Making Cognitive-Behavioral Therapy Work, Third Edition: Clinical Process for New Practitioners - Rilegato

Ledley, Deborah Roth; Marx, Brian P.; Heimberg, Richard G.

Rilegato

ISBN 10: 1462535631 ISBN 13: 9781462535637

Casa editrice: Guilford Press, 2018

Riassunto

"What should I do when a client asks me personal questions?" "How do my client's multiple problems fit together, and which ones should we focus on in treatment?" This engaging text--now revised and updated--has helped tens of thousands of students and novice cognitive-behavioral therapy (CBT) practitioners build skills and confidence for real-world clinical practice. Hands-on guidance is provided for developing strong therapeutic relationships and navigating each stage of treatment; vivid case material illustrates what CBT looks like in action. Aided by sample dialogues, questions to ask, and helpful checklists, readers learn how to conduct assessments, create strong case conceptualizations, deliver carefully planned interventions, comply with record-keeping requirements, and overcome frequently encountered challenges all along the way.

New to This Edition
*Chapter with advice on new CBT practitioners' most common anxieties.
*All-new case examples, now with a more complex extended case that runs throughout the book.
*Chapter on working with special populations (culturally diverse clients, children and families).
*Special attention to clinical and ethical implications of new technologies and social media.
*Updated throughout to reflect current research and the authors' ongoing clinical and teaching experience.

Su questo libro

Informazioni sull?autore

Deborah Roth Ledley, PhD, is a psychologist in private practice in suburban Philadelphia. She spent several years on the faculty of the University of Pennsylvania’s Center for the Treatment and Study of Anxiety. Dr. Ledley’s research has focused on the nature and treatment of anxiety. She has published over 50 scientific papers and book chapters as well as several books, including Making Cognitive-Behavioral Therapy Work, Third Edition; Improving Outcomes and Preventing Relapse in Cognitive-Behavioral Therapy; Becoming a Calm Mom; and The Worry Workbook for Kids. She lectures widely on the treatment of childhood anxiety.

Brian P. Marx, PhD, is a staff psychologist at the National Center for Posttraumatic Stress Disorder (PTSD), Veterans Affairs Boston Healthcare System, and Professor of Psychiatry at Boston University School of Medicine. Dr. Marx has written numerous articles and book chapters on behavior therapy and assessment. His research interests include the assessment and treatment of PTSD, identifying risk factors for posttraumatic difficulties, and the association between PTSD and suicidal behaviors.

Richard G. Heimberg, PhD, is the Thaddeus L. Bolton Professor of Psychology and Director of the Adult Anxiety Clinic of Temple at Temple University. He is past president of the Association for Behavioral and Cognitive Therapies (ABCT) and the Society for a Science of Clinical Psychology (SSCP) and former editor of the journal Behavior Therapy. Well known for his efforts to develop and evaluate cognitive-behavioral treatments for social anxiety and other anxiety disorders, Dr. Heimberg has authored several books and 450 articles and chapters. As an educator and mentor of clinical psychology doctoral students, he has received awards from ABCT, SSCP, the Society of Clinical Psychology, and the American Psychological Association of Graduate Students.

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Making Cognitive-Behavioral Therapy Work

Clinical Process for New Practitioners

By Deborah Roth Ledley, Brian P. Marx, Richard G. Heimberg

The Guilford Press

Copyright © 2018 The Guilford Press
All rights reserved.

ISBN: 978-1-4625-3563-7

Contents

Cover, 
Also Available, 
Title Page, 
Copyright Page, 
Dedication Page, 
About the Authors, 
Preface, 
Acknowledgments, 
Prologue: Common Challenges for New Clinicians, 
1. The Process of Cognitive-Behavioral Therapy, 
2. Initial Interactions with Clients, 
3. The Process of Assessment, 
4. Conceptualizing the Case and Planning Treatment, 
5. The Bridge from Assessment to Treatment, 
6. The First Few Sessions of CBT: Goals and Challenges, 
7. The Course of CBT: Goals and Challenges, 
8. Terminating Therapy: Goals and Challenges, 
9. Doing CBT with Special Populations, 
10. The Process of Supervision: Goals and Challenges, 
11. Revisiting the Common Challenges, 
Appendix A. Recommended Readings in CBT, 
Appendix B. Further Reading on Special Topics in CBT, 
Appendix C. Treatment Manuals and Client Workbooks, 
Appendix D. Useful Information for Cognitive-Behavioral Therapists, 
References, 
Index, 
About Guilford Press, 
Discover Related Guilford Books, 

CHAPTER 1

The Process of CognitiveBehavioral Therapy

The process of becoming a therapist can be daunting. Clients who are suffering with emotional and behavioral problems entrust their therapists with their deepest thoughts and feelings and perhaps share experiences with us that they have never shared with anyone else. They place hope in us that we will be able to fix what ails them. This is a great responsibility.

Given that psychotherapy is a human interaction, we must remember that our clients come into this situation with beliefs they held long before their interactions with us. Perhaps they had negative experiences with other therapists. Maybe they grew up with highly critical parents. Years of failure at school and work might have led them to believe that they can never succeed, even with great effort. We must accept our clients as they walk in the door. Whatever they bring with them becomes part of our work together.

Engaging in psychotherapy means being faced with emotions all day. Over the course of a typical day, a therapist might sit with anger, sadness, intense anxiety, or even steely silence that is hard to attach to any one emotion. We must learn how to react effectively to our clients' emotional states and how to leave work at the end of the day in a comfortable emotional place, rather than carrying the burden of our clients into our lives outside of work.

Moreover, being a therapist involves exposure to all sorts of different behaviors. Every day, we meet clients who engage in dysfunctional behaviors like smoking, drinking, binge eating, and gambling. We encounter clients who fail to engage in the behaviors that might improve their lives — for example, a depressed client who stays in bed all day rather than getting up and doing things that might help him or her feel better. We see clients who miss out on participating in their lives because of fear and avoidance. It can also be challenging to regularly meet people who hold views we might personally disagree with (e.g., supporting a political view we find repugnant) or who engage in behaviors that we find morally wrong (e.g., shoplifting, child neglect). In our personal lives, we might choose to distance ourselves from such people, but in our professional lives, this might all be in a day's work. The range of behaviors that presents in our offices can seem overwhelming. We might wonder how we can even begin to help every person who walks through the door.

In this chapter, we discuss how you can gain confidence as a clinician. But, first, we offer a useful metaphor for the therapy process — going on a journey.

THERAPY AS A JOURNEY

Many people love to travel. Some people are "fly-by-the-seat of their pants" kinds of travelers, but more often than not people like to make a plan before leaving on a journey. After all, time and resources are limited when we travel, and we like to make the most of it!

Perhaps we begin planning a trip by choosing a general location. We can reach this decision based on who is going on the trip, what the weather is at the time of year we are traveling, consideration of cost, how much time we have, and so forth. Once a general location is selected, it can be helpful to print out a map of that area and trace a route from place to place that might end up on the itinerary.

It often makes sense to consider the beginning, middle, and end of a trip. On the first few days of a trip, we can get acquainted with the place we're visiting — maybe by walking around or taking a bus tour to get a sense of what would be interesting to see. The middle of the trip can be exciting — maybe a really long, strenuous hike in a national park, seeing and hearing an amazing concert, or having a meal at a special restaurant. And it's always nice to leave a day or two at the end of the trip to pack up your belongings and get things in order before heading back to "real" life.

The process of treatment planning in cognitive-behavioral therapy (CBT) is like making an itinerary for our trip. This itinerary leads us from the beginning of our trip to its end — and spells out all the points in between. As with a trip, therapy ideally begins with an acquaintance period. Therapist and client get to know each other, learn about the style of therapy and the presenting problem together, and discuss particular therapeutic strategies that may be employed both during and between sessions. The "exciting" part of the voyage involves all the tools of CBT — cognitive work, exposures, relaxation exercises, mindfulness techniques, and so forth — all carefully selected to get the client to an end point, some agreed-upon goal. Along the way, we might face challenges. When we travel, we might get a flat tire, someone might get ill, or a long-awaited attraction or destination might be closed for renovation or other unforeseen reason. In therapy, we might encounter clients who are resistant to change, clients who lead chaotic lives, or we — as therapists — might bring our own issues into the interpersonal relationship that make the process less than ideal. All these challenges must be effectively worked through so that the client can attain his or her goals in some reasonable time frame.

In the same way that it can be nice to enjoy a calm ending to a trip, therapy also should not finish abruptly. There is a way to conclude, to consider gains, and to ensure that these gains are maintained into the future. In other words, before hopping on a plane back to "real life," we want to ensure that our clients have packed their souvenirs (CBT strategies) in their luggage. Throughout this book, we discuss how to travel the path of CBT successfully with our clients.

It is essential to note that mapping out a plan in advance of a trip does not mean we cannot deviate from it. Maybe the hotel that looked great online turned out to be a dump. Perhaps a place where we planned to spend 2 days was so wonderful that we decided to spend 5 days there instead. Or, maybe we met a local fellow in a far-off place who took us on an adventure we could never have planned with our tour books back home. The case conceptualization is just like our trip itinerary. We set our itinerary before we leave home, but we always need to allow room for adjustments. In CBT, we create a case conceptualization that helps us to understand the client, his or her problems, and how we will resolve them at the beginning of the therapeutic relationship. But this conceptualization cannot be static. We must constantly examine whether it needs to be adjusted to best serve our client's needs. Throughout this book, we also show you how to formulate and revise a case conceptualization so that our voyage together is rewarding and effective.

UNDERSTANDING THE THEORY BEHIND CBT

It is beyond the scope of this book to provide you with an in-depth understanding of the theoretical assumptions that guide CBT case conceptualization and practice. Instead, we briefly offer some insights into its theoretical underpinnings. A clear understanding of this theory is essential while reading this book for two reasons. First, the book discusses the process of doing CBT. Understanding the theory behind CBT helps therapists to see what maintains problematic beliefs and behaviors, and what methods may be used to help clients change their lives. Second, this book moves beyond technique and uses CBT strategies to help therapists overcome difficulties that they might encounter in their day-to-day work with clients. The beauty of CBT is that we can use the theory and techniques to help ourselves as well as our clients.

CBT is an integration of two originally separate theoretical approaches to understanding and treating psychological disorders: the behavioral approach and the cognitive approach. The behavioral approach (at its strictest) focuses exclusively on observable, measurable behavior and ignores all mental events. It views the mind–brain as a "black box" that is not easily known and, therefore, not a suitable focus of attempts at therapeutic change. It focuses instead on the interactions of environment and behavior. The cognitive approach focuses on the role of mind and specifically on cognitions as determinants of feelings and behaviors.

The Behavioral Approach

John B. Watson (1913), often considered to be the "father of behaviorism," saw all behavior, and all behavior change, as a function of learning via classical conditioning. He posited that even complex behaviors could be broken down into component behaviors that had all been acquired through simple learning processes. There are four key elements of classical conditioning: (1) the unconditioned stimulus, (2) the unconditioned response, (3) the conditioned stimulus, and (4) the conditioned response. The "unconditioned stimulus" is any stimulus that is capable of producing a particular reflexive response. An example of an unconditioned stimulus is food — it naturally elicits salivation, an unconditioned response. The "conditioned stimulus" is one that is neutral prior to being paired with an unconditioned stimulus. For example, when a baby is shown a green light, he has no particular response to it (beyond looking at it). However, if the baby is repeatedly presented with the green light immediately before his mother begins to feed him, he would eventually start to salivate in response to the green light alone. Salivation has now become a conditioned response — with repeated pairings, the conditioned stimulus (the green light) now elicits the same response, more or less (salivation), that occurred with the unconditioned stimulus alone (food). Watson believed that all learning (and thus all behavior change) occurred through these types of simple stimulus–response pairings.

Here are some more examples that clearly show classical conditioning at work in the kinds of problematic behavior that CBT therapists are interested in. Watson and his colleague (and later, wife) Rosalie Rayner Watson (see Watson & Watson, 1921) did a famous experiment with a little boy named Albert. Albert had never seen a white rat, and thus he had no learned response to it. In other words, the white rat was a "neutral stimulus" for Albert. Watson and Rayner showed Albert the rat, at the same time pairing it with a loud noise (unconditioned stimulus). The noise was known to elicit a startle or fear response (unconditioned response) in Albert. With just seven pairings of the white rat and the loud noise, Albert came to exhibit a fear response (conditioned response) to the rat alone (conditioned stimulus). Albert had "learned" to fear the rat. In fact, Albert came to fear many white, furry objects, including rabbits and a mask of Santa Claus. In behavioral terms, Albert's fear "generalized" to other white, furry objects. Another study, referred to as the case of Little Peter (Jones, 1924), demonstrated how fears could also be "unlearned." A young boy named Peter who was afraid of rabbits (the origin of his fear was not known) was exposed to a rabbit in its cage for many days while he was eating lunch. Peter gradually lost his fear of the rabbit, leading the experimenters to assume that Peter developed a new association between rabbits and the pleasure of eating lunch, rather than between rabbits and fear. These early experiments in learning and unlearning are important to our current understanding of how people acquire fears and how we can then help to extinguish these fears.

B. F. Skinner (1976) was another key figure in the rise of behaviorism. Skinner's theories of conditioning were more sophisticated than Watson's; they focused on operant rather than classical conditioning. In operant conditioning, stimuli are not thought of as eliciting responses. Instead, as organisms interact with their environments, they emit all sorts of responses (called operants); when the organism is rewarded for a particular response, the response is more likely to occur again; in behavioral terms, it has been "reinforced." Let's look at an example of operant conditioning at work in the kinds of problem we see as clinicians. Consider a child who cries before school and is then permitted by his mother to stay home from school. He greatly enjoys his day at home, spending time alone with his mom (whom he usually has to share with his siblings), watching TV, and playing video games. This child is likely to continue crying each morning since he has learned that this behavior yields a desired consequence. If the mother then reads in a parenting magazine that she should make her child go to school regardless of his crying, the crying behavior will eventually be extinguished since the child will learn that crying no longer yields the desired outcome. In other words, he will unlearn the association between crying and being permitted to stay home from school.

The purely behavioral approach does apply to some of the problems that we see as cognitive-behavioral therapists. However, simple stimulus–response associations cannot explain all learned behaviors. As the complexity of behavioral phenomena increases, we require more complex explanations for behaviors. Knowing what people are thinking and feeling is also important to understanding their behavior.

The Cognitive Approach

The cognitive approach most clearly deviates from the strictly behavioral approach when contrasted to the staunch behaviorists' "black-box" view of the mind. The cognitive model is interested in the mind. Specifically, thoughts are considered important because they serve as intervening variables between stimuli and our responses to them.

The cognitive model, and the therapy associated with it, is most closely associated with Aaron T. Beck (1979; see also Beck, Rush, Shaw, & Emery, 1979). Beck developed cognitive therapy in the early 1960s as a treatment for depression, but it has since been applied to virtually every psychiatric disorder, as well as to general "problems of daily living." Cognitive therapy is based on the cognitive model, which proposes that distorted or dysfunctional thinking underlies all psychological disturbances. Furthermore, dysfunctional thinking has an important effect on our emotions and behavior. The key concept of the cognitive model, which dates back to the writings of the ancient Greeks, is that it is not events themselves that affect our behavior, but rather how we perceive events (see J. S. Beck, 2011, p. 31).

The cognitive model starts with a situation or event. Consider this situation: Emily makes plans to meet a friend for a movie at 7:00 P.M. It is now 7:30; Emily's friend has not arrived and the movie is about to begin. At this point, Emily experiences automatic thoughts. These are "quick, evaluative thoughts [that are] not the result of deliberation or reasoning" (J. S. Beck, 2011, p. 31). Beck points out that automatic thoughts can be so quick that we might not even be aware of them. Rather, we might only notice the emotions or behaviors that follow from them.

When Emily's friend does not arrive for the movie, her automatic thoughts are as follows: "She must have had a car accident" and "Something terrible has happened." Emily also has images of her friend in a totaled car in the middle of the freeway.

This interpretation of the initial event (her friend being late for the movie) leads to several reactions. Emily feels terribly anxious and worried (emotional reaction). She begins to repeatedly text her friend (behavioral reaction). When she does not get a text back, she notices her heart racing and her hands sweating (physiological reaction).

Another person might have a different reaction. José's automatic thoughts in the same situation are "She doesn't like me" and "She's out with other friends instead." These thoughts lead to sadness and anger (emotional reaction), and José goes home alone and drinks far too much (behavioral reaction). Taylor, also in the same situation, assumes her friend just forgot to meet her, as she has often done in the past. This might leave Taylor feeling annoyed (emotional reaction), and she might then decide to head into the theater on her own (behavioral reaction). Kevin might think that maybe he got the time or date wrong ("I'm so stupid"; automatic thought). This would leave him feeling rather sad (emotional reaction), and he might head to the store on his way home to buy the appointment book that he has been meaning to get for weeks (behavioral reaction). A single situation can elicit various emotional, behavioral, and physiological responses, depending on how the person perceives the situation. This is really the crux of the cognitive model.

(Continues...)

Excerpted from Making Cognitive-Behavioral Therapy Work by Deborah Roth Ledley, Brian P. Marx, Richard G. Heimberg. Copyright © 2018 The Guilford Press. Excerpted by permission of The Guilford Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Dettagli dell'edizione

• Editore: Guilford Press
• Data di pubblicazione: 2018
• Lingua: Inglese
• ISBN 10: 1462535631
• ISBN 13: 9781462535637
• Rilegatura: Copertina rigida
• Numero edizione: 3
• Numero di pagine: 290
• Contatto del produttore: non disponibile
• Persona responsabile: non disponibile