Editori: Sadock, Benjamin J.; Sadock, Virginia A.

, Ruiz, Pedro Titlu: Kaplan &'s Comprehensive Textbook Sadock de Psihiatrie, ediia a 9 Copyright 2009 Lippincott Williams & Wilkins Table> Cuprins> Volumul II> 30 - Psihoterapii> 30.7 - Terapia cognitiv 30.7 Cognitive Therapy Cory F. Newman dr. Aaron T. Beck MD Introducere i Definitie O trstur central a teoriei cognitive de tulburri emoionale se pune accent pe importana psihologic a lui convingerile oamenilor despre ei nii, lumea lor personale (inclusiv oamenii n viaa lor), iar viitorul lor-"triada cognitive." Cnd oamenii de experien, dezadaptative emoional primejdie excesive, este legat de lor problematice,, prtinitor interpretri stereotip pertinente la acest triadei cognitive, lumea auto, si viitorul. De exemplu, punct de vedere clinic pacienii cu depresie pot fi predispus s cread c ei sunt incapabili si neajutorat, pentru a vedea alii ca fiind judeca i critic, i viitorul ca fiind sumbru i neprofitabil. n mod similar, la pacienii cu tulburri de anxietate poate fi apt de a se vedea ca fiind foarte vulnerabile, alii ca fiind mai capabil, i viitorul ca ar putea fi caracterizat de catastrofe personale. Desi pacientului puncte de vedere Sunt de greit i disfuncionale, ele totui tind s fie perpetuat de ctre cognitive procese care le menin. De exemplu, pacienii cu depresie pot participa selectiv la informaii care sugereaz c acestea sunt eecuri care sunt paragin de ctre alii, neglijnd s se concentreze pe probele de realizarile lor sau oamenii n viaa lor, care au oferit suport. Astfel de prejudeci n prelucrarea informaiilor duce de multe ori persoanele deprimate s neglijeze relaiile lor interpersonale i s renune la p rematur n ncercarea de a atinge obiectivele importante. Rezultatul este o aprofundare a pesimism lor, o agravare de starea de spirit, i un cerc vicios de retragere n continuare. n mod similar, pacienii anxietate poate imagina selectivcel mai ru caz scenarii, care s conduc la evitarea de satisfacii i importante activiti de altfel. Aceti pacieni discount dovezi incontestabile c punctele de la beneficiile i a potenialului istoric de a se angaja n activiti, cum ar fi participarea la clas i / sau de munc, socializare, i de cltorie n mod liber din loc n loc. Credina sisteme dezadaptative de pacieni conduce la modele comportamentale care s ntreasc negativ convingerile lor, provocnd astfel mai multe tulburri, n curs de desfurare i un sentiment de neajutorare i disperare care necesit intervenie clinic. Terapeuti Cognitive nvee pacienii lor sistematic abilitile de identificare, examinarea i modificarea acestora gndire s tiluri maladaptative. Obiectivul primordial este ca pacienii s ctige un obiectiv i uor de gestionat vedere mai mult de problemele lor i potenialul soluiile lor. Te rapia cognitiva este format dintr-un set larg de tehnici cognitive i comportamentale utilizate strategic n contextul unui caz conceptualizare cuprinztoare, facilitat de o nelegere, de acceptare, terapeutice relaie empatic. Terapia cognitiva este un (P.2858) timp -eficiente,, colaborare tratament structurat foarte mult c se concentreaz asupra crerii i educarea pacienilor n abilitile psihologice, cum ar fi rspuns, obiectiv raional auto -monitorizare, formularea i testarea ipotezelor personale, comportament auto-management, problema rezolvarea, i altele. Terapeutii cognitiv utiliza teme pentru acasa pentru a consolida ac este abilitati, astfel nct pacienii s nvee i amintii-v cum s se ajute singuri i, astfel, s menin terapeutice ctigurile lor pe termen lung. ntr -adevr, meninerea ameliorrii clinice este un semn de eficacitatea terapiei cognitive. Terapia cognitiva a fost utilizat cu succes n tratamentul de tulburri de dispoziie (i n reducerea riscului de suicid), tulburri de anxietate (de exemplu, fobii, tulburri de panic, anxietate social tulburare, tulburarea de anxietate generalizat), tulburri psihotice, tulburri de personalitate, abuz de substane, precum i tulburri de alimentaie, precum i pentru un numr de tulburri psihofiziologice (de exemplu, sindrom de colon iritabil, fibromialgie, disfuncie sexual). Terapia cognitiva a fost studiat, de asemenea, ca un tratament adjuvant pentru afeciuni medicale, cum ar fi durerile cronice, anxietate de sntate la pacienii cu cancer, i competen social n urma leziunilor cerebrale, printre altele. Terapia cognitiva pot fi utilizate n, individuale, de grup cuplu, i formate de familie. ntr-adevr, exist dovezi empirice n sprijinul eficacitatea terapiei cognitive pentru cupluri, precum i pentru tratamentul de copii, adolesceni i vrstnici. , Interesant Evoluiile recente n terapia cognitiv-au avut ca rezultat, noi abordri bazate pe empiric pentru tratamentul tulburrilor bipolare, tulburri de atenie, i schizofrenie. Unul dintre punctele forte ale terapiei cognitive n tratamentul acestor probleme clinice din urm este sa s e concentreze pe modificarea "dezadaptative convingerile pacienii despre a lua medicamente (de exemplu," Dac m simt bine, pot s ncetai s luai medi camentul "). Rezultatul este o sinergie mbuntit ntre terapia cognitiv i farmacoterapie, de care beneficiaz pacienii n multiple feluri. n concluzie, terapia cognitiv este o experien de nvare n care terapeutul joac un rol activ n sprijinirea pacienilor de a recunoate, identifica i modifica prejudeci cognitive care provoca primejdie nejustificate i care ar mpiedica n caz contrar rezolvarea problemelor constructive. Tratamentul ajut pacienii s devin mai activ n viaa de zi cu zi, astfel nct acestea s dezvolte un sentiment mai mare de auto -eficacitate i stpnirea, care prevede c experienele corective negativistic convingerile contra despre sine i viitorul unul. Un binevoitor, deschis terapeutice relaie de colaborare ajut la meninerea pacienilor angajate n terapie in timp ce invata, practic, i de auto -ajutor aptitudini master care va dinui. Astfel, o alian pozitiv este maximizat, iar riscul de a pacientului a deveni dependent de terapeut este minimizat. History Fundamentele teoretice ale terapiei cognitive (cum este formulat de ctre Aaron Beck) include teoria psihanalitica, psihologia cognitiv, terapie comportamental, i-umaniste abordare fenomenologica la psihologie. Neo-freudiene psihologi, cum ar fi Otto Rank, Horney Karen, i Alfred Adler (n special) a subliniat importana nelegerii pacienilor n cadrul contient experiena lor, precum i beneficiile de a evalua modul n care "punctul de vedere subiectiv pacienii influena lor conturile lor experienele de via n curs de desfurare. Contribuiile majore ale psihologilor cog nitive includ lui Kelly conceptul George de "personal construiete", ca un factor determinant al comportamentului, precum i teoriile cognitive de emoie formulate de Magda Arnold i pe Lazr Richard:.Terapie comportamentala Micarea a contribuit crucial terapeutice mai multe strategii Structurarea interviu , pregtete ordinea de zi a sesiunilor individuale, stabilirea obiectivelor, provoca reacii, operaionalizarea procedurilor, testarea ipotezelor, formularea i pun erea n aplicare a tehnicilor de rezolvare a problemei, i atribuirea ntre-sesiuni de teme pentru acas. Terapia cognitiva lui, empatic abordare bazat pe colaborare care implic un stil de interogatoriu i necondiionat acceptare blnd datoreaz mult orientate spre client terapia de Carl Rogers. Ideea empiric a terapiei cognitive a fost influenat de activitatea i comportamental oriented scriitori cognitive, cum ar fi Albert Bandura, Frank Jerome, Goldfried Marvin, Lazr Arnold, Michael Mahoney, Meichenbaum Donald, i G. Wilson Terence.

Probleme teoretice cognitive Procesarepsihopatologice state, la nivel de funcii cognitive superioare (de exemplu, testarea realitatii, anticipnd costurile i beneficiile) sunt inhibate sau depreciate, care s conduc la extreme de furie, anxietate, tristete, exaltare (ca n manie), i alte emoii care apar inadecvate sau disproporionate la o dat fiind situaia sau de timp. Etiologia psihopatologiei este complicat i multilateral, implicnd i biologice factori genetici, mpreun cu prelucrarea cognitive i contingenele de mediu. Cu toate acestea, terapia cognitiv prevede intrarea efectiv n puncte "psihologic sistemele de pacieni pentru intervenie. n diverse afectiuni, disfuncionale anumite convingeri relevante pentru neputin, pericol, i unlovability (printre altele) joac un rol important n prelucrarea informaiilor. Aceste convingeri disfuncionale mucegai individuale de gndire i s contribuie la erorile cognitive tipice d e psihopatologie Logic erori ngndire observator.logicerorile din stilul de gndire sunt de obicei observate la persoanele ale cror nivel subiectiv de stres pare a fi mrit sau inutile n afara acesteia. Dei toate persoanele sunt supuse la astfel de erori, cei cu tulburri psihice au tendina s dea dovad mai frecvente, mai grave, i o gam mai larg de procese de gndire, cum ar dezadaptative dect populaiile normative. Un set prezint neexhaustiv de erori, cum ar este prezentat dup cum urmeaz Arbitrare inferenta contrar.asemenea, cunoscut colocvial ca "de a trage concluzii," aceasta se r efer la atingerea de o concluzie n absena unor dovezi de susinere ntr -adevr, chiar n faa probe. Un exemplu este persoana concluzia o c el se ntmpl s-i piard locul de munc i au o catastrof financiar, bazat pe un e-mail de la angajatorul su cerndu-i s participe la o reuniune special n dimineaa urmtoare Selectiv de abstractizare Acest.se refer la concentrndu-se pe un detaliu luate afara contextului, ignornd, mai importante alte caracteristici ale situaiei, i conceptualizarea ntreaga experien pe baza a acestui element circumscris. De exemplu, un student primete un set stelar de clase, dar nu pot opri neastmprat and rumegam despre imperfect scorul unul, care s conduc la impresia c evaluarea general reprezint "eec". Suprageneralizarea Acest proces se produce atunci cnd cineva crede n i urmeaz o regul general pe baza de exemple limitat. De exemplu, un tnr decide c femeile nu pot fi de ncredere, bazat pe o singur (dei suprtor), situaie n care o fosta pr ietena-l nelai. Mrire iMinimizarea persoaneleatribui uneori subiective "greuti" interpretrilor lor de situaii, astfel nct evenimente negative sunt date mai mult greutate, i evenimente pozitive sunt considerate ca fiind mai puin semnificative prin comparaie. Un exemplu de acest favoritism sistematice n stil gndire este vzut ntr -o femeie care este preocupat de faptul c cererea ei de la o coal de absolvent special a fost respins (lupa negativ), n timp ce abia participa la faptul c ea a fost acceptat la un prestigios program comparabil (minimiznd n acelai timp, pozitiv) "P.2859. dihotomice" All-sau-Nu de gndire Persoanele reduce uneori situatii de "fie-sau" algoritmi sau "versus alb-negru." Acest lucru simplific prea situaii, nbuind rezolvarea n mod creativ, care s conduc la catastrophization, i incitarea la suprat inutile i / sau conflict. De exemplu, un om care are un dezacord cu soia sa este de prere c "Ori eu sunt n control, sau ea este n control." Aceast credin dihotomice l mpiedic s vad cum poate negocia i de compromis cu soia sa, i, n schimb conduce la fiinei sale furios i opoziie atunci cnd o soluie panic, de altfel, evident. Diminuarea Abilitatea de a se angaja n Avnd perspectiv (Metacogniia) Unul din semnele distinctive de gndire de ordin superior este abilitatea de a atinge punctul de vedere, sau sa se gandeasca de o gndire. Piaget menionate la acest proces, n etapa a propus sa operaiunilor de gndire formal, care este presupus a fi indicative de prelucrare cognitive mature. Oamenii se angajeaz n aceste strategii, atunci cnd pauz pentru a reflecta, cerndu -se ntrebri, cum ar fi, "De ce am ajuns la aceast concluzie special?" i "Ce a putea s fi fost gndit s fi avut o astfel de reacie emoional puternic peste ceva att de mici? "Aceasta este o abilitate care terapeutii cognitive strduiesc s nvee pacienii lor. Persoanele cu tulburri psihice s-au dovedit a avea deficiene n perspectiv, innd. Ei au dificulti n "distanndu-se" de la automat gndurile lor i, astfel, sunt mpiedicate de la re-evaluarea lor ntr-o gndire, ne-critic mod productiv. Prin contrast, persoanele care sunt calificai i bine practicat n raional rspunde i atentie sunt mai mult adept la luarea automat gndurile lor ", cu un bob de sare". Suprat de o serie de dezamgiri interpersonale, o persoan poat e crede, "Eu niciodat nu am de gnd s m las pasa de oameni vreodat din nou toate acestea. ", dup cum el sau ea are stoc de ace st gnd, individul repede ajunge la concluzia c aceast auto-declaraie nu este nici realist, nici constructiv. n schimb, persoana recunoate c durerea emoional a momentului este leg at n gndire prtinitoare, i c soluia pentru a recupera de la evenimente de via negative necesit nvare din situaii dificile i se deplaseaz pe. Relaia dintre perceptiile emotii si comportamente teme cognitive pot fi identificat cu emoii corespunztoare i tendine comportamentale. afecta depresive este determinat atunci cnd exist o percepie de pierdere-o nfrngere sau privarea-frecvent sub form de pozitive sau disconfirmed ateptri nemplinite sau la perturbarea o relaie personal valoare. Consecinele de obicei includ retragerea, un sentiment de neputin i disperare, precum i o devalorizare de sine sau o experien de via, acum i n viitor. Disforie-a, deseori tranzitorii i a acceptat o parte normal a unui imperfect de via devine exagerate i rezistente la schimbare atunci cnd perpetuat de gnduri, cum ar fi, "Viaa mea este ruinat," i "Nu exist nici un punct n ncercarea de mai." The profund disperare rezultant se poate chiar cineva loc la riscul de suicid. Anxietatea este evocat atunci cnd oamenii sunt preocupai de vulnerabilitatea lor la vtmri fizice sau psihologice i prin urmare, sunt indemnati sa evite, scape, sau potoli setea. -Sau-zbor rspunsuri Lupta-din nou, o parte normativ a funcionrii sntoase-devin overreactive la stimuli, induse de gnduri catastrofice despre riscul de respingere, jena, circumstan viata sa diminuat, vtmare sau de deces. n unele privine, anx ietate poate fi interpretat ca cealalta parte temporal de depresie, anxietate este despre ceea ce s-ar putea pierde n viitorul apropiat, n timp ce depresia este despre ceea ce crede c o are deja pierdutexcesiv.

abuziv Furie apare n legtur cu teme de , maltratarea, nedreptate, i are nevoie de zdrnicite. Furios persoan patologic nu vede doar el sau ea ca au fost lezate, ci mai degrab interpreteaz situaia, astfel cum rezult din neglijen lui cineva, incompeten, i / sau rea -voin. Acest lucru poate duce la anii persoan care devine agresiv i atacnd (de exemplu, verbal, fizic), dei individuale pot punctul su de vedere sau aciunile sale ca justificabile i pentru auto-aprare:.Cognitive Modelul Aplicaii peste Dereglari specifice Fiecare dintre tulburri psihiatrice se caracterizeaz de, idiosincratic convingeri dezadaptative care ajuta pentru a marca psihologic boala special. (Pacienii cu tulburri comorbide au adesea mai multe seturi de aceste credine disfuncionale, multe dintre care pot consolida reciproc, astfel fcnd cognitive prejudecile lor, cu att mai ncpnat mpotriva modificrilor n tratament.) Sunt de urmtoarele prezentri generale a teoriilor cognitive ale o selecie parial a zone de diagnosticare. Trebuie remarcat faptul c nici stilurile cognitive i nici tulburri psihice sunt ortogonale construcii. Asta este, nu este neobinuit pentru cognitive stiluri urmtoarele intercorrelate i s se suprapun, n funcie de specificul unui caz particular i.Depresie "Triada cognitive" Din punct de vedere cognitiv, tulburri depresive sunt caracterizate prin negative vederi dysfunctionally de sine, cuiva experien de via (i lumea n general), i una de viitor triada cognitive. Pacienii depresivi de multe ori se vad pe sine ca fiind defecte, neajutorat, i / sau neiubit, i au tendina de a atribui neplacute experienele lor de a lor fizice, mentale, i / sau moral deficite presupuse. Ei tind s se simt excesiv de vinovat, creznd c ei sunt fr valoare, condamnabil, i respins de sine i de ceilali. Ele pot avea un timp foarte dificil de vizionare ei nii ca persoane care ar putea reui vreodat, s fie acceptate, sau se simt bine despre ei nii. Unele dintre manifestrile cele mai izbitoare a acestei zone de prtinire cognitive sunt "de pacieni, cum ar nclinaie pentru atributele lor de vedere pozitiv, descalificarea realizarile lor ca fiind minor sau lipsite de sens, i neinnd seama de ngrijire, va bun, i grija de altii ca fiind bazate pe mil sau susceptibile de a fi pierdut cu uurin n cazul n care aceste alii tiau "real" pacientului. Pacienii depresivi vedere vieile lor fr nici un fel de placere sau de recompens, prezentnd obstacole de netrecut import ante pentru atingerea scopurilor lor. Totul pare i se simte "prea greu pentru a gestiona," i alte persoane sunt vzute ca pedepsirea (sau potenial aa). Ei cred c necazurile lor va continua la nesfrit, i c viitorul va aduce doar privarea de greuti n continuare, i frustrare. "Paralizia va" rezultatele de la de primat "pacieni pesimism i disperare. Ateapt eforturile lor s se ncheie cu eec, ei sunt reticeni s se angajeze s-orientate spre obiective de cretere, iar activitatea scade nivelul lor. Creznd c ei nu pot afecta rezultatul diferitelor situaii, au experien o dorinta de a evita astfel de situaii. dorete suicidare sunt o expresie extrem de dorina de a scpa de probleme care par a fi incontrolabile, interminabile, i insuportabil. Modelul cognitiv postuleaz c anumite persoane sunt predispui la afeciuni, cum ar fi depresia, n parte, din cauza convingerilor disfuncionale dezvoltat mai devreme n viaa lor. Aceste convingeri sunt modelate de experienele personale, i de tulpin de la identificare cu alii semnificativ i de percepiile lor de atitudinile altor oameni fa de ei. Odat ce o credin de baz este format special (de exemplu, "Nimeni nu -mi place"), acesta poate influena formarea conceptului ulterioare i de a dezvolta ntr-un cognitive "set" sau schem de durat (de exemplu, "Eu sunt iubita"). n plus, schema dezadaptative pot influena apoi persoanei de a aciona n moduri care sprijin fr s vrea, sau s menin schema -aa-numit n tulburri de personalitate de cazuri, ca "auto -ndeplinirea. Profeie" The efecte negative dezadaptative scheme de cele mai multe sunt vizibil vzute vor fi descrise mai trziu sau.Dei latent inactiv la moment dat, schemele sunt activate de anumite situaii similare celor experiene timpurii care au modelat dezvoltarea schemei. Atunci cnd aceste scheme sunt activate, disforie marcat de multe ori apare. Dac aceast persist, o depresie clinica poate avea ca rezultat. De exemplu, dac o persoan a pierdut un printe n timpul copilriei, ntreruperea unei relaii interpersonale strnse la varsta adulta poate activa conceptul de pierdere ireversibil implantate de experienele anterioare. Depresia poate fi, de asemenea, o reacie cu zi experiene traumatice prezent care nu au neaprat legturi asociative la trecut P.2860. , Tipic precipitarea Alte evenimente includ obinerea de feedback critic de la alii, care se confrunt cu un eec profesional sau academic, avnd un obiectiv important dejucat, care se ncadreaz bolnav, sau nu s rspund la ateptrile o, printre altele. Un indiciu puternic c o schem negativ a fost activat este o persoan emotionale si comportamentale reactie adversa care este disproporionat n raport cu situaia. De e xemplu, o femeie a devenit suicid dup ce a primit. On "mai aproape de evaluare" tunsoarea ru, extrem de prime jdie ei a fost bazat pe o activare de scheme care a condus-o s cread c ea a fost defect, neiubit, pe cale de a fi abandonai de ctre prietenul ei, i destinate s fie singur pentru tot restul vieii ei de -o situaie dorea s acapararea de moarte. "risc-Resources" Model de anxietate Cnd contemplam un ambigue sau situaie problematic, pacienii au tendina de nerbdtori n mod automat s se anticipeze consecinele cele mai negative. Dei poate fi adaptive n unele situaii s anticipeze cel mai rau caz posibil, pacienii cu anxietate clinice sunt n mod constant fixat pe posibilitatea de a rezultatelor extreme i, prin urmare sunt hypervigilant la, psihologice, i / sau sociale ameninri fizice. Aceasta reprezint o mrire de sentimentul de ameninare, sau de risc,.Similar persoanelor cu tulburri de anxietate, de asemenea, misperceive sau trece cu vederea dovezi sugestive de capaci tatea lor de a gestiona, a rezolva, sau a face fa situaiei problematice. De exemplu, ei au gnduri automate, cum ar fi, "Acest lucru este prea mult pentru mine s se ocupe; am de gnd s se destrame," sau "Nu am o idee despre ce s fac," sau "Nu mai e nimeni m pot transforma pentru sfaturi. "Prin i mari, dezada ptative astfel de gnduri insufle un sentiment de neputin i reprezint o reducere de persoane resurse n a fi capabil s se ocupe cu tot ce este cauza" lupta -zbor-congela "reacii. Persoanele care vedea n mod obinuit a riscurilor de situaii ca fiind mai mare dect sunt n realitate n timp ce simultan presupunnd c resursele lor sunt mai puin adecvate dect este necesar va tind s aib reacii de anxietate de prea multe ori, n multe situaii prea. n plus, aceste persoane vor avea tendina s ia msuri pentru a scpa de riscul perceput, adesea sub forma de comportament de evitare. Evitarea pare sa "lucreze" pentru astfel de persoane, n msura n care le elimin dintr-un sentiment iminent de ameninare sau pericol. Acest lucru ntrete negativ comportamentul de evitare n timp ce, n acela i timp l mpiedic persoana nerbdtor s vad limitele adevrat a riscului, precum i capacitatea lui sau a ei pentru a face fa active. n acest mod, perpetueaz evitarea distorsiunilor cognitive jur de risc i resurse i poate deveni foarte nrdcinat ca o strat egie de adaptare defect a lungul timpului. Persoanele cu tulburare de anxietate generalizat sunt predispuse s v facei griji cu privire la o gam larg de probleme n mod regulat, de multe ori se intreaba " Ce se ntmpl dac scenarii? "ntrebri care evoca cel mai ru caz. n mod similar, persoanele care sufer de tulburri de anxietate social sunt obiceiul s se atepte c vor eua n situaii sociale, estimarea c ei nu vor ti ce s spun, c nu se va potrivi n, i c acestea vor fi judecai i / sau respinse. Atacurile de panica se caracterizeaz printr-o interpretare eronat catastrofale de senzatii corporale sau experiene mentale (de exemplu, "palpitatii ale inimii nseamn am de gnd s mor de un atac de cord chiar acum!" i "Feeling mental nseamn cea Imi pierd mintea mea!") . In -compulsiva tulburare obsesiv, coninutul de gndire obsesiv graviteaz n jurul un avertisment sau o ndoial c nu pot fi ignorate, n timp ce constrnger e este determinat de un ndemn

pentru a nltura pericolul printr-un act repetitiv. Acest lucru se manifest n convingerea c ceva ru se va produce cu excepia cazului n care persoana se angajeaz n comportamentul Personalitate.Tulburari ritualistic.alt ilustrare a modelului cognitiv este vzut n tulburrile de personalitate, fiecare dintre care se caracterizeaz printr-un set de convingeri disfuncionale De exemplu, persoana cu tulburare de personalitate evitanta este de prere c "Dac nu ncercm, atunci eu nu pot da gres," cei cu personalitate inei-compulsiva tulburare obsesiv c "am s v asigurai c totul este" doar att ", n vederea s se simt mulumii ", i persoane cu tulburare de personalitate narcisica susin c" eu sunt merit de consideraii speciale de mai sus pe cele ale altora tulburari . "Atunci cnd persoanele demonstra personalitatea comorbide, ele dein adesea mai multe seturi de convingeri disfuncionale care traverseaz liniile de diagnosticare. De interes, n tulburri de personalitate borderline, pacienii sunt adesea "dubla legat" de pe plan intern contradictorii convingerile lor. Un exemplu tipic este pacientul care simultan crede "Eu sunt vulnerabile n cazul n care cineva devine aproape de mine" si "M atept s fie abandonate, iar acest lucru m va devasta." Astfel, aceti pacieni se simt vulnerabili dac acestea sunt ntr-o relaie strns sau nu i par a fi ntr-o permanent stare de conflict i tulburri despre cel mai important ataamentele lor 30.7-1.Tabelul. Exemplu Scheme (domeniile de baz ale convingerile negative) Unlovability / "rutatea" /defectele abandonului/ sociale izolare Nencrederea / abuz / vulnerabilitatea la vtmare Incompetena /dependena privareaemotionala Lipsade individuaie / subjugare Dreptul / limite insuficiente inexorabil standarde

Pacienii cu tulburri de personalitate, n special, sunt predispui s fie afectate de rigid credinele de baz fundamentale , cunoscut sub numele de scheme maladaptative. Tabelul 30.7 - 1 ofer o list eantion de scheme frecvent ntlnite n practica clinic Tulburrile de alimentaie sunt.Anorexia i bulimia caracterizat printr-o constelaie de convingeri dezadaptative care s ncurajeze suferinzi s continue modelele lor alimentare nesntoase n timp ce le descurajeaz s ncerce s modifice mananca comportamentul acestora, astfel nct pentru ao face mai normativ. De exemplu, pacientul anorexice va menine adesea convingeri defecte, cum ar fi, "Este virtuoase pentru a merge fara a manca pentru perioade lungi de timp" i "Dac a putea obine pn la greutatea mea [nespecificat, anormal de sczut figura], voi fi fericit i totul va fi bine obezitatea. "nplus, ele ilustreaz problemele asociate toate-sau-nici unul cu gndire destul de izbitor de exprim convingerea c orice cretere a lor n a mnc a n mod necesar va duce excesive mnca i. Ele demonstreaz, de asemenea distorsiuni perceptuale n care vizioneaz ei nii ca fiind "gras" atunci cnd alii le vedea la fel de subtire, sau de a fi mulumit cu aspectul lor, n timp ce alii le vd ca slab i bolnav aspect. ntr-un mod similar, pacienii bulimic au convingeri maladaptativ, cum ar fi, "eu nu pot tolera sentimentul de plin, astfel trebuie s vomit de a scpa de acest sentiment groaznic," si "I pot mnca nimic i tot ceea ce vreau, atta timp ct am posibilitatea de a vomita, fr ca cineva s tie despre el. "CauzaConceptualizarea Pentru a pregti un plan de tratament pentru fiecare pacient n parte, terapeutul dezvolt o conceptualizare caz preliminar (care este modificat i actualizat ca date clinice suplimentare sunt colectate pe parcursul tratamentului). n mod ideal, aceast formulare include o nelegere a persoanei disfunctionale convingerile idiosincratic, vulnerabilitilor specifice, i modul n care viaa pacientului stres afectul aceste vulnerabilitati pentru a activa prezint simptome. conceptualizri Case de odihn pe att i prospectiv de evaluare istoric a modelului de exacerbare simptom n raport cu situaii i pacientului nelegerea dintre ele. Prin cutarea de numitori comuni printre simptome, se pot identifica pacientului vederi de situaii diverse i lor cognitive, modelul de baz. Acesta e ste un pas important devreme n procesul de schimbare terapeutic. P.2861 O femeie a prezentat pentru terapia cu probleme de control al furiei. Ea a trimis o mulime de ostile voice-mail i mesajele e-mail la un coleg, a avut nstrinate vecinii ei cu plngerile sale despre zgomot, i a fost rugat s prseasc bowling liga ei, dup dou altercaii fizice cu me mbrii de alte echipe. O analiz atent a pacientului gndurile i credinele din jur aceste situaii au relevat un numitor comun de un sentiment de nencredere i de drepturi. n fiecare situaie, ea a crezut c persoanele care au fost obiecte de furia ei au ieit din modul lor de ei maltrateze. Mai mult, ea a avut un sentiment exagerat de auto-importan reprezentat de credine, cum ar fi, "Nimeni nu are dreptul sa ma trateze asa," "Eu nu ar trebui s se ocupe de aceti oameni i prostia lor," i "trebuie s arat-le c nu pot mpinge vreodat m n jurul pacientului. "Pentru acest lucru, furia ei a fost justificat, ca ea a incercat sa se apere de com portament nepotrivit altora. Cu toate acestea, pentru observatorul din afar, pacientul a fost un "tun n vrac", care a luat infraciune la pictur de o plrie i al crui comportament a fost scandalos i nejustificat. n terapia, pacientul la primul nu a fost deschis la vizionarea problem furia ei n maniera descris mai sus. Cu toate acestea, ca ea a nvat s recunoasc activarea ei scheme de nencredere i de drepturi, ea a devenit mai dispus s analizeze modalitile n care ea ar putea modifica pu ncte de

vedere ei i comportamente. Aceast schimbare pozitiv a fost facilitat de terapeutului empatica rspunsurile la pacient m ai credibile povesti de maltratare ea a primit de la familia ei, a crui abuziv comportament ia dat mesajul c ea nu ar trebui s ncredere n nimeni i c ea niciodat nu trebuie s pun cu maltratat din nou. Tehnici de relaie terapeutic Ca i n alte terapii, a relaiei terapeut-pacient este important n terapia cognitiv i ofer un mediu de mbuntire. Terapeuii funcie ca ghizi pentru a permite pacienilor lor de a dobndi nelegerea i abilitile care i vor ajuta s fac fa mai bine cu problemele lor. Terapeuii utilizare descoperire ghidat, un proces de grijuliu interogatoriu care ncurajeaz pacienii s ia n considerare problemele lor n mod logic i mai atent i mai puin impulsiv and catastrofal. Acestea servesc ca modele pentru pacientii lor, demonstrnd optimism, linitit ncredere n sine, bunvoin fa de alii, i entuziasm despre a face dificile i uneori dificil munca de terapie pe care.Stilul de terapeut n autentic manifestarea caldura ne-critic i acceptare este similar cu de-centrat sau Rogerian terapeut client. n contrast i s psihanalitice terapeuti Rogerian, cu toate acestea, terapeutul cognitive joac un rol activ n a ajuta la identificarea problemelor actuale , concentrndu-se pe domenii importante, propunnd i timp pentru repetiii cognitive i comportamentale tehnici specifice, precum i planificarea teme pentru acas. Terapeutul colaboreaza cu pacientul la construi o ordine de zi pentru fiecare sesiune i s fac schimb de feedback construct iv cu privire la coninutul sesiunii i ntre-sesiuni de teme pentru acasa. Terapeutul este atent la semne c pacientul este adpostirea ndoieli cu privire la modul n care terapia este procedur i, astfel, ntreab despre pacientului gandurile despre tratament, terapeutul lui comportamentul, argumente pro i contra a temelor de cas, i pacient alte reacii la terapie. La ori, pacienii menine credinele disfuncionale despre terapia c, odat identificate, devin extrem de exemple utile ale pacienilor "stilul cognitiv problematice. De exemplu, un pacient ar putea oftat adnc n rspuns la comentariile lui terapeut ncurajarea ei. Terapeutul, observnd ace st semn de comportament al unei schimbri de afecteaz, solicit pacientul, prin mintea ta? "Pacient Rspunsurile," Ce a mers doar "Ai prea mult ncredere n mine, am de gnd s v dezamgesc." Acest schimb apoi duce la o discuie fructuoas a modului n care pacientul susine convingeri despre a nu fi capabil de a tri pn la ateptrile celorlali i modul n care ea interpreteaz grija, ncurajnd comentarii ca o povar adugate la "executa" la un nivel de competen crede ea nu este capabile s ating. Procesul este similar cu conceptul psihanalitice de transfer, n sensul c relaia terapeutic este un teren de testare pentru identificarea i schimbarea "interpersonale distorsiuni pacieni. Similarly, resistance (eg, to homework) is dealt with in terms of underlying dysfunctional beliefs (eg, I won't be able to do the homework, and then I'll feel stupid, and then I 'll get suicidal, so what's the point?). As cognitive therapy has developed to treat more severe problems such as substance abuse and personality disorders, greater attention has been paid to the management of difficulties in the therapeutic alliance. Cognitive therapists are alert for patients' misgivings that could lead to premature termination of therapy, and therefore they ask their patients for feedback every session. Structure of the Therapy Program The separation of cognitive therapy interventions into categories of behavioral techniques and cognitive techniques is sometimes misleading, in that many of the techniques affect both the patient's behavioral patterns and thought processes. Nevertheless, it is instructive to make this distinction to highlight the relative emphases on behavior change and cognitive change. Behavioral Techniques These are used prominently at the beginning of therapy with severely depressed patients who may be disinclined to engage in the introspection and abstraction needed to identify and evaluate automatic thoughts, deeper beliefs, or schemas. Often, the first step is to obtain baseline data by asking patients to complete the Daily Activities Schedule (DAS) form. This provides information on how patients are spending (or misspending) their time, as in the vegetative depressed patient who remains in bed until the middle of the afternoon and then watches television for hours. Such a pattern is low in pleasure or mastery, keeps the patient socially isolated, and predictably keeps the patient mired in helplessness and hopelessness. The data obtained from the DAS help therapists and patients to identify behavioral problems and set new behavioral goals. Next, they may agree on prospectively scheduling activities that help to mobilize the patient, thus counteracting depressogenic inertia. Because most patients who are deeply depressed need to proceed in small, gradual steps, a graded-task assignment is developed to enable them to have progressively greater success experiences at a realistic pace. Table 30.7-2 lists typical behavioral techniques. Some patients may have a wide variety of negative thoughts regarding the behavioral assignments. It is not uncommon for patients to think that I won' t be able to do it, It won't help me, or I'll just feel stupid and it will make me worse. These cognitions become grist for th e mill and can be formulated as predictions or hypotheses that the patients can then test as part of the behavioral assignment. Therapists present the behavioral tasks (indeed, all self-help assignments) as win-win propositions. If the patient is able to do some or P.2862 all of the self-help tasks, this is a triumph. If patient is not, then it is still useful to assess and address the negative cognitions related to the difficulties that he or she encountered. These may be indicative and emblematic of other negativistic cognitions that keep the patient discouraged and immobile. The elucidation of these problematic cognitions becomes an important part of the case conceptualization, which represents progress in itself. Table 30.7-2. Behavioral Techniques (Sample) Daily activity schedule Mastery and pleasure ratings Graded tasks Role playing

Behavioral experiments Assertiveness practice

Role playing is an especially useful method in session. Through the use of this technique, patients can practice a number of important psychological skills in the safety of the therapist's office. Patients can also gain valuable guidance and feedback from their therapists as their skills are shaped for use in everyday life. For example, the socially shy individual may practice (with the therapist) initiating and sustaining friendly conversations. Difficulties in doing the role-plays can lead to fruitful discussions of the patient's inhibitory thought process (eg, I look stupid. I can't do this right). Through repetition, patien ts habituate to their anxiety, progressively learn a new behavioral repertoire, and de-catastrophize their concomitant thinking. Role playing can be used in similar fashion to enact pointcounterpoint discussions about the costs and benefits of patients' negative automatic thoughts and schemas, to practice ass ertiveness, and to re-enact psychologically important events in a patient's life for reprocessing, among other purposes. Cognitive Techniques Cognitive therapists teach their patients to view their excessively negative emotions as cues to ask themselves, What is going through my mind right now? The goal is for patients to learn how to self-monitor their key automatic thoughts, perhaps leading to ascertaining deeper beliefs and schemas. An automatic thought (which can include both verbal ideas and images) occurs spontaneously and rapidly, representing an immediate interpretation of a situation. Most people are unaware that their automatic thoughts are associated with unpleasant feelings and behavioral problems. With some training and practice, however, patients increase their awareness of these thoughts and are able to pinpoint them with a high degree of regularity. It is possible to perceive a thought, focus on it, and evaluate it just as it is possible to identify and reflect on a sensation such as pain. Patients generally take for granted that their automatic thoughts are accurate and factual rather than view them as subjective representations of reality. In cognitive therapy, patients learn to evaluate their automatic thoughts in a critical manner, with a nonjudgmental spirit. By changing their thoughts, patients can cope more effectively and devise ways to deal with the situation productively. Depressed and anxious patients predictably interpret many situations in systematically biased ways, even though more plausible interpretations are available. When asked to reflect on alternative explanations and to use Socratic questions patients may realize that their initial interpretations rest on questionable inferences. As patients learn to view their thoughts with greater objectivity, they begin to clarify and modify the meanings they have assigned to upsetting events. Through a process of collaborative empiricism, the therapist and patient help the patient to produce shifts in thinking that result in a boost in morale, improved hopefulness, and increased self-efficacy. For example, a depressed patient became particularly discouraged on calling a friend and having the call go to voice mail. As the patient assessed her automatic thoughts at that moment, she realized that her emotions went beyond the simple disappointment of not being able to talk to her friend at that moment. Instead, she had the thought, They [all my friends] have all gone out and left me behind, and now they don't even want to pick up my calls. Such an automatic thought demonstrates the cognitive distortions of arbitrary inference (there could be other reasons why the friend did not pick up the call) and overgeneralization (the patient only called one friend and cannot truly know what the other friends are doing or thinking). This patient completed an Automatic Thought Record (ATR) in which she spelled out the situation, wrote down her automatic thoughts (with percentage ratings representing how much she believed her automatic thoughts on reflection), the corresponding emotions (rated on a scale of 0 to 100 for intensity), some hypothesized rational responses, and the outcome (in terms of emotions). Rational responses are objective, even-handed, fair-minded self-statements that improve the patients' morale and aim them toward a higher standard of coping. Figure 30.7-1 presents a sample ATR. Therapists teach their patients to hypothesize reasonable responses to their automatic thoughts via the use of Socratic questions that help them to improve their reality testing. Socratic questions assist this process by helping patients to think more adaptively, logically, flexibly, and hopefully. They include the following: What are some other plausible ways I can look at this situation? What concrete, factual evidence supports or refutes my automatic thoughts? Realistically, what is the worst thing that can happen in this situation, and would I be able to live through it? What is the best thing that could happen? Now that I have considered both extremes, neither of which is statistically likely to occur, what is the most likely outcome of this situation? What constructive action can I take to deal with this situation? What are the pros and cons of maintaining my automatic thoughts as they are? What are the pros and cons of trying to modify my thinking in this situation? What sincere, helpful, realistic advice would I give to a good friend in the same situation? As a result of answering these questions, patients gain the benefit of a more constructive, benign view of most situations and thus reduce their level of subjective distress. When their situations truly represent adverse life events, the process of rational responding helps patients to cope more effectively and to respond in ways that will facilitate problem solving. As the foregoing process illustrates, the reality testing of automatic thoughts is carried out by treating them (as well as their corresponding underlying beliefs and schemas) as hypotheses to be tested. The therapist and patient may design a homework assignment (or experiment) to test the patient's thoughts by gathering new evidence. For example, the patient may proclaim that she will n ot try to contact Sally anymore because she is certain that Sally will be unresponsive and the patient will only feel rejected yet again. The therapist may assign the patient the homework assignment of sending Sally a friendly e-mail that reaffirms her interest in getting together socially. The homework assignment also involves the patient documenting her mood states and thoughts as she awaits a reply from Sally. These data (along with a report on whether Sally responded) are brought to the next session for discussion. Again, this procedure is a win-win proposition, in that the patient transcends a state of angry hopelessness simply by virtue of testing her negative hypothesis, and she may actually reap the benefit of an unexpectedly friendly response from her friend. If patients resist testing their hypotheses, their automatic thoughts pertinent to this refusal are identified and discussed as any other set of automatic thoughts. Thus, useful clinical material is gained, no matter how active or inactive the patient is in following through with the assigned homework.

As cognitive therapy progresses, greater attention is focused on the patient's underlying beliefs and related schemas, such a s, If I make a mistake then I am a failure and If I am rejected, it means I am thoroughly unlovable. These beliefsalthough more all-encompassing and fundamental than automatic thoughtsare identified and re-evaluated in much the same way; namely, in terms of the evidence supporting them, the logical basis on which they rest, and empirical testing. However, it is expected that schemas will be more difficult to modify. Thus, more repetitions of both cognitive and behavioral techniques are needed, including experimenting with new strategies and activities in everyday life. Thus, even if the patients base their negative P.2863 schemas on actual adverse or traumatic events from the past, they will be able to construct new beliefs about themselves, their lives, and their futures on the basis of creating new patterns of functioning. The purpose of developing and practicing new strategies is to improve the patients' self-image and general life condition.

Figure 30.7-1. Sample automatic thought record (ATR).

A recent development in the field of cognitive therapy has been the articulation of techniques under the headings of mindfulness, metacognition, and acceptance-based interventions. Broadly speaking, the techniques under these rubrics put great emphasis on patients' learning to recognize the thoughts that give them distress (eg, anxiety, hopelessness), as would be the case in standard cognitive therapy. However, patients are then taught to change their relationship to these thoughts so they are not necessarily confronted or modified but rather put in perspective and accepted with greater equanimity. Such techniques have been studied in the treatment of mood disorders, anxiety disorders, posttraumatic stress disorder, borderline personality disorders, and others. Homework If the therapist's office is the lab, the patient's everyday life is the field. It is well and good for patients to feel better under laboratory conditions (eg, being attended to by a caring, effective therapist in the office), but real, durable change must occur in the patient's life between sessions. To maximize the chance that this will occur, the therapist and patient collaborate to design homework assignments that patients will use to practice new skills, test important hypotheses, and help to prevent relapse once therapy is over. Although homework is not absolutely necessary for patients to improve in therapy, data support the hypothesis that patients who regularly engage in homework make quicker, longer-lasting, more-generalized progress in cognitive therapy. Typical homework assignments can include the standard techniques such as the DAS (eg, recording, planning, and rating activities for mastery and pleasure), the ATR (spotting, recording, and changing problematic thought processes), and behavioral experiments (eg, trying new behaviors, testing hypotheses), but they can also include more creative methods that fit the patient's individual situation. For example, Barry was a highly anxious audiovisual technician. He audiorecorded most of his cognitive therapy sessions and then edited the sessions so that he could play a 2-hour audio compilation of some of his best moments in therapy, such as when he expressed optimism or learned a new way of solving a problem. When Barry would experience an elevation in his generalized anxiety, he would listen to this best of Barry in cognitive therapy anthology on his MP -3 player. As Barry would come to tire of one such recording, he would put together another montage. In this manner, Barry could reinforce the most important principles he had experienced and learned in therapy by reviewing them for homework in everyday life. Sample Applications of Cognitive Therapy Conceptualization and Techniques Suicidality Suicidal individuals have been found to evince high levels of hopelessness both in terms of baseline hopelessness (pessimistic views of the future even when their mood is not particularly depressed) and sensitivity to hopelessness (increase in negativistic views of the future as their mood worsens). They also demonstrate such maladaptive beliefs as the following: My problems are too much to bear. Death is the only solution. I am a burden to those I love. They would be better off without me. I hate myself and can't live with myself anymore. The only way to eliminate my pain is to die. If I try suicide I will find out who really cares about me. If I kill myself I will punish those people who have hurt me. P.2864 As this list of beliefs indicates, suicidal thinking has a rigid, all-or-none quality that inhibits productive problem solving and interferes with healthy communication with others. Thus, when treating suicidal individuals, the cognitive therapist focuses heavily on promoting a good therapeutic relationship, with special emphasis on direct, empathic communication. The patients are encouraged to talk and write about their hopeless thoughts and anguished feelings rather than acting them out in dangerous ways. Furthermore, such patients are urged to communicate in this manner with their friends and family so that their relationships are solidified in times of crisis. Therapists also assist their suicidal patients with problem solving so that they can build a sense of self-efficacy and exert incrementally greater degrees of positive control over their lives. In some instances, merely breaking vicious cycles of hopeless thoughts, feelings, and behaviors is enough to stem the tide and improve a patient's outlook. Additional techniques for suicidal individuals include weighing the pros and cons of killing oneself versus living life as best as one can, focusing on deterrents (eg, religious beliefs, likely traumatization of loved ones, risk of crippling oneself, loss of positive legacy), imagining positive possibilities in the future, establishing goals for improving oneself and one's lot, and learning to delay and distract oneself when urges to commit acts of self-harm are high. Of course, cognitive therapists also follow the full range of standard clinical practices of risk management, including increasing contact with the patient, evaluating the need for hospitalization, collaborating with other professionals and (at times) the patient's family, updating the treatment plan, and collaborating on a contract for safety between sessions in the context of additional goals and strategies.

Anxiety Disorders Part of the anxiety patient's socialization into the cognitive model depends on the therapist's teaching them to self-monitor their thoughts that magnify their sense of risk and their related thoughts that minimize confidence in their resources to cope. The patients' catastrophic expectations are catalogued and examined for accuracy and functionality. At the same time, the therapist normalizes the patients' experience by describing the rout ine, adaptive functioning of the sympathetic nervous system, explaining that anxiety disorders involve an overactivity of this system, fueled by cognitively engineered ideation of doom and disaster. For example, a man with social phobia entering a room full of people is not simply a little bit self-conscioushe is prepared to be judged, rejected, ridiculed, and shunned. A woman with generalized anxiety disorder is not relieved when she actually gets the promotion she originally feared she would lose she now worries that she will not be able to do the job and will get fired, with devastating personal and financial results. Persons with panic disorder are not reassured that their heart palpitations have never once signified cardiac distressthey are certain that this time they are really going to have a heart attack. These examples demonstrate how anxiety patients literally think their way into states of worry, fear, and panic. Similarly, these patients are taught the methods of thinking their way out of their unnecessary distress. For example, many anxious individuals believe that their anxiety is constantly high, but in fact their symptoms come in fluctuating waves. Self-monitoring anxiety symptoms helps patients to recognize that anxiety has a beginning and a peak and then tapers off unless they continue to add to the anxiety with a fresh supply of negative thoughts. Thus, if they can simply observe their symptoms, allowing them to run their natural course, the patients may find that the period of highest distress can be ridden out with little difficulty. However, if the patients begin to have worries about their worries, or fears about the fear, the symptoms are perpetuated. A key intervention is to identify and modify the negative thoughts that prevent the normal decay of the anxiety symptoms. As noted earlier, one of the typical linguistic markers of anxiety-ridden thoughts and speech is the patients' use of negative, rhetorical What if? questions. No matter what the situation, including those that seem benign and positive to the objective observer, the patients will ask themselves, But what if something goes wrong? What if this time my sense of unreality means that I'm truly going insane? What if they don't like me? What if I can't do the coursework? The list goes on and on, as anxiety patients can generate multitudes of such distress-perpetuating queries. An important intervention is to doggedly, painstakingly, thoroughly answer the What if? question literally and positively. In other words, what would happen if they had difficulty with the coursework, or if someone rejected them, or if they ever needed more serious psychiatric care? How would they respond most effectively? How would it affect their lives, and how could they get through the difficult times in order to experience an improvement in life situation again? These constructive questions demand active problem solving, which is an excellent counterattack to catastrophic thinking. The therapist teaches patients to use for themselves the method of Socratic questioning to cognitively restructure the beliefs that typically magnify their perception of risk and minimize their attention to resources. Imagery techniques can be used to help patients live through a frightening situation in the ir mind's eye in the therapist's office. Patients are asked to imagine best case, worst case, and most realistic case scenarios and outcomes. This technique helps patients to gain a more complete perspective of the feared situation and constitutes a learning experience. It is very important for patients to face the situations from which they typically shy away. The use of cognitive restructuring and imagery helps to prepare patients to try out what they have learned in actual threatening situations. These tasks are assigned in a graded fashion so that patients are gradually exposed to their fears and build a sense of self-efficacy step by step. In these situations, patients continue to monitor their automatic thoughts and, when possible, to re-evaluate them. The treatment of panic disorder focuses on the patient's tendency to make catastrophic misinterpretations about bodily sensations or mental experiences. The panic attacks are studied carefully and data are collected (eg, where, when, and in what situations do the panic attacks occur, and what are the accompanying thoughts and physical symptoms?). This helps the patient to see that the attacks do not come out of the blue (as the patien t may believe), but rather are correlated with predictable situations and experiences that need to be modified in some subjective and/or objective ways. This understanding begins to take some of the mysteryand the fearout of the panic attacks. It is usually possible to produce a mild panic-like attack in the therapist's office through hyperventilation, imagery, spinning around, or other stimuli, depending on the specific case. Patients are taught methods such as rational responding (eg, I am not going crazyI am having high anxiety, which is uncomfortable but will not harm me), and benign distraction to interrupt the vicious cycle of anxiety and catastrophic thinking (eg, reading license plate n umbers to reduce the feelings of panic that occur while traveling as a passenger in a vehicle). The explicit goal is not for patients to be panic-free per se (which cannot be guaranteed), but for patients to cease being fazed by panic attacks, should they occur. The resultant increase in P.2865 self-efficacy is a cognitive condition that is often sufficient to cause the attacks to reduce in frequency and sometimes to remit entirely. Bipolar Disorder Cognitive therapy is an important adjunct to pharmacotherapy in the comprehensive treatment of bipolar spectrum disorders. Cognitive therapists directly address the bipolar patients' negative beliefs about their medicationsthe sort of beliefs that may otherwise encourage them to abandon their pharmacotherapy, with unfortunate results. A patient may believe that, Taking my [mood stabilizer] will turn me into a different person and I 'll lose myself. However, in cognitive therapy, this individual learns to examine this belief critically, constructing alternative viewpoints that may facilitate medication adherence. An effective rational response for the foregoing belief may be, The bipolar disorder itself risks robbing me of myself, while my medication may give me the best chance to live normally, and to be myself, free of the burden of active symptoms. Among the strategies of cognitive therapy for bipolar disorder are the following: Teach patients to spot their early warning signs of depressive or manic episodes so that they can implement an early, aggressive self-help program that mutes the full effect of the mood swing and buys some time for their pharmacotherapy to be altered so as to deal with the internal biochemical change that is taking place. Use the skills of self-monitoring and rational responding to make therapeutic changes not only in depressive thinking, but in hyperpositive thinking as well. This reduces impulsivity and recklessness and spares the patients additional problems and their accompanying stressors. Appreciate and nurture their social support system so that they neither avoid and withdraw from friends, colleagues, and family nor produce conflict with them through poor self-control. Patients are taught to consult with their trusted others to get valuable reality checks and to use the best principles of communication in the process. Compensate for distractibility by using organizing tools, such as written lists, audio recordings of their therapy sessions, summary statements in conversation (including the dialogue with their therapists), and well-rehearsed behavioral routines (eg, set times and places for taking medications).

Cognitive therapy can also be a boon to family therapy when one of the members suffers from bipolar disorder and can be used in groups designed specifically for bipolar patients. Furthermore, cognitive therapy may be the most helpful therapeutic approach for situations in which medications are contraindicated for medical reasons. Attention-Deficit/Hyperactivity Disorder (ADHD) Similar to the treatment of bipolar disorder (where pharmacotherapy is a well-researched first-line intervention), there is an expanding body of evidence that cognitive therapy can provide an effective supplement to the psychiatric care of ADHD populations both in adolescents and adults. Patients with ADHD often experience difficulties and failures in activities requiring good executive functioning. School and work are areas of particular distress, with patients drawing negative, stable, global conclusions about themselves that inhibit them from persevering toward important but challenging goa ls (eg, I don't know how to organize my thoughts, There is no point in trying to be punctual because I can't ever get myself together on time, I'm too scattered to do this right now; I'll do it later). In cognitive therapy, ADHD patients are taught a number of problem management skills, along with methods for noticing, assessing, and modifying their negative assumptions about effectively handling tasks and regulating themselves. For example, a cognitive therapist helps a college student with ADHD to recognize a pattern in his functioning that leads to habitual procrastination. The pattern is that the student contemplates studying or writing, resulting in negative thoughts such as I am no good at this sort of thing. This belief (now activated) raises his level of anxiety, whereupon the student now operates on the maladaptive assumption that I can't do anything while I'm feeling anxious, so I will wait until I stop feeling anxious. The anxiety never goes away sufficiently (predictably), and the student never completes the assignment. However, rather than determining that he had numerous opportunities to get the work done, the college student truly believes that there was no way he could have worked on the task for all of the aforementioned subjectiv e reasons and feelings. The cognitive therapist goes on to help the student to break down this pattern, step by step, and to experiment with substituting more productive ways of thinking about and acting on the task. One such method is to turn an overwhelming goal-oriented thought (eg, I have to finish that paper) into a more manageable implementation-oriented thought (eg, I am going to spend an hour working on an outline). Posttraumatic Stress Disorder (PTSD) Cognitive therapy for PTSD is comprised of a number of empirically supported treatment packages for long-term, dysfunctional responses related to specific types of traumas. These include war-related experiences, physical/sexual assault and abuse, accidents/disasters, and others. Although the nature of the trauma differs from one another, there are common principles of treatment that cut across these subtypes. For example, PTSD patients commonly try to avoid thinking about (or otherwise exposing themselves to reminders of) the traumatic experience but nonetheless find themselves plagued by intrusive ideation, affect, and physiological symptoms reminiscent of the trauma. This leads to more avoidance, but the intrusions (eg, flashbacks) continue, leading to a sense of hopelessness, anticipatory anxiety, and low self -efficacy. Furthermore, the patients begin to avoid areas of life that might otherwise improve their mood and outlook, such as relationships, travel, recreational activities, and the like. They then become more isolated, fearful, and prone to think of themselves as irreparably damaged. In cognitive therapy, PTSD patients are given a rationale for the importance of being able to face and constructively process their memories and interpretations of their traumatic experiencesnamely, that direct, careful, graded exposure to these stimuli allows for a rational integration of the trauma into the overall narrative of their lives. Otherwise, the trauma stimuli remain as unfettered fragments of ideation and emotion that contaminate the quality of their everyday life and general self-image. Typical techniques and assignments include writing successively more detailed accounts of the traumatic experience(s) (to habituate to the memories and put them in proper perspective), doing cognitive restructuring of the personal meanings of the trauma (eg, working to modify a person's belief that Being raped makes me damaged, defective, and unable to have an intimate relationship ever again), and engaging in prog ressively more activities that are part of a full life but that unfortunately had become associated with the trauma (eg, being willing to get into a vehicle again following an accident). Substance Abuse Although the cognitive model of substance abuse is not an etiological model (ie, cognitions do not cause addictions), it is extremely useful as a guide to understanding the maintenance of substance abuse behaviors, the triggers for relapse, and the multiple areas of potential intervention. For example, those who abuse substances often develop beliefs that reinforce their drug abuse. Sometimes these beliefs are modeled from their drug-using cohorts, and at other times they are self-produced to justify their addictive behavior, thus lowering cognitive dissonance. Scales have been developed to tap into these beliefs, including self-report items such as, I won't be able to cope without drugs and P.2866 The cravings will drive me crazy. Table 30.7 -3 includes a more extensive sample of patients' typical dysfunctional beliefs about drugs, cravings, and relapse. Table 30.7-3. Dysfunctional Beliefs about Drugs, Cravings, and Relapse: Selected Items from Questionnaires My life won't get any better, even if I stop using. I could not be social without using. I can't relax without drugs. Having this drug problem means that I am fundamentally a bad person. I can't make my life fun unless I use. When craving drugs it's okay to use alcohol to cope. Once the craving starts I have no control over my behavior.

Since I'll have the craving the rest of my life I might as well go ahead and use drugs. If I don't stop the cravings they will get worse. Craving can drive you crazy.

Cognitive therapy is especially well suited to help substance abusers cope with the dysphoria, anxiety, and anger that often serve as internal, high-risk stimuli for using. Rather than continuing to self-medicate via alcohol and other drugs, patients can learn to talk to themselves in a hopeful manner, reminding themselves of constructive ways to solve their problems and of useful ways to ride out their cravings until they naturally subside. Patients are taught to focus not only on earning the support of sober loved ones, but also on their potential sense of empowerment in being the master of their impulses, as well as methods to find joy in life through nonaddictive means. Eating Disorders Therapists initially teach eating-disordered patients to self-monitor their eating as well as their associated thoughts and feelings, thus establishing a linkage and gaining vital data. This is followed in short order by graded task assignments to attempt increased food intake (anorexia) or decreased binge eating and purging (bulimia). Discussion focuses on specific problematic beliefs regarding eating and its effect on body weight, the importance of appearance, the qualities that constitute one's personal appeal, and the patient's insistence on extreme self-control. As therapy progresses, the cognitive analysis spreads to various other dysfunctional beliefs such as the patient's negative self-concept (helpless, unlovable, undesirable), hypersensitivity to control by others, and wishes for approval. Personality Disorders A complete elaboration of cognitive therapy of the personality disorders has been published, as well as a specialized manual on treating patients in the borderline spectrum. Persons with personality disorders often suffer quite obviously from the effects of their rigid, pervasive, long-standing schemas and often cause difficulties for others around them as well. In contrast to the treatment of Axis I disorders, treatment of Axis II disorders requires a longer period of therapeutic work often at least 1 year. In addition, given that interpersonal problems are often a central feature of the more serious of the personality disorders (eg, narcissistic, paranoid, borderline), greater attention is paid to problems (and their solutions) in the therapeutic relationship. Misunderstandings and other forms of strife in the therapeutic alliance are often explainable in terms of the activation of patients' schemas of mistrust, abandonment, dependence, entitlement, and the like. Similarly, cognitive therapists need to be aware ofand managetheir dysfunctional thoughts in treating personality-disordered patients because the work is often difficult, frustrating, and even threatening. This focus on phenomena akin to transference and countertransference illustrates a c onvergence with psychodynamic therapy. The major differences remains that cognitive therapy is more active and directive, the therapeutic sessions are more structured, the content is weighted toward conscious rather than unconscious or repressed memories, beliefs are tested as hypotheses, and patients are expected to carry out between-sessions homework assignments. Schizophrenia During the period of early development of the cognitive model and therapy, it was not thought possible that cognitive therapy could be used with persons whose thoughts were as severely disordered as those with schizophrenia. Now there is evidence that patients with schizophrenia can improve their conditions if they are taught the skills of self-reflection, guided discovery questioning, seeking evidence, generating alternative viewpoints, and experimenting with new ways of thinking. To see how cognitive therapy can be tailored to fit the needs of this population, consider a patient with disturbing auditory hallucinations who may believe that Whatever the voices say must be true, and I must obey. The therapist can point out that the voices are just another percept ual manifestation of automatic thoughts. As such, they are subject to flaws of logic and may be inaccurate and misguided. Patients can then learn to construct rational responses even to terrifying command hallucinations so as to put the voices in their place. Such an exercise can demonstrate to the patients that their voluntarily produced thoughts are most adaptive and therefore should guide their behavior. Delusions can also be loosened by cognitive therapy techniques, especially in the context of a collaborative therapeutic relationship. The therapist neither blithely accepts the patients' delusional beliefs nor confronts them harshly. Instead, therapist and patient work together to explore the delusional beliefs, including their etiology, functionality, relation to other themes (schemas) in their life, costs and benefits, and so on. Guided discovery questioning is used to test the plausibility of the delusions, and the patients are empowered, in that they can arrive at their own conclusions that the delusional beliefs need to be revised. A graduate student named Eugene reported that he had deliberately failed his compr ehensive examination owing to the risk that his correct answers would be seen by spies who would use the patient's calculations to design weapons of mass destruction. The cognitive therapist immediately thought that Eugene's ideation sounded grandiose and paranoid, but, in the interest of collaboration and empiricism, decided to ask his patient a series of questions to assess his ideation more thoroughly. The therapist asked how many other students took the comprehensive exams (the answer was 8), and asked whether they also had to sabotage their work to prevent the leakage of potentially sensitive military information. Eugene added that the spies we re interested only in his work and not that of the other students. This answer represented an idea of reference, thus supporting the idea that Eugene's ideation was paranoid and psychotic. Clearly, Eugene would require greater clinical supervision and a re-evaluation of his medications. However, in the meantime, the cognitive therapist continued the process of guided discovery questions. He asked whether Eugene could meet with the chairperson of the Physics Department so as to demonstrate his knowledge one-on-one, in a secure environment, and then destroy the calculations if necessary. At least Eugene would not have to sacrifice his academic standing, the therapist reasoned. The therapist figured that if Eugene accepted this arrangement, then perhaps he could prevent a downward spiral of failing, leaving his graduate program, and having no structure in his life at a time of psychological crisis. In the meantime, Eugene's pharmacotherapy could be intensified. Eugene agreed to enact this problem-solving scenario, and to see his psychiatrist promptly as well. Furthermore, the cognitive therapist engaged

Eugene in a thorough discussion of the issues of needless self-sacrifice and the importance of resisting taking drastic measures (eg, failing an important examination) based on unconfirmed hypotheses. P.2867 Relationship Discord Cognitive therapy has been applied successfully with couples. Treatment addresses each partner's views of the other and how these views are shaped and misshaped by time, experience, and misinterpretations of the other's motivations. Communication skills training is an important component of therapy, with the cognitive piece involving how each partner construes what the other is trying to convey. Therapists are cued in to the likelihood that a cognitive distortion is occurring in session when the therapist thinks that a person has just uttered a caring, hopeful, conciliatory statement but the partner's nonverbal response indicates an adverse reaction. At such moments, the therapist will ask the distressed partner, What did you hear [him or her ] say just now that upset you? This allows for a reality check, a re-evaluation of the interpretation, and a reworking of the communication skills toward the goal of increased clarity. In the spirit of assessing and modifying beliefs, cognitive couples therapy deals wi th each person's unwritten rules for the relationship, learned (perhaps) from their respective families of origin, and how these rules may be unrealistic and counterproductive. Examples of such problemat ic beliefs are, If I have to ask my partner for what I want, it spoils everything and If my partner turns me down when I want to have sex, that means I'm being totally, utterly rejected. An important direction for treatment is to help the couple to articulate a new hybridization of their previously d isparate beliefs. The couple then can try to adhere to the new rules for their relationship in the spirit of collaboration and shared goals. Homework assignments often involve putting the new, revised rules into practice so that the couple can see the level of functionality that is possible and to make further adjustments as needed. Clinical Issues Indications Cognitive therapy can be used to (1) remove or moderate the symptoms of a disorder as a sole treatment or in combination with medication; (2) reduce the likelihood of relapse or recurrence; (3) increase adherence to recommended medication treatment; (4) address specific psychosocial difficulties (eg, marital discord, job stress, caregiver's burnout) that may have preceded, coincided with, or been caused by the disorder; and/or (5) modify underlying beliefs and schemas that contribute to dysfunctional personality trends or disorders. The indications for cognitive therapy are determined more by patient and therapist variables than by the nature of the disorder. Patients The ideal patients are able to recognize and label their emotions, to become aware of their automatic thoughts, and to see the linkages among thoughts, feelings, and behaviors. Recent studies have lent support to the hypothesis that patients who learn and show competency in the specific skills of cognitive therapy demonstrate improved outcome and maintenance. High intelligence is not a prerequisite, and motivation for therapy is important but not initially crucial. Some hopeless, unmotivated, or lethargic patients become increasingly invested in treatment as they begin to experience improvement. Patients who are new to therapy are often extremely receptive to the pragmatic, comprehensible approach of cognitive therapy. Some patients who are veterans of many years of previous psychoanalytic therapy may have an initial period of adjustment into cognitive therapy, but most can make the transition and soon learn to apply the cognitive model successfully. Therapists The ideal therapists are attentive, empathic, and nonjudgmental, as in any model of psychotherapy. To be maximally effective in an active treatment such as cognitive therapy, practitioners have to be comfortable in giving direct information and feedback and generally interacting in a give-and-take manner. Although good cognitive therapists know how to sit back and listen when appropriate, they do not allow for long silences as a matter of routine, and they are willing to answer most direct questions with a therapeutically direct answer. Cognitive therapists do not cloak their craft in mystery. Quite to the contrary, they work hard to make the tenets and procedures of the treatment as accessible to their patients as possible. The goal is to teach patients to become skilled in being their own cognitive therapists for the long haul. Not surprisingly, several studies have supported the conventional wisdom that there is a high correlation between therapists' competency and successful treatment outcome. Competency in cognitive therapy requires more than a passive knowledge of the theory and procedures. Typically, experienced therapists who wish to specialize in cognitive therapy need at least 1 year of supervised clinical experience in using the model, ideally having their work directly scrutinized and rated via the use of session recordings. Limitations The early outcome studies on cognitive therapy demonstrated that depressed patients could show significant improvement in approximately 12 weeks of biweekly and weekly sessions. Similarly, a number of studies on cognitive therapy for panic disorder found that panic attacks could be significantly diminished within four to eight sessions. More recent studies have indicated that the use of posttherapy booster sessions (eg, at periodic intervals following the official termination of the regular course of treatment) can be a boon to the maintenance of therapeutic gains already a strong point in cognitive therapy. These are exciting and hopeful findings. However, they have at times been interpreted too broadly, thus creating a faulty assumption that all levels and classifications of pathology will respond as quickly. This unrealistic expectation does disservice to a sophisticated understanding of individual patient differences and the heterogeneity of clinical disorders. For example, panic patients with comorbid avoidant and/or dependent personality disorders will probably show a diminution of panic attacks early in treatment. However, their tendency to shy away from fear-producing situations and their overreliance on the safety people in their lives may persist quite a bit longer and require considerably more treatment. Similarly, patient s who are chronically suicidal will need to be followed for some time beyond the point of depressive remission to ensure that the risk of self-harm will not re-emerge under stress. Studies on cognitive therapy for patients with bipolar disorder, chronic depression, and personality disorders allow for a longer course of therapy (eg, 1 year or more), and results have been promising. The 12-week model does not reasonably fit all patients. Complications There are no known complications that are caused by cognitive therapy when it is used properly and in the appropriate context. The model is designed to teach patients a wide range of self-help skills and thus is meant to empower them. Thus, the cognitive therapy model does not lend itself to encouraging patient dependence on their therapists. Termination issuessalient in any psychotherapyare dealt with proactively in cognitive therapy, with the therapist often alluding to the time-effective approach, the importance of being your own therapist, and posttherapy follow-up.

Clinical crises are handled in cognitive therapy with a combination of standard risk-reduction procedures (eg, increased frequency of sessions, inclusion of significant others, emergency consultations, hospitalization), along with a cognitive conceptualization of the emergent problem. For example, a patient who becomes suicidal in response to a homework assignment will be afforded the standard protective interventions. However, once the acute crisis subsides, the P.2868 therapist will attempt to explore the patient's subjective vulnerability to the assignment. Perhaps the patient felt incompetent in doing the homework and began to catastrophize that he was doomed to fail in therapy and in life. Thus, he fell into a spiral of worsening thoughts and feelings, became helpless and hopeless, and began to contemplate suicide. The therapist in this instance would help the patient to reassess the catastrophic cognitions that turned a benign, constructive homework assignment into a reason to want to die. The goal is to prevent such inadvertently iatrogenic reactions in the future and for the patient to become less vulnerable to this sort of magnification of routine life stressors. Contraindications Although cognitive therapy has been shown to be efficacious as part of the treatment package for very serious psychiatric disorders, it is generally understood that pharmacotherapy should be part of the overall regimen for disorders such as schizophrenia and bipolar disorder. Although there is some evidence that cognitive therapy alone can be helpful in cases of bipolar disorder in which medical complications make the use of pharmacotherapy problematic, it is generally not appropriate for patients with such serious psychiatric disorders to pursue cognitive monotherapy. Generalized Anxiety Disorder Mr. M was a Hispanic, 33-year-old middle school science teacher who was divorced and had a 10-year-old son. He entered therapy complaining of being overwhelmed with stress. Although he had been taking various anxiolytic medications prescribed by his primary care physicia n for years, he had never previously attended any sort of talk therapy. Mr. M had gone back to his doctor asking for a change in his medications, but the physician flatly said that it was high time for Mr. M to enter therapy to get feedback from a qualified counselor. Mr. M had been advised by a friend that cognitive therapy was an excellent treatment to deal with excessive worries, and so he took the plunge, not knowing exactly what to expect. At intake, Mr. M rev ealed that he could never relax and that even when things were going well he would dwell on any number of things in his life that might fall apart at any time. He worried about the emotional well-being of his son, the possibility of failing as a teacher and losing his job, his father's health, money, and his prospects of ever being in a romantic relationship again. He complained of working long hours grading homework and exams, frequently being in conflict with his ex-wife over money and their son, having almost no time for recreation or a social life, and being unable to unwind even when he felt that he should be relaxing. The patient admitted that he was starting to use his anxiolytic medications too frequently and that he was worried about addiction and impairment. Still, when his physician recommended cognitive therapy rather than prescribe more medications, Mr. G wondered how he was going to cope with his anxiety. Case Conceptualization In conceptualizing the case, Mr. G and his therapist examined Mr. G's life history, as well as his current stressors. Mr. G described an upbringing in which he had responsibilities that transcended what a child should be expected to do. He was the oldest of four siblings and often was put in charge of caretaking them, especially because his mother was often ill (she later died during his college years). Mr. G's father never lacked for employment, but he often drank heavily in the evening, thus leaving Mr. G to be in charge of supervising the household at a time when he was trying to do his homework and have occasional contact with friends. Mr. G came to believe that The whole family would fall apart without me. The patient noted that he could never relax because even when he was trying to enjoy watching a baseball game with friends, he could get a phone call at any time asking him to escort his drunken father home from the bar, or he might have to find a babysitter while he drove his acutely ill mother to the emergency room. Even when he succeeded in gaining admission to college, Mr. G felt compelled to live at home, where his excessive family responsibilities continued unabated. Still, through all of the stress and strain, the death of his mother, and the continuing drinking of his father, Mr. G completed a degree in secondary education. Mr. G married his college sweetheart shortly after his graduation from college, even though he was still a part-time student (in a Master's of Education program) and earning a modest salary as a junior teacher. They soon had a baby boy and began planning to buy a house. Mr. G recalled this time of his life as being full of promise, but being pulled in a thousand different directions all the time. He had extensive responsibilities as a teacher , often taking a personal interest in his young students, to whom he felt to be a vital mentor, as he had been to his younger siblings while he was growing up. He also did his best to be an involved parent, taking care of his son whenever he could. Furthermore, Mr. G continued to assist his father with the younger siblings, including the drug addiction problems of two of them. Once again, Mr. G could never relax for minute. Mr. G's life situation became worse when he learned that his wife had bec ome disenchanted with the marriage and wanted a divorce. Mr. G explained that he had lost interest in sex, and his wife felt neglected and resentful. Mr. G reported that he didn't have the energy or will to contest the divorce, and they agreed to joint custody of their son. However, Mr. G's financial difficulties multiplied. I feel like I'm supporting three households, he lamented . At the time that Mr. G entered therapy, he was worried that he was losing his ability to manage his life's responsibilities, felt continually anxious and frustrated, and was horrified to think that he might turn out like his father if he continued to take anxiolytic medications in ever-increasing doses. Mr. G certainly had many things on his plate and needed some professional assistance in finding ways to manage his problems and his time in a healthier way. It was also clear that Mr. G's thinking style was anxiogenic, in that he believed that it was impossible to relax, that bad things could happen at any moment, and that he had to take care of everything. Certainly there was more than a kernel of truth in Mr. G's perceptions; given his personal his tory and current life situation; however, it was also clear that he was preventing himself from finding respite or feeling a sense of accomplishment for all he had done. In addition, Mr. G's approach to his pharmacotherapy also suggested that he was preoccupied with the risk of addiction. This fear became a strong impetus to his pursuing cognitive therapy. Interventions First, the therapist consistently expressed concern and empathy for all of Mr. G's travails and stressors in his life, including the losses of his mother and wife, the addictions of his father and siblings, and his significant obligations toward his son and his students. In addition, the therapist demonstrated respect for Mr. G's accomplishments, giving him credit for having helped so many people in his life. The therapist also validated some of Mr. G's beliefs, saying that he had had to deal with so many problems in his life that it was no wonder that he believed he could never relax or his life would fall apart. Nevertheless, it was apparent that Mr. G's quality of life was suffering greatly, and his approach to self-care needed a significant overhaul. The therapist asked Mr. G to do some self-monitoring in the form of a daily activity schedule (broken down hour by hour) and a journal of thoughts that crossed his mind when he thought he should be relaxing but could not. Mr. G complied with this homewor k assignment, producing data that showed that he almost never took time out for recreation or socializing. At first, Mr. G reasoned that he did not have time for these activities, but on further questioning it became clear

that he also maintained the belief that he would be irresponsible to engage in enjoyable activities while so many serious issues required his attention. Thi s belief showed up in his journal writings in various forms, such as the entry, It would be selfish of me to go to the gym whe n I have tests to grade. Even when Mr. G tried to do something funsuch as take his son to an amusement parkhe found himself worrying about fighting with his ex-wife if he brought his son home later than anticipated. In general, Mr. G's self-monitoring exercises portrayed a man who rarely did things for pleasure, often worried about anticipated negative outcomes, chastised himself for being irritable and tense when he should be relaxing, but then felt guilty if he d id forget his troubles for a brief time. The therapist and Mr. G agreed to set up an intervention program that involved a number of components. First, to combat his excessive guilt and general selfcriticism, the therapist asked Mr. G to document and discuss his accomplishments in life. At first Mr. G demurred, reasoning that he would feel uncomfortable speaking highly of himself. However, the cognitive therapist explained that this intervention would serve to counterbalance his biased tendency to look only at what he thought he might fail to do (eg, not give his son or students enough time and attention; not help his father enough in dealing with the drug-abusing siblings), rather than all the contributions he had made to the lives of others. Mr. G tried to avoid talking about his accomplishments, but his therapist was quite directive in staying on this topic until Mr. G gave it his full attention. Second, to reduce unwarranted anxiety, the therapist asked Mr. G to make distinctions between verifiably negative events and anticipated negative events. Previously, Mr. G had responded to these two categories of stressors as if they were indistinguishable, leading him to create as many new stressors as his imagination could produce. By separating actual from anticipated events, Mr. G could then enact problem-solving methods in response to the actual events and cognitive restructuring exercises to de-catastrophize the anticipatory anxieties and modify his excessive guilt. Third, the therapist helped Mr. G to establish new, healthier ways to utilize his time, such as taking a bike ride with his son and asking coworkers to go with him to a major league baseball game. These activities would combine important goals, including getting some exercise, solidifying important relationships, gaining a respite from the drudgery of working at home, and reducing the sort of rumination in which Mr. G would engage while alone. Mr. G was able to wean off his medication entirely, which greatly alleviated his worries about potential addiction. He no longer went to extremes in dwelling on thoughts about lack of job security or in fearing that he was not doing enough for his son or students. He began to take his father's health problems more in stride and to assert himself with a sober sibling to share some of the responsibilities in helping their father navigate the health care system. Mr. G joined a biking club and soon began dating a woman he met there. By the end of therapy, Mr. G happily noted that he and his new girlfriend were going on a 2-week biking vacation through a scenic part of the country as soon as the school year ended. P.2869 Posttraumatic Stress Disorder Ms. Y, a 49-year-old single white woman, lived alone in a spartan apartment devoid of almost any furniture, including a bed. She presented with multiple problems, including cyclical unemployment, chronic abdominal pain, loneliness, and a wide range of fears related to feeling vulnerable at the hands of others. Ms. Y did not like being alone, but she was terribly frightened of the negative judgments of other women and the physical and sexual harm that men could inflict on her. Thus, she often turned down social invitations or failed to show up for get-togethers that she had previously agreed to attend. This pattern led to greater isolation and unhappiness. The Therapeutic Relationship and Case Conceptualization Because the therapist was a man, Ms. Y was very ambivalent about participating in cognitive therapy, envisioning malevolent things that the therapist could do to her, such as hypnotize me and rape me. The therapist offered to refer her to a female therapist, but Ms. Y stated flatly that she was tired of avoiding everything and that she needed to stop letting fears dictate everything. The therapist noted that Ms. Y's views on this ma tter, albeit rather harsh and unsympathetic in tone toward herself, were nonetheless significant steps in a therapeutic direction. They agreed that Ms. Y had allowed a deep sense of personal vulnerability and worthlessness to limit her life severely and to make decisions that served more to punish than to help herself. Ms. Y understood from reading the literature that cognitive therapy would focus largely on making productive changes in her thought processes and behavioral habits in the here-and-now, toward a more hopeful future. She also understood that regular suicide risk assessments would necessarily be part of the treatment plan. However, Ms. Y was surprised when her cognitive therapist inquired about her history so as to gain an empathic, conceptual understanding of Ms. Y's negative beliefs about herself and the world around her. At first, Ms. Y was hesitant to discuss her past, and the therapist did not force the issue. Instead, he suggested that they go ahead with current interventions (eg, homework assignments to add creature comforts, including a bed, to her residence) and to let Ms. Y's potential difficulties in following through with these interventions serve as hints that something in her long-standing belief systems was interfering with treatment. Indeed, this is what occurred. Ms. Y found herself avoiding the assignments that asked her to take care of herself (eg, see her doctor about her gastrointestinal distress, buy plants for her apartment, accept friends' social invitations, document examples of her kindness toward others and successes in overcoming hardship). Ms. Y would often dissolve into tears in session, saying that she was paralyzed with fear and a bad patient who should surely be expelled from therapy. The therapist expressed empathy for Ms. Y, saying that she was brave to endure the discomfort inherent in therapy and that her reactions would help them understand her internal world better. The therapist and Ms. Y decided that they would try to understand the etiology and maintenance of her dysfunctional beliefs about herself while simultaneously continuing with interventions to help her in the here-and-now. One of Ms. Y's assignments was to assess and write down her thoughts whenever she found herself repulsed by the idea of helping herself. What emerged were long diatribes expressing self-disgust and unworthiness, linked to years of sexual abuse, first by her mother's boyfriend and then by drug-abusing boyfriends of her own. Ms. Y never told anyone about her experiences and instead accepted the word of the abusing men, who reportedly told her that she was to blame for her own mistreatment (eg, she was a tease, she wanted it, she didn't know how to be a real woman). Ms. Y learned to feel ashamed of herself and came to lead an isolated life of deprivation in which any attempt to help herself led her to feel unworthy, self-indulgent, and likely to suffer devastating setbacks. Ms. Y led her life based on beliefs such as, I do not deserve to be ta ken care of, not even by myself, I could be harmed at any time, so I need to stay away from others, and If I deny all my wants and needs, I'll never be disappointed. Interventions Because Ms. Y's deficits in self-care were profound, she was encouraged to get a medical checkup, which she had sorely neglected. Ms. Y admitted that she was frightened of medical procedures because they reminded her of having been raped. A great deal of work focused on unlinking her memories of abuse from her perceptions of medical treatment. One method centered on concept ualizing Ms. Y's flashbacks as fragments of memory that had not yet been integrated into the full narrative of her life experience. Planned exposures to such flashbacks, via scheduled medical appointments, journal writings about her abuse, and imagery exercises of the abuse scenarios in which she would simultaneously use rational responses to make clear distinctions between then and now, helped

Ms. Y to habituate to the flashbacks and be less fearful of them. The therapist encouraged Ms. Y to engage in additional interventions of exposures plus rational responding, such as signing up for a class, sitting in a room that included male students, and preparing herself to construe any flashbacks she might get as fearful stimuli that had nothing to do with her current reality and that she would learn to tolerate if she stayed in the class and took notes. Sometimes these notes simply would be about the course material, and sometimes they would be Ms. Y's attempts to remind herself that she was worthy of being in this class, safe from physical attack, and wise to put herself in this growth-enhancing situation. Ms. Y also improved the quality of her living quarters by buying a bed, playing soothing music in the background, using fragrant incense, and planning meals with healthy, comfort foods. Ms. Y also exposed herself to social situations by inviting female friends to lunch, to the museum, to movies, and to take walks or jogs together. The therapist helped Ms. Y to prepare for these encounters by engaging in role-playing exercises of the phone calls and of the anticipated conversations with her friends. When Ms. Y would experience a spike of anxiety or an awareness of self-doubt, she practiced identifying her thoughts and writing down rational responses. Again, the therapist and patient used role-playing exercises to assist in this process, with the therapist playing devil's advocate by stating Ms. Y's typical self-doubting thoughts while Ms. Y had to generate powerful responses that would validate her right to interact with friends with a sense of worthiness and safety. By the time treatment tapered to monthly meetings (after almost 1 year of regular sessions) Ms. Y was working part-time at a bookstore, taking two classes at a nearby community college, living in a more comfortable home environment, getting appropriate medical care for her colitis, and socializing with at least three female friends. Her flashbacks and suicidal ideation had diminished markedly, and her Beck Depression Inventory and Beck Anxiety Inventory scores were now in the mild range of symptomatology. Ms. Y still was not dating, and she was still completely estranged from her family of origin, but she explained that she was satisfied with these states of affairs. P.2870 Goals of Treatment The goals of treatment are geared to the needs of the individual patient and are articulated in a joint, collaborative way between therapists and their patients. Most obviously, the primary goal of cognitive therapy is to help patients to alleviate their emotional sufferingthe most extreme example being the reduction of the risk of suicide. However, the particulars of cognitive therapy indicate that this relief should be gained through the learning of self-help skills, so that the patients acquire a sense of mastery and autonomy in coping. Cognitive therapists assist their patients in spelling out their goals early in the process of treatment. This prevents aimless wandering that may not be timeeffective and orients the patients to an active, directive model of therapy. As in the case of most psychosocial approaches to treatment, cognitive therapy aims to teach and reinforce therapeutic goals that are associated with mature functioning. For example, patients are encouraged to take stock of themselves and make changes without denigrating and/or demoralizing themselves. They are taught to evaluate even the most adverse life situations as providing opportunities for personal growth and a greater appreciation for life. Along the same lines, patients learn the tools to help them to reduce impulsivity and delay gratification, to take responsibility for their thoughts, feelings, and behaviors, and to know how to accept the things that cannot be changed. Although cognitive therapy is not overtly dubbed as an interpersonal therapy, it is certainly a goal of treatment to help patients interact more congenially, meaningfully, and collaboratively with others. Thus, communication and assertiveness skills are often part of the treatment plan, and role playing is commonly used toward these ends. Patients aim to learn how to be adaptive, flexible, and open-minded in their approach to solving problems and to maintain hopefulness and constructive behavior in the face of disappointment, frustration, and adversity. Ernest Hemingway once described the concept of courage as grace under pressure, and this is an apt descriptor of the sort of mentality that cognitive therapists hope to instill in their patients , no matter what their presenting problems. The standard duration of cognitive therapy is 15 to 20 visits over a 12-week perioda time frame reflective of the early, breakthrough outcome studies on cognitive therapy. However, in everyday practice, cognitive therapy is best described as time-effective rather than time-limited per se. A great premium is placed on using session time well so that patients can learn self-help skills in a timely fashion and thus can begin to gain the benefits of cognitive therapy promptly, building hope and efficacy and averting further crises. The assignment of homework facilitates this process because patients progress more quickly when they practice the self-assessment methods and change-inducing interventions that comprise cognitive therapy. However, cognitive therapists focus on the needs of each individual patient and thus are flexible and collaborative in determining the appropriate length of therapy in any given case. Some patients have many personal and environmental resources, are motivated for treatment, engage in the homework, and improve very quickly (eg, making significant gains within as few as four sessions). Others are more challenged and may be hard-pressed to have their disorders remit within 15 to 20 sessions, although they make noticeable progress (eg, a panic patient whose panic attacks cease but who still feels dependent on her mother in order to travel away from home). Others still require a longer course of therapy, such as those having chronic disorders, numerous previous (failed) treatments, and developmental traumas. Thus, recent clinical trials of cognitive therapy with severe depression, bipolar disorder, and personality disorders have allowed for 1 year of treatment or more. Nevertheless, strong emphasis is placed on making every session count and on teaching patients the skills with which to improve their conditions and help themselves for the long run. Ethical Issues Although cognitive therapy places emphasis on teaching patients to become their own therapists, this is an ideal, not a mandate. Thus, if patients are in need of ongoing treatment beyond the usual short-term model, therapy will not be summarily denied them. Cognitive therapyas is the norm in the field at large recognizes that patients must not be abandoned in their time of need and that arrangements must be made for an appropriate continuation of care when the patient is still at risk. Most outcome studies on cognitive therapy allow for extended care as part of the protocol. Patients who need treatment beyond the specifications of the study are readily given the chance to receive it, even if it means that the protocol is broken and thus their data must be evaluated with special considerations. Unlike traditional psychoanalytic psychotherapy, cognitive therapists do not assume that treatment will necessarily involve an analysis of the transference phenomenon. Nonetheless, patients may perceive the therapist as they perceived significant others from the past (eg, parents), and the therapist can be helpful in identifying this connection. Still, in contrast to psychoanalysis, cognitive therapists do not maintain a distant demeanor of neutrality, believing instead that a more open-ended, personable approach will facilitate collaboration and learning, without risking tainting the case conceptualization. Nevertheless, as in psychoanalytic psychotherapy, cognitive therapists adhere to the profession-wide guidelines on the appropriate maintenance of boundaries. They avoid dual

relationships and carefully evaluate the therapeutic issues involved in ambiguous situations, such as when the patient repeatedly comes to the therapist's office bearing gifts. In clinical supervision, cognitive therapists are unlikely to address the psychological functioning of their supervisees unless there is a P.2871 need to do so to provide the trainee's patients with the proper standard of care or if the student's professional fitness is in question. The relationship between clinical supervisor and supervisee is much more akin to teacherstudent than therapistpatient. Cognitive therapy, with its special focus on depression, hopelessness, and helplessness, has important applications in the treatment of suicidal individuals. This is an extremely important and delicate area of practice, in that meeting the standards of care literally can be a life or death situation. The various Beck inventories (including suicide assessment) are commonly used in cognitive therapy, and great attention is paid to the patient's level of hopelessnessa variable empirically demonstrated to be linked to the prediction of suicide. Thus, the cognitive therapist can be ever mindful of assessing and managing clinical risk, using a combination of objective measures and subjective observations to maximize safety. There has been increasing emphasis on acquiring cultural competency in conducting cognitive therapy so that an informed, respectful, nondiscriminatory, and empathic understanding of the experiences and mores of minority groups can be incorporated into the delivery of cognitive therapy. This development has been seen in research programs that have studied cognitive therapy for specific minority populations across a range of disorders, in special interest groups on minorities that have been formed in the major professional organizations that practice cognitive therapy (eg, the Association for Behavioral and Cognitive Therapy), and in publications that address and explicate adaptations of cognitive therapy for specific ethnic groups. Research and Evaluation A recent review paper summarized 16 methodologically rigorous meta-analyses on cognitive therapy outcomes that included almost 10,000 patients in well more than 300 studies. Effect sizes (ES) were calculated, both controlled (ie, between cognitive therap y and alternative treatments or control conditions) and uncontrolled (ie, the magnitude of improvement in cognitive therapy from pretreatment to posttreatment). Effect sizes from 0.5 to 0.8 are considered moderate, and effect sizes greater than 0.8 are considered large. An effect size of 1.0 translates to one standard deviation difference, or an average outcome superior to 84 percent of the comparison group. The review suggested that cognitive therapy (and treatments labeled by authors as cognitive behavioral therapy) is highly effective for the following clinical problems: Adult, adolescent, and childhood unipolar depression; childhood anxiety disorders; adult anxiety disorders, including generalized anxiety disorder, social anxiety disorder, and panic disorder with and without agoraphobia; and PTSD. For these disorders, the authors calculated a comparison-weighted grand mean effect size of 0.95 (standard deviation = 0.08) when compared to no-treatment, wait-list, or placebo controls. In the area of eating disorders, the data are most promising for bulimia, with effects sizes (M = 1.27, SD = 0.11) significantly greater than those found for pharmacotherapy. Cognitive therapy promotes remission in bulimia, but more work is needed to effect lifetime recovery. Anorexia remains more difficult to treat, with some forms of family therapy showing more favorable outcome. When combined with medication, cognitive therapy has shown promising results in the treatment of schizophrenia, with an average uncontrolled (withingroups) effect size of 1.23 compared to an uncontrolled effect size of 0.17 for patients with schizophrenia who received treatment as usual. The studies conducted in the United Kingdom and Canada reported that the cost of cognitive therapy was offset by reduced service utilization and associated costs during treatment and subsequent follow-up. Moderate, controlled effect sizes were found for cognitive therapy for such clinical problems as anger, conjoint couple therapy, and both childhood and adult somatic/pain disorders. In direct comparison with alternative treatments, cognitive therapy was somewhat superior to antidepressants (ES = 0.38) and equally effective as behavior therapy in the treatment of adult unipolar depression. Cognitive therapy and behavior therapy were found to be equally effective for obsessive-compulsive disorder, but individual studies seemed to indicate that cognitive therapy had more beneficial effects on concurrent depression than behavior therapy at posttest. A recent individual study found that intensive cognitivebehavioral therapy for obsessive-compulsive disorder (either alone or in combination with clomipramine) was more efficacious in producing short-term therapeutic effects than clomipramine alone. In addition, cognitive therapy was highly efficacious in comparison to nondirective, supportive psychotherapy for adolescent depression and generalized anxiety disorder (two studies each). On the issue of maintenance, the meta-analyses demonstrated broad support for the staying power of the therapeutic gains made by patients in cognitive therapy across many disorders, particularly in groups of patients with depression and panic disorder. Relapse rates were found to be approximately half of those found in pharmacologic treatments for the same populations. For a comprehensive viewing of the data across all cited meta-analyses, the reader is referred to the 2006 paper by Andrew Butler and colleagues in Clinical Psychology Review. Significantly, there is evidence that cognitive therapy is a robust treatment even for more severe mood disorders than mild to moderate unipolar depression. A multisite, randomized, clinical trial studied the relative efficacy of antidepressant medication and cognitive therapy in the treatment of moderate to severe depression. Contrary to position statements from previous American Psychiatric Association practice guidelines, cognitive therapy was equally efficacious as antidepressant medication with severely depressed patients, with a trend toward superiority in terms of long-term maintenance and long-term cost containment. Another report showed that cognitive therapy, when combined with standard hospital treatment, was more effective than standard hospital treatment (usually involving antidepressant medications) followed by a period of outpatient therapy. In addition, contrary to expectations, cognitive therapy was found to be as effective in endogenous as in nonendogenous depressed patients. Of particular interest was the finding of a response rate of 81 percent for cognitive therapy for hospitalized patients with depression who received no medication. Several controlled studies have shown cognitive therapy to be at least as effective as antidepressant medication in the treatment of depressed elderly patients. A number of randomized, controlled trials across multiples sites demonstrated that cognitive therapy can exert a significant, positive effect on bipolar patients, above and beyond that of medication alone. Indeed, cognitive therapy has been shown to increase bipolar patients' fidelity to their pharmacotherapy, along with decreased symptoms, less frequent hospitalizations, longer interepisode periods of normative functioning, and higher adaptive global functioning. Follow-up sessions seem to be essential to improve long-term maintenance, and early intervention is best, given that patients with 12 or more symptom episodes did not show the same responsivity to cognitive therapy as those with fewer than 12 symptom episodes. Relatively few studies have been conducted involving cognitive therapy for substance abuse, personality disorders, and suicidal patients. However, there is evidence that cognitive therapy is efficacious for these high-risk groups. For example, a 10-week cognitive therapy intervention with recently hospitalized suicide attempters succeeded

P.2872 in reducing the rate of further attempts by 50 percent by teaching the patients to improve hopefulness and self-efficacy in the face of adverse life conditions (most of the patients were members of urban minorities of low socioeconomic status). Both a randomized, controlled trial (conducted in the Netherlands and comparing schema-focused cognitive therapy with transference-focused psychotherapy) and an open trial of cognitive therapy for borderline p ersonality disorder recently supported the hypothesis that cognitive therapy can effect a remission from borderline personality disorder, in that many of the patients who completed treatment showed a decrease in the scope of the symptoms such that they became subthreshold for the diagnosis at outcome and follow-up. In the open trial (in which patients received approximately 1 year of treatment), significant improvements were achieved on measures of depression, hopelessness, suicidal ideation, and dysfunctional beliefs specific to borderline personality disorder. Of interest, patients in this study continued to improve from the termination of treatment until the 6-month follow-up point, suggesting that they continued to consolidate the benefits of cognitive therapy in their everyday lives, perhaps as a result of seeing for themselves that they could cope well, even in the absence of their therapists. In the Netherlands study (in which the patients received up to 3 years of treatment), schema-focused cognitive therapy was superior to transference-focused therapy in terms of outcome, as well as with regard to retention of patients for the full course of treatment. In the area of addictions, cognitive therapy has been shown to be efficacious as a smoking cessation treatment, as well as a program for cocaine abuse. One study found that cognitive therapy provided better long-term outcome than clinical management, and another found that participants in cognitive behavioral therapy were significantly more likely to achieve abstinence than those who participated in a 12-step program. Of interest, cognitive therapy may exhibit its therapeutic effects best on those substance abusers with comorbid depression, whereas those without depression may be less successful in reducing their illicit drug use in cognitive therapy. Additional lines of new research and development in cognitive therapy include the following: There have been a number of studies using neuroimaging assessments (eg, positron emission tomography [PET] scans) to study changes in regional glucose metabolism in the brains of patients who have received cognitive and behavioral treatment for disorders such as obsessive-compulsive disorder and major depression. Similar to patients who responded well to pharmacotherapy (eg, paroxetine), those who benefited from cognitive and behavioral therapy demonstrated notable changes in neurological functioning, although the treatment-specific changes overlapped only minimally. Further neuroimaging data can help to elucidate important distinctions between patients who respond differentially well to psychosocial versus pharmacologic interventions. Researchers are exploring the effectiveness of using computer-assisted cognitive therapy to maximize the coverage of patient care while keeping therapist hours within manageable limits. The promise of this approach lies in being able to impart the self-skills of cognitive therapy (as exemplified by homework assignments) to underserved populations, to those who would seek therapy if the cost were more manageable, and to anyone who would be motivated to begin learning cognitive therapy promptly and quickly. Lack of availability of qualified cognitive therapists in a given locale would then pose less of an immediate concern. Because there are limitations and problems associated with the use of benzodiazepines in conjunction with cognitive therapy for anxiety disorders, a new line of research has begun to focus on the advantages of using isolated doses of d-cycloserine prior to exposure and cognitive restructuring. Early reports indicate that cognitivebehavioral therapy techniques (especially exposure) are more potent in extinguishing patients' fear responses when dcycloserine is used shortly before the time of the intervention. It is hoped that this sort of combined treatment will reduce patients' avoidance behaviors, increase their sense of self-efficacy in facing previously feared situations, and reduce the risk of overreliance on potentially habit-forming medications. In conclusion, cognitive therapy appears to be applicable to an increasingly large number of disorders, formats, populations, and clinical contexts. Age, gender, socioeconomic, and racial or ethnic background do not appear to be important factors in predicting outcome, provided that the particular cognitive therapy protocol being used adapts to address the special features associated with the population being treated and studied. Although cognitive therapy was originally developed as a means to treat unipolar depression and anxiety disorders, it has evolved to treat multiple populations, including patient groups traditionally thought to be relatively unresponsive to psychosocial treatment approaches. In addition, the empirical foundations of cognitive therapy place it in an advantageous position to adapt further, thus providing more patients with the hope of an efficacious treatment, whether used alone, in combination with medications or other somatic interventions, or with computer assistance. Future Directions In recent years the field of cognitive therapy has seen a divergence in terms of new conceptual manifestations of the model, typically put forth by clinicians, theoreticians, and researchers who have been trained in or made their professional identity as cognitive and behavioral therapists. These branches of cognitive therapy include such areas as constructivism, positive psychology, mindfulness approaches, and acceptance and commitment therapy (ACT). In addition, some researchers have put additional emphasis on the therapeutic relationship, most notably the repair of alliance ruptures in the course of treatment with challenging patients. Some writers have identified their particular branch of study as stemming directly from the tradition of cognitiv e therapy, whereas others have presented their work as distinct models. However, as time goes on, it is likely that these permutations of cognitive therapy will converge once again under one general umbrella of research and practice, based on the shared values of collaborative empiricism, the importance of patients' subjective phenomenology, and the linkage between skills acquisition and maintenance. In addition, it is likely that increasing emphasis will be placed on the active application by cognitive therapists of the robust methods that they impart to their patients to their own well-being. Already appearing in the literature are signs that self-practice and self-reflection are becoming vital parts of a person's training and development as a cognitive thera pist. The empirical and practical success of cognitive therapy has led to an enormous growth of training centers and practitioners, with clinical institutions identifying themselves with cognitive therapy now operating on six continents. More and more, cognitive therapy will come to the attention of policy makers in the area of mental health, such that cognitive therapists, along with their research programs and clinical and training facilities, will receive more support. Recent dramatic developments in the United Kingdom, where the National Health Service is providing significant resources for the availability and development of cognitive therapy, serve as a model that will be replicated P.2873 in other countries. This will allow more patients to have affordable access to the benefits of cognitive therapy while greatly improving the overall cost benefit ratio of effective talk therapy to society.

In general, dissemination of cognitive therapy will increase. This will take the form of an ever-expanding number of cognitive therapy publications translated into many different languages, the lay population being better informed about the benefits and accessibility of cognitive therapy, and more practitioners working with underserved populations. Related to this latter point, the proliferation of research on (and training in) cognitive therapy for specific disorders will mean that patients will have more options for specialized treatment, whether in terms of a particular disorder (eg, PTSD, ADHD, substance abuse, schizophrenia), demographic population (eg, geriatric, pediatric), or modality (individual, group, couple, family). As noted earlier, computer-assisted cognitive therapy will also become more commonly available to patients who otherwise may be unable to meet readily with practitioners in person. Also as alluded to earlier, cognitive therapy will be at the forefront of the interface between psychosocial and physiological factors in psychiatric illness and treatment. Cognitive therapy will continue to grow as a treatment approach for chronic pain patients, for those who suffer from well-understood medical ailments and their psychological consequences (eg, cancer, Parkinson's disease, cardiac ailments), and for those who battle medical problems that have been difficult to define without consideration of the psychological variables involved (eg, chronic fatigue syndrome, multiple chemical sensitivities, fibromyalgia). The increasing use of neuroimaging techniques will allow cognitive therapy researchers to determine how brain studies can help to inform effective therapy, as well as to demonstrate structural and metabolic changes in brain functioning that can be achieved through cognitive therapy. The implications for predicting patients' responsivity to cognitive therapy, candidacy for combined cognitive therapy with pharmacotherapy, and risk for relapse will be significant. Suggested Cross-References See Chapter 31 on biological therapies, Section 13.8 on depression, Section 13.9 on bipolar disorder, and Chapter 14 on anxiety disorders. References *Beck AT: The current state of cognitive therapy: A 40-year retrospective. Arch Gen Psychiatry. 2005;62:953. *Beck AT, Freeman A, Davis D, Associates: Cognitive Therapy of Personality Disorders. 2nd ed. New York: Guilford Press; 2004. *Beck AT, Rector NA, Stolar N, Grant P: Schizophrenia: Cognitive Theory, Research, and Therapy. New York: Guilford Press; 2008. Bennett-Levy J, Lee N, Travers K, Pohlman S, Hamernik E: Cognitive therapy from the inside: Enhancing therapist skills through practising what we preach. Behav and Cog Psychotherapy. 2003;31:143. *Brown GK, Have TT, Henriques GR, Xie SX, Hollander JE: Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA. 2005;294:563. Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P, Beck AT: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord. 2004;18:257. Butler AC, Chapman JE, Forman, EM, Beck AT: The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clin Psychol Rev. 2006;26:17. Butler G, Fennell M, Hackmann A: Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges. New York: Guilford Press; 2008. *Clark DA, Beck AT, Alford BA: Scientific Foundations of Cognitive Theory and Therapy of Depression. New York: Wiley; 1999. Clark DM, Salkovskis PM, Hackmann A, Wells A, Ludgate J: Brief cognitive therapy for panic disorder: A randomized controlled trial. J Consult Clin Psychol. 1999;67:583. Cottraux J, Bouvard MA, Maud M: Combining pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder. Cogn Behav Ther. 2005;34:185. DeRubeis RJ, Hollon SD, Amsterdam JD, Shelton, RC, Young PR: Cognitive therapy vs. medications in the treatment of moderate to severe depression. Arch Gen Psychiatry. 2005;66:409. Ellis TE: Cognition and Suicide: Theory, Research, and Therapy. Washington, DC: American Psychological Association; 2006. Epstein N: Cognitive-behavioral therapy with couples: Empirical status. J Cogn Psychother. 2001;15:299. GiesenBloo J, Van Dyck R, Spinhoven P, Van Tilberg W, Dirksen C: Outpatient psychotherapy for borderline personality disorder: A randomized trial of schemafocused therapy vs transference-focused therapy. Arch Gen Psychiatry. 2006;63:649. Gilbert P, Leahy RL: The Therapeutic Relationship in Cognitive Behavioral Psychotherapies. London: Routledge; 2007. Hollon SD, DeRubeis RJ, Shelton RC, Amsterdam JD, Salomon RM: Prevention of relapse following cognitive therapy vs. medications for moderate to severe depression. Arch Gen Psychiatry. 2005;66;417. Kennedy SH, Konarski JZ, Segal, ZV, Lau MA, Bieling PJ: Differences in brain glucose metabolism between responders to CBT and venlafaxine in a 16-week randomized controlled trial. Am J Psychiatry. 2007;164:778. Kuyken W, Byford S, Taylor RS, Watkins E, Holden E, White K, Barrett B, Byng R, Evans A, Mullan E, Teasdale JD: Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol. 2008;76:966. Kuyken W, Padesky CA, Dudley R: Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive-Behavioral Therapy. New York: Guilford Press; 2008. Lam DH, Hayward P, Watkins ER, Wright K, Sham P: Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after two years. Am J Psychiatry. 2005;162:324. MaudeGriffin PM, Hohenstein JM, Humfleet GL, Reilly PM, Tusel DJ: Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: Main and matching effects. J Consult Clin Psychol. 1998;66:832. Newman CF, Leahy RL, Beck AT, Reilly-Harrington NA, Gyulai L: Bipolar Disorder: A Cognitive Therapy Approach. Washington, DC: American Psychological Association; 2001. Otto MW, Basden SL, Leyro TM, McHugh RK, Hofmann SG: Clinical perspectives on the combination of d-cycloserine and cognitive-behavioral therapy for the treatment of anxiety disorders. CNS Spectrums. 2007;12:51. Ramsay JR, Rostain AL: Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. New York: Routledge; 2007. Scott J, Paykel E, Morriss R, Bentall R, Kinderman P: Cognitive-behavioural therapy for severe and recurrent bipolar disorder: Randomised controlled trial. Br J Psychiatry. 2006;188:213. Tarrier N, Sommerfeld C: Treatment of chronic PTSD by cognitive therapy and exposure: A 5-year follow-up. Behav Ther. 2004;35:231. Wells A, King P: Metacognitive therapy for generalized anxiety disorder: An open trial. J Behav Ther Exp Psychiatry. 2006;37;206. Whisman MA: Adapting Cognitive Therapy for Depression: Managing Complexity and Comorbidity. New York: Guilford Press; 2008. Wilson GT, Grilo CM, Vitousek KM: Psychological treatment of eating disorders. Am Psychol. 2007;62:199. Wright JH, Wright AS, Alabano AM, Basco MR, Goldsmith LJ: Computerassisted cognitive therapy for depression: Maintaining efficacy while reducing therapist time. Am J Psychiatry. 2005;162:1158. Young J, Klosko J, Weishaar M: Schema Therapy: A Practitioner's Guide. New York: Guilford Press; 2003.