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4. Jacobson AM, Parmelee DX: Psychoanalysis: Critical Explorations in Contemporary Theory and Practice. New York, BrunnerMazel, 1982. 5 . Klerman G, Weissman M, Rovsanville B, Chevron E: Interpersonal Psychotherapy of Depression. New York, Basic Books, 1984. 6. Luborsky L: Theories of cure in psychoanalytic psychotherapies and the evidence for them. Psychoanalytic Inquiry 16(2):257-264, 1996. 7. Mann J: Time-Limited Psychotherapy. Cambridge, MA, Harvard University Press, 1973. 8. Sloane RB, Staples FR, Cristol AH, et al: Psychotherapy Versus Behavior Therapy. Cambridge, MA, Harvard University Press, 1975. 9. Wachtel PL: Psychoanalysis and Behavior Therapy. New York, Basic Books, 1977. 10. Stem DN: The Interpersonal World of the Infant. New York, Basic Books, 1985. I I . Rothstein A: Models of the Mind. New York, International Universities Press, 1985. 12. Vaillant GE (ed): Ego Mechanisms of Defense: A Guide for Clinicians and Researchers. Washington, DC, American Psychiatric Press, 1992.

4 1. COGNITIVE-BEHAVIORAL THERAPY
Jacquehe A.Samson, Ph.D
1. What is cognitive-behavioral therapy? Cognitive-behavioral therapy (CBT) combines treatment approaches of both cognitive and behavioral therapy. The principles were first outlined in a treatment manual specifically targeted to depression by Beck et aL3 The basis of cognitive therapy is the observation that negative feelings result from faulty cognitive processing. Incoming information is selectively filtered so that perceptions are distorted toward negative conclusions. Faulty processing is identified by examining a patients spontaneous thoughts occurring throughout the day or after specific events. These automatic thoughts are key to understanding a patients core system of assumptions and beliefs about the self and the world. CBT treatments first help a patient become aware of automatic thoughts and underlying assumptions and beliefs. The patient is then encouraged to seek evidence by which to support or refute the assumptions, and to modify beliefs based on a more balanced view of all available information. Behavioral techniques are integrated throughout CBT treatment to facilitate change. Specific exercises for thought stopping, relaxation, and impulse control may be combined with monitoring and adjusting daily activities to increase mastery and pleasure experiences. Graded task assignments and systematic graded exposures also may be used.
2. Give an example of cognitive distortion. A depressed patient reported to her cognitive therapist that she felt sad over the weekend. In reconstructing the events of the weekend, she noted that the sadness began during a telephone call on Saturday morning from an old friend. The therapist then encouraged her to remember the conversation and the point at which she first felt sadness. She remembered that her friend Sarah was discussing her plans to take a vacation but did not invite the patient to come along. Her first automatic thought was: Sarah doesnt want me along because Im no fun. Her next thought was, Nobody wants to be with me. I have no friends. She then thought, 1 will be alone for the rest of my life. Gloomy thoughts indeed! The patients faulty processing began with her first reaction to the news of Sarahs vacation. When the therapist asked the patient to examine the evidence for her assumption that Sarah did not want to be in her company, she had to say that there was no evidence; the fact that Sarah called indicated that Sarah enjoyed her company. Once the distortion i n the automatic thought was worked through, the patient felt more hopeful about the future and was able to say that she might ask Sarah if they could plan to do something together soon.

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3. What is the cognitive triad?

The cognitive triad refers to negative biases that are characteristic of depressed patients. The patient tends to: (1) view him- or herself in a negative light and assume excessive responsibility for failures or negative experiences; (2) view the world in a negative light and as presenting obstacles that cannot be overcome; (3) view the future negatively, consisting only of more failure and insurmountable obstacles.

4. What are the main cognitive processing errors that contribute to maintaining negative biases? In general, cognitive errors involve: ( I ) making predictions about the future or how others will behave without sufficient evidence; (2) selectively focusing only on information that is consistent with ones expectations and ignoring information that runs counter to expectations; ( 3 ) assuming too much responsibility for negative events without acknowledging the contributions made by others or the situation; and (4) seeing situations as all-or-nothing and failing to acknowledge partial success or progress.
Cognitive Processing Errors Emotional reasoning: A conclusion or inference based on an emotional state; e.g., I feel this way; therefore, I urn this way. Overgeneralization: Evidence drawn from one experience or a small set of experiences to reach an unwarranted conclusion with far-reaching implications. Catastrophic thinking: An extreme example of overgeneralization, in which the impact of a clearly negative event or experience is amplified to extreme proportions; e.g., If I have a panic attack I will lose all control and go crazy (or die). All-or-nothing (black-or-white; absolutistic) thinking: An unnecessary division of complex or continuous outcomes into polarized extremes; e.g., Either Im a success at this, or Im a total failure. Shoulds and musts: Imperative statements about self that dictate rigid standards or reflect an unrealistic degree of presumed control over external events. Negative predictions: Use of pessimism or earlier experiences of failure to prematurely or inappropriately predict failure in a new situation; also known as fortune telling. Mind reading: Negatively toned inferences about the thoughts, intentions, or motives of another person. Labeling: An undesirable characteristic of a person or event is made definitive of that person or event; e.g., Because Ifuiled to be selected for ballet, I am afuilure. Personalization: Interpretation of an event, situation, or behavior as salient or personally indicative of a negative aspect of self. Selective negative focus (selective abstraction): Focusing on undesirable or negative events, memories, or implications at the expense of recalling or identifying other, more neutral or positive information. In fact, positive information may be ignored or disqualified as irrelevant, atypical, or trivial. Cognitive avoidance: Unpleasant thoughts, feelings, or events are misperceived as overwhelming and/or insurmountable and are actively suppressed or avoided. Somatic (mis) focus: The predisposition to interpret internal stimuli (e.g., heart rate, palpitations, shortness of breath, dizziness, or tingling) as definite indications of impending catastrophic events (heart attack, suffocation, collapse).
Adapted from Thase ME, Beck AT Overview of cognition therapy. In Wright JG, Thase ME, Beck AT, Ludgate JW (eds): Cognitive Therapy with Inpatients. New York, Guilford, 1993, pp 3-34.

5. How do patients learn to correct cognitive processing errors? By working with a therapist who questions their logic. The therapist may use the socratic method
and encourage the patient to identify errors in rational thinking by asking questions such as: What is the evidence that this is true? What is the evidence that this is not true? Is there another way of looking at this? Once alternative explanations have been generated, the therapist may collaborate with

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the patient to design a mini-experiment in which the patient gathers information to confirm, refute, or modify the assumption.

6. How does correction of cognitive errors result in mood change?

Although the exact mechanisms involved in clinical change are not known, it is hypothesized that the tendency to filter incoming information through a negative lens systematically excludes the positive information needed to maintain a balanced perspective. The process of change involves completing homework assignments. This is a critical step because it requires that the patient take concrete action to gather data (i.e., fill out daily activity monitoring forms). Patients are more likely to follow through on such assignments when they understand the rationale of the treatment, and evidence of its usefulness has been demonstrated in the initial therapy sessions (see Question 2). This behavioral component increases the patients activity level and, usually, sense of self-efficacy. Once the patient becomes more active and is feeling somewhat empowered, opportunities for positive feedback from others increase. Mood improves as the negative cognitive biases are refuted by experience or evidence, and the patient begins to see more options.
7. How is the role of the cognitive-behavioral therapist different from more psychodynamically oriented therapists? The cognitive-behavorial therapist takes an active, problem-oriented,and directive stance in the therapy relationship. Early in the relationship, the therapist assumes a direct teaching role and conveys the basic principles of cognitive therapy to the patient. In later sessions, the therapist assumes the role of coach, as the patient takes on more responsibility. Sessions are structured: the therapist and patient ( 1 ) jointly set an agenda, (2) briefly review the previous session, (3) review homework completed since the last session, (4) work on additional topics spurred by the homework or events of the week, ( 5 ) set up homework for the following week, and (6) end with a summary of the key points from the session. Throughout the session the therapist actively summarizes and highlights points as they occur and selectively pursues issues for further work.

Structure of a Typical CBT Session

1. Mood check

Examination of symptom severity score (e.g., Beck Depression Inventory)

2. Set the agenda

3. Weekly items Review of events since last session Feedback on reactions to previous session and review of key points Homework review 4. Todays major topic 5. Set homework for next week 6. Summarize key points of todays session 7. Feedback on reactions to todays session

8. How many sessions typically are involved? Protocols for CBT of depression and anxiety disorders are relatively brief (typically 12-20 sessions). The patient is expected to gradually master the skills of this method so that he or she may
continue to monitor automatic thoughts and test assumptions independently after therapy termination. For patients with multiple diagnoses or comorbid personality disorders, more sessions may be needed to address target problems.
9. To what degree is early developmental experience examined in CBT? In general, cognitive-behavioral therapists are oriented toward the present and encourage patients to examine how present thoughts affect specific behaviors. Examination of a number of automatic thoughts may reveal recurring themes. Such themes can then be examined in more detail to

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understand core beliefs or schemas about oneself or the world that may be driving the thoughts. Although core beliefs are likely to have developed as a result of early experience, it is not necessary to spend a great deal of therapy time exploring such experiences. Rather, the patient may be encouraged to write a brief autobiography outside the session from which likely links between schemas and early experiences can be drawn with the therapist in the next session. The therapist can help the patient to trace how the core belief may have evolved from painful early experiences and to see how they are understandable in that light. However, the emphasis is primarily on examining the ways in which old beliefs distort present thinking and behaviors and on developing an action plan for change.

10. Is there research evidence that CBT works? Yes. A growing number of well-designed studies demonstrate that CBT is effective for patients with depression or anxiety disorders. Studies also show CBT to be as effective as antidepressant medication in mildly to moderately depressed patients; in patients with severe depression, this evidence is mixed. For both disorders, there is no clear evidence that a combination of CBT and medication is superior to either alone, or that the combination is less effective than either alone. Studies comparing CBT to psychodynamically oriented therapies have not been conclusive, partly because of differences in the length of the treatments and difficulties in establishing standardized treatment protocols.
11. How do relapse rates for CBT and pharmacotherapycompare? Follow-up studies find that 70-80% of depressed patients treated with CBT alone continue to be well 2 years later. These rates are significantly higher than the maintenance rates in patients who are withdrawn from antidepressant medication after a comparable initial trial, and equal to the rate in patients who continue on antidepressant medications.

12. Which disorders are responsive to CBT? Efforts to apply CBT techniques to various types of patients have expanded rapidly in the past decade. Included among the disorders shown to be responsive to CBT are panic disorder, generalized anxiety disorder, social phobia, and bulimia nervosa. Preliminary studies show some promise applying CBT techniques to post-traumatic stress disorder, obsessive compulsive disorder, and dysthymia. There are guidelines for applying CBT techniques to personality disorders, but efficacy has not been established across all diagnostic groups. Such application may require more extensive (longer) treatment, and may explain why some depressed and anxious patients with comorbid personality disorder do not show complete response to a brief trial of CBT. Cluster C personality disorders are likely to be most responsive.

13. Are there patients for whom CBT does not work?
Studies predicting outcome based on patient characteristics are only now being completed. A strong predictor of positive outcome is whether a patient completes homework assignments between sessions. Preliminary work suggests that patients who have borderline personality disorder or a great deal of difficulty forming a work alliance with the therapist are likely to show a poor response to a brief trial of cognitive therapy. However, these patients also are likely to show poor response to other forms of brief therapy. Historically, patients with bipolar depression or psychotic features have been excluded from research trials and assumed to be less responsive to intervention with CBT alone. CBT recently has had some success in relapse prevention in bipolar patients; it also has decreased the conviction of psychotic beliefs in patients with delusional features.
BIBLIOGRAPHY
1. 2. 3. 4.
Beck AT: Depression, Causes and Treatment. Philadelphia, Uuiversity of Pennsylvania Press, 1967. Beck AT, Emery G: Anxiety Disorders and Phobias: A Cognitive Perspective. New York, Basic Books, 1985. Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive Therapy of Depression. New York, Guilford Press, 1979. Beck JS: Cognitive Therapy: Basics and Beyond. New York, Guilford Press, 1995.

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5. Beutler LE, Engle D, Mohr D, et al: Predictors of differential response to cognitive, experiential and self-directed psychotherapeutic procedures. J Consult Clin Psychol 59:333-340, 1991. 6. Dobson K: A meta-analysis of the efficacy of cognitive therapy for depression. J Consult Clin Psychol 57:414419, 1989. 7. Elkins I, Shea T, Watkins J, et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program. Arch Gen Psychiatry 46:971-982, 1989. 8. Evans M, Hollon SD, DeRubeis RJ, et al: Differential relapse following cognitive therapy and pharmacotherapy for depression. Arch Gen Psychiatry 49:774-78 1, 1992. 9. Fennel1 MJ: Depression. In Hawton K, Salkovskis PM, Kirk J, Clark DM (eds): Cognitive Behavior Therapy for Psychiatric Problems. A Practical Guide. New York, Oxford University Press, 1989, pp 169-234. 10. Hollon SD, Beck AT: Cognitive and cognitive-behavioral therapies. In Bergin AE, Garfield SL (eds): Handbook of Psychotherapy and Behavior Change, 4th ed. New York, John Wiley & Sons, 1994, pp 428466. 1 I . Hollon SD, DeRubeis RJ, Evans MD, et al: Cognitive therapy and pharmacotherapy for depression: Singly and in combination. Arch Gen Psychiatry 49:774-781, 1992. 12. Hollon SD, Shelton RC, Loosen PT: Cognitive therapy and pharmacothei-apy for depression. J Consult Clin Psychol 59:88-99, 1991. 13. Thase ME, Beck AT: Overview of cognitive therapy. In Wright JG, Thase ME, Beck AT, Ludgate JW (eds): Cognitive Therapy with Inpatients. New York, Guilford, 1993, pp 3-34.

42. BEHAVIOR THERAPY

Carry Welch, Ph.D., and Jacqueline A. Samson, Ph.D.

1. What is behavior therapy? Behavior therapy is a scientifically based approach to the understanding and treatment of human problems. It arose from laboratory experiments of animal behavior conducted in the early 1900s and has developed since from a large body of clinical research and experience. The goals of behavior therapy are: Enhance relationships Improve daily functioning Maximize human potential Reduce emotional distress Behavior therapy first came into common use in the 1960s and is now applied to a wide range of human problems. Originally the emphasis was on overt, measurable behavior and the application of classical and operant conditioning principles. However, since the 1980s it has been expanded to include cognitive aspects that emphasize the role of inner mental processes and emotional states. In addition, a new consideration of the broader social context of behavior has developed. The current focus of behavior therapy is not only what we overtly do, but also what we think and feel; all of these elements are influenced by the fundamental principles of learning.

2. Which patients are most likely to benefit from behavior therapy? Behavior therapy has been proven effective for the treatment of specific health problems requiring behavior change, such as smoking cessation, weight loss, stress, and pain management. In addition, treatment protocols for anxiety disorders and phobias such as obsessive-compulsive disorder (OCD), agoraphobia, and panic disorder show success equivalent to or exceeding medication alone. Behavior therapy and token economy systems (see Question 15) have been used with good outcome in patients with developmental disabilities and severely disturbed psychotic patients. It is the treatment of choice for severely ill patients who cannot participate in standard insight-oriented or cognitive therapies.

3. How do operant and classical conditioning differ?

Behavior therapy draws heavily on principles derived from classical (or Pavlovian) and operant (or instrumental) conditioning. Both forms of conditioning are important influences in daily life