Handbook of Brief Cognitive Behaviour Therapy - Hardcover

Hardcover

ISBN 10: 0471491071 ISBN 13: 9780471491071

Verlag: John Wiley & Sons Inc, 2002

Inhaltsangabe

In this unique handbook, Frank Bond and Windy Dryden, have brought together a prominent cast of authors, to discuss issues concerning the definition, assessment and, in particular, the practice of brief Cognitive Behaviour Therapy (CBT).

Contents include -
* the difference between brief and regular CBT and evidence for its effectiveness
* How to use brief CBT in your own area of practice
* Applying brief CBT to emotional disorders, anxiety, workplace stress and more

This handbook is accessible to a wide range of readers, including academics, practitioners, psychotherapists, counsellors, and students training in CBT.

Über diesen Titel

Über die Autorin bzw. den Autor

Frank W. Bond, PhD, is professor of psychology and management at Goldsmiths, University of London, where he is also director of the Institute of Management Studies.He has published widely in the areas of ACT and organizational behavior, and the processes that underpin peak performance and well-being.

Windy Dryden, BSc, DipPsych, MSc, PhD, CPsychol, is Professor of Counselling at Goldsmiths College, University of London. He is the editor or author of over 125 books in the area of counselling and psychotherapy. His primary interests are rational emotive behaviour therapy and disseminating its theory and techniques to the general public, through writing short, accessible, self-help books.

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Brief Cognitive Behaviour Therapy can be applied to the treatment of a wide range of problems in many different settings. In this unique handbook, Frank Bond and Windy Dryden, have brought together a prominent cast of authors, to discuss issues concerning the definition, assessment and, in particular, the practice of brief Cognitive Behaviour Therapy (CBT).

Contents include:
* The difference between brief and regular CBT and evidence for its effectiveness

* How to use brief CBT in your own area of practice

* Applying brief CBT to emotional disorders, anxiety, workplace stress and more
This handbook is accessible to a wide range of readers, including academics, practitioners, psychotherapists, counsellors, and students training in CBT.

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Handbook of Brief Cognitive Behaviour Therapy

By Frank W. Bond

John Wiley & Sons

Copyright © 2002 Frank W. Bond
All right reserved.
ISBN: 9780471491071

Chapter One

Brief Cognitive-Behavioral Therapy: Definition and Scientific Foundations

Holly Hazlett-Stevens and Michelle G. Craske Department of Psychology, UCLA, Los Angeles, CA, USA

Over the past 50 years, cognitive-behavioral therapies (CBT) have become effective mainstream psychosocial treatments for many emotional and behavioral problems. Behavior therapy approaches were first developed in the 1950s when experimentally based principles of behavior were applied to the modification of maladaptive human behavior (e.g., Wolpe, 1958; Eysenck, 1966). In the 1970s, cognitive processes were also recognized as an important domain of psychological distress (Bandura, 1969). As a result, cognitive therapy techniques were developed and eventually integrated with behavioral approaches to form cognitive-behavioral treatments for a variety of psychological disorders. In this paper, we review the evidence for brief forms of CBT across various disorders. First, we consider the basic principles of CBT that render such therapies well suited for abbreviated formats.

BASIC PREMISES OF CBT

Although a number of different cognitive-behavioral techniques have been developed to address a variety of specific clinical problems, a set of basic principles and assumptions underlies all of these techniques. First, psychological dysfunction is understood in terms of mechanisms of learning and information processing. Basic learning theory incorporates findings from laboratory research on classical and operant conditioning. For example, certain phobic symptoms may represent a classically conditioned fear response that persists long after the removal of the original unconditioned stimulus. In this event, repeated, unreinforced exposure to the conditioned stimulus without the unconditioned stimulus is assumed to extinguish the conditioned fear response. In a similar vein, operant conditioning explains how undesired symptoms or behaviors are maintained as a function of the consequences that follow. For example, chronic pain behaviors are believed to be maintained in large part by attention from others. Therapies that teach persons to operate in their environment, so as to maximize positive reinforcement for adaptive behaviors and minimize such reinforcement for problematic behaviors, have developed from early operant conditioning research. Cognitive research has shown that distortions in processing information about oneself and the environment are integral to many behavioral and psychological problems. For example, biases toward attending to threatening information or toward interpreting ambiguous situations as threatening contribute to excessive or unnecessary anxiety. Similarly, memory biases for distressing events or negative details of events may contribute to depressed mood. Learning to shift appraisals, core beliefs, and associated biases in attention and memory forms the basis of cognitive therapies.

Second, the cognitive-behavioral approach to treatment is guided by an experimental orientation to human behavior, in which any given behavior is seen as a function of the specific environmental and internal conditions surrounding it (Goldfried & Davison, 1994). Behavior is therefore lawful and can be better understood and predicted once its function is revealed. Because cognitive processes as well as overt behavior are viewed as adaptive and subject to change, the cognitive domain is also appropriate for therapeutic intervention (Goldfried & Davison, 1994). CBTs are therefore designed to target specific symptoms and behaviors that are identified as a part of the diagnosis or presenting problem for treatment. The cognitive-behavioral therapist approaches treatment with the assumption that a specific central or core feature is responsible for the observed symptoms and behavior patterns experienced (i.e., lawful relationships exist between this core feature and the maladaptive symptoms that result). Therefore, once the central feature is identified, targeted in treatment, and changed, the resulting maladaptive thoughts, symptoms, and behaviors will also change. For example, a CBT therapist treating panic disorder might discover that the patient holds the erroneous belief that a rapid heartbeat indicates a heart attack. Treatment would therefore aim to challenge this misconception with education and cognitive restructuring while encouraging the patient to experience intentionally the sensation of a rapid heartbeat in order to learn that a heart attack does not occur.

Third is the premise that change is effected through new learning experiences that overpower previous forms of maladaptive learning and information processing. For example, facing feared objects or situations without escape or avoidance enables new approach behaviors and judgments of safety to be learned. Change can therefore occur in the short term as a result of learning these new thoughts and behaviors, and be maintained over the long term as these newly acquired responses generalize across situations and time. CBT also often involves the teaching of new coping skills (such as assertiveness, relaxation, or self-talk) for more effective response to environmental situations. This is expected to lead to improved outcome over time as the new skills are practiced and repeatedly implemented. Clinical improvement can therefore result from two different pathways. First, as previous maladaptive thoughts and behaviors are replaced with more adaptive responses, new learning occurs as the result of new experiences. Second, the individual may learn effective coping skills that lead to improved functioning over time as these skills are practiced and developed.

Fourth is the value of scientific method for CBT, as reflected in the therapist's ongoing evaluation of change at the level of the individual patient. From their experimental orientation, CBT therapists generate hypotheses about an individual's cognitive and behavior patterns, intervene according to that hypothesis, observe the resulting behavior, modify their hypothesis on the basis of this observation, and so on. Thus, the CBT therapist is not simply bound to a set of techniques, but practices from a basic philosophical position consistent with scientific methods (Goldfried & Davison, 1994). This experimental approach is also apparent in the large number of randomized, controlled psychotherapy outcome research studies of the efficacy of CBT. In 1995, a Task Force of the American Psychological Association's Division of Clinical Psychology reviewed the psychotherapy outcome research literature to determine which treatments were considered effective, according to certain research criteria. By their 1996 update (Chambless et al., 1996), 22 different treatments were deemed "well-established," meeting the most rigorous research criteria for efficacy, while an additional 25 treatments met the less stringent criteria of "probably efficacious treatments." The great majority of these "empirically supported therapies" were cognitive-behavioral treatments for a variety of problems, including anxiety disorders, depression, physical health problems, eating disorders, substance abuse, and marital problems. Thus, much research evidence is available to support the use of CBT to treat a number of specific symptoms and behavioral problems.

The cognitive-behavioral conceptualization of psychological dysfunction, the specific nature of the target of CBT, the hypothesized mechanisms of therapeutic change, and the value of the scientific method all render CBT suitable for brief formats. That is, once the critical maladaptive learning and information processing is understood, crucial therapeutic learning experiences can be structured and coping skills can be taught in a very short period of time. Similarly, continuous evaluation of the efficacy of CBT enables variations in its delivery to be examined. One such variation is the length of treatment.

BRIEF CBT

As a result of the problem-focused approach, CBT treatments are typically brief and time-limited in nature. Many CBT treatments lead to significant clinical improvement and symptom reduction, relative to other forms of psychotherapy, in as few as 10-20 sessions. However, treatment researchers are now working to streamline existing effective CBTs to make them even more efficient, cost-effective, and affordable. Some approaches to increase the efficiency of CBT treatments include adapting individual treatments to a group format, self-help materials and bibliotherapy, and computer-assisted therapy programs. The most common approach for enhancing efficiency, however, is to abbreviate existing CBT treatments by reducing the number of treatment sessions. Not only is this trend a pragmatic response to external pressures such as the rise of managed health care in the USA, but it also reflects the underlying assumption (already stated) that effective CBT results from identifying and changing specific cognitions and behaviors that are responsible for the presenting problem. As CBT treatment research progresses, more powerful therapies containing only those techniques that lead to significant change are developed. Similarly, as additional research further pinpoints the likely cause of a particular disorder, treatments become better targeted at the maladaptive features in need of intervention.

Brevity has many clear advantages. Increased cost-effectiveness could make treatment accessible to more individuals in need of assistance. Patients enjoy rapid treatment gains, and this may also improve the credibility of the treatment and increase the motivation for further change. However, this approach may be disadvantageous in some circumstances. Abbreviated CBT approach assumes that the target for change is clearly defined and circumscribed. Patients presenting with more diffuse symptoms or with particular comorbid conditions that interfere with directly targeted programs (such as Axis II disorders) may need more lengthy treatment. The abbreviated approach also assumes that the patient is motivated to participate in the treatment and is ready to make cognitive and behavioral changes. Therefore, patients who are ambivalent about change and unwilling to comply with necessary homework assignments may not benefit from treatments with very limited durations. Similarly, brief CBT puts a greater burden on the patient to engage actively in treatment both during and between sessions. The CBT patient assumes much responsibility for learning necessary therapeutic material and practice of related exercises and skills, significantly more so when such treatment is abbreviated. Finally, the brief CBT approach demands that the therapist be able to keep the patient focused on the specific goals and tasks of treatment. This requires the therapist to be skilled at redirecting patients quickly while maintaining a strong therapeutic alliance. Not all therapists may be suitable for brief CBT. These potential disadvantages clearly warrant empirical investigation.

In the next section, we provide a brief overview of the empirical research evidence that supports the practice of brief CBT. Although there is no clear, standard definition of "brief" CBT, we considered CBT interventions consisting of fewer than 10 sessions. This cutoff was based on the observation that current standard CBT treatments typically span 10-20 sessions. We located empirical studies of the efficacy of brief CBT by asking experts in a variety of areas about available research and by searches of Psychological Abstracts. This section is not an exhaustive review of the current literature, but an overview with a focus on studies that employed randomized controlled group psychotherapy outcome research designs. We structured our review by diagnostic category, as there has been no empirical investigation of the efficacy of brief CBT across different disorders.

In evaluating the research to date for brief CBT, several issues become noteworthy. The first issue, to which we already alluded, is that certain disorders may be more amenable to brief CBT than other disorders. Specifically, more circumscribed disorders with more readily definable lawful relationships, such as specific phobias, seem most suitable for brief CBT. In accord, the specific phobias have been studied more than any other disorder vis-`a-vis brief CBT. The remaining issues have to do with the quality of research to date regarding brief CBT; they are summarized in Table 1.1. For example, how should the efficacy of brief CBT be evaluated? We found very few studies that directly compared abbreviated to unabbreviated CBT, and those that did were often "confounded" by the incorporation of self-help adjunct materials for the abbreviated CBT only. Unconfounded studies were found in the treatment of specific phobias only. The majority of studies compare brief CBT to another type of therapy (e.g., nondirective), an attention placebo control, or waiting list control. While important, these designs do not directly assess the relative merits of brief CBT versus unabbreviated CBT.

A third issue concerns the dimensions along which to compare abbreviated and unabbreviated CBT: is abbreviated CBT as effective as unabbreviated CBT in terms of acute response, long-term response, and nontargeted symptoms or conditions? Most studies evaluate short-term or acute response as well as long-term status. Despite the reasoning that relapse may be elevated after brief CBT relative to unabbreviated CBT, particularly if skills and new learning are not repeated and reinforced after the end of treatment, the evidence generally suggests good long-term response to brief CBT. With respect to nontargeted symptoms and comorbid conditions, evidence for the benefits of unabbreviated CBT is growing, at least with respect to anxiety disorders. For example, targeted treatment for panic disorder leads to significant improvements in other comorbid anxiety disorders, depressive disorders, and Axis II features (e.g., Brown & Barlow, 1995; Tsao et al., 1998). Some studies have investigated the effects of brief CBT on measures that are not specific to the particular disorder (e.g., depression, general anxiety, and overall psychological functioning), but yet to be evaluated is whether brief CBT has the same broad-based effect on diagnosed comorbid conditions.

A fourth consideration is whether the process of therapeutic change is the same in brief CBT as in unabbreviated CBT. Rachman & Whittal (1989) compared fast and slow responders to exposure therapy for fears of spiders and snakes. They hypothesized that steady and slow reductions in fear reflect a type of trial and error learning, whereas fast reductions in fear reflect insight and reasoning, akin to a "flashbulb" effect. Obviously, the goal of brief CBT is to structure the learning experiences in order to maximize this second type of learning. Very rarely have therapeutic mechanisms been studied, to date.

A final issue concerns individual difference variables that predict outcome from brief CBT, such as attitudes to treatment, chronicity, severity, and ongoing life stressors. Some available research suggests that, as with standard CBT, positive attitudes toward treatment predict treatment response to brief CBT. Other findings suggest that brief CBT may be more effective with less severe populations. However, some studies found no significant predictors of outcome. More research is needed to elucidate which individual characteristics lead to improved treatment outcome under what treatment conditions. Finally, the relationship between therapist variables, such as level of experience, and therapeutic outcome is also of importance and has been rarely studied.

PANIC DISORDER AND AGORAPHOBIA

A number of advances have been made to reduce the number of treatment sessions for panic disorder and agoraphobia. Traditional CBT is provided over 10-20 sessions and includes several treatment components (Craske, 1999). Education and cognitive restructuring address faulty beliefs and misconceptions about the meaning of bodily sensations. Corrective breathing techniques are sometimes incorporated to regulate breathing. Finally, various forms of interoceptive and in vivo exposure are designed to reduce fear and avoidance of physical sensations and agoraphobic situations. Several investigations support the use of abbreviated CBT to treat panic disorder and agoraphobia.

Continues...

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Details zur Ausgabe

• Verlag: John Wiley & Sons Inc
• Erscheinungsdatum: 2002
• Sprache: Englisch
• ISBN 10: 0471491071
• ISBN 13: 9780471491071
• Einband: Tapa dura
• Anzahl der Seiten: 336
• Herausgeber: Bond Frank W., Dryden Windy
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: Nicht verfügbar