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CONTENTS
SPECIAL SERIES: ADAPTING CBT FOR RECALCITRANT POPULATIONS
SPECIAL SERIES: COGNITIVE THERAPY OF BIPOLAR DISORDER
REGULAR ARTICLES
ABSTRACTS
Although cognitive behavioral treatments (CBTs) are empirically established for a wide array of psychological disorders, a fair proportion of patients fail to respond to these treatments. For these reasons, clinicians and researchers continue to modify and adapt CBT for refractory populations. The purpose of this special section is to highlight adaptations of CBTs for disorders that are traditionally more difficult to treat and/or recalcitrant in nature. These articles focus on chronic depression, panic disorder with moderate to severe agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder related to childhood abuse, and alcohol dependence. A description of each treatment is provided in each article, along with relevant clinical case examples illustrating adaptations of the techniques.
Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was developed specifically for the chronically depressed patient. CBASP has been shown to be as efficacious as medication singly, and in combination with antidepressant medication is associated with notably high response rates in chronic depression. CBASP’s core procedure, “situational analysis,” is highly structured, and designed to bring about changes in thinking and behavior by emphasizing the relationships between these factors and specific situational outcomes. CBASP conceptualizes the chronically depressed patient as having interpersonal difficulties that are likely to emerge in the therapeutic relationship. These difficulties are anticipated through “transference hypotheses” formulated early in treatment and instructions regarding the constructive resolution of therapeutic impasses are an integral part of treatment.
The current article presents a detailed description of an intensive treatment program for panic disorder with moderate to severe levels of agoraphobia (PDA), called Sensation-Focused Intensive Treatment (SFIT). Although the efficacy of traditional CBT treatment programs has been well established for the treatment of PDA, patients with moderate to severe levels of agoraphobia generally do worse, and those with residual agoraphobia at the end of treatment are at greater risk for relapse. SFIT is an 8-day treatment program that directly targets feared physical sensations and agoraphobic avoidance. SFIT combines techniques used in traditional CBT along with intensive, ungraded, massed exposure. Preliminary data support the utility and durability of this intensive treatment program for those with moderate to severe levels of agoraphobia.
In this article, we describe a cognitive behavioral treatment approach to cases of obsessive-compulsive disorder (OCD) that have not responded to standard outpatient evidence-based treatment. The approach begins with an assessment of the reasons why patients have not responded to treatment, which can be grouped into two categories: (a) inadequacies in the level of OCD treatment the patient has received; and (b) The presence of treatment-interfering behaviors that have obstructed the patient’s ability to participate adequately in treatment. Treatment is then assigned according to category. Patients in Category 1 receive a more intensive level of evidence-based OCD treatment. Patients in Category 2 receive readiness treatment, a cognitive behavioral treatment designed to help patients get ready for OCD treatment by modifying treatment-interfering behaviors. Case examples are provided to illustrate this treatment approach.
Women who have PTSD related to childhood abuse have significant deficits in the areas of emotion regulation and interpersonal skills. These problems are associated with impaired functioning in social, work, and home life. In addition, there is substantial clinical concern that limited emotion-regulation skills puts this population at risk for early dropout and symptom exacerbation in treatment focusing on emotional processing of traumatic memories. Skills Training in Affective and Interpersonal Regulation plus Modified Prolonged Exposure (STAIR/MPE) is an evidence-based, 2-phase cognitive behavioral treatment designed to address these concerns. Specifically, this treatment targets PTSD symptoms, emotion-regulation deficits, and interpersonal difficulties. The purpose of this article is to describe the rationale for and clinical application of STAIR/MPE, detailing the essential clinical components and presenting relevant case examples.
Estimates of the prevalence of alcohol dependence among Americans approach 14% (Read, Kahler, & Stevenson, 2001). Alcohol dependence was once considered among the most recalcitrant of problem behaviors, with only 20% to 30% attaining sustained abstinence (Hunt Barnett and Branch, 1971). Although current definitions of treatment success now consider lapses and recycling (e.g., DiClemente, 2003), sustained abstinence remains the gold standard and is achieved in up to 60% of people in efficacy trials of current psychosocial treatments (e.g., Project MATCH). This paper describes our efforts to develop the next-generation CBT treatment manuals for patients in early abstinence from alcohol, Broad Spectrum Treatment (BST). BST attempts to simultaneously address two seemingly incompatible treatment research goals. First, BST is a flexible but manual-guided treatment that can be standardized and used in the field with the broad spectrum of alcohol abusers. Second, BST seeks to maximize treatment effectiveness by tailoring the specific treatment package to the individual patient’s needs and capacities. Use of explicitly defined a priori decision trees is the vehicle through which these goals can be accomplished. This paper describes the manual in its current form, and discusses the manner in which we are presently testing the efficacy of the manual as it stands. Special Series Cognitive Therapy of Bipolar Disorder
Bipolar illness is related to high rates of hospitalization, suicide, divorce, job loss, and other negative outcomes. Although psychotropic medication is an important component of treatment, the effectiveness of medication is compromised by increased risk of rapid cycling, noncompliance with treatment, and decreased longer-term efficacy. The articles in this issue provide the basis for a cognitive-behavioral approach to the treatment of bipolar illness, stressing psychoeducation, Socratic dialogue, mood monitoring, anticipation of setbacks, suicide prevention, confronting hopelessness, evaluating risky thinking during mania, and precommitment to risk-control strategies.
This article describes the application of cognitive-behavioral therapy (CBT) to the treatment of rapid cycling bipolar disorder. Between 10% and 24% of bipolar patients experience a rapid cycling course, with 4 or more mood episodes occurring per year. Characterized by nonresponse to standard mood-stabilizing medications, rapid cyclers are particularly in need of effective, adjunctive treatments. Adjunctive CBT has been shown to improve medication compliance and reduce relapse rates in patients with bipolar disorder. However, no published trials to date have examined the application of CBT to the treatment of rapid cyclers, with only a single case study existing in the literature. We address challenging clinical problems in the treatment of patients with rapid cycling bipolar disorder and include strategies for managing frequent mood fluctuations, medication compliance, sleep hygiene, lifestyle regularity, mood elevation, suicidality, and comorbidity. A case example is included to illustrate the treatment approach.
Bipolar disorder exacts a terrible toll on its sufferers owing to the repeated, severe disruptions in the patients' lives, the discomfort and uncertainties of being on rigorous, ongoing pharmacotherapy regimens, the emotional difficulties inherent in experiencing depression and mania, and the fear of a deteriorating course. Patients with bipolar disorder can become quite hopeless about improving their lot, a state of mind that is related to suicide risk. Indeed, the conservative lifetime suicide rate for bipolar sufferers is 15%, thus making the risk of self-harm a typical part of the therapeutic agenda with this population. Therapists assess the patients' risk for suicide via structured interviews, self-report inventories, and an exploration of their "suicidogenic beliefs." Treatment counteracts the potential threat of suicide on a number of fronts, including: (a) establishing a collaborative, respectful therapeutic relationship in which the therapist strives to understand the patient’s despair and provide accurate empathy; (b) devising antisuicide plans of action, including contracts; (c) teaching a wide range of skills, including rational responding, problem solving, communication, moderating activities to experience an optimal amount of mastery and pleasure, objectively assessing the pros and cons of living and dying, and others; (d) maximizing the patient’s social support network, including improving family relationships, interacting more effectively with friends and associates, and joining self-help, advocacy groups; and (e) fighting the stigma of bipolar disorder via the acceptance of limitations, while still striving to live life to the fullest through treatment, an optimistic attitude, with long-range, meaningful goals.
Bipolar individuals engage in risky behavior during manic phases that contributes to their vulnerability to regret during their depressive phases. A cognitive model of risk assessment is proposed in which manic risk assessment is based on exaggeration of current and future resources, high utility for gains, low demands for information to assess risk, discounting of losses and regret, and overestimation of the ability to replicate behavior. Drawing on this manic model of decision-making, specific cognitive interventions are described that assist the manic individual in moderating risky behavior.
This article comments on the three articles (Leahy, 2005; Newman, 2005; and Reilly-Harrington & Knauz, 2005) that deal with the applications of cognitive therapy to treatment of bipolar disorder. They focus on the uses of cognitive therapy in treating three important facets of the special problems of bipolar patients: rapid cycling, severe depression/suicidality, and manic states. This article concludes its commentary with several open questions and ideas about the role of thought suppression and rebound processes in the cycling between depressive or euthymic and manic states in bipolar disorder. Regular Articles
The strengths and weaknesses of behavioral couple therapy (BCT) are well documented and disseminated, and it this approach to couples continues to evolve. Newer behaviorally- based approaches share an openness to integration and can enhance the ability of BCT to address three key process-related variables: the therapeutic alliance, hope, and diversity. Similarly, some non-behavioral techniques fit the format of typical BCT sessions and can be integrated into a BCT framework; they can facilitate the couple’s ability to benefit from BCT, and function to accomplish the same goals. Examples of interrelated usage of these techniques with a case example and relevant citations provide practical ways to enhance the ability of BCT to address the therapeutic alliance, hope, and diversity throughout treatment.
Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment for young children with severe behavior problems. Typically, it is individually administered to families by a therapist and a cotherapist. However, converting PCIT to a group format can be a cost-effective way to reach a larger number of families in need of treatment. In addition, PCIT offers techniques to facilitate parents’ skill development and generalization of skills that are not commonly used in group parent training programs. This article has multiple goals: (a) to review the structure of a group PCIT program, (b) to discuss the empirical rationale for use of the program, and (c) to provide a case example that illustrates the rewards and challenges of group PCIT.
Research suggests that Parent-Child Interaction therapy (PCIT) works to improve the child’s behavior by changing the child-parent interaction. PCIT has been effective in treating disruptive behavior in young children. This article describes a pilot study to apply PCIT to the treatment of separation anxiety disorder (SAD). A multiple-baseline design was used with 3 families with a child between the ages of 4 and 8 who had a principal diagnosis of SAD. Following treatment with PCIT, clinically significant change in separation anxiety was observed on all measures. Disruptive behaviors also decreased following treatment. Treatment gains were maintained at a 3-month follow-up interval. These findings suggest that PCIT may be particularly useful for treatment of young children with SAD, the most prevalent yet underresearched anxiety disorder of childhood. The results of this study support research delineating the important contribution of family factors to anxiety in childhood. Several mechanisms are proposed that may account for the dramatic decrease in separation-anxious behaviors seen in children during PCIT, including increased levels of child control, increased social reinforcement of brave behaviors, improved parent-child attachment, and decreased levels of parent anxiety. Results of this study provide promising initial evidence that PCIT may be efficacious for treating young children with SAD. A randomized clinical trial is warranted to further elucidate the efficacy of PCIT for treatment of SAD in young children.
Following a historical précis regarding exposure and a brief description of a representative cognitive-behavioral therapy (CBT) program for anxiety disorders in youth, we discuss several factors related to conducting exposure tasks in youth. Topics include assessing anxious situations, creating a hierarchy, and using imaginal, as well as in vivo and in- and out-of-session exposure tasks. We also describe and discuss the posture of the therapist with regard to the development and maintenance of rapport, the process of consulting with the child, the use of shaping and rewarding effort, the restraining from reinforcing avoidance, modeling for parents, and how to deal with the occasional less-than-successful exposure task. Developmental level of the child and contextual factors are examined as they might influence the design and implementation of exposure tasks. Last, we consider professional practice issues of liability, applications in private practice, and the challenges that face new therapists undertaking exposures. Examples and illustrations from actual clinical cases are included throughout. |
The Growing Up of Cognitive and Behavioral Practice