment of ASD include (a) the systematic implementation based on ABA principles, (b) the interventions being introduced as early as possible, (c) the individualized curriculum implemented on a one-to-one teacher-to-student ratio, and (d) a focus on age-appropriate behaviors with an emphasis on parent training (Makrygianni et al., 2018). A recent review of ABA interventions for children with ASD found that behavioral interventions were moderately to highly effective at improving a variety of skills (e.g., intellectual abilities, communication skills, expressive language skills, receptive-language skills, adaptive behavior) in children with ASD (Makrygianni et al., 2018). Behavioral interventions are also considered as the best-practice, evidence-based approach to the treatment of ASD by the American Psychological Association and the U.S. Surgeon General. Another major application of ABA that has been quickly expanding is Positive Behavior Supports (PBS). PBS uses ABA principles and procedures to promote a wraparound approach that enhances an individual’s overall quality of life (Carr et al., 2002). Applications of PBS within school settings is referred to as School-Wide Positive Behavior Supports (SWPBS), which is an educational framework that addresses educational and behavioral concerns in schools by modifying the school climate and creating better and more efficient systems that lead to improved student outcomes (e.g., Bradshaw et al., 2010). SWPBS involves a three-tiered approach that emphasizes prevention at a school-wide level and a continuum of strategies to target individual students who require additional supports (Sugai & Horner, 2006). Research suggests that SWPBS has been effective at creating greater organization within a school, reducing office discipline referrals, and improving academic achievement (e.g., Bradshaw et al., 2008; Horner et al., 2009; Lassen et al., 2006).

DIVERSE APPLICATIONS Applications of ABA in different environments and populations have started to gain traction, making the populations receiving behavior analysis services more



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heterogeneous. One area of application is teaching safety skills such as gunsafety skills, abduction prevention, poison hazards, and sexual abuse prevention to children (e.g., Himle, Miltenberger, Gatheridge, & Flessner, 2004; Johnson et al., 2006; King & Miltenberger, 2017; Miltenberger & Hanratty, 2013). Another growing application is physical activity promotion. ABA interventions have been shown to increase physical activity in typically developing adults (e.g., Normand, 2008; Valbuena et al., 2015), children (e.g. Hayes & Van Camp, 2015; Zerger et al., 2017), and adults with intellectual disabilities (Krentz et al., 2016). Other successful applications of ABA include enhancing performance in sports such as dance (e.g., Quinn et al., 2015, 2017), yoga (Downs et al., 2015), soccer (Brobst & Ward, 2002), golf (Fogel et al., 2010; O’Brien & Simek, 1983), martial arts (BenitezSantiago & Miltenberger, 2016; Harding et al., 2004), and football (e.g., Smith & Ward, 2006; Tai & Miltenberger, 2017), to name a few. Still other areas of application include ABA procedures to enhance staff performance in foster care (e.g., Crosland et al., 2018) and gerontology (e.g., Buchmeier et al., 2018). Although this section is not a comprehensive review of the areas of application of ABA beyond ASD and school settings, it provides a look at the diverse applications of ABA.

CONCLUSION The hallmark of ABA is the focus on objectively defined target behavior and manipulation of environmental events to change the behavior. Behavior analysts use the graphical display of the target behavior to monitor behavior change with the implementation of a behavioral intervention. ABA emphasizes the influence of the antecedent and consequent stimuli on the behavior of an individual. The basic principles of ABA can be applied to teach individuals new behaviors or to increase an already existing behavior that occurs at low levels. ABA procedures can also be used to decrease problematic behaviors. ABA emphasizes function-based assessment and intervention. This means conducting functional assessments to identify the antecedent stimuli that evoke and the consequences that maintain a behavior, and developing interventions that modify those antecedents or consequences to modify that behavior. ABA interventions should modify behavior that is meaningful to the client in a way that is acceptable to the client (two aspects of socially validity), and the changes in behavior should generalize to situations that the individual will encounter in their everyday life.

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Anglesea, M. M., Hoch, H., & Taylor, B. A. (2008). Reducing rapid eating in teenagers with autism: Use of a pager prompt. Journal of Applied Behavior Analysis, 41(1), 107– 111. https://doi.org/10.1901/jaba.2008.41-107 Athens, E. S., & Vollmer, T. R. (2010). An investigation of differential reinforcement of alternative behavior without extinction. Journal of Applied Behavior Analysis, 43(4), 569– 589. https://doi.org/10.1901/jaba.2010.43-569 Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97. https://doi.org/ 10.1901/jaba.1968.1-91 Bailey, J., & Burch, M. (2018). Research methods in applied behavior analysis (2nd ed.). Routledge. Beck, K. V., & Miltenberger, R. G. (2009). Evaluation of a commercially available program and in situ training by parents to teach abduction-prevention skills to children. Journal of Applied Behavior Analysis, 42(4), 761–772. https://doi.org/10. 1901/jaba.2009.42-761 BenitezSantiago, A., & Miltenberger, R. G. (2016). Using video feedback to improve martial arts performance. Behavioral Interventions, 31(1), 12–27. https://doi.org/10. 1002/bin.1424 Bijou, S. W., Peterson, R. F., & Ault, M. H. (1968). A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. Journal of Applied Behavior Analysis, 1(2), 175–191. https://doi.org/10.1901/jaba.1968.1-175 Bradshaw, C., Koth, C., Bevans, K., Ialongo, N., & Leaf, P. (2008). The impact of schoolwide positive behavioral interventions and supports (PBIS) on the organizational health of elementary schools. School Psychology Quarterly, 23(4), 462–473. https://doi. org/10.1037/a0012883 Bradshaw, C., Mitchell, M., & Leaf, P. (2010). Examining the effects of schoolwide positive behavioral interventions and supports on student outcomes. Journal of Positive Behavior Interventions, 12(3), 133–148. https://doi.org/10.1177/1098300709334798 Brobst, B., & Ward, P. (2002). Effects of public posting, goal setting, and oral feedback on the skills of female soccer players. Journal of Applied Behavior Analysis, 35(3), 247– 257. https://doi.org/10.1901/jaba.2002.35-247 Buchmeier, A. L., Baker, J. C., Reuter-Yuill, L. M., & MacNeill, B. R. (2018). Considerations for preference and reinforcer assessments with older adults with developmental disabilities. Behavior Analysis: Research and Practice, 18(1), 103–116. https:// doi.org/10.1037/bar0000085 Cannella, H. I., O’Reilly, M. F., & Lancioni, G. E. (2005). Choice and preference assessment research with people with severe to profound developmental disabilities: A review of the literature. Research in Developmental Disabilities, 26(1), 1–15. https:// doi.org/10.1016/j.ridd.2004.01.006 Carr, E., Dunlap, G., Horner, R., Koegel, R., Turnbull, A., Sailor, W., Anderson, J. L., Albin, R. W., Koegel, L. K., & Fox, L. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4(1), 4–16. https://doi. org/10.1177/109830070200400102 Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18(2), 111–126. https:// doi.org/10.1901/jaba.1985.18-111 Clark, H. B., Rowbury, T., Baer, A. M., & Baer, D. M. (1973). Timeout as a punishing stimulus in continuous and intermittent schedules. Journal of Applied Behavior Analysis, 6(3), 443–455. https://doi.org/10.1901/jaba.1973.6-443 Codding, R. S., Livanis, A., Pace, G. M., & Vaca, L. (2008). Using performance feedback to improve treatment integrity of classwide behavior plans: An investigation of observer reactivity. Journal of Applied Behavior Analysis, 41(3), 417–422. https://doi. org/10.1901/jaba.2008.41-417



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Conyers, C., Miltenberger, R., Maki, A., Barenz, R., Jurgens, M., Sailer, A., Haugen, M., & Kopp, B. (2004). A comparison of response cost and differential reinforcement of other behavior to reduce disruptive behavior in a preschool classroom. Journal of Applied Behavior Analysis, 37(3), 411–415. https://doi.org/10.1901/jaba.2004.37-411 Cooper, J., Heron, T., & Heward, W. (2007). Applied behavior analysis. Prentice Hall. Crosland, K., Joseph, R., Slattery, L., Hodges, S., & Dunlap, G. (2018). Why youth run: Assessing run function to stabilize foster care placement. Children and Youth Services Review, 85, 35–42. https://doi.org/10.1016/j.childyouth.2017.12.002 Dietz, S. M., & Repp, A. C. (1973). Decreasing classroom misbehavior through the use of DRL schedules of reinforcement. Journal of Applied Behavior Analysis, 6(3), 457– 463. https://doi.org/10.1901/jaba.1973.6-457 Downs, H. E., Miltenberger, R., Biedronski, J., & Witherspoon, L. (2015). The effects of video self-evaluation on skill acquisition with yoga postures. Journal of Applied Behavior Analysis, 48(4), 930–935. https://doi.org/10.1002/jaba.248 Durand, V. M., Crimmins, D. B., Caulfield, M., & Taylor, J. (1989). Reinforcer assessment I: Using problem behavior to select reinforcers. Journal of the Association for Persons With Severe Handicaps, 14(2), 113–126. https://doi.org/10.1177/154079698901400203 Falcomata, T. S., Roane, H. S., Hovanetz, A. N., Kettering, T. L., & Keeney, K. M. (2004). An evaluation of response cost in the treatment of inappropriate vocalizations maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 37(1), 83–87. https://doi.org/10.1901/jaba.2004.37-83 Filcheck, H. A., McNeil, C. B., Greco, L. A., & Bernard, R. S. (2004). Using a wholeclass token economy and coaching of teacher skills in a preschool classroom to manage disruptive behavior. Psychology in the Schools, 41(3), 351–361. https://doi. org/10.1002/pits.10168 Fisher, W., Piazza, C., & Roane, H. (2011). Handbook of applied behavior analysis. Guilford Press. Fogel, V. A., Weil, T. M., & Burris, H. (2010). Evaluating the efficacy of tagteach as a training strategy for teaching a golf swing. Journal of Behavioral Health and Medicine, 1(1), 25–41. https://doi.org/10.1037/h0100539 Foxx, R. M., & Shapiro, S. T. (1978). The timeout ribbon: A nonexclusionary timeout procedure. Journal of Applied Behavior Analysis, 11(1), 125–136. https://doi.org/10. 1901/jaba.1978.11-125 Gatheridge, B. J., Miltenberger, R. G., Huneke, D. F., Satterlund, M. J., Mattern, A. R., Johnson, B. M., & Flessner, C. A. (2004). Comparison of two programs to teach firearm injury prevention skills to 6- and 7-year-old children. Pediatrics, 114(3), e294– e299. https://doi.org/10.1542/peds.2003-0635-L Hagopian, L. P., Farrell, D. A., & Amari, A. (1996). Treating total liquid refusal with backward chaining and fading. Journal of Applied Behavior Analysis, 29(4), 573–575. https://doi.org/10.1901/jaba.1996.29-573 Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014). Producing meaningful improvements in problem behavior of children with autism via synthesized analyses and treatments. Journal of Applied Behavior Analysis, 47(1), 16–36. https:// doi.org/10.1002/jaba.106 Hanley, G. P., & Tiger, J. H. (2011). Differential reinforcement procedures. In W. W. Fisher, C. C. Piazza, & H. S. Roane (Eds.), Handbook of applied behavior analysis (pp. 229– 249). Guilford Press. Harding, J. W., Wacker, D. P., Berg, W. K., Rick, G., & Lee, J. F. (2004). Promoting response variability and stimulus generalization in martial arts training. Journal of Applied Behavior Analysis, 37(2), 185–195. https://doi.org/10.1901/jaba.2004.37-185 Hayes, L. B., & Van Camp, C. M. (2015). Increasing physical activity of children during school recess. Journal of Applied Behavior Analysis, 48(3), 690–695. https://doi.org/10. 1002/jaba.222

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Himle, M. B., Miltenberger, R. G., Flessner, C., & Gatheridge, B. (2004). Teaching safety skills to children to prevent gun play. Journal of Applied Behavior Analysis, 37(1), 1–9. https://doi.org/10.1901/jaba.2004.37-1 Himle, M. B., Miltenberger, R. G., Gatheridge, B. J., & Flessner, C. A. (2004). An evaluation of two procedures for training skills to prevent gun play in children. Pediatrics, 113(1), 70–77. https://doi.org/10.1542/peds.113.1.70 Horner, R., Sugai, G., Smolkowski, K., Eber, L., Nakasato, J., Todd, A., & Esperanza, J. (2009). A randomized, wait-list controlled effectiveness trial assessing school-wide positive behavior support in elementary schools. Journal of Positive Behavior Interventions, 11(3), 133–144. https://doi.org/10.1177/1098300709332067 Iwata, B. A., Deleon, I. G., & Roscoe, E. M. (2013). Reliability and validity of the functional analysis screening tool. Journal of Applied Behavior Analysis, 46(1), 271– 284. https://doi.org/10.1002/jaba.31 Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27(2), 197–209. https://doi.org/10.1901/jaba.1994.27-197 Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimental analysis and extinction of self-injurious escape behavior. Journal of Applied Behavior Analysis, 23(1), 11–27. https://doi.org/10.1901/jaba.1990.23-11 Jerome, J., Frantino, E. P., & Sturmey, P. (2007). The effects of errorless learning and backward chaining on the acquisition of Internet skills in adults with developmental disabilities. Journal of Applied Behavior Analysis, 40(1), 185–189. https://doi.org/10. 1901/jaba.2007.41-06 Johnson, B. M., Miltenberger, R. G., Knudson, P., Egemo-Helm, K., Kelso, P., Jostad, C., & Langley, L. (2006). A preliminary evaluation of two behavioral skills training procedures for teaching abduction-prevention skills to schoolchildren. Journal of Applied Behavior Analysis, 39(1), 25–34. https://doi.org/10.1901/jaba.2006.167-04 Kazdin, A. E. (2011). Single-case research designs: Methods for clinical and applied settings. Oxford University Press. Kazdin, A. E., & Bootzin, R. R. (1972). The token economy: An evaluative review. Journal of Applied Behavior Analysis, 5(3), 343–372. https://doi.org/10.1901/jaba. 1972.5-343 King, S., & Miltenberger, R. (2017). Evaluation of video modeling to teach children diagnosed with autism to avoid poison hazards. Advances in Neurodevelopmental Disorders, 1, 221–229. https://doi.org/10.1007/s41252-017-0028-2 Krentz, H., Miltenberger, R., & Valbuena, D. (2016). Using token reinforcement to increase walking for adults with intellectual disabilities. Journal of Applied Behavior Analysis, 49(4), 745–750. https://doi.org/10.1002/jaba.326 Laraway, S., Snycerski, S., Michael, J., & Poling, A. (2003). Motivating operations and terms to describe them: Some further refinements. Journal of Applied Behavior Analysis, 36(3), 407–414. https://doi.org/10.1901/jaba.2003.36-407 Laraway, S., Snycerski, S., Olson, R., Becker, B., & Poling, A. (2014). The motivating operations concept: Current status and critical response. Psychological Record, 64, 601– 623. https://doi.org/10.1007/s40732-014-0080-5 Lassen, S., Steele, M., & Sailor, W. (2006). The relationship of school-wide Positive Behavior Support to academic achievement in an urban middle school. Psychology in the Schools, 43(6), 701–712. https://doi.org/10.1002/pits.20177 LeBlanc, L. A., Raetz, P. B., Sellers, T. P., & Carr, J. E. (2016). A proposed model for selecting measurement procedures for the assessment and treatment of problem behavior. Behavior Analysis in Practice, 9, 77–83. https://doi.org/10.1007/s40617015-0063-2 Lennox, D., & Miltenberger, R. (1989). Conducting a functional assessment of problem behavior in applied settings. Journal of the Association for Persons With Severe Handicaps, 14(4), 304–311. https://doi.org/10.1177/154079698901400409



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Lerman, D. C., Iwata, B. A., & Wallace, M. D. (1999). Side effects of extinction: Prevalence of bursting and aggression during the treatment of self-injurious behavior. Journal of Applied Behavior Analysis, 32(1), 1–8. https://doi.org/10.1901/ jaba.1999.32-1 Lerman, D. C., Kelley, M. E., Van Camp, C. M., & Roane, H. S. (1999). Effects of reinforcement magnitude on spontaneous recovery. Journal of Applied Behavior Analysis, 32(2), 197–200. https://doi.org/10.1901/jaba.1999.32-197 Lerman, D. C., & Vorndran, C. M. (2002). On the status of knowledge for using punishment implications for treating behavior disorders. Journal of Applied Behavior Analysis, 35(4), 431–464. https://doi.org/10.1901/jaba.2002.35-431 Lovaas, O. I. (1981). Teaching developmentally disabled children: The me book. University Park Press. Makrygianni, M., Gena, A., Katoudi, S., & Galanis, P. (2018). The effectiveness of applied behavior analytic interventions for children with autism spectrum disorder: A meta-analytic study. Research in Autism Spectrum Disorders, 51, 18–31. https://doi. org/10.1016/j.rasd.2018.03.006 Maxfield, T. C., Miltenberger, R. G., & Novotny, M. A. (2019). Evaluating small-scale simulation for training firearm safety skills. Journal of Applied Behavior Analysis, 52(2), 491–498. https://doi.org/10.1002/jaba.535 Miltenberger, R., Bloom, S., Sanchez, S., & Valbuena, D. (2016). Functional assessment. In N. Singh (Ed.), Clinical handbook of evidence-based practices for persons with intellectual disabilities (pp. 69–97). Springer. https://doi.org/10.1007/978-3-31926583-4_4 Miltenberger, R., & Hanratty, L. (2013). Teaching sexual abuse prevention skills to children. In D. Bromberg & W. O’Donohue (Eds.), Handbook of child and adolescent sexuality: Developmental and forensic psychology (pp. 419–447). Elsevier. https://doi. org/10.1016/B978-0-12-387759-8.00017-9 Miltenberger, R., Rapp, J., & Long, E. (1999). A low-tech method for conduction realtime recording. Journal of Applied Behavior Analysis, 32(1), 119–120. https://doi.org/ 10.1901/jaba.1999.32-119 Miltenberger, R., Sanchez, S., & Valbuena, D. (2015). Teaching safety skills to children. In H. Roane, J. Ringdahl, & T. Falcomata (Eds.), Clinical and organizational applications of applied behavior analysis (pp. 477–499). Elsevier. https://doi.org/10.1016/B9780-12-420249-8.00019-8 Miltenberger, R., Zerger, H., Novotny, M., & Livingston, C. (2017). Behavioral skill training. In J. Leaf (Ed.), Handbook of social skills and autism spectrum disorder: Assessment, curricula, and interventions (pp. 325–342). Springer. https://doi.org/10. 1007/978-3-319-62995-7_19 Miltenberger, R. G. (2016). Applied behavior analysis: Principles and procedures (6e). Cengage Learning. Miltenberger, R. G., Fogel, V. A., Beck, K. V., Koehler, S., Shayne, R., Noah, J., McFee, K., Perdomo, A., Chan, P., Simmons, D., & Godish, D. (2013). Efficacy of the stranger safety abduction-prevention program and parent-conducted in situ training. Journal of Applied Behavior Analysis, 46(4), 817–820. https://doi.org/10. 1002/jaba.80 Miltenberger, R. G., Gatheridge, B. J., Satterlund, M., Egemo-Helm, K. R., Johnson, B. M., Jostad, C., Kelso, P., & Flessner, C. A. (2005). Teaching safety skills to children to prevent gun play: An evaluation of in situ training. Journal of Applied Behavior Analysis, 38(3), 395–398. https://doi.org/10.1901/jaba.2005.130-04 Miltenberger, R. G., & Weil, T. M. (2013). Observation and measurement in behavior analysis. In G. J. Madden (Ed.), APA handbook of behavior analysis: Methods and principles (pp. 127–150). American Psychological Association. https://doi.org/10. 1037/13937-006

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Mowery, J., Miltenberger, R., & Weil, T. (2010). Evaluating the effects of reactivity to supervisor presence on staff response to tactile prompts and self-monitoring in a group home setting. Behavioral Interventions, 25(1), 21–35. Noell, G. H., Witt, J. C., Slider, N. J., & Connell, J. E. (2005). Treatment implementation following behavioral consultation in schools: A comparison of three follow-up strategies. School Psychology Review, 34(1), 87–106. Normand, M. P. (2008). Increasing physical activity through self-monitoring, goal setting, and feedback. Behavioral Interventions, 23(4), 227–236. https://doi.org/10. 1002/bin.267 Northup, J., Wacker, D., Sasso, G., Steege, M., Cigrand, K., Cook, J., & DeRaad, A. (1991). A brief functional analysis of aggressive and alternative behavior in an outclinic setting. Journal of Applied Behavior Analysis, 24(3), 509–522. https://doi.org/ 10.1901/jaba.1991.24-509 O’Brien, R. M., & Simek, T. C. (1983). A comparison of behavioral and traditional methods for teaching golf. In G. L. Martin & D. Hrycaiko (Eds.), Behavior modification and coaching: Principles, procedures, and research (pp. 175–186). Charles C. Thomas. O’Neill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional assessment and program development for problem behavior: A practical handbook. Brooks/Cole. Petscher, E. S., Rey, C., & Bailey, J. S. (2009). A review of empirical support for differential reinforcement of alternative behavior. Research in Developmental Disabilities, 30(3), 409–425. https://doi.org/10.1016/j.ridd.2008.08.008 Piazza, C. C., Roane, H. S., Keeney, K. M., Boney, B. R., & Abt, K. A. (2002). Varying response effort in the treatment of pica maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 35(3), 233–246. https://doi.org/10.1901/jaba. 2002.35-233 Quinn, M., Miltenberger, R., Abreu, A., & Narozanick, T. (2017). An intervention featuring public posting and graphical feedback to enhance the performance of competitive dancers. Behavior Analysis in Practice, 10(1), 1–11. https://doi.org/10. 1007/s40617-016-0164-6 Quinn, M. J., Miltenberger, R. G., & Fogel, V. A. (2015). Using TAGteach to improve the proficiency of dance movements. Journal of Applied Behavior Analysis, 48(1), 11– 24. https://doi.org/10.1002/jaba.191 Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 512–520. https://doi.org/10.1007/s10803-011-1218-9 Roane, H., Ringdahl, J., & Falcomata, T. (2015). Clinical and organizational applications of applied behavior analysis. Academic Press. Ruth, W. J. (1996). Goal setting and behavior contracting for students with emotional and behavioral difficulties: Analysis of daily, weekly, and total goal attainment. Psychology in the Schools, 33(2), 153–158. https://doi.org/10.1002/(SICI)1520-6807 (199604)33:23.0.CO;2-S Sanchez, S., & Miltenberger, R. G. (2015). Evaluating the effectiveness of an abduction prevention program for young adults with intellectual disabilities. Child & Family Behavior Therapy, 37(3), 197–207. https://doi.org/10.1080/07317107.2015.1071178 Schwartz, I. S., & Baer, D. M. (1991). Social validity assessments: Is current practice state of the art? Journal of Applied Behavior Analysis, 24(2), 189–204. https://doi.org/ 10.1901/jaba.1991.24-189 Shrestha, A., Anderson, A., & Moore, D. W. (2013). Using point-of-view video modeling and forward chaining to teach a functional self-help skill to a child with autism. Journal of Behavioral Education, 22(2), 157–167. https://doi.org/10.1007/ s10864-012-9165-x



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23 Cognitive Bias Modification Emily E. E. Meissel, Jennie M. Kuckertz, and Nader Amir

I

ncreased emphasis on evidence-based practice (EBP) represents a significant advance in the understanding and treatment of psychopathology over the past 20 years (Haynes et al., 1996). This framework has led to the development and validation of effective treatments for many psychological disorders including cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs; Chambless et al., 1996). Despite the substantial advances from this research emphasis on evidence-based interventions, the increase in knowledge has yet to match the overwhelming need for services in the community. Barriers such as lack of trained clinicians, limited dissemination of services to rural communities, and financial strain have limited the clinical impact of evidence-based interventions (Gunter & Whittal, 2010). The availability gap for effective treatments has created frustration in patients and providers alike, with some expressing the sentiment that “for the past 50 years, calls for placing more behavioral and developmental health care providers in rural areas have failed” (Kelleher & Gardner, 2017, pp. 1301–1302). One avenue to address this gap is to use basic research to identify basic mechanisms thought to be involved in the maintenance of various psychological conditions and try to ameliorate them. Cognitive bias modification (CBM) interventions designed specifically to be low cost and easily disseminated exemplify such an attempt (Beard, 2011). These computerized interventions are rooted in over 30 years of research demonstrating that individuals with different forms of psychopathology demonstrate patterns of information processing selectivity for emotional content relevant to their clinical condition (Williams et https://doi.org/10.1037/0000218-023 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  673 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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al., 1997). For example, individuals with social anxiety may selectively attend to threat-relevant faces when compared with neutral faces (attentional bias; Amir et al., 1996). Similarly, these individuals may interpret ambiguous situations (e.g., people laughing at a party) as threatening (e.g., laughing directed at something embarrassing they did) rather than neutral (e.g., someone told a joke; Amir et al., 2005). If this selectivity in processing information relevant to the clinical condition is causally involved in the maintenance of the disorder, then attempts to modify such biases should lead to reduction of symptoms. Thus, CBM interventions attempt to shift these maladaptive information processing patterns to be more in line with the pattern of information processing in healthy individuals. They accomplish this by repeated exposure to task contingencies that favor reduction of this processing selectivity (MacLeod & Mathews, 2012). Enthusiasm for CBM as a clinical tool has increased rapidly since its first introduction to clinical populations over a decade ago (Amir, Beard, Burns, & Bomyea, 2009; Amir, Beard, Taylor, et al., 2009; Schmidt et al., 2009). Since that time, CBM has been examined across various populations including anxiety (e.g., MacLeod & Mathews, 2012), obsessive-compulsive disorder (e.g., Salemink et al., 2015), posttraumatic stress disorder (e.g., Woud et al., 2017), depression (e.g., Blackwell & Holmes, 2010; Williams et al., 2013), substance use disorders (e.g., Schoenmakers et al., 2010; Wiers et al., 2015), and eating disorders (e.g., Kemps et al., 2014; Yiend et al., 2014). At least two critical and overarching questions dominate the field regarding this intervention: To what extent is CBM intervention useful as a clinical tool for the treatment of psychological disorders? And what are the underlying mechanisms of action in CBM, and to what extent are current CBM programs successful in manipulating these mechanisms? Thus, in the current chapter, we summarize the existing literature on CBM and highlight issues in the field from both clinical and mechanistic perspectives.1 Moreover, we comment on new technologies available for assessment, personalization, and dissemination of CBM that allow for more focused and rapid examination of these issues. Finally, we review novel engagement strategies that allow for assessment of CBM’s effects at the biological, behavioral, and symptom domains (the Research Domain Criteria Initiative from the National Institute of Mental Health [NIMH]; Insel et al., 2010).

UNDERLYING THEORY CBM relies on the assumption that information processing biases characterize various clinical conditions and that these biases are causally involved in the pathogenesis or maintenance of these conditions. Throughout the chapter, we focus on attention bias modification (ABM) and interpretation bias modification (IBM), which are the most commonly researched forms of CBM. Clinical examples are disguised to protect patient confidentiality.

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Attention Bias Modification ABM is based on research that demonstrates that anxious individuals selectively attend to threatening information when compared with benign (e.g., neutral or positive) information in their environment (see Bar-Haim et al., 2007; Cisler & Koster, 2010). In turn, the tendency to attend to and process threatening information decreases the likelihood of attending to benign information, leading to a negative filter and causing a vicious cycle of attention to threat, increased anxiety symptoms, and increased attention to threat. The goal of ABM is to recalibrate this negative attention filter so as to decrease the individual’s tendency toward selective, automatic processing of threating stimuli and, conversely, to increase automatic processing of benign stimuli (Beard, 2011). In addition, some studies have found that ABM also modifies attentional control, which refers to a broader ability to direct attention in a goal-oriented manner (Heeren et al., 2015; Klumpp & Amir, 2010; McNally et al., 2013). According to dual process models of attention, attention can be divided into both top-down (i.e., goal-directed, strategic) and bottom-up (i.e., stimulus-driven) processes (Corbetta & Shulman, 2002). Indeed, more recent conceptualization of the human attentional network confirm and extend the notion of three attention networks systems, alerting, orienting, and executive control (Posner & Petersen, 1990; Petersen & Posner, 2012). However, these basic science conceptualizations and their implications for ABM have been largely ignored by ABM researchers. In a notable exception, attentional control theory (Eysenck et al., 2007) implies that the relation between the bottom-up and top-down attentional processes are affected by anxiety. Specifically, this theory states that anxiety increases the extent to which bottom-up (stimulus-driven) processing is dominant while top-down (strategic) processing is weakened. The increased emphasis on bottom-up processing then maintains anxiety. Finally, attentional control theory states that difficulty controlling attentional response to task-irrelevant or distractor stimuli characterizes anxiety. Initial investigations of ABM training programs hypothesized that reduction in attention bias should interrupt preferential processing of threat-relevant information, thereby reducing anxiety symptoms (MacLeod et al., 2002). Thus, most ABM paradigms focus on training visual attention away from threatening information. Despite initial promising results, training attention away from threatening stimuli has demonstrated inconsistent effects on anxiety (Cristea, Kok, & Cuijpers, 2015; Cristea, Mogoașe, et al., 2015; Heeren et al., 2015; Jones & Sharpe, 2017; Liu et al., 2017; MacLeod & Grafton, 2016; Mogg & Bradley, 2016; Mogg et al., 2017; Price et al., 2016; Van Bockstaele et al., 2014). Thus, a recent review suggested that the varying results have stemmed from treatments that claim to target only one (automatic bias to threat) of the multiple attention processes (including salience-driven automatic biases and goal-directed cognitive control [CC]; Mogg & Bradley, 2018) involved in attention bias in anxiety. As these authors suggested, attentional biases measured from a probe detection task, a popular computer task designed to capture biases by measuring reactions

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to probes following neutral stimuli compared with threatening stimuli (described in more detail later), may reflect both salience-driven and goal-directed processes, which are influenced by both individual differences and situational variables (Mogg & Bradley, 2018). Accordingly, ABM research would benefit from targeting multiple processes underlying anxiety and threat-related attentional biases, including three key features: (a) orientation away from threat, (b) threat-distractor inhibition, and (c) goal-directed CC. Interpretation Bias Modification IBM research is based on theoretical models (Clarke & Wells, 1995; Rapee & Heimberg, 1997) and empirical studies (Amir et al., 1998, 2012; Beard & Amir, 2009; Huppert et al., 2007; Mathews & MacLeod, 2005) suggesting that anxious individuals have the tendency to interpret ambiguous information as threatening rather than benign. This interpretation bias then promotes anxiety symptoms as the world is viewed as more dangerous than it may be objectively (Beck & Clark, 1997; Clark & Beck, 2010). Interpretation biases have been implicated in several diagnoses including generalized anxiety disorder (GAD; Amir et al., 2012; Butler & Mathews, 1983), depression (Everaert et al., 2017; Mogg et al., 2006), obsessive-compulsive disorder (Jelinek et al., 2009), and social anxiety disorder (SAD; Constans et al., 1999). In comparison with ABM, IBM programs target this later, more elaborative aspect of cognitive biases. Similar to the CBT technique of cognitive restructuring, IBM is designed to change negative interpretation of ambiguous information (i.e., interpretation bias). However, contrary to cognitive restructuring, which uses Socratic questioning, IBM uses associative learning principles whereby ambiguous scenarios are repeatedly associated with neutral words via reinforcement in order to improve symptoms (Lau & Pile, 2015). In a seminal IBM study, Mathews and Mackintosh (2000) demonstrated that shifting interpretation biases reduces anxiety symptoms. In the past two decades, researchers have developed several variations of IBM training programs (e.g., Beard & Amir, 2010; Mathews et al., 2007). These studies suggest that IBMs are effective in changing interpretation biases, resulting in changes in positive interpretations of ambiguous scenarios, small to medium improvements in interpretational style, and small improvements in mood (Menne-Lothmann et al., 2014).

DESCRIPTION OF PARADIGMS Attentional Bias Modification Traditional ABM paradigms commonly modify attention using variations of the probe detection task (also referred to as the dot-probe task; MacLeod et al., 1986), spatial cuing task (Posner, 1980), and visual search task (e.g., GilboaSchechtman et al., 1999; Rinck et al., 2003). Although these paradigms were initially designed to assess attentional biases, their parameters have been adapted to facilitate training (leading to modification) of attentional biases.



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Methods for creating a training program are described below, and they are typically achieved via building a contingency between the responses required of participants in the presence of threatening versus benign information. As research progresses, the interventions have been refined so as to optimize participant engagement, stimuli types, contingencies between different stimuli categories and participant responses, and timing of the stimulus and probe presentations. The Probe Detection Task Since its introduction to the literature over 30 years ago, the probe detection task has been the most widely utilized assessment of attentional bias (Linetzky et al., 2015). In the probe detection task, two stimuli (e.g., words or pictures) are presented on a computer screen separated vertically or horizontally (MacLeod et al., 2002). One stimulus is neutral (e.g., table), and the other stimulus is emotionally salient (e.g., anxious). The stimuli then disappear and are immediately followed by a probe (e.g., an up or down arrow) in the same screen location as either the emotional or neutral stimulus. The response latency is recorded when participants press a button that identifies the probe type (e.g., an up or down arrow). As an assessment task, the probe follows the emotional and neutral words with equal likelihood. Researchers can then examine allocation of attention by comparing response latency to detect probes following the neutral stimuli with the response latency to probes following an emotional stimulus. One method of comparing these response latencies is to calculate a difference score (i.e., attentional bias), with higher scores indicating greater relative attentional bias for emotional stimuli. However, there may be inherent psychometric limitations when using difference scores from highly correlated constructs (see Furr & Bacharach, 2014, Chapter 6, for a detailed description of the psychometric properties of difference scores). Furthermore, there are several processes involved in response latencies that affect the psychometric properties when used as a difference score (for a full discussion, see Miller & Ulrich, 2013). Examining the response latency to detect probes following emotional stimuli and the response latency to detect probes following neutral stimuli may address some of the limitations of the traditional bias scores. In the intervention version of the task (i.e., ABM), the proportion of trials in which the probe follows the neutral stimulus is higher than those in which the probe follows the threatening stimulus; hence, attention is trained to neutral stimuli and, by implication, away from the emotional stimuli (e.g., Amir, Beard, Burns, & Bomyea, 2009). However, traditional bias calculation from the probe detection paradigm does not allow for the independent assessment of difficulty disengaging attention from emotional stimuli and speeded attentional engagement (e.g., hypervigilance) for emotional stimuli. Recent research has sought to disambiguate the role of engagement and disengagement bias scores by including a neutral-only condition, in which the same neutral stimulus is presented both on top and bottom locations. By comparing the reaction time on trials in which the probe follows the emotional stimulus and trials in which the

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probe follows the location opposite the emotional stimulus with the neutral-only trials, one can calculate an index of vigilance (in the former case) and an index of disengagement (in the latter case; Koster et al., 2006). Others have sought to measure biases at the trial level (Zvielli et al., 2015), using a response-based method (Evans & Britton, 2018) or regression-based measures (Amir et al., 2020) in order to reliably examine difference components of attentional bias. The Spatial Cuing Paradigm Similar to the probe detection paradigm, the spatial cuing paradigm requires participants to determine the location (or identity) of a probe following presentation of a stimulus but also allows for the differentiation of vigilance for emotional stimuli versus difficulty disengaging attention from emotional stimuli (Amir et al., 2003; Yiend & Mathews, 2001). However, Mogg et al. (2008) argued that difficulty disengaging can be better accounted for by a slowing effect of threat, which is not related to attentional cuing. In this paradigm, researchers present either a neutral or an emotional stimulus (cue) on the screen. The probe follows the stimulus at either the cued (valid trial) or uncued (invalid trial) location. Using this paradigm researchers can calculate three response time comparisons: (a) bias = emotional invalid trials compared with emotional valid trials, (b) vigilance = emotional valid trials compared with neutral valid trials, and (c) disengagement difficulty = emotional invalid trials compared with neutral invalid trials. When using the assessment version of this task, there is no contingency between cue validity and valence of the cue. In contrast, when used as an attentional training paradigm, the majority of neutral cues are valid whereas the majority of emotional cues are invalid (e.g., Bar-Haim et al., 2011). Visual Search Paradigm The visual search paradigm is another commonly used measure of attentional bias toward emotional information (Gilboa-Schechtman et al., 1999). The visual search paradigm presents participants with a matrix of images and instructs them to determine whether all the stimuli are the same or if one is different. Participants press a corresponding key as quickly as possible. Attentional bias is revealed when reaction time to detect a threatening face is faster for emotional faces embedded in a set of neutral faces than when neutral faces are embedded in a set of emotional faces. To train attention using this paradigm, researchers have presented happy faces embedded in a set of angry faces, thereby encouraging allocation of attention to happy faces (Waters et al., 2013, 2015, 2016). Novel ABM Programs A recent review suggested that games designed to keep adolescents engaged with positive information in favor of negative information using virtual reality and biofeedback may result in clinically significant reductions in anxiety and may be more enjoyable than traditional ABM (Barnes & Prescott, 2018).



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Indeed, with the rapid increase of easily accessible apps (i.e., small applications), the gamification of ABM by which points are awarded for decreases in bias, has been met with promising results (Amir et al., 2016). Other attempts to increase the game-like nature of ABM include using moving faces. For example, the person identity matching task (Notebaert et al., 2015) is a matching card game that requires participants to engage with a person in a photo and determine whether they are the same model with a different facial expression. Interpretation Bias Modification To modify interpretations, researchers encourage the nonthreatening interpretation of the ambiguous stimuli. Common IBM paradigms include ambiguous scenarios (Mathews & Mackintosh, 2000), homographs (words with two meaning, e.g., the word “mean” can imply average or nasty; Grey & Mathews, 2000), and the word-sentence association paradigm (WSAP; Beard & Amir, 2009). Ambiguous Scenarios Paradigms Ambiguous scenarios tasks require participants to read and imagine themselves in ambiguous scenarios that end with a word fragment that disambiguates the scenario in either a nonthreatening (positive or neutral) or threatening manner (Mathews & Mackintosh, 2000). To train interpretation, Yiend et al. (2005) presented participants with brief emotionally ambiguous paragraphs, each of which was resolved with an incomplete emotion word in the last sentence. For example, “Your partner asks you to go to an anniversary dinner that their company is holding. You have not met any of their work colleagues before. Getting ready to go, you think that the new people you will meet will find you . . . [participant saw either of the following options: “bo- -ng” (boring) or “fri- -d-y” (friendly)].” Participants completed the word fragment by entering the appropriate letters from a keyboard and subsequently answered a comprehension question about the scenario’s meaning to reinforce learning the intended interpretation (e.g., “Will you be disliked by your new acquaintances?”). If the training was toward negative meaning of the scenario, a “yes” response was correct, and if training was toward positive meaning, a “no” response was correct. These researchers provided corrective feedback according to the above contingency. In that study, 80% of the scenarios were resolved in either the negative direction or the positive direction, depending on group assignment. After completing the training, these researchers tested participants’ interpretation bias using a new set of scenarios and tested their recognition ratings of previously disambiguated scenarios. These researchers found that the interpretation of ambiguity could be induced and maintained for up to 24 hours after training. Furthermore, those who were trained to actively resolve ambiguity negatively reported an increase in anxious mood compared with those who were trained to interpret ambiguity positively reported a reduction in anxiety level.

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Homograph Tasks Homographs are words that are spelled the same but have more than one meaning (e.g., “stroke” is both a medical problem and a swimming style). The homograph disambiguation task takes advantage of this feature of these words to assess automatic biases in interpretation. In a typical trial, participants see a homograph (e.g., “stroke”) followed by a word fragment that is either the negative (e.g., “d_sease”) or benign (e.g., “sw_m”) interpretation of the homograph. Faster resolution of the threat meaning implies a bias for interpreting the homograph in a threatening manner. To train interpretations, researchers present the nonthreatening meaning consistently (Grey & Mathews, 2000). Word-Sentence Association Paradigm In the WSAP (Beard & Amir, 2009), a threatening (e.g., “embarrassing”) or benign (e.g., “funny”) word is presented on screen. Next, an ambiguous sentence is presented (e.g., “People laugh after something you said”) that may be interpreted as related or not-related to the word. Participants then press a button that indicates whether the word and sentence are related. During training, participants are provided with the feedback “You are correct!” contingent on a nonthreat interpretation of the relation between the word and the sentence. For example, if participants indicate that the benign word and ambiguous sentence are related or that the threat word and ambiguous sentence are unrelated, they would be told that they are correct. Similarly, they receive the feedback “You are incorrect” contingent on a threat interpretation of the relation between the word and the sentence. For example, if participants indicate that the benign word and ambiguous sentence are unrelated or that the threat words and ambiguous sentence were related, they receive the feedback “You are incorrect.” In the control training version of the task, participants received positive and negative feedback with equal probability. Novel IBM Programs Strategies to increase the efficacy of IBM include increasing the engagement of the tasks. For example, enhancing imagery before IBM through explicit instruction decreased the response to a stressor compared with no imagery (Edwards et al., 2017; Holmes et al., 2006). Researchers have also ported these paradigms to smartphones. For example, Yang et al. (2017) compared the efficacy of a single session of ABM, IBM, and combined ABM + IBM with CC delivered via smartphone. These researchers found no group differences in attentional bias after a single session, but the IBM group showed significantly less threat interpretation and more benign interpretation than the CC group. Another recent study found that a mobile IBM can be used in conjunction with heart-rate sensing watches to track changes in mental state associated with IBM (Boukhechba et al., 2018). As these studies demonstrate, as technology becomes more advanced, it will become necessary for evidence-based treatments to become more adaptive and user-friendly.



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EFFICACY Attention Bias Modification Efficacy studies of ABM focused initially on the treatment of anxiety disorders. Preliminary studies indicated clinically significant symptom reduction (Amir, Beard, Burns, & Bomyea, 2009; Amir, Beard, Taylor, et al., 2009; Schmidt et al., 2009). Following early successes of ABM in reducing anxiety, researchers applied ABM to other clinical conditions, including childhood obesity (Boutelle et al., 2014), alcohol dependence (Schoenmakers et al., 2010), and cigarette smoking (McHugh et al., 2010) . Meta-analytic research examining the effects of ABM training away from threatening stimuli (i.e., angry faces in anxiety) versus away from appetitive stimuli (i.e., alcoholic drinks in alcohol dependence) suggest that ABM is a more appropriate intervention for anxiety than externalizing disorders (Beard et al., 2012). On posttreatment measures, Beard et al. (2012) reported a mediumsized effect of training away for threatening stimuli (g = 0.30) and a nonsignificant effect of training for appetitive stimuli (g = –0.03). Meta-analyses generally indicate that the effect of ABM appears specific to anxiety symptoms (i.e., small-to-medium effect sizes) and not depressive symptoms (nonsignificantto-small effect sizes; Beard et al., 2012; Cristea, Kok, & Cuijpers, 2015; Cristea, Mogoașe, et al., 2015; Hakamata et al., 2010; Hallion & Ruscio, 2011; Heeren et al., 2015; Linetzky et al., 2015; Mogoaşe et al., 2014). Inherent in the theory of CBM is that biases in information processing cause symptoms, and changing these biases is the mechanism for symptom change. However, the modest outcomes derived from 20 years of randomized clinical trials (RCTs) in this area have resulted in reevaluation of the methods used to measure and change biases (see McNally, 2019). Specifically, the probe detection task has been held up as an example of a laboratory task and criticized for demonstrating poor reliability (Schmukle, 2005; Staugaard, 2009). Poor reliability suggests that across some studies, the score may reflect a true score, and in others, it may reflect error. Because of the group comparison design of most studies, the lack of reliability of the bias score may be circumscribed or explained by other factors (e.g., diagnostic group). Improving the reliability of information processing biases derived from the difference score is only just beginning to be addressed. Because the probe detection task is widely used in the assessment of changes in bias in ABM, here we summarize some approaches to improve the reliability of the probe detection task. One proposed solution is to predict its reliability in a particular experiment based on certain parameters (e.g., when two response time variables have unequal variance) and then decide whether or not to use the difference scores (Trafimow, 2015). Similarly, one can use idiographic and adaptive approaches allowing the collection of data until a stable bias score is achieved (Amir et al., 2016). However, the latter two approaches may not be practical for many studies needing to measure attentional selectivity. Another route is to use only the

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reliable components of previously collected data. For example, in a reanalysis of three studies, Price et al. (2015) described three strategies for increasing the reliability of the probe detection task, including (a) only analyzing trials in which the probe appears in the bottom half of the screen, (b) averaging across assessment points from multiple occasions, and (c) Winsorizing outliers as opposed to selecting an arbitrary cutpoint. Other approaches have taken a theory-based approach to target specific patterns of responding. For example, attention bias variability, or the amount that attention bias scores vary within a single session, may be more reliable (Price et al., 2015) and predict posttraumatic stress symptoms better than the traditional bias scores (Iacoviello et al., 2014). In order to parse the temporal variability in attention bias, Zvielli et al. (2015) used the nearest neighbor approach to compute bias scores at the individual trial. This process results in trial level bias scores (TL-BS) rather than a single AB score. TL-BS can then be used as items to assess psychometrically. However, subtraction requires two trials to create the bias score and results in at most half, and often a lot fewer, TL-BS scores. With 160 trials, the TL-BS indices demonstrate modest first-half-second-half reliability (r ranged from 0.44 to 0.67 for six indices; Zvielli et al., 2015). Another approach is to use response-based trial level scores to separate trials based on the attentional process employed that may have unique a relationship with anxiety (Evans & Britton, 2018). This is achieved by calculating the mean reaction time to neutral or probe following neutral trials and subtracting each probe following threat and probe following neutral trial from the mean score. The scores are then sorted into six different response types (AB vigilance, AB avoidance, vigilance, avoidance, fast disengagement, or slow disengagement). To identify the number of trials necessary to achieve high internal consistency, Evans & Britton (2018) computed Cronbach’s alpha for two to 24 trials and determined that at least 20 trials of each bias score type are needed to achieve adequate reliability for clinical use (defined at alpha  =  0.70). However, the response-based scores did not reach adequate levels of test-retest reliability nor significant relationships with anxiety symptoms. A final possible solution is to use raw reaction times. Reaction time measures have excellent internal consistency, test-retest reliability, and convergent and divergent validity. Thus, subtracting two highly correlated constructs needlessly sets an unacceptably low upper limit of internal consistency, test-retest reliability, and convergent and divergent validity of the subsequent score (see Miller & Ulrich, 2013). Thus, using reaction time measures rather than difference scores may be a way forward and a method of increasing the psychometric properties of the cognitive measures at an individual level. In response to the psychometric “crisis” of attentional bias reaction time measures (McNally, 2019), others have used different physiological measures. Moreover, it is possible to measure attentional biases to images using electrophysiological techniques (e.g., EEG; Kappenman et al., 2014) and assess responsiveness to treatment through heart rate (Boukhechba et al., 2018). Regardless of the measure of assessment, similar calls for establishing the reli-



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ability of laboratory measures (Hajcak et al., 2017) have begun to take route in assessing the quality of nontraditional psychological measures. The majority of the evidence supporting the relation between attentional bias and anxiety is the result of group comparison studies that increase the power to detect an effect even if a measure does not have high reliability. Thus, the reliability of traditional bias scores may affect the reported effect sizes of RCTs included in meta-analyses by setting an upper limit on the relationship between bias and anxiety. On the other hand, it is vital to find measures of bias that demonstrate improved reliability from the same task (i.e., raw reaction times or electrophysiological measures), which may improve confidence in the efficacy of ABM. Interpretation Bias Modification Fewer studies have examined the efficacy of IBM when compared with ABM. These studies have primarily focused on improving negative affect. To date, one meta-analysis has examined the efficacy of IBM in adults for mood and anxiety (Menne-Lothmann et al., 2014). The authors reported a small but significant effect of IBM training toward benign interpretation on improving negative mood in over 2,500 participants (effect size [ES] = 0.25). Another meta-analysis focused specifically on IBM for adolescent anxiety (Krebs et al., 2017). The authors demonstrated that over one session of training, IBM had a significant but moderate effect on reducing negative interpretations (g  =  –0.70) and increasing positive interpretations (g = –0.52) when compared with negative training. They found a small but significant effect of IBM on self-reported anxiety (g = –0.17). Additional investigations have included IBM in larger mixed CBM metaanalyses (Cristea, Kok, & Cuijpers, 2015; Cristea, Mogoașe, et al., 2015; Hallion & Ruscio, 2011). The effect sizes for IBM on symptoms are generally smaller; however, IBM does have a significant effect on change in interpretations. Lau and Pile (2015) found that at posttreatment, adolescents who completed benign IBM had fewer negative interpretations and more positive interpretations relative to control conditions (Cohen’s d ranging from 0.78 to 1.53, depending on age and gender). Similar effects have been found in adult populations. Specifically, post-IBM toward benign stimuli, 91% of adults endorsed positive interpretations more often than negative interpretations. The effects for benign IBM are also stronger than control versions of the task (ES = 1.33 compared with ES = –0.05 for Negative, ES = 0.49 for Neutral, and ES = –0.28 for No Training; QM3 = 137.70, p < .01; Menne-Lothmann et al., 2014). Further, there was a significant difference in the strength of posttraining interpretation bias for healthy subjects compared with those high in symptoms (β = 0.69, p < .01) but not changes in mood state (β = 0.15, p > .05; Menne-Lothmann et al., 2014). Regarding developmental considerations, targeting interpretation biases may be the most effective during mid- to late adolescence (Krebs et al., 2017; Lau, 2013; Lau & Pile, 2015) perhaps due to a more developed and stable

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cognitive processing style compared with younger children. However, a more malleable cognitive style of younger children may be more susceptible to intervention and thus prevent maladaptive biases from developing, especially in at-risk children (e.g., with subclinical symptoms or a family history of disorder). Some researchers suggest that IBM may be a promising addition to CBT because IBM targets automatic interpretation biases while CBT targets overt biases (Beard, 2011; Lau & Pile, 2015; Williams et al., 2013). However, automatic biases are comprised of multiple processes (McNally, 1995) that can be parsed via response time or electrophysiological measures (e.g., late positive potential [LPP]; Moser et al., 2014) in addition to overt interpretation biases measured via endorsement rates. For example, a single task (e.g., the WSAP; Beard & Amir, 2009) can be used to examine the number of benign and threat interpretations, response time of the interpretation, and neural response to a benign versus threat interpretation. Using multiple units of analysis in examining biases may increase understanding of the time course of interpretation in various emotional disorders and inform the design of targeted interventions. Extant IBM research suggests that symptoms do not change unless the intervention successfully changes interpretation biases (Amir & Taylor, 2012; Menne-Lothmann et al., 2014; Williams et al., 2013). In order to advance the use and impact of IBM, optimal methods for manipulating these mechanisms are yet to be established. Additionally, questions remain regarding the psychometric properties of interpretation bias paradigms and IBM. Combined Cognitive Bias Modification Attention and interpretation biases are thought to interact and influence one another in maintaining symptoms (Amir et al., 2010; White et al., 2011). Given the individual efficacy of both ABM and IBM, a growing number of studies have examined the efficacy of combined ABM and IBM (Beard et al., 2011; Naim et al., 2018; Yang et al., 2017). Beard et al. (2011) found that the combination of ABM and IBM was efficacious in reducing symptoms compared with a placebo control condition in 32 participants with social anxiety (Cohen’s d = 0.70). However, this study did not include separate control conditions for ABM or IBM. Naim et al. (2018) assigned 95 participants diagnosed with social anxiety to four groups: ABM + IBM, both active combination; ABM + IBM, both control; ABM active + IBM control; and ABM control + IBM active. They found that the active ABM alone group demonstrated both clinician-rated (d = 0.64) and self-report symptom (d = 0.77) reduction over the control condition. A possible interpretation of these findings is that active IBM in combination with ABM may erode the effects of ABM due to order or salience effects. This is in line with previous literature that despite the “pure” effects of ABM, ABM as an additive treatment did not increase efficacy (e.g., SSRIs: Browning et al., 2010; or CBT: Rapee et al., 2013). Further research is needed to understand the mechanisms involved in ABM, IBM, and how they may influence one another.



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MECHANISMS OF CHANGE Attention Bias Modification ABM is a theoretically informed, mechanism-driven treatment. Specifically, ABM interventions assume that (a) the target population has a selective attentional bias toward threat (e.g., anxiety, depression) or appetitive stimuli (e.g., substance use disorders), (b) the procedure of ABM (e.g., creating a contingency between stimuli type and participant responses) will actually succeed in changing attentional biases over the course of training, and (c) the changes observed in attentional biases will correspond with changes in symptoms. Within the ABM literature, there has been an increasingly prominent focus on empirically testing and critically examining these assumptions (Clarke et al., 2014; Kuckertz & Amir, 2015; MacLeod & Clarke, 2015; Mogg & Bradley, 2018). In a systematic review of the literature, MacLeod and Clarke (2015) found that in studies for which ABM actually succeeded in reducing attentional bias (i.e., the hypothesized mechanism underlying the intervention), anxiety symptoms and vulnerability were also reliably reduced. Importantly, in ABM studies in which anxiety symptoms were not reduced, attentional bias was also not successfully reduced. Thus, these researchers have proposed that inconsistent findings and small effect sizes in the ABM outcomes literature may not be due to flaws in the theory underlying ABM (i.e., that attentional bias relates to symptoms), but rather that existing ABM procedures are not consistently sufficient to produce change in the intended mechanism of action (attentional bias). Consistent with this notion, several meta-analyses have shown medium (r = .42; Mogoaşe et al., 2014) to large (r = .75; Hakamata et al., 2010) associations between changes in attentional bias and changes in symptoms. Several other factors warrant consideration in the ongoing study of ABM mechanisms. For example, a deeper understanding of (a) the time course of attentional bias (Mogg et al., 2004), (b) the role of avoidance of threat versus difficulty disengaging from threat in attention bias (Amir et al., 2003), (c) the role of bias toward threat versus no bias toward positive (e.g., Pishyar et al., 2004; Taylor et al., 2011), (d) the effects of state and trait anxiety in attentional bias (Amir et al., 1996; Garner et al., 2006; Mansell et al., 2002), and (e) the role of general attentional control compared with attentional bias from specific stimuli (Cisler & Koster, 2010; Heeren et al., 2012; Klumpp & Amir, 2010) would allow researchers to design and implement more mechanistically precise ABM procedures. Furthermore, poor psychometric properties of measures used to assess each of these attentional processes may be adding noise to the existing literature and likely limit the ability of researchers to examine questions of mechanisms (Price et al., 2015). Finally, developmental factors may affect each of these questions (Carmona et al., 2015; Schneier et al., 2016). For example, older youth (11–17 years old) experiencing clinical levels of anxiety demonstrate significant attentional biases away from threat while their younger counterparts (8–10  years old)

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demonstrate attentional bias toward threat (Carmona et al., 2015). Nonclinical youth demonstrate comparable age-related patterns (Lonigan & Vasey, 2009; Reinholdt-Dunne et al., 2012). These studies suggest that ABM to reduce attentional bias toward threat may be effective in younger children and adults, but the same mechanism may be less strongly implicated among anxious adolescents. Interpretation Bias Modification The theoretical model of IBM is similar in structure to that of ABM; interpretation biases contribute to several forms of psychopathology (Mathews, 2012; Mathews & MacLeod, 2005), and when interpretation biases are successfully altered, symptoms may decrease. Like ABM, this hypothesis has been examined by several research groups. In adult samples, researchers have found a significant correlation (r  =  .58) between change in interpretation bias and decrease in negative mood or anxiety symptoms (Menne-Lothmann et al., 2014). Several research groups have found that changes in interpretation bias mediate the effects of IBM on symptoms, including depressive symptoms in a sample of clinically depressed patients (Williams et al., 2013) as well as social anxiety symptoms in a sample of socially anxious patients (Amir & Taylor, 2012). Similar to the ABM literature, these studies suggest that IBM only reduces symptoms when it effectively changes interpretation biases. One question integral to optimizing IBM paradigms is whether interpretation biases are best reflected by lack of endorsement of benign interpretations, the over endorsement of threat interpretations, or their combination (Amir et al., 2012; Huppert et al., 2003). However, traditional interpretation bias assessment paradigms are not designed to assess these separate processes. The WSAP does allow for the disentangling of the bias to interpret ambiguous situations as threatening versus the bias to not interpret ambiguous situations as benign. Results from the WSAP indicate that different types of psychopathology are associated with different patterns of interpretation bias. In patients with SAD compared with controls, more threat interpretations were endorsed and fewer benign interpretations were endorsed (Amir et al., 2012). In comparison, individuals high in obsessive-compulsive symptoms endorse more threat interpretations than nonanxious controls, whereas they endorse the same amount of benign interpretations (Kuckertz et al., 2013). A second research question regarding the mechanistic target of IBM paradigms is whether interpretation biases should be trained to endorse more positive versus neutral interpretations of ambiguous situations (Holmes et al., 2006). Few studies have directly assessed the differences between the two types of training (cf. Holmes et al., 2006). It is possible that greater or longer lasting effects will be found from training toward neutral or a mix of neutral and positive interpretations of ambiguity. Although questions of measurement and mechanism remain, the effects of IBM as predicted through the hypothesized mechanisms are promising.



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DISSEMINATION Ease of dissemination of CBM as a potential intervention for clinical populations due to its cost-effectiveness and portability is one advantage of this intervention. However, of the eight studies that have included location (e.g., at-home versus in-lab setting) as a moderator for ABM efficacy, five have demonstrated larger effects in the laboratory when compared with remote administration (Cristea, Mogoașe, et al., 2015; Heeren et al., 2015; Linetzky et al., 2015; Kampmann et al., 2016; Price et al., 2016), with the remaining finding no difference (Cristea et al., 2016; Mogoaşe et al., 2014). Although the finding that an intervention is more effective in a controlled setting is not entirely surprising, more research is needed to determine specific factors (e.g., distracted attention in ABM) that may be associated with this differential efficacy. Indeed, one of the greatest strengths of CBM is that it can be administered via any computer. One potential factor contributing to the differential efficacy of CBM may be participant engagement. Traditional CBMs have been described as “repetitive” and are thus not intrinsically motivating to complete (Beard et al., 2012). A recent qualitative analysis suggests that patients with social anxiety attitudes toward ABM predicted treatment change (Kuckertz et al., 2019). The authors suggested that providing a rationale for ABM in and of itself may improve adherence and symptoms. Another implication of these results may also be to increase engagement through games. For example, Notebaert et al. (2015) used a cardlike game to train attention, and Amir et al. (2016) introduced reward points that increased as bias changed over and above traditional ABM. IBM was more enjoyable to patients because the treatment seemed more directly applicable to their symptoms and the stimuli were more interesting. Making ABM (and IBM) more intrinsically motivating by including such rewarding games and explaining the rationale may be useful in increasing the efficacy of at home treatment using ABM. Another fruitful avenue for efficacy and dissemination research may be in the development of smartphone-compatible CBM games. A recent poll suggests that 77% of Americans own smartphones (Pew Research Center, 2018), which would also increase the accessibility of CBM. Smartphone apps (e.g., Daily Diary, iCBT, AnxietyCoach) are frequently used in clinical practice, but research has just begun on the efficacy of the game version of ABM. For example, Dennis-Tiwary et al. (2016) demonstrated that a single session of an iPad game version of ABM reduced self-reported anxiety and attentional bias, and it improved performance on an anxiety-related stress task (Dennis & O’Toole, 2014; Dennis-Tiwary et al., 2016). Indeed, the game versions of CBMs may be a necessary conduit for dissemination.

CLINICAL EXAMPLE Melissa was a 30-year-old woman who presented to our clinic in response to a study flyer advertising “computerized treatment for anxiety.” Melissa had

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never received previous psychiatric treatment. Melissa was seeking treatment because of her anxiety, which had become progressively worse in the past 2 years. She reported experiencing difficulty at work due to her social anxiety. Specifically, she had been experiencing significant anxiety about speaking with her boss and speaking up in team meetings. Additionally, Melissa reported avoiding social situations in which she would be expected to interact in a group, such as parties, and having difficulties finding a romantic partner. After completing a semistructured interview, we diagnosed Melissa with SAD and GAD. We also administered the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987), a clinician-rated measure that provides scores for fear and avoidance of 24 social interaction and performance situations. Melissa’s total LSAS score at baseline was 75 (clinical cutpoint for generalized SAD  =  60; Mennin et al., 2002). As part of the research study, participants were randomized to complete an adaptive, idiographic, and multi-component ABM (AABM) twice per week for 4 weeks in the clinic. During in-clinic visits, Melissa completed two sessions of the training program in succession in a private office. At home, Melissa was instructed to complete as many sessions as she wished. The program was a modified spatial cuing task. During each trial, a fixation cross appeared in the center of the screen, the fixation cross disappeared after 500 ms, and then a single word appeared either above or below the fixation cross. The word then disappeared and a probe (either the letter “E” or the letter “F”) appeared replacing the probe. She responded using a button corresponding to the “E” or “F.” Each session consisted of 360 trials using 15 (five negative, five positive, and five neutral) personally relevant words. In the AABM task, the probe always appeared in the opposite location of the negative word (i.e., invalid cues), and the probe always appeared in the same location of the positive word (i.e., valid cues). The neutral words could serve as either valid or invalid cues, which occurred at equal frequency. The task had a practice phase and a training phase. During the practice phase, participants increased in levels by accurately performing the task. Simultaneously, the difficulty was gradually increased by using the color of the fixation cue to predict probe location at the beginning and gradually fading the color of the cue for emotional words so that the valence of the word served as the location cue. Also, beginning at Level 20, additional letters were added, flanking the probe to increase the attentional demand of the task. At the beginning of the training phase, a pop-up window informed participants that they would now move through levels of a program by increasing their positive attention bias and/or decreasing their negative attention bias. Either a 1 ms increase or decrease would increase their level in the game. The training was cumulative, such that at the end of each session, the game would save the current level and was subsequently reloaded at the next session. To reduce frustration, there was also a recalibration feature such that if participants had not moved up after 100 trials, their bias was reset to their current level so that advancing in levels would become easier.



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After 4 weeks, Melissa was assessed for clinical change. Melissa noted that she was feeling less anxious at work and was “more flexible” in anxiety-provoking situations. Melissa reported clear behavioral examples of improvement in her anxiety. She reported that she was interacting more comfortably with her coworkers and was no longer reporting physiological symptoms of anxiety. Melissa continued to be somewhat nervous in large groups or when interacting with unfamiliar people, but that her nervousness only lasted a few minutes. Moreover, Melissa’s LSAS score at posttraining was a 46. We determined that Melissa no longer met criteria for SAD or GAD. Although Melissa reported that she found the task repetitive and boring, she stated that she appreciated that she was able to seek treatment without the use of medication. An assessor completed a follow-up interview with Melissa approximately 2 months following the posttraining assessment. At that time, Melissa reported continuing to function “much better,” appeared more confident at work, and had recently volunteered to lead a volunteer group and plan a birthday party for her friend. Melissa’s LSAS score at follow-up was a 39.

CONCLUSION AND FUTURE DIRECTIONS In this chapter, we have summarized the current state of CBM, specifically ABM and IBM. We have focused on both the mechanistic background of CBM and its respective clinical efficacy, as we believe that clinical utility and mechanism are likely intertwined. In sum, studies of both ABM and IBM have demonstrated significant effects on symptoms. However, many studies have also produced null results. This chapter highlights the importance of clearly defined mechanisms in the clinical utility of any treatment package. We echo the emphasis of the NIMH to focus on mechanistic research for clinical interventions. Indeed, the first strategic objective of the NIMH is to “define the mechanisms of complex behavior.” We call for research on CBM to focus on theory; for instance, studies from the ABM literature have demonstrated that only when bias changes do symptoms change (e.g., Amir & Taylor, 2012). Despite the reliability and measurement issues, and perhaps more than any other treatment package, CBMs promise a clearly defined quantifiable mechanism (attentional or interpretation bias). Outcomes literature suggests that when CBM produces change in bias, there is a corresponding impact on symptoms (MacLeod & Clarke, 2015). Therefore, similar to traditional CBTs, therapists should consider CBM as a viable treatment option. In parallel, CBM (and all treatment package) researchers should continue to examine the mechanisms and predictors of treatment response. For example, patients who enjoy ABM are more likely to have symptoms reductions. Similarly, there are individual differences in level of bias. Indeed, not every patient diagnosed with a disorder will have an attentional or interpretation bias. Further, traditional bias measurements may have less than ideal psychometric properties. Novel reaction time calculation methods and

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technologies such as event-related potentials offer fruitful research areas for reliably measuring biases. In order to personalize treatment and appropriately prescribe ABM, clinicians can consider patient enjoyment and engagement as indications for treatment while clear definitions of biases are empirically examined. One consideration for any treatment package is the application to diverse populations. In the traditional sense, there has been little research on the application of CBM to diverse populations. However, CBM research is rapidly growing to include a wide range of participants, a diversity of symptom targets, and a broad range of bias targets (MacLeod et al., 2009). One limiting factor of CBM is that it is limited to populations who have access to a computer or research laboratories. However, as a field, CBM is moving toward having stimuli be selected at an adaptive and idiographic level (e.g., Amir et al., 2016) in order to target specific biases at an individual level, regardless of demographic variables. Of course, more research is needed to determine the relative efficacy of the process of CBM in diverse populations. Thus, emphasis on the development of better theoretically based measures of attention bias and interpretation bias would move the field and targeted treatments of such disorders. For instance, it is possible that attentional processes assessed using any of the existing attentional bias paradigms combine multiple processes and that a better measurement tool would better predict individual attentional biases. Further, it is possible that the existing stimuli do not capture attention or interpretation the same way for every individual. A better way of fitting the paradigms to the individual, such as using machine learning to select the best fitting stimuli to the person, may better address the mechanism of symptom change. Specific measures of these mechanisms and personalization of the paradigms are exciting avenues of research in the reach for personalized medicine in the mental health field.

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Huppert, J. D., Foa, E. B., Furr, J. M., Filip, J. C., & Mathews, A. (2003). Interpretation bias in social anxiety: A dimensional perspective. Cognitive Therapy and Research, 27 (5), 569–577. https://doi.org/10.1023/A:1026359105456 Huppert, J. D., Pasupuleti, R. V., Foa, E. B., & Mathews, A. (2007). Interpretation biases in social anxiety: Response generation, response selection, and self-appraisals. Behaviour Research and Therapy, 45(7), 1505–1515. https://doi.org/10.1016/j.brat. 2007.01.006 Iacoviello, B. M., Wu, G., Abend, R., Murrough, J. W., Feder, A., Fruchter, E., Levinstein, Y., Wald, I., Bailey, C. R., Pine, D. S., Neumeister, A., Bar-Haim, Y., & Charney, D. S. (2014). Attention bias variability and symptoms of posttraumatic stress disorder. Journal of Traumatic Stress, 27(2), 232–239. https://doi.org/10.1002/jts. 21899 Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., Sanislow, C., Wang, P. (2010). Research domain criteria (RDoC): Toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748–751. https://doi.org/10.1176/appi.ajp.2010.09091379 Jelinek, L., Hottenrott, B., Randjbar, S., Peters, M. J., & Moritz, S. (2009). Visual false memories in post-traumatic stress disorder (PTSD). Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 374–383. https://doi.org/10.1016/j.jbtep.2009.02.003 Jones, E. B., & Sharpe, L. (2017). Cognitive bias modification: A review of metaanalyses. Journal of Affective Disorders, 223, 175–183. https://doi.org/10.1016/j.jad. 2017.07.034 Kampmann, I. L., Emmelkamp, P. M. G., & Morina, N. (2016). Meta-analysis of technology-assisted interventions for social anxiety disorder. Journal of Anxiety Disorders, 42, 71–84. https://doi.org/10.1016/j.janxdis.2016.06.007 Kappenman, E. S., Farrens, J. L., Luck, S. J., Proudfit, G. H., Pfabigan, D. M., & Grubert, A. (2014). Behavioral and ERP measures of attentional bias to threat in the dot-probe task: poor reliability and lack of correlation with anxiety. Frontiers in Psychology, 5, 1368. https://doi.org/10.3389/fpsyg.2014.01368 Kelleher, K. J., & Gardner, W. (2017). Out of sight, out of mind: Behavioral and developmental care for rural children. New England Journal of Medicine, 376, 1301– 1303. https://doi.org/10.1056/NEJMp1700713 Kemps, E., Tiggemann, M., & Hollitt, S. (2014). Biased attentional processing of food cues and modification in obese individuals. Health Psychology, 33(11), 1391–1401. hhtp://dx.doi.org/10.1037/hea0000069 Klumpp, H., & Amir, N. (2010). Preliminary study of attention training to threat and neutral faces on anxious reactivity to a social stressor in social anxiety. Cognitive Therapy and Research, 34(3), 263–271. https://doi.org/10.1007/s10608-009-9251-0 Koster, E. H., Crombez, G., Verschuere, B., Van Damme, S., & Wiersema, J. R. (2006). Components of attentional bias to threat in high trait anxiety: Facilitated engagement, impaired disengagement, and attentional avoidance. Behaviour Research and Therapy, 44(12), 1757–1771. https://doi.org/10.1016/j.brat.2005.12.011 Krebs, G., Pile, V., Grant, S., Degli Esposti, M., Montgomery, P., & Lau, J. Y. (2018). Research Review: Cognitive bias modification of interpretations in youth and its effect on anxiety: A meta-analysis. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 59(8), 831–844. Kuckertz, J. M., & Amir, N. (2015). Attention bias modification for anxiety and phobias: Current status and future directions. Current Psychiatry Reports, 17(2), 9. https://doi.org/10.1007/s11920-014-0545-x Kuckertz, J. M., Amir, N., Tobin, A. C., & Najmi, S. (2013). Interpretation of ambiguity in individuals with obsessive-compulsive symptoms. Cognitive Therapy and Research, 37(2), 232–241. https://doi.org/10.1007/s10608-012-9478-z Kuckertz, J. M., Schofield, C. A., Clerkin, E. M., Primack, J., Boettcher, H., Weisberg, R. B., Amir, N., & Beard, C. (2019). Attentional bias modification for social anxiety



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24 The Unified Protocol A Transdiagnostic Treatment for Emotional Disorders Todd J. Farchione, Julianne G. Wilner Tirpak, and Olenka S. Olesnycky

P

rior to 1980, psychopathology was defined by broad categories rooted in psychoanalytic theories of etiology (e.g., neuroses, psychosis). However, following the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, continuing through DSM-IV in 1994 and arguably to the present day with DSM-5, classification of mental disorders shifted from broad, overarching categories toward an objective, empirically based classification system emphasizing diagnostic reliability. This shift resulted in several decades of treatment development and consequential evaluative research on treatment manuals developed to address various disorders, many of which have gained strong empirical support (Barlow et al., 2014).1 However, differentiating or “splitting” psychopathology into such narrow diagnostic categories may have come at the expense of validity (see Barlow et al., 2014). This is evident in the substantial phenotypic overlap of symptoms across anxiety, depressive, and related disorders, and the corresponding high rates of comorbidity among them (Allen et al., 2010; Brown et al., 2001; Kessler et al., 1996; Roy-Byrne et al., 2006; Tsao et al., 2002, 2005). Indeed, results from a study of 1,127 patients at the Center for Anxiety and Related Disorders (CARD) at Boston University indicated that of all patients presenting with a principal anxiety disorder, 55% had at least one additional anxiety or depressive disorder at the time of assessment, and 76% did when including lifetime diagnoses (Brown et al., 2001). Additionally, research suggests that when treating one anxiety or depressive disorder (i.e., with a single-disorder protocol Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-024 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  701 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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[SDP]), symptoms from comorbid anxiety and mood disorders tend to decrease as well (Allen et al., 2010; Borkovec et al., 1995; Tsao et al., 1998, 2002). Furthermore, research in affective neuroscience points to shared neurobiological mechanisms across anxiety and depressive disorders. Specifically, a body of literature has demonstrated both increased hyperexcitability of limbic structures and limited inhibitory control by cortical structures among those with anxiety and depressive disorders, foci that have been associated with increased negative emotional states (Etkin & Wager, 2007; Porto et al., 2009; Shin & Liberzon, 2010). Dysregulated cortical inhibition of amygdala responses has also been indicated in studies of various anxiety and related disorders, including generalized anxiety disorder, social anxiety disorder, and depression (Etkin et al., 2010; Holmes et al., 2012; Phan et al., 2006, respectively). In light of this evidence, there has been increased focus on understanding the common underlying factors that may be maintaining symptoms across the range of anxiety and depressive disorders. This includes both underlying processes that have been described by Harvey et al. (2011) as being “descriptively transdiagnostic” (i.e., processes that are present in a range of diagnoses), as well as those that are more “mechanistically transdiagnostic” (i.e., processes that reflect a causal, functional mechanism for co-occurrence). Two primary underlying temperamental vulnerabilities have been identified to account for the onset, overlap, and maintenance of anxiety, depressive, and related disorders: neuroticism and (to a lesser degree) deficits in positive affect (Barlow, 2002). Neuroticism (also referred to as negative affect, trait anxiety, behavioral inhibition, and harm avoidance in the literature; Barlow et al., 2014) is the tendency to experience frequent and intense negative emotions. Compared with healthy counterparts, individuals with emotional disorders have been shown to have higher baseline levels of negative affect/neuroticism (Brown & Barlow, 2009) and express negative emotions more frequently (Campbell-Sills et al., 2006; Mennin et al., 2005). Anxiety and depression have also been associated with lower levels of positive affect (i.e., extraversion or behavioral activation), the tendency to experience the world in an energetic, sociable, more engaged way (Brown, 2007; Brown et al., 1998; Rosellini et al., 2010). This often presents clinically as responding in ways that minimize positive emotional experiences (Carl et al., 2013; Eisner et al., 2009; Feldman et al., 2008; Tugade & Fredrickson, 2007). Hierarchical statistical models developed by Brown et al. (1998) support these findings on differences in affect, demonstrating that there are higher order trait dimensions (e.g., negative and positive affect) that influence the development, course, and severity of emotional disorders in expected directions. Taken together, these underlying temperamental vulnerabilities appear to put one at risk for the development and maintenance of anxiety and depressive disorders, leading to a biological predisposition to experience strong emotions (i.e., emotional sensitivity) and increased negative reactions to these emotions when they occur (e.g., “I shouldn’t feel this way, this is horrible”). Individuals with these disorders often rely on maladaptive regulation strategies that back-



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fire (Purdon, 1999), maintaining high levels of negative affect and contributing to the persistence of symptoms. Because of the role of emotional experiences in the development and maintenance of the full range of anxiety, depressive, and related disorders, we refer to these conditions as emotional disorders to emphasize this common feature (for more information on the nature of emotional disorders, see Barlow et al., 2014). Interest in identifying underlying psychopathological mechanisms has also led to the development of treatments designed specifically to target these transdiagnostic constructs and, in doing so, offer more parsimonious, cost-effective treatments that can be broadly applied across diagnoses. These transdiagnostic treatments offer several advantages over existing treatments that tend to target only one disorder at a time, referred to as SDPs. First, by addressing comorbidity in a more comprehensive fashion, these treatments are more cost-effective and efficient for both patients and clinicians and arguably may lead to better treatment outcomes. Second, by providing a treatment that more adequately maps onto “real-world” patient presentations, transdiagnostic treatments may be more acceptable to clinicians in community settings where evidence-based psychological treatments (EBPTs) are sorely needed. Third, these treatments provide clinicians with the necessary skills to treat a broad range of problems with a single protocol, thereby greatly reducing the burden of training. Therapists only need to become proficient in the delivery of a single protocol for a range of disorders, rather than completing costly and timeintensive training for multiple interventions (McHugh et al., 2009). Thus, transdiagnostic treatments have the potential to increase the availability of evidence-based treatments to meet a significant public health need (McHugh & Barlow, 2010; Stewart et al., 2012).

DESCRIPTION OF THE UNIFIED PROTOCOL The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow, 2011; Barlow, Farchione, Sauer-Zavala, et al., 2017) is a cognitive behavioral intervention designed to address the full range of emotional disorders by targeting temperamental characteristics, particularly neuroticism, and resulting emotion dysregulation (Barlow et al., 2014). Specifically, the UP addresses negative, avoidant reactions to emotions resulting from a propensity to find emotional experiences aversive and unmanageable. There are a number of associated constructs reflecting this negative reactivity and perceived lack of control of intense emotions that are addressed by core modules of the UP, which are described in further detail below. These include experiential avoidance, or the urge to escape or avoid uncomfortable internal experiences such as thoughts, memories, or emotions (Hayes et al., 1996), and anxiety sensitivity, which refers to the tendency to believe that symptoms of anxiety and fear will have negative consequences (Reiss, 1991), deficits in mindfulness, and negative (and very rigid) appraisals and attributions of persons (including oneself) and situations.

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The UP is a modular treatment designed for administration in 12 to 16 sessions, not including the initial session dedicated to assessment and case formulation within a transdiagnostic framework. The UP is made up of eight different treatment modules, five of which are considered “core”: (a) present-focused awareness, (b) cognitive flexibility, (c) changing emotional behaviors, (d) awareness and tolerance of physical sensations, and (e) emotion exposures. In addition, these five core modules are preceded by a module on motivation and readiness for change and treatment engagement, in addition to an introductory module that provides psychoeducation and a framework for tracking emotional experiences. After the five core modules are completed, a final module on relapse prevention is provided. Flexibility is built into the treatment administration to allow for more or fewer sessions to be spent on specific modules on a case-by-case basis. In the following case presented in this chapter, treatment was conducted over sixteen 50- to 60-minute individual treatment sessions. Structure of sessions included the following: (a) tracking of general levels of anxiety and depressive symptoms, (b) homework review (with troubleshooting noncompliance, if necessary), (c) introduction of a new skill or continued practice with a previously presented concept, and (d) development of homework.

EFFICACY AND EFFECTIVENESS The UP has gained strong empirical support as a treatment for a range of emotional disorders. In an initial, small, randomized controlled trial (RCT; N = 37), the UP was found to significantly reduce symptoms for a range of anxiety disorders compared with a wait-list control group, with patients continuing to improve even 18 months after treatment (Farchione et al., 2012; Bullis et al., 2014). More recently, in a much larger RCT (N = 223) comparing the UP to four gold standard, evidence-based SDPs for principal diagnoses of generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, or panic disorder, and a wait-list control group. Results posttreatment and at a 6-month follow-up indicate clear improvements in principal diagnosis severity and quality of life in the treatment groups relative to the control condition (Barlow, Farchione, Bullis, et al., 2017; Wilner et al., 2020). The UP was at least as efficacious as SDPs at both time points while resulting in significantly less attrition. It is also worth noting that 62% of patients treated with the UP no longer met diagnostic criteria for any emotional disorder following treatment, and these improvements were largely maintained 6 months later (Barlow, Farchione, Bullis, et al., 2017). In this study, the UP also reduced symptoms associated with clinically significant, comorbid disorders not directly targeted in treatment (Jarvi-Steele et al., 2018). In addition to these two RCTs evaluating the UP for anxiety disorders, there has been preliminary support for the UP in the treatment of alcohol use disorders (Ciraulo et al., 2013), unipolar depressive disorders (Boswell et al., 2014), bipolar disorder (Ellard et al., 2012), borderline personality disorder (Sauer-



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Zavala et al., 2016), and posttraumatic stress disorder (Gallagher, 2017). Additionally, in a preliminary exploration of group delivery of the UP, patients generally demonstrated moderate to large improvements in symptoms of anxiety and depression, functional impairment, experiential avoidance, and quality of life (Bullis et al., 2015).

TRAINING AND DISSEMINATION Efforts are underway to promote dissemination of the UP. These include the development of a nonprofit training program, the Unified Protocol Institute (UPI). The UPI has successfully expanded the ability of domestic and international mental health providers to receive varying degrees of training in the protocol and offers consultation on implementation of the protocol. Recent program implementation efforts, including a multisite, inpatient eating disorder treatment facility (Thompson-Brenner et al., 2019), have been shown to be promising. Our group is also finalizing a web-based UP treatment program that we hope will reduce barriers to seeking and receiving empirically supported treatment, including clinician availability, access to evidence-based treatments, and stigma associated with seeking mental health treatment.

CASE EXAMPLE Eleanor was a 37-year-old, married, Caucasian women who was self-referred to our center. She has a master’s degree in social work and was working as a therapist at a community mental health center. She presented to the evaluation saying that she felt an “overwhelming sense of impending doom” and reported “worrying constantly.” She also endorsed concerns that she may be evaluated negatively by others. Eleanor completed a clinical assessment that included the Anxiety Disorders Interview Schedule for DSM-IV (DiNardo et al., 1994), a semistructured clinical interview focusing on the diagnosis of anxiety disorders and their accompanying mood states, and a set of standardized self-report inventories. During the interview, she reported excessive and difficult-to-control worries about a number of areas in her life, more days than not in the 6 months prior to the assessment. Specifically, she worried about work (e.g., concerns about being fired, whether she is doing her job well), punctuality, finances, and her safety (e.g., worry about terrorist attacks, home invasion, being assaulted or abducted). She also worried about her relationship and expressed a need to be reassured by her partner that he is happy in their relationship and that he still finds her attractive. In addition, she reported recent difficulties making decisions, stating, “I always get caught up in all of the different possible outcomes . . . and all I can think about is what bad thing might happen or what might go wrong.” She noted procrastinating at work and had difficulty completing projects because of

706  Farchione, Tirpak, and Olesnycky

a desire for them to be “perfect.” She reported being “a worrier” her “whole life,” but noticed a significant increase in her anxiety about 8 months prior to the evaluation following a reorganization at her work that resulted in several employees (including her best friend) being laid off from their jobs. Around the same time, she also began experiencing daily low mood and feelings of anhedonia in addition to other symptoms of depression, such as decreased appetite and weight loss (she lost 5 pounds in the month prior to the assessment), fatigue, and a sense of worthlessness. She noted that she did not “feel like [herself],” was isolating from others, and in general felt like she was “just going through the motions” when completing daily tasks. Eleanor also reported experiencing cued and uncued panics attacks. During most attacks, she experienced racing heart, sweating, trembling hands, shortness of breath, dizziness, and feelings of unreality. She also had limited-symptom attacks that were characterized by racing heart only. She described the feelings of unreality as being particularly distressing, and she would often become concerned that she may be “going crazy” or “losing her mind” as a result of the attacks. She reported significant sensitivity to her physical sensations and noted that she often escapes situations in an effort to diminish those feelings. Also, she reported worrying about the physical and social consequences of having panic attacks. Although she did not describe the worry as being very strong, she engaged in a number of behaviors designed to prevent the occurrence of additional attacks, such as reducing her intake of caffeine, carrying items with her that make her feel safe, and sometimes asking her partner to accompany her when she goes into situations that are more likely to provoke an attack. She endorsed mild agoraphobic apprehension and avoidance in a number of situations, including driving, going to the hairdresser or nail salon, taking public transportation, going to the grocery store, and traveling away from home. Eleanor also endorsed marked fear and avoidance of many social situations, including formal speaking; meeting new people; talking to people in authority, such as her supervisor at work; and maintaining a conversation. In addition, she described herself as a “people pleaser” and noted difficulty being assertive at work and occasionally with her friends. When asked why she felt anxious in these social situations, she reported concerns that she would say the wrong thing, offend or upset people, or appear foolish or incompetent. She reported being “shy” as a child and experiencing anxiety in social situations since childhood but noted that her fears began to be more distressing to her during junior year of high school, when she felt unattractive, was taller than the other girls, and had gained weight at that time. She believed that her social fears prevented her from being more outgoing and “greatly affected” her ability to develop and maintain meaningful friendships. Also, she noted that limited networking and professional interactions might have hindered her professional development. Although she reported some improvement in her social anxiety over the years, she was still quite bothered by the symptoms and wanted to feel more comfortable in social situations. Last, Eleanor endorsed excessive fear and strong avoidance of the dentist. She reported concerns that dental procedures would be painful and that the



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dentist and dental assistants would not be understanding of her fear and would ignore her if she asked them to stop. She indicated that she has “always been freaked out by the dentist,” though her fear intensified several years ago following what she described as a “painful” and “torturous” root canal. Although she went to the dentist twice since that time for routine care, she often canceled appointments and had not seen a dentist for several years. She was distressed by her fear of the dentist and felt that it prevented her from taking care of herself. Also, she expressed concern that she would not be able to go to the dentist for a more extensive procedure if it were necessary or, if she did go, that she would find it incredibly anxiety provoking and possibly even “traumatic.” Eleanor reported recurrent gastrointestinal distress and previously received a diagnosis of irritable bowel syndrome but otherwise did not report any other ongoing medical difficulties. At the time of initial intake, she reported taking bupropion-XR (300 mg/day), clonazepam (1 mg twice daily), and escitalopram (10 mg/day) for anxiety and depression and had been taking them consistently for approximately 4 years. She received psychodynamic therapy for 8 years prior to the assessment but discontinued before initiating treatment with the UP. She denied a history of psychiatric hospitalizations. Case Conceptualization On the basis of the information obtained during the assessment, which was complemented by scores on baseline self-report questionnaires and additional clinician-administered measures (selected measures are presented in Tables 24.1 and 24.2), a principal diagnosis of generalized anxiety disorder (DSM-IV, 300.02; clinical severity rating [CSR] = 6 on a scale of 0 to 8, with 8 being most severe and interfering) was assigned. Additional diagnoses of major depression, mild, recurrent (DSM-IV, 296.31; CSR = 5); panic disorder and agoraphobia (DSM-IV, 300.21; CSR = 4); social phobia (DSM-IV, 300.23; CSR = 4); and specific phobia of dental procedures (DSM-IV, 300.29; CSR = 5) were assigned. TABLE 24.1. Change in ADIS-IV CSRs of Principal and Co-Occurring Diagnoses Baseline

S4

S8

S12

S16

6MFU

12MFU

GAD

6

5

6

5

3

1

2

MDD

5

5

5

4

3

0

1

PDA

4

4

4

3

2

0

0

SAD

4

3

3

2

1

0

1

Specific (dentist)

5

5

5

1

1

0

1

Note. CSR = clinical severity rating (range = 0–8; clinical cutoff = 4; Brown & Barlow, 2014); S4 = Treatment Session 4; S8 = Treatment Session 8; S12 = Treatment Session 12; S16 = Treatment Session 16/posttreatment; 6MFU = 6-month follow-up; 12MFU = 1-year (12-month) follow-up; GAD = generalized anxiety disorder; MDD = major depressive disorder; PDA = panic disorder/agoraphobia; SAD = social anxiety disorder; Specific (dentist) = specific phobia (dentist).

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TABLE 24.2. Scores on Self-Report and Clinician-Administered Measures During Treatment and at Follow-up Baseline

S4

S8

S12

S16

6MFU

12MFU

SIGH-A

42

26

31

16

7

0

16

SIGH-D

26

18

27

9

7

1

12

PANAS-PA

26

28

25

35

39

34

38

PANAS-NA

35

31

20

24

16

12

13

Q-LES-Q

35

45

38

49

61

60

52

Note. All scores represent raw total scores. S4 = Treatment Session 4; S8 = Treatment Session 8; S12 = Treatment Session 12; S16 = Treatment Session 16/posttreatment; 6MFU = 6-month follow-up; 12MFU = 1-year (12-month) follow-up; SIGH-A = Structured Interview Guide for the Hamilton Anxiety Scale (range = 0–56; Hamilton, 1959); SIGH-D = Structured Interview Guide for the Hamilton Depression Scale (range = 0–53; Hamilton, 1960); PANAS = Positive and Negative Affect Scales (range = 10–50; Watson & Clark, 1999); PANAS-PA = PANAS Positive Affect; PANASNA = PANAS Negative Affect; Q-LES-Q = Quality of Life and Enjoyment and Satisfaction Questionnaire (range = 14–70; Endicott et al., 1993).

Like many patients presenting to treatment for anxiety, depressive, and other emotional disorders, Eleanor was assigned several comorbid DSM-IV diagnoses. In accordance with a transdiagnostic formulation of her presenting symptoms (during an initial session), however, her presenting symptoms were conceptualized as reflecting a primary underlying tendency to experience negative affect coupled with overreliance on maladaptive emotion regulation strategies (i.e., neuroticism). Functionally, this underlying mechanism was seen as manifesting in a number of ways, including high anxiety sensitivity, which may have been associated with her tendency to experience panic attacks and likely contributed to her fear of dental procedures, anxious and negative thinking, and maladaptive, avoidant behaviors. Eleanor reported many behaviors that can all be viewed as different manifestations of emotion avoidance. That is, the behaviors were functioning to prevent or reduce intense negative emotions, which may have helped her to feel better in the short term but were seen as contributing to an increase in the frequency of strong, negative emotions and resulting in continued distress in response to her experience of strong emotions. Specifically, she identified patterns of worry and rumination, noted that she had been “isolating” herself from others, and was avoiding situations that were likely to elicit strong negative emotions, including social situations, situations that were likely to cause panic, and going to the dentist, among others. Finally, Eleanor described some difficulties being present (i.e., “in the moment”), particularly when experiencing strong emotions. Eleanor’s maladaptive patterns of emotional responding were viewed as the primary treatment target. This included her tendency to worry excessively, which was ultimately identified as a (maladaptive) strategy that Eleanor relied on to manage feelings of distress when faced with the possibility of a situation that she (inaccurately) perceived as being dangerous. During the first session of treatment, she described her worry as providing “control” over future events; however, she also recognized the fact that her



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worry was often coupled with (and she believed may have contributed to) behavioral avoidance that paradoxically increased the likelihood of the negative event occurring. For example, she described a situation at work in which she “put off” responding to an email from her supervisor out of fear that she may not express herself clearly and that he would be upset with her as a result. She worried about it for days but failed to take action. As a result, she was ultimately reprimanded for not responding in a timely fashion. It was expected that as Eleanor gained greater tolerance of her emotions and began to modify maladaptive patterns of responding in the face of distressing thoughts and aversive mood states, she would develop alternative, more adaptive, emotionregulation skills and ultimately experience a reduction in presenting symptoms of anxiety and depression. Module 1: Increasing Motivation and Readiness to Change Prior to beginning Module 1, Eleanor completed an introductory treatment session. In that session, the therapist provided her with an introduction to the treatment program, including the primary treatment components, and reviewed her presenting difficulties while discussing the treatment model. The therapist also introduced the use of routine monitoring of progress during treatment using the self-report Overall Anxiety Severity and Impairment Scale (OASIS; Norman et al., 2006) and the Overall Depression Severity and Impairment Scale (ODSIS; Bentley et al., 2014). Weekly scores from these scales are presented in Figure 24.1. FIGURE 24.1. Change in Weekly Depression and Anxiety Symptom Scores During

Treatment

Note. All scores represent raw total scores. ODSIS = Overall Depression Severity and Impairment Scale (range = 0–20; clinical cut off = 8; Bentley et al., 2014); OASIS = Overall Anxiety Severity and Impairment Scale (range = 0–20; clinical cut off = 7; Norman et al., 2006).

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Following this introductory session, the therapist presented Eleanor with Module 1 of the UP. Module 1, which is typically conducted in one session, aims to foster and enhance motivation. This module was incorporated into the UP based on research conducted by Westra and her colleagues illustrating the efficacy of such techniques as an adjunct in the treatment of anxiety disorders (Westra & Dozois, 2006; Westra et al., 2009) and includes two exercises commonly used in motivational interviewing (Miller & Rollnick, 2002, 2012) to reduce ambivalence regarding treatment and to increase self-efficacy. During this module, the therapist worked with Eleanor to develop specific treatment goals based on information gathered during the initial treatment session. Eleanor initially identified a primary goal to “feel less anxious” by the end of treatment. In light of the distress patients often feel about their anxiety, and other intense emotions, this is not an uncommon goal. However, as the UP emphasizes an increased tolerance of emotion, we typically try to help patients reframe this goal to be more in line with the treatment model. In this case, while the therapist validated Eleanor’s desire to reduce feelings of anxiety, it was determined that this desired endpoint would be better achieved by focusing on increasing tolerance of emotions and changing associated avoidance behaviors, such as procrastination (particularly at work), worry, and a tendency for Eleanor to withdraw from her partner when feeling upset or hurt. Following this discussion, the therapist asked Eleanor to complete an in-session exercise to explore the potential “pros” and “cons” of change (and staying the same) during treatment. She noted that reducing her tendency to worry (and some of the physical symptoms associated) would improve her relationship with her partner and make her day-to-day life “easier” and “less stressful.” Further, she noted that she would perform better at her job, as she often avoided daily tasks that elicited anxiety (e.g., responding to emails, finishing required documentation and clinical reports), and would feel better about herself and “more in control” of her life. Regarding the potential “cons” of change, which even motivated patients often find more difficult to identify, she noted concerns that others might expect more from her if she were not as anxious as she is now and that she might ultimately be asked to take on more responsibility at her job (if she were more productive), the thought of which she described as “overwhelming.” Module 2: Understanding Emotions The overarching goal of Module 2, which is typically conducted in one to two sessions, is for the patient to develop greater awareness of emotions as they occur. This is done through psychoeducation, emphasizing several key points, namely that emotions are adaptive, that they are made of three interacting components (i.e., thoughts, physical sensations, and behaviors), and that emotions are shaped by antecedents and consequences. In this module, the therapist used a didactic but interactive approach to help Eleanor grasp the idea that emotions are innate, normal processes that are often helpful and adaptive to



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her daily life. To communicate this, the therapist listed each core emotion and Socratically solicited from Eleanor what she thought was the function of each of these emotions. For example, Eleanor described escape as the function of fear and felt that anxiety might help her focus and be more aware of her surroundings. Next, the therapist reviewed the three-component model of emotions and helped Eleanor to identify the antecedents and consequences of an emotional response. The therapist utilized an example from Eleanor’s own life that she brought up at the beginning of the session in which she was feeling overwhelmed while shopping at the mall with her partner and felt a strong urge to escape the situation. Understanding the antecedents, responses, and consequence (what we have dubbed the “ARC”) of emotions is depicted in the following exchange between Eleanor and her therapist: THERAPIST: For example, say you left the store, just left all the items. How do

you think you would have felt right as you left the store? ELEANOR:

I would have felt like I was stupid, I would have felt like, “Why can’t you manage?” It would have turned into just beating myself up.

THERAPIST: I see . . . in the parking lot you would’ve felt embarrassed and

bad, but what about right as you were escaping, right after you walked out of those doors? ELEANOR:

Um—

THERAPIST: Right as you were getting out of that crowded store, or even

right as you made that decision— ELEANOR:

I probably would’ve felt some relief.

THERAPIST: Right. ELEANOR:

It would’ve been like, “Whew!” but then I would’ve have been like, “Why did you just leave the store?”

The therapist and Eleanor continued discussing the short- and long-term consequences of engaging in the escape behavior, and the therapist emphasized that that immediate feeling of relief as soon as she made the decision to leave the store is what reinforces the unhelpful responses to her emotions, in this case, feelings of anxiety and fear. The therapist continued: THERAPIST: In general, avoidance and escape make it harder the next time.

Every time you engage in those behaviors you sort of validate the initial level of emotion you were feeling. It’s like telling yourself, “Whew! Barely made it out of that mall alive.” ELEANOR:

[laughs]

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THERAPIST: Right? Like you would have really passed out there in the mid-

dle of the Gap. You know? ELEANOR:

Right. Yeah.

THERAPIST:

And sometimes it really does feel that way; you feel like it’s going to happen. But every time you run away, or do something else to feel stop feeling your emotions, you’re just telling yourself that you barely made it out of there and that if you had stayed, it wasn’t going to end well.

ELEANOR:

Yeah, that’s true.

The therapist continued to explain the potential role of negative reinforcement in the maintenance of the emotional response. She also drove the point home by stating that even though Eleanor is very smart and highly motivated to change, this pattern of responding is the reason why she continues to feel anxiety and what they will be targeting in treatment, which resonated with the patient. Module 3: Present-Focused Awareness Deficits in mindfulness occur across emotional disorders (Baer et al., 2006; Brown & Ryan, 2003; Cash & Whittingham, 2010; Rasmussen & Pidgeon, 2011). The goal of Module 3 (the first core module), which is typically conducted in one to two sessions, is to address these deficits by helping Eleanor increase present-focused attention to her emotional experiences in context, as they are happening in a given moment (i.e., mindfulness). The other main component of this module is an emphasis on developing a nonjudgmental stance toward emotional experiences by increasing understanding of emotional processes, recognizing that we often have negative emotions in response to emotions that are already there, which often exacerbates the experience (e.g., scolding oneself for feeling anxious in a social situation). Additionally, judging emotions to be harmful or problematic increases the desire to avoid them, leading to behaviors that ultimately backfire and contribute to maintenance of the emotional response in the long term. Although Eleanor seemed to understand this at a conceptual level, she had some difficulty with the nonjudgmental component of mindfulness, as illustrated below: THERAPIST: The second piece is what’s sometimes harder—which is, non-

judgmental emotion awareness. And that’s where you say to yourself, “It’s okay that I’m feeling the way that I’m feeling.” ELEANOR:

But it’s not okay because I shouldn’t be feeling that way.

THERAPIST: It’s not always rational—that’s true. ELEANOR:

You’re right.



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THERAPIST: But how does it help you in the moment to say, “That feeling is

not okay”? That’s part of this problematic response that you get. That “that feeling is not okay” response is what leads to avoidance and escape. ELEANOR:

Mhm

THERAPIST: Trying to stuff down your feelings, suppress them, deny them. It

doesn’t resolve anything. ELEANOR:

Yeah.

THERAPIST: So while it’s true that a lot of your emotions are in proportion to

what is happening in reality, and in that way they’re maladaptive in the long run—but we need to start cultivating an idea of “it’s okay, it’s okay to have anxiety in the grocery store, even though most people don’t. It’s okay.” To practice present-focused, nonjudgmental awareness, the therapist led Eleanor through a guided mindful meditation exercise in which she was encouraged to notice her physical sensations, thoughts, and behaviors, without doing anything to escape or change her emotional experience. Following the practice, she and the therapist discussed her reaction to the exercise: ELEANOR:

It was fine until we got past the sounds part, and it was like, “I’m ready for this to be over with.”

THERAPIST: Okay, so you noticed yourself getting impatient with it, toward

the end. ELEANOR:

But yeah, the rest of it was good. Yeah, like focusing on the breathing, and the sensations, and I kept having an itch and I was like, looking at the itch like, “Stop it, stop it.”

THERAPIST: Did you try to focus your attention on the itch? ELEANOR:

Yeah, I was like, “You’re not itching, you’re not itching.” But then I was itching. [itches self]

THERAPIST: Oh, well see, it’s not about trying to change it, right? ELEANOR:

Right.

THERAPIST: It’s just about noticing it, and really trying to like, experience

it . . . what does that itch feel like exactly? Where does it extend to on my hand? The therapist continued, asking Eleanor about her experience with thoughts (e.g., “I’m ready for this to be over with”) and behaviors and gathered ratings on the experience and how effective she was at being present and nonjudgmental. The therapist sent the recorded audio from the meditation to the

714  Farchione, Tirpak, and Olesnycky

patient over email and assigned continued practice over the course of the week. The following session, the corresponding skill anchoring in the present was taught. Here, Eleanor was encouraged to use a cue (e.g., her breath) to direct her attention to the present moment and complete a “three-point check,” noticing her thoughts, physical sensations, and behaviors. Acknowledging that this can be a difficult task when feeling neutral, the therapist posited that anchoring can be that much more challenging when triggered by a strong emotion. To practice anchoring when feeling a strong emotion, Eleanor was asked for homework to identify a song that typically evokes an emotional reaction. Using this song, the therapist facilitated a musical mood induction in-session, playing the song and instructing Eleanor to notice her thoughts, physical sensations, and behaviors. Eleanor identified that she felt nostalgic and reflective and had thoughts about how the lyrics of the song reminded her of different parts of her life. As her emotional reaction was largely positive, the therapist expressed that it would be good practice to try the musical mood induction with a song that brings up negative emotions for homework. Of note, at this point in treatment, Eleanor remarked that she noticed that she was starting to feel better and that even though her depressive and anxiety scores had been up and down, she was feeling better able to tolerate strong emotions. Module 4: Cognitive Flexibility The primary purpose of Module 4 (the second core module), which is typically conducted over one to two sessions, is to address pessimistic, negative, and, most importantly, very rigid and automatic appraisals common to the emotional disorders by encouraging flexible thinking using principles originated by Beck (1976) and modified in our setting over the decades (e.g., Craske & Barlow, 1988). The concept of automatic appraisals was introduced to Eleanor, and the reciprocal association between thoughts and emotions was highlighted. The therapist presented her with an illustrated picture from the UP Client Workbook depicting a scene of a young female in a hospital bed and two other individuals, one male and one female, in the doorway hugging. Eleanor was asked to examine the picture and describe what was happening. THERAPIST: We’re going to do a little exercise. [hands Eleanor the picture]

Tell me, when you look at this picture, what do you think is going on? ELEANOR:

That someone is either sick or dead and that an older woman is being comforted by a younger man.

THERAPIST: So when you think of that, that the woman is dead, how does it

make you feel? ELEANOR:

It makes me feel sad. It’s a pretty depressing scene.

THERAPIST: Now, is there anything else that might be going on there? Maybe

there’s another way to think about it?



The Unified Protocol  715 ELEANOR:

Yeah, I guess she might’ve had a liver transplant that saved her life. And these other two [pointing to the image of the man and older woman] might be hugging out of celebration and relief. I guess also she might’ve just had a baby and that’s the father [pointing to the image of the man].

THERAPIST: It’s true. And when you interpret it that way, I imagine you feel

different than before. ELEANOR:

Yeah, I feel sort of hopeful, I suppose. Definitely not sad.

Following this exercise, the therapist went on to discuss the importance of thoughts as one of the primary components of the emotional response (in line with a prior treatment module) and introduced the concept of cognitive flexibility, the act of generating alternative interpretations and outcomes for a given situation. During this module, the therapist also introduced two primary thinking traps (or cognitive distortions) that appear common to the emotional disorders—jumping to conclusions (i.e., overestimating the probability of a particular outcome) and thinking the worst (i.e., assuming that the worst possible outcome is going to happen and we will be unable to cope). The patient was able to provide examples of thoughts that would fall into each of these categories, or both, including several specific thoughts regarding the emotions themselves, such as “I shouldn’t feel like this” and, in relation to her partner, that her anxiety “will push him away.” The therapist then focused on helping Eleanor utilize the challenging questions provided in the UP workbook to reevaluate her thinking patterns, with the goal of increasing flexibility in thinking. She struggled at first with applying this skill, especially to thoughts related to feelings of insecurity in her marriage, but she was able to apply the skill more effectively as treatment progressed. Module 5: Changing Emotional Behaviors Individuals with anxiety and depressive disorders report high levels of experiential avoidance (Begotka et al., 2004; Berking et al., 2009; Kashdan et al., 2010; Shahar & Herr, 2011) and tend to overutilize unhelpful emotion regulation strategies, such as emotion suppression, worry, and rumination. Module 5 (the third core module), which is typically conducted over one to two sessions, focuses on identifying and changing maladaptive patterns of emotional responding. This includes behaviors designed to avoid intense or uncomfortable emotions and what we have referred to as emotion-driven behaviors, or behaviors that tend to occur in response to an emotion that has been triggered. At the beginning of this module, the therapist worked with Eleanor to identify maladaptive behavioral patterns of emotional responding. She reported avoiding energy drinks because they “make [her] jittery” and crowded situations such as “riding the train at rush hour.” Further, she noted that when feeling anxious, she tries to use “deep breathing” to calm herself down, as described in

716  Farchione, Tirpak, and Olesnycky

the clinical vignette below. Although deep breathing may not be a maladaptive behavior in and of itself, and can be effectively used to mitigate stress and anxiety, in this case, both Eleanor and the therapist recognized that the function of the behavior was primarily to suppress her emotions when feeling anxious and overwhelmed and, as such, was seen as being maladaptive. In contrast, deep breathing could be more adaptively used to anchor oneself in the present, consistent with Module 3. ELEANOR:

I try to remember to do deep breathing when I’m feeling stressed and overstimulated. It doesn’t work though.

THERAPIST: That’s a common strategy people use to try to force themselves

to calm down in situations. But the approach we try to take is to say you don’t need to help yourself calm down . . . you don’t need to do anything about your emotions. You can treat them like a little wave . . . or big wave sometimes . . . they happen and then resolve. ELEANOR:

But what if my emotions get out of control? Sometimes I just feel out of control. I’m like, “I can’t do this. What if I panic while I’m driving?” It feels like I want to jump out of my skin.

THERAPIST: Yes, and you know what, that can be really hard. When you’re

feeling a strong emotion, we want you to take a step back and notice it. It’s important to recognize that you can have that strong desire to do something but not actually do it. You can have that feeling and say, “Okay, that feeling is there and it’s strong, but I don’t need to do anything about that feeling . . . I can continue to do what I need to be doing and that feeling will eventually pass and go away . . . and I don’t need to try to make it go away or get rid of it,” you know, by leaving the room or anything like that. ELEANOR:

My concern with that . . . there’s times when I’m so activated I don’t think I can do anything. My heart beats fast . . . and I feel like I have to stop what I’m feeling.

THERAPIST: Don’t worry, we’ll work on learning to tolerate those feelings in

the coming weeks. Eleanor reported many other emotional behaviors, including distraction (playing games on her phone), “zoning out,” watching television, and drinking alcohol. Regarding the latter, she noted drinking more frequently when feeling stressed or anxious and admitted that there have been past periods of daily drinking during times when she was feeling “really anxious.” She described this behavior as a way to “numb out” her feelings. Through this module, the therapist helped Eleanor develop a greater appreciation for how her emotional behaviors can be helpful under certain circum-



The Unified Protocol  717

stances but can also serve to maintain the emotional response in the long term. Engaging in avoidance and escape behaviors prevent the patient from challenging anxious and negative thoughts about the situation and essentially eliminating the possibility of acquiring corrective information or feedback regarding the situation or (very importantly) the emotions and the patient’s ability to tolerate them. Also, because the behaviors often have reinforcing consequences in the short-term (by avoiding or reducing intense emotion), it can be difficult for patients to engage in an alternative (and possibly more adaptive) behavior when a similar situation arises in the future. The end of the module focuses on changing maladaptive emotional behaviors. In this case, the therapist asked Eleanor to take an “approach-oriented style” and to “lean into” her emotions, as reflected in the following exchange: THERAPIST: Can you imagine going into a situation thinking, “If I’m scared,

I’m scared . . . being scared isn’t the end of the world”? ELEANOR:

Yeah [laughing], depending on the situation.

THERAPIST:

Right, but it would feel very different. It’s like taking away all the power. As soon as you don’t care whether you’re afraid or not, like genuinely don’t care, then the fear is suddenly so much less.

ELEANOR:

You’re right.

THERAPIST: It doesn’t work to try to hold off emotions. So what we want

instead is to take this approach where we think, “I want to do what I want to do and be engaged fully in the situation, and if that means feeling strong emotions then I can handle that . . . I know I can.” So instead of going into the situation kind of halfway and cringing and not really looking, you just go in saying, “Alright, here I am . . . go ahead, let’s feel what I’m going to feel.” The emotion will come, it’ll be what it is . . . but I bet it would be less than what you’re worried it will be. ELEANOR:

Yeah, that’s true.

THERAPIST: You just let it in and say “whatever,” be with the emotion and

allow it to decrease naturally with time. ELEANOR:

No, you’re right, because when I was taking my licensing exam, I was freaking out . . . didn’t sleep the night before. And I remember that I sat down and my friend had told me to just smile at the test . . . just smile at it. I felt really stupid but I did that, I smiled at it. And I felt better. I was like, “Okay, let’s do this . . . show me what you got.” And I ended up doing much better than I thought I would and scored way above what I needed. But I let myself be like, “Okay, you’re really, really scared right now . . . and that’s okay.” It’s kind of like that whole “feel the fear but do it anyway” thing.

718  Farchione, Tirpak, and Olesnycky THERAPIST: Exactly. It’s the ability to be understanding of our emotions but

at the same time say, “You’re not the boss of me. I’m in control here.” Now we may not be in control of our emotions sometimes, or at least they can be more intense than we would like them to be. But if we can see the emotion, as it unfolds, we get to decide how we’re going to respond. We choose how we want to act. Eleanor was also instructed to engage in opposite or alternative actions in response to her typical emotion-driven behaviors. As an example, Eleanor reported that when she feels upset or angry, she struggles with waiting for her partner to call or respond to her texts or phone calls. As a result, she described texting him “a million times” and calling him repeatedly until he responds. In this case, the alternative action that Eleanor identified was to wait until he responds even if she has to shut off her phone for a period of time. The idea here is that Eleanor may initially experience a strong emotional reaction by restricting the maladaptive behavior; however, over time, and with further practice adopting the new behavior, the frequency and intensity of the emotion will diminish. Module 6: Awareness and Tolerance of Physical Sensations Another transdiagnostic construct that has been identified as a factor in the development of emotional disorders is anxiety sensitivity, which refers to the tendency to believe that symptoms of anxiety and fear will have negative consequences (Reiss, 1991). Although anxiety sensitivity has primarily been studied in the context of panic disorder with agoraphobia (e.g., Maller & Reiss, 1992; Plehn & Peterson, 2002; Rassovsky et al., 2000), research has shown that it also is associated with other anxiety and depressive disorders (Boettcher et al., 2016; Boswell et al., 2013; Naragon-Gainey, 2010; Taylor, 1999). The overarching goal of Module 6 (the fourth core module), which is typically conducted in one session, is to increase patients’ awareness of the role physical sensations play in their experience of emotion and increase their tolerance of those physical sensations so that they learn that even while having strong physical sensations, they can tolerate the feelings without needing to respond by changing their experience in any way. The module begins with a discussion on the interaction between physical sensations and other components of the emotional response and the rationale for gaining greater tolerance of uncomfortable physical sensations. THERAPIST: Physical sensations can contribute to the intensity and the dura-

tion of an emotional experience that you’re having because you react to them, you make predictions based on them: “Oh my heart is racing, oh my God, maybe I’m going to have a heart attack!” or “This is going to get worse and be like the last time



The Unified Protocol  719

when x, y, z happened.” Physical sensations get all caught up in the spiral of emotions. ELEANOR:

Definitely.

THERAPIST: So essentially what we want to do is separate the actual physical

component of physiological arousal (which does happen—it’s not all in your head that your palms are sweating or your heart is beating; that really happens) from the negative thoughts and interpretations in reaction to them. ELEANOR:

Right.

THERAPIST:

We want you to be able to observe them like any other thing you observe in your body.

The therapist continued, providing the following example: THERAPIST: If you wake up with your shoulders sore after doing rigorous

yoga the night before, you don’t think anything more about that other than just like, “Oh, I can feel that my shoulder is sore”— that’s the level that it stays at. Versus, when you’re already anxious and in the middle of the grocery store and your heart starts to pound and you start to have thoughts like, “I can’t handle this,” “This is only going to get worse,” “I need to get out of here,” or “I have to stop this feeling.” ELEANOR:

Hmm, hmm okay.

THERAPIST: We want you to be able to view that heart pounding just the

same as your shoulder: “Oh, I notice my heart is beating fast. Cool. I can deal with this. I can be where I need to be. I’ve dealt with this before. And it’s fine.” [THERAPIST PAUSES] THERAPIST: I know, much easier said than done. ELEANOR:

No . . . I can see how that can be helpful. I actually did that this past week. I was having a bad night, just frustrated with everything, life . . . and was having difficulty breathing. My chest was starting to feel tight, and I was like, “Okay, you’re having difficulty breathing. You’ve had this before. This could turn into a panic attack, it could not. But either way, you’re not gonna die. You’re gonna be fine.” And I honestly was like, “Don’t judge the fact that your heart is beating fast. You’re lying in bed, watching a comedy. And your heart is racing out of chest. That’s fine, all good.”

THERAPIST: Absolutely!

720  Farchione, Tirpak, and Olesnycky ELEANOR:

And then it took a little bit, I think maybe it’s because I was paying attention to it more. I wanted to see how long it was going to take before this actually goes away. It made it much more bearable though. It was still annoying, but it wasn’t like, “Oh my God! I need to take an Ativan.” It wasn’t this overwhelming “taking over” thing.

THERAPIST:

Perfect. Yes, that’s exactly right! It’s like you’re reading my mind.

After providing this rationale, the therapist asked Eleanor to complete many different in-session exercises (e.g., breathing through a thin straw, hyperventilation, spinning in circles, running in place) designed to induce physical symptoms most often associated with her intense emotions (i.e., interoceptive exposures). The therapist demonstrated each exercise to ensure that it would be completed correctly and to model tolerance of the physical sensations. After each exercise, the therapist helped Eleanor assess the similarity of the symptominduction exercise to the physical sensations she normally experiences during strong emotional reactions, including panic attacks, as well as the distress produced by the exercise. On the basis of data collected from these exercises, the therapist worked with Eleanor to identify which exercises would be helpful to be repeated (i.e., those that were most similar and distressing) for homework and potentially used in combination with other emotion exposures during Module 7. Module 7: Emotion Exposures Module 7 (the fifth and final core module), which typically occurs over two to four sessions, focuses on exposure to internal (i.e., physical sensations, thoughts) and external situations that the patient is avoiding because of their association with, or tendency to elicit, strong emotions. Given the transdiagnostic nature of the UP, any strong emotion/emotional-eliciting situation (which could be a combination of situational, imaginal and interoceptive exposures) can be added to the hierarchy. For example, a patient with comorbid social anxiety disorder and generalized anxiety disorder could have one exposure focused on participating in class and another exposure to begin work on the day it is assigned rather than procrastinating. Positive emotions can be included as doing something kind for oneself (e.g., pampering, self-care) but can also be distressing for some patients. The emotion exposure provides patients with an opportunity to combine and practice all the skills they learned in treatment (e.g., anchoring in the present, cognitive flexibility, countering emotion-driven behaviors) with the aim of allowing the patient to (a) test hypotheses about what will happen if they experience strong emotions and (b) help them learn that they are in fact capable of tolerating strong emotions without engaging in avoidance or other unhelpful action tendencies. During the first session of this module, the therapist worked collaboratively with Eleanor to develop a hierarchy of situations that bring on strong emotions.



The Unified Protocol  721

Eleanor identified many situations that she anticipated would elicit strong emotions, including grocery stores, going to the mall, driving in heavy traffic, meeting with her supervisor, speaking with her partner about (problems with) their relationship, being at home alone (or traveling alone) for several days, and going to the dentist. In subsequent sessions, the therapist reviewed the exposures Eleanor completed between sessions and then completed in-session exposures to assist her with the application of treatment skills, including walking through a crowded downtown area, staying in a confined space while feeling panicky, and riding a crowded subway train. Eleanor also completed many exposures for homework, such as going to the dentist, shopping in a crowded mall, and meeting new people through meetup groups. Throughout this module, the therapist asked Eleanor to gradually increase the level of difficulty of the exposures by moving up the hierarchy and by further reducing patterns of avoidance. Early in this module, Eleanor struggled with reducing patterns of emotion avoidance during the exposures. For instance, in one exposure in which she went shopping in a crowded mall, Eleanor used breathing and distraction as a way to feel less uncomfortable. Also, she noted that the exposure was not successful because she was unable to reduce her anxiety as she had hoped and, as a result, was forced to leave the mall before the exposure was completed. In this case, the therapist reminded Eleanor that the focus of the exposures was not on reducing the intensity of what she felt or on suppressing the emotional response, but rather on increasing tolerance of her intense emotions while responding in more goal-directed, adaptive ways: ELEANOR:

I just couldn’t calm myself down. I had to get out of there.

THERAPIST: I’m glad you mentioned that. Remember that the goal is not

necessarily to be calm during these, and it’s okay if you never get to that point. It’s okay if you’re anxious and uncomfortable and get through it. But as long as you’re in that mode of like, “I’m accepting that I’m anxious and uncomfortable.” Not like white knuckling through it. ELEANOR:

Right . . . right.

THERAPIST: But, you know, don’t try to force your anxiety down by deep

breathing or that kind of thing. You can check in with yourself and say, “Okay, all that’s happening is that I’m right here in the mall.” ELEANOR:

Right.

THERAPIST: But if in your head you’re thinking “I’m totally freaking out

because there’s all these people . . . I need to calm down,” my sense is that may actually make things worse for you. Maybe you could just think, “I’m feeling anxious right now but I can stay here.” Your brain is screaming “Ahhh, you need to leave,” but maybe instead you can just take your brain along for a ride.

722  Farchione, Tirpak, and Olesnycky

However, as Eleanor completed more exposures, both for homework and during treatment sessions, she noted a greater ability to tolerate her emotions and demonstrated an ability to engage in more adaptive patterns of emotional responding. In the following vignette, Eleanor describes a planned exposure to the dentist for a much overdue check-up that resulted in a more anxietyprovoking situation involving a surgical procedure: ELEANOR:

I went to the dentist.

THERAPIST: That’s terrific news. What happened? ELEANOR:

Well, you know, I was supposed to just have a consultation, but then they sent me to the emergency clinic. So I see this guy there and he says that I have two teeth that have to come out. So I’m like, “Can I have some nitrous . . . I just need something to get me out of this space.”

THERAPIST: Uh huh. ELEANOR:

And then I’m like, “Wait a minute . . . what are your tools?”

THERAPIST: That’s great. I’m so impressed. ELEANOR:

So I’m like, okay, “I’m at the dentist . . . you do not like the dentist . . . but why don’t you like the dentist? It’s because you had negative experiences before. This is a completely new dentist and they do this all the time.” I was also concerned that I might not be numb. I had this urge to ask the doctor about it but I didn’t. I mean, I really wanted to [laughing]. But I said to myself, “No way . . . don’t do it.”

THERAPIST: Excellent! How did the actual procedure go? ELEANOR:

[laughing] I mean, it wasn’t fun. But I got through it. I remember the needle was coming at me and I’m like, “Okay . . . just relax . . . just accept the needle, welcome the needle.” I’m not sure if it really helped . . . I felt like I was going to jump out of the damn chair, but I just tried to stay in the moment.

Eleanor noted an urge to engage in several emotional behaviors, such as reassurance seeking, conveying her fear to others, and stopping the doctor to “take a break,” but, instead, she chose to be mindful during the experience, focus on her breathing, and allow the doctor to complete the procedure. This new, more adaptive pattern of responding was evident in several other exposures she completed as treatment progressed. Over the course of this module, Eleanor demonstrated greater tolerance of her emotional response and noticed a reduction in her anticipatory distress as a result. Further, she reported less anxiety in the situations she confronted even though she continued to eliminate avoidance behaviors.



The Unified Protocol  723

Module 8: Review and Relapse Prevention The final module of the UP, which is typically conducted in one session, focuses on reviewing skills learned in treatment, identifying and troubleshooting common or potential triggers, and promoting skill generalization for preventing relapse. At the start of the module, while discussing an exposure Eleanor had completed since the last session, she recognized her improvement in therapy, stating, “I’m cured. I honestly feel like a completely different person. It just has me thinking about everything differently . . . I’ve really pushed myself to do stuff I have not wanted to do.” The therapist shared with Eleanor a copy of her original fear and avoidance hierarchy from earlier in treatment, without showing the distress/avoidance rating, and asked her to rerate her current distress and avoidance of each item. Afterward, she showed Eleanor her previous ratings and had her compare the two. In looking at this juxtaposition, Eleanor was surprised by the gains she had made in treatment and reported feeling good about her accomplishments. In reviewing the skills learned during treatment, Eleanor stated, “I think that the emotion awareness was the most important component for me. I’ve noticed that the reason why I’m so tired all the time is that I was always worried. Even little stuff, and I think, why are you worried about that? It doesn’t really matter. Or, it’s not that big a deal. That was huge for me. And also the emotion-driven behaviors, like, recognizing things that I do to that reinforce my anxiety, even my responses to others’ actions.” Eleanor added that she had become increasingly aware of her physical sensations, and she remarked that she realized now that “it will pass.” She also noted that treatment provided her with new confidence: “Well when you haven’t felt powerful in a long time, that’s awful. And then to realize that in a short amount of time . . . you can really turn that around . . . Looking ahead, you have confidence that when something comes up, you can deal with it . . . It’s just a change in my perspective about everything.” Following a review of treatment skills, the therapist helped Eleanor to articulate long-term goals. Eleanor wanted to work on developing stronger relationships with her friends, spend more time socializing with coworkers, and travel more with her partner. Eleanor expressed conviction she could achieve these goals without being in therapy, but she acknowledged, “It’s going to be weird not to be in therapy.” Here, the therapist encouraged her to take on the role of “being her own therapist” and suggested weekly assessment check-ins with herself about anxiety symptoms and avoidance behaviors and/or asking herself what a therapist might say in a given situation. Finally, the therapist worked with Eleanor to identify upcoming triggers and warning signs of worsening symptoms. Eleanor remarked that one warning sign is if she finds herself isolating from friends or noticing anxiety symptoms becoming more frequent and more severe, in which case she may reach out for a booster session.

724  Farchione, Tirpak, and Olesnycky

Outcomes Eleanor responded well to treatment and experienced marked decreases in diagnostic severity across all disorders, as well as improved psychosocial functioning (see Tables 24.1 and 24.2). These improvements were reflected in her scores on both self-report and clinician-administered measures. Scores on the ODSIS and OASIS, which are administered weekly as part of the treatment protocol, fluctuated slightly during treatment but overall evidenced a gradual decline. Scores on both measures were below clinical cut-offs by the end of treatment (Bentley et al., 2014; Norman et al., 2006; see Figure 24.1). These self-report ratings were corroborated by changes on the clinician-administered HAM-A (Hamilton, 1959) and HAM-D rating scales (Hamilton, 1960), which also reduced to normal levels at posttreatment. On the ADIS-IV, clinician ratings of diagnostic severity were in the subclinical range for the principal generalized anxiety disorder diagnosis as well as comorbid diagnoses. This indicates that at the end of treatment Eleanor did not meet criteria for any DSM-IV diagnosis. In addition, her frequency of negative affect decreased and frequency of positive affect increased over the course of treatment, as evidenced by changes on the Positive and Negative Affect Scales (PANAS). Her score on the Anxiety Sensitivity Index (ASI), a measure of the tendency to fear the somatic and cognitive symptoms of anxiety, also reduced considerably during treatment. Finally, she reported an increase in quality of life, as measured by the Quality of Life Scale (QOLS). Improvement on all measures was generally maintained during the follow-up period. Though scores on the HAM-A and HAM-D were slightly higher at a 12-month follow-up and she reported a slight decrease in her overall well-being, this was not reflected in clinician ratings of diagnostic severity on the ADIS-IV or on measures of positive and negative affect, which actually continued to improve slightly over time. Functionally, Eleanor was able to meet many of her treatment goals. She worked hard to challenge patterns of avoidance at work. Specifically, she reduced her tendency to procrastinate at work and began returning phone calls and replying to emails more quickly and consistently. This change in her behavior was recognized by other coworkers as well as her supervisor. She also demonstrated improvement in her ability to prioritize tasks at work; she would intentionally address the most important work first, as opposed to putting it off until last, even though it caused her to feel more anxious and overwhelmed. Her supervisor also complimented her on several occasions for taking the lead on work-related projects. She noted some improvements in her marriage as well. Specifically, she noted feeling less upset and angry with her partner and noted greater intimacy between them. It is also worth noting that Eleanor discontinued her medication during the course of treatment.

CONCLUSION AND FUTURE DIRECTIONS In this chapter, we presented a case study illustrating the application of the UP with a patient presenting with comorbid DSM-IV anxiety and depressive disor-



The Unified Protocol  725

ders. Consistent with existing research supporting the efficacy of this protocol, treatment was effective in simultaneously addressing Eleanor’s presenting difficulties, as evidenced by a reduction in disorder-related symptoms and functional impairment as well as improvement on underlying factors that appear to be important to the development and maintenance of emotional disorders, namely negative affectivity and anxiety sensitivity. The UP has gained empirical support as an evidence-based, transdiagnostic, cognitive-behavioral treatment for a range of emotional disorders, and recent evidence suggests equivalency between UP and single-disorder protocols (Barlow, Farchione, Bullis, et al., 2017). The UP is also able to be delivered in a group format (Bullis et al., 2015), which may further increase implementation feasibility while reaching the most people in need. Further, there is research suggesting acceptability, feasibility, and preliminary efficacy of the UP in other countries, including Japan (Ito et al., 2016), Denmark (Reinholt et al., 2017), and Spain (Osma et al., 2015). Recently, CastroCamacho et al. (in press) also completed a cultural adaption of the UP to treat the severe emotional difficulties experienced by victims of the armed conflict in Colombia. Further evaluation of these cultural adaptations and the UP’s effectiveness in different clinical settings and across more diverse patient populations is needed. The UP, with its focus on addressing shared mechanisms associated with neuroticism (i.e., negative evaluation and avoidance of intense emotional experience), has the potential to simplify training efforts while also addressing concerns about generalizability to routine care settings. Addressing these current barriers to widespread dissemination and implementation of EBPTs (McHugh & Barlow, 2010; Kazdin & Blase, 2011) has implications for bridging the science-to-service gap. Ultimately, we hope that the UP and other transdiagnostic approaches to treatment will increase the availability of EBPTs to those in need.

REFERENCES Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome. Journal of Psychopathology and Behavioral Assessment, 32(2), 185–192. https://doi.org/10.1007/s10862-0099151-3 Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using selfreport assessment methods to explore facets of mindfulness. Assessment, 13(1), 27– 45. https://doi.org/10.1177/1073191105283504 Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). Guilford Press. Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., SauerZavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74(9), 875–884. https://doi.org/10.1001/jamapsychiatry.2017.2164

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Barlow, D., Farchione, T., Fairholme, C., Ellard, K., Boisseau, C., Allen, L., & Ehrenreich May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide (1st ed.). Oxford University Press Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Murray-Latin, H., Ellard, K. K., & Bullis, J. R., Bentley, K., Boettcher, H., & Cassiello-Robbins, C. (2017). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide (2nd ed.). Oxford University Press. Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365. https://doi.org/10.1177/2167702613505532 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press, Inc. Begotka, A. M., Woods, D. W., & Wetterneck, C. T. (2004). The relationship between experiential avoidance and the severity of trichotillomania in a nonreferred sample. Journal of Behavior Therapy and Experimental Psychiatry, 35(1), 17–24. https://doi.org/ 10.1016/j.jbtep.2004.02.001 Bentley, K. H., Gallagher, M. W., Carl, J. R., & Barlow, D. H. (2014). Development and validation of the Overall Depression Severity and Impairment Scale. Psychological Assessment, 26(3), 815–830. https://doi.org/10.1037/a0036216 Berking, M., Neacsiu, A., Comtois, K. A., & Linehan, M. M. (2009). The impact of experiential avoidance on the reduction of depression in treatment for borderline personality disorder. Behaviour Research and Therapy, 47(8), 663–670. https://doi. org/10.1016/j.brat.2009.04.011 Boettcher, H., Brake, C. A., & Barlow, D. H. (2016). Origins and outlook of interoceptive exposure. Journal of Behavior Therapy and Experimental Psychiatry, 53, 41–51. https://doi.org/10.1016/j.jbtep.2015.10.009 Borkovec, T. D., Abel, J. L., & Newman, H. (1995). Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 63(3), 479–483. https://doi.org/10.1037/0022-006X.63.3.479 Boswell, J. F., Anderson, L. M., & Barlow, D. H. (2014). An idiographic analysis of change processes in the unified transdiagnostic treatment of depression. Journal of Consulting and Clinical Psychology, 82(6), 1060–1071. https://doi.org/10.1037/ a0037403 Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W., Fortune, M. R., & Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior Therapy, 44(3), 417–431. https://doi. org/10.1016/j.beth.2013.03.006 Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822– 848. https://doi.org/10.1037/0022-3514.84.4.822 Brown, T. A. (2007). Temporal course and structural relationships among dimensions of temperament and DSM-IV anxiety and mood disorder constructs. Journal of Abnormal Psychology, 116(2), 313–328. https://doi.org/10.1037/0021-843X.116.2.313 Brown, T. A., & Barlow, D. H. (2009). A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: Implications for assessment and treatment. Psychological Assessment, 21(3), 256–271. https://doi.org/10.1037/a0016608 Brown, T.A., & Barlow, D.H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5-Lifetime Version. Oxford University Press. Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4), 585–599. https://doi. org/10.1037/0021-843X.110.4.585



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25 Contemporary Cognitive Behavioral Therapy Nikolaos Kazantzis, Hoang Kim Luong, Hayley M. McDonald, and Stefan G. Hofmann

I

n the 50 years that have passed since the development of cognitive therapy, now commonly referred to as cognitive behavioral therapy (CBT), we have witnessed a treatment for depression become widely adapted and tested for a range of clinical populations (A. T. Beck, 1963, 1964, 1967/1970, 1974, 1976; A. T. Beck et al., 1979; A. T. Beck & Shaw, 1977; Rush & A. T. Beck, 1978; Shaw & A. T. Beck, 1977; Dobson & Dobson, 2016). Central to the longevity of CBT is a clear undergirding theoretical framework that can be flexibly applied (see Kazantzis et al., 2010), as well as the commitment to its evaluation within randomized controlled trials and cutting edge studies (e.g., Bell et al., 2013; Cristea et al., 2015; Crits-Christoph et al., 2017; Garratt et al., 2007; Hundt et al., 2013; Lemmens et al., 2016; Lorenzo-Luaces et al., 2015; Webb et al., 2012).1 The current state of the evidence for CBT has been subject to scrutiny in many meta-analyses, which generally report favorable results for CBT. However, there is marked variability in the effect size estimates within disorder groupings (i.e., small to medium effects in Cooper et al., 2017; Cuijpers et al., 2014, 2016; Cusack et al., 2016; Hall et al., 2016; Harrison et al., 2016; Hofmann et al., 2017; Knouse et al., 2017; Li et al., 2017; Öst et al., 2015; Tolin et al., 2015; Weston et al., 2016). Well-conducted reviews of meta-analyses also provide a very helpful broad perspective on the outcome data (e.g., Crowe & McKay, 2017; Cuijpers, 2017; Hofmann et al., 2012). Although these findings support CBT's efficacy, the variability in treatment effects suggests that some Clinical examples are disguised to protect patient confidentiality.

1

https://doi.org/10.1037/0000218-025 Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor) Copyright © 2021 by the American Psychological Association. All rights reserved. Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  731 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

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clients respond quite differently from others. We argue that this is an artifact caused by the reliance on a latent disease model to describe human suffering. We return to this point below. On the basis of these strong outcome data supporting the modality’s efficacy, nationwide implementation of CBT in services within community settings have also been undertaken in different countries (U.S.: Wiltsey Stirman et al., 2009; U.K.: Department of Health, 2012; Health and Social Care Information Centre, 2017), which enable a greater proportion of the community to benefit from its empowering skill-focused approach. It is unquestionable that CBT has helped to alleviate human suffering in many countries. Increasingly, there is research interest in testing the mechanism by which CBT produces its effects, in particular whether etiological processes and insession processes serve as mediators. This moves the field away from basic questions of “What works for whom?” to the more clinically relevant questions of “What works for whom, under what contexts?” and “Why do treatments work?” For example, a recent review of meta-analyses found small to large effect sizes were obtained for modifying cognitive processes and appraisals, whereas large effect sizes were obtained for interventions of imagery rehearsal (see the review in Kazantzis et al., 2018). These findings support the identification and modification of cognitions as a primary change mechanism in CBT. Similarly, effect sizes ranged from small to large for exposure and response prevention in CBT for anxiety disorders, and the manner in which CBT was delivered (e.g., alliance and use of homework) showed robust relations with outcome (also Cuijpers et al., 2019).

CONTEMPORARY CBT As the evidence base for CBT has evolved, we have seen that most diagnoses reflect heterogeneous human experiences. For example, on the basis of selfreport data, a diagnostic label such as “depression” has been assigned to individuals with widely differing sets of problems that are assumed to be the independent expressions of one or more latent disease entities (Kazantzis & Hofmann, 2019). There is a similar problem with transdiagnostic protocols that attempt to reduce symptoms associated with two or more disorders because the “disorder” involves a definition of pathology involving an arbitrarily defined set of symptoms. This simplistic medical model has led to disappointing results (see review in Cuijpers, 2018; Huibers et al., 2020; Kazantzis & Hofmann, 2019). Most recently, complex network approaches offer an alternative and less restrictive model (Hofmann & Curtiss, 2018; Nelson et al., 2017). Accordingly, clinical presentations are viewed as a set of functionally interconnected problems that lead to suffering. This approach opens new opportunities for treatment, psychopathology, and nosology. In summary, contemporary CBT can be defined by its practice, involving (a)  identifying etiological processes of human suffering in assessment (e.g.,



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A. T. Beck & Bredemeier, 2016, for the unified theory of depression), (b) targeting those processes of etiology in technique use based on a functional analysis or cognitive conceptualization of those processes (Hayes & Hofmann, 2017; Kazantzis, 2018; Petrik et al., 2013), as well as (c) expanding the focus of therapeutic outcome to include whatever the client determines to be meaningful (e.g., enhanced quality of life, prosperity, posttraumatic growth, enhancement of positive emotional states). This is consistent with definitions of modern process-based CBT appearing in the literature (e.g., Hayes & Hofmann, 2017; Wenzel, 2017). Here, we have been asked to provide an overview of the distinctive practice elements of contemporary CBT as a resource for the practicing clinician. Many excellent chapters have already been published on the topic, and after acknowledging the evidence base, they usually begin with an outline of “misconceptions of CBT” before outlining the role of structured in-session process, including the integration of between-session practice tasks, also referred to as “homework” (see Kazantzis et al., 2005). We wanted to take a novel approach to bringing together latest advancements in theory and practice and in particular, the advancements to CBT practice. We represent a team of researchers associated with the Cognitive Behavior Therapy Research Unit (CBTRU) based at The Institute of Social Neuroscience. CBTRU draws together a group of local and international experts in CBT practice, training, and research who share a common goal of identifying and testing enhancements to CBT. Therefore, we are honored to make this contribution to this important volume on behalf of our group. In this chapter we will start with a clinical case study and present a comprehensive case conceptualization before outlining the treatment in that case, including both technique and process elements. At each point, we will introduce opportunities for contemporary and flexible practice—ways in which other clinicians may have supported the client to attain similar therapeutic goals. The goal here is to convey how change processes are embedded in the way techniques are used.

COMPREHENSIVE COGNITIVE CASE CONCEPTUALIZATION A variety of forms and formats of CBT conceptualization exist, which provides a cross-sectional on longitudinal perspective on etiological and maintaining factors of distress (Easden & Kazantzis, 2018). Terminology also varies, with some resources referring to a “formulation” that can be confused with diagnostic formulation as basic formulation (i.e., presenting, precipitating, perpetuating, predisposing, and protective factors). At the situation level, we conduct “functional analysis” of behavior and expand that basic behavioral view with attention to the content and process of cognition (Padesky & Mooney, 1990). This is similar to the “chain analysis” of a sequence of problematic situations that help provide insight into a series of situations within Linehan’s (1980) dialectical

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behavior therapy. Jacqueline Persons’s approach also emphasizes “the problem list,” which helps clients to list and prioritize current areas for change in the establishment of therapy goals (Persons, 1989, 2008). Turning to a more “comprehensive” or longitudinal case conceptualization, Judith Beck’s case conceptualization diagram encourages not only attention to multiple (at least three) problematic situations but also to key developmental experiences, core beliefs (i.e., absolute ideas about self, others, world, and the future), intermediate beliefs, assumptions, rules (i.e., cross-situational beliefs that guide behavior), and behavioral coping strategies (J. S. Beck, 2011). “Overdeveloped” and “underdeveloped” behavioral strategies can also be identified, as can attachment styles and values within attention to relationship history. For example, given their importance for the therapeutic relationship, we emphasized key relationship experiences and beliefs about the relationship in our modification to Judith Beck’s case conceptualization diagram (see Kazantzis, Dattilio, & Dobson, 2017). Some comprehensive case-formulation approaches also place a central emphasis on identifying client strengths or protective factors (Kuyken et al., 2009). Suzanne was an only child who described a deeply distressing and traumatic early life experience. She had been subjected to sexual abuse by an uncle and was exposed to a predominantly emotionally neglectful and punitive parenting style that often invalidated her perspective and emotions, which lead to the development of persistent suspicion about other people’s motives (i.e., abuse/ mistrust schema). However, her parents would oscillate in their parenting style and, on other occasions, would also provide excessive praise about her physical appearance, which promoted a strong sense of entitlement in Suzanne. She believed “I am special” and “I am unique, and if people do not see that, they do not know me yet” (i.e., entitlement schema), which were views that coexisted with those generated as a function of her abuse: “I am bad” and “I am broken” (i.e., defectiveness schema). Part of what made life difficult for Suzanne was the activation of different core beliefs within interpersonal interactions in her adult life, as at times, beliefs associated with entitlement and defectiveness were activated within the same interaction. This was evident in sessions in which Suzanne would initially state very high expectations about what should be achieved in therapy and in homework, but then feel markedly suspicious and emotionally dysregulated when taking the first step—interpreting her uncertainty and emotional and physiological discomfort as evidence of her therapist’s malicious intent. Because Suzanne’s parents were so focused on their own careers, her developmentally appropriate emotional responses to events were not acknowledged or nourished. She came to understand that her emotions were “just more things that are wrong with me” and that those who had subjected her to abuse and neglect were “always right—because parents are always right.” This meant that when Suzanne experienced frustration as an adult, she viewed it as evidence of the malicious or incompetent actions of others (i.e., activating her abuse/mistrust schema) or dismissed it as unimportant (i.e., activating her enti-



Contemporary Cognitive Behavioral Therapy  735

tlement schema). As conveyed here, in order to fully understand the development of Suzanne’s frame for viewing the world as an adult presenting for treatment of depression, there is a need to understand the developmental context in which that frame was developed. As might be expected in the context of early life experience involving sexual abuse, Suzanne viewed other people as being “dangerous, critical, and better [than me],” while her current view of herself was characterized by a sense of failure and lacking self-worth: “There is something critically wrong with me.” She had even a tattoo around her ankle reading “defective,” which she said was just part of “being real” and “not bullshitting myself.” So desperate was her need to feel accepted, she would go to great lengths to please others, varying from sacrificing her time and resources (e.g., money) for others to having brief sexual encounters (“party favors”) in night clubs in exchange for drugs. Of course, the down side of such efforts was that she felt as though she had been taken advantage of and abused. Suzanne viewed her emotions as dangerous and “bad.” She was certain that if she did not do something to change the situation, such as distract herself, or if that did not work, she would self-harm through cutting her already heavily scarred left arm or thighs and engaging in risk-taking behaviors involving consumption of a “cocktail” of central nervous system (CNS) acting substances (i.e., alcohol with cocaine or methamphetamine, plus ecstasy was her preferred combination). At the time of starting therapy, Suzanne did not have the insight to see the emotional regulatory function of these behaviors or link her own perspective on emotions to what she had learned through her early life experience. From your current understanding of psychotherapy, you will know that a primary aim is to support clients as they move toward more adaptive patterns of functioning in occupational, family, and other relational settings. When clients present with chronic problems, such as chronic depression, or pervasive problems in their relationships, it is again not surprising that contemporary CBT may focus on helping the client to enhance their understanding of and improve their functioning in all relationships. As in Suzanne’s case, it was necessary to start with a shared comprehensive case formulation, which linked her life experiences to belief generation and thereby provided a perspective that did not support her self-blame and inappropriate guilt surrounding abuse experiences. In acknowledging the complexity in her belief system, the comprehensive conceptualization also alleviated her perceived sense of failure in “being confused with everything in my life.” From there, the work centered on emotion identification and coping (especially frustration tolerance) as a foundation to intervention with substance abuse, and on developing more adaptive patterns of relating to others (e.g., distinguishing assertiveness from aggressiveness and practicing assertiveness to ensure her emotional needs were met in relationships). Given her relationship history, we might expect that Suzanne would have a pattern of unsatisfying relationships, characterized by a detached attachment style, and rigid core beliefs about other people and the world. Figure 25.1 shows

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FIGURE 25.1. Portions of Suzanne’s Cognitive Case Conceptualization With a Relational Focus

Note. See Kazantzis, Dattilio, and Dobson (2017) for complete diagram. Copyright J. Beck, 2017. Adapted from CBT Workshop Packet (2017 edition) and used with permission.

these aspects of the case conceptualization for Suzanne, incorporating the above-mentioned developmental experiences, core beliefs, schema, and underlying assumptions.

THERAPEUTIC RELATIONSHIP—IN-SESSION PROCESSES When Aaron T. Beck and colleagues first outlined how to practice cognitive therapy (A. T. Beck et al., 1979), the therapeutic relationship was positioned as central to effective practice. A. T. Beck et al. outlined that both general elements of the therapeutic relationship (e.g., expressed empathy, positive regard, the alliance) and CBT-specific elements of collaboration, empiricism, and the client’s adoption of a style of self-questioning were important for effective therapy (Kazantzis, 2018; Kazantzis, Dattilio, & Dobson, 2017). The evidence base for the manner in which CBT is delivered shows greatest evidence for the alliance, feedback, and homework (Cuijpers et al., 2019; Kazantzis et al., 2018), but it is important to note that therapist competence in CBT-specific therapeutic relationship elements of collaboration, empiricism, and Socratic dialogue have not been studied to date. Even from the first contact with the client, the CBT therapist begins to think about the client’s belief system and relational patterns and to form hypotheses about how their problems came to develop. This process of hypothesis generation is different from a therapist’s “interpretation” in modalities such as the



Contemporary Cognitive Behavioral Therapy  737

interpersonal and analytic therapies. In CBT, the clinician tries to understand the client’s worldview and requires the client to provide the “data” to support or not support their hypotheses. For example, if the early interactions with the client include instances in which the client is eager to demonstrate work done, is responsive to ideas and suggestions, and offers the clinician constructive and encouraging feedback about their initial work together, then this is most likely part of the client’s general ways of relating—but the therapist should not interpret this as “people pleasing.” Instead, the skilled CBT practitioner would be curious to identify with the client under which beliefs these behaviors function. In Suzanne’s case, the therapist could reasonably expect a range of behaviors to occur in session ranging from marked hostility to suspicion, attention seeking, and disruptive behavior. This was not deemed as being “problematic” or a “disruption” or form of “resistance,” but rather simply a reflection of the activation of beliefs—which in turn stemmed from Suzanne’s relationship history. For example, when Suzanne presented for a session hurried and feeling embarrassed for being 5 minutes late, due to a night out with friends, she described feeling self-conscious because she had not taken the time to put on makeup and get ready in the manner she usually would. Suzanne’s main concern was that facial characteristics (i.e., freckles) and blemishes were visible (it was noticeable that Suzanne would usually wear heavy makeup). However, Suzanne said, “You’re going to be cross with me—no . . . you ARE cross with me because I’m not properly prepared for today’s session!” By maintaining a positive regard for the client, the therapist provides immediate evidence that may not be consistent with the client’s previous life experiences. This provision of a different relationship experience is central to effective CBT (J. S. Beck, 2011; Kazantzis, Dattilio, & Dobson, 2017). For example, clients with a significant abuse history may not have experienced an empathic listener who values them as a human being first and foremost, regardless of their in-session behavior—which may promote tearfulness, suspicion, or anger depending on the client’s interpretation of the therapist’s behavior and the core beliefs being activated. Over time, these new relational experiences will also indirectly challenge long-held core beliefs, assumptions, and rules about the world. The process of therapy varied with Suzanne. Initially, she presented as being cooperative and willing to engage in the process of therapy. At various points in therapy, however, Suzanne would become emotionally dysregulated, usually precipitated as a flushed neck (as this area was less covered with makeup than was her face), sighing, and in presenting a series of critical comments about what was being discussed, including criticisms of the therapist. It was notable that Suzanne had prepared for sessions with questions to ask the therapist, which had been generated in discussions with her best friend Sylvia. It was obvious to the therapist that these questions conveyed a perspective of opposition to therapy, were a challenge to the therapist himself, and were characterized by persistent suspicion about the therapist’s intentions. It seemed that Sylvia was aligned with Suzanne in sharing a stereotyped view of men, and as the therapist was male, expected that therapy was about “control and

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influence” rather than support. This protracted progress in therapy significantly. However, because of the therapist’s stance of unconditional positive regard coupled with a consistently respectful tone, later in therapy, Suzanne noted, “You’re actually okay—you [surprisingly] never react to anything I say in a negative way, which tells me you’re on my side and want the best for me.” A comprehensive assessment and psychometric testing had been completed in earlier sessions, but because Suzanne’s primary therapeutic goal was to minimize the harm caused by her frequent binge drinking and substance abuse, there was a need to first understand the drinking in specific terms. As Suzanne was stepping through some initial questions on her weekly alcohol intake with her therapist (N. K.), she expressed some concerns: SUZANNE:

You’re an asshole! [shouting]

THERAPIST: Excuse me? SUZANNE:

You don’t give a shit about how this makes me feel, I’ve told you, I can be cooperative, a nice person, but sometimes I just go on the attack. Sometimes people need to learn they can’t mess with me. All the shit I have put up with in my life, no asshole is going to take advantage of me.

THERAPIST: Okay. You’re angry—I get it. SUZANNE:

Damned straight!

THERAPIST:

Well, first and foremost, let me say I am glad you told me all that. We can come back to the matter of how we overtly convey our respect to each other in the way we speak, our tone, and what words we use in-session, but for now, I would be interested to understand more about what’s going on.

SUZANNE:

Hmmm . . . yes? [in a sarcastic tone]

THERAPIST: This is a safe place for you to talk about those things that are

most challenging to you. Also, I always need my clients to tell me if things are simply not what they would want to talk about that day. That’s the emphasis on collaboration we’ve had through our work together. SUZANNE:

Well—why do you think I am still here? [in a sarcastic tone]

THERAPIST: . . . and I appreciate that you are. You’re grappling with deeply

distressing emotions and helping me to gain a clear perspective to better support you—now, what just happened? SUZANNE:

Look, I almost walked out.

THERAPIST: I could tell. It’s great you stuck with our session.



Contemporary Cognitive Behavioral Therapy  739

SUZANNE:

Alright . . . talking about all the partying really gets me fired up—it’s all I’ve got and it’s all I basically do with my friends. Mum and Dad were such fucking hypocrites, they always lectured me on how I should be and what I shouldn’t do, and when I started using in my teens, they went crazy—yet they drink daily! Usually it’s the assholes who go on about being all pure and perfect that stuff their fat asses with wine, sugar, and caffeine. If it’s not one thing, it’s another. Everyone’s addicted to something.

THERAPIST: So . . . if people get on their high horse (pardon the pun) and

look down on others, there’s a disconnect between their behavior and what they are saying. They’re judging? SUZANNE:

Fuck yeah! [shouting]

THERAPIST: So what was the trigger this time? Was it my asking how many

drinks you had over the last week since last session? SUZANNE:

Yeah. I could almost hear my mother screaming “you’re out of control—you crazy little bitch!” which lead me to think “this asshole, he’s just like the rest of them, I bet he drinks beer every night himself.”

THERAPIST: Well if that’s what was going through your mind—it’s no won-

der you reacted that way. What else was going on? SUZANNE:

That I hate being exposed ‘cause it means I’m going to get judged and rejected. People always reject me when they find out what’s wrong with me.

THERAPIST: . . . and you were concerned that if I knew the extent of your

alcohol use that would give me reason to view you negatively? SUZANNE:

Of course! Look, I know it’s your job not to judge, you’re not supposed to, but you’re still human. You still have your own opinion and even asking me about how many drinks I’ve had implies that it’s a problem.

THERAPIST: I can see what you’re saying. At the same time, let me say I have

a duty of care to you, and I need to collect good information regularly to identify if we need to adjust our approach and focus. It’s part of our shared commitment to minimizing harm for you. SUZANNE:

Yeah . . . yeah . . . I know. [in a sarcastic tone] So you’re saying that even though we were talking about alcohol use you were actually asking because it’s part of the process here?

THERAPIST: Yep!

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SUZANNE:

Now I feel bad for losing my shit . . . or is that your fault for making me feel bad?

THERAPIST:

Well, let’s not judge here. I would say an open and frank dialogue is part of what makes this a safe place. Your reactions are okay; they are simply a reflection of your beliefs, and that reflects your life experience. I like your emotions. In my view, your worth as a human being is never questioned, and it’s definitely not my role in this work to judge others. Here, today, I would like to take some of the responsibility—I was not 100% clear in providing a rationale for the line of questioning. That’s totally my responsibility. At the same time, I want to acknowledge the powerful voice of your mother in your head when we did. That must have made it very difficult. How did you feel before you felt angry?

SUZANNE:

Vulnerable . . . rejected . . . anxious.

THERAPIST: Right, and that’s a great articulation of emotions and perceptions

by the way. I wonder if we can put this down on paper, as I think seeing the pattern might help us going forward? Would you be okay if we did that? SUZANNE:

I see the rationale alright. Yes, I am happy to do it. But you’re just too damned nice! Seriously though, I appreciate that you asked me. I like the way you always seek my consent before we do stuff here.

THERAPIST: Damned straight! SUZANNE:

Okay, touché! [laughs]

In this dialogue, the therapist demonstrated two centrally important elements of the therapeutic relationship in cognitive therapy—collaboration and Socratic dialogue. We will examine these constructs to illustrate their definition and function in contemporary CBT. Collaboration is by definition teamwork, or shared contributions and decision making. This requires the therapist to engage in four specific behaviors: (a) inviting client input, (b) being responsive to that input, (c) offering the client the opportunity to make a suggestion and decision, and (d) soliciting periodic feedback (Kazantzis, Dattilio, & Dobson, 2017). However, each one of those behaviors has the potential to mean different things to different clients, and sometimes that meaning varies during the course of therapy and the relationship with the therapist. In the example here, Suzanne interpreted an assessment question to be evidence of judgment through being exposed, a view that the therapist validated immediately. From there, the therapist shifted to a greater emphasis on feedback not only to confirm their hypotheses about what was going on, but to ensure the client accepted the rationale and was willing to proceed (i.e., shared decision making about the focus of discussion). Collaboration was also evident



Contemporary Cognitive Behavioral Therapy  741

in the balance of dialogue contributions between Suzanne and her therapist (A. T. Beck et al., 1979; Dattilio & Hanna, 2012; Kazantzis et al., 2013). Socratic dialogue is expected in every session in CBT (Rutter & Friedberg, 1999). Different definitions of Socratic dialogue exist, but it can be broadly defined as involving three stages: (a) identifying the client’s concern, (b) examining new information to the client’s concern, and (c) synthesizing that new information in the context of the existing viewpoint (Kazantzis et al., 2014; Kazantzis & Stuckey, 2018). In the interaction with Suzanne, the therapist asked the client for information outside of her current awareness, such as the intrusive unwanted memory and various primary emotions leading to the secondary emotion of anger. In this dialogue exchange, Socratic questioning aided in the assessment and understanding of Suzanne’s concern. Over the next few therapy sessions, it was evident that supporting her in discovering new ideas for herself was an especially useful strategy. For example, first, the therapist often asked questions designed to encourage Suzanne to consider an alternative view (e.g., How would someone you hold in high regard respond in the same situation? If a friend or loved one was having the same internal experience as you, during therapy, what advice might you give them based on your experience today?). Second, over time, Suzanne was able to adopt the same types of questions for herself between therapy sessions— supporting the processes of emotion identification and coping, as well as cognitive reappraisal. A lot could be said about the importance of maintaining appropriate expectations for respectful dialogue in-session, but clearly, the work of the therapist is often to “weather the storm” of emotions that clients bring to session, and indeed, without emotion present during sessions, sessions are unlikely to be useful to clients (see also Kazantzis, Dattilio, & Dobson, 2017). Here, the therapist was striving to serve as a model for tolerating emotional discord in relationships, while maintaining a calm and empathetic tone in exploring what happened during the session. The fact of the matter was that Suzanne’s voice was often piercing—to the extent that other therapists in neighboring rooms and administrative support staff commented to the therapist that they could hear her voice despite the office door always being closed during sessions. Suzanne’s vocal volume and pitch was clearly matched with situations in which her sense of entitlement was activated and usually involved interrupting and talking over the therapist. Over time, the therapist’s calm and empathic approach incorporated limit setting, whereby they attended to the importance of teamwork in therapy and that allowing each other’s contributions to conclude was a cardinal sign of respect. When Suzanne transferred that strategy into her personal life (as part of targeting interpersonal skills training) she was able to have more authentic interactions with others that moved beyond the superficial nature of emotionally avoidant discussions about the minutia of day-to-day life with friends and social media contacts. As we have discussed elsewhere (Kazantzis, 2018; Kazantzis et al., 2015; Kazantzis & Hofmann, 2019), there is a need for research methods that

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specifically study CBT-specific elements of the therapeutic interaction. There is need for observational assessments that move beyond the general constructs of the alliance and expand upon the assessment of CBT-specific therapeutic relationship elements. This research is important for validating the claims made by Aaron T. Beck and colleagues regarding the central role of collaboration, empiricism, and Socratic dialogue in the successful delivery of CBT.

TREATMENT PROCESSES Earlier this chapter, we defined contemporary CBT. In practice, this involves the identification and targeting of processes of etiology in techniques (i.e., What works for which problems?) and doing so in a manner that is suitable for the individual client—and, in particular, a manner which further supports those treatment processes (i.e., What works for which problems under which contexts?). A range of processes have been identified and agreed upon for modern doctoral training in CBT (see review in Klepac et al., 2012). Consistent with the foundational model proposed by Aaron T. Beck, we center here on the treatment process of cognitive reappraisal but acknowledge that others, including emotion identification and coping and interpersonal skill training have been discussed here in the context of the case example of Suzanne (see Hayes & Hofmann, 2018, for a comprehensive list of treatment processes). However, there are some variations, which we will outline here, in the manner in which we facilitate cognitive reappraisal that are central to contemporary CBT. From “Thinking Errors” to Patterns of Thinking Thinking errors, such as overgeneralization, personalization, and rigid or “black and white” thinking (see J. S. Beck, 2011, for complete list) have long been criticized for not being clearly defined and pathologizing normal human thinking, which should not be perfectly logical all the time. This does not dispute that there can be value in labeling thinking patterns. For example, some clients may find it useful to notice when they are tending to “focus on the negative,” but our point is that this simple label is unlikely to promote clinically significant change. Rather, a person experiencing depression such as Suzanne may experience persistent worry about their performance or the negative evaluation of others. Similarly, Suzanne believed in the importance of negative thoughts and images, and that “my thoughts would not occur if they are not important.” Few clients present for therapy with a refined scientific approach to evaluating their experience. Fewer still have a comprehensive understanding of how their early life experience led to the creation of their beliefs. Indeed, many people consider their sense of self, or their personality, to be defined by and intertwined with their beliefs. In addition, few clients have considered their sense of self beyond the development of beliefs. They are often surprised when posed with the guided discovery question, “What attributes and characteristics did your family



Contemporary Cognitive Behavioral Therapy  743

notice in you before you went to school? Before you learned these beliefs about yourself, others, and the world?” Pervasive processes of worry and unwanted intrusive thinking are of course present in most anxiety disorders, whether it be about the specific catastrophic outcome from physiological sensations, as in panic disorder, or worry about a range of threats to one’s own and family members’ safety, as in generalized anxiety disorder (GAD; Holmes & Newman, 2006), or worry about the meaning and likely result of unwanted distressing thoughts as in obsessive-compulsive disorder (OCD; Franklin & Foa, 2014). Many experiences also involve unhelpful or unbalanced thoughts about the meaning of the thinking process, as with people with GAD who are worried about being worried. People with OCD may be worried about the frequency of their thinking and believe they “must” control their thoughts to prevent some disastrous event from occurring (e.g., a parent with fleeting intrusive and repulsive thoughts of harming their children worries that they might lose control and act on the image even though they do not have the urge, intention, or history of doing so). Not surprisingly, contemporary models of CBT focus on worry with a special focus on beliefs about worry, such as in Adrian Wells’s (2008) metacognitive therapy. The model established by Edward Watkins (2018) focuses specifically on the related process of rumination (i.e., “passively and repetitively focusing on one’s symptoms of distress and the circumstances surrounding these symptoms”; Nolen-Hoeksema et al., 1997, p. 855). It is not surprising then that the early pioneering work in CBT for anxiety disorders has moved to a greater attention and focus on thought process (Clark & Beck, 2011) and unified treatments attending to the common treatment targets between anxiety disorders (Barlow et al., 2004). Therefore, contemporary CBT considers the client’s pattern of information processing in case formulation as a basis for technique selection. For example, when beliefs about thinking are identified as being central to the etiology and maintenance of client problems, experiments to evaluate those beliefs and experimentation with different behaviors in response to unwanted patterns of thinking target those etiological processes. Put differently, we would not only attend to worry in the context of GAD and intrusive thinking in the context of OCD but in any client presentation in which they were conceptualized to lead to distress—and we would use the tried-and-tested techniques from GAD and OCD treatment to help. Other contemporary CBT models that emphasize the process of thinking include Thomas Lynch’s radically open dialectical behavior therapy (Lynch, 2018). Here’s a sample of therapy with Suzanne that focused on cognitive reappraisal: THERAPIST: So we’ve been talking about the pros and cons of sharing a little

more with your friend Don. I think there could be merit in examining that some more—if that sounds okay and you’re willing? SUZANNE:

Sure. It’s part of the reason I’m in therapy. I hide my real self from people to keep safe. People have no idea how much I

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desperately need them. At the same time, I feel like screaming at the top of my voice, and I’m sure no one would care whether I was here or not. THERAPIST: I see. Am I right in hearing there’s a conflict in wanting to con-

nect in a meaningful way in your friendships, to help give the relationships more balance and authenticity . . . and as a consequence, help you to build a more supportive network that hopefully inspires you to a more fulfilling life? SUZANNE:

Yes. That’s a nice way of putting it. In my words, the shit has never been good.

THERAPIST: What do you think is at the heart of the fear you feel about shar-

ing in relationships? SUZANNE:

Intense fear.

THERAPIST: Would you tell me a little more about that? SUZANNE:

When they get to find out the real me, how screwed up I am, they always reject me. Usually I lash out at people in such a way that they don’t want to be around me—they don’t want me to be around their families, or their children.

THERAPIST: I hear you. [long pause] In acknowledging that, I’m remember-

ing something you told me previously—that you have several ways of joining or connecting with people. Did I remember that your art is a safer way to convey a part of yourself and that each work conveys something specific—such as a part of view? SUZANNE:

Yeah.

THERAPIST: I wonder if there are parallels. SUZANNE:

What do you mean? [raised piercing tone]

THERAPIST: I wonder if we can start small. Just like the way an artist exhibits

their work over time, or indeed, over their lifetime. They might show work on a theme or a particular series or project. I suppose an even smaller step would be showing just one piece? SUZANNE:

I see. Don is interested in my art, and we do talk a lot about his sculptures. . . .

THERAPIST: I remember. One thing we could do would be to set this up as a

kind of test of your beliefs. I acknowledge this feels absolutely true right now, but it might be more information in the relationship or situation that is important but is being missed. What do you think? SUZANNE:

You’re saying there’s more than meets the eye.



Contemporary Cognitive Behavioral Therapy  745 THERAPIST:

Or more than meets the eye with your current lenses fitted. New lenses might help us (or you) to figure out precisely what is going on, and you might try different pairs for different landscapes and activities, so to speak.

SUZANNE:

Right. How do we start?

THERAPIST: The first idea, or hypothesis, is that people will leave you if they

find out about your personal challenges—how would you put that in your own words? SUZANNE:

“If they find out something about the real me, it’s only a matter of time before they will leave me out in the cold—abandon me.”

THERAPIST: How much does that feel true right now on a 0 to 100% scale? SUZANNE:

100%

THERAPIST: What’s another hypothesis here, another one we could test? SUZANNE:

That they won’t abandon me?

THERAPIST: What does that look like? SUZANNE:

If I was in their shoes, I would express concern, interest, and try to be supportive.

THERAPIST: So, hypothetically, if your friend Don shares similar attributes to

you, he might do the same, and exercise more concern, empathy, and kindness towards you? SUZANNE:

Yes, but I am only 50:50 on that outcome.

THERAPIST: Can you think of a way you might have a discussion about a past

painting that was inspired by a challenge or problem in your life, which you might want to tell Don part of? In the above exchange, the therapist helped Suzanne to identify and rate competing ideas for evaluation in a behavioral and cognitive experiment. The belief rating, within the client’s experience, serves as the gauge for the evaluation of the experiment. Other times, we may be interested to help clients evaluate a surface or situationally specific automatic thought (i.e., a momentto-moment image, memory, fantasy, or evaluation). In those instances, we would prioritize thoughts based on emotion—link each thought to the emotions in the situation to identify the most emotionally “hot” thought for evaluation. Further still, we may support the client in an understanding of how their behavior reflects an unmet need from childhood or personality pattern. From Cognitive Content Evaluation to Acceptance and Values Work For other clients, we might support them in encouraging a nonjudgmental contact with their cognition. Of course, this still represents a treatment process

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since attentional changes occur with an acceptance strategy. This acknowledgment of client experience can foster acceptance, particularly when there has been a link to the client’s strongly held values and purpose in life. Put differently, this process helps clients to acknowledge the evidence supporting their thoughts and also to highlight the fact that their thinking is the result of prior learning. Clients often understand but rarely reflect on the fact that they were not born into this world with their beliefs. A detailed coverage of how to use these treatment processes is beyond the scope of this chapter but can be found in Hayes and Hofmann (2018). “Behavioral” Interventions as Cognitive Techniques Techniques that have an overt focus on behavior naturally produce changes in cognition. However, there are often times where focusing on behaviors is a primary target of interventions in contemporary CBT. Two central examples are exposure and activation processes. Here, we work with clients to identify the triggers and antecedents of the problem. With that shared understanding, clients can identify alternative behaviors that might be linked with a different and more functional emotional state. For example, in depression, we support clients in gathering good data on their emotional experience and its fluctuations at different times of day and in relation to different activities and periods of low activity. Those data then serve as the groundwork for the scheduling of active behaviors, as well as those behaviors associated with a sense of pleasure or accomplishment. As a further example, in the context of social anxiety disorder, a client may try alternative behaviors to their usual withdrawal in social situations, such as initiating discussions and engaging in more dialogue through the use of questions, summaries, and sharing of their own experience. This forms a further treatment process in contemporary CBT, helping the client to better understand and engage with the context of their life. Other chapters in this volume provide further detail on innovations in behavioral interventions (e.g., inhibitory learning framework in exposure). Collaborative Empiricism as the Nexus Between Relationship and Technique The material here on thought evaluation illustrates the cognitive therapy element of collaborative empiricism (Tee & Kazantzis, 2011). When clients are engaged in thought-content evaluation, it comprises (a) identification of a thought that is clearly within the client’s own experience and not an interpretation or reframe from the therapist; (b) the opportunity to identify their own gauge for its evaluation, such as a rating of percentage of belief in the thought before and after the evaluation; and (c) the testing of multiple thoughts in the evidence gathering exercise (i.e., three components of an empirical test). There may be many reasons a therapist might not use all of these aspects here, or in other techniques, but when (a) through (c) are incorporated, then we can say that the interaction has high levels of empiricism. Therefore, this combined



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construct should be embedded in all techniques to support treatment processes (i.e., each technique adopts an experiment emphasis) and also involves some degree of collaboration (e.g., an in-session or relationship process). A detailed clinical discussion of collaborative empiricism is beyond the present chapter scope but can be found in Kazantzis, Dattilio, and Dobson (2017). Linking Techniques and Case Conceptualization One of the most centrally conceptual issues important for learning how to practice contemporary CBT is understanding the flexibility in the approach. In the previous section, we conveyed how different clinical presentations (especially disorder groupings) have similar etiological processes, but the specific configuration of processes will be entirely unique to each client presentation. This is a rather simple conceptual issue, but complex for fidelity assessment—in other words simply figuring out a way of tracking when it is applied skillfully. If we review the empirical literature on CBT, we find that comprehensive specification of the techniques within a therapy is rare, and detail linking how the techniques target processes is almost absent (see discussion in Hayes et al., 2019). Exceptions are studies of specific treatments that have a focused change process (e.g., studies of exposure in social anxiety). However, in day-to-day clinical practice, contemporary CBT involves addressing various treatment processes that require nuanced methods of technique adaption. Taking three of the core treatment change processes—attentional change, cognitive reappraisal, and context engagement—Table 25.1 outlines the TABLE 25.1. Contemporary Cognitive Therapy Treatment Processes and Technique Use

Treatment process Technique use

Attention training/ acceptance tolerance

Decentering defusion/cognitive reframing/cognitive reappraisal

Acknowledged and accepted Linked to client values Encouraged nonjudgmental contact with cognition

Identified cognition Evaluated cognition Linked cognition to emotion Defused/distanced (separated) from Linked to current state or “mode” Linked to unmet childhood needs/ personality patterns

Behavioral exposure/activation Identified triggers/antecedents Identified consequences/responses Identified alternative behaviors/coping strategies Taught role of behavior in negative moods Evaluated potential outcomes of alternative behaviors Encouraged active approach in situations Evaluated exposure to unpleasant situations/people Assigned activities to increase sense of mastery/pleasure Managed situational contingencies Linked to avoidance (maladaptive coping) behaviors Linked to client strengths/adaptive coping

Note. Data from Kazantzis, Petrik, et al. (2017) and Kazantzis (2018).

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specific therapist behaviors involved in achieving those treatment processes. The specific “uses” of techniques here are important because there are so many CBT techniques that can be used for the same purpose, and a simple list of techniques tells us nothing about how they were actually used in the session (Petrik et al., 2013). For example, a therapist may use an empty chair technique in one session and a thought record in another, and yet both are used for the same purpose of linking cognition to emotion within the broader objective of cognitive reappraisal. This tailored treatment approach has always been a cardinal feature of Beckian CBT; what we have now is (a) this useful conceptual clarity and articulation of what is being done in sessions (see also Hofmann, 2011; Wenzel et al., 2016) as well as (b) the data analytic strategies for its measurement (Hofmann & Curtiss, 2018; Nelson et al., 2017). Readers interested in guidance for clinical decision making in process-based care are referred to Hayes et al. (2019). Let us take two clients from a hypothetical group CBT service. Jake is a man in his early 30s who experiences significant health anxiety that culminates in frequent panic attacks and worry about his health. Judy is a woman in her early 20s who experiences panic attacks several times per day but has experienced clinically significant depression since the death of her brother when she was 16 years of age. Both Jake and Judy joined the anxiety service to address their anxiety symptoms, even though the context and etiology of their anxiety were quite different. The first two group sessions were devoted to understanding intense anxiety experiences, including a situational conceptualization of panic and exposure to intense physiological arousal similar to naturally occurring panic. Through the use of tailored ratings of similarity between induced and naturally occurring panic, developing individual client hypotheses about the meaning of physiology in panic situations, the group facilitator embedded a degree of empiricism. Similarly, using these techniques in slightly different ways, such as enabling each group member to start at different points of the panic situation and relying on the client’s own words for their experience, ensured a degree of collaboration. Figure 25.2 summarizes the therapeutic goal, treatment processes, and techniques being used in these initial group sessions. Specifying Targets The target is one way to tailor the technique being used in cognitive therapy. Jake’s automatic thought was that his panic was clear evidence that he was suffering from a heart condition that had not been accurately detected in his medical tests. His experience of panic was so intense that it lasted several hours and was characterized by colorful intrusive imagery of his heart working under significant strain and showing dysfunction. Judy’s automatic thought was that her depression was so bad that it was clear evidence of her failure as a person, and she was about to lose control of her sanity. Judy also experienced a distressing image, which showed her being admitted to an inpatient ward.



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FIGURE 25.2. Summary of Therapeutic Goal, Processes, and Techniques Being Used in Early Group Cognitive Behavioral Therapy for Panic Disorder

Specifying Use Still further, there is the matter of how the technique is being used. For Jake, the group facilitators helped him to identify and link his cognition to his physiological state. For Judy, the group facilitators not only helped her to identify her distressing and intrusive unwanted image but helped her to identify the situational triggers to her panic. Judy was previously operating with the understanding that her panic happened “out of the blue” without any clear pattern. By understanding a link between cognition, physiology, emotion, and situational triggers, both clients gained an enhanced understanding of their experience of panic, which in turn alleviated some of their feelings of shock and despair when in panic situations. In both cases, the approach taken was to help the clients to identify alternative hypotheses based on the evidence gained from the discussions in group and gather prospective data on these over the coming weeks. Figure 25.3 shows the link between target, technique, and hypotheses for Jake and Judy. These examples illustrate how contemporary CBT is a fully individualized intervention that precisely targets the unique processes of etiology in a client’s presentation. This is very different to a protocol-based intervention where the techniques, and their uses for each client, are predetermined or prescribed.

CONCLUSION In this chapter, we have taken a novel approach to the discussion of CBT by drawing together the unique, yet ubiquitous, practice elements that underpin

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FIGURE 25.3. Illustration of How the Same Technique Was Targeted for Different Features of Jake and Judy’s Experience of Panic

Note. H1 = hypothesis 1; H2 = hypothesis 2.



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the changes that clients experience. It is clear that these practice elements transcend rigid diagnostic boundaries between disorders and emphasize the bespoke nature of CBT. By focusing our attention on the in-session experiences of the client, we have emphasized a view of CBT incorporating distinct, and vital, relational elements, as opposed to the incorrect view that classical or contemporary CBT is purely a collection of techniques. Indeed, one size does not fit all, and in fact, by placing oneself within the microcosm of each client’s unique worldview, the task at hand becomes more focused on collaboration, empiricism, Socratic dialogue, and tailoring those relational elements with a comprehensive cognitive case conceptualization. Of course, the conceptualization is never “done”; it grows and evolves with our understanding of the client and with the client developing insight and awareness. Only with a more accurate and complete case conceptualization can there be appropriate selection of techniques to promote change. This chapter is not meant as a conclusion but as a starting point. There are really no boundaries to the inclusion of processes, and in fact, we anticipate that process-based CBT will incorporate more treatment processes (those that have empirical support and clear outlines of their mechanism of action) from a range of modalities. This is analogous to the ways in which CBT adopted the techniques from different therapies but used them to facilitate cognitive change. There are also parallels to the difference between a strictly “behavioral” and “cognitive behavioral” use of techniques because the frame of hypothesis testing (i.e., collaborative empiricism) can promote a range of cognitive reappraisals (e.g., through empiricism) and is dependent on in-session and relationship processes (i.e., collaboration). Our aim has been to provide a practical guide for the clinician while encouraging new ideas, discussion, and hopefully, further research into processes within contemporary CBT. We have tied together the ideas of both treatment and in-session and relationship processes, and we hope this chapter has been as interesting and stimulating for you as it was for us to produce. In some ways this approach is complex; in other ways, it is beautifully straightforward in enabling the targeting of etiological processes in therapy. Our community is on the brink of a new understanding about how to define, measure, and practice psychotherapy—we hope this encourages you to read more about a process focus in contemporary CBT.

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INDEX

A ABA. See applied behavior analysis (ABA) ABAI. See Association for Behavior Analysis International (ABAI) abbreviated progressive relaxation training (APRT), 351 anxiety reduction and, 354 clinical procedures for, 351–354 reduced tonic sympathetic nervous system arousal, 354 stress reduction and, 354 ABC (antecedent-behavior-consequences) model, 238 ABCT. See Association for Behavioral and Cognitive Therapies (ABCT) ABM. See attention bias modification (ABM) abstinence violation effect, 388 abstraction, 39 Academy of Cognitive Therapy, 434 acceptance, 319, 573 acceptance and commitment therapy (ACT) and, 578–579 strategy, 746 Acceptance and Action Questionnaire (AAQ), 590 acceptance and commitment therapy (ACT), 4, 24, 35, 36, 40, 44, 52, 567, 578–579. See also ACT theoretical model acceptance and, 578–579 adolescents and, 585 behavioral rigidity and, 572 behavior analysis and, 569–572 case example of, 575–584

case formulation and, 149 children and, 585 cognitive fusion and, 571 committed action and, 582–584 contact with the present moment and, 581–582 control as the problem and, 578–579 creative hopelessness and, 576–577 defusion and, 579–581 dissemination and, 588–589 diverse populations and, 589–591 efficacy of, 584–587 functional contextualism and, 569–575 hexaflex diagram and, 575–576 history of, 567–568 mechanisms of action in, 587–588 mental and behavioral health and, 584–586 psychological flexibility and, 572 psychological inflexibility and, 572, 587, 588 resources, 589 self-as-context and, 579–581 theoretical foundations of, 569–575 as a third-wave CBT, 567–568 training in, 589 as a transdiagnostic intervention, 584 values-directed behavior and, 582–584 acceptance and commitment training (ACT), 586 acceptance-based behavior therapy, 367 acceptance-based group therapy, 105 Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  757 Wenzel Copyright © 2021 American Psychological Association. All rights reserved.

758 Index

acceptance of the treatment rationale (ATR), 254 outcome data and, 254–255 acceptance-oriented behaviors, 375 acceptance-oriented skills, 375 accidental reinforcement, 643 accommodation, 12 acrophobia, 284 ACT. See acceptance and commitment therapy (ACT) action plans, 429, 479 activation. See behavioral activation (BA) active directive approach, 450 actively disputatious model, 15 activity log, xix–xx monitoring, 246–248, 255–256 scheduling, 237–239, 248–250, 255 ACT theoretical model, 572–575 acceptance and, 573 cognitive fusion and, 572 committed action and, 574, 582–584 contact with the present moment and, 573, 581–582 experiential avoidance and, 572 inaction and, 574 lack of values clarity and, 574 loss of contact with the present and, 573 psychological inflexibility and, 588 self-as-content and, 573–574 self-as-context and, 574, 579–581 as a transdiagnostic intervention, 587 values and, 574 adaptive functioning, 37, 422 adaptive, idiographic, and multi-component ABM (AABM), 688 adaptive schemas, 495 addictive behaviors motivational interviewing (MI) and, 322–325 ADDRESSING (Age, Developmental and acquired Disabilities, Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender) model, 141, 183–184 affect labeling, 287 Agnew-Davies Relationship Measure (ARM-12), 147 agoraphobia, 60–61, 97 breathing retraining and, 290 exposure therapy for, 289–290 interoceptive exposure for, 290 therapist-guided exposure and, 289 Albert Ellis Institute, 450 alcohol use disorder, 114–115 ambiguous scenarios paradigms, 679 American Psychological Association (APA), 252, 292

on dissemination, 556 amygdala, 96, 97 anger control, 52 antecedent-behavior-consequences (ABC) model, 238 antecedent control strategies, 657–658 problematic behavior and, 657 reinforcement and, 657 antecedent stimuli, 645 anterior cingulate cortex (ACC), 96 antidepressant medication (ADM), 57, 252, 595 maintenance antidepressant medication (mADM) and, 596 serotonergic, 109 sertraline, 294, 312 anxiety, 38, 40. See also anxiety disorders; childhood anxiety abbreviated progressive relaxation training (APRT) for, 354 attentional control theory and, 675 exposure therapy and, 275 hyperventilation and, 356 positive affect and, 702 rumination and, 111 sensitivity, 284 sensitivity and Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 703, 718 treating with PR, DB, and mindfulness-based approaches, 368–371 Anxiety Diary form, 369 anxiety disorders, 42, 51, 52, 430–431. See also anxiety attention bias modification (ABM) and, 681–683 avoidance behavior and, 98–99 case formulation and, 146 CBT for, 199 cognitive reappraisal and, 106 extinction phase learning, 96 false alarms and, 98 fear and extinction learning and, 94 negative imagery and, 113 relapse prevention and, 389, 400 trait factors of, 97 treatment for using fear conditioning and extinction model, 93–94 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 704–705 Anxiety Disorders Interview Schedule for DSM-IV, 705 Anxiety Sensitivity Index (ASI), 724 applied behavior analysis (ABA), 20, 637–638 autism spectrum disorder (ASD) and, 664



Index  759

behavioral deficit and, 637, 639 behavioral excess and, 639 characteristics of, 637 data analysis and, 637, 638–641 data display and, 641 dissemination and, 664–665 extinction and, 642–643 functional approach to assessment and intervention and, 651–657 functional relationship and, 641 indirect assessment and, 638 mechanisms of change in, 641–644 observing and recording for objective measurement of, 639–640 operant conditioning and, 645 outcomes, 664–665 permanent product recording and, 638 physical activity and, 665 Positive Behavior Supports (PBS) and, 664 reinforcement and, 641–642 research design and, 641 School-Wide Positive Behavior Supports (SWPBS) and, 664 sports and, 665 applied learning theory, 20 appraisal theory, 104 Aristotle, 6 Aspects of Theory of Syntax, 13 assessment functional assessment and, 651–652 intervention and, 651–657 protocol, 481 techniques, 248, 255–256 assimilation, 12 Association for Behavioral and Cognitive Therapies (ABCT), 588 Association for Behavior Analysis International (ABAI), 588 Association for Contextual Behavioral Science (ACBS), 569–570, 588–589 RFT and, 570–573 associationism, 18–22 associative learning, 18–22 ATT. See attention training technique (ATT) attachment theory, 15–16, 177 current, 16–17 attendance agreements, 544 attention bottom-up, 675 networks systems, 675 top-down, 675 attentional biases, 108, 618, 675. See also biases measurement of, 678 probe detection task for measuring, 675 variability, 682 attentional control theory, 675 anxiety and, 675

attention bias modification (ABM), 674, 675–676 anxiety disorders and, 681 attentional control theory and, 675 attention and, 675 automatic processing and, 675 biofeedback and, 678 dissemination and, 687 efficacy of, 681–683 goal of, 675 interpretation bias modification (IBM) vs, 683 mechanisms of change in, 685–686 negative attention filter and, 675 novel programs, 678–679 paradigms, 676–679 probe detection task and, 677–678 reaction time measures for, 682 spatial cuing paradigm and, 678 threatening information processing and, 675 trial level bias scores (TL-BS) and, 682 virtual reality and, 678 visual search paradigm and, 678 attention training technique (ATT), 618, 627–628 attention switching and, 628 auditory attentional tasks of, 628 divided attention and, 628 reduction in self-focused attention and, 631 selective attention and, 628 attribution causal, 13 model of depression, 13 theory, 13 Austin, J. L., 9 autism spectrum disorder (ASD), 664 automatic appraisals, 714 automaticity, 10 automatic processing, 675 attention bias modification (ABM) and, 675 subsystem, 38, 422 automatic reinforcement, 642 automatic thought, xviii, 424, 599 metacognitive therapy (MCT) and, 622 negative, 215 autonomic nervous system (ANS), 349 avoidance behavior, 251–252, 256–257 anxiety disorders and, 98–99 behavioral activation and, 100 depressive disorders and, 100 fear learning and, 99–100 instrumental learning and, 99 avoidance learning, 98–100 danger and, 98 avoidant personality disorder, case conceptualization for, 509–510 awfulizing, 7, 14

760 Index

B BA. See behavioral activation (BA) backward chaining, 649 Bandura, Albert, 19, 22–23 social learning theory and theory of self-efficacy of, 34 Bargh, John, 10 Barlow’s Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders. See Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) Bartlett, Frederick, 11–12 Beck, Aaron T., 7, 37, 207–208, 417, 445–446 cognitive theory of, 34 development of CBT and, 51 Beck Community Initiative (BCI), 168, 434 Beck Depression Inventory, 529 Beck Depression Inventory-II (BDI-II), 55, 134, 141, 600 Beckian cognitive model automaticity and, 10 core feature of, 11 Platonic model vs, 5–6 Beck Initiative Training Program in Cognitive Therapy, 168, 434 Beck Institute for Cognitive Behavior Therapy, 434 Beck’s cognitive theory of depression, 110 behavioral activation (BA), 33, 52, 100, 112, 117, 226, 237, 248, 257 activation and environmental reward association, 257–258 activation assignments and, 248 activity log and, xix–xx activity monitoring, 246–248 activity scheduling and, 248–250, 255 Antecedent-Behavior-Consequences (A-B-C) model use, 238 antidepressant medication vs, 252 assessment techniques for, 248, 255–256 association between processes and outcomes, 258 avoidance and, 256–257 avoidance and other barriers to activation for, 251–252 change in mechanism processes, 257 clinical practice and, 261 cognitive therapy vs, 252 contextualism and, 238 continuing education (CE) training and, 261 cross-cultural application of, 245 cross-culturally adaptable of, 235 description of, xix–xx, 235, 243–252 differences between variants of, 238

dissemination and implementation of, 260–262 dissemination of, 236 functional analysis, 238 history of, 236–238 implementation strategies for, 263 manuals for, 243–244 mechanisms of change data, 256–259 mobile phone applications for, 261 models of psychopathology and treatment mechanism underlying, 241 negative reinforcement and, 239 outcome data and, 252–257 populations served by, 253–254 rationale, 244–246 reinforcement, 238 relapse prevention and, 399 reversing the cycle of depression and, 242 strategies, 39 therapy, 4 Behavioral Activation for Depression Scale (BADS), 257 Behavioral Activation for Depression Scale Short Form (BADS-SF), 257 behavioral activation treatment for depression (BATD), 235, 237, 238 change in mechanism processes, 257 behavioral analysis, acceptance and commitment therapy (ACT) and, 569–572 Behavioral Apptivation, 261 behavioral assessment, 637 behavioral avoidance tests (BATs), 282 behavioral chain. See chaining behavioral contracts, 661–662 main components of, 662 behavioral deficit, 637 behavioral economics, 11 behavioral excess, 639 punishment and, 658–660 behavioral experiments, xxi, 213 behavioral flexibility, 40 behavioral interventions, 39, 44 as cognitive techniques, 746 cognitive models and, 34 behavioral models, historical and philosophical precursors of, 16–25 behavioral pattern breaking, 505 behavioral preparedness, 159–160 behavioral reattribution, 623–624 behavioral rigidity, 572 behavioral self-monitoring, 428 behavioral skills training (BST), 649–650 feedback and, 650 in situ training and, 650 instructions and, 649 modeling and, 649 rehearsal and, 650 behavioral techniques, 505, 523–527



Index  761

behaviorism, 3, 16–25, 17–18 Cartesian dualism vs, 17 complexities of, 23–24 contemporary, 23–25 early, 17–21 experimental science and, 23 methodological, 17 radical, 17 reductionist, 9 behaviorist model of language, rejection of, 13 behavior modification, 20 therapy, 22–23 behaviors acceptance-oriented, 375 antecedent control strategies for changing, 657 behavioral contracts to change, 661–662 bidirectional property of, 39 chaining, 648–649 change oriented, 375 consequent strategies for changing, 657 establishing new, 645–651 modification of existing, 641–645 negatively reinforced, 40 shaping, 650–651 token economy for changing, 660–661 verbal, 21 behavior therapy (BT), 3, 21, 22–23, 32 early trends in, 21 learning theory and, 16–17 limitations of, 32 operant principles and, 21 progressive relaxation (PR) and, 351 research and, 16–25 waves of, 24 belief rating, 745 systems, 422 bell and pad method, 20 biases. See also attentional bias; attention bias modification (ABM); interpretation bias modification (IBM) interpretation, 108 memory, 109 negative interpretation, 108 processing and implicit associations, 109 binge-eating disorder (BED), 115–116, 553 biological vulnerabilities, 541 biosocial model of emotion dysregulation, 541–542 emotion dysregulation and, 541 bipolar disorder, 53 relapse prevention and, 399–400 body scan, 598 booster sessions, 395 preparing for, 396 borderline personality disorder (BPD), 371, 493, 528, 539, 540

case conceptualization for, 507–509 comorbid posttraumatic stress disorder (PTSD) and, 553 description of, 371 dialectical behavior therapy (DBT) and, 371–378 Bowlby, John, 15–16 Bowlby’s attachment model, 16–17 brain overload, 475, 478–479 overcoming, 478–479, 483 breathing training techniques, 355–362 agoraphobia and, 290 capnometry-assisted respiratory training (CART), 356 clinical guidelines for, 362 history of, 356 Brief Intervention and Contact (BIC), 329 brief mindfulness of seeing and/or hearing, 599 British Psychological Society, 150 Bruner, J. S., 11 BT. See behavior therapy (BT) Buddhism, 362 Buddhist meditation practices, 349, 350, 363 Zen practice and, 540 bulimia nervosa (BN), 52, 53, 553 case formulation and, 146 metacognitive therapy (MCT) and, 619

C California Critical Thinking Test, 232 Campbell Systematic Review of mindfulness-based stress reduction (MBSR), 366 Canadian Association of Cognitive-Behavioural Therapy, 434 cancer survivors, metacognitive therapy (MCT) for, 629 capnometry-assisted respiratory training (CART), 356 Cartesian dualism vs. behaviorism, 17 case formulation, 41–42, 131–134, 423. See also cognitive case formulation acceptance and commitment therapy (ACT) and, 149 anxiety disorders and, 146 for avoidant personality disorder (APD), 509–510 benefits of, 138 for borderline personality disorder (BPD), 507–509 bulimia nervosa and, 146 change over time and, 145–146 comorbidity and, 136–137, 138 complexity and, 136, 139 components of, 140 conceptualization and, 133–134

762 Index

case formulation (continued) diagram, 734 dialectical behavior therapy (DBT) and, 149 disorder-specific model of, 41 elements of, 131–132, 137 evidence-based, 137, 144–148 function of, 137–139 future directions of, 150–151 generic model of, 41 goal oriented, 423 idiosyncratic cognitive schema (ICS) and, 145–146 key components of, 41 levels of, 133 logical functional analysis and, 145–148 longitudinal, 734 low-intensity CBT and, 148 main components of, 132 mechanism hypotheses and, 142 metacognitive therapy (MCT) and, 622 mindfulness-based cognitive therapy (MBCT) and, 149 with mode model, 506–510 multiple causality framework, 132 nonadherence and, 139 optimization through assessment, 140–144 problem lists and, 140–141 problem orientation of, 132 quality, 144–145 Quality of Cognitive Case Formulation Rating Scale and, 144–145 reasons to use, 138 reliability of, 144–145 structured clinical interviews for, 141 systems perspective approach, 132 therapeutic relationship and, 133 training for, 136, 144–145 transdiagnostic interventions and, 148–149 treatment implications of, 143–144 treatment intervention selection and, 137 treatment outcomes and, 145–148 treatment plans and, 133 validation of, 145–146 Case Formulation Content Coding Manual Version 2 (CFCCM v2), 147 Case Formulation Content Coding Method (CFCCM), 144 categorical imperative, 7–8 CBM. See cognitive bias modification (CBM) CBT. See cognitive behavioral therapy (CBT) CBT case formulation. See case formulation CBT for depression (CBT-D), 168 peer consultation groups, 168 CBT Training Consultant Rating Scale, 169 CBT with a well-being focus (CBT-WB), 604

Center for Anxiety and Related Disorders (CARD), 701 chain analysis, 545, 733 chaining, 648–649 backward, 649 forward, 648–649 task analysis and, 648 total task presentation and, 649 chair dialogues, 517–518 change talk, 317, 319, 321, 328, 331 Checklist to Assess Organizational Readiness (CARI) for Evidence-Informed Practice (EIP) Implementation, 162 child-focused exposure-based practice, 294 childhood anxiety CBT and, 293 exposure therapy for, 293 Chomsky, Noam, 13 classical conditioning, 20, 99, 207 bell and pad method for, 20 for fear, 93 claustrophobia, 99 Clinical Global Impression-Improvement Scale (CGI-I), 146 clinical interviews, 143–144 Clinical Outcomes in Routine Evaluation– Short Form (CORE-SF), 147 A Clockwork Orange, 21 Cluster C PDs, 493, 528. See also avoidant personality disorder; obsessive-compulsive disorder (OCD) Cochrane database for systemic reviews, 53 Cochrane Review, 60, 63, 64 cognition, 7, 12, 116–117 automaticity and, 10 cognitive restructuring and, 208 conceptualization of, 37–41 description of, xviii–xix maladaptive, 42 primacy of, 10 process-related perspective and, 39 cognitive appraisal, 39, 43 cognitive architecture, 15 cognitive attentional syndrome (CAS), 620, 622 cognitive behavioral therapists, 181 addressing and, 183 cognitive restructuring and, 189 criticism of, 184 individual differences and, 182–183 psychoeducation, 188–189 social skills modeling and, 190 transference and, 193–194 cognitive behavioral therapy (CBT), 4, 31, 41, 43. See also behavior therapy (BT); dissemination; evidence-based psychotherapy (EBP); internet-based CBT (iCBT); Unified Protocol for



Index  763

Transdiagnostic Treatment of Emotional Disorders (UP) acceptance strategy and, 746 activation therapy and, 746 active behaviors and, 746 agoraphobia and, 60–61 antecedent-focused strategies, 35 antidepressants and, 57 anxiety disorders and, 400 barriers challenging the maximization of, 298 behavioral interventions and, 746 belief rating and, 745 bipolar disorder and, 399–400 case conceptualization and, 733–736, 747–750 chain analysis and, 733 childhood anxiety outcome data and, 293 clinical infrastructure to support, 160 cognitive mechanisms and, 103–114 cognitive reappraisal and, 104–107, 742, 743 cognitive vs. behavioral techniques, 237–239 collaboration and, 180–181 collaborative empiricism and, 746–747 competency-based training for, 158–159 competency in, 159–160, 166–167 computer assisted, 298 constructivism and, 9 contamination of, 159–160 contextual, 35, 40 corruption from persuasion and, 214–215 cost offset associated with, 169 criticisms of, 34–35 definition of, xvi, 32, 34, 417 delivery of by paraprofessionals, 67 depression and, 33, 399, 595 diaphragmatic breathing (DB) and, 356 direct-to-consumer education about, 160 disorder-specific, 293 dysfunctional belief modification and, 107–110 early theoretical developments of, 32–35 effects of, 64–65 efficacy of, 53, 55, 91, 208 efficacy of for mental and behavioral disorders, 157 efficacy of with RCTs, 66 evolution of, xv–xvii exposure therapy and, 113, 275, 746 as family of interventions, 31 first wave of, 51 flexibility of, 32 functional analysis and, 733 generalized anxiety disorder (GAD) and, 59 guided discovery and, 183–184 implementation, 160–165

increasing access to, 67 individualized intervention and, 749 internet-based, 91, 298 interpersonal psychotherapy (IPT) vs, 55–56, 68 knowledge-based training for, 158–159 learning deficits and efficacy of, 96 learning mechanisms and, 92–103 as a learning therapy, 92–93 linking techniques in, 747–750 long-term effects of, 57–58 mean remission rates reported in studies of depressive and anxiety disorders and, 55 mechanisms of action in, 68–69, 96, 98 medication vs, 157 mental imagery and, 113–114 meta-analyses of, 52–53, 731 Mindfulness-Based Cognitive Therapy (MBCT) vs, 602–603 motivational interviewing (MI) and, 321, 326–327 non-trauma-focused, 61 obsessive-compulsive disorder (OCD) and, 62 other therapies vs, 62–63 panic disorder and, 60–61 personality disorders and, 401 pharmacological strategies and, 102 phobias and, 59 placebo vs, 55 process-oriented models of, 40, 45 psychoeducation and, 67 real relationship and, 179 recent theoretical developments of, 35–37 relapse prevention and, 386, 389, 401–403 relaxation vs, 65 response-focused therapeutic interventions and, 35 rumination and, 743 rumination-focused, 112 schema therapy (ST) vs, 529 secondary outcomes reduction in psychotic disorders and, 53 second wave of, 51 self-efficacy and, 106 severe depression and, 56–57 social anxiety disorder (SAD), 59–60, 93, 104–105 subgroups who are more responsive to, 67–68 substance abuse and, 400 symptom remission and, 65 technique selection in, 743 technique use and, 747–749 technology and dissemination of training, 159–160 therapeutic alliance and, 314

764 Index

cognitive behavioral therapy (continued) therapeutic relationship and, 33, 175, 198–200, 736–742 thinking patterns and, 742–745 third wave of, 52 thought records and, 224–225 training in, 298 transdiagnostic, 63 trauma-focused, 61 treatment processes and, 742–749, 747–749 unavailability of, 157–158 unfavorable attitudes toward, 159–160 unfavorable effect of avoidance behaviors on, 99 waves of, xvi–xviii, 51–52 worry and, 743 cognitive behavior modification, 22 Cognitive Behavior Therapy Research Unit (CBTRU), 733 cognitive bias, 107–110 cognitive bias modification (CBM) attention bias modification (ABM) and, 675–676 attention bias modification (ABM) vs. interpretation bias modification (IBM) and, 683 availability gap for effective treatments and, 673 clinical example of, 687–689 combined ABM and IBM treatments and, 684 conditions used for, 674 dissemination and, 687 diverse populations and, 690 goal of, 674 participant engagement and, 687 smartphone-compatible games and, 687 underlying theory of, 674–676 cognitive case formulation, 132–134. See also case formulation cognitive theory and, 132–134 collaborative empiricism and, 134 comparison of models, 135–137 context-oriented, 44 elements of, 133 maladaptive core beliefs, 133 process-oriented, 44 strength-focused approach to, 134 cognitive change, 34, 296, 431–432 bringing about, 36 cognitive behavioral therapy (CBT) treatments to evoke, 41–43, 229 cognitive continuum method, 226 cognitive coping skills, 432 cognitive distancing, 24 cognitive distortions, 419, 715 identification and labeling of, 425–426 cognitive distraction, 447

cognitive errors, examples of common, 425–426 cognitive flexibility, 715 cognitive framework, 213 cognitive fusion, 571, 572 defusion and, 572 cognitive map, 11, 12 cognitive mediation, 32 cognitive model, 4, 34, 419–420, 423. See also generic cognitive model (GCM) automaticity and, 10 behavioral interventions and, 34 cognition as the “proximate” cause, 4 cognitive structures and, 420 content-specificity hypothesis and, 421 depression and, 12, 419 diathesis-stress model and, 420 Ellis's, 14–15 empiricism and subjectivism and, 9 epistemology and, 4–8, 9–10 external reality and, 4 Frankl’s, 14 generic cognitive model (GCM) expansion of, 421 Kelly's, 14 knowledge and, 4–5 neuroscience and, 9 of psychopathology, 16–17 social psychology, depression and, 13 thinking and, 4–5 cognitive processing therapy, 61, 166 shifting and, 41–43 cognitive psychoeducation program (CPE), 606 Cognitive Psychology, 11 cognitive reactivity, 596 cognitive reappraisal, 104–107, 229–230, 741, 742, 743 anxiety disorders and, 106 depression and, 106 social anxiety and, 105 threat reappraisal and, 105 cognitive restructuring, xviii, 34, 37, 39, 189–190 behavioral experiments and, 213 best practices for, 215 cognitive framework and, 213 cognitive reappraisal vs, 229–230 collaborative empiricism and, xviii, 213–214 core belief continua and, 212 core beliefs and, 209, 225–229 description of, 208 diverse populations and, 230–231 downward arrow technique and, 212, 218–220 events encased in cognition and, 208 evidence weighing and, 212 exposure and, 212



Index  765

future directions of, 231–232 groundwork for, 216–217 guided discovery and, xviii, 214 hot thoughts and, 217 main procedures of, 212–227 mediating thoughts and, 217 mood and thought association and, 216 outcome data and, 228–229 schema and, 209 selecting targets for, 217–218 Socratic dialogue and, xviii, 212, 220–224 theoretical premises of, 208 therapeutic relationship and, 189 thought records and, xix, 216, 224– 225, 425 underlying theory of, 208–212 cognitive revolution, 10–16 cognitive model of psychopathology and, 16 cognitive processes and, 10–11 major developments in, 11 primacy and, 10 cognitive techniques, 505, 511–512. See also cognitive restructuring; problem solving cognitive therapy (CT), xv–xvii, 3, 4, 31, 117, 417. See also mindfulness-based cognitive therapy anxiety disorders and, 430–431 automatic thoughts and, 424 behavioral self-monitoring, 428 behavioral therapy vs, 237–239 case conceptualization and, 423 cognitive change and, 431–432 cognitive coping skills and, 432 cognitive model and, 423 cognitive restructuring and, 208 collaborative empiricism, 426–427 continuation CT, 401 correction of cognitive distortions and, 424 deconstructionism and, 9 depression and, 430 dichotomous thinking and, 433 dissemination and, 434 distancing and, 424 distinctive elements of, 419 diverse populations and, 435 downward arrow technique and, 426 emergence of, 207–208 focus of, 36 founder of, 9 guided discovery and, 427 history of, 418–419 homework and, 429 main procedures of, 423–429 maladaptive thought processes and, 424 mechanism of change and, 431–433 mindfulness-based, 31

outcome data and, 429–431 philosophical foundations of, 4–9, 7 positive cognitive compensatory strategies and, 432 psychosis and, 431 rational response and, 425 recognition of idiosyncratic cognitions, 424 relapse prevention and, 386 scaffolding approach to, 424 Socratic questioning and, 427 therapeutic interview and, 423 therapeutic relationship and, 428–429 therapeutic techniques of, 424–425 thought records and, 425 Treatment of Depression Collaborative Research Project (TDCRP) and, 429 underlying theory of, 419–423 Cognitive Therapy of Depression, 237 Cognitive Therapy Rating Scale (CTRS), 169, 180 collaboration, 180–181, 740 ruptures to, 191 collaborative empiricism, xviii, 134, 213–214, 426–427, 746–747 components of, 746 guided discovery and, 214 Columbia University Teachers College, 462 Combined Behavioral Intervention (CBI), 324–327 generalized anxiety disorder (GAD) and, 325–327 committed action, 574, 582–584 Community Behavioral Health (CBH), 434 community treatment by experts (CTBE), 550 compassion, 319 competency-based training, 158–159, 159–160, 165, 168 competitive memory training, 52 complex reflections, 320 comprehensive distancing, 64, 568–569 computer administered behavioral activation (CBA), 329 conditioned reflex, 18–22 conditioned reinforcers, 660 conditioned response (CR), 277, 645 conditioned stimulus (CS), 18–22, 93, 95, 275, 277, 645. See also stimulus safety cue and, 95 conditioning. See also classical conditioning deconditioning and, 19 differential, 96 Little Albert experiment and, 19 operant, 20, 207 Pavlovian, 20 single cue, 96 congnitive processing and emotions, 107 consciousness, 10

766 Index

consequent strategies, 657 constructivism, 9, 12–13 knowledge and, 12 consultation team, 548, 559 phenomenological empathy agreement and, 548 contact with the present moment, 573, 581–582 contemporary cognitive behavioral therapy (CBT), 732–733 content-specificity hypothesis, 42, 421 context-oriented conceptualizations, 44 contextual CBT. See acceptance and commitment therapy (ACT) contextualism, 24, 238 contingency contracts. See behavioral contracts continuous recording, 639 dimensions measured and, 639 Control Your Depression, 237 coping, 468 emotion-focused, 468 methods of, 497 problem-focused, 468 skills, 114–115 styles, 496 Coping With Depression, 237 core beliefs, xviii, 209, 219–221, 225–227, 226. See also schema cognitive continuum method and, 226 continua, 212 correction of cognitive distortions, 424 corrective emotional experiences and ruptures, 192 cortisol, 354 countertransference, 179, 193–194 creative hopelessness, 576–577 crisis service utilization, 551 CT. See cognitive therapy (CT) Cultural Formulation Interview for DSM-5, 141 Culturally Informed Functional Assessment, 141

D Daily Record of Dysfunctional Thoughts. See thought, records Darwin’s evolutionary theory, 18, 20, 25 DB. See diaphragmatic breathing (DB) DBT. See dialectical behavior therapy (DBT) DBT-LBC certification, 557 DBT replication (DBT-R), 550 CTBE vs, 550 DBT Skills Training Manual, 547 D-cycloserine (DCS), 102, 295 decentering, 12, 37 deconditioning, 19 deconstructionists, 9

deepened extinction, 286 defusion, 24, 572, 579–581 delayed emergence effect, 401 Delphi process, 165 Department of Veterans Affairs (VA), 166 CBT for PTSD and, 166 direct-to-consumer outreach strategies for EBPs, 167 dissemination of PST-based programs and, 484 evidence-based systems and, 166 national EBP public awareness website (veteran portal) and, 167 recovery-oriented system and, 166 Treatment Works For Vets platform, 167 depression, 33, 51, 52 antidepressant medication (ADM) and, 595 avoidance behavior and, 100 behavioral activation and, 235 behavioral approach to reversing cycle of, 242 cognitive model and, 419 cognitive reactivity and, 596 cognitive reappraisal and, 106 cognitive therapy (CT) and, 430 disability from, 595 dysphoria and, 596 maintenance antidepressant medication (mADM) and, 596 metacognitive therapy (MCT) and, 619 mood-related cognitive changes and, 596 pharmacotherapy for, 429 phases of, 399 positive affect and, 702 predictors of relapse for, 390 problem-solving therapy (PST) and, 474 recurrence of, 398, 595 relapse signature and, 600 relapse toolkit for, 600 rumination and, 111 severe, 56–57 treatments for acute phase, 595 Depression Anxiety Stress Scales, 326 Depression-Relapse Active Monitoring (DRAM), 609 Descartes, Rene, 7 desensitization, systematic, 276 detached mindfulness (DM), 624–626 free association task and, 624–625 tiger task and, 625–626 worry/rumination postponement and, 624–626 determinant frameworks, 163 diagnosis-specific therapy, 41–43 Diagnostic and Statistical Manual of Mental Disorders (DSM), 140, 527, 603 Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 53



Index  767

Diagnostic and Statistical Manual of Mental Disorders (DSM-III), 701 diagnostic imagery, 518, 520 dialectical behavior therapy (DBT), 4, 24, 52, 349, 350. See also DBT replication (DBT-R) for adolescents, 554 aspects of treatment, 541–543 biological vulnerabilities and, 541 borderline personality disorder (BPD) and, 371–378, 539, 540–542, 549–550 case study of, 557–559 certification in, 556–557 comorbid BPD and PTSD and, 553 components of treatment, 373, 542–548 consultation team and, 548, 559 crisis service utilization and, 551 DBT-LBC certification and, 557 description of, 539 dialectics and, 541–543 dissemination and, 556–557 diverse populations and, 554 eating disorders and, 553 efficacy of, 549–552 emotional escalation and, 542 emotion dysregulation and, 539, 552 emotion regulation and, 376, 553, 555–556 frames of, 541–543 Harborview Mental Health Services (HMHS DBT) and, 551 history of, 539–541 individual therapy and, 543–546, 558 invalidation and, 541–542 mechanisms of change in, 555–556 phone coaching and, 547, 558 quality-of-life (QOL) outcomes from, 550 randomized controlled trial (RCT) for, 549–551 self-control and, 555–556 skills group and, 547, 559 stages of treatment, 542 style of, 548–549 substance use BPD (S-DBT) and, 552–553 suicide and, 539 training in, 557 as a transdiagnostic treatment, 552–554 uncontrolled trials (real world settings) and, 551 validation and, 549 Zen practice and, 540–542 dialectics, 541 diaphragmatic breathing (DB), 355–362 clinical procedures for, 356–357 cognitive behavioral therapy (CBT) and, 356 combining PR, DB, and mindfulness-based approaches, 369–372

dissemination and, 358–360 exposure therapy and, 360 focusing strategy for, 357 generalized anxiety disorder (GAD) and, 356, 359 history of, 356 improved respiratory and physiological regulation and, 358 mechanisms of change in, 358–360 panic disorder and, 356, 360 respiratory physiological mechanisms of, 358–359 diary card, 543, 544, 546 diathesis-stress model, 38, 420 dichotomous thinking, 433 differential conditioning, 96 differential reinforcement, 655 extinction vs, 655 types of, 655 differential reinforcement of alternative behavior (DRA), 655–656 functional communication training (FCT) and, 655 goal of, 655 differential reinforcement of low rates of behavior (DRL), 655, 656–657 full-session, 656 spaced-responding, 656–657 differential reinforcement of other behavior (DRO), 655, 656 functional assessment and, 656 reinforcers and, 656 direct observation assessments, 652–653 advantages and limitations of, 653 descriptive ABC recording and, 652 goal of, 652 direct-to-consumer education, 160 Discourse on Method, 7 discrimination training. See stimulus discrimination training discriminative stimulus (SD), 644 disorder-specific CBT, 293 disorder-specific model, 41, 507 disorder-specific treatment vs. transdiagnostic treatment, 63 disputing, 454 logical, 454 pragmatic, 454 realistic, 454 disruption, 373 dissemination acceptance and commitment therapy (ACT) and, 588–589 behavioral activation (BA) and, 236, 260–262 cognitive bias modification (CBM) and, 687 cognitive therapy (CT) and, 434 definition of, 161

768 Index

dissemination (continued) Department of Veterans Affairs (VA) and, 166 dialectical behavior therapy (DBT) and, 556–557 diaphragmatic breathing (DB) and, 358–360 emotion-centered problem-solving therapy (EC-PST) and, 484–485 exposure therapy and, 296–299 frameworks and models, 163–165 implementation vs, 161 interpretation bias modification (IBM) and, 687 large health care systems and, 165–169 metacognitive therapy (MCT) and, 632 mindfulness-based cognitive therapy (MBCT) and, 608–609 mindfulness-based stress reduction (MBSR) and, 365–367 motivational interviewing (MI) and, 333–334 multilevel approach to, 166 progressive relaxation (PR) and, 355 provider-level barriers, 158–159 relapse-prevention therapy (RP) and, 402 schema therapy (ST) and, 531 Treatment Works For Vets platform and, 167 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 705, 725 diverse populations acceptance and commitment therapy (ACT) and, 589–591 cognitive restructuring and, 230–231 cognitive therapy (CT) and, 435 dialectical behavior therapy (DBT) and, 554 exposure therapy and, 299–300 metacognitive therapy (MCT) and, 631 mindfulness-based cognitive therapy (MBCT) and, 609 motivational interviewing (MI) and, 333–334 rational emotive behavior therapy (REBT) and, 461 schema therapy (ST) and, 527, 532 DM. See detached mindfulness (DM) double-sided reflections, 320 downward arrow technique, 212, 218– 220, 426 introduction and explanation of, 219–221 dynamic structuralism, 9 Dysfunctional Attitudes Scale, 142 dysfunctional beliefs, 107–110 dysfunctional child modes, 498 dysfunctional coping modes, 499 dysfunctional parent modes, 499, 501

dysfunctional schema modes, 493 dysphoria, 596 dysregulation (severe emotion), 539

E early maladaptive schemas, 493, 495–497 eating disorders, 115–116, 530, 553 dialectical behavior therapy (DBT) for, 553 EBP. See evidence-based psychotherapy (EBP) EBP Shared Decision-Making Toolkit for Mental Health Providers, 167 Ego Psychology movement, 15–16 Ellis, Albert, 7, 14–15, 445–458 development of CBT and, 51 Ellis model, 11 feminism and, 450 rational-emotive theory of, 34 sexual revolution and, 449 emotional avoidance, 43 emotional bond, 177, 186–187 emotional control, 97 emotional dysregulation, 475, 482, 553 overcoming, 479–480 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 703 emotional expression, 43 emotional mental imagery, 113–114 exposure therapy and, 113 imagery rescripting and, 114 emotional mindfulness, 480 emotional processing theory, 24 emotional sensitivity, 702 emotional suppression, 35 emotion-centered problem-solving therapy (EC-PST), 473 clinical example of, 480–483 dissemination and, 484–485 enhancing motivation for action toolkit and, 479 ethnically diverse populations and, 485 guided practice and, 480 mechanisms of change in, 484 planful problem-solving toolkit, 477–478 problem-solving multitasking toolkit, 478–479 skills for, 478–479 stop and slow down toolkit and, 479–480 toolkits for, 475 emotion dysregulation, 350, 371, 373, 539, 552, 553, 555, 556, 703 biosocial model of, 541 pervasive, 373–374 severe, 539 vulnerabilities to, 374



Index  769

emotion regulation, 35, 104, 229–230, 349, 350, 372, 555–556 antecedent focused, 35 dialectical behavior therapy (DBT) and, 371–378, 376 disruption of, 373 emotional cues for, 35 manipulation of experience of emotions and, 35 mindfulness-based stress reduction (MBSR) and, 365 response focused, 35 skills, 350, 372–373 social responses and, 375–376 steps of, 374 emotions, 4. See also negative emotions cognitive processing and, 107 emotion-focused coping, 468 emotion-focused objectives, 477–478 emotion-regulation training, 482–483 exposure to, 720–722 healthy negative, 453, 455 knowledge vs, 5 Stoics and, 7 unhealthy negative, 453 empathy, 180 empathic confrontation, 515–517 empathic listening, 222 expressed, 179 Empathy Reconsidered: New Directions for Psychotherapy, 549 empirically supported treatments (ESTs), 297 empiricism, 8 empty chair technique, 223 Enchiridion, 6 end-tidal CO2, 361 Enhancing Motivation for Action, 475 Enhancing Motivation for Action toolkit, 479 Environmental Reward Observation Scale (EROS), 257 Epictetus, 6, 14 epistemology, 4–8 cognitive, 7–8 cognitive model and, 9–10 cornerstone of, 7 genetic, 12 innate ideas and, 5 logical positivism and, 8 Essay Concerning Human Understanding, 8 eudemonia, 6 evidence-based interventions, 41–43 evidence-based practice (EBP), 41, 673 case conceptualization and, 41 evidence-based psychological treatments (EBPTs), 703 evidence-based psychotherapy (EBP), 157–158

direct-to-consumer outreach for, 167 engagement strategy for, 167 factors contributing to the low uptake and delivery of, 167 national EBP public awareness website (veteran portal), 167 evidence weighing, 212 evoking, 319 existentialism, 14 expectancy violation, 285 experiential avoidance, 40, 44, 572 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 703, 715 experiential techniques, 505, 516–522 chair dialogues and, 517–518 historical role play and, 522–523 imagery exercises and, 518–522 experimental neurosis, 21 experimental science and behaviorism, 23 explanatory style and attribution theory, 13–14 exposure therapy, xx–xxi, 24, 97, 113, 199, 212, 275 behavioral experiments and, xxi children and, 284 clinical example of, 300–302 cognitive change and, 296 delivery methods, 287–288 desensitization and, 276 deviation from protocol and, 297 diaphragmatic breathing (DB) and, 360 different medical conditions and, 299–300 dissemination and, 296–299 diverse populations and, 299–300 dropout and, 297 emotional mental imagery and, 113 exercises, 43 exposure with response prevention (ERP) and, 276 fear hierarchy development and, xx, 278–280 fieldwork and, 287 gradual, 448 habituation and, 275 history of, 275–276 imagery and, 282–283 imaginal, xx implementation of, 297 inhibitory learning model and, 278, 285, 285–287 initiating exposure and, 300–301 inpatient and residential, 287 interoceptive, xx interoceptive exposure and, 284 in vivo exposure and, xx, 282 litigation and, 297 mechanisms of change in, 295–296 multiple contexts for, 286

770 Index

exposure therapy (continued) muscle relaxation and, 276 obsessive-compulsive disorder (OCD) and, 275, 276–277 in office, 287 outcome data and, 288–295 parent-coached, 294 Pavlov and, 275 posttraumatic stress disorder (PTSD) and, 275, 277 prolonged exposure (PE) and, 283–284 remote treatment and, 288 separation anxiety disorder (SAD) and, 294 social cost exposure and, 291 telehealth and, 288 theory underlying of, 277–278 trauma and, 283–284 virtual reality, xx virtual reality exposure and, 284–285 exposure with response prevention (ERP), 117, 276, 326 obsessive-compulsive disorder (OCD) and, 283 expressed empathy, 179 externalization, 478–479 extinction, 295, 642–643, 645, 654 bursts, 643, 654 consistency and, 654 maintaining reinforcers and, 654 process, 277 reinforcement during the process of, 643 reinforcement schedule and, 643 reinforcers and, 654 safety and, 654 spontaneous recovery and, 643 extinction learning, 93–96 amygdala and, 96 brain activation during, 96, 97 fear habituation vs, 98 habitual response and, 99 measurement of, 98 neural bases of, 96 pharmacological enhancers of, 102–103 protection from, 99 eye-movement desensitization and reprocessing (EMDR), 61

F fading. See stimulus prompt fading false alarms, 98 fear acquisition, 95, 99 associations, 94 avoidance behavior and, 99 habituation vs. extinction learning, 98 hierarchy, xx, 278–280 inhibition learning, 24

network, 96 reduction, 277 reinstatement, 94 renewal, 94 spontaneous recovery from, 94 stimulus and virtual reality, 59 fear conditioning, 19, 96 extinction model and, 93–94 graph of, 93 studies of, 94–98 terms and abbreviations used in, 95 fear extinction, 93–96 generalization and, 102 overgeneralization and, 101 fear learning, 96 avoidance and, 99–100 cognitive behavioral therapy (CBT) outcome and, 97–98 generalization and, 101–102 as a mechanism of change in cognitive behavioral therapy (CBT), 97 feedback, 181–182, 650 feminism, 450 Ferster, C. G., 33, 239 formal operational thinking, 12 forward chaining, 648–649 frameworks, 163–165 classification of, 163 determinant, 163 dissemination and implementation of, 163 Theoretical Domains Framework, 165 Frankl, Victor, 14 free association task, 624–625 Friday Night Workshops, 451 From Death-Camp to Existentialism, 14 full-session DRL, 656 functional analysis, 238, 653, 733 reinforcers and, 653 target behavior and, 653 functional assessment, 651–652 differential reinforcement of other behavior (DRO) and, 656 direct observation assessments and, 652–653 functional analysis and, 653 functional approach to intervention and, 654–657 indirect assessments and, 652 methods for conducting, 652–654 reinforcement contingencies and, 652 functional communication training (FCT), 655–656 functional contextualism, 569–575

G GAD. See generalized anxiety disorder (GAD) gateway, 218–220



Index  771

GCM. See generic cognitive model (GCM) Gelso, Charles, 179 generalization, 644–645. See also promoting generalization fear learning and, 101–102 self-generated mediator of, 663 generalized anxiety disorder (GAD), 58–59, 108, 605 Combined Behavioral Intervention (CBI) for, 325–327 diaphragmatic breathing (DB) and, 356, 359 exposure techniques for, 113 exposure therapy and, 290 metacognitive model of, 619 patients and worry, 111 general mode approach, 507 generic cognitive model (GCM), 37–39, 44, 421–423 adaptive functioning and, 422 automatic processing subsystem and, 422 cognitive model vs, 421 cognitive schemas and, 422 maladaptive functioning and, 422 motivations and, 38 negative bias and, 422 positive bias and, 422 reflective processing subsystem and, 422 schemas and, 38 self-expansive mode and, 422 self-protective mode and, 422 Generic Implementation Framework (GIF), 164 generic models, 45 genetic epistemology, 12 Good Practice Guidelines on the Use of Psychological Formulation, 150 group schema therapy (GST), 528 clinical effectiveness of, 528 cost-effectiveness of, 528 The Guest House, 364 guided discovery, xviii, 5, 183–184, 214, 221, 427 collaborative empiricism and, 214 stages of, 427 guided practice, 480

H habituation, 24, 275 Haigh, E. A., 37 HAM-A. See Hamilton Rating Scale for Anxiety HAM-D. See Hamilton Rating Scale for Depression (HRSD) Hamilton Rating Scale for Anxiety, 724 Hamilton Rating Scale for Depression (HRSD), 55–56, 604, 724

Hanson, Norwood Russell, 9 Harborview Mental Health Services (HMHS DBT), 551 harm avoidance, 702 Hartmann, Heinz, 15–16 Hayes, Steven C., 568–569 Health Enhancement Program (HEP), 609 Health Survey Version 2, 141 healthy modes, 499 adult, 502 healthy negative emotions, 453, 455 heart rate variability (HRV), 354 progressive relaxation (PR) and, 354 hedonism, 18–19 helplessness, learned, 13 heuristics, 11 hexaflex, 575 hierarchy development, 300 hippocampus, 96 historical role play, 522–523 homework, 479 importance of, 429 homograph tasks, 680 hopelessness, 475 overcoming, 479, 483 Horney, Karen, 448 hot thoughts, 217, 224 hydrocortisone, 103 hyperventilation, 356, 358, 360, 361 voluntary, 357 hypocapnia, 356, 360, 361 hyperventilation-induced, 362 hypochondriasis, 64 motivational interviewing (MI) for, 326 hypoxia, 358

I idealism, 5 idiosyncratic cognitive schema (ICS), 145–146 imagery, 282–283 diagnostic imagery exercises, 518 exercises, 518–522 generalized anxiety disorder (GAD) and, 290 in vivo exposure and, 283 rescripting, 114, 518, 520–521, 530 rescripting, phases of, 520–521 visual, 478–479 immunoglobulin, 354 implementation, 160–165. See also preimplementation Beck Community Initiative (BCI) and, 168 behavioral activation (BA) and, 260–262 bottom-up, 168 characteristics of effective, 162

772 Index

implementation (continued) Checklist to Assess Organizational Readiness (CARI) for Evidence-Informed Practice (EIP) Implementation, 162 computer-asssited, 298 definition of, 161 Department of Veterans Affairs (VA) and, 166 determinant, 163 dissemination vs, 161 distinguishing characteristics of, 161 exposure therapy and, 297 frameworks and models and, 163–165 Generic Implementation Framework (GIF), 164 large health care systems and, 165–169 multilevel approach to, 166 organizational readiness domains of, 163 patient-level barriers and, 167 process, 163–165 psychometric data for, 162 pull strategies for, 166 push strategies for, 166 research-to-practice gap and, 166 science, 161, 163, 166 stakeholders in, 161 strategies, 165 tailoring, 164 top-down, 168 Treatment Works For Vets platform and, 167 in the United Kingdom, 167 implicit associations, 109 Improving Outcomes and Preventing Relapse, 386 indirect assessment, 638, 652 individual therapy, 543–546 attendance agreements form and, 544 chain analysis and, 545 life-interfering behaviors and, 545 pretreatment, 543 quality-of-life interfering behaviors and, 545 secondary targets and, 546 skills group and, 545 skills training agreement form and, 544 Stage 1, 544–546 suicidal behaviors agreement form and, 544 target behaviors and, 544 therapy agreements form and, 544 therapy interfering behaviors agreement form and, 544 therapy-interfering behaviors and, 545 inferior frontal gyrus (IFG), 97 informational questions, 221 informed consent, 161 informed interventions, 41 inhibition learning theory, 24

inhibitory learning model, 94, 278, 285–287 affect labeling and, 287 deepened extinction and, 286 expectancy violation and, 285–286 exposure in multiple contexts and, 286 in multiple contexts, 286 occasional reinforced extinction and, 286 removal of safety cues and, 286 variability and, 286 initiating exposure, 300–301 inoculation training, 61 in situ training, 650 Institute of Rational Therapy, 450 The Institute of Social Neuroscience, 733 instrumental learning, 99 avoidance behavior and, 99 insula, 96, 97 integrated behavioral therapy (IBT), 294 selective mutism (SM) and, 294–295 intelligence figurative, 12 operative, 12 intention-to-treat (ITT) analyses, 604 intermittent reinforcement, 643 internal working model, 16–17 International Classification of Diseases (ICD), 140 International Conferences on Motivational Interviewing, 333 International Society for Schema Therapy (ISST), 531 internet-based CBTs (iCBTs), 67, 91 mindfulness-based cognitive therapy (MBCT) and, 608 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 705 interobserver agreement (IOA), 640 interoceptive exposure, 284, 289 agoraphobia and, 290 interpersonal effectiveness skills, 372 interpersonal psychotherapy (IPT), 53, 55–56, 186, 429 cognitive behavioral therapy (CBT) vs, 55 relapse prevention and, 399 interpersonal relationships, 191 interpretation bias, 108 interpretation bias modification (IBM), 676. See also biases ambiguous information and, 676 ambiguous scenarios paradigms and, 679 attention bias modification (ABM) vs, 683 automatic interpretation biases and, 684 dissemination and, 687 efficacy of, 683–684 goal of, 676 homograph tasks and, 680 mechanisms of change in, 686 novel programs and, 680 probe detection task and, 676



Index  773

smartphones and, 680 word-sentence association paradigm (WASP) and, 680 interval recording, 639–640 invalidation, 541–542 in vivo desensitization, 448, 456 in vivo exposure, 282 imagery and, 283 IPT. See interpersonal psychotherapy (IPT) irrational thinking, 453

J Jacobson, Edmund, 350 Jarret, Robin, 401 Jones Intentional Multicultural Interview Schedule, 141 Jones, Mary Cover, 19 Journal of Applied Behavior Analysis, 22 Journal of Contextual Behavior Science (JCBS), 588

K Kabat-Zinn, Jon, 350, 363, 366 Kaiser Permanente, 168 Kant, Emmanuel, 7–8 schemas and, 7–8 Kelly, George, 14–15 cognitive therapy and, 9 knowing. See epistemology knowledge based training, 158–159 constructivism and, 12 emotion vs, 5 phenomenological theories of, 8 platonic understanding of, 5 relativistic, 8 theory of, 5 Korzybski, Albert, 454 Kuhn, Thomas, 9

L language, 39, 44 acquisition device, 13 bidirectional property of, 39 games, 8 generative function of, 13 rule-guided transformations in, 13 Language and Mind, 13 large health care systems, 165–169 late positive potential (LPP), 684 law of effect, 18–22 Lazarus, Arnold, 445–446 Lazarus, Richard, 10 learned helplessness, 13 learning associative, 18–22

deficits, 96 early theory, 17–21 fear inhibition, 24 habitual, 99 inhibitory, 94 language, 13 mechanisms, 92–103 observational, 19–20 place, 11 response, 11 stimulus relations and, 12 theory, 10, 16–17, 278 therapy, 92–93 vicarious, 32 Lewinsohn, Peter, 33, 236–238 Liebowitz Social Anxiety Scale (LSAS), 688 limited reparenting, 493, 513–515, 530 limit setting, 741 Linehan, Marsha, 350, 371, 539 Linehan’s dialectical behavior therapy, 733–734 Little Albert experiment, 19 Living School, 451 Locke, John, 8, 20 Platonic model, rejection of, 8 logical empiricist, 19 logical functional analysis, 145–148 logical positivism, 17 behaviorism and, 17 challenges to, 8–9 core tenets of, 8–9 Wittgenstein's rejection of, 8–9 Love and Marriage Problems (LAMP) Institute, 449 low frustration tolerance, 7, 14 low-intensity CBT, case formulations and, 148

M maintaining reinforcers and extinction, 654 maintenance. See relapse prevention maintenance antidepressant medication (mADM), 596 major depressive disorder (MDD), 595 phases of, 595 maladaptive cognitions, 42, 44, 105 maladaptive coping modes, 501 maladaptive core beliefs, 133. See also core beliefs maladaptive functioning, 422 maladaptive schema. See also schema activation of, 496 classification of, 496 coping styles for, 496 maladaptive systems, 37 maladaptive thought processes, 424 mania, 38 Man’s Search for Meaning, 14

774 Index

Marlatt’s model, 387 MBCT. See mindfulness-based cognitive therapy (MBCT) MCT. See metacognitive therapy (MCT) mechanism hypotheses, 142 clinical interview and, 143–144 Dysfunctional Attitudes Scale and, 142 origins and precipitants of, 142–143 Young Schema Questionnaire – Short Form and, 142 mechanisms of action, 96 cognitive behavioral therapy (CBT) and, 98 mechanisms of change, 116–117 cognitive reappraisal, 104–107 cognitive therapy (CT) and, 431–433 comparison of different types of, 116–117 coping skills as, 114–115 dialectical behavior therapy (DBT) and, 555–556 identification of, 91–92 mental imagery and, 113–114 mindfulness-based cognitive therapy (MBCT) and, 606–608 mindfulness-based stress reduction (MBSR) and, 365 motivational interviewing (MI) and, 330–333 rumination and worry and, 112 schema therapy (ST) and, 530–531 structural evaluation of, 92 medial prefrontal cortex (mPFC), 365 mediation, 35, 158–159 analysis, 587–588 mediating thoughts, 217 mediators and, 92 models, 33 Medical Research Council U.K., 630, 632 meditation, 362–367, 460 3-minute breathing space, 598 3-minute coping space, 599 body scan, 598 brief mindfulness of seeing and/or hearing, 599 choiceless awareness and, 364 descriptions of, 598–599, 599–600 formal, 597 hatha yoga stretches and, 364–369 informal, 597 mindful eating, 598 mindfulness meditation interventions, 362–367 mindfulness of daily activities, 598 mindful stretching (Hatha yoga), 598 sitting meditation (focused attention, 598 sitting meditation (open monitoring), 598 walking as, 364–369, 598 Meichenbaum, Donald, 22 memory

bias, 109 competitive training of, 52 false, 12 positive vs. negative information and, 107 rumination and, 110 schema theory and, 11–12 trait concepts and, 11 Meno, 5 mental disorders, etiological models of, 42 mental imagery, 113–114 negative, 113 mentalism, 17 metacognition, 36, 617, 620 metacognitive awareness, 626 metacognitive beliefs, 617 danger related, 623–624 types of, 621 metacognitive change, 617, 622 metacognitive knowledge, 620 types of, 621 metacognitive processes, 617 metacognitive skills, 596 metacognitive therapy (MCT), 4, 35, 35–37, 40, 44, 59, 617, 743 attention training technique (ATT) and, 627–628 bulimia nervosa and, 619 cancer survivors and, 629 case formulation and, 622 cognitive behavioral therapy (CBT) vs, 619, 629, 631 cognitive therapy and, 619 cost-effectiveness of, 630 depression and, 619 dissemination and, 632 diverse populations and, 631 efficacy of, 629–630 generalized anxiety disorder (GAD) and, 629 history of, 617–619 main procedures of, 622–628 mechanisms of change in, 630–631 metacognitive change and, 622 negative automatic thoughts and, 622 obsessive-compulsive disorder (OCD) and, 619, 629, 631 outcome data and, 628–630 posttraumatic stress disorder (PTSD) and, 619 rumination and, 623 schema theory and, 619 self-regulatory executive function (S-REF) and, 617, 620–621 specialist training for, 632 structure of, 619 as a transdiagnostic therapy, 630 uncontrollability beliefs modification and, 623 underlying theory of, 620–621



Index  775

worrying and, 623 methylene blue, 103 Meyer, Victor, 21 Miller, George, 10–11 Miller, William, 315 mindful eating, 598 Mindful Mood Balance (MMB), 608 mindfulness, 35, 44, 712. See also mindfulness meditation; mindfulness-based cognitive therapy (MBCT) basic elements of, 363 of daily activities, 598 definition of, 362–363 information about, 366 interventions, 362–367 psychological components of, 371 stretching (Hatha yoga), 598 training, 365, 597–599 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 712 mindfulness-based cognitive therapy (MBCT), 36, 40, 52, 57, 105, 112, 149, 350, 363, 367, 597. See also mindfulness-based interventions (MBIs) 3-minute breathing space and, 597 assessment and eligibility and, 600–601 case formulation and, 149 childhood trauma and relapse prevention, 606 cognitive behavioral therapy (CBT) vs, 602–603 cognitive behavioral training and, 599–600 cognitive psychoeducation program (CPE) vs, 606 components and structure of, 597–603 depression and, 605 depression-relapse active monitoring (DRAM) and, 609 depressive relapse and, 603, 604–605 dissemination and, 608–609 diverse populations and, 609 efficacy of, 367 generalized anxiety disorder (GAD) and, 605 instructor qualification and, 601 intention-to-treat (ITT) analyses and, 604 internet-based treatments and, 608 mechanisms of change and, 606–608 meditative practice taught in, 597–599 mindfulness training and, 597–599 momentary positive emotions and, 607 outcome data and, 603–605 recurrence and, 57–58 relapse prevention and, 402, 605 rumination reduction and, 112

session structure, 601–602 TAU vs, 605 mindfulness-based eating-awareness therapy (MB-EAT), 367 mindfulness-based interventions (MBIs), 349. See also mindfulness-based cognitive therapy (MBCT) efficacy of, 64 hypochondriasis and, 64 origins of, 350, 362 prevention of relapse in recurrent depression and, 64 mindfulness-based relapse prevention for substance use (MB-RP), 367 mindfulness-based stress reduction (MBSR), 350, 363, 402, 597 applications, 365–367 Campbell Systematic Review of, 366 combining PR, DB, and mindfulness-based approaches, 369–372 depressive relapse prevention and, 350 dissemination and, 365–367 efficacy of, 366 emotion regulation and, 365 mechanism of change and, 365 mind-body connections and, 350 mind-body medicine and, 367 procedures for, 364 relapse prevention and, 402 A Mindfulness-Based Stress Reduction Workbook, 366 mindfulness-mediated stress responses, 365 Mini-International Neuropsychiatric Interview (MINI), 141 The Miracle of Mindfulness, 371 MI-SafeCope, 329 modeling, 649 prompt, 646 mode model, 505 approach, 498 case conceptualization and, 506–510 disorder-specific, 507 general mode approach and, 507 modes abandoned, abused child, 500 angry/enraged child, 500 angry protector, 501 attention- and approval-seeking, 502 avoidant protector, 501 bully and attack, 502 categories of, 498–499 compliant surrender, 501 demanding parent, 501 dependent child, 500 detached protector, 501 detached self-soother, 501 dysfunctional child, 498 dysfunctional coping, 499

776 Index

modes (continued) dysfunctional parent, 499 happy child, 500 healthy, 499 impulsive, 500 lonely child, 500 perfectionistic overcontroller, 502 punitive parent, 501 Schema Mode Inventory (SMI) and, 500 self-aggrandizer, 502 suspicious overcontroller, 502 therapeutic tasks for, 502–504 undisciplined, 500 Mood Coach, 261 Moodivate, 261 motivating operations (MOs), 642 abolishing operations type, 642 establishing operations type, 642 motivational interviewing (MI), 329 acceptance and, 319 addictive behaviors and, 322–325 change talk and, 317, 319, 321 clinical example of, 335 cognitive behavioral therapy (CBT) and, 321, 326–327 compassion and, 319 complex reflections and, 320 components of, 317 computer administered behavioral activation (CBA) and, 329 core skills of, 320 cultural adaptations of, 334 definition of, 318 description of, 314–316 discord and, 319 dissemination and, 333–334 diverse populations and, 333–334 double-sided reflections and, 320 elements of its spirit, 318 engaging and, 319 evoking and, 319 exposure with response prevention (ERP) and, 326–327 focusing and, 319 generalized anxiety disorder (GAD), 325–327 goal of, 316, 317 history and evolution of, 316–318 hypochondriasis and, 326 limitations of measuring, 332–333 main procedures of, 318–321 mechanisms of change in, 330–333 minority groups and, 333–334 outcome data and, 321–329 outcome data variability and, 330 partnership and, 318–319 planning and, 319 principles to guide clinical practice for, 317

problem-focused orientation of, 315 reflective listening and, 314, 320 relapse prevention and, 388, 390 relational hypothesis for, 331 relational pathway in, 317 safety planning and, 329 simple reflections and, 320 suicide prevention and, 328–330 sustain talk and, 317, 319, 321 technical hypothesis for, 331 technical pathway in, 317 training in, 333 as a transdiagnostic intervention, 318 Motivational Interviewing Network of Trainers (MINT), 333 Motivational Interviewing Skill Code (MISC), 332 Motivational Interviewing Treatment Integrity (MITI) scales, 332 motivation and generic cognitive model (GCM), 38 Motivation and Problem Solving (MAPS), 325–328 posttraumatic stress disorder (PTSD) and, 327 Moving Forward therapists, 484 Mowrer, O. H., 20 Mowrer, W. M., 20 muscle relaxation. See progressive relaxation (PR)

N Nagel, Thomas, 9 naltrexone, 324–327 national EBP public awareness website (veteran portal), 167 National Institute for Health and Care Excellence (NICE), 260 National Institute for Health and Clinical Excellence (NICE), 367 National Registry of Evidence-Based Programs and Practices (NREPP), 366 natural reinforcer, 649 natural selection, 18 negative affect, 52, 703, 724 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 724 negative attention filter, 675 negative bias, 37, 422. See also biases negative emotions awareness of, 480 managing, 479–480 stimulus-response association and, 480 unhealthy, 453 negative interpretation bias, 108 social anxiety and, 108 negatively reinforced behavior, 40



Index  777

negative metacognitive belief (NMB), 621 disorder specific, 621 modification of, 622–623 thought-action fusion and, 621 thought-event fusion, 621 thought-object fusion and, 621 types of, 621 negative reinforcement, 239, 642, 655 differential reinforcement of alternative behavior (DRA) and, 655 negative repetitive thinking, 110–112. See also rumination worry and, 110 Neisser, Ulric, 11 network meta-analysis, 60 neuroimaging, 68 neuroscience and cognitive model, 9 neuroticism, 702 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 703 neutral stimulus (NS), 645 New Harbinger, 589 Nicomachean Ethics, 6 NMB. See negative metacognitive belief (NMB) N-methyl-D-aspartate (NMDA) pathways, 295 nociceptive flexion reflex (NFR), 355 nonadherence, 139 nonexclusionary time-out, 658 nonjudgment awareness, 712–714 nonsuicidal self-injury (NSSI), 549, 550, 551, 552, 553. See also parasuicidal behaviors noumena, 7–8

O Oasis Institute, 366 observational learning, 19–20 observing and recording, 639–640 continuous recording and, 639 defining and, 639 interobserver agreement (IOA) and, 640 interval recording and, 639–640 logistics of recording, 639 observers and, 639 reactivity and, 640 recording instruments, 640 recording methods, 639 time sample recording, 640 obsessive-compulsive disorder (OCD), 21, 23, 52, 62, 530 cognitive therapy vs. exposure with response prevention (ERP) and, 291–292 exposure therapy for, 113, 275, 276–277, 291–292

exposure with response prevention (ERP) and, 283 metacognitive therapy (MCT) and, 619 subtypes of, 291 thought-action fusion and, 621 thought-event fusion and, 621 thought-object fusion and, 621 occasional reinforced extinction, 286 OCD. See obsessive-compulsive disorder (OCD) operant behavior, 641, 645 operant conditioning, 20, 207, 645 core principles of, 645 operant behavior and, 645 orbitofrontal cortex (OFC), 97 outcome data acceptance of the treatment rationale (ATR) and, 254–255 behavioral activation (BA) and, 252–257 cognitive behavioral therapy (CBT) with childhood anxiety and, 293 cognitive restructuring and, 228–229 cognitive therapy (CT) and, 429–431 exposure therapy and, 288–295 exposure therapy for agoraphobia and, 289–290 exposure therapy for childhood anxiety and, 293 exposure therapy for generalized anxiety disorder (GAD) and, 290 exposure therapy for obsessive-compulsive disorder (OCD) and, 291–292 exposure therapy for phobias and, 288–289 exposure therapy for posttraumatic stress disorder (PTSD) and, 292 exposure therapy for social anxiety disorder (SAD) and, 290–291 exposure therapy selective mutism (SM) and, 294–295 metacognitive therapy (MCT) and, 628–630 mindfulness-based cognitive therapy (MBCT) and, 603–605 motivational interviewing (MI) and, 321–329 rational emotive behavior therapy (REBT) and, 461–462 relapse prevention and, 398–401 relapse prevention for for standard CBT and, 398–401 ruptures and, 192 schema therapy (ST) and, 527–530 separation anxiety disorder (SAD) and exposure therapy and, 294 therapeutic alliance and, 186–188 therapeutic relationship and, 185, 199

778 Index

Overall Anxiety Severity and Impairment Scale (OASIS), 709 Overall Depression Severity and Impairment Scale (ODSIS), 709 overgeneralization, 96 oxytocin, 103

P panic disorder, 60–61, 97 cognitive therapy vs. exposure therapy for, 289 diaphragmatic breathing (DB) for, 356 exposure therapy for, 289–290 panics attacks, 706 paradigm shifts, 9 paranoia, 38 paraphrasing, 179 paraprofessionals, 67 parasuicidal behaviors, 549, 550, 552, 563. See also nonsuicidal self-injury (NSSI) parent-coached exposure therapy, 294 partnership, 318–319 Patient Health Questionnaire-9 (PHQ-9), 600 patient-level barriers, 167 Paul, Gordon, 351 Pavlov, Ivan, 17–21, 295 exposure therapy and, 275 extinction process and, 277 Pavlovian conditioning, 12, 20, 93 pCO2, 361 PCT. See preventive cognitive therapy (PCT) Penn State Worry Questionnaire, 141 perseverative thinking, 618, 622 personality disorders (PDs), 53, 493 remission and, 401 personalized advantage index (PAI), 68 personalized medicine, 67–68, 302 genetics and, 68 neuroimaging and, 68 personalized medicine and personalized advantage index (PAI), 68 pharmacological enhancers, 102–103 D-cycloserine (DCS), 102 hydrocortisone, 103 methylene blue, 103 oxytocin, 103 yohimbine, 103 pharmacotherapy, 106 antidepressant medication (ADM) and, 595 maintenance antidepressant medication (mADM) and, 596 phenomenologism, 8 phenomenological empathy agreement, 548

Philadelphia Department of Behavioral Health and Intellectual Disability Services, 168 Philosophical Investigations, 8 phobias exposure therapy for, 288–289 relaxation therapy vs. cognitive behavioral therapy (CBT) for, 59 virtual reality (VR) and, 59 phone coaching, 547, 558 physical prompt, 646, 649 Piaget, Jean, 12 planful problem solving, 469–470, 482, 483 planful problem solving toolkit, 475, 477–478 decision making and, 478–479 emotion-focused objectives and, 477–478 generating alternative solutions and, 477–478 problem definition and formulation and, 477–478 problem-focused goals and, 477–478 solution implementation and verification and, 478–479 Plato, 4–5 forms and, 5 guided discovery and, 5 idealism and, 5 knowledge and, 5 theory of knowledge and, 5 Platonic model vs. Beckian model, 5 policy change, 165 polyvagal theory (PVT), 359 positive affect, 724 anxiety and, 702 deficits in, 702 depression and, 702 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 724 Positive and Negative Affect Scales (PANAS), 724 Positive Behavior Supports (PBS), 664 School-Wide Positive Behavior Supports (SWPBS) and, 664 positive bias, 37, 422. See also biases positive cognitive compensatory strategies, 432–433 positive metacognitive beliefs (PMBs), 621, 622 disorder specific, 621 mismatch strategies and, 627 modification of, 626–627 reducing conviction in, 626–627 verbal reattribution of, 626 positive regard, unconditional, 180 positive reinforcement, 642, 655 differential reinforcement of alternative behavior (DRA) and, 655 positive symptoms, 53



Index  779

positivism, 6 postevent processing, 111 postimplementation, 164 posttraumatic stress disorder (PTSD), 52, 61–62, 96 CBT in group formats for, 61 cognitive processing therapy for, 61 comorbid BPD and, 553 exposure therapy for, 113, 275, 277, 292 eye-movement desensitization for, 292 inoculation training for, 61 metacognitive therapy (MCT) and, 619 Motivation and Problem Solving (MAPS) for, 327 muscle relaxation for, 61 prolonged exposure (PE) therapy for, 61 prolonged exposure (PE) therapy vs stress-inoculation training (SIT) for, 292 relaxation training for, 292 trauma-focused CBT (TF-CBT) for, 61 preadaptive functions, 15–16 precision medicine. See personsonalized medicine preference assessments, 645 preimplementation, 162. See also implementation enhanced preparedness and, 161 informed consent and, 161 readiness and, 161–163 present-focused attention, 712 three-point check and, 714 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 712 preventive cognitive therapy (PCT), 57 antidepressants and, 58 relapse prevention and recurrence, 57–58 Principles and Practice of Relapse Prevention, 386 private self-consciousness. See self-focused attention probability calculation method, 223 probe detection task, 675, 676, 677–678 improving reliability of, 681–682 problematic behavior, antecedent control strategies for, 657 problem-focused coping, 468 problem-focused goals, 477–478 problem lists, 140–141 problem orientation, 468 importance of, 469 negative, 469, 470, 482 positive, 468 training, 474 problem solving. See also emotion-centered problem-solving therapy (EC-PST) avoidant, 470 effective, 477–478 effective vs. ineffective, 470–471

poor, 475 styles, 468 problem-solving multitasking toolkit, 475, 478–479 externalization and, 478–479 simplification and, 479–480 visual imagery and, 478–479 problem-solving therapy (PST), 472–473 depression and, 474 efficacy of, 473–474 Enhancing Motivation for Action toolkit, 479 problem-orientation training and, 474 studies of, 476 as a transdiagnostic intervention, 475 process-based therapies, 36 processing bias, 109 process-oriented CBT, 40 conceptualizations of cognition and, 40 process-oriented conceptualizations, 44 progressive relaxation (PR), 350–355 behavior therapy and, 351 breathing training techniques and, 349 combining PR, DB, and mindfulness-based approaches, 369–372 conditions benefiting from, 355 dissemination of, 355 empirical evidence for, 354–355 heart rate variability (HRV) and, 354 muscles and, 61 origins of, 350–351 recall and counting and, 351 recall procedures and, 353 reduced tonic sympathetic nervous system arousal and, 354 tension-release cycles and, 351 Project MATCH, 322–325 prolapse, 388 prolonged exposure (PE) therapy, 61, 166, 283–284 promoting generalization, strategies for, 663 prompts, 646–648 delay of, 648 extrastimulus, 647 generalization of, 662–663 gestural, 646 intrusive nature of, 646 modeling, 646 physical, 646 response, 646 stimulus, 647 stimulus prompt fading, 647–648 transferring stimulus control and, 647 verbal, 646 within-stimulus, 647 protection from extinction, 99 provider-level barriers, 158–159 pseudoalliance, 178

780 Index

psyche, 3, 25 psychoanalysis, 7, 445, 450 psychodynamic model, 7, 15–16 psychodynamic psychotherapy, 10, 179 ruptures and, 192 psychoeducation, 67, 112, 188–189, 222, 453–456 therapeutic relationship and, 189 psychological flexibility, 572 psychological inflexibility, 572, 587, 588 Acceptance and Action Questionnaire (AAQ) for measure of, 590 psychological preparedness, 159–160 Psychological Review, 10 psychology philosophy vs., 3 three waves of, 3 psychopathology, 4 awfulizing and, 7 biased thinking processes and, 51 cognitive models of, 14–15 diathesis–stress model in, 38 differentiating of, 701–702 evidence-based practice (EBP) and, 673 generic models of, 45 low frustration tolerance and, 7 should statements and, 7 stress and, 471 understanding behaviors associated with, 33 vulnerabilities for, 38 psychopharmacotherapy. See medication psychosis, 53, 115–116, 431 psychotherapy, 66 ambivalence about change and, 314 lack of increased use of, 158–159 person-centered, xvi–xviii psychoanalytic approach to, 445 rational emotive behavior therapy (REBT) and, 450 readiness for, 313 research about, 178 Rogerian client-centered, 454–457 therapeutic alliance and, 177 therapeutic relationship and, 175 psychotic disorders, 53 PsycInfo, 53 PubMed, 53 punishment, 643–644, 645 behavioral excess and, 658–660 factors influencing, 644 negative, 643–644 positive, 643 response cost and, 660 time-out and, 658–660 using, 658–660

Q Quality of Cognitive Case Formulation Rating Scale, 144–145 quality-of-life interfering behaviors, 545 Quality of Life Scale (QOLS), 724 Quick Inventory of Depressive Symptomatology, 529

R radical behaviorism, 17, 236–238 radically open dialectical behavior therapy, 743 randomized controlled trials (RCTs), 54, 55, 58, 59, 62, 63, 65, 66, 91, 92, 102, 110, 116, 146, 147, 150, 316, 325, 327, 329, 469, 474, 475, 527, 528, 530, 531, 537, 549, 550, 551, 552, 553, 554, 555, 568, 604, 605, 610, 681, 683, 704. See also outcome data rational emotive behavior therapy (REBT), xv–xvii, 445–446 ABCDE procedures of, 456 brief therapy and, 460–461 disputing and, 454–457 diverse populations and, 461 history of, 446–452 outcome data and, 461–462 procedures of, 455–458 therapeutic change and, 459–461 unconditional acceptance, forms of, 457–458 underlying theory of, 452–455 rational emotive imagery, 456–459 rational emotive theory, 34 rational emotive therapy (RET), 4, 14–15. See also rational emotive behavior therapy (REBT) philosophical roots of, 7 rationality, 4 rational principle, 5 rational response, 425 rational thinking, 453–456 rational therapy (RT). See rational emotive behavior therapy (REBT) Rayner, Rosalie, 19 reaction time measures, 682 realistic disputing, 454–457 reality testing, 39 real-life problems, 466–467 barriers and, 466 reactions to, 466 real-life solutions, 467 real relationship, 179 real world, 31, 34, 41–43 reappraisal coping strategies, 39 reattribution, verbal, 623–624, 626 strategies, 627



Index  781

REBT. See rational emotive behavior therapy (REBT) recall false, 12 procedures, 353 reciprocal inhibition, 21, 276 recognition of idiosyncratic cognitions, 424 recording instruments, 640 methods, 639 reduced motivation, overcoming, 479 reductionist behaviorism, 9 reflecting, 179 reflective listening, 314, 320 reflective processing subsystem, 422 system, 38 rehearsal, 650 reinforcement, 238, 641–642, 645 accidental, 643 antecedent control strategies and, 657 automatic, 642 consistency and, 642 contingencies, 652 differential, 655 differential reinforcement of alternative behavior (DRA) and, 655 immediacy and, 642 intermittent, 643 model of language, 13 motivating operations (MOs) and, 642 negative, 239, 642, 655 positive, 642, 655 schedule, 643 social, 642 reinforcers, 641 chaining and, 649 conditioned, 660 differential reinforcement of other behavior (DRO) and, 656 extinction and, 654 functional analysis and, 653 natural, 649 reinstatement, 94 relapse, 57, 388 definition of, 386–387 depressive, 388 lapses and, 387 Marlatt’s model and, 387 mindfulness-based interventions (MBIs) and, 64 returning to therapy after, 397 signature, 600 therapist considerations when dealing with, 398 toolkit, 600 relapse prevention, 723. See also relapse abstinence violation effect and, 388 anxiety disorders and, 389, 400

behavioral activation (BA) and, 399 bipolar disorder and, 399–400 booster sessions and, 395 continuing self-therapy and, 394–401 depression and, 390 future directions for, 408–409 history of, 385–386 important factors of, 390 interpersonal psychotherapy (IPT) and, 399 interventions, 58 main procedures of, 389–391 managing expectations for, 397–398 metaphors and, 394–401 mindfulness-based cognitive therapy (MBCT) and, 402 mindfulness-based stress reduction (MBSR) and, 402 motivational interviewing (MI) and, 388, 390 outcome data for standard CBT and, 398–401 personality disorders and, 401 research about, 386 self-maintenance and, 396 self-management and, 387 self-therapy and, 394–395 strategies for, 391–398 substance abuse and, 400 suicide and, 400 underlying theory of, 387–389 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and, 723 Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, 386 relapse-prevention therapy (RP), 401–403 clinical example of, 402–407 delayed emergence effect and, 401 dissemination and, 402 relational frame theory (RFT), 24, 37–41, 39–40, 44, 568–569 acceptance and commitment therapy (ACT) and, 570–573 language and, 39 relationships and interpersonal effectiveness skills, 372 relaxation, 65. See also progressive relaxation therapy, 59 training, 292 remission, 65 removal of safety cues, 286 renewal, 94 repetitive negative thinking. See negative repetitive thinking repetitive transcranial magnetic stimulation (rTMS), 116–117 The Republic, 4, 5 Rescorla, Robert, 12

782 Index

research-to-practice gap, 166 respiratory biofeedback breathing training, 361 respiratory sinus arrhythmia (RSA), 358 respondent behavior, 645 respondent conditioning, 645 response-contingent positive reinforcement (RCPR), 239, 257 factors relating to, 240 response cost, 660 response-focused therapeutic interventions, 35, 36 response learning, 11 response prompts, 646 response prompt fading, 647 types of, 646 responses conditioned response (CR), 645 unconditioned response (UR), 645 responsibility reattribution, 104 Reward Probability Index (RPI), 257 RFT. See relational frame theory (RFT) risk ratio (RR), 64 Rogers, Carl, 228, 318 Rogerian client-centered psychotherapy, 454–457 Rollnick, Stephen, 315 rumination, 110–112, 743. See also worry emotional distress and, 111 focused CBT, 112 memory and, 110 metacognitive therapy (MCT) and, 623 modification of, 627 modifying danger metacognitive beliefs about, 623–624 postponement and, 626 social anxiety disorder (SAD) postevent processing and, 111 spontaneous negative thought vs, 624 ruminative cognitive-affective processing, 596, 607 ruptures, 190, 191–192 cognitive behavioral strategies to repair, 194–198 collaborative relationships and, 191 corrective emotional experiences and, 192 negotiation and, 192 outcomes and, 192 psychodynamic psychotherapy and, 192 rupture-repair episodes and, 192 therapeutic relationship and, 192

S SAD. See social anxiety disorder (SAD) safety behaviors. See avoidance behaviors safety cues, 95, 97 safety planning, 329

schema, xviii, 7–8, 9, 11, 11–12, 12, 14–15, 38, 44, 209, 226, 419–420. See also core beliefs abandonment, 504 automatic processing subsystems and, 38 based automatic processing. See cognitive bias cognitive restructuring and, 209, 422 core, 209 domains, 496 early maladaptive, 493, 495–497 information processing and, 38 maladaptive, 38 metacognitive therapy (MCT) and, 619 modes, 497–502 negative, 210 negative cognitive, 110 processing, 7–8 reflective processing systems, 38 summative conclusions and, 209 theory, 11–12 Young Schema Questionnaire – Short Form, 142 schema coping avoidance and, 497 methods of, 497 overcompensation and, 497 surrender and, 497 Schema Mode Inventory (SMI), 500 schema modes, 500–502 child modes, 500 dysfunctional parent modes, 501 healthy adult mode, 502 maladaptive coping modes, 501 schema therapy (ST), 117, 493 behavioral pattern breaking and, 505 behavioral techniques and, 505, 523–527 borderline personality disorder (BPD) and, 493, 527, 528 case conceptualization with mode model and, 506–510 chair dialogues and, 517–518 channels of change and, 505 Cluster C PDs and, 493, 528 cognitive behavioral therapy (CBT) and, 529 cognitive techniques and, 505, 511–512 dissemination and, 531 distinctive features of, 495 diverse populations and, 532 dysfunctional modes and, 493 early development and, 495 early maladaptive schemas and, 493, 495–497 eating disorders and, 530 emotional core needs and, 495 empathic confrontation and, 515–517 etiology focus of, 504



Index  783

experiential techniques and, 495, 505, 516–522 focuses of treatment and, 504–505 future directions for, 532 historical role play and, 522–523 history and development of, 494–495 imagery exercises and, 518–522 limited reparenting and, 493, 495, 513–515 major aspects of, 494 mechanism of change and, 530–531 mode model approach to, 498 obsessive-compulsive disorder (OCD) and, 530 outcome data and, 527–530 personality disorders (PDs) and, 493, 527 posttraumatic stress disorder (PTSD) and, 530 problems, present and future and, 504 therapeutic relationship and, 504, 512–516 transference-focused therapy (TFP) vs, 527 treatment goals of, 502–504 treatment plans and, 505–506 schizophrenia, 53 School-Wide Positive Behavior Supports (SWPBS), 664 teaching safety skills and, 665 Screening, Brief Intervention, and Referral to Treatment (SBIRT), 323–326 Searle, John, 9 secondary outcomes, 53 secondary targets, 546 dialectical dilemmas of, 546 selective attention, 628 selective mutism (SM), 294–295 child-focused exposure-based practice for, 294 integrated behavioral therapy (IBT) and, 294–295 self-regulatory executive function (S-REF), 617, 618, 620 cognitive attentional syndrome (CAS) and, 620 levels of cognition in, 620 low-level form of processing in, 620 online level of processing in, 620 Seligman, Martin, 445–446 separation anxiety disorder (SAD) cognitive behavioral therapy (CBT) vs. exposure therapy for, 294 exposure therapy outcome data and, 294 severe depression, 56–57 sexual revolution, 449 shaping, 650–651 steps involved with, 650–651 Shared Decision-Making (SDM), 167 Shedler, Jonathan, 188

Short Form 36 (SF-36), 141 should statements, 7 simple reflections, 320 simplification, 479–480 single cue conditioning, 96 single-disorder protocol (SDP), 701 sitting meditation focused attention, 598 open monitoring, 598 skills group, 545, 547, 559 modules taught, 547 skills training, 237–239 agreement, 544 change oriented, 375 Skinner, B. F., 13, 17, 20, 236–238 cognition and, 21 Skinnerian model, 13 slow down techniques, 480 social anxiety cognitive reappraisal and, 105 negative interpretation bias and, 108 social anxiety disorder (SAD), 59–60, 93, 104–105 biases and, 108 cognitive therapy vs. exposure therapy, 290 exposure therapy for, 113, 290–291 mindfulness-based stress reduction (MBSR) and, 365 postevent processing and, 111 public speaking and virtual reality, 291 social cost exposure, 291 Social Problem-Solving Inventory–Revised (SPSI-R), 477 social problem solving (SPS), 467–468, 484 deficits and, 471–472 planful problem solving and, 469–470 problem-focused coping vs, 468 problem orientation and, 468 problem-solving styles and, 468, 469 psychotherapy and, 470–472 social problem-solving therapy. See problem-solving therapy social psychology, 13 social reinforcement, 642 social skills modeling, 190–192 cognitive behavioral therapists and, 190 interpersonal relationships and, 191 therapeutic relationship and, 191 verbal content-based social skills training and, 190 verbal content-based training, 190 Society for the Scientific Study of Sexuality (Quad S), 449 Socrates, 184–185 Socratic ignorance, 221 Socratic dialogue, 189, 212, 220–224, 227, 741 conducting, 221–224

784 Index

Socratic dialogue (continued) definition of, 220 empathic listening and, 222 empty chair technique and, 223 frequent summaries during, 222 as guided discovery, 221 informational questions and, 221 key hypotheses examination and, 221 persuasion vs. self-discovery and, 220–221 psychoeducation and, 222 stages of, 741 synthesizing questions and, 222 Socratic questioning, xviii, 427 functions of, 228 impact of, 229 somatoform disorders, 52 spaced-responding DRL, 656 spatial cuing paradigm, 678 spontaneous recovery, 94, 643 ST. See schema therapy (ST) standardized mean difference (SMD), 53 stimulus. See also conditioned stimulus (CS); transferring stimulus control antecedent, 645 behavioral responses to, 32 complex, 276, 280 conditioned, 95, 275 conditioned, danger cue, 95 conditioned, safety cue, 95 control, 644–645 discrimination training, 644 discriminative stimulus (SD), 644 distractor, 675 extrastimulus prompts, 647 generalization, 95 inhibitory conditioned, 95 neutral stimulus (NS), 645 other stimulus (S-delta), 644 overgeneralization of fear to neutral, 96 prompt fading, 647–648, 649 prompts, 647 response association, 480 unconditioned stimulus (US), 18–22, 93, 95, 275, 277, 645 variation, 101 within-stimulus prompts, 647 Stoic model emotion in, 7 goal of, 6–7 self-sufficiency and, 7 Stoics, 6–8, 14, 208 stop and slow down, 475 stop and slow down, think and act (SSTA), 480 toolkit, 479–480

stress abbreviated progressive relaxation training (APRT) for, 354 generation, 471 stress-ninoculation training (SIT), 292 Structured Clinical Interview, 529 Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD), 557 Structured Clinical Interview for DSM Diagnosis (SCID), 141 Structured Clinical Interview for DSM Disorders (SCID), 603 types of, 141 Subjective Units of Distress Scale (SUDS), 279 Substance and Mental Health Services Administration (SAMHSA), 366 substance use disorders, 53 relapse prevention and, 400 substance use BPD (S-DBT), 552–553 suicide, 539. See also nonsuicidal self-injury (NSSI); parasuicidal behaviors community treatment by experts (CTBE) and, 550 DBT replication (DBT-R) and, 550 prevention and motivational interviewing (MI) and, 328–330 relapse prevention and, 400 safety planning and, 329 suicidal behaviors agreement and, 544 summarizing, 179 summative conclusions, 209 suppression, 35, 44 sustain talk, 319, 321, 331 symbolic content, 12 Symptom Checklist-90-Revised, 141 synthesizing questions, 222 systematic desensitization, 276, 351 systems perspective, 132

T target behavior, 544, 546, 639 behavioral contracts and, 661 functional analysis and, 653 task analysis, 648 tCBT. See transdiagnostic CBT treatment (tCBT) technical pathway, 317 technology, 159–160. See also internet-based CBTs (iCBTs) telehealth, 288 tension-release cycles, 351, 352 Theoretical Domains Framework, 165 theory-driven approach to transdiagnostic treatment, 43 therapeutic alliance, 177–178, 185, 314 causality and, 186 components of, 186–187



Index  785

definition of, xvii key components of, 177 outcome and, 186–188 pseudoalliance and, 178 psychotherapy and, 177 therapeutic relationship, 33, 175, 184–185, 215, 428–429, 504, 530, 736–742 ADDRESSING and, 183 cognitive restructuring and, 189 collaboration and, 740 definition of, 176–177 future directions for research on, 198–199 interactional pattern within, 185 limit setting and, 741 measurement of, 178 nonspecific, 180 outcome and, 185, 199 psychoeducation and, 189 psychotherapy and, 175 real relationship and, 179 ruptures and, 190, 192 social skills modeling and, 191 Socratic dialogue and, 741 therapeutic alliance and, 178 therapeutic relationship techniques, 512–516 empathic confrontation and, 515–517 limited reparenting and, 513–515 schema therapy (ST) and, 512–516 therapists confidence and, 180 contentment with, 187–188 countertransference and, 179 emotional bonds to client and, 177 empathy and, 180 guided exposure and agoraphobia and, 289 overestimation of CBT skills and, 158–159 skills of, 169, 179 unconditional positive regard and, 180 Thinking, Fast and Slow, 10 third-wave CBT therapies, 63–64 acceptance and commitment therapy (ACT) and, 52, 567–568 behavioral activation (BA) and, 52 competitive memory training and, 52 dialectical behavioral therapy (DBT) and, 52 mindfulness-based cognitive therapy (MBCT) and, 52 movement, 36 Thorndike, Edward L., 18–22 threat reappraisal, 105–106 reevaluation, 100 3-minute breathing space, 597, 598 3-minute coping space, 599 tiger task, 625–626

time-out, 658–660 escape from, 659 exclusionary, 658 factors influencing its effectiveness, 658–659 interactions during, 659 length of, 659 nonexclusionary, 658 practicality of, 659 safety of, 659 time sample recording, 640 token economy, 660–661 conditioned reinforcers and, 660 Tolman, Edward, 11 total task presentation, 649 Tractatus Logico-Philosophicus, 8 training distance-based approaches to, 159–160 experience, 168 ongoing consultation after initial training, 160 transcranial direct current stimulation (tDCS), 116–117 transdiagnostic CBT treatment (tCBT), 41–43, 45, 52, 63 approaches to, 42 case formulation and, 148–149 depression vs. anxiety outcomes and, 63 disorder-specific treatment vs., 63 efficacy of, 63 motivational interviewing (MI) and, 318 negative affectivity and, 52 pragmatic approach to, 43 primary approaches to, 43 problem-solving therapy (PST) and, 475 theory-driven approach to, 43 transference, 193–194 transference-focused therapy (TFP) and, 527 transferring stimulus control, 647 prompt delay and, 648 response prompt fading and, 647 stimulus prompt fading and, 647 trauma exposure therapy and, 283–284 trauma-focused CBT (TF-CBT) and, 61 treatment as usual (TAU), 53 Treatment of Depression Collaborative Research Project (TDCRP), 56, 429 treatment plans, 505–506 Treatment Works For Vets platform, 167 trial level bias scores (TL-BS), 682

U unconditional acceptance, 451, 457–458, 459 unconditional positive regard, 180 unconditioned response (UR), 18–22, 645

786 Index

unconditioned stimulus (US), 18–22, 93, 95, 275, 277, 645 uncontrollability beliefs, modification of, 623 Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), 52 anxiety disorders and, 704–705 anxiety sensitivity and, 703, 718 automatic appraisals and, 714 case conceptualization and, 707–709 case example of, 705–724 cognitive distortions and, 715 cognitive flexibility and, 715 description of, 703–704 dissemination and, 705, 725 efficacy of, 704–705 emotion dysregulation and, 703 experiential avoidance and, 703, 715 mindfulness and, 712 Module 1 (increasing motivation and readiness to change), 709–710 Module 2 (understanding emotions), 710–712 Module 3 (present-focused awareness), 712–714 Module 4 (cognitive flexibility), 714–715 Module 5 (changing emotional behaviors), 715–718 Module 6 (awareness and tolerance of physical sensations), 718–720 Module 7 (emotion exposures), 720–722 Module 8 (review and relapse prevention), 723 negative affect and, 724 neuroticism and, 703 nonjudgment awareness and, 712–714 positive affect and, 724 present-focused attention and, 712 relapse prevention and, 723 single-disorder protocol (SDP) vs, 704 training in, 705 treatment modules, 704 web-based treatment programs and, 705 Unified Protocol Institute (UPI), 705 University of Massachusetts (UMass) Center for Mindfulness in Medicine, Health Care, and Society, 366 Medical School, 363 Stress Reduction Clinic, 366 University of Pennsylvania, 168 Department of Behavioral Health and Mental Retardation Services (DBHMRS), 434 UP. See Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders UP Client Workbook, 714 urge-surfing, 391–398 U.S. Department of Veterans Affairs, 261

utilitarianism, 18 model of, 8

V vagal tone, 359 validation, 549 values, 574, 582–584 consistent activation, 238 directed behavior, 582–584 lack of values clarity and, 574 ventromedial prefrontal cortex (vmPFC), 96 verbal reattribution, 623–624, 626 strategies, 627 verifiability principle, 8, 9 vicarious learning, 32 Vienna Circle of Logical Positivists, 8–9 virtual reality exposure therapy, 284– 285, 289 virtual reality (VR), 59 visual imagery, 478–479 visualization, 479 visual search paradigm, 678

W walking meditation, 598 Watson, J. B., 19 Weiner, Bernard, 13 whole-body breathing, 359 Wittgenstein, Ludwig, 8 Wolpe, Joseph, 21, 351 word-sentence association paradigm (WASP), 680, 686 World Health Organization (WHO), 260 Brief Intervention and Contact (BIC), 329 worry, 110–112, 743 change in, 111 generalized anxiety disorder (GAD) patients and, 111 metacognitive therapy (MCT) and, 623 mismatch strategies for modifying, 627 modifying danger metacognitive beliefs about, 623, 623–624

Y Yale-Brown Obsessive-Compulsive Scale (YBOCS), 147 yohimbine, 103 Young, Jeffrey, 493 Young Schema Questionnaire – Short Form, 142 Young Schema Questionnaire – Short Form 3, 142

Z Zajonc, Robert, 10 Zen practice, 540. See also Buddhism



Index  787