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By Barbara LoFrisco
Cognitive Behavioral Seminar
University of South Florida
Cognitive Therapy – The Theory
 In order to understand an emotional disturbance, one
must understand the mental processes...
Cognitive Therapy- The Process
1. Patient becomes aware of cognition
2. Patient frames cognition as a hypothesis
3. Patien...
Cognitive Therapy- The Process
 Patient will start to apply these techniques to new
events
 Many of the skills learned i...
Cognitive Therapy- Schema Work
 Cognitive errors (or “automatic thoughts”) are based
on schema, or “patterns of thinking”...
Cognitive Therapy- Cognitive Errors
 We are all subject to cognitive errors
 They occur more often in affective episodes...
Cognitive Therapy- Cognitive Errors
5. Mind Reading
6. Fortunetelling
7. Magnifying/Minimizing
8. Emotional Reasoning
9. M...
Cognitive Therapy- Cognitive Errors
How many cognitive errors can you spot in this story?
Mary felt isolated and alone. Ma...
Cognitive Therapy- Cognitive Errors
Mary felt isolated and alone. Mary had been married
to an abusive man for 5 years and ...
Cognitive Therapy- Therapeutic
Interaction
 Relationship is one of collaboration
 Patient is expert on his or her own ex...
Cognitive Therapy- Therapeutic
Interaction
 Meaning system of each patient is idiosyncratic
 Patients must take an activ...
Cognitive Therapy – Behavioral
Methods
 Behavioral methods sometimes used to increase
behaviors or provide experiences in...
Behavioral Methods- Applications:
Self-Monitoring
 Hour-by-hour record of activities and associated
moods is kept
 Patie...
Behavioral Methods- Applications:
Self-Monitoring
 Detailed examination of this record is much better
than patient’s memo...
Behavioral Methods: Applications:
Scheduling Activities
 Purpose is to get patient to engage in activities he or
she is (...
Behavioral Methods: Applications:
Scheduling Activities
 A thorough analysis of cognitive obstacle can be
performed
 3 T...
Behavioral Methods: Applications:
Scheduling Activities
 Patient can use self-monitoring to monitor mood after
activities...
Behavioral Methods: Applications:
Other Behavioral Activities
 Breaking down larger tasks into smaller units
 Makes task...
Cognitive Methods: Daily Record of
Dysfunctional Thoughts
 Find DRDT in Dobson’s book. In mine it’s p. 359.
 Most of the...
Cognitive Methods: Daily Record of
Dysfunctional Thoughts
 Some patients don’t know the difference between
thoughts and f...
Cognitive Methods: Daily Record of
Dysfunctional Thoughts
 Teach patients that it is the thoughts about the
situation, no...
Cognitive Methods: Three
Questions
1. What is evidence for and against this belief?
2. What are the alternative interpreta...
Cognitive Methods: Downward
Arrow Technique
 Patient’s first thoughts are usually not therapeutically
useful in that they...
Cognitive Methods: Cognitive
Errors
 Teach patient to recognize when one of his or her
thoughts falls into one of the cat...
Cognitive Methods: Identifying
Schemata
 After a while in therapy, a certain consistency emerges
in patient’s cognitive e...
Cognitive Methods: Indentifying
Schemata with DAS
 The DAS has 9 interpretable factors:
1. Vulnerability
2. Approval
3. P...
Cognitive Methods: Socratic
Questioning and Guided Discovery
 Probably the most distinctive stylistic feature
 Most diff...
Cognitive Methods: Socratic
Questioning and Guided Discovery
 Therapist should avoid closed questions and
declarative sta...
Treatment Procedures- Beginning
of Treatment
 Goals:
1. Assessment
 Beck Depression Inventory (BDI); also can be used as...
Treatment Procedures- Middle
Phase of Therapy
 Solidify work on cognitive coping skills
 Patient uses DRDT to track thou...
Treatment Procedures- Middle
Phase of Therapy
 Answer: to help client make sense of his or her
schemata
Treatment Procedures- Final Phase
 Gains are reviewed
 Relapse prevention:
 Anticipate situations that would tax patien...
Treatment Procedures- Final Phase
 Patients feelings or beliefs about terminating therapy
are addressed
 Patient may fee...
Empirical Status- Depression
 Rush et al. (1977) found that patients treated with
cognitive therapy experienced greater s...
Empirical Status- Depression
 Then…Elkin et al. (1989) discovered that cognitive
therapy did not perform as well as medic...
Empirical Status- Depression
 Finally, in another placebo-controlled randomized
study, Jarrett et al. (1999) found that t...
Empirical Status- Depression
 Rush et al. (1977) found that at 12-month follow-up (but
not at 6) that CT patients scored ...
Depression- Therapist Behavior
 Collaborative Study Psychotherapy Rating Scale
(CSPRS) measures therapists’ adherence to ...
Depression-Patient Cognitions
 Hollon et al. (1988) proposed 3 kinds of changes that
occur:
1. Deactivation – suppress ol...
Depression- Patient Cognitions
 DeRubeis (1990) studied patients from the Holland et
al. (1992) study, found that improve...
Depression- Patient Cognitions
 But….Miranda and Persons (1988) disagreed, stating
that the depressive schemata may simpl...
Depression- Patient Cognitions
 A method is needed to require a patient to PRODUCE
rather than RECOGNIZE coping skills. M...
CT Course of Change
 Ilardi and Craighead (1994) observed that 60% - 70% of
symptom improvement occurs in the first 4 wee...
Therapist Patient Alliance
 Recent research continues to show a positive
relationship between alliance and outcome
 Good...
Therapist Patient Alliance
 As opposed to measuring it at various points during the
therapy process
 Beckham (1989), DeR...
Panic Disorder and Agoraphobia
 There is also cognitive therapy for OCD, anxiety and
hypochondriasis, which follows a sim...
Panic Disorder and Agoraphobia
 The phenomenology and treatment of panic disorder
have been well developed:
 Patient fee...
Panic Disorder and Agoraphobia
 Patient focuses on catastrophic consequences of
symptom
 ** Patient loses ability to vie...
Panic Disorder and Agoraphobia
 Recent development in treatment: beware of
dependence on safety behaviors
 In the mid-ei...
Panic Disorder and Agoraphobia
Cognitive Therapy Treatment:
1. Therapist and patient map out vicious cycle
2. Patient beli...
Panic Disorder and Agoraphobia
Behavioral Methods:
 Establish methods to induce panic
 Patient learns that the methods d...
Panic Disorder and Agoraphobia
 If patient has learned controlled breathing, patient
may think that if they don’t get con...
Empirical Status of Panic Disorder
 Sanchez et al. (2010) did a meta-analysis of various
treatments for panic d/o with or...
Empirical Status of Anxiety/OCD
 Chambless & Gillis (1993) reviewed 9 clinical trials and
found mostly support for CT’s e...
Impediments to CBT Treatment for
Anxiety Disorders
 Anxiety disorders are the most prevalent class of
disorders (Gunter &...
Impediments to CBT Treatment for
Anxiety Disorders
 CBT approaches are the only empirically supported
approaches to anxie...
Impediments to CBT Treatment for
Anxiety Disorders
 Limited training opportunities
 Dissemination of CBT is complex
 Tr...
Impediments to CBT Treatment for
Anxiety Disorders
 Lack of training at the doctoral/internship levels
 From 1993 – 2003...
Impediments to CBT Treatment for
Anxiety Disorders
 Perception is that study was done on patients with
only one very spec...
CBT and Dyspareunia
 Kabakçi & Batur (2003) studied 16 Turkish couples
who were treated for vaginismus at a hospital. CBT...
OCD and Hoarding
 Hoarding not usually related to OCD (Tolin et al.,
2010).
 More likely related to anxiety and depressi...
OCD and Hoarding
 Tolin et al. (2010) studied 558 hoarders, primarily
Caucasian and female
 They found that insight was ...
References
Beck, A. T. & Greenburg, R. L. (1974). Coping with depression.
New York: Institute for Rational Living.
Beck, A...
References
Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet,
A., Ladouceur, R., et al. (2010). A randomized cli...
References
Jacobson, N.S. & Hollon, S.D. (1996a). Cognitive-behavior
therapy versus pharmacotherapy: Now that the jury’s
r...
References
Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., &
Gómez-Conesa, A. (2010). Psychological treatment o...
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Cognitive Therapy

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Cognitive Therapy

  1. 1. By Barbara LoFrisco Cognitive Behavioral Seminar University of South Florida
  2. 2. Cognitive Therapy – The Theory  In order to understand an emotional disturbance, one must understand the mental processes or cognitions  These mental events are readily accessible  Patient’s beliefs are examined: him/herself, future and world  Any concern will be in one of these domains  This is the “cognitive triad” (Beck, Rush, Shaw & Emery, 1979)  Common themes are found with both anxious and depressed patients
  3. 3. Cognitive Therapy- The Process 1. Patient becomes aware of cognition 2. Patient frames cognition as a hypothesis 3. Patient scrutinizes belief 4. Patient gradually arrives at a different view 5. Changes in the emotional reaction should follow 6. Eventually, concern over recent events will diminish 7. Thus, negative affect is removed from ruminations about said events 8. Result: Less negative mood
  4. 4. Cognitive Therapy- The Process  Patient will start to apply these techniques to new events  Many of the skills learned in Cognitive Therapy are used by people who have never had depression  If the patient does not use these skills, the risk for relapse is high
  5. 5. Cognitive Therapy- Schema Work  Cognitive errors (or “automatic thoughts”) are based on schema, or “patterns of thinking”  These are the “themes” of dysfunctional thinking  All patients have them  They can be uncovered by examining cognitive errors  Can be uncovered using Downward Arrow technique  Or using “If then” logic. For example, “If I fail this exam, then I am a failure as a person”.  Old schema can be replaced with new
  6. 6. Cognitive Therapy- Cognitive Errors  We are all subject to cognitive errors  They occur more often in affective episodes  There is a list of common errors that patients can compare their own thoughts to: 1. All or nothing thinking 2. Over generalizing 3. Discounting the Positives 4. Jumping to conclusions
  7. 7. Cognitive Therapy- Cognitive Errors 5. Mind Reading 6. Fortunetelling 7. Magnifying/Minimizing 8. Emotional Reasoning 9. Making “should” statements 10. Labeling 11. Inappropriate Blaming
  8. 8. Cognitive Therapy- Cognitive Errors How many cognitive errors can you spot in this story? Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. “I should have done it much sooner”, she reported. Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive. “What is wrong with me? I’m never going to meet anyone!”
  9. 9. Cognitive Therapy- Cognitive Errors Mary felt isolated and alone. Mary had been married to an abusive man for 5 years and had finally decided to leave him. “I should have done it much sooner”, she reported (#7 Minimizing, #9 should statements, #11 Inappropriate Blaming). Mary reported that she had a history of attracting abusive men, so therefore all men must be abusive (#2 Overgeneralization). “What is wrong with me? I’m never going to meet anyone!” (#1 All or nothing thinking, #6 Fortune Telling).
  10. 10. Cognitive Therapy- Therapeutic Interaction  Relationship is one of collaboration  Patient is expert on his or her own experience, and the meaning he or she attaches to events  Therapist is expert on the model  Therapist does not make interpretations, rather solicits this information from clients  More of a state of “not knowing”  Thoughts are not replaced until patient understands the meaning of the thoughts and has decided they are not true
  11. 11. Cognitive Therapy- Therapeutic Interaction  Meaning system of each patient is idiosyncratic  Patients must take an active role in therapy  Differs from Michenbaum’s Cognitive Behavioral Modification: thoughts are behaviors that can simply be modified without understanding underlying meaning  Different from Michenbaum’s SIT (Self Instructional Training): client is taught to repeat specific self-coping statements rather than question their inferences  Differs from Ellis’ REBT: therapist infers clients’ thinking errors
  12. 12. Cognitive Therapy – Behavioral Methods  Behavioral methods sometimes used to increase behaviors or provide experiences in pleasure  Focus is always on changes in beliefs resulting from change in actions  Behavioral changes serve as “experiments” to check out a “hypothesis” that the patient and therapist have developed; or formulate a new one  But….Jacobson et al. (1996) found that 12 weeks of behavioral methods had outcomes comparable to 12 weeks of cognitive therapy.
  13. 13. Behavioral Methods- Applications: Self-Monitoring  Hour-by-hour record of activities and associated moods is kept  Patients record mood on a 0-100 scale, where 0 is the worst they have ever felt and 100 is the best  Beck et al. (1979) suggests the patient also record the degree of mastery or pleasure associated with the activity  Patients are sometimes surprised at how they are spending their time  Can also serve as a baseline
  14. 14. Behavioral Methods- Applications: Self-Monitoring  Detailed examination of this record is much better than patient’s memory for testing hypothesis  Patient’s memory is often selective  Therapist can ask patient to recall thoughts that occurred during both good and bad events  Therapist can look for consistencies in the record: which events are associated with good or bad moods, or with mastery or pleasure
  15. 15. Behavioral Methods: Applications: Scheduling Activities  Purpose is to get patient to engage in activities he or she is (unwisely) unwilling to do  Remove decision making as an obstacle in initiation of activity  Has decision making ever been an obstacle for you in initiating an activity? (Share with the class if you feel comfortable)  Non-adherence can be addressed therapeutically  Usually “failures” are similar to what has been troubling the patient.
  16. 16. Behavioral Methods: Applications: Scheduling Activities  A thorough analysis of cognitive obstacle can be performed  3 Types of Activities to schedule: 1. Those associated with mastery, pleasure or good mood 2. Those that had been rewarding in the past but that the patient has been avoiding 3. New activities that might be rewarding or informative
  17. 17. Behavioral Methods: Applications: Scheduling Activities  Patient can use self-monitoring to monitor mood after activities  Activities can be “experiments”  Patients are more likely to do activities if they are framed as “experiments”
  18. 18. Behavioral Methods: Applications: Other Behavioral Activities  Breaking down larger tasks into smaller units  Makes task more concrete and less overwhelming  This is called “chunking”  Easier tasks can be accomplished first  This is called “Graded tasks”  Although simplistic, these methods can be effective because they change how patient views the (formerly) difficult task
  19. 19. Cognitive Methods: Daily Record of Dysfunctional Thoughts  Find DRDT in Dobson’s book. In mine it’s p. 359.  Most of the work in Cognitive Therapy centers around Daily Record of Dysfunctional Thoughts (DRDT) Beck et al. (1979)  Four most important columns correspond to the three points in the cognitive model (situation, belief, emotional consequence).  Patients first use DRDT to record unpleasant or puzzling emotions  Patient must first understand what emotions are (see handouts)
  20. 20. Cognitive Methods: Daily Record of Dysfunctional Thoughts  Some patients don’t know the difference between thoughts and feelings  Therapist may have to educate patient  Can give feeling chart to patients so that they can understand what different feelings are  In addition to situation and emotions, patient must also record thoughts in DRDT  This may be more difficult because patients often think situations “cause” emotions
  21. 21. Cognitive Methods: Daily Record of Dysfunctional Thoughts  Teach patients that it is the thoughts about the situation, not the situation that produces the emotion  Teach patient to examine his or her own inferences  It is these inferences that are the cause of distress  Automatic thoughts can be re-rated for strength of belief after alternative thought has been formulated  If ratings are similar, then the initial concern is not resolved  Affective response can also be re-rated in a similar way.  Again, lack of change means something is missing
  22. 22. Cognitive Methods: Three Questions 1. What is evidence for and against this belief? 2. What are the alternative interpretations? 3. What are the real implications, if the belief is correct?
  23. 23. Cognitive Methods: Downward Arrow Technique  Patient’s first thoughts are usually not therapeutically useful in that they do not describe the implications to the patient  Use Downward Arrow Technique to uncover the implications of thought  Ask “What would it mean if….?”  Or “What if it is true that….?”  Or “What about that bothers you?”  Repeat until thought is produced that will benefit from cognitive therapy
  24. 24. Cognitive Methods: Cognitive Errors  Teach patient to recognize when one of his or her thoughts falls into one of the categories of cognitive errors (p. 353 of Dobson, or slide #6)  Teaches patients that these are common cognitive errors: normalization
  25. 25. Cognitive Methods: Identifying Schemata  After a while in therapy, a certain consistency emerges in patient’s cognitive errors  These consistencies, or “themes” are the schema  They are found at the level of personal meaning  Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978) to assess schemata and track changes during treatment
  26. 26. Cognitive Methods: Indentifying Schemata with DAS  The DAS has 9 interpretable factors: 1. Vulnerability 2. Approval 3. Perfectionism 4. Need to please others 5. Imperatives 6. Need to impress others 7. Avoidance of weakness 8. Control over emotions 9. Disapproval Class give examples of 3 of them
  27. 27. Cognitive Methods: Socratic Questioning and Guided Discovery  Probably the most distinctive stylistic feature  Most difficult for therapists to master  Guided discovery: through use of leading questions, helping patients arrive at new perspectives  Therapists must walk a line between guiding patient and allowing patient to free-associate  Common errors of inexperienced therapists is to be in a hurry and lecture the patient or ask overly leading questions.  Even facial expression can be a factor (LoFrisco)
  28. 28. Cognitive Methods: Socratic Questioning and Guided Discovery  Therapist should avoid closed questions and declarative statements  This maximally engages client to think about problem and come up with solution  Helps foster independence and prevent relapse (LoFrisco)  Will have a greater chance of addressing any idiosyncratic issues; more client centered
  29. 29. Treatment Procedures- Beginning of Treatment  Goals: 1. Assessment  Beck Depression Inventory (BDI); also can be used as a session-to-session measure 2. Socializing patient into cognitive model  Have patient read the booklet Coping With Depression (Beck & Greenberg, 1974)  Helps to instill hope 2. Dealing with patient’s pessimism
  30. 30. Treatment Procedures- Middle Phase of Therapy  Solidify work on cognitive coping skills  Patient uses DRDT to track thoughts that produce negative affect  Therapist uses Downward Arrow Technique to help patient fine-tune their responses  Therapist reviews DRDT with patient  Patterns associated with schemata are identified  Developmental history of schemata is discussed. Why?
  31. 31. Treatment Procedures- Middle Phase of Therapy  Answer: to help client make sense of his or her schemata
  32. 32. Treatment Procedures- Final Phase  Gains are reviewed  Relapse prevention:  Anticipate situations that would tax patient and review the skills they have learned  Because…patients usually attribute their improvement to changes in their environment, not changes in themselves
  33. 33. Treatment Procedures- Final Phase  Patients feelings or beliefs about terminating therapy are addressed  Patient may feel like they “can’t do it on their own”  Schedule “booster” or “check-up” sessions  Jarrett et al. (1998) found that monthly check-up sessions helped to prevent relapse  Even less frequent boosters can be beneficial
  34. 34. Empirical Status- Depression  Rush et al. (1977) found that patients treated with cognitive therapy experienced greater symptom remission at the end of 12 weeks compared with those taking a tricyclic antidepressant (randomized trial)  Blackburn et al. (1981) and Murphy et al. (1984) did a similar study and found cognitive therapy equally effective  Dobson (1989) meta-analysis: a greater degree of change than wait-list, pharmacotherapy, behavior therapy and other psychotherapies
  35. 35. Empirical Status- Depression  Then…Elkin et al. (1989) discovered that cognitive therapy did not perform as well as medication in severely depressed patients  A later report (Elkin et al., 1995) showed even more dismal results  The saga continues…Hollon et al. (1992) found that cognitive therapy performed at least as well as medication, even among the severely depressed  OK, let’s get serious. DeRubeis et al. (1999) performed a mega-analysis from these studies and found cognitive therapy just as effective as medication.
  36. 36. Empirical Status- Depression  Finally, in another placebo-controlled randomized study, Jarrett et al. (1999) found that the two treatments performed equally well. Conclusion? Even in the short run, cognitive therapy is a potent alternative to medication. But does it last?
  37. 37. Empirical Status- Depression  Rush et al. (1977) found that at 12-month follow-up (but not at 6) that CT patients scored lower on depression severity measures than the antidepressant group  Murphy et al. (1984) found patients that received CT during the acute treatment phase were less likely to relapse than those treated with drugs  Hollon et al. (1992) had similar results  Several studies have found that a relatively short course of CT following a successful course of antidepressants is as effective in preventing relapse as is continuing the meds.
  38. 38. Depression- Therapist Behavior  Collaborative Study Psychotherapy Rating Scale (CSPRS) measures therapists’ adherence to CBT model.  CT- Concrete: measures active methods  CT- Abstract measures discussions about CT rationale  DeRubeis & Feeley (1990); Feeley et al. (1999) discovered that CT-Concrete was associated with greater changes in BDI; and CT-Abstract was not  Therefore, it is critical for therapists to focus on problem-solving aspects of CT, at least early on
  39. 39. Depression-Patient Cognitions  Hollon et al. (1988) proposed 3 kinds of changes that occur: 1. Deactivation – suppress old schema 2. Accommodation – modify/create new schema 3. Development of compensatory skills – applying CT skills to future situations
  40. 40. Depression- Patient Cognitions  DeRubeis (1990) studied patients from the Holland et al. (1992) study, found that improvement on the:  Beck Hopelessness Scale  DAS  Attributional Style Questionnaire Play a meditational role. (patients who improved on these measures also had subsequent change in depressive symptoms) Therefore, attributional style and dysfunctional attitudes mediate the reduction of risk of CT
  41. 41. Depression- Patient Cognitions  But….Miranda and Persons (1988) disagreed, stating that the depressive schemata may simply be latent.  So….they developed a negative mood induction procedure prior to administering the DAS.  Segal et al. (1996) found that scores on mood induced DAS predicted relapse, just like Hollon had found.  Measures of changes in compensory skills are less plentiful  Most measures of coping skills came from interests other than CT
  42. 42. Depression- Patient Cognitions  A method is needed to require a patient to PRODUCE rather than RECOGNIZE coping skills. Most patients can recognize them.  Barber and DeRubeis (1992) developed the Ways of Responding (WOR) to address this need.  To measure changes in beliefs as they occur in session (rather than a static measurement) Tang and DeRubeis (1999) developed Patient Cognitive Change Scale.
  43. 43. CT Course of Change  Ilardi and Craighead (1994) observed that 60% - 70% of symptom improvement occurs in the first 4 weeks. But this was inferred from group mean.  Actually….Tang and DeRubeis (1999) report 40% - 60% of change occurs in the first 4 weeks.  Why would this be clinically relevant?  Tang and DeRubeis (1999): In addition to a shorter course, individual therapy gains can be much more sudden than group therapy gains; called “sudden gains”  Occurs among more than 50% of patients  Accounts for more than 50% of total relief
  44. 44. Therapist Patient Alliance  Recent research continues to show a positive relationship between alliance and outcome  Good therapeutic alliance tends to be the RESULT of symptom improvement, rather than a PREDICTOR  So….therapists should adhere to concrete CT, and they will build alliance  This differs from past findings….  Studies that took the average over time of the alliance, and then correlated it to the outcome
  45. 45. Therapist Patient Alliance  As opposed to measuring it at various points during the therapy process  Beckham (1989), DeRubeis and Feeley (1990), Feeley et al. (1999) found that therapeutic alliance measured early in therapy process did not predict good outcome  Furthermore, DeRubeis and Feeley (1990), Feeley et al. (1999) found that later in therapy, alliance was actually predicted by outcome  Lastly, Tang and DeRubeis (1999) found that alliance in the session prior to the sudden gain was significantly lower as compared to the session after the gain.
  46. 46. Panic Disorder and Agoraphobia  There is also cognitive therapy for OCD, anxiety and hypochondriasis, which follows a similar form to what was just described (for depression).
  47. 47. Panic Disorder and Agoraphobia  The phenomenology and treatment of panic disorder have been well developed:  Patient feels a particular symptom  Attributes it to the start of a panic attack (from experience)  Because he/she thinks it’s pathological, the progression of the panic attack continues  I.e.. chest pain= heart attack  But there are other explanations for these symptoms  I.e.. You will be lightheaded if you get up too fast
  48. 48. Panic Disorder and Agoraphobia  Patient focuses on catastrophic consequences of symptom  ** Patient loses ability to view symptoms objectively***  This is what turns anxiety into a panic attack  Vicious cycle: fear makes symptoms worse, which makes fear worse, etc.  At this point symptoms seem uncontrollable  This spontaneous attack is a “phobia” of internal conditions
  49. 49. Panic Disorder and Agoraphobia  Recent development in treatment: beware of dependence on safety behaviors  In the mid-eighties, using relaxation or distraction procedures was the norm  This has been recently found to prevent full recovery in certain cases  Because patients think they MUST do them to stop panic attack  Harmless?
  50. 50. Panic Disorder and Agoraphobia Cognitive Therapy Treatment: 1. Therapist and patient map out vicious cycle 2. Patient beliefs are identified (i.e.. “If I hyperventilate I will die.”) 3. Beliefs are challenged using safety behaviors (i.e.. controlled breathing) 4. Safety behaviors used only to disprove belief 5. More realistic beliefs are identified 6. Images experienced by patient are altered
  51. 51. Panic Disorder and Agoraphobia Behavioral Methods:  Establish methods to induce panic  Patient learns that the methods did not result in catastrophy  Thus these symptoms are not reliable warnings of danger  Patients are encouraged to expose themselves to situations they have avoided due to fear
  52. 52. Panic Disorder and Agoraphobia  If patient has learned controlled breathing, patient may think that if they don’t get control of their breathing the results will be catastrophic (because then they will definitely have the anxiety attack)  This is reinforced continually via negative reinforcement (patient does breathing exercise and they do not faint)  Harmless? Now what do you think?
  53. 53. Empirical Status of Panic Disorder  Sanchez et al. (2010) did a meta-analysis of various treatments for panic d/o with or w/out acrophobia.  CT was moderately useful on its own, but its effectiveness increased dramatically when paired with exposure therapy.  Clark (1996) showed that across 5 different studies, between 74% - 94% of CT patients remained panic- free.  CT was found to be superior to applied relaxation, exposure and pharmacotherapy.
  54. 54. Empirical Status of Anxiety/OCD  Chambless & Gillis (1993) reviewed 9 clinical trials and found mostly support for CT’s effectiveness in treating GAD  Two additional studies, Barlow et al. (1992) and Durham et al., 1994) support this  For OCD, Van Oppen et al. (1995) found CT equivalent to exposure and response prevention (an OCD treatment with established efficacy).  A number of studies (Compas et al., 1998) have found CT effective for bulimia nervosa
  55. 55. Impediments to CBT Treatment for Anxiety Disorders  Anxiety disorders are the most prevalent class of disorders (Gunter & Whittal, 2010)  CBT treatments are “poorly disseminated” to practitioners  Of 84% of adults w/ anxiety that saw a health care practitioner, only 23% received appropriate treatment  Only 11% received appropriate psychological services  Psychopharmacology: $2305; individual counseling: $1357; group $523
  56. 56. Impediments to CBT Treatment for Anxiety Disorders  CBT approaches are the only empirically supported approaches to anxiety (EMDR for PTSD a possible exception)  Gap between research findings and clinical practice is large  WHY?
  57. 57. Impediments to CBT Treatment for Anxiety Disorders  Limited training opportunities  Dissemination of CBT is complex  Treating anxiety requires temporarily increasing symptoms (i.e.. exposure)  Most psychological treatments do not do this  Thus, exposure treatments have a “bad rap”  Counter to ethical mandate: do no harm  Many therapists fear hurting their clients  Perceived contraindications lack empirical support
  58. 58. Impediments to CBT Treatment for Anxiety Disorders  Lack of training at the doctoral/internship levels  From 1993 – 2003 there has been very little increase in the amount of CBT training available  Many therapists “eclectic”, including non-CBT approaches  Almost all effective approaches for anxiety are forms of CBT  Practitioners tend to rely on their clinical experience, rather than outcome studies
  59. 59. Impediments to CBT Treatment for Anxiety Disorders  Perception is that study was done on patients with only one very specific disorder, rather than the more complex mix we see typically in patients  General lack of attention to practitioner concerns  Standardized treatment protocols are “cold” and “calculated”  Difficulty in finding the funding to train clinicians appropriately
  60. 60. CBT and Dyspareunia  Kabakçi & Batur (2003) studied 16 Turkish couples who were treated for vaginismus at a hospital. CBT treatment included cognitive reframing. All couples were able to achieve successful intercourse  Bergeron et al (2001) found that CBT, including cognitive restructuring was effective in treating dyspareunia  But…it was no more effective than biofeedback (Bergeron et al., 2001)  …. And less effective than vestibulectomy (Bergeron et al., 2001)
  61. 61. OCD and Hoarding  Hoarding not usually related to OCD (Tolin et al., 2010).  More likely related to anxiety and depression  It’s a public health problem  Behavioral treatments and medication for OCD fair poorly  Possibly because hoarders generally have poor insight  Previous studies may not have represented hoarders, as they do not always identify with having OCD
  62. 62. OCD and Hoarding  Tolin et al. (2010) studied 558 hoarders, primarily Caucasian and female  They found that insight was related to hoarding behavior  Future treatments of hoarding should be centered around raising awareness and insight
  63. 63. References Beck, A. T. & Greenburg, R. L. (1974). Coping with depression. New York: Institute for Rational Living. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Bergeron, S., Binik, Y. M., Khalifé, S., Pagidas, K., Glazer, H. I., Meana, M., et al. (2001). A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain, 91(3), 297-306. Dobson, K.S. (2003). Handbook of Cognitive Behavioral Therapies. New York: The Guilford Press.
  64. 64. References Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., et al. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1), 46-58. Gunter, R. W., & Whittal, M. L. (2010). Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clinical Psychology Review, 30(2), 194-202.
  65. 65. References Jacobson, N.S. & Hollon, S.D. (1996a). Cognitive-behavior therapy versus pharmacotherapy: Now that the jury’s returned its verdict, it’s time to present the rest of the evidence. Journal of Consulting and Clinical Psychology, 64, 74-80. Jarrett, R. B., Basco, M. R., Risser, R., Ramanan, J., Marwill, M., Kraft, D., & Rush, A. J. (1998). Is there a role for continuation phase cognitive therapy for depressed oupatients? Journal of Counseling and Clinical Psychology, 66, 1036-1040. Kabakçi, E., & Batur, S. (2003). Who benefits from cognitive behavioral therapy for vaginismus. Journal of Sex & Marital Therapy, 29(4), 277-288.
  66. 66. References Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clinical Psychology Review, 30(1), 37-50. Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants’ perceptions of insight in compulsive hoarding. Cognitive Therapy and Research, 34(1), 69-81. Weissman, A. N., & Beck, A. T., (1978). Development and validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the meeting of the American Educational Research Association, Toronto.

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