SPECIAL SERIES
GOING BEYOND THE MANUAL: INSIGHTS FROM EXPERIENCED CLINICIANS
Jonathan D. Huppert and Jonathan S. Abramowitz
Introduction
Jonathan D. Huppert and Sandra L. Baker-Morissette
Beyond the Manual: The Insider's Guide to Panic Control Treatment
Jonathan S. Abramowitz, Martin E. Franklin, and Shawn P. Cahill
Approaches to Common Obstacles in the Exposure-Based Treatment of Obsessive-Compulsive Disorder
Elizabeth A. Hembree, Sheila A. M. Rauch, and Edna B. Foa
Beyond the Manual: The Insider's Guide to Prolonged Exposure Therapy for PTSD
Paula R. Young, Paul Grant, and Robert J. DeRubeis
Some Lessons From Group Supervision of Cognitive Therapy for Depression
Ann E. Goebel-Fabbri, Janna Fikkan, and Debra L. Franko
Beyond the Manual: The Flexible Use of Cognitive Behavioral Therapy for Bulimia Nervosa
CHILD AND ADOLESCENT ISSUES David Hansen, Ph.D., Section Editor
Catherine E. Moffitt, Bruce F. Chorpita, and Shantel N. Fernandez
Intensive Cognitive-Behavioral Treatment of School Refusal Behavior
REGULAR ARTICLES
Edelgard Wulfert, Edward B. Blanchard, and Rebecca Martell
Conceptualizing and Treating Pathological Gambling: A Motivationally Enhanced Cognitive Behavioral Approach
Douglas W. Nangle, Jeffrey E. Hecker, Rachel L. Grover, and Melinda G. Smith
Perspective Taking and Adolescent Sex Offenders: From Developmental Theory to Clinical Practice
Norah C. Feeny, Elizabeth A. Hembree, and Lori A. Zoellner
Myths Regarding Exposure Therapy for PTSD
Craig Simpson and Costas Papageorgiou
Metacognitive Beliefs About Rumination in Anger
ABSTRACTS
Introduction to the Special Series: Going Beyond The Manual: Insights From Experienced Clinicians Introduction
Jonathan D. Huppert, University of Pennsylvania School of Medicine, and Jonathan S. Abramowitz, Mayo Clinic
Treatment manuals assist in providing structure and guidelines for many types of cognitive and behavioral therapies. However, clinical experience suggests that there are a variety of obstacles to each type of treatment that manuals do not fully address. We have asked clinicians experienced with manualized treatments for panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, depression, and bulimia nervosa to make recommendations that may help clinicians in most service settings to employ manualized therapy protocols more effectively.
Beyond the Manual: The Insider's Guide to Panic Control Treatment
Jonathan D. Huppert, University of Pennsylvania, and Sandra L. Baker-Morissette, Boston University
Based on our combined clinical experience in treating patients with panic disorder (PD) using the Mastery of Anxiety and Panic therapist guide and in supervising others in its use, we felt that there were additional issues beyond what is articulated in the manual that could assist therapists conducting CBT for PD. While as much as possible is articulated in manuals (e.g., Craske, Barlow, & Meadows, 2000). We divide the paper into 6 sections: general principles, psychoeducation, cognitive restructuring, interoceptive exposure, situational exposure, and consolidating treatment gains/termination. We hope that these clinically practical strategies facilitate the dissemination of this effective treatment.
Approaches to Common Obstacles in the Exposure-Based Treatment of Obsessive-Compulsive Disorder
Jonathan S. Abramowitz, Mayo Clinic, Martin E. Franklin and Shawn P. Cahill, University of Pennsylvania School of Medicine
Treatment manuals have proven extremely useful in implementing exposure and ritual prevention (EX/RP) with patients with obsessive-compulsive disorder (OCD). Nevertheless, treatment manuals cannot possibly attend to all possible situations encountered in therapy, especially with OCD patients who have such a diverse range of presentations. In this article we address four commonly encountered issues not explicitly described in the widely used EX/RP treatment manuals. First, we offer suggestions on how to help patients understand their OCD symptoms in ways that fit into the theoretical framework of the treatment procedures. Second, we address how to manage excessive reassurance-seeking behavior that is often observed in patients with particularly severe symptoms. Third, we describe the importance of consistent exposure during (and after) treatment. Fourth, we discuss clinical decision-making regarding the implementation of ritual prevention.
Beyond the Manual: The Insider's Guide to Prolonged Exposure Therapy for PTSD
Elizabeth A. Hembree, Sheila A. M. Rauch, and Edna B. Foa, University of Pennsylvania
Prolonged Exposure therapy (PE; Foa & Rothbaum, 1998) has strong empirical support for its efficacy in reducing trauma-related psychopathology in individuals with chronic PTSD (Rothbaum, Meadows, Resick, & Foy, 2000). In the process of providing PE to many clients and in training therapists in a variety of settings in its use, we in the Center for the Treatment and Study of Anxiety have amassed extensive experience with this therapy. This article extends the treatment guidelines provided in the PE treatment manual by sharing the knowledge and wisdom that years of experience have brought us. We emphasize the importance of forging a strong therapeutic alliance and providing a thorough rationale for treatment, discuss ways to implement in-vivo and imaginal exposure so as to promote effective emotional engagement with traumatic memories, and conclude with some recommendations for how therapists who conduct PE for PTSD can take care of themselves while delivering a therapy that is very rewarding and, at times, emotionally challenging.
Some Lessons From Group Supervision of Cognitive Therapy for Depression
Paula R. Young, Paul Grant, and Robert J. DeRubeis, University of Pennsylvania
While much has been written on cognitive therapy of depression, we have found that our trainees have the same questions and difficulties year after year. This article reflects the questions and topics that have been asked most frequently during several years of group supervision led by the third author. We cover topics such as the specifics of the agenda, special uses of language, the pacing of therapy, and therapeutic alliance. We aim to address issues, such as guilt, self-blame, and vegetative symptoms, that arise with depressed patients. In addition, attributions of symptom change for patients concurrently taking antidepressant medications, as well as the special problems related to chronic depression, are covered in detail.
Beyond the Manual: The Flexible Use of Cognitive Behavioral Therapy for Bulimia Nervosa
Ann E. Goebel-Fabbri and Janna Fikkan, Joslin Diabetes Center, Boston, and Debra L. Franko, University of Massachusetts, Dartmouth
The treatment manual applying cognitive behavioral therapy principles for bulimia nervosa originally was used in early treatment outcome studies and was later expanded and enhanced by Fairburn, Marcus, and Wilson (1993) for broader clinical use. The manual is well researched as an effective treatment and currently is advocated as the first-line treatment for bulimia nervosa. However, despite the research data supporting its use, these manual-based techniques are still not widely practiced in the treatment of eating disorders outside of academic research settings. This article aims to elaborate on aspects of the manual that may have hindered some therapists in its use. We focus on clarifying aspects of the treatment process that may assist clinicians to flexibly apply the treatment manual's specific techniques by emphasizing stylistic approaches to help facilitate treatment adherence, diminish risks of treatment dropout, and address behaviors that interfere with treatment.
Intensive Cognitive-Behavioral Treatment of School Refusal Behavior
Catherine E. Moffitt, Bruce F. Chorpita, and Shantel N. Fernandez, University of Hawaii at Manoa
The present investigation is a single-subject treatment of a preadolescent child with school refusal behavior. This study represents an A–B design in which treatment was designed to begin with a standard cognitive-behavioral approach and to continue with a functional analytic and intensively applied problem-solving strategy if difficulties arose during the implementation of cognitive behavioral treatment (CBT). Consistent with the design, systemic problems interfered with the implementation of traditional, office-based CBT and the intensive approach was applied. Under this design, problems were identified and mitigated using strategies beyond those employed in traditional manualized CBT. The participant was a 12-year-old female who was attending school sporadically and with great difficulty, and who was experiencing both separation anxiety and social anxiety in the school setting. Following the intensive treatment, she began to attend school more regularly, and her fear ratings decreased considerably; however, she continued to have difficulties with school attendance that appeared to be more related to systemic issues than anxiety. This study describes a potential method of increasing the clinical utility of manualized treatments for highly challenging cases through an intensive, functional analytic strategy, and also describes the challenges of working with anxiety disorder cases in which there are multiple variables in addition to the child?s anxiety that contribute to clinical disturbance.
Conceptualizing and Treating Pathological Gambling: A Motivationally Enhanced Cognitive Behavioral Approach
Edelgard Wulfert and Edward B. Blanchard, University at Albany, State University of New York, and Rebecca Martell, Center for Problem Gambling, Albany, NY
The field of pathological gambling is in its infancy. In this paper, we describe cognitive and behavioral models and treatment approaches to pathological gambling. We conclude that, based on controlled outcome research, cognitive behavioral therapies are among the more promising interventions. However, these interventions seem to pay insufficient attention to motivational factors and are marred by high attrition rates. As a possible remedy, we propose a motivationally enhanced cognitive behavioral intervention to increase pathological gamblers' engagement in, and commitment to, the treatment process. We present a case report to illustrate this intervention.
Perspective Taking and Adolescent Sex Offenders: From Developmental Theory to Clinical Practice
Douglas W. Nangle, Jeffrey E. Hecker, Rachel L. Grover, & Melinda G. Smith, University of Maine
Clinical child researchers and practitioners face increasing pressure to more fully incorporate developmental findings and principles into their work. In describing a developmental approach to the assessment and treatment of perspective-taking deficits in adolescent sex offenders, we discuss some of the benefits and difficulties inherent in such integrative efforts. Following an overview of the clinical literature on juvenile sexual offending that focuses on the roles of perspective taking and empathy, we turn to a review of the developmental literature. This literature, particularly the model proposed by Selman, provides a rich conceptual foundation for understanding the relationship between perspective-taking skills and sexual offenses. We then describe our efforts to incorporate this model into clinical practice. The article concludes with an illustrative case example.
Myths Regarding Exposure Therapy for PTSD
Norah C. Feeny, Case Western Reserve University, Elizabeth A. Hembree, University of Pennsylvania, and Lori A. Zoellner, University of Washington
Considerable evidence exists for the efficacy and tolerability of exposure therapy for PTSD (cf. Foa & Rothbaum, 1998; Rothbaum, Meadows, Resick, & Foy, 2000). However, the use of exposure therapy in real-world settings has lagged behind such findings. It is our belief that this gap between science and practice is partly due to several clinical myths regarding the use of exposure therapy. In this article, we outline four such myths, discuss relevant empirical findings, and argue that exposure therapy is indeed applicable for the treatment of a variety of patients with PTSD by clinicians in a variety of real-world settings.
Metacognitive Beliefs About Rumination in Anger
Craig Simpson, North Manchester General Hospital, and Costas Papageorgiou, University of Lancaster
Rumination has been found to heighten angry mood and has been implicated in the maintenance of anger-control problems. Despite this, little is known about the nature of rumination in anger. In this study, 10 patients with anger-control problems were assessed using a semistructured interview to investigate whether they actively ruminated during and after an anger-instigating episode and whether they held positive or negative metacognitive beliefs about ruminating. All patients indicated that they ruminated both during and after an anger incident. Eight patients identified positive metacognitive beliefs concerning the benefits of rumination in improving understanding, preparation, and coping and promoting self-justification of one's behavior. All participants also identified negative metacognitive beliefs. These beliefs related to the adverse emotional impact of rumination and its detrimental effect on functioning and relationships. The conceptual and clinical implications of the study are discussed.
