THE EVIDENCE BASED PRACTITIONER

Our ever-growing knowledge base for psychotherapy in general and CBT (and related therapies) in particular is the result of many decades of research on principles of human functioning and change. As a field, we have tested and found support for the benefits of teaching our clients skills such as: (1) planning and enacting behavioral activities that boost their sense of accomplishment, enjoyment, and connection, (2) approaching (rather than avoiding) uncomfortable situations that can improve their sense of self-efficacy and expand their life experiences, (3) being self-aware of physiological sensations in a way that allows for a reduction in hyper-arousal, (4) being self-aware of thoughts in a way that allows for cognitive flexibility and perspective-taking, (5) enacting problem-solving to reduce impulsivity and improve one’s life situation, (6) mindfulness, self-soothing and self-compassion methods to moderate dysregulated emotions and promote positive states of mind, (7) communication and assertiveness skills to improve interpersonal relationships, and others. These are categories of interventions in CBT that have produced so many positive outcomes across a range of clinical problem areas (Hayes & Hofmann, 2018).

            Therapists are trained to deliver the above (and related) interventions to their clients to meet their individual needs, and to teach their clients to self-apply psychological skills for long-term maintenance. Imparting these interventions is part of what is known as the “functional competencies” of therapists, to go along with such related competencies as possessing diagnostic and case conceptualization skills. It is also important for us to mention the “foundational competencies” of therapists that underlie the above, such as respect for the scientific method, alliance-building skills, self-assessment and self-correction, and cross-cultural humility  (Iwamasa & Hays, 2019), among others (see Newman, 2010).

            Now that we have briefly summarized the competencies of the CBT therapist, what do we mean by the term meta-competencies? Loosely defined, the term “meta-competencies” refers to those qualities or characteristics that therapists bring to bear on their interactions with clients that maximize the positive impact and staying power of the interventions so that clients find therapy to be memorable, inspirational, and a catalyst for further growth (Whittington & Grey, 2014).

            CBT takes a psycho-educational approach to psychotherapy, therefore it is apropos to consider the notion that to some extent therapists are in fact teachers. If we think back to our school days, we recognize that many teachers more or less competently followed a similar rubric (perhaps analogous to a therapy protocol), but some teachers were more memorable and positively influential than others (hence, they possessed greater meta-competencies). What were some of the qualities that those teachers exhibited that helped us not only to learn, but to value learning, and how can we relate these qualities to the meta-competencies of conducting CBT? We may hypothesize that the educational process works best when teachers challenge their students to think for themselves, while still offering guidance if the students struggle. Such teachers may be seen as somewhat demanding, but never demeaning, and they typically demonstrate confidence in their students’ capacity to learn, trying to instill in their students greater belief in themselves. These teachers bring life to the subject material through interesting stories, creative use of language, clarity of communication, and by encouraging lively dialogue on the subject at hand. They show genuine interest in what they are teaching – shown in part by their energy, engagement, and preparedness – and try to inculcate this level of interest in their students so they will want to continue to learn long after their coursework with the particular teacher in question is complete.

            We can see how the above readily relates to the tasks that comprise competency and meta-competency in CBT. We take an evidence-based set of procedures and deliver them with a keen understanding of the sensibilities and needs of the client, based in part on having done our homework about the client’s learning history, and in part by paying close attention to the client’s verbal and non-verbal reactions in session so that we are “in tune” with them. We serve as role models for thoughtfulness, composure, sincerity, self-reflection, and perseverance. We practice congruence by utilizing for ourselves the same psychological skills we endeavor to impart to our clients (Bennett-Levy et al., 2015). This not only improves our skill set through repetition, but provides us with enhanced empathy for the clients’ experiences in utilizing interventions, and boosts our hopefulness about therapeutic change because we undergo it ourselves.

            The following is a non-exhaustive list of the characteristics we may call meta-competencies – qualities that are not always mentioned in CBT treatment protocols but that play significant roles nonetheless. Some of these meta-competencies have an extensive and ever-growing evidence base (e.g., repairing ruptures in the therapeutic alliance), and some have considerably less of a data base (e.g., matters of timing in delivering interventions), but let us take a glance at some of these hypothesized factors just the same:

1.  Interweaving the therapeutic relationship with case conceptualization and interventions: The positive power of therapy is amplified when therapists can weave together their conceptual understanding of their clients’ background and current life situation into their manner of interacting with the clients in the here and now (thus being able to express accurate empathy), along with introducing and explaining interventions that fit the needs of the clients and make sense to them.
2. Juggling multiple lines of discussion across sessions and within sessions: For maximum breadth of coverage of relevant agenda items, therapists have to keep track of multiple topics, goals, and life circumstances of their clients. Therapists who areorganized, attentive, and adept at “connecting the dots” can address a broad range of client concerns, doing so without ever getting too far off track or losing sight of the central themes being addressed. Being prompt and thorough with clinical documentation assists this process.
3. Having an interdisciplinary fund of knowledge: When therapists have a range of personal interests, are well-read, are “students of life,” and learn from each of their clients, they continually improve their ability to connect with their clients by alluding to relevant subject material that clients find personally interesting and compelling (e.g., regarding current events, history, arts and literature, the substance of the client’s profession, the details of the client’s hobbies, the language and customs of the client’s culture, etc.).
4. Valuing self-reflection, self-correction, and personal growth: When therapists self-reflect on their work, this is considered a foundational competency in doing psychotherapy. When therapists value thoughtful self-reflection and self-correction as a way of life, it is a meta-competency that helps them develop and mature as human beings, which in turn assists them in their work (see Bennett-Levy et al., 2015).
5. Viewing ruptures in the therapeutic alliance as opportunities to do problem-solving. Being adept at forming and maintaining good therapeutic alliances is an important competency. Having a positive outlook about repairing alliance ruptures is a meta-competency whereby therapists model the valuable attitude, “We can work it out.” This meta-competency is related to the ability to demonstrate grace under pressure (Muran & Eubanks, 2020), as therapists may need to maintain a pleasant and hopeful demeanor even in the face of criticism and pessimism expressed by clients. Therapists who welcome the opportunities presented by doing interpersonal problem-solving will enhance both their own and their clients’ interpersonal resiliency and satisfaction.
6. Communicating clearly: Therapy is largely a verbal medium. Therapists express empathy, provide psycho-education, share their reflections and conceptualizations, and provide direction in how to implement a wide range of interventions. These are all important competencies in conducting therapy. What makes them meta-competencies is the therapist’s ability to be maximally comprehensible in communicating all of the above, so that clients more readily grasp and retain what the therapist is saying, without having to strain or otherwise work too hard to focus or keep track. Therapists who extensively read, write, and give academic presentations gain a lot of practice in being clear communicators.
7. Possessing a good sense of timing: Admittedly, this is subjective and difficult to measure. It can refer to the therapist’s cadence of verbal delivery such that what they are saying provides extra emotional emphasis (similar to the methods of skilled stand-up comedians, stage actors, and orators) or it can refer to knowing when to say something in particular, and when to wait.
8. Having facility in using metaphors, imagery, stories, and hypothetical questions to make the messages of therapy more vivid and compelling. Sometimes it is indeed the case that a picture (or a metaphor) is worth a thousand words (Hackmann et al., 2011; Stott et al.,  2010). Similarly, a lesson of therapy embedded in an interesting vignette can make a lasting impact, Likewise, thought-provoking hypothetical questions can maximize the power of guided discovery (Newman, 2000; Waltman et al., 2021).
9. Knowing how and when to use the best of your personality, including humor and judicious use of self-disclosure. It is a meta-competency when therapists are adept at “using themselves,” such as by having a knack for introducing good-natured mirth and irreverent humor into a session (Linehan, 1993), and perhaps by knowing how to appropriately share one’s own feelings and experiences in the service of bonding with clients and helping them feel better understood (Farber, 2006).
10. Having a good memory and using it in the service of creating continuity across sessions, and inspiring clients to remember the lessons of therapy in return. For example, when therapists remember what clients said many sessions ago, they serve as role models for clients to remember what their therapists have said. To make therapy more memorable, we can use methods of “memory support” (Harvey et al., 2016) and we can demonstrate that the clients themselves are memorable.

            The above-mentioned meta-competencies may be viewed as tied to the concept of “therapist effects,” referring to personal qualities and habits that make some therapists “better” than others, regardless of modality or theoretical orientation of the therapy being delivered (Castonguay & Hill, 2017). A key question is whether (and/or to what degree) these meta-competencies can be learned through formal training, and/or perhaps via personal growth endeavors (including going through therapy as clients) (see Whittington & Grey, 2014). These are intriguing questions, reminding us that maximizing the efficacy of our psychological treatments is inextricably tied to improving our capabilities as therapists in delivering these treatments.

References

Bennett-Levy, J., Thwaites, R., Haarhoff, B., & Perry, H. (2015). Experiencing CBT from the

inside out: A self-practice, self-reflection workbook for therapists. Guilford Press.

Castonguay, L. G., & Hill, C. E. (Eds.) (2017). How and why are some therapists better than

            others? American Psychological Association.

Farber, B. A. (2006). Self-disclosure in psychotherapy. Guilford Press.

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in cognitive

            therapy. Oxford University Press.

Harvey, A. G., Lee, J., Smith. R. L., Gumport, N. B., Hollon, S. D., Rabe-Hesketh, S., et al.

(2016). Improving outcomes for mental disorders by enhancing memory for treatment. Behaviour Therapy and Research, 81, 35-46.

Hayes, S. C., & Hofmann, S. G. (2018) (Eds.). Process-based CBT: The science and core

            clinical competencies of cognitive behavioral therapy. New Harbinger Publications.

Iwamasa, G. Y., & Hays, P. A. (Eds.) (2019). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). American Psychological Association.

Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder.

            Guilford Press.

Muran, J. C., & Eubanks, C. E. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.

Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational,

functional, and supervisory aspects. [For the Special Section on Psychotherapy Competencies and Supervision of Trainees]. Psychotherapy: Theory, Research, Practice, Training, 47(1), 12-19.

Newman, C. F. (2000). Hypotheticals in cognitive psychotherapy: Creative questions, novel

            answers, and therapeutic change. Journal of Cognitive Psychotherapy: An

            International Quarterly, 14(2), 135-147.

Stott, R., Mansell, W., Salkovskis, P., Lavender, A., & Cartwright-Hatton, S. (2010). Oxford

            guide to metaphors in CBT. Oxford University Press.

Waltman, S. H., Codd, R. T. III, McFarr, L. M., & Moore, B. A. (2021). Socratic questioning

            for therapists and counselors: Learn how to think and intervene like a cognitive

            behavior therapist. Routledge.  

Whittington, A., & Grey, N. (Eds.) (2014). How to be a more effective CBT therapist:

Mastering meta-competencies in clinical practice. Wiley Blackwell.

Kennedy Wong, Psy.D. 

Objective #1: Define Fear of Cancer Recurrence (FCR) and Its Impact on Psychological Well-Being

Fear of Cancer Recurrence (FCR) refers to the concern that cancer may return or progress (Lebel et al., 2016). It is a common worry for patients at any stage following diagnosis and can affect individuals across the cancer continuum, regardless of diagnosis or prognosis (Armes et al., 2009). In addition to FCR being a commonly reported symptom for any person affected by cancer, the prevalence is even higher among patients that are newly diagnosed, younger in age when entering survivorship, have a heightened risk perception, experienced severe treatment side effects, and have preexisting psychological conditions (Simard et al., 2013; Thewes et al., 2013). Caregivers also experience significant FCR, often with an impact similar to that of survivors (Smith et al., 2022). Addressing FCR is crucial, as reducing it can improve both psychological and functional outcomes for both patients and caregivers.

FCR can range from low, adaptive levels that motivate treatment adherence to high, clinical levels that cause significant distress and impair daily functioning (Butow et al., 2018). The Fear of Cancer Recurrence Inventory (FCRI) is one of the most frequently used, empirically validated measures to assess FCR. The short-form version of this assessment (FCRI-SF) is frequently used as a screening tool for FCR as well, given that it is a nine-item measure (Simard & Savard, 2009). Scores above 13 on the FCRI-SF suggest possible clinical levels, while scores above 22 indicate a need for intervention (Simard & Savard, 2009). In practice, it is important to help patients differentiate between normative FCR and distressing levels, addressing FCR at any stage. FCR is distinct from other mental health disorders, though it shares similarities with other diagnostic constructs in the DSM-V like illness anxiety disorder (Butow et al., 2018). It involves excessive worry about treatment-related side effects and a loss of trust in one’s health and one’s own body (Hall et al., 2019). Symptoms include intrusive thoughts, distressing emotions, and maladaptive behaviors like avoiding medical appointments or excessive reassurance-seeking (Hall et al., 2019; Luigjes-Huizer et al., 2022; Maheu et al., 2021). Survivors with FCR often seek more medical care, which can reinforce FCR and lead to unnecessary healthcare costs (Urquhart et al., 2025). Recognizing these features is essential for developing effective interventions for patients seeking therapy for these concerns. 

Objective #2: Explain the Cognitive Processing Model of FCR

Fardell and colleagues (2016) completed a systematic review to better understand the conceptualization of FCR. Several theoretical models explain FCR, each with strengths and weaknesses. The Self-Regulation Model (SRM) suggests that FCR arises when cancer is seen as a persistent threat but doesn’t fully address emotional distress or cognitive biases. The Cognitive-Behavioral Model (CBM) focuses on maladaptive thoughts and behaviors but doesn’t explain why some individuals are more vulnerable to FCR. Attentional Bias Models highlight excessive monitoring of cancer-related stimuli but overlook other factors like social support. The Emotional Processing Model suggests unresolved emotional distress fuels FCR but doesn't address cognitive or behavioral patterns. The Self-Regulatory Executive Function (S-REF) Model and Intolerance of Uncertainty Model focus on beliefs about worry itself but miss key aspects like threat perception. An integrated approach that combines cognitive, emotional, and behavioral mechanisms with social factors is likely most effective in addressing FCR in clinical settings (Fardell et al., 2016).

Fardell and colleagues (2016) proposed the Cognitive Processing Model (CPM) for FCR to address gaps in the existing theories identified in their review. This model integrates insights from various frameworks, suggesting that individual vulnerabilities—such as past losses, stressful experiences, and lack of information—shape the cancer experience, leading to existential challenges. These challenges influence emotional, behavioral, and cognitive coping mechanisms, which can either promote normal adaptation or heighten FCR. In cases of normal adaptation, distress and intrusive thoughts about cancer decrease over time, and concerns about recurrence, while persistent, don’t dominate daily life. Emotional responses like anxiety lessen, and behavioral and cognitive responses, such as medical check-ups and intrusive thoughts, remain balanced. For those with heightened FCR, information processing becomes maladaptive, with excessive worry, self-focus, and frequent self-examination. This Cognitive-Attentional Syndrome (CAS) includes attempts to control or avoid thoughts of recurrence, paradoxically maintaining distress. Metacognitive beliefs, such as “worrying prepares me for recurrence,” further reinforce worry, leading to chronic anxiety, distress, and depression. Behavioral patterns like excessive symptom-checking, reassurance-seeking, and persistent intrusive thoughts impair daily life (Fardell et al., 2016). This model informs future research and interventions, highlighting targets for cognitive-behavioral therapy (CBT) and other evidence-based approaches to reduce worry, improve emotional regulation, and promote adaptive coping strategies in the face of FCR.

Objective #3: Identify Evidence-Based Psychotherapy Interventions for Treating FCR

To address vulnerability factors in the Cognitive Processing Model of Fear of Cancer Recurrence (FCR), evidence-based practices can reduce susceptibility to heightened FCR (Fardell et al., 2016). A key vulnerability is the lack of information on health monitoring after a cancer diagnosis, leading to confusion about checking behaviors (Fardell et al., 2016). Integrated care, particularly the Collaborative Care Model (CoCM), can be tailored to address this vulnerability factor in the context of FCR (Johns et al., 2020). CoCM involves a multidisciplinary team, including primary care providers and behavioral health specialists, to deliver comprehensive mental health care alongside medical treatment. It has proven effective for managing anxiety and depression in cancer patients and can be tailored to screen and treat FCR (Johns et al., 2020). Routine mental health screening, such as the Fear of Cancer Recurrence Inventory Short Form (FCRI-SF), helps detect FCR early. A behavioral health manager can coordinate care, provide interventions, and facilitate communication between providers. Patients showing severe avoidance or reassurance-seeking behaviors should be referred for further psychotherapy. Engaging patients in treatment planning, normalizing FCR, and reinforcing strategies for health control—like regular medical checkups and healthy behaviors—are vital in the application of CoCM to screening for, identifying, and addressing FCR utilizing integrated care (Johns et al., 2020).

As previously stated in the key factors of the Cognitive Processing Model of FCR, caregiving roles and other sources of psychological stress can significantly increase vulnerability to FCR (Fardell et al., 2016). Many cancer patients who live at home require assistance with activities of daily living, basic medical care, social needs, and patient advocacy (Fardell et al., 2016). Research demonstrates that caregiver support plays a crucial role in meeting these needs and contributes to improved health outcomes for the patient (Fardell et al., 2016). However, it is important to recognize that caregivers themselves are also at risk for developing and experiencing FCR (Berry, Dalwadi, and Jacobson, 2017). The emotional, physical, and mental toll of caregiving can heighten their own distress, making them equally susceptible to fears about the patient’s health and future (Sklenarova et al., 2015). Therefore, implementing evidence-based treatments for caregivers within the context of cancer care is essential (Smith et al., 2022). These interventions not only help caregivers manage their own FCR but also reduce the vulnerability of the cancer patient by fostering a more supportive and resilient caregiving environment. One valuable resource that addresses caregiver challenges is the Caring for the Caregiver booklet provided by the National Cancer Institute. This free resource offers guidance and support, helping caregivers navigate their role while prioritizing their own well-being. The booklet validates and normalizes the emotional experiences of caregivers, acknowledging the stress, fear, and uncertainty they often face. It also provides practical strategies for seeking help, including ways to delegate household tasks while focusing on the patient’s care. Suggestions include asking for assistance with errands, childcare, meal coordination, and communication with extended family and friends regarding treatment updates. Additionally, the booklet offers key questions caregivers can ask the medical team, as well as information on support groups and other community resources. By addressing these challenges, caregivers can buffer the impact of vulnerability factors through self-care and personal resilience (Fardell et al., 2016; Smith et al., 2022). This concept aligns with the well-known “airplane oxygen mask” metaphor—caregivers must take care of themselves first in order to provide the best care for their loved one. The strategies outlined in this resource serve as a foundation for promoting caregiver well-being and reducing FCR.

Meaning-Centered Psychotherapy (MCP) is another therapeutic approach designed to help individuals find or rediscover meaning and purpose, particularly in the face of suffering, illness, loss, or aging (Breitbart et al., 2010). It addresses another key factor of the CPM of FCR: the impact of cancer-related stressors, which can lead to existential challenges such as feelings of despair and disconnection from sources of meaning (Fardell et al., 2016). The MCP approach is rooted in Viktor Frankl’s logotherapy which describes the search for meaning as a fundamental human drive. By fostering a sense of purpose, MCP can enhance well-being, build resilience, and offer comfort in adversity, ultimately helping to reduce or buffer against FCR symptoms (Mozafari et al., 2018). MCP interventions focus on several key areas to help individuals reconnect with meaning in their lives (Breitbart et al., 2010). These include exploring personal sources of meaning, such as relationships, work, spiritual beliefs, or personal values, and reframing challenges in a way that allows for a sense of growth and purpose. Existential reflection encourages individuals to deeply consider life’s purpose, core values, and how they can live meaningfully in the present. Legacy building helps individuals focus on how they wish to be remembered or contribute to others: both hold potential to reinforce a sense of purpose. Spiritual exploration, regardless of religious affiliation, allows for a deeper understanding of life’s meaning, while mindfulness practices promote engagement with the present moment. Life reflection exercises, such as journaling or guided conversations, help individuals recognize and appreciate the meaning derived from significant life experiences. Through these interventions, MCP provides a structured approach to addressing existential concerns, fostering resilience, and mitigating the psychological distress associated with FCR (Breitbart et al., 2010; Mozafari et al., 2018). 

In the context of heightened fear of cancer recurrence (FCR), individuals often exhibit maladaptive behavioral responses, such as excessive symptom checking, avoidance of cancer-related reminders, or frequent reassurance-seeking (Fardell et al., 2016). These behaviors can create a cycle that negatively reinforces anxiety and distress rather than alleviating them (Fardell et al., 2016). Emotionally, heightened FCR leads to persistent feelings of anxiety, distress, and even depression (Fardell et al., 2016). Several cognitive-behavioral therapy (CBT) techniques have been found to be effective in addressing these symptoms (Park & Lim, 2022). One such approach is adopting a response prevention mindset for reassurance-seeking behaviors. This involves understanding the reassurance-seeking cycle and implementing strategies such as cognitive refocusing or engaging in distractions when the urge arises to excessively check for symptoms or contact healthcare providers for reassurance. Behavioral activation is another useful intervention, particularly for combating depressive symptoms associated with heightened FCR, by encouraging engagement in meaningful and rewarding activities. Additionally, mindfulness-based approaches can help individuals develop a nonjudgmental acceptance of the natural emotions triggered by FCR while also creating space to challenge excessive or unhelpful worry (Hall et al., 2018). It is important to note that most research on CBT interventions for FCR has been conducted in the context of in-person, group treatment settings. However, these strategies anecdotally have been effective when utilized in one-on-one psychotherapy sessions by the current author, demonstrating their adaptability and usefulness in addressing the challenges associated with FCR.

Objective #4: Adapt and Apply Cognitive Restructuring to FCR in Psychotherapy

It is essential to recognize that FCR includes a very real and valid component—the realistic fear at the root of the worry given the person's prior lived experience (Butow et al., 2018). This presents a challenge when applying cognitive-behavioral therapy (CBT) interventions, such as cognitive restructuring, as the goal is not to dismiss or invalidate these fears but rather to help individuals manage them more effectively. To do so, cognitive techniques must be adapted to specifically target the underlying cognitive mechanisms that contribute to and maintain heightened FCR. 

According to the CPM of FCR, these underlying cognitive mechanisms include a problematic style of information processing known as the cognitive-attentional syndrome (CAS), a construct first described by Adrian Wells, Ph.D. in Metacognitive Therapy (MCT: https://mct-institute.co.uk/) for anxiety and depression. Fardell and colleagues (2016) write about MCT applications for FCR, including phenomena of excessive worry, self-focused attention, and frequent self-examination. In an effort to manage their fears those with FCR may attempt to control, avoid, suppress, or minimize thoughts about recurrence (Fardell et al., 2016). However, these strategies are paradoxically counterproductive, as they serve to maintain and even amplify distress. A key factor in this cycle is also the presence of unhelpful metacognitions—beliefs about worry that reinforce and perpetuate anxiety (Fardell et al., 2016). Common examples include “If I worry about cancer coming back, I will be prepared,”“I cannot stop these thoughts. Worry thoughts cannot be controlled,” and “My worry will prevent recurrence.” By addressing these thought patterns while acknowledging the legitimacy of the fear itself, CBT interventions can help individuals develop healthier, more balanced ways of processing their concerns without becoming overwhelmed by them (Butow et al., 2018). 

The goal of cognitive restructuring for FCR is to address the unhelpful cognitive mechanisms that contribute to or maintain heightened FCR without invalidating the legitimacy of the patient’s fears (Butow et al., 2018). The primary targets of this process include unhelpful beliefs about worry or metacognitions, rather than the FCR thoughts themselves. To effectively implement cognitive restructuring, it is crucial to consider a handful of adaptations. First, donot minimize the patient’s fears or attempt to provide reassurance based on their current health status (e.g., “Well, you’re in remission now, so everything will be okay!”). Additionally, donot directly challenge the accuracy of FCR thoughts, as this can invalidate the patient's experience and increase distress. Consider the use of validation as a therapeutic technique within sessions with patients endorsing FCR, drawing from principles in Dialectical Behavior Therapy (DBT). According to DBT, validation acknowledges and accepts a person’s emotions and behaviors, with six levels of validation guiding this approach (Linehan, 1987). In the context of FCR, levels four and five are particularly relevant: recognizing that a patient’s fear is understandable given their past experiences, learning history, or biological factors, and normalizing their feelings as a common response to their situation. 

On the other hand, when utilizing the tool of cognitive restructuring for patients with FCR, clinicians do want to identify unhelpful beliefs about worry (metacognitions) that heighten FCR, and work on challenging these beliefs rather than the FCR worry thoughts themselves. For example, instead of focusing on whether FCR thoughts are true, encourage patients to reflect on whether the act of worrying is truly helpful or influencing their situation for the better in any way (“Does worry help, or is it my actions that prepare me?”). Help patients develop coping statements or alternative responses to use when unhelpful beliefs arise, such as “Worrying or ruminating does not minimize my chances of recurrence. What helps me is engaging in health-related behaviors, including…” Encourage patients to actively engage with these coping statements throughout the day by writing them down or reading them aloud when distressed. 

Another key aspect to consider when adapting cognitive restructuring as a therapist working with patients endorsing FCR is the importance of promoting self-reliance. Do not enable patients to rely solely on external reassurance from providers or loved ones in an attempt to soothe their distress caused by FCR. Instead, empower patients to use emotion-focused coping strategies that help patients self-soothe and reduce their own experience of distress without trying to “problem solve” the worries away. Additionally, it is important to help patients recognize avoidance behaviors and build awareness of common triggers for acute increases in FCR thoughts so they can take a proactive approach to coping in situations where they are more likely to experience FCR thoughts arising. Encouraging increased engagement in values-based activities, a technique drawn from Meaning-Centered Psychotherapy (MCPT), Acceptance and Commitment Therapy (ACT), and DBT, can be a meaningful way to promote cognitive refocusing in the face of excessive worry. When patients are more aware of what can influence their own experience of FCR worry thoughts, they can be better equipped to proactively engage in self-soothing strategies, cognitive refocusing, or seeking social support to mitigate further increases in distress. Simple actions, such as calling a friend to ask about their day or volunteering to help someone else in a time of need, can shift attention away from excessive worry and promote emotional well-being. Through these techniques, patients can build resilience, develop effective coping mechanisms, and regain a sense of control over their fears.

In conclusion, Fear of Cancer Recurrence (FCR) poses significant challenges for cancer survivors and caregivers, impacting psychological well-being and functioning. Understanding FCR’s cognitive, emotional, and behavioral aspects is essential for effective interventions. The CPM offers valuable insight into how vulnerabilities and maladaptive coping mechanisms contribute to heightened FCR (Fardell et al., 2016). Evidence-based treatments, such as CBT, mindfulness, and MCP, provide pathways to alleviate distress. A holistic approach that validates the patient’s experience while equipping them with adaptive coping strategies is crucial. Support for caregivers is equally important, as their well-being directly impacts the patient’s recovery. By fostering resilience and adaptive coping, we can improve the quality of life for those navigating FCR.

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Maheu, C., Singh, M., Tock, W. L., Eyrenci, A., Galica, J., Hébert, M., Frati, F., & Estapé, T. (2021). Fear of cancer recurrence, health anxiety, worry, and uncertainty: A scoping review about their conceptualization and measurement within breast cancer survivorship research. Frontiers in Psychology, 12, 644932. https://doi.org/10.3389/fpsyg.2021.644932

Mozafari, S., Rahimian Boogar, I., Talepasand, S., & Ghahreman Fard, F. (2018). Effectiveness of Meaning-Centered Psychotherapy on existential anxiety and fear of cancer recurrence in breast cancer survivors: A randomized clinical trial. Women’s Health Bulletin, 5(1), 1–7. https://doi.org/10.5812/whb.13917

Park, S. Y., & Lim, J. W. (2022). Cognitive behavioral therapy for reducing fear of cancer recurrence among breast cancer survivors: A systematic review of the literature. BMC Cancer, 22, 217. https://doi.org/10.1186/s12885-021-08909-y

Simard, S., & Savard, J. (2009). Fear of cancer recurrence inventory: Development and initial validation of a multidimensional measure of fear of cancer recurrence. Supportive Care in Cancer, 17(3), 241–251. https://doi.org/10.1007/s00520-008-0444-y

Simard, S., Thewes, B., Humphris, G., et al. (2013). Fear of cancer recurrence in adult cancer survivors: A systematic review of quantitative studies. Journal of Cancer Survivorship, 7(3), 300–322. https://doi.org/10.1007/s11764-013-0276-x

Sklenarova, H., Krümpelmann, A., Haun, M. W., Friederich, H.-C., Huber, J., Thomas, M., Winkler, E. C., Herzog, W., & Hartmann, M. (2015). When do we need to care about the caregiver? Supportive care needs, anxiety, and depression among informal caregivers of patients with cancer and cancer survivors. Cancer, 121(10), 1513–1519. https://doi.org/10.1002/cncr.29223

Smith, A., Wu, V. S., Lambert, S., et al. (2022). A systematic mixed studies review of fear of cancer recurrence in families and caregivers of adults diagnosed with cancer. Journal of Cancer Survivorship, 16(6), 1184–1219. https://doi.org/10.1007/s11764-021-01109-4

Thewes, B., Bell, M. L., Butow, P. N., et al. (2013). Psychological morbidity and stress but not social factors influence level of fear of cancer recurrence in young women with early breast cancer: Results of a cross-sectional study. Psycho-Oncology, 22(12), 2797–2806. https://doi.org/10.1002/pon.3372

Urquhart, R., Kendell, C., & Lethbridge, L. (2025). Fear of cancer recurrence is associated with higher primary care use after cancer treatment: A survey-administrative health data linkage study. Supportive Care in Cancer, 33, 172. https://doi.org/10.1007/s00520-025-09242-x

U.S. Department of Health & Human Services, National Institutes of Health, & National Cancer Institute. (2024). Caring for the Caregiver (No. 24-6219). https://www.cancer.gov/publications/patient-education/caring-for-the-caregiver2024.pdf

Sandy Capaldi, PsyD - Center for the Treatment and Study of Anxiety

Excerpted and adapted from Capaldi, S., & Foa, E. B. (2025). Prolonged exposure therapy for adolescents with PTSD: emotional processing of traumatic experiences. In Evidence-Based Treatments for Trauma-Related Disorders in Children and Adolescents (pp. 271-290). Cham: Springer Nature Switzerland.

Prolonged Exposure therapy for adolescents with PTSD (PE-A; Foa et al. 2008) is an adaptation of the widely studied, empirically validated adult Prolonged Exposure (PE) protocol (Foa et al. 2019). Developed for and tested with adolescents ages 12-18, PE-A is a manualized, symptom-focused treatment designed to target PTSD symptoms in the aftermath of all types of trauma. The treatment consists of four key phases: pretreatment preparation, psychoeducation and treatment planning, exposures, and relapse prevention/treatment termination. Each phase is comprised of several modules that emphasize a specific therapeutic task or goal. While PE-A is delivered in an individual format, it remains flexible, allowing for the inclusion of parents or caregivers in portions of sessions. The structure accommodates varying session lengths and pacing, ensuring adaptability to the developmental needs of each adolescent. The typical course of treatment occurs over 10–15 weekly sessions lasting 60-90 minutes each.

Emotional Processing Theory

The treatment is grounded in cognitive-behavioral therapy and learning theory. Drawing from classical and operant conditioning paradigms, the theory behind PE was influenced by Mowrer's two-factor model of avoidance (Mowrer, 1960). In Mowrer’s model, fear is initially acquired through classical conditioning, reinforced through avoidance, and maintained through operant conditioning. Expanding on these ideas, Foa and Kozak (1986; Foa et al. 2006) integrated Lang’s (Lang, 1977) concept of fear structures, developing what has become known as emotional processing theory (EPT). EPT provides a framework for understanding the factors that contribute to the development and maintenance of post-traumatic stress symptoms, the mechanisms underlying natural recovery from these symptoms, and the amelioration of these symptoms via exposure treatments. EPT proposes that emotions like fear are represented in memory as an emotional structure which serves as a blueprint for action. This structure consists of three core elements: representations of the feared stimuli, corresponding fear responses, and the meanings associated with the stimuli and the responses. A fear structure becomes maladaptive when it incorporates inaccurate or exaggerated associations between the meanings associated with the stimuli and responses, leading to fear responses to harmless stimuli. For example, an adolescent who was bitten by a dog might generalize this fear to all dogs, avoiding them completely—even friendly ones—because they believe any dog poses a threat.

According to EPT, traumatic memories are structured emotional representations that encode the stimuli present during the trauma, the individual's emotional and physiological responses (e.g., fear, guilt, shame, freezing), and the meanings attributed to those experiences. In PTSD, the trauma memory contains an excessive number of stimuli erroneously linked to danger. For example, an adolescent who was sexually assaulted may associate related but harmless stimuli, such as men with similar builds as the perpetrator or small, enclosed spaces, with the meaning of danger. As a result, individuals with PTSD are likely to perceive the world as entirely dangerous. In addition, representations of the individuals’ responses during and following the trauma often become associated with the meaning of incompetence (e.g., “I failed to protect my friend”; “My PTSD symptoms mean I am weak”). These two perceptions – that the world is entirely dangerous and the person is very incompetent – serve to maintain PTSD symptoms.

PTSD symptoms often emerge immediately after a traumatic event, but for many individuals, these symptoms naturally diminish over time without intervention. EPT suggests that natural recovery occurs through repeated exposure to trauma-related memories, emotions, and situations in daily life. Engaging with these reminders—whether by discussing the trauma, reflecting on associated emotions, or encountering related environments—provide information that disconfirms the perception that the feared stimulus is dangerous. For individuals who develop PTSD, however, avoidance of trauma-related thoughts, feelings, and situations impedes activation of the trauma memory and integration of disconfirming information that would alter the pathological elements in the fear structure. To counteract this, treatment is designed to approach the safe but feared situations to allow the opportunity to experience the absence of negative consequences, which reduces or eliminates the two perceptions that help to maintain PTSD symptoms – that the world is entirely dangerous and the person is very incompetent.

For example, if an adolescent girl who experienced a vicious dog attack avoids all dogs, she never learns that most dogs she might encounter are actually safe. Additionally, by avoiding thinking about what happened, this adolescent’s memory will often remain fragmented and poorly articulated, and the erroneous perception that she may have been responsible for the attack will remain unquestioned. The adolescent’s avoidance behaviors are negatively reinforced because they temporarily reduce distress and so become habitual in similar circumstances. If she sees a dog approaching her on the street and quickly crosses to the other side, she experiences immediate relief. If she begins to think about the attack, becoming highly distressed, and immediately pushes those thoughts away or tries to distract herself, she may also experience relatively quick relief. However, while avoidance reduces distress in the short term, it perpetuates PTSD by blocking experiences that would otherwise modify the pathological elements in the fear structure. In our example, this adolescent girl does not get the opportunity to learn that the dog could have been safe (because she avoided it) or to learn that she is not to blame for the attack (because she does not allow herself to think about it).

Learning about the relative safety of trauma-related situations and memories and the relative competence of the individual who experienced the trauma is achieved for many individuals who do not develop PTSD through natural recovery. In essence, natural recovery includes approaching trauma-related triggers in daily life so that learning can occur. Effective PTSD treatment modifies the pathological elements of the fear structure and reduces pathological reactions by simulating natural recovery. In order to achieve this, two conditions are necessary. First, the fear structure must be activated (i.e., feared stimuli must be approached). Second, new information that is incompatible with the unrealistic elements (i.e., the feared stimuli is not dangerous) must be available and incorporated. When this new learning (or emotional processing) takes place, stimuli that used to evoke pathological responses will no longer do so.

PE-A aims to promote emotional processing by encouraging adolescents to talk about the trauma, referred to as revisiting and recounting the trauma memory (imaginal exposure), and to approach objectively safe situations that are trauma reminders, referred to as real-life experiments (in vivo exposure). By deliberately confronting safe but avoided trauma-related thoughts, feelings, and situations, the pathological fear structure is activated, and erroneous elements are modified through corrective experiences. Repeatedly recounting the traumatic memory reduces the anxiety associated with thinking about the trauma, provides opportunities to organize and better understand what happened, and helps the adolescent to explore and disconfirm other erroneous perceptions (e.g., that the adolescent’s actions mean he/she is incompetent or at fault for the trauma). Confronting trauma reminders and situations that are erroneously perceived as dangerous via real-life experiments reduces PTSD symptoms by breaking the habit of avoidance, promoting recognition that these situations are not harmful, and increasing the adolescent’s confidence in his or her ability to cope.

Research Evidence

Research on Prolonged Exposure Therapy for Adolescents (PE-A) has demonstrated its effectiveness in treating PTSD and superiority to active comparison treatments in multiple randomized controlled trails (RCTs).

• PE-A vs. Time-Limited Dynamic Psychotherapy (TLDP): In Gilboa-Schechtman et al.’s (2010) RCT, adolescents (ages 12–18) with PTSD stemming from a single-event trauma (n = 38) were randomized to receive either PE-A or TLDP. Results showed that 73.7% of PE-A participants achieved good end-state functioning compared to 31.6% in TLDP. Furthermore, 68.4% of adolescents in the PE-A group no longer met criteria for PTSD post-treatment, compared to 36.8% in TLDP. These improvements were sustained at 6- and 17-month follow-ups.
  
  
• PE-A vs. Client-Centered Therapy (CCT): This RCT (Foa et al., 2013) assessed adolescent females (ages 13–18) with PTSD related to sexual abuse (n = 61) who sought treatment in a community mental health setting. PE-A led to greater reductions in PTSD and depression symptoms, as well as enhanced global functioning compared to CCT. At post-treatment, 83.3% of adolescents receiving PE-A no longer met PTSD criteria, versus 54% in the CCT group. These gains persisted at 12-month follow-up.
  
  
• PE-A vs. Supportive Counseling (Delivered by Psychotherapy-Naïve Nurses): In this RCT, Roussouw et al. (2018) examined PE-A’s effectiveness among adolescents (ages 13–18) with chronic PTSD due to interpersonal trauma (n = 63) in South African schools. The PE-A group showed more significant PTSD and depression symptom reductions and improved global functioning compared to those receiving supportive counseling. By post-treatment, 80% of PE-A participants no longer met PTSD criteria, compared to 48% in the counseling group. These results remained stable at 12- and 24-month follow-ups (Roussouw et al., 2022). Notably, this study demonstrated that psychotherapy-naïve nurses could successfully deliver PE-A with fidelity, reinforcing its potential for broad implementation, particularly in low- and middle-income countries.
  
  
• Impact on behavioral symptoms & suicidal ideation: Utilizing data from Foa et al. (2013), Zandberg et al. (2016) found that adolescents treated with PE-A exhibited greater reductions in externalizing symptoms, including rule-breaking, aggression, and conduct problems, compared to those receiving Client-Centered Therapy (CCT). Additionally, Brown et al. (2020) observed that suicidal ideation decreased more rapidly in adolescents who underwent PE-A than in those randomized to CCT.
  
  
• Therapeutic alliance and treatment outcomes in PE-A: Process-focused research has highlighted the importance of therapeutic alliance in PTSD recovery. Capaldi et al. (2016) analyzed data from Foa et al. (2013) and found that adolescent-rated alliance improved more in PE-A than in CCT, with stronger alliance associated with better treatment outcomes across both therapies. These findings challenge concerns that exposure-based interventions might disrupt therapeutic relationships, demonstrating that symptom-focused trauma work can enhance alliance rather than hinder it.
  
  
• Mechanisms of change in PE-A: Studies examining the underlying processes in PE-A suggest that modifications in trauma-related cognitions play a central role in symptom relief. McLean et al. (2015) found that changes in negative trauma-related beliefs mediated reductions in both PTSD and depression symptoms. Later research (McLean et al., 2017) reinforced this connection, showing that PTSD symptom reductions during PE-A led to subsequent decreases in depressive symptoms.
  
  
• Exploratory research on “intensive” PE-A:
• Hendriks et al. (2017) examined a five-day intensive PE-A program for adolescents (ages 12–18) with PTSD and comorbid disorders stemming from multiple interpersonal traumas. The model consisted of 15 PE-A sessions in five days, followed by three weekly booster sessions. Findings indicated significant reductions in PTSD, depression, anxiety, and dissociation symptoms from pre- to post-treatment, with no dropouts or adverse events, suggesting potential benefits for treatment retention.
  
  
• Tijsseling et al. (2024) conducted a trial examining an intensive PE-A format that included four half days of treatment per week for two weeks and included 90 minutes of PE-A and 90 minutes of EMDR each day. Results indicated PTSD remission rates of 58%–62% and decreases in PTSD severity compared with baseline, with treatment effects maintained at 1-month and 3-month follow-ups and a dropout rate of 13%.
  
  
• Rentinck et al. (2025) investigated an intensive treatment format that consisted of six treatment days, divided into three treatment days per week, for two consecutive weeks and included 90 minutes of PE-A and 90 minutes of EMDR each day. Findings showed a significant reduction in PTSD symptoms (Cohen’s d = 1.66) and depressive symptoms (Cohen’s d = 1.02) from pre-treatment to one month after treatment, with 70% (n=52) showing a clinically meaningful response, and 65% (n=48) no longer meet the PTSD criteria one month after treatment. Dropout was 4% (N = 3) and no adverse events or worsening of symptoms were observed.

These findings underscore PE-A’s effectiveness and adaptability across different populations and settings, making it a vital evidence-based intervention for adolescents with PTSD. Research on PE-A has expanded beyond its core effectiveness to examine secondary outcomes and treatment processes as well.

While existing studies support PE-A as an effective intervention, further research is warranted to refine its implementation. Larger-scale randomized clinical trials comparing PE-A with other evidence-based PTSD treatments in adolescents are needed. Future research should also explore cultural adaptations, mechanisms driving symptom change, and predictors of treatment success and failure to optimize outcomes. Although additional studies are necessary, current evidence strongly supports PE-A as a first-line treatment for adolescent PTSD

Brown LA, Belli G, Suzuki N, Capaldi S, & Foa EB. (2020). Reduction in suicidal ideation from prolonged exposure therapy for adolescents. Journal of Clinical Child & Adolescent Psychology, 49(5), 651-659. https://doi.org/10.1080/15374416.2019.1614003

Foa EB, Chrestman K, & Gilboa-Schechtman E. (2008) Prolonged exposure therapy for adolescents with PTSD: Emotional processing of traumatic experiences. Oxford University Press.

Foa EB, Hembree EA, Rothbaum BO, & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences - therapist guide, 2nd edition. Oxford University Press.

Foa EB, Huppert JD, & Cahill SP. (2006). Emotional processing theory: an update. In: Rothbaum BO (ed) Pathological anxiety: emotional processing in etiology and treatment (pp. 3–24). Guilford Press.

Foa EB & Kozak MJ. (1986). Emotional processing of fear: exposure of corrective information. Psychological Bulletin, 99, 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Foa EB, McLean CP, Capaldi S, & Rosenfield D. (2013). Prolonged exposure vs. supportive counseling for sexual abuse-related PTSD in adolescent girls: a randomized controlled trial. JAMA, 310, 2650–2657. https://doi.org/10.1001/jama.2013.282829

Gilboa-Schechtman E, Foa EB, Shafran N, Aderka IM, Powers MB, Rachamim L, Rosenbach L, Yadin E, & Apter A. (2010). Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1034–1042. https://doi.org/10.1016/j.jaac.2010.07.014

Hendriks, de Kleine, RA, Heyvaert, M, Becker, ES, Hendriks, GJ, & van Minnen, A. (2017). Intensive prolonged exposure treatment for adolescent complex posttraumatic stress disorder: a single-trial design. Journal of Child Psychology and Psychiatry and Allied Disciplines., 58(11), 1229–1238. https://doi.org/10.1111/jcpp.12756

Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior Therapy, 8(5), 862–886. https://doi.org/10.1016/S0005-7894(77)80157-3

McLean, CP, Su, Y, Carpenter, JK, & Foa, EB. (2017). Changes in PTSD and depression during prolonged exposure and client-centered therapy for PTSD in adolescents. Journal of Clinical Child & Adolescent Psychology, 46(4), 500-510, https://doi.org/10.1080/15374416.2015.1012722

McLean, CP, Yeh, R, Rosenfield, D, & Foa, EB, Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents, Behaviour Research and Therapy, 68, 64-69. https://doi.org/10.1016/j.brat.2015.03.008

Mowrer, OH. (1960). Learning theory and behavior. John Wiley & Sons Inc. https://doi.org/10.1037/10802-000

Rentinck, E. M., van Mourik, R., de Jongh, A., & Matthijssen, S. J. M. A. (2025). Effectiveness of an intensive outpatient treatment programme combining prolonged exposure and EMDR therapy for adolescents and young adults with PTSD in a naturalistic setting. European Journal of Psychotraumatology, 16(1). https://doi.org/10.1080/20008066.2025.2451478

Rossouw, J., Yadin, E., Alexander, D., & Seedat, S. (2018). Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: Task-shifting randomised controlled trial. The British Journal of Psychiatry, 213(4), 587-594. https://doi.org/10.1192/bjp.2018.130

Rossouw, Yadin, E., Alexander, D., & Seedat, S. (2022). Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: a task-shifted intervention. Psychological Medicine., 52(6), 1022–1030. https://doi.org/10.1017/S0033291720002731

Tijsseling, I., Noordende, A. T. V. T., Zijlstra, B. J., Merbis, M., & Veen, S. C. V. (2024). The Effectiveness and Tolerability of an Intensive Outpatient Trauma Treatment Program for Adolescents With PTSD. Journal of EMDR Practice and Research, 18(2), 68-81.

Zandberg, L, Kaczkurkin, AN, McLean, CP, Rescorla, L, Yadin, E, & Foa, EB. (2016). Treatment of adolescent PTSD: The impact of prolonged exposure versus client-centered therapy on co-occurring emotional and behavioral problems. Journal of Traumatic Stress, 29(6), 507–514. https://doi.org/10.1002/jts.22138

William Kuyken, PhD - University of Oxford

Hiking in the Lake District of England, I stopped for lunch in a cemetery. There was a headstone with a name and this simple inscription: “A Life Well Lived.” What does a life well lived look like? It’s a question that we’ve all asked in one form or another. It’s been a question that has been asked for millennia by artists, from musicians, painters, dancers, sculptors to rappers, philosophers, contemplatives, and poets. What does mindfulness have to do with this?

Mindfulness: Three Keys to Living Well

Mindfulness offers three keys that can help unlock a life well lived (Feldman & Kuyken, 2019).

Key 1: Befriending Your Mind

“My mind can be my worst enemy or best friend," said Raheem Sterling, a young English soccer player. Sterling is known for inspiring others through his work ethic, for his family values, and for raising awareness of important social issues. He meditates because it helps him befriend his mind, which in turn helps him with his sport, mental health, and wider work.

What does friendship mean to you? What words or phrases best describe your friendships? What does a good friend do for you—now and over years, through the good and the bad patches of your life?

I’ve posed these questions to hundreds of people in workshops around the world, and here is what people said most often.

“Mindfulness is about our mind being and becoming our best friend.”

Does your idea of a good friend describe how you feel about your own mind? Maybe you already talk to yourself in affirming ways, with messages like “You’ve got this,” Steady,” “Take a breath,” “I’ve got your back; it will be okay.”  Or maybe the voice you use with yourself is critical--“I can’t do that”--or demanding: “I don’t have time.” If you already have a sense of your mind as a friend, you can always develop that friendship further. You can choose to befriend your mind, so it becomes as practiced and natural as putting on your shoes before you go out.  If you don’t feel like your mind is your friend, you’ll learn in the following pages how to change that, whatever challenges it throws up and amid whatever life circumstances you’re in.

Key 2: Using Your Values as Your Compass

Certain ideas and values have become mainstream:

• I measure myself by how much I get done, what I'm bringing in, whether it's on a personal level or for the greater good, sort of like my "Gross Domestic Product.”
• I put myself first because it is a dog-eat-dog world.I've got to always be on point – you know, look amazing, stay youthful, stay in shape, be attractive, and show that I'm making it in life.
• If I let my guard down, I’ll get taken advantage of.
• Busyness is good.
• Being tough is good; being kind is soft.
• Being in the spotlight, that's what gives my life meaning. I'm this close to striking it rich, if only I can score the perfect job, hit that jackpot, blow up as an influencer, or just start hanging with the right crowd.

From an early age, we feel pressure to have an opinion--about who we are, other people, what we like and don’t like, our favorite this or that, what we want to do when we grow up. We may claim certain “values” just to avoid uncertainty or to avoid feeling ashamed of not knowing what our values are. With all the pressure on us to do well, be better, achieve, prove we deserve our place in the world, or look a certain way, we may simply adopt prevalent ideas without question. When we do, we may end up pursuing someone else’s vision for our life. Of course productivity is necessary, but few people at the end of their lives look back and say, “I had a good life because I was productive and successful in this dog-eat-dog, getting-ahead world.” And if they do, did it make them and the people around them happy? Ask yourself right now what makes you happy.  What or whom do you care most about? What are you passionate about?  No need to overthink, just note what comes up, then let it go and see what else comes up. And don’t worry if not much arises; that’s fine too.

Your answers to these questions of what matters most point to your values. We’re all different, and an important part of living well is knowing what’s meaningful to us.

Here are some of the values that people often mention.

Wherever you are, whatever you’re doing, your values, like a compass, point you in the right direction.

Values are at the root of mindfulness; they guide how we are in the world and what we say and do. And just as important, they guide what we don’t say or do. If family is a foundational value, this shapes choices and even lives. Faith provides a set of values that can provide a sense of belonging and meaning. Everyone’s story involves learning a set of values. My father has a strong work and family ethic, developed in very difficult circumstances when he found himself the “man of the family” as a young boy interned in a concentration camp with his mother and younger sisters and brother. Throughout his life he provided selflessly for his family through hard work. I know he regarded the savings he left behind to provide for my mother and my sisters and me a key part of his life work. 

These three keys of mindfulness together bring to life how your values can be your sense of direction, your compass, the route map on your phone. Your role is to explore your values and how they can guide you. To embrace your values and be courageous enough to value what is truly important. The landscape of our lives, our family, our school, workplace, community, planet is created by human minds and hearts. It can be tempting to retreat to routine, to where we feel safe, to what we know. But try asking, “Is this enlarging and in line with my values or reassuring but ultimately diminishing?” Enlarge your mind, your relationships, your life, your sense of what is possible in the world. Seek out what enlarges you, whatever that is. It may be people in your life, sport, art, a favorite phrase, or an idea. Who and what enlarges you? Can they be what protects you, vitalizes you, and gives you a sense of purpose?

Key 3: Waking Up and Paying Attention

There are a lot of pulls on our attention, and this can give us a sense of being fragmented. With all the demands on us, it’s easy to react by checking out and sleepwalking through life. Zoning out can be comfortable, but there are many good reasons to live with a sense of being fully awake.

Leading the life we want means waking up and paying attention.

Attention is one of your most important resources (McGilchrist, 2023). What you focus on shapes what you think, your decisions, what you feel, and ultimately, your reality. It's like the spotlight that illuminates certain conversations, people, successes, problems, feelings, while leaving others in the shadows (Jha et al., 2007). How much of today have you been awake? I don’t mean awake literally; I mean awake in the sense of feeling alive. Twenty-five percent, 50 percent, most of the day? In the pages ahead you’ll find ways you can learn to pay attention to how you spend your days - and the moments of each day. Every moment is already here, waiting for you to pay attention to it. In a sense you don’t need to do anything differently. It is more of an adjustment in how you approach your day, choosing to pay attention, on purpose, with attitudes of curiosity and friendliness.

When you’re guided by your values, you befriend your mind, and you live with awareness, you focus on what matters, and your deepest values and daily life come together in a way that feels whole. Vulnerability can align with strength, kindness can be a force for positive change, compassion can be tough, and love can seep into and out from the people in your life.

Extracted from my 2024 book Mindfulness for Life (Kuyken, 2024): The Mindfulness for Life curriculum (Kuyken, 2024), is based on ancient wisdom, modern psychology (Feldman & Kuyken, 2019) and the essential structure of mindfulness-based stress reduction (Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (Segal et al., 2013; Teasdale et al., 2003).

Feldman, C., & Kuyken, W. (2019). Mindfulness: Ancient wisdom meets modern psychology. Guilford.

Jha, A. P., Krompinger, J., & Baime, M. J. (2007). Mindfulness training modifies subsystems of attention [Article]. Cognitive Affective & Behavioral Neuroscience, 7(2), 109-119. https://doi.org/10.3758/cabn.7.2.109

Kabat-Zinn, J. (1990). Full catastrophe living: how to cope with stress, pain and illness using mindfulness meditation. Delacorte.

Kuyken, W. (2024). Mindfulness for Life. Guilford Press.

McGilchrist, I. (2023). The Matter With Things: Our Brains, Our Delusions, and the Unmaking of the World. Perspectiva.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression. (Second edition ed.). Guilford Press.

Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness training and problem formulation. Clinical Psychology-Science and Practice, 10(2), 157-160. https://doi.org/Doi 10.1093/Clipsy/Bpg017

Gabriele Wilz, PhD - Friedrich-Schiller-Universität (Friedrich Schiller University Jena)

“Anger is completely normal” – Emotion regulation and stress management for family caregivers of people with dementia

The extreme demands of family caregiving

People who care for a family member with dementia face an abundance of complex, challenging, and time-consuming demands. Caregivers support care recipients with the activities of daily life (e.g., household management; assistance with food and fluid intake; personal hygiene, especially for incontinence; visiting public authorities, attending doctor visits). Caregivers also work to provide a supportive socioemotional context for the care recipient through, for example, conversation and activities. Caregivers also manage the behavioral and psychological symptoms of dementia, such as orientation disorders, confusion, self-threatening behavior, or personality changes. Caregivers often find managing the behavioral and psychological symptoms especially challenging; the care recipient’s behavioral and psychological symptoms are stronger predictors of the caregiver’s well-being and institutionalization of the care recipient than the care recipient’s functional or cognitive impairments, the number of caregiving tasks, or duration of care (Coen et al., 2002; Perren et al., 2006).

The challenges of caring for a family member with dementia are often compounded by number of factors. For instance, caregiving tasks are constantly evolving as the person’s dementia progresses. Caregivers are often working or taking care of their children at the same time that they are providing care. Sleep deprivation, social isolation, lack of leisure time, and loss of personal freedom can further increase stress. Given these multifaceted demands and constraints, it is unsurprising that family caregivers are more likely to experience depressive symptoms and anxiety (Collins & Kishita, 2020; Kaddour & Kishita, 2020), lower quality of life (Kurz & Wilz, 2011), and physical morbidity (Cheng et al., 2017) than their non-caregiving peers.

Anger, rage, and aggression

Family caregivers sometimes react to the extreme demands of caregiving with anger, rage and unintentional aggression. The experience of such strong, negative emotions and impulses can set a vicious cycle in motion. Caregivers feel ashamed or guilty, especially when they have acted out aggressively toward the person with dementia. They reproach themselves for their emotions and lack of self-control. They may feel depressed or anxious about their ability to control their own impulses, doubt their caregiving competence, and ultimately lose self-esteem. The negative feelings and self-blame add to the burden of caregiving, thereby increasing the likelihood that the caregiver will react to challenging situations with anger, rage and aggression.

Caregivers’ anger and subsequent self-reproach can also have serious negative consequences for care recipients. Highly-burdened family caregivers and family caregivers who doubt their competence are more likely to act abusively toward the care recipient (Fang et al., 2019; Karrasch, 2008; Välimäki et al., 2020; Konopik et al., 2022; Sasaki et al., 2007; Stall et al., 2019). In fact, elder abuse and especially psychological violence (typically unintended) frequently occur in high-burden informal caregiving situations. About 5% of caregivers report at least one incidence of physical violence (e.g., shaking or hitting the care recipient); far more report losing patience or lashing out verbally.

In light of its negative impact on caregivers as well as care recipients, addressing anger should be an integral part of psychotherapy with family caregivers (Wilz, 2024). Specifically, therapists and caregivers should work together to reduce caregivers’ anger and impulsive reactions, but also foster caregivers’ acceptance of burdensome emotions in situations that cannot be changed.

Psychotherapeutic strategies for reducing anger, improving emotion regulation, and fostering acceptance

An important aspect of working with family caregivers is de-pathologizing anger and aggressive impulses. Clarifying that it is normal to experience negative emotions and impulses in challenging, stressful situations usually has an immediate, alleviating effect. Family caregivers are relieved to learn that other family caregivers have similar emotions and impulses. Family caregivers should have the opportunity to openly discuss incidences of aggression. Therapists should communicate that aggression is understandable, but also clearly undesirable and avoidable. Family caregivers should be encouraged to reflect on how aggressive reactions can be prevented in the future.

Often family caregivers do not know what to do with their negative emotions; they lack an outlet for their anger. Caregivers should therefore be encouraged to vent and act out their anger in therapy sessions. Crying, screaming, or physical exercises can relieve tension and help caregivers manage stress. It should be noted, however, that this “acting out” of anger should not occur in the presence of the care recipient, as people with dementia can be overwhelmed by the expression of strong negative emotions.

The therapist and family caregiver should also work together to develop strategies to defuse acute feelings of anger. Being able to distance themselves from their emotions can help caregivers analyze a situation more clearly. The therapist and family caregiver should therefore identify how the individual caregiver can distance themselves and “cool down” in acute problem situations (e.g., leaving the room, going for a walk) (Kaluza, 2015). The therapist and caregiver then analyze the extent to which specific problem situations could be improved. Caregivers must have a degree of emotional detachment in order to make this decision. Behavior and situation analyses can be used to analyze the highly stressful situation in more detail and find out strategies for dealing with them constructively. When the caregiver recognizes that it would be possible to improve the situation, the therapist can use problem-solving training to identify and assess potential courses of action.

Some stressful aspects of the caregiving situation cannot be changed, such as the care recipient’s recurring challenging behavior. Therapeutic work should thus not only to address how the caregiving situation could be improved, but also foster caregivers’ acceptance of negative thoughts and emotions in situations that cannot be changed. Here acceptance means perceiving and experiencing negative thoughts and feelings without trying to change or avoid them. There is robust empirical evidence that trying to avoid negative emotions is counterproductive. Research has shown, for instance, that suppressing negative emotions is associated with lower well-being, lower interpersonal functioning, and lower positive affect (Gross & John, 2003). Caregivers who tend to deny or avoid their negative emotions have higher levels of emotional distress (Spira et al, 2007) and higher mean arterial pressure (an indicator of physiological stress; Losada et al., 2014). In contrast, family caregivers of people with dementia with more functional thoughts regarding acceptance have lower depression, anxiety, and grief, and higher psychological quality of life (Risch et al., 2022; Wrede et al., 2024). Working with caregivers to improve their acceptance of negative emotions that cannot be changed can therefore help them maintain their health and well-being. Strategies from acceptance and commitment therapy (e.g., Hayes et al., 2008) are particularly helpful for decreasing caregivers’ experiential avoidance, that is, the tendency to avoid unchangeable aversive emotions, sensations or thoughts (Risch et al., 2024).

Finally, therapists and caregivers should work together to reduce the caregiver’s general level of tension. Relaxation exercises and addressing how the caregiver can pursue valued activities within the constraints of the caregiving situation can help caregivers to reduce stress over the long-term, and thereby lessen the likelihood of anger, rage and impulsive reactions.

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Collins, R. N., & Kishita, N. (2020). Prevalence of depression and burden among informal care-givers of people with dementia: a meta-analysis. Ageing & Society, 40(11), 2355-2392.

Fang, B., Yan, E., & Lai, D. W. L. (2019). Risk and protective factors associated with domestic abuse among older Chinese in the People’s Republic of China. Archives of Gerontology and Geriatrics, 82, 120-127.

Gross, J.J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348−362.

Hayes, S. C., Luoma, J., & Walser, R. D. (2008). Handbuch der Acceptance & Commitment-Therapie. Junfermann.

Kaddour, L., & Kishita, N. (2020). Anxiety in Informal Dementia Carers: A Meta-Analysis of Prevalence. Journal of Geriatric Psychiatry and Neurology, 33(3), 161-172.

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Spira, A. P., Beaudreau, S. A., Jimenez, D., Kierod, K., Cusing, M. M., Gray, H. L., & Gallagher-Thompson, D. (2007). Experiential Avoidance, Acceptance, and Depression in Dementia Family Caregivers. Clinical Gerontologist, 30(4), 55-64.

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Wrede, N., Töpfer, N. F., Risch, A. K., & Wilz, G. (2024). How do care-related beliefs contribute to depression and anxiety in family caregivers of people with dementia? Testing a cognitive vulnerability-stress model. Aging & mental health, 1–9.

Gabriele Wilz, PhD - Friedrich-Schiller-Universität (Friedrich Schiller University Jena)

People caring for an older family member, or a family member with dementia, are at high risk for developing health impairments such as exhaustion and depressive symptoms (Collins & Kishita, 2019; Kaddour & Kishita, 2019). As the population ages and caring for a family member becomes more and more common, there is an urgent need to bolster family caregivers’ (CGs) resilience. There is robust evidence that psychotherapeutic interventions can effectively improve family CGs mental health and quality of life (Cheng et al., 2019; Toepfer et al., 2021). A primary focus of psychotherapy with family caregivers should be addressing CGs dysfunctional and functional thoughts about caregiving (Risch et al., 2022; Wilz, 2023).

Cognitions Moderate the Experience of Caregiving

The family caregiving situation can certainly be characterized as a chronically and highly demanding situation. Nevertheless, people react to the demands of caregiving very differently. Some people experience caregiving as manageable or even rewarding, while other people suffer intensely. How a person experiences caregiving depends to some extent on their own, subjective appraisals and evaluations of the situation. According to the transactional stress model (Lazarus & Folkman, 1984) and generic cognitive models of depression and mental diseases (Beck & Haigh, 2014), cognitive appraisal processes play a decisive role in how people react to stressful situations and the formation of mental illness. Likewise, family CGs automatic thoughts and attitudes are seen as key determinants of their ability to contend with the strains (Risch et al, 2022; Losada, Montorio et al., 2006) and experience the positive aspects (Yu et al., 2018) of caregiving.

As Losada, Montorio, and colleagues (2006) describe, there are pathological and healthy cognitive pathways in caregiving. Dysfunctional thoughts and attitudes, such as perfectionism, unrealistic goals and standards, and irrational interpretations of the care recipient’s behavior are common (Risch et al., 2022). Among family caregivers, dysfunctional cognitions are strongly associated with the perceived burden of caregiving (Vázquez-Sánchez et al. 2012), physical and mental stress (Losada et al., 2011; McNaughton et al., 1995; Sullivan et al., 2016) and depression (Márquez-González et al., 2007; McNaughton et al., 1995). Moreover, CGs dysfunctional cognitions can elicit a negative emotional response towards the care recipient, which in turn can instigate a negative cycle of problematic interactions between the caregiver and care recipient (Losada, Montorio, et al., 2006). In contrast, caregivers who have functional cognitions about caregiving (e.g., high caregiving self-efficacy; confidence that one is able to manage the demands of caregiving) are more likely to experience positive aspects of caregiving (Semiatin & O’Conner, 2012).

Although well-established theoretical models and existing empirical evidence both point to family CGs cognitions as key determinants of their resilience, few caregiver intervention concepts have explicitly aimed to modify cognitions as a treatment goal (Wilz, 2023). The few existing studies found that cognitive behavior therapy (CBT) reduced CGs depression specifically by reducing their dysfunctional thoughts (Losada et al., 2011; Márquez-Gonzalez et al., 2007). These findings substantiate the importance of addressing CGs care-related cognitions in psychotherapeutic interventions.

Which Cognitions Matter? Four Domains of Dysfunctional and Functional Care-related Cognitions

Risch and colleagues (2022) proposed four domains of dysfunctional and functional care-related cognitions particularly relevant for family caregivers of people with dementia:

(1) Dysfunctional caregiving standards include a sense of bearing the sole responsibility for caregiving; perfectionism; and self-blame when caregiving ideals have not been met. Beliefs that caregiving “must” be provided on one’s own, or that “strangers” could not provide adequate care, may prevent caregivers from utilizing professional and informal sources of support. Some caregivers may see their need for support as a personal failure. Caregivers may feel guilty or ashamed if they think they are  unable to provide adequate care on their own, or that they have fallen short of their own ideals. They may feel guilty delegating responsibility to someone else, even temporarily, or devoting time and attention to their own needs. Indeed, family caregivers of people with dementia with higher dysfunctional caregiving standards tend to have worse mental health (Cabrera et al., 2021; Losada et al., 2010; Losada, Robinson Shurgot, et al., 2006; McNaughton et al., 1995; Risch et al., 2022).

(2) Dysfunctional thoughts and attitudes about dementia include misinterpretations of the care recipient’s behavior; irrational expectations; and inaccurate assumptions about the pathogenesis and course of the disease. Family members often experience the behavioral symptoms of dementia as expressions of spite, ignorance, or defiance. Such misinterpretations can be emotionally burdensome and lead to conflicts with the care recipient. Some family caregivers harbor the belief that their past behavior caused their family member to develop dementia. Among family caregivers of people with dementia, more accurate knowledge about dementia and caregiving may predict better mental health, while dysfunctional attitudes toward dementia have been associated with higher depression and anxiety (Risch et al., 2022).

(3) Functional thoughts and attitudes about self-care include CGs beliefs about leisure and regeneration, and the importance of recovery for the quality of care. Clinical experience suggests that caregivers who take care of themselves tend to cope better with the caregiving situation over the long term. Positive beliefs about self-care might help caregivers to acknowledge their own needs and individual limits, and enable them to mentally distance themselves from the caregiving situation when appropriate. Evidence suggests that caregivers who engage in more self-care and leisure activities, and perceive more leisure time, also perceive less burden and have better mental health (Losada et al., 2010; Romero-Moreno et al., 2011; Schüz et al., 2015; Waligora et al., 2018). Based on their literature review, Oliveira and colleagues (2019) concluded that interventions designed to improve CGs health and lifestyle improved CGs depression, perceived burden, and quality of life.

(4) Functional thoughts and attitudes concerning acceptance include assumptions about the controllability of the caregiving situation; how caregivers process negative, unchangeable events; and detachment in stressful situations (i.e., taking the perspective of an observer who is less affected by the situation; Kalish et al., 2005). According to the model of acceptance and commitment therapy (ACT; see Hayes et al., 2006), acceptance is the willingness to experience unchangeable, adverse external (e.g., a family member’s dementia diagnosis) and internal (e.g., negative emotions and thoughts) events without trying to avoid or suppress them (e.g., denial, substance use). Among family caregivers, acceptance is associated with better mental health (Risch et al., 2024; Losada et al., 2015) and lower depression (Spira et al., 2007). In contrast, the avoidance or suppression of negative thoughts and emotions (i.e., experiential avoidance) is associated with worse depression, anxiety, physical health, and health-related quality of life (Risch et al., 2024; Goodwin & Emery, 2016; Wenze et al., 2018). Functional thoughts and attitudes concerning acceptance are associated with lower depression and anxiety in family caregivers of people with dementia (Risch et al., 2022, 2024). Caregivers who approach the caregiving situation with a certain degree of detachment and a high degree of acceptance may be able to react to stressful situations more pragmatically and permit themselves more leisure time.

Strategies for Addressing CGs Care-related Cognitions

Interventions for family caregivers of people with dementia should aim to reduce dysfunctional attitudes towards dementia and dysfunctional caregiving standards while, at the same time, also aim to foster functional cognitions related to self-care and acceptance. In the first sessions of work with CGs, psychotherapists should therefore focus on uncovering and identifying CGs own, individual automatic and unconscious thought patterns. The questionnaire from Risch and colleagues (2022) can aid in the assessment of family CGs dysfunctional and functional cognitions about caregiving.

In the next step, therapists should work with family caregivers to clarify the links between the caregiver’s dysfunctional (unhelpful) cognitions on the one hand, and their behavior, emotions and experience of burden on the other hand. Acknowledging factors such as incongruence; role discrepancies; motives for caregiving; and social, cultural, and familial norms as reference points for self-appraisals can support developing clarity and new constructive perspectives. Once the links between specific cognitions and specific caregiving experiences have been established, caregivers are in a better position to resolve conflicts between their caregiving tasks and their own values and needs; clarify their motivation for caregiving; and approach their caregiving decisions more deliberately. Subsequently, CGs dysfunctional cognitions can be evaluated, questioned and re-negotiated. Through Socratic dialogue, guided discovery, and Ellis’ ABC Model (A: Activating Event, B: Beliefs, C: Consequences, Ellis, 1973), the therapist and caregiver can work out alternative, more helpful ways of thinking as well as possibilities to practice these new ways of thinking in real life.

Approaches based on ACT are conducive to strengthening family CGs functional cognitions about self-care and acceptance. In line with an ACT-based approach, therapists should direct their focus toward helping caregivers come to terms with the unchangeable aspects of the care recipient’s condition and the caregiving situation. It can be particularly helpful to facilitate the expression of distressing emotions and coping with loss and grief. Therapists can also employ ACT-based approaches to encourage family caregivers to live in closer alignment with their own values and needs (Risch et al., 2024).

In sum, psychotherapists working with family caregivers should consider following an integrative approach combining aspects of CBT and ACT that together address CGs dysfunctional and functional cognitions about caregiving while supporting skillful relationship with the challenges inherent in the CGs role. The Tele.TAnDem intervention concept is an effective psychotherapeutic intervention for family caregivers based primarily on CBT and ACT (Wilz, 2023). The manual provides comprehensive and specific guidance on how therapists can work with caregivers to recognize debilitating thought patterns, and develop alternative, potentially stress-reducing and encouraging ways of thinking.

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Ann M Steffen, PhD - University of Missouri - St. Louis

Synchronous (live) psychotherapy delivered via video conference or telephone-only can be an effective way to provide CBT to adult clients across the lifespan, including CBT with older adults. There is a longstanding recognition that many prospective mental health clients experience physical barriers that can be addressed through telemental healthcare. Those living in rural communities are especially unlikely to have easy access to in-person psychotherapy with a local provider. Others live with a range of acute and chronic physical health conditions that limit mobility and make attending weekly therapy sessions very difficult. Poor access to transportation compounds these challenges for many. It is important for us to recognize that none of these barriers are new. The identified need for, interest in, and research on telephone-based and video-conferenced psychotherapy are all well-established (Riper & Cuijpers, 2016). Many healthcare systems across the globe and within the US have decades of experience in providing live/synchronous teletherapy to clients (Myers & Turvey, 2012).

For most psychotherapists, however, the initial COVID-19 lockdown created their first, and very sudden, experience with providing therapy by videoconference and/or telephone. Along with coping with other aspects of the pandemic, we lived through a wide range of challenges with this pivot away from in-person sessions. Some of these difficulties have remained for therapists who include teletherapy within their clinical practice. As we reach the four-year anniversary of the 2020 initial lock-down within the United States, it is helpful to address ongoing concerns by examining lessons learned, especially in CBT practice with older adults who are living independently in the community. Because of the complexities involved, this article will not focus on the added challenges of clinical work in the context of assisted living or skilled nursing care (interested readers are referred to resources provided by Psychologists in Long Term Care; www.pltcweb.org).

Evidence Base - How confident can we be regarding our evidence base for using telehealth to provide psychotherapy?

Does it work?  Meta-analytic reviews have evaluated both the efficacy (randomized controlled trials) and effectiveness (evaluations in routine clinical settings) of both video-conferenced and telephone-based psychotherapy compared to in-person sessions. These reviews have generally concluded that client outcomes are similar among delivery formats for clients across the adult lifespan and across a range of presenting concerns (Lin et al., 2022; Varker et al., 2019). This “equal outcomes across delivery formats” conclusion has been echoed in reviews for CBT interventions specifically (Nelson & Duncan, 2015), CBT for depression (Cuijpers et al., 2019) and with older adults (Freytag et al., 2022; Gentry et al., 2019). Individual research studies focused on older adults suggest comparable findings. Positive outcomes have been reported for telephone-delivered CBT for older, rural Veterans with depression and anxiety in home-based primary care (Barrera et al., 2017), telehealth problem-solving therapy for depressed low-income homebound older adults (Choi et al., 2014), and telehealth CBT for depression and insomnia in ethnically diverse older adults in rural south (Scogin et al., 2018). Outcomes for telehealth interventions with dementia family caregivers have also been favorable for a range of psychosocial outcomes including depression (Steffen & Gant, 2016).

Is teletherapy acceptable to clients?  A rather important question has been whether older psychotherapy patients will accept the use of remote technology to engage with their clinician. Although some aging individuals expressed initial hesitance before beginning use in a qualitative study, most concluded after participating in a telehealth intervention that they appreciated the convenience and were able to feel emotionally connected with their provider (Choi et al., 2014). Beyond qualitative interviews with service recipients, data on attendance patterns and attrition can also answer questions about acceptability. Clients receiving telephone-based CBT have the very lowest attrition rates (i.e., are less likely to drop out of therapy prematurely), followed by those participating in video-conferencing sessions, with attrition rates highest for in-person CBT (Cuijpers et al., 2019; Cuthbert et al., 2022).

Common Challenges

Despite this evidence, it is clear that as CBT clinicians, we continue to experience a range of issues in our psychotherapy practices that involve video-conferencing or telephone-only sessions. Most of these challenges occur in telehealth CBT sessions with clients across the lifespan. These include a host of familiar concerns including spotty wifi and connectivity issues (or complete lack of internet access), reliance on smart phones leading to screens too small for use of printed materials or screen sharing, distractions in the home such as other people, pets, tv; increased client expectations for last-minute rescheduling of sessions, desire for more session time devoted to supportive counseling, gauging clients’ engagement in therapy, and especially challenges in assigning and reviewing between session practice forms (aka “homework’).

Some clinicians describe concerns in their teletherapy CBT practice that are perhaps not unique to older adults but may occur more frequently. Certainly, age-associated sensory changes in vision and hearing are something that we accommodate for, whether sessions are held in person or via a different delivery format; holding sessions by video conference or telephone-only can compound these challenges. Most older adults are both familiar with and routinely use a range of technologies (Greenwald et al., 2018), yet may require more frequent reminders and additional time for managing some of the details of videoconferencing (logging in procedures, turning on video and adjusting audio levels, hiding self-view). Repeated use of a small set of printed handouts and between-session worksheets can be quite useful (Steffen et al., 2021). Importantly, anxiety about difficulties that arise when using video conferencing technologies and software can provide opportunities for therapeutic responding, including problem-solving, exposure strategies, along with other CBT interventions to address the challenges of telehealth that are associated with distress.

Table 1 shown below, from Freytag et al. (2022) provides a nice starting point for thinking about your own ways of addressing some of these concerns.

Table 1 from Freytag et al (2022). Reproduced with permission.
Note: VTH refers to Video Telehealth

Concluding Comments

There are now a variety of resources and tips available for CBT therapists who would like to improve the impact of their telehealth sessions with older adults. These include strategies to manage procedural aspects of telehealth sessions, develop and maintain therapeutic rapport, and enhance therapy effectiveness with older adult clients.

Barrera, T. L., Cummings, J. P., Armento, M., Cully, J. A., Bush Amspoker, A., Wilson, N. L., & ... Stanley, M. A. (2017). Telephone-delivered cognitive-behavioral therapy for older, rural Veterans with depression and anxiety in home-based primary care. Clinical Gerontologist: The Journal Of Aging And Mental Health, 40(2), 114-123. doi:10.1080/07317115.2016.1254133

Choi NG, Hegel MT, Marti N, Marinucci ML, Sirrianni L, Bruce ML. (2014), Telehealth problem-solving therapy for depressed low-income homebound older adults. Am J Geriatr Psychiatry. 2014 Mar;22(3):263-71. doi: 10.1097/JGP.0b013e318266b356.

Choi NG, Wilson NL, Sirrianni L, Marinucci ML, Hegel MT. (2014), Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: qualitative interviews with the participants and aging-service case managers. Gerontologist, 54(4):704-13. doi: 10.1093/geront/gnt083.

Cuijpers, P., Noma, H., Karyotaki, E., Cipriani, A., & Furukawa, T. A. (2019). Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: a network meta-analysis. JAMA Psychiatry, 76(7), 700-707.

Cuthbert, K., Parsons, E. M., Smith, L., & Otto, M. W. (2022). Acceptability of telehealth CBT during the time of COVID-19: evidence from patient treatment initiation and attendance records. Journal of behavioral and cognitive therapy, 32(1), 67-72.

Freytag J, Touchett HN, Bryan JL, Lindsay JA, Gould CE. Advances in Psychotherapy for Older Adults Using Video-to-Home Treatment. Adv Psychiatry Behav Health. 2022 Sep;2(1):71-78. doi: 10.1016/j.ypsc.2022.03.004. Epub 2022 Sep 9. PMID: 38013747; PMCID: PMC9458515.

Gentry, M. T., Lapid, M. I., & Rummans, T. A. (2019). Geriatric telepsychiatry: systematic review and policy considerations. The American Journal of Geriatric Psychiatry, 27(2), 109-127.

Greenwald, P., Stern, M. E., Clark, S., & Sharma, R. (2018). Older adults and technology: In telehealth, they may not be who you think they are. International Journal of Emergency Medicine, 11(1), 2–4.

Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials. Clinical Psychology: Science and Practice, 29(2), 167–178. https://doi.org/10.1037/cps0000056

Luxton, D. D., Nelson, E. L., & Maheu, M. M. (2022). A practitioner's guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. 2nd edition. American Psychological Association.

Myers, K., & Turvey, C. (Eds.). (2012). Telemental health: Clinical, technical, and administrative foundations for evidence-based practice. Newnes.

Nelson, E.-L., & Duncan, A. B. (2015). Cognitive behavioral therapy using televideo. Cognitive and Behavioral Practice, 22(3), 269–280. https://doi-org.ezproxy.umsl.edu/10.1016/j.cbpra.2015.03.001

Riper, H., & Cuijpers, P. J. (2016). Telepsychology and eHealth. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, & R. Krishnamurthy (Eds), APA handbook of clinical psychology: Applications and methods, Vol. 3, (pp. 451-463). Washington, DC, US: American Psychological Association, xvi,

Scogin, F., Lichstein, K., DiNapoli, E. A., Woosley, J., Thomas, S. J., LaRocca, M. A., Byers, H. D., Mieskowski, L., Parker, C. P., Yang, X., Parton, J., McFadden, A., & Geyer, J. D. (2018). Effects of integrated telehealth-delivered cognitive-behavioral therapy for depression and insomnia in rural older adults. Journal of Psychotherapy Integration, 28(3), 292–309. https://doi.org/10.1037/int0000121

Steffen, A.M., Dick-Siskin, L., Bilbrey, A., Thompson, L.W., & Gallagher-Thompson, D. (2021). Treating Later-Life Depression: A Cognitive Behavioral Approach Workbook. 2nd edition, 358 pages. Treatments that Work Series; Oxford University Press.

Steffen, A. M., & Gant, J. R. (2016). A telehealth behavioral coaching intervention for neurocognitive disorder family carers. International Journal Of Geriatric Psychiatry, 31(2), 195-203. doi:10.1002/gps.4312

Varker, T., Brand, R., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of Synchronous Telepsychology Interventions for People With Anxiety, Depression, Posttraumatic Stress Disorder, and Adjustment Disorder: A Rapid Evidence Assessment. Psychological Services, 16(4), 621-635.

Lori A Brotto, PhD - Department of Obstetrics and Gynaecology, University of British Columbia

A lack of interest in sexual activity that creates personal distress and strains relationship satisfaction is the most common reason that women seek sex therapy. Described frequently by patients as “I’ve lost my libido,” or “It takes a long time for me to get sexually excited,” or “I would be content if we never had sex again!”, the presence of little or no desire for sex has received widespread attention from clinicians, researchers, and the lay public because of its complexity and seeming resistance to treatment. Female sexual interest/arousal disorder (SIAD) appears in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). SIAD is based on polythetic criteria whereby women must endorse at least three of six of the following criteria in order to receive a diagnosis, with symptoms lasting at least six months (APA, 2013).

1. lack of interest (or no interest) in sexual activity;
2. reduced or absent erotic thoughts or fantasies;
3. reduced level of initiating sex and/or responding to a partner’s sexual advances;
4. reduced pleasure during sexual activity;
5. lack of responsive sexual desire (i.e., desire that emerges with or after sexual arousal); and
6. reduced genital and nongenital sexual sensations (i.e., arousal).

The use of polythetic criteria means that a diagnosis of SIAD may involve different symptom expressions (Brotto et al., 2015). 

Since SIAD has been in existence only since 2013, epidemiological studies on its prevalence have yet to be published, except for one online Flemish study that evaluated both spontaneous and responsive sexual desire (Hendrickx, Gijs, & Enzlin, 2014); however, there have been many large and representative studies focusing on the symptom of low or absent sexual desire. The third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) assessed 6777 women (who had a sexual partner in the last year) and found that 34.2% of women across ages endorsed low desire (Mitchell et al., 2013). Across the age cohorts, the highest prevalence was among women in the 55-64 year old category, and age was negatively associated with sexual desire. Between 15%-35% of women across the age categories reported having a discrepant level of sexual interest compared to their partners (Mitchell et al., 2013). In a study of Canadian middle-aged women, these rates of low desire were similar (Quinn-Nilas, Milhausen, McKay, & Holzapfel, 2018), and those with medical health conditions and poor overall health were more likely to report low desire in both studies. Low sexual desire is common among women affected by serious or life-threatening illnesses (e.g., cancer, cardio-vascular diseases). This is true for acute illnesses, and chronic conditions (e.g., thyroid disease, multiple sclerosis, arthritis) (McCabe et al., 2016). Women who have experienced childhood sexual abuse experience lower levels of sexual desire compared to non-abused women (Loeb et al., 2002; Stephenson, Hughan, & Meston, 2012).

The Role of Attention in Women’s low Sexual Desire

The Incentive Motivation Modelprovides a robust theory of sexual response that accounts for the roles of attention, memory, thoughts, and emotional reactions to determine whether a sexual stimulus might elicit sexual arousal in women. This theory illustrates how biological, psychological, and contextual factors interact to elicit sexual desire and arousal. It holds that sexual desire results from an interaction between a sexual response system and potent stimuli that activate the system. The incentive motivation model captures the experience of how sexual desire and arousal unfold for many women (regardless of whether they have sexual difficulties or not) because it highlights the important role of adequate sexual stimuli (i.e., internal or external cues that are perceived as sexually exciting) that trigger sexual motivation. This model is useful for identifying where a woman might experience a difficulty in sexual desire and/or arousal; for example, there is ample evidence that cognitive distraction during sex can be a significant precipitant of sexual difficulty (Nobre & Pinto-Gouveia, 2006) .This distraction, in turn, can impede the individual’s ability to notice sexual sensations in the body, and prevent desire from emerging following arousal (otherwise known as responsive sexual desire; Basson, 2001). Distraction, inattention, and/or judging of one’s unfolding sexual response have all been implicated in sexual desire and arousal difficulties in women (Chivers & Brotto, 2017).

Evidence for the Benefits of Mindfulness in the Treatment of low Sexual Desire in Women

With this theoretical understanding of the processes that elicit sexual arousal and desire, and evidence for mindfulness in a host of other domains of health, there is a solid rationale for the application of mindfulness-based approaches to improving desire and arousal difficulties in women.  In the early 2000s, mindfulness began to be applied to sexual dysfunction in women. Hypothesized mechanisms are that mindfulness training may allow women with low desire to become more aware of emerging physical changes during or in anticipation of sexual activity (e.g., genital vasocongestion, tingling), which may boost and maintain their experience of sexual arousal and desire, and further synching their physiological and psychological experience. There is also the putative role of helping an individual to recognize negative sex-related beliefs as simply “mental events”.

One of the earliest documented empirical tests of mindfulness as an aid for sexual desire and arousal was in the context of gynecologic cancer survivors who experienced a profound sense of loss of sexual response following their treatment, and struggled with sexual desire, arousal, and satisfaction Over three monthly sessions in which a group of gynecologic cancer survivors with sexual dysfunction practiced mindfulness in and between sessions, there were significant increases in perceptions of physical as well as self-reported arousal, desire, satisfaction, and decreases in distress. In particular, some of the participants remarked that despite a change in arousal and responsivity following their cancer treatment, mindfulness allowed them to detect some residual arousal that they believed was gone, and that by using a combination of arousal enhancing techniques and mindfulness, they were now able to tune into their response and amplify it.

Following this initial small study, several other studies of mindfulness as a treatment for low desire and associated sexual problems in women have been carried out. In one of the few large randomized clinical trials of mindfulness versus supportive sex education to women meeting diagnostic criteria for sexual interest/arousal disorder(Brotto et al., 2021) women attended 8 weekly groups where the facilitator guided mindfulness practice in session, followed by daily practice of mindfulness at home. Participants practiced mindfulness exercises formally in the first few sessions, and then progressively integrated mindfulness practice in progressively more sexual contexts such as while looking at oneself in a mirror, engaging in self-touch, non-sexual touching with a partner (e.g., sensate focus), and eventually during sex with a partner. Immediately after treatment, the mindfulness group led to significant improvements in sexual desire, sexual distress, relationship satisfaction, and rumination, and these improvements were retained at both the 6-month and 12-month follow-up time points.Moreover, participants self-reported a significant improvement to their quality of life and a general satisfaction with the treatment and the improvements they saw. By comparison, a psychoeducational comparison group that integrated elements of supportive-expressive therapy did not exhibit the magnitude of improvements in sexual distress, relationship satisfaction, or rumination that was seen in the mindfulness group; however, this group did show comparable improvements in sexual desire, suggesting that psychoeducational information, when delivered in a supportive-expressive environment, can be a very effective approach to improving sexual desire in women.

What are the Mechanisms by Which Mindfulness Improves Sexual Desire in Women?

Different underlying mechanisms have been proposed to account for the means by which mindfulness-based interventions improve suffering. For example, in his book Full Catastrophe Living, Kabat-Zinn postulated that there were seven specific attitudinal foundations by which mindfulness worked, and these included but were not limited to: Non-judging (reducing the tendency to categorize experiences as good or bad); Beginner’s Mind (attempting to experience repeated sensations as if for the first time); and Non-Striving (having no goal other than noticing one’s current experience). More contemporary interpretations of the mechanisms of mindfulness have been proposed (Brown et al., 2015), and include: that mindfulness cultivates the ability to notice that the primary aspects of one’s present experience are distinct; that mindfulness increases one’s ability to notice the automatic processes thus allowing one to make intentional decisions; and that mindfulness can foster meta-cognitive awareness.In contrast to the broader literature exploring mediators of mindfulness, very few studies have empirically evaluated the mediators of mindfulness-based therapy in the treatment of sexual dysfunction. Our team analyzed the mechanisms underlying the beneficial effects of mindfulness-based group sex therapy on desire and arousal symptoms in women, and we found thatimprovements in interoceptive awareness, self-compassion, self-criticism, depressive symptoms, and changes in mindfulness mediated the improvements in desire and distress (Brotto et al., 2023). Knowing that these were mediators of improvement after treatment of desire and arousal concerns means that a health care provider might recommend mindfulness for patients who have low desire and simultaneously have low levels of interoceptive awareness, self-compassion, and mindfulness, and higher levels of self-criticism and depressive symptoms. In addition to these identified mediators from quantitative analyses, another study analyzed qualitative feedback from patients to understand the mechanisms by which a mindfulness-based approach was effective for treating low desire in women. The authors found that shifts in patients’ locus or quality of attention during sex, their reduced avoidance behavior, their ability to disengage from negative thoughts, and their overall feelings of normalization when in a group with other women experiencing sexual difficulties were the mechanisms by which mindfulness improved low sexual desire (Meyers et al., 2023).

If you want to read more about the science of mindfulness as it has been applied to sexual health, and women’s sexual desire in particular, you may find my 2018 book, Better Sex Through Mindfulness, to be of interest. And for those of you who may be interested in sharing the mindful sex treatment guide with your own clients, my 2022 workbook may also be of interest!

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Basson, R. (2001). Using a different model for female sexual response to address women’s problematic low sexual desire. Journal of Sex & Marital Therapy, 27(5), 395-403.

Brotto, L. A. (2022). The Better Sex Through Mindfulness Workbook: A Guide to Cultivating Desire. Vancouver, Canada: Greystone Publishing.

Brotto, L. A. (2018). Better Sex Through Mindfulness: How women can cultivate desire. Vancouver, Canada: Greystone Publishing.

Brotto, L. A., Graham, C. A., Paterson, L. Q., Yule, M. A., & Zucker, K. J. (2015). Women’s endorsement of different models of sexual functioning supports polythetic criteria of Female Sexual Interest/Arousal Disorder in DSM-5. Journal of Sexual Medicine, 12, 1978–1981.

Brotto, L. A., Zdaniuk, B., Chivers, M. L., et al. (2021). A randomized trial comparing group mindfulness-based cognitive therapy with group supportive sex education and therapy for the treatment of female sexual interest/arousal disorder. Journal of Consulting and Clinical Psychology, 89(7), 626-639.

Brotto, L. A., Zdaniuk, B., Chivers, M. L., et al. (2021). A randomized trial comparing group mindfulness-based cognitive therapy with group supportive sex education and therapy for the treatment of female sexual interest/arousal disorder. Journal of Consulting and Clinical Psychology, 89(7), 626-639.

Brotto, L. A., Zdaniuk, B., Chivers, M. L., Jabs, F., Grabovac, A. D., & Lalumière, M. L. (2023). Mindfulness and sex education for sexual interest/arousal disorder: mediators and moderators of treatment outcome. The Journal of Sex Research, 60(4), 508-521.

Brown, K. W., Creswell, J. D., & Ryan, R. M. (Eds.). (2015). Handbook of mindfulness: Theory, research, and practice. The Guilford Press.

Chivers, M. L., & Brotto, L. A. (2017). Controversies of women’s sexual arousal and desire. European Psychologist, 22(1), 5-26.

Hendrickx, L., Gijs, L., & Enzlin, P. (2014). Prevalence rates of sexual difficulties and associated distress in heterosexual men and women: Results from an Internet survey in Flanders. Journal of Sex Research, 51, 1–12.

Loeb, T. B., Rivkin, I., Williams, J. K., Wyatt, G. E., Carmona, J. V., & Chin, D. (2002). Child sexual abuse: Associations with the sexual functioning of adolescents and adults. Annual Review of Sex Research, 13, 307–345.

McCabe, M. P., Sharlip, I. D., Atalla, E., Balon, R., Fisher, A. D., Laumann, E. O., … Segraves, R. T. (2016). Definitions of sexual dysfunctions in women and men: A consensus statement from the Fourth International Consultation on Sexual Medicine 2015. Journal of Sexual Medicine, 13, 135–143.

Meyers, M., Margraf, J., & Velten, J. (2023). Subjective effects and perceived mechanisms of change of cognitive behavioral and mindfulness-based online interventions for low sexual desire in women. Advance online publication.

Mitchell, K. R., Mercer, C. H., Ploubidis, G. B., Jones, K. G., Datta, J., Field, N., … Wellings, K. (2013). Sexual function in Britain: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet, 382, 1817–1829.

Nobre, P., & Pinto-Gouveia, J. (2006). Dysfunctional sexual beliefs as vulnerability factors for sexual dysfunction. Journal of Sex Research, 43(1), 68-75.

Quinn-Nilas, C., Milhausen, R. R., McKay, A., & Holzapfel, S. (2018). Prevalence and predictors of sexual problems among midlife Canadian adults: Results from a national survey. Journal of Sexual Medicine, 15, 873–879.

Stephenson, K. R., Hughan, C. P., & Meston, C. M. (2012). Child Abuse & Neglect Childhood sexual abuse moderates the association between sexual functioning and sexual distress in women. Child Abuse & Neglect, 36, 180–189.

Toates, F. (2009). An integrative theoretical framework for understanding sexual motivation, arousal, and behavior. Journal of Sex Research, 46, 168–193.

Cory F. Newman, PhD, ABPP - University of Pennsylvania, Perelman School of Medicine

A common misconception about CBT is that the therapeutic relationship is not given sufficient attention; that it is taken for granted and not addressed as an important factor in therapy. A simple review of the literature in CBT demonstrates otherwise, in which the early, seminal works of A.T. Beck explicitly state that the methods of cognitive therapy (or CBT, as the two have become intertwined over the decades) require a caring, constructive, collaborative therapeutic relationship for the patient to benefit optimally from treatment (e.g., Beck, 1976; Beck, Rush, Shaw, & Emery, 1976). In 1980, Beck, along with Jeffrey Young, developed the Cognitive Therapy Scale (CTS: Young & Beck, 1980), which is perhaps the most widely used measure of competency in conducting generic, Beckian CBT. The CTS includes three scoring categories out of eleven that measure aspects of the therapeutic relationship, demonstrating the high priority that is placed on the relational competencies of the CBT therapist. In the ensuing years, many publications in the field of CBT offered empirical and clinical support for the importance of the therapeutic relationship in CBT, including methods for understanding, managing, and resolving difficulties in the alliance between therapist and patient (e.g., Safran & Segal, 1990; Gilbert & Leahy, 2007).

When patients have significant, perhaps pervasive and chronic problems in their interpersonal lives, it is not uncommon for them to bring these difficulties into the therapeutic relationship (Safran & Segal, 1990). Sometimes this is manifested by a penchant for mistrusting the therapist, having unrealistic expectations for treatment, communicating in ways that are inadequate and/or aversive, and other such problems (see Newman, 1997, for extreme examples). Such scenarios pose special challenges for CBT therapists, who may come to realize that being pleasant, professional, attentive, and competent are necessary but insufficient conditions to earn optimal collaboration from some patients. Additionally, even when the patients do not necessarily manifest serious interpersonal dysfunction, they may have areas of psychological vulnerability (e.g., early maladaptive schemas, see Young, Klosko, & Weishaar, 2003) that can lead to alliance strains or ruptures when well-meaning therapists make a misstep (e.g., saying something that is invalidating). Therapists, as all humans, are fallible, and sometimes their errors can create stress and strain in the therapeutic relationship (e.g., forgetting something very important about a patient, to the patient’s dismay and chagrin). When any of these scenarios occur, it is a vitally important competency for the CBT therapist to be able to recognize the problem, conceptualize what is happening, take ownership of at least part of the process, maintain composure, empathy, and professionalism, and intervene to repair the strain or rupture in the therapeutic relationship (see Eubanks, 2022; Zilcha-Mano, Eubanks, Bloch-Elkouby, & Muran, 2021).

The literature on problems in the therapeutic relationship has described two broad categories – withdrawal ruptures, and confrontation ruptures. Withdrawal ruptures refer to those scenarios in which the patient is disengaging from therapy, either within a session (e.g., giving perfunctory but inauthentic comments just to be polite) or outside a session (e.g., failing to show up for a session and then not returning the therapist’s messages). Withdrawal ruptures that occur in a session can sometimes be difficult to detect, as the patient often is not being explicit about their discomfort or displeasure with what is occurring in therapy. Therapists in this situation may ascertain that the energy in the session is low, and/or that progress in the session is sub-optimal, but they may not want to jump to the conclusion that the patient is silently unhappy with the process. Even when therapists ask their patients for feedback, there is a chance that the patient will simply state that things are fine, avoiding discussing their actual thoughts and feelings. Confrontation ruptures are more overt, in that they characteristically involve patients making comments or otherwise engaging in behaviors that are patently negative. Such comments may be described as complaining about or disagreeing with the methods of treatment, criticizing or blaming the therapist, and sometimes even expressing demands and threats. Here, the therapist’s main challenges are maintaining a professional demeanor, staying empathic, being able to listen, and then having the conceptual understanding and communication acumen to begin a process of trying to do constructive problem-solving with the patient, perhaps under duress.

As mentioned above, therapists sometimes make mistakes that play a role in the alliance rupture, and this needs to be acknowledged. Nonetheless, there is evidence that alliance ruptures have been found to be more common in working with patients diagnosed with personality disorders than when treating patients without such diagnoses (Coutinho, Ribeiro, Sousa, & Safran, 2014). Interestingly, there is evidence that alliance ruptures with patients who have diagnosed personality disorders may present a positive opportunity for therapists to present the patients with a meaningful, corrective experience (in repairing the rupture) that allows their work to continue, perhaps with more of a sense of collaboration and optimism than was evident prior to the rupture, and with improved outcomes (Strauss et al., 2006; Cummings, Hayes, Newman, & Beck, 2011). With this in mind, therapists who are confronted with significant difficulties in their interactions with patients can rally themselves with the understanding that if they bring a high level of conceptual, relational, and technical skills to the situation they may be catalysts for significant therapeutic change. Recent studies of the phenomena and skills pertinent to repairing alliance ruptures suggest that the requisite competencies to manage these challenging situations can be taught (Eubanks, 2022; Muran, Safran, Eubanks, & Gorman, 2018), thus adding impetus to inclusion of this topic in supervised clinical practica and continuing education training.

Clinical Examples

The following are two, brief, representative examples of therapists recognizing and addressing alliance ruptures – a withdrawal rupture, followed by an example of a confrontation rupture. Each example is comprised of four parts: (1) situation, (2), patient’s responses, (3) therapist’s conceptualization of the patient’s responses, and (4) therapist’s responses.

Withdrawal Rupture

1. Situation: The patient, a young cisgender female diagnosed with a severe mood disorder, also shows signs of excessive eating restriction and a possible trauma history, neither of which she acknowledged at intake (or since). I (the therapist) delicately state that I would like to ask more about her eating habits as part of today’s session agenda, expressing worry about her gaunt appearance.
2. Patient’s Responses: The patient looks downward, keeps her glance fixated there, and goes silent for a long period of time. She does not interact with me, even when I express concern and empathy, and even when I apologize for bringing up such a sensitive topic without advance notice.
3. Therapist’s Conceptualization: The patient has stated earlier that she often feels that she has “no control” over her personal space and time in the face of demands and intrusions from her parents and her employer. It is also possible that she has experienced traumatic intrusions into her personal space that she has not yet discussed. She tries to maintain some semblance of control by circumscribing what she is willing (and not willing) to discuss in therapy. Apparently, I have just breached her boundary, and she is experiencing a negative affect shift, manifested by going mute and not making eye contact. This behavior may also reflect a self-protecting trauma response of trying to hide, though this is a topic we have not previously discussed. Now I have to facilitate giving her back a sense of control and safety.
4. Therapist’s Responses: (At first remaining quiet, hoping that the patient will look up and see my sympathetic demeanor, but she does not, so I quietly, caringly state the following). “I can see you’re in some distress, and I’m concerned that my comments may have triggered you (long pause). I gather that asking about your eating is a very sensitive topic for you, and I probably should have realized that (long pause). If my comments and questions came across as a jarring invasion of your privacy, or maybe sounded like an accusation I sincerely apologize (long pause). You have a right to set the agenda for your own therapy, and I owe it to you to respect your agenda (short pause). I also think I owe it you to share with you my best clinical observations so you can have the most effective treatment plan, and that’s why I asked about your eating (short pause). I hope you will talk to me to let me know how you’re doing right now. I get bored listening to myself talk. I would much rather have a collaborative dialogue with you. I promise that I will be very respectful of what you have to say on this matter.”

Confrontation Rupture

1. Situation: The patient, a middle-aged cisgender male with a range of anxiety disorders and related IBS, notes that he succeeded in going hiking with some friends, overcoming his fear of heights and possibly not being able to find a bathroom when he might need it. I (the therapist) congratulate him, showing genuine enthusiasm for the patient’s accomplishment, and I wonder aloud how the patient might be able to generalize this success experience to attempt to face other previously avoided situations.
2. Patient’s Responses: (Voice grows progressively more irritated in tone). So, you’re saying that what I did wasn’t enough? I should just do more, right? All this anxiety I’ve had my whole life, I should just fix it, right? That’s what you’re saying? You think it’s easy? Do I get a chance to just enjoy one small respite from my humiliation, or do I have to do more, and more, and more in this therapy? (Looking very tense in facial expression and sitting posture).
3. Therapist’s Conceptualization: This patient has a long history of being humiliated for decades by his father for having anxiety and “not being a man.” Consequently, the patient – though he has friends and a successful career – has felt a deep sense of shame, often experiencing great anticipatory anxiety that his peers will discover his vulnerabilities and reject him. Currently, the patient does not hear my comments as supportive, respectful, and hopeful, but perhaps as patronizing, dismissive of the significance of what he has just done, and/or demanding more from him because he is not yet “good enough.” The patient’s fight-or-flight responses become heightened, as he experiences both anxiety and anger at this perceived insult and invalidation.
4. Therapist’s Responses: (First, gathering myself in response to the patient’s unexpectedly angry comments, then proceeding in a manner that was meant to run totally counter-schematically to what the patient would have expected from his father, as Safran & Segal’s text would recommend). “I am genuinely happy for you. I also recognize that going hiking required a great deal of fortitude and belief in yourself. It’s a major deal, and I respect you for making this important step forward – probably at least 30,000 steps if we look at your Apple Watch. I would never, ever make light of anyone’s therapeutic achievements, and I never take for granted how difficult it can be to keep pushing beyond one’s comfort zone, again and again. You are way beyond “good enough.” And I am committed to supporting you.  

Concluding Comment

The clinical examples above are but “snippets” of what happens when a therapist identifies, conceptualizes, and responds therapeutically to an alliance rupture. It is not typically a quick or easy process, nor can it be expected to be linear (Lipner et al., 2023). The pathway forward can be dramatically positive, or less so, depending in part on how the patients perceive and respond to the therapist’s attempts to repair their rift. Regardless, the examples above provide a flavor of what is involved, how it fits very well within a CBT model, and how important it can be in preventing treatment drop-out and in promoting more positive therapeutic outcomes.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.

Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

Coutinho, J., Ribeiro, E., Sousa, I., & Safran, J. D. (2014). Comparing two methods of identifying alliance rupture events. Psychotherapy, 51, 434-442. https://doi.org/10.1037/a0033171.

Cummings, J. A., Hayes, A. M., Newman, C. F., & Beck, A. T. (2011). Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid Axis-I disorders. International Journal of Cognitive Therapy, 4, 397-414. DOI:10.1521/ijct.2011.4.4.397

Eubanks, C. F. (2022). Rupture repair. Cognitive and Behavioral Practice, 29(3), 554-559. https://doi.org/10.1016/j.cbpra.2022.02.012

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Brian Thompson, PhD - The Portland Psychotherapy Clinic, Research, and Training Center

Exposure therapy is a major success story with an extensive research base in the treatment of anxiety and obsessive-compulsive and related disorders (Norton & Price, 2007). Throughout the decades since exposure was first demonstrated in Mary Cover Jones’ pioneering work (Kazdin, 1978), there have been several models developed to better understand how exposure works. For over 30 years, the most dominant model of exposure—to a degree that it is almost synonymous with exposure—has been the emotional processing theory (EPT; Foa & Kozak, 1986). According to EPT, exposure to the feared stimulus activates response and meaning elements of an emotion network and allows for the incorporation of newer corrective information through decreases in fear across exposures—what is called between-session habituation (Rupp, Doebler, Ehring, & Vossbeck‐Elsebusch, 2017). Newer research, however, has found that fear reduction is a poor predictor of whether people benefit from exposure therapy (Baker et al, 2010; Kircanski, et al, 2012). Consequently, EPT does not appear to fit with contemporary exposure research (Craske et al., 2008).

Acceptance and commitment therapy (ACT) is a newer cognitive behavioral treatment that emphasizes increasing psychological flexibility—taking action towards what is important to us even when in contact with uncomfortable thoughts, feelings, and bodily sensations—as a target of treatment. ACT has been described as an “exposure-based therapy” because it encourages people to remain in contact with difficult experiences they may otherwise avoid (Luoma, Hayes, & Walser, 2017). As it explicitly deemphasizes symptom reduction, in contrast to EPT, viewing a focus on symptom reduction as fostering a “fear of fear,” ACT theory is one alternative model for guiding exposure therapy that is consistent with new research. Additionally, ACT is a more process-based treatment in its focus on broader transdiagnostic processes of change compared to other cognitive behavioral evidence-based treatments that are more protocol-driven, (Hayes & Hofmann, 2021).

Within ACT, psychological flexibility has been described as both a single process, and it has also been broken down into smaller processes. The ACT hexaflex is the most common grouping of ACT processes that comprise psychological flexibility:

• Contact with the present moment
• Willingness (or acceptance) to stay in contact with discomfort (e.g., emotions; bodily sensations).
• Defusion, or the ability to be aware of thoughts with some distance without necessarily believing in their literal reality
• Self-as-context, or the ability to flexibly shift between perspectives rather than fusing with a particular self-concept or perspective
• Values, meaningful life directions in which we may choose to orient behavior
• Committed action, or taking action based on our values

Exposure appears to strengthen psychological flexibility whether delivered in an ACT context or not (Thompson, Twohig, & Luoma, 2021; Twohig et al., 2018), and the ACT process of acceptance or willingness appears to be a better predictor of change in exposure therapy than habituation (Reid et al., 2017). Overall, psychological flexibility appears to be an important transdiagnostic process of change even in other non-ACT treatments (e.g., Arch et al., 2012).

When compared against exposure therapy based on EPT, ACT-informed exposure performs about as well on primary outcomes (Arch et al., 2012; Craske, Niles, et al., 2014) Twohig et al., 2018). Rates of relapse in ACT-informed exposure are also comparable to those of traditional exposure (Arch et al., 2012; Twohig et al., 2018). There is some evidence that clients in ACT-informed exposure demonstrate additional improvements in symptom severity and psychological flexibility between treatment completion and follow-up, whereas those in traditional exposure simply maintain gains at follow-up (Arch et al., 2012; Craske, Niles, et al., 2014).

In our recently published pandemic project, a therapist guide on using ACT-informed exposure, ACT-Informed Exposure for Anxiety: Creating, Effective, Innovative, Values-Based Exposures Using Acceptance and Commitment Therapy, (Thompson, Pilecki, & Chan, 2023), my coauthors and I make a case for how the ACT psychological flexibility model has advantages over traditional exposure based on EPT in offering an expanded nomenclature for understanding and targeting processes common to exposure therapy. For example, acceptance of discomfort during exposure is important in facilitating new learning in any type of exposure. When clients engage in covert avoidance behavior such as rushing through an exposure exercise or tensing up, we know these behaviors can interfere with learning because, if clients are unable to be present and practice acceptance with feared stimuli, this behavior may reinforce anxiety and avoidance (e.g., Benito et al., 2018; Ong et al., 2022). ACT has a variety of exercises and metaphors for orienting clients to this process (e.g., Hayes, Strosahl, & Wilson, 2012; Eifert & Forsyth, 2005), offering the therapist and client a shared way of speaking about acceptance or willingness during exposure. In exposure approaches based on EPT, by contrast, acceptance tends to be more implicit (Moscovitch, Antony, & Swinson, 2009).

The research on ACT-informed exposure is still nascent—especially compared to exposure based on EPT. However, ACT-informed exposure appears promising and is consistent with emergent data on mechanisms of change during exposure. It offers a flexible, process-based alternative to traditional exposure.

Arch, J.J., Eifert, G.H., Davis, C., Plumb Vilardaga, J.C., Rose, R.D., & Craske, M.G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80, 750-765.

Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M.G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour Research and Therapy, 48(11), 1139-1143.

Benito, K.G., Machan, J., Freeman, J.B., Garcia, A.M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., Sapyta, J., & Franklin, M. (2018). Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. Journal of Consulting and Clinical Psychology, 86(7), 615–630.

Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27.

Craske, M.G., Niles, A.N., Burklund, L. J., Wolitzky-Taylor, K.B., Vilardaga, J.C.P., Arch, J.J., ... & Lieberman, M.D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of Consulting and Clinical psychology, 82(6), 1034-1048.

Eifert, G.H., & Forsyth, J.P (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.

Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.

Hayes, S.C., & Hofmann, S.G. (2021). “Third‐wave” cognitive and behavioral therapies and the emergence of a process‐based approach to intervention in psychiatry. World Psychiatry, 20(3), 363-375.

Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.

Kazdin, A.E. (1978). History of behavior modification: Experimental foundations of contemporary research. Baltimore: University Park Press.

Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A.S., Mystkowski, J.L., Yi, R., & Craske, M.G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745-751.

Luoma, J.B., Hayes, S.C., & Walser, R.D. (2017). Learning ACT: An acceptance & commitment therapy skills training manual for therapists (2^nd ed.). Oakland, CA: Context Press.

Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal of Nervous and Mental Disease, 195(6), 521-531.

Moscovitch, D.A., Antony, M.M., & Swinson, R.P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). Oxford University Press.

Ong, C.W., Petersen, J.M., Terry, C.L., Krafft, J., Barney, J.L., Abramowitz, J.S., & Twohig, M.P. (2022). The “how” of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder. Journal of Contextual Behavioral Science, 24, 87-95.

Reid, A.M., Garner, L.E., Van Kirk, N., Gironda, C., Krompinger, J.W., Brennan, B.P.,…Elias, J.A. (2017). How willing are you? Willingness as a predictor of change during treatment of obsessive-compulsive disorder. Depression and Anxiety, 34, 1057-1064.

Rupp, C., Doebler, P., Ehring, T., & Vossbeck‐Elsebusch, A.N. (2017). Emotional processing theory put to test: A meta‐analysis on the association between process and outcome measures in exposure therapy. Clinical Psychology & Psychotherapy, 24(3), 697-711.

Thompson, B.L., Luoma, J.B., & LeJeune, J.T. (2013). Using acceptance and commitment therapy to guide exposure-based interventions for posttraumatic stress disorder. Journal of Contemporary Psychotherapy, 43, 133-140.

Thompson, B.L., Pilecki, B.C., & Chan, J.C. (2023). ACT-informed exposure for anxiety: Creating, effective, innovative, values-based exposures using acceptance and commitment therapy. Oakland, CA: Context Press.

Thompson, B.L., Twohig, M.P., & Luoma, J.B. (2021). Psychological flexibility as shared process of change in acceptance and commitment therapy and exposure and response prevention for obsessive-compulsive disorder: A single case design study. Behavior Therapy, 52(2), 286-297.

Twohig, M.P., Abramowitz, J.S., Smith, B.M., Fabricant, L.E., Jacoby, R.J, Morrison, K.L., Lederman, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1-9.