- •Contents
- •Contributors
- •Foreword
- •Introduction
- •Cognitive therapy with in-patients
- •Why do cognitive therapy with in-patients?
- •Specific problems relating to cognitive therapy with in-patients
- •Case example (Anne)
- •Short case history and presentation
- •Assessment of suitability for cognitive therapy
- •Beginning of cognitive formulation of case
- •Session 2 (continuation of assessment for suitability for cognitive therapy)
- •Progress of therapy
- •Session 3
- •Session 4 (three days later)
- •Session 5 (next day—half an hour)
- •Session 6 (next day)
- •Sessions 7–26
- •Outcome
- •Ratings
- •Discussion
- •References
- •Cognitive treatment of panic disorder and agoraphobia: a brief synopsis
- •A many layered fear of internal experience: the case of John
- •Second session
- •Tenth session
- •Postscript
- •References
- •Introduction
- •The behavioural model
- •Cognitive hypotheses of obsessive-compulsive disorder
- •The cognitive hypothesis of the development of obsessional disorders
- •The role of cognitive and behavioural factors in the maintenance of obsessional disorders
- •Applications of the cognitive model
- •General style of treatment
- •Assessment factors
- •Problems encountered in implementing assessment
- •Content
- •Effects of discussion
- •More specific concerns
- •Embarrassment
- •Chronicity
- •Broadening the cognitive focus of assessment
- •Treatment
- •Engagement and ensuring compliance
- •Further enhancing exposure treatments
- •Dealing with negative automatic thoughts
- •Dealing with concurrent depression
- •Dealing with obsessions not accompanied by compulsive behaviour
- •Relapse prevention
- •Conclusions
- •Acknowledgements
- •References
- •Introduction
- •Cognitive-behavioural hypothesis
- •Increased physiological arousal
- •Focus of attention
- •Avoidant behaviours
- •The importance of reassurance
- •Principles of cognitive treatment of hypochondriasis
- •Case 1
- •Treatment strategies and reattribution
- •Alternative hypotheses
- •Case 2
- •Cognitive-behavioural intervention
- •Case 3
- •Conclusions
- •Notes
- •References
- •Introduction
- •Prevalence of psychological problems in cancer patients
- •Why use cognitive behaviour therapy?
- •Specific issues in applying cognitive behaviour therapy to cancer patients
- •Grieving for the ‘lost self’
- •Locus of control
- •Physical status
- •Pain
- •Treatment issues
- •Longstanding deficits in coping strategies
- •Specific problems in applying cognitive behaviour therapy in cancer patients
- •Case study
- •Sessions 1 and 2
- •Session 3
- •Session 4
- •Sessions 5 to 7
- •Session 8
- •Sessions 9 and 10
- •Outcome
- •Conclusions
- •References
- •Introduction
- •Case history
- •Medical assessment
- •Psychological assessment
- •Treatment plan
- •Developing motivation for treatment
- •Rationale for treatment
- •Providing information and education
- •Weight restoration
- •Eating behaviour
- •Binge eating
- •Vomiting and laxative abuse
- •Identifying dysfunctional thoughts
- •Dealing with dysfunctional thoughts
- •Dealing with other areas of concern
- •Maintenance and follow-up
- •Being a therapist with anorexic and bulimic patients
- •References
- •Treatment of drug abuse
- •Drug withdrawal
- •General treatment measures
- •Cognitive models of drug abuse
- •A scheme for cognitive behaviour therapy with drug abusers
- •Engaging the patient
- •Establishing a therapeutic relationship
- •Motivation
- •Rationale
- •The role of negative cognitions in the process of engagement and commitment
- •Cue analysis
- •Problem solving and cue modification
- •Modifying situational factors
- •Cue exposure and aversion
- •Predicting and avoiding high-risk situations
- •Coping with high-risk situations
- •Modifying emotional factors
- •Underlying assumptions
- •Self-schemas in addiction
- •Modifying cognitive structures
- •Conclusion
- •References
- •Introduction
- •Other clinical approaches with the offender
- •Problems of working with offenders
- •Cognitive-behavioural techniques with offenders
- •General strategies
- •Explaining the role of cognitions
- •Developing trust
- •Collaboration
- •Common cognitive patterns in interaction with offenders
- •Self-defeat
- •Levels of involvement
- •Analysis of the offence
- •Assessing change; deciding on the need for therapy
- •Cognitive therapy
- •Case example
- •Presentation
- •Sessions one to three
- •Background
- •Exposure history
- •Analysis
- •The treatment decision
- •Session four
- •The issue of control
- •The issue of deterrents
- •Explaining the role of cognitions
- •The self-help task
- •Session five
- •Session six
- •Re-analysis
- •Session seven
- •Dependency
- •The issues of wanting to expose and pleasure
- •The issue of dissatisfactions
- •Session eight
- •Session nine
- •Conclusion
- •References
- •Introduction
- •Suicidal thoughts during therapy for depression
- •Secondary prevention immediately following deliberate self-harm
- •Outline for therapy
- •Vigilance for suicidal expression
- •Case transcripts
- •Reasons for living and reasons for dying
- •Evaluating negative thoughts within a session
- •Inability to imagine the future
- •Some common problems
- •Concluding remarks
- •References
- •Emergent themes
- •Cross-sectional and longitudinal assessment
- •Engagement in and explanation of cognitive therapy
- •Techniques for eliciting thoughts and feelings within the session
- •Dealing with dysfunctional attitudes
- •Other applications of cognitive therapy
- •Application of cognitive therapy to clients with a learning difficulty
- •Case 1
- •Case 2
- •Case 3: Cognitive Restructuring
- •The cognitive framework
- •Different cognitive levels
- •Implications of a ‘levels’ model for therapy methods
- •Theoretical cogency of a ‘levels’ model
- •Future Research
- •Basic research on cognitive processes
- •Future strategies for clinical research
- •Note
- •References
- •Index
OBSESSIONS AND COMPULSIONS 33
and enhance treatment. Furthermore, cognitive techniques can considerably simplify the often difficult process of engaging the patient in behavioural treatment and ensuring compliance (see p. 63; Salkovskis and Warwick 1985).
General style of treatment
The general style of therapy is particularly important with obsessional patients. Obsessionals sometimes become argumentative, particularly if they are seeking reassurance from the therapist. If this happens, therapy seldom proceeds well, particularly as the patient ceases to process information fully from the therapist, and instead begins to look for defects in the information they are being given. This can usually be avoided by being less didactic and using a high proportion of questions, so that the information which is used to alter beliefs is provided by the patients themselves in answer to the therapist’s questions. Whenever the sessions are in danger of becoming combative (i.e. when the patient and therapist begin to show signs of arguing), the therapist needs to summarise the discussion so far, ending by agreeing that the patient could be right in their assertions, and that the object is to find out the real situation rather than taking anything for granted. For instance, if the patient really believes that one further wash would make all the difference, this must be considered seriously as a strong possibility. What is the evidence from past experience? Has the patient ever believed that before? What happened? How could we find out whether it might be so. on this occasion? Therapy utilises summaries by both therapist and patient as a way of clarifying the discussion from time to time.
As in cognitive therapy in general, reframing is used in order to enhance the collaborative relationship. Homework is presented as an exercise in finding out what will happen rather than simply exercises in mastering a series of therapist-devised tasks. Early in treatment, emphasis is placed on the idea that, whatever the outcome of homework, the exercise will have been a useful one. Patients are told, ‘From time to time, people find the homework that has been set can be difficult. Sometimes, it is so difficult that it isn’t completed. If that ever happens, then that’s really important information, because it tells us a great deal about the kind of problems which you have. It would be particularly helpful if you could make careful notes on your homework sheet about what happened, what thoughts went through your mind and anything else which seemed important about the situation.’
Assessment factors
The cognitive hypothesis has implications for both the implementation and the focus of assessment. These two factors are examined in turn.
Problems encountered in implementing assessment
When attempting to assess obsessional problems one often encounters difficulties not found amongst other emotional disorders; often simply demonstrating an awareness of these problems in a matter-of-fact way is sufficient to change the patient’s belief in the acceptability of their thoughts. The message which is conveyed is: ‘OK, yes, I understand your worries about this. These are obsessional thoughts, I’ve dealt with them before lots of times, and they are not even slightly shocking to me. It’s common both to have the thoughts and the worries associated with them. Let’s sit down together, talk about them and get going with helping you deal with your problems.’
Content
By definition, the content of obsessional thoughts is unacceptable and often repugnant to the patient. Obsessional patients often believe that the thoughts reveal that they are unpleasant people; sometimes, that others (including their therapist) would criticise or reject them, or believe them to be insane. These beliefs are usually associated with considerable reluctance to describe their thoughts. Similarly, the thoughts may concern socially embarrassing subjects (e.g. contamination by faeces, urine, or seminal fluid). Obsessionals have often been described as being ‘of tender conscience’; the difficulty they may experience in describing their worries to a total stranger is apparent.
Effects of discussion
Some patients have obsessional fears that talking about the obsession may make it worse or more real, or even make them act out the thoughts.
34 COGNITIVE THERAPY IN CLINICAL PRACTICE
More specific concerns
Patients may have specific fears, such as the obsession being a sign of schizophrenia (implying immediate hospitalisation against their will). When the thoughts or impulses concern violence or other illegal or morally repugnant acts, patients often worry that the therapist will have them arrested.
Embarrassment
Patients with very severe problems (especially when extensive compulsive behaviour is involved) can be ashamed by the extent to which their obsessions are out of control, particularly as most patients regard obsessional thoughts as intrinsically senseless.
Chronicity
In chronic cases, the assessment and formulation is made more difficult by the habitual (‘overlearned’) nature of the behaviours. Compulsive behaviour and avoidance in such instances can become so extensive that the patient may have ceased to be aware of the underlying pattern of thinking and voluntary behaviours which pre-empt and mask obsessional thoughts, impulses, and images.
Cognitive techniques can be effectively employed to deal with these difficulties. The focus of these techniques is identification of cognitions which are making the assessment difficult, then helping the patient to find alternative responses. For example, a 37-year-old married woman with two children (3 and 7 years old) was referred. She complained of upsetting thoughts, the content of which she would not discuss with the referring psychiatrist. When she attended for assessment, she immediately apologised for wasting the therapist’s time, and began to cry.
P: I shouldn’t really be wasting your time.
T: It sounds like you had a really upsetting thought just now. P: Yes.
T: What went through your mind right then?
P: I thought that I must be a very bad patient because I can’t tell you about my problems.
T:Well, it’s interesting you should say that, because it seems to me that you have just told me one of your problems; I mean that you have a problem talking about your difficulties.
P: Yes, but that’s not my real problem.
T:Well, it sounds to me like it’s a real problem. Also, if you can solve the problem about talking about the difficulties that would mean that we could start to deal with your real problem?
P: I see what you mean.
T:OK, but my guess is that you might be able to tell me about the kind of thoughts you have when you try to talk about your problem. That would seem like a really good place to start.
P : [Laughs.] You’re right.
This brief initial interaction establishes a rapport with the patient, a focus on cognitive factors and how they affect the patient. Most important, it explicitly takes the pressure off the patient with respect to the need to disclose immediately the details of the problem. During the next few minutes, the therapist needs to build up the rapport already established.
T:I understand that it is often very difficult to discuss your problems with a complete stranger. In fact, it is actually a bit unusual if someone finds it easy. So, it’s difficult for you; are there any questions you want to ask me which might help
you feel a little easier? and/or:
T: Could you tell me a bit about the difficulties which you have with talking about your problem? P: I’m worried about what you might do, who you might tell.
T: You’re worried about how I might react when you tell me your problem? P: Yes. I worry that you might think I’m a terrible mother.
T: You worry that I might think you’re a terrible mother…because of the thoughts you have? P: Yes.
T:It might be helpful for you to know that you’re not the first person who has said that to me. In fact, I very often see people who have that worry; so far, it’s never even crossed my mind that any of the people concerned were terrible mothers. Usually, I think that they might be unhappy, and troubled by upsetting thoughts.
P: Other people have worries like this?