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  • 02/03/2018 9:43 AM | Anonymous

    Lynne Siqueland, PhD - Children's and Adult Center for OCD and Anxiety

    It is useful to consider three levels of family involvement when conceptualizing and planning treatment of child and adolescent anxiety: education, coaching parents and other family members and caregivers, and improving family relationships.  This conceptualization has been useful for assessment of needs and clinical decision making by articulating levels of intervention for the treatment of childhood anxiety and related disorders.  These three levels of intervention have also been suggested by other clinical investigators who have written about family factors relevant in child anxiety (Rapee, 2012).  In what follows, straight forward language is offered that can be used by clinicians and other providers when speaking directly to parents and children in practice.  

    Psychoeducation about anxiety

    Cognitive-behavioral therapists overall rely on psychoeducation as an essential part of their work.  The first level of intervention then is psychoeducation about the nature of anxiety in children and an understanding of what ameliorates or exacerbates anxiety. This is the starting point and often essential for all families. It is useful to teach parents about what anxiety looks like in children and teens in terms of body reactions, thoughts and behavior. Many children and parents are not aware of the links between physical symptoms and anxiety. It helps for them to notice patterns.  If, for example, a child is complaining of stomach pain each school day morning but does not have difficulty or pain during the school day or after school in the afternoons or weekends then there is likely a link to anxiety or separation fears rather than stomach condition alone.  

    Also clarifying for parents that the discomfort or pain is real but will often be relieved by managing anxiety rather than treating the stomach or other regions of the gastrointestinal system with medications can be helpful.  Or addressing anxiety first can help clarify physical symptoms that remain after anxiety is lessened.  Headaches and stomachaches are the most common physical symptoms reported along with vague physical complaints.  Finally sleep issues are common in anxiety, especially around falling asleep.  If sleep issues are caused primarily by anxiety then treating worry or separation anxiety in the daylight hours is often essential before there can be success in sleep difficulties.  Another important psychoeducation issue is the reverse.  Too little or disrupted sleep can cause anxiety and treating sleep issues may significantly reduce anxiety without formal treatment of the anxiety.  Indeed psychoeducation and information alone has been helpful in child anxiety (Ginsburg, Drake, Tien et al., 2015).  For some children and families education may be all they need to address concerns.

    Cognitive-behavioral therapy (CBT) can be especially helpful in teaching youth and parents to recognize that there are thinking patterns that arise when anxiety is present, including beliefs that anxiety is problematic or dangerous.  The first reaction the child shows is the anxiety reaction – it is automatic and often inaccurate or “false alarm”.  For children and teens, that anxiety reaction is either a “freak-out” as kids often call it, or a “No” or refusal to do something or a combination of both.  It helps parents and other caregivers to recognize this first response as the anxiety reaction and not how their child thinks or feels when not anxious. While it is clear that the child may not be able to help the first reaction, the child is expected to learn, and the parents are to help their child cultivate, another more reasonable response.  It helps everyone to not be surprised or disappointed or to panic if the anxiety reaction occurs.  Instead they can respond by calmly saying, “We thought this might happen and we have a plan.”

    Finally the major issue for parents to understand is how avoidance maintains anxiety.  Many parents understand this at higher levels of avoidance but not in the subtler versions of day-to-day living.  It really helps for parents to understand that it is true that the anxiety goes down in the short run if they take over for a child (contact a friend or teachers for them) or allow a child to not attend a planned activity or event. However, avoidance maintains and exacerbates the anxiety in the long-run. Both prevention and intervention trials have targeted working with parents alone and providing educational information with good outcomes (e.g. Ginsburg, Drake, Tein, et al., 2015); Thirlwall, Cooper, Karalus,, Voysey, Willetts & Creswell, 2013).

    Coaching Caregivers to Coach Children

    The second component of coaching children during anxious moments comes into the clinical plan and is usually needed to some extent for all child and teen clients and their parents.  If parents have a way to help their children rather than the past options of trying to force their child, getting angry, or letting their child avoid, then parents feel that they can do something.  Also kids feel empowered because they also have something useful and different to do in the moment so often they are more willing to approach situations.  The therapist reminds parents and child clients that humans forget or do not use their therapeutic strategies at first and especially in times of stress if the strategies have not been sufficiently practiced.  It takes repeated practice for new skills to become available in times of stress. So it is important to review tools non-reactively and before they are needed, including after stressful events in anticipation of the next time.  Overall, therapists want both kids and parents to know that anxiety disorders are no-fault conditions.  Everyone is doing the best they can but in treatment parents and kids are asked to do some things differently based on what mental health professionals know about the nature of anxiety.  

    It is important to educate children, teens and their parents about the nature of exposures to feared situations and symptoms. There is no force involved but instead the therapist, child and parent are work together to make a plan to face fears step by step.  Children and teens should be told ahead of time what is going to happen, and informed that parents are going to do things differently.  Everyone in the family is told that it can be hard at first and uncomfortable but gets better with practice and time. One essential fact to learn about anxiety is that it often goes away on its own with doing next to nothing. The reaction to the anxiety is the problem more than the anxiety itself.  Parents and kids see that you often do not have to use all cognitive or behavioral approaches for anxiety to change if you just expose yourself to the feared situation and pay attention to the actual objective outcome.  The anxiety goes up and down on its own.  One of the pieces of coaching advice is that “this bad feeling will pass.”  Anxiety does not mean you have to do something.  This fact alleviates pressure on children, teens and their families alike.

    Parents and their children have a role in CBT treatment.  Parents’ role in exposures is making time for exposures at home, taking kids places to do them and setting up plans like playdates.  In this new role, parents are limiting reassurance, working to stay calm, and encouraging a different way of asking for help.  Most importantly, therapists help parents pay a lot of attention to kids’ healthy coping responses and a lot less to anxiety. They can help their children use the CBT strategies or just simply help their children continue or return to what they would be doing if anxiety were not getting in the way.  Psychologist Deborah Ledley, Ph.D. describes the child’s primary instruction as “just do it”-  try the exposures planned, use your strategies and do not get too mad at your parents for taking you to treatment or asking you to do homework.

    Many parents, with the psychoeducation and coaching, can do a great job and rather quickly take over the role as an encouraging side-by-side coach or background coach for their children. However some parents and families have difficulty doing this.  If one or both parents have significant anxiety, and especially if the anxiety is untreated, they may be modeling an anxious response in words or other behaviors or may not be able to complete exposures.   Many parents with anxiety who have formally received treatment or found their own ways to challenge themselves despite anxiety can be excellent coaches.  

    Parents very appropriately model for their kids coping by speaking out loud in the moment how they cope or describe how they coped in past situations.  A parent might say, “I was pretty nervous to talk to someone at work about something I did not like because I did not want them to be mad at me or I did not want to look stupid.  So I thought about how I wanted to say it and looked for a good time to talk to my coworker.  It was hard because they were a little upset when I talked to them, but later at lunch we were able to talk again comfortably.”  Often parents who cannot manage their own anxiety particularly well can still provide support and coaching for their child.

    Other parents with or without anxiety might have strongly held beliefs either about parenting or anxiety that make it hard for them to feel that it is ok or safe for their child to be anxious.  Oftentimes a session or two with parents alone focused on hearing their concerns with patience and understanding can lead these to be evaluated and challenged by attending to their child’s actual experience in treatment.   It can be really enlightening for a parent to see a child either do an exposure with the therapist or come back from an exposure and report to the parent what they did.  For example, parents will be surprised sometimes to hear the child did an exposure such as asking for a book in a bookstore or talking to another child in the waiting room.  Seeing their child actually competent in doing these tasks helps challenge the belief about the child or anxiety.  Also if there is one parent who is less anxious, that parent can do the exposures alone with the child first to help the child feel confident and competent and then transition to practicing with the more anxious parent.

    Family accommodation has been well documented to directly relate to severity of OCD and anxiety symptoms.  Improvements in limiting family accommodation lead to improvements in OCD and anxiety symptoms.  Whereas in OCD family accommodation is often related to involvement in rituals, in the other anxiety disorders accommodation can take forms such as allowing avoidance or doing things for the child rather than promoting independence (Liebowitz, Scharfstein & Jones,2014; Merlo, Lehmkuhl, Geffken & Storch, 2009).

    Improving Relationships with Caregivers

    The third level of intervention is work on improving family relationships including improving communication, lowering conflict and promoting autonomy and independence.  In some families, the level of conflict or anger or difficulties in communication can really limit the ability to do the CBT treatment.  Therapists can decide if they have the interest in and experience working with families on these issues prior to or concurrent with CBT treatment.   Otherwise families can be referred to individual, couples or family treatment with another provider.  Both research studies and clinical experience show that many children and teens can make major improvements in CBT treatment even if their family does not change so it is important to keep offering the individual treatment option even in the family is not willing to engage in family work. The main difficulties that can arise when just an individual treatment model is used include therapy-interfering behaviors that take the form of parent accommodation, avoidance or parental difficulty helping children in anxious moments.

    However other therapists can decide to take on the often rewarding and crucial work in some cases to meet with different family members to improve communication, lower conflict, increase closeness and attachment. Especially teens, but also younger children, are amazing at telling their parents how they feel when their parent reacts in a certain way.  They might be able to tell parents how they feel when their parent gets anxious, or how it feels when the parent is mad when the child cannot help their anxiety reaction.  For some families individuation and contrasting beliefs or choices are compromised for fear of conflict, hurting others feelings, or guilt.  This family work is best done carefully and thoughtfully and working with child, parents / caregivers or dyads separately to plan for different kinds of conversations.  Therapists can evaluate for kids and teens whether it is safe or useful for a child or teen to express their feelings and whether or not the parent is willing to listen and can be helped to hear.  Families can be helped to promote competence and independence in their children and to “enact” different conversations and interactions (Bogels & Siqueland, 2016). Parents also need a safe place to discuss any differences in parenting philosophy or beliefs about anxiety that are limiting their ability to help their child.  Therapists can often help parents to find a compromise approach or to respectfully tag team using different strengths and contributions of each parent.  This third level of intervention is not needed for all families.

    Bogels, S & Siqueland, L. (2006). Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2) 134-141.

    Ginsburg, GS, Drake KL, Tein JY Teetsle, R and Riddle, M.  (2015).  Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. American Journal of Psychiatry, 172:1207-1213.

    Lebowitz  ERScharfstein LA and Jones. J. (2014). Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children, Depression and Anxiety, 31(12):1018-25.

    Manassis K., Lee, T.C., Bennett, K., et al (2014). Types of parental involvement in CBT with anxious youth: a preliminary meta-analysis. Journal of Consulting and Clinical Psychology, 82 (6):11631172.

    Merlo, L, Lehmkuhl, HD, Geffken, GR & Storch, E A (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive–compulsive disorder, Journal of Consulting and Clinical Psychology, Vol 77(2), 355-360.

    Rapee, RM  (2012). Family Factors in the Development and Management of Anxiety Disorders, Clinical Child and Family Psychology Review, Volume 15 (1) pp 69-80

    Thirlwall,  K, Cooper, PJKaralus, JVoysey, MWilletts LCreswell C  (2013).  Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial. British Journal of Psychiatry. Dec; 203(6): 436-44.

    Note: This article is based on the PBTA workshop entitled, “Family involvement in the treatment of children with anxiety disorders,” that was given by Lynne Siqueland, Ph.D. and Deborah Ledley, Ph.D.

    Published February 3, 2018

  • 09/02/2017 9:45 AM | Anonymous

    Joanna Kaye, MS - Department of Psychology, Drexel University

    A large body of literature has determined that exposure-based cognitive-behavioral therapies are highly effective for a variety of anxiety disorders (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). Exposure therapies (ET) refer to a group of treatments that use exposure techniques to help individuals confront feared stimuli in a prolonged, repeated, and intense manner (Richard & Lauterbach, 2007). The various forms of exposure techniques include in vivo exposure (i.e., directly confronting feared stimuli in the real world), simulated exposure (i.e., confronting feared stimuli through role-play or “simulated” real-world scenarios), imaginal exposure (i.e., recounting anxiety-provoking thoughts or images verbally or in the form of written narratives), and interoceptive exposure (i.e., intentionally invoking feared body sensations). 

    Meta-analyses have determined that exposure-based cognitive-behavioral treatments (CBTs) lead to symptom improvement with large effect sizes in the treatment of panic disorder, specific phobia, social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD; Bandelow et al., 2015; Deacon & Abramowitz, 2004; Mayo-Wilson et al., 2014; Olatunji, Davis, Powers, & Smits, 2013; Olatunji et al., 2010). Additionally, exposure to feared stimuli is widely considered an empirically-supported principle of behavior change for anxiety disorders (Lohr, Lilienfeld, & Rosen, 2012). Exposure techniques are the cornerstone of CBT protocols for anxiety disorders, so much so that many debate if other treatment components add any incremental benefit above exposure alone (Barrera, Szafranski, Ratcliff, Garnaat, & Norton, 2016; Olatunji et al., 2010). 

    Given this evidence, why aren’t all mental health clinicians using exposure?

    Despite the demonstrated efficacy of ET, many therapists do not use exposure therapy or use it only rarely (Becker, Zayfert, & Anderson, 2004; Freiheit, Vye, Swan, & Cady, 2004; Hipol & Deacon, 2013; Whiteside, Deacon, Benito, & Stewart, 2016). A key factor is lack of adequate dissemination of ET training. However, even when therapists indicate that they endorse a cognitive-behavioral orientation and have been trained in the use of exposure therapy methods, many report they do not utilize these methods or use them only infrequently. Given the established efficacy of exposure treatments for anxiety disorders, it is critical that we expand efforts to understand how to increase implementation of exposure techniques. 

    Another concerning factor related to the implementation of ET is the research that has found that even among therapists who report using exposure techniques, many do not deliver them in an optimal manner. Therapists in community settings appear to utilize client-directed exposure substantially more than therapist-directed exposure (Freiheit et al., 2004; Hipol & Deacon, 2013), which is concerning given indications that self-directed exposure is less effective (Abramowitz, 1996). Additionally, although findings suggest that effective exposure treatment requires its delivery in a prolonged, repeated, and intense manner, many therapists also endorse promoting arousal reduction techniques (e.g., deep breathing exercises) during exposure, despite theoretical and empirical contraindications for doing so (Blakey & Abramowitz, 2016; Schmidt et al., 2000). For example, Deacon and colleagues (2013) found that many therapists delivering interoceptive exposure for panic disorder utilized controlled breathing strategies during delivery, which have shown no benefit in treatment and stand in direct contrast to the prolonged and intense delivery suggested by validated treatment manuals. 

    Given the efficacy of exposure therapies for anxiety disorders, it is critical to examine the reasons behind underutilization and improper use of these methods. Many factors are likely to impede dissemination and effective implementation, including lack of adequate training, persistent beliefs that empirically-supported treatments conducted in research settings are irrelevant to clinical practice, therapists’ overemphasis on clinical intuition, and therapist concerns about exposure therapy (Deacon & Farrell, 2013). 

    What do we do about this?

    Research must determine how to improve the implementation of exposure therapy through clinical training. Further investigation onto the barriers to dissemination and effective training will provide guidance about how to achieve these goals. Mental health clinicians clearly desire more training in exposure therapy. However, the question remains: which training method will prepare clinicians to deliver the most effective exposure therapy?

    Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600.

    Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 30(4), 183-192.

    Barrera, T. L., Szafranski, D. D., Ratcliff, C. G., Garnaat, S. L., & Norton, P. J. (2016). An Experimental comparison of techniques: Cognitive defusion, cognitive restructuring, and in-vivo exposure for social anxiety. Behavioural and Cognitive Psychotherapy, 44(2), 249-254.

    Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277-292.

    Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1-15.

    Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60(4), 429-441.

    Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In Handbook of treating variants and complications in anxiety disorders (pp. 363-373). New York: Springer.

    Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J., Sy, J. T., Zhang, A. R., & McGrath, P. B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale. Journal of Anxiety Disorders, 27(8), 772-780.

    Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive-behavioral therapy for anxiety: Is dissemination working?. The Behavior Therapist, 27(2), 25-32.

    Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming A survey of practicing psychotherapists. Behavior Modification, 37(2), 170-188.

    Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.

    Lohr, J. M., Lilienfeld, S. O., & Rosen, G. M. (2012). Anxiety and its treatment: Promoting science-based practice. Journal of Anxiety Disorders, 26(7), 719-727.

    Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

    Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91-110.

    Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America, 33(3), 557-577.

    Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33-41.

    Richard, D. C. S. & Lauterbach, D. L. (2007). Handbook of exposure therapies. Boston: Academic Press.

    Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424.

    Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders40, 29-36.

    Published September 2, 2017

  • 08/30/2016 9:47 AM | Anonymous

    Ronald S. Kaiser, PhD, ABPP - Jefferson Headache Center, Thomas Jefferson University

    The American Migraine Prevalence Study (Lipton et al, 2007), the largest study of migraine in America ever conducted, found that 12% of Americans have migraine, and 90% of them can’t function normally on days when they have migraine.  30% of them are bedridden on those days.  Obviously, that level of impairment impacts quality of life as well as mood.

    Working with migraine headache patients can be challenging, but it can also be one of the most rewarding therapeutic experiences that can occur for both the patient and the therapist – so long as each pursues the therapeutic process with the proper mindset.  Because of the size of the migraine population, there has been considerable research to provide guidance for understanding and treating migraine patients.

    Reviews of the literature (Kaiser et al, 2015, Kaiser et al, 2016), as well as clinical experience, provide principles for psychotherapeutic effectiveness in treating migraine patients.

    1. In almost every case, migraine is a neuro-biochemical disorder that may include pain, nausea, light and sound sensitivity, and fatigue. Various brain chemicals have been implicated in the migraine process including serotonin, norepinephrine, and calcitonin gene-related peptide (CGRP).  Unlike many other types of pain patients whose pain is caused by structural damage (e.g., herniated or bulging discs, diabetic neuropathy), improved control over physiology can lead to lasting changes. Thus, migraine patients don’t have to assume that “living with the pain” is as good as it can get.  Some individuals are currently disabled or otherwise impaired by their head pain, but it is important to be mindful of the fact that MIGRAINE PATIENTS CAN GET BETTER.
    2. The term, migraine, is not a description of the degree of impairment that the patient may be experiencing. Since most people have had headaches, some of which have been accurately or inaccurately described as migraine, there is a good chance that the therapist working with the migraine patient has had headaches him/herself.  It is important to not assume that the patient’s experience is the same as that of the therapist.  Listen to the patient’s description of pain and also ask about associated symptoms.
    3. Appropriately diagnosed migraine is neither a terminal illness nor the type of disorder that deteriorates organs, but it does negatively impact upon quality of life. Migraine can reduce or severely limit productivity at school or work, curtail social involvements, affect family relationships, and cause the patient to feel physically and emotionally drained even when overtly functioning in a successful manner.
    4. Migraine patients don’t wear badges such as casts, walkers, etc. Because they look “normal”, many have had to deal with the stigma of being seen as having weakness, hypochondriasis, drug-seeking behaviors, and secondary gains (Young et al, 2013).  To cope with being stigmatized, patients may develop counterproductive coping strategies.  McCrea et al (2013) found that such patients developed a dislike for interacting with others, while Waugh et al (2014) found that internalized stigma had a negative relationship with self-esteem and pain self-efficacy – even when controlling for depression.  In many cases, stigmatizers have included medical and mental health professionals as well as family members, friends, and coworkers.  Until proven otherwise, the patient may not trust your ability to be empathic.
    5. Without proper guidance, many headache patients develop their own coping strategies – with differing degrees of appropriateness and effectiveness.   In some cases, they may overuse medications for pain in order to keep functioning.  Some patients withdraw from normal activities for fear of aggravating their headaches, and they become physically and emotionally deconditioned and depressed.  Others have mastered the art of being a migraine patient – treating the migraine as part of life, but not part of the definition of self.

    For the therapist, there can be no better patient than a motivated headache patient.  Regardless of the patient’s current means of coping, there usually is a history of success that can be called upon.  There is the probability of getting better, and there usually are some bad habits that can be changed to reduce the centrality of the headache.  When migraine patients feel they are being understood, they typically become willing allies in their treatment.  

    If the patient is getting appropriate medical treatment, the therapist is part of a treatment team.  Long before integrated care became a buzzword, cooperation between physicians and mental health professionals was taking place in the field of headache medicine

    There have been many psychological approaches to migraine treatment. Although some appear to be promising, such as acceptance and commitment therapy (ACT), mindfulness, neurofeedback, and yoga, there are four approaches that have attained an “A” rating from the U.S. Headache Consortium:  relaxation training; thermal biofeedback plus relaxation training; EMG biofeedback; and cognitive-behavioral therapy (CBT) (Silberstein, 2000).

    Because of its focus upon the thinking process as an agent of change, CBT is particularly well-suited to working with headache patients whose typically good cognitive functioning enables them to be active participants in their treatment plans (Kaiser & Weatherby, 2009).  In addition, while both anxiety and depression significantly affect headache-related quality of life (HRQoL), catastrophizing has been found to be an independent and greater predictor of HRQol – as it intensifies the negative aspect of pain and exaggerates helplessness (Holroyd et al, 2007). Of course, a major focus of CBT is the reduction of catastrophic thinking.

    The positive focus utilized in working with migraine patients has led to the widespread incorporation of positive psychology techniques in the treatment process.  Goal-Achieving Psychotherapy (GAP), a unique offshoot of CBT and positive psychology, was developed, based upon strategies that have been successfully implemented to promote positive behavior change at the Jefferson Headache Center in Philadelphia (Kaiser, 2012).

    Certain principles have emerged in our work that can be helpful in guiding the mental health professional in working with migraine patients.

    1. Any patient with chronic and/or debilitating migraine needs to be under the care of a knowledgeable and supportive physician who has done an appropriate evaluation to determine whether we are dealing with a primary migraine disorder or whether the patient’s pain is secondary to a medical condition that has to be addressed differently.
    2. As with any therapy patient, a comprehensive history should be taken to determine whether, instead of dealing with a primarily medical disorder, we are dealing with a symptom of a complicated psychological issue that requires special attention - such as past trauma or severe psychopathology such as a delusional disorder or dissociation.
    3. Because migraine patients often have a history of being misunderstood, marginalized, and stigmatized, therapeutic empathy is particularly important in working with this population.
    4. Migraine-oriented treatment needs to be positive, forward looking, and active. Homework assignments provide a system for measuring progress.
    5. While CBT is an effective treatment modality, it is important to not just address negative thoughts and irrational statements, but also to quickly get the patient into a positive mindset by addressing what can go right.
    6. Research is quite clear in reflecting the fact that positive change and progress in three main areas  - health and fitness, intellectual functioning, and social functioning - is associated with achievement and happiness (Achor, 2010). Working on improving one’s body, mind, and character is incompatible with spending an inordinate amount of time focusing upon one’s pain.  Goals for improvement need to be realistic and individually designed to maximize chances for success.
    7. Incorporating techniques such as biofeedback, meditation, and yoga can aid the patient in gaining a sense of control over seemingly involuntary aspects of physiology.  Techniques that can help regulate physiology may have the added side-effect of helping migraine patients reduce or wean from their medications over time.
    8. Speaking of medications, it is important for the therapist working with migraine patients to be aware of the range of effective preventive and abortive medications that utilized to treat migraine as well as being knowledgeable of guidelines for their use.  Conversely, it important to recognize which medications should not be used. Because we are not trying to promote the notion of indefinitely living with pain, headache physicians discourage excessive use of pain medications, especially opioids.  Even the daily use of over-the-counter analgesics can cause changes in physiology that interfere with the potential for effective headache control.
    9. It is not accidental that a physical and socially bonding activity has evolved as a centerpiece of the migraine awareness movement.  Now taking place in several cities, Miles for Migrainerun/walk events enable migraine patients, family members, health care professionals, and other supporters to live the message that migraine needs to be confronted proactively rather than reacted to in a passive manner. It is part of good mental health treatment for the therapist to encourage patients to participate in such physical activities at a level consistent with their abilities.  In addition, monies raised from Miles for Migraine events support research and public awareness of migraine – enabling patients and their supporter to be actively involved in reducing the stigma of migraine and ultimately achieving control over the disease.

    Despite all the progress that has been made, migraine is a stubborn disorder that does not always respond to appropriate medical treatment.  Treating migraine is a process.  Neither the patient nor the therapist can expect it to follow the type of predictable course that people have learned to expect from a bout with the flu or the recovery following a surgical procedure.  Patience is required, and sometimes it is required for a pretty long time.  Being active, however, reduces the centrality of the migraine in the patient’s life. Progress in making positive changes that affect body, mind, and character provide the evidence that change can occur – as can the recognition that, once the bad stuff has been ruled out, we are working on a potentially solvable problem.  The therapist’s role includes being a cheerleader for change because, indeed, MIGRAINE PATIENTS CAN GET BETTER.

    Achor, S. (2010). The happiness advantage. New York: Crown.

    Holroyd, K., Drew, J., Cottrell, C., Romanek, K., & Heh, V. (2007). Impaired functioning and quality of life in severe migraine: The role of catastrophizing and associated symptoms. Cephalalgia, 27(10), 1156-65.

    Kaiser, R. (2012). Goal-achieving psychotherapy.  Retrieved from

    Kaiser, R., Kurzyna, A., & Mooreville, M. (in press). Psychological factors and headache. Medlink Neurology.

    Kaiser, R., Mooreville, M., & Kannan, K. (2015) Psychological interventions for the management of chronic pain: A review of current evidence. Current Pain and Headache Reports, 9, 43. doi: 10.107/s11916-015-0517-9.

    Kaiser R, & Weatherby S. (2009). Psychology in headache management. In: Kernick D, Goadsby PJ (eds). Headache: A practical manual. Oxford: Oxford University Press, 248-251.

    Lipton,R., Stewart, W., Diamond, S., Diamond,M., & Reed, M.  (2001). Prevalence and burden of migraine in the United States: Data from the American migraine study II. Headache61, 646-657.

    McCrea, S, Kaiser, R., & Young, W. (2014) The relationship between personality factors and perceptions of stigma in chronic and episodic migraine patients. Headache, 54, :59.

    Silberstein, S. (2000) Practice parameter: Evidence-based guidelines for migraine headache (an evidenced-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology, 55(6), 754-762.

    Waugh, O., Byrne, D., & Nicholas, M. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 1-10.

    Young, W., Park, J., Tian, I., & Kempner, J. (2013). The stigma of migraine. Plos One. Retrieved from

    Published August 30, 2016

  • 07/28/2016 9:49 AM | Anonymous

    Melissa Hunt, PhD - University of Pennsylvania Department of Psychology

    People with chronic GI disorders fall into two large categories – those with functional disorders like Irritable Bowel Syndrome (IBS) and those with disorders in which tissue pathology and other pathognomic indicators can actually be identified, like the Inflammatory Bowel Diseases including Crohn’s and ulcerative colitis. Surprisingly, both groups can benefit enormously from cognitive-behavioral therapy.

    IBS is characterized by recurrent abdominal pain that is relieved by defecation, and is accompanied by abnormalities in the frequency and/or form of bowel movements (i.e. characterized by constipation, diarrhea or an alternating mix of the two.)  In practice, individuals with IBS often experience urgency and develop a number of maladaptive coping strategies, most of which are designed to help them avoid visceral sensations and the possibility of needing to get to a bathroom urgently and not making it “in time.”  Many people with IBS develop catastrophic cognitions about pain, about the possibility of incontinence and about the potential repercussions, both socially and occupationally, of needing the bathroom both frequently and urgently and not being able to “hold it.”  Many people with IBS also develop considerable avoidance behaviors which can meet diagnostic criteria for agoraphobia.  Avoidance can include many feared “danger” foods which are believed to “trigger” IBS “attacks” and avoidance of situations in which getting to a bathroom quickly and unobtrusively might be difficult.  That includes numerous venues (malls, parks, stadiums, concerts, places of worship) and numerous situations (long drives, trains, planes, work environments that prohibit quick exits such as classrooms, reception, factory work, conference calls, and so on.)  In many ways, IBS falls at the intersection of panic disorder with agoraphobia and social anxiety disorder, along with significant health anxiety and catastrophizing about both pain and other visceral sensations.

    Fortunately, CBT is very well adapted to tackle both catastrophic cognitions and maladaptive avoidance behavior.  Indeed, CBT is the intervention with the most empirical support in the treatment of IBS. With a little knowledge and minor adjustments, most CBT practitioners can probably address the concerns of IBS patients.  First, one should always start with a good assessment, including coordination of care with medical providers in order to review the patient’s medical history and the various diagnostic procedures they have undergone.  In most cases, the diagnostic tests will all have been negative.  If the patient has not been tested for celiac disease (an autoimmune disorder that leads to true gluten intolerance), they should be, as this is an important differential medical diagnosis to rule out.  However, extensive, invasive testing, including colonoscopy and endoscopy is not recommended by current medical guidelines , unless the patient has “alarm” symptoms (such as blood in the stool, inflammatory markers in the blood or stool, fever, nutrient deficiencies or unexplained weight loss) that may signal an underlying inflammatory process (Brandt et al., 2009).  The next step is psychoeducation about how stress can result in sympathetic nervous system arousal and reduced parasympathetic autonomic activity that directly affect the gut.  This is important because it provides the rationale for relaxation training and stress management strategies like cognitive restructuring and CBT more generally. Next comes relaxation training, especially deep diaphragmatic breathing, which has been shown to optimize GI motility, as well as sympathovagal balance and heart rate variability.

    Once the patient has a better grasp on the relationship between stress, distress and GI discomfort and is using deep breathing (and/or other strategies including mindfulness, imagery, progressive muscle relaxation and so on) effectively, the therapist can move on to the basic CBT model, introducing the notion that beliefs (not situations) affect our emotions and that beliefs can be right or wrong.  This is all standard CBT fare (thought records, benign alternatives, evaluating evidence) but will often have to focus on situations in which the person’s gut is acting up.  Behavioral experiments are an important part of this process.  For example, send the patient to a movie theater or house of worship, have them sit in the very back, and count how many people actually get up at some point to leave and then come back.  They will be surprised by how often this happens and how little most people react.

    Finally, in vivo exposure therapy that reduces behavioral avoidance is a crucial part of every successful treatment for IBS.  This may need to include food (hint – there are no “danger” foods), food-related situations, abdominal sensations, and any situation the person avoids for fear of not being able to get to a bathroom in time.  Using standard in-vivo exposure strategies (e.g. constructing a fear hierarchy and working up it using graded exposure) works quite well.  For example, if the person is afraid of long car trips, have them sit in the car in their driveway for 30 minutes.  Then progress to driving around the block near their home 20 times.  Then drive a mile away and drive back.  At home, when they feel the urge to defecate, see if they can delay going to the bathroom for 1 minute.  After mastery of 1 minute then try increasing the duration of time (2,3…5 minutes) so the person learns that they can indeed “hold it” without experiencing incontinence. Such exposure can be a huge confidence booster.

    Another important area to target is “subtle” avoidance, especially use of a pharmacopeia of medications including anti-diarrheal agents, anti-gas agents and antacids.  Patients will often insist that it is perfectly rational and sensible to use these medications, but further probing will often reveal that they are using them in maladaptive ways that perpetuate the cycle of anxious avoidance.  For example, if the person knows they have a stressful day coming up at work, they may take one or two Imodium before they even leave the house just in case.  Many will recognize such safety behaviors as similar to those seen in people with panic disorder who use benzodiazepines PRN to fend off possible panic attacks.  Whether or not the person also meets diagnostic criteria for anxiety disorders, this safety utilization behavior will maintain distress if not targeted in treatment. Moreover, while anti-diarrheal medications are quite safe, they can cause constipation and bloating and thus also perpetuate further avoidance and distress and maintain maladaptive beliefs.  For example, people can become convinced that needing to poop is a catastrophe to be avoided at all costs.  Turns out that getting people to stop using these medications on a regular basis is an important part of reducing GI specific catastrophic cognitions and visceral sensitivity, and ultimately it actually leads to reductions in abdominal discomfort and urgency.

    Many IBS patients can benefit from a self-help book that makes this entire protocol accessible and easy to implement on their own.  Reclaim Your Life from IBS: A Scientifically Proven Plan for Relief Without Restrictive Diets (available at Amazon or Barnes and Noble online) was tested in a randomized controlled trial and was shown to be quite effective (Hunt,Ertel, Coello, & Rodriguez, 2014). It can also be used as a treatment manual or guide for interested clinicians.

    Unlike IBS, inflammatory bowel diseases lead to actual tissue damage and can have life threatening complications.  They are auto-immune disorders that have a genetic basis and are probably related in part to disruptions in both the immune system itself and the microbiome of the gut.  They are less prone to stress related exacerbations than IBS (Kovács & Kovács, 2007) but stress is still implicated in symptom exacerbation and relapse (Sajadinejad, Asgari, Molavi, Kalantari, & Adibi, 2002).  In addition, CBT for GI disorders can have a very positive effect on health related quality of life, catastrophizing, visceral sensitivity and the secondary depression and anxiety that accompany many chronic and serious health conditions.  CBT for IBDs varies somewhat from CBT for IBS, in that people may actually need to get to rest rooms urgently, may struggle with fecal incontinence, and may require significant medical management to target both the underlying inflammatory/auto-immune problems and the symptoms themselves.  For individuals with IBDs, it is important to learn to distinguish between abdominal discomfort that can be safely ignored and abdominal pain that signals either a flare or a serious complication like a small bowel obstruction.  There is a current trial ongoing at the University of Pennsylvania testing a self-help CBT protocol for IBD patients against an active psychoeducational control.  If you know an IBD patient who might benefit from a GI informed approach to CBT, consider encouraging them to enroll in the trial.  They can learn more at

    Brandt, L. J., Chey, W. D., Foxx-Orenstein, A. E., Schiller, L. R., Schoenfeld, P. S., Spiegel, B. M., & ... Quigley, E. M. (2009). An evidence-based position statement on the management of irritable bowel syndrome. The American Journal Of Gastroenterology, 104 Suppl 1S1-S35. doi:10.1038/ajg.2008.122

    Hunt, M., Ertel, E., Coello, J., & Rodriguez, L. (2015). Empirical Support for a Self-help Treatment for IBS. Cognitive Therapy & Research, 39(2), 215-227.

    Kovács, Z., & Kovács, F. (2007). Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease.International Journal Of Psychiatry In Medicine, 37(3), 245-255. doi:10.2190/PM.37.3.a

    Sajadinejad, M. S., Asgari, K., Molavi, H., Kalantari, M., & Adibi, P. (2012). Psychological issues in inflammatory bowel disease: an overview. Gastroenterology Research And Practice, 2012106502. doi:10.1155/2012/106502

    Published July 28, 2016

  • 07/23/2016 9:50 AM | Anonymous

    Michael Morrow, PhD - Arcadia University

    Evidence-based practice (EBP) in clinical and counseling psychology is both an ethical and social justice imperative. Clients of all backgrounds deserve the psychosocial treatments most likely to benefit them and not cause harm (Lilienfeld, 2007). Accordingly, graduate programs are charged to provide students with sufficient preparation in EBP. Ideally, students should graduate their programs with a clear understanding of EBP, emerging skills in empirically supported assessments and treatments, and a firm commitment to maintaining an evidence-based orientation throughout their careers (Morrow, Lee, Bartoli, & Gillem, 2016). While graduates will undoubtedly require further training to master EBP, their education should plant the seeds needed to later bloom into competent evidence-based practitioners.

    As a clinical psychologist (reared in a clinical science program) and a counselor educator, I am tasked with the privilege and challenge of helping MA-level counseling students begin their transformation into evidence-based practitioners, all in roughly three years of coursework and applied training. MA-level practitioners comprise the bulk of frontline mental healthcare in many communities (Weisz, Chu, & Polo, 2004); thus, it is critical to provide them with strong training in EBP. Over the past five years, I have learned that guiding students toward competence in EBP is no easy feat; in fact, simply helping them grasp the meaning of EBP is a major challenge, especially in light of the many misinterpretations that plague the field.

    While definitions have evolved over time, EBP currently represents a broad framework for clinical decision making and service based on three key components: the strongest available research, clinical expertise, and client characteristics (e.g., preferences, strengths, and culture; Kazdin, 2008). When (and only when) these three components are thoughtfully and continually integrated throughout treatment, EBP occurs. Recent models also emphasize the role of the therapeutic relationship and other common factors (Ackerman et al., 2001).

    Unfortunately, many students fail to internalize EBP as an overarching orientation and reduce it solely to using empirically supported treatments (ESTs): interventions supported by rigorous research for particular disorders (Norcross & Karpiak, 2012). While EBP involves using ESTs, it is a broader framework for decision making and intervention. This tendency to minimize EBP to ESTs is well documented (Luebbe, Radcliffe, Callands, Green, & Thorn, 2007) and poses a significant barrier to the proliferation of EBP. Creative teaching strategies are needed to ensure that students acquire a fuller and more accurate understanding of EBP.

    Learning theory and research indicate that metaphors can be powerful teaching tools (Hansen, Richland, Baumer, & Tomlinson, 2011). Recently, I developed a metaphor to introduce EBP to counseling students. As a novice painter, I liken EBP to oil painting. I start by explaining that artists utilize a variety of tools (brushes, paint knives, and palettes) to mix and apply various materials (gesso, paint, and varnish); these tools and materials are analogous to practitioners’ knowledge and skills, including their competence in making evidence-based decisions, building strong therapeutic alliances, conducting and interpreting assessments, and delivering specific interventions (e.g., cognitive behavior therapy or exposure and response prevention).

    I then add to the metaphor the adoption of an evidence-based orientation. Artists often begin oil paintings by covering the whole canvas with a wash of acrylic paint (e.g., a flat layer of light blue acrylic paint). While numerous layers of paint will be added atop, this wash provides an underlying tone for the entire piece (i.e., the blue wash will interact with each new layer of paint). This acrylic wash represents the adoption of an overarching evidence-based orientation, a guiding framework that colors key clinical decisions, such as choosing assessment tools, formulating conceptualizations, selecting treatment modalities, tailoring interventions, and monitoring progress. To illustrate this point, I ask students to visualize a blank treatment plan and imagine painting “EBP” in a light hue across the background (Figure 1).

    Figure 1

    Next, I add to the metaphor the process of utilizing research to guide treatment planning. Once the acrylic wash has dried, artists add their first layer of oil paint, which typically blocks out major forms (e.g., a flat grey patch denoting a mountain range) and creates a basic composition for the piece. Regarding EBP, this first layer reflects evidence from the best available research (Lilienfeld et al., 2013). When the research base is strong for treatments targeting a particular condition, it offers a very clear picture for treatment.

    For instance, when working with a child with significant disruptive behavior, rigorous efficacy studies deem behavioral parent training a well-established intervention (Eyberg, Nelson, & Boggs, 2008). In this example, students can visualize themselves painting “behavioral parent training” atop a treatment plan already washed in a background of EBP (Figure 2). However, when research is lacking (e.g., ESTs for child Adjustment Disorders), it provides a much fainter picture of treatment. In these cases, practitioners must rely more heavily on the other components of EBP: clinical expertise and client characteristics.

    Figure 2

    I next introduce practitioners’ use of clinical expertise. Artists then add additional layers of oils and other materials (varnish, sand, stones) atop the previous layers to achieve various effects (detail, contrast, texture, depth, shine). Relative to EBP, these new layers reflect the integration of practitioners’ professional expertise to fill in any major gaps left uncovered by the extant research. In working with a child with an Adjustment Disorder, a practitioner could draw from her experience working with youth with this disorder or similar symptomology. If the child is presenting with a mix of internalizing symptoms, the practitioner could utilize well-established treatments (e.g., cognitive behavior therapies) for pediatric anxiety or depression.

    Moreover, the final layers reflect practitioners’ efforts to incorporate client characteristics into treatment. In discussing this topic, it is critical to distinguish “modifying” and “tailoring” treatments. When modifying, practitioners alter treatment in a substantial way (e.g., removing elements or delivering components out of sequence). While such modifications can be justified (Lindhiem, Bennett, Trentacosta, & McLear, 2014), evidence-based practitioners are more likely to tailor by infusing client characteristics into the treatment framework (e.g., offering examples to match clients’ interests and building upon clients’ resources and values to help them reach their goals; Figure 3). This process reflects the notion of “breathing life” into an evidence-based protocol (Kendall, Chu, & Gifford, 1998), and, in my opinion, represents the precise point where the science and art of therapy intersect in the context of EBP.

    Figure 3

    Finally, I tack two remaining concepts onto the metaphor: progress monitoring and objective thinking. Artists frequently step back to view their work from afar (and from various angles). Similarly, evidence-based practitioners repeatedly examine clients’ progress by carefully monitoring changes in symptoms and behaviors. Stepping back to evaluate the full course of treatment offers invaluable information to further case conceptualization and treatment planning. Moreover, viewing a painting from different angles is analogous to considering alternate plausible hypotheses (e.g., reevaluating the primary factors maintaining a problematic behavior), which is critical to avoiding errors in clinical judgment (Spengler & Strohmer, 1994).

    As paintings evolve with each brush stroke, the initial acrylic wash remains a unifying foundation for the entire work, just as an evidence-based orientation should guide the entire course of treatment.  While I have experienced some success with this metaphor, I encourage other educators to develop their own based on their personal interests (e.g., sport, dance, music, cooking). Further, it would be helpful to start a field-wide dialogue on methods for teaching EBP, perhaps via a dedicated listserv or even an edited volume of different pedagogical approaches. Finally, I challenge all graduate instructors to guide their students to practice teaching others about EBP in order to prepare them to “carry the torch” from their education into the mental health landscape and paint their own pictures of EBP.

    Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C., et al. (2010). Empirically supported therapy relationships: Conclusions and recommendations for the Division 29 Task Force. Psychotherapy: Theory, Research, Practice, Training, 38, 495-497.

    Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37, 215-237.

    Hansen, J., Baumer, E. P. S., Richland, L., & Tomlinson, B. (2011). Metaphor and creativity in learning science. Paper presented at the annual conference of the American Educational Researchers Association, New Orleans, LA.

    Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146-159.

    Kendall, P. C., Chu, B., & Gifford, A. (1998). Breathing life into a manual: Flexibility and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5, 177-198.

    Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.

    Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

    Lilienfeld, S. O., Lynn, S. J., Ritschel, L. A., Cautin, R. L., & Latzman, R. D. (2013). Why many practitioners are resistant to evidence-based practice in clinical psychology: Root causes and constructive remedies. Clinical Psychology Review, 33, 883-900.

    Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence-based practice in psychology: Perceptions of graduate students in scientist practitioner programs. Journal of Clinical Psychology, 63, 643-655.

    Morrow, M. T., Lee, H., Bartoli, E., & Gillem, A. (2016). Strengthening counselor preparation in evidence-based practice. Submitted to the International Journal for the Advancement of Counseling.

    Norcross, J. C., & Karpiak, C. P. (2012). Teaching clinical psychology: Four seminal lessons that all can master. Teaching of Psychology, 39, 301-307.

    Spengler, P. M. & Strohmer, D. C. (1994). Counselor complexity and clinical judgment:  Challenging the model of the average judge. Journal of Counseling Psychology, 41, 1-10.

    Published July 23, 2016

  • 07/12/2016 9:56 AM | Anonymous

    Irismar Reis de Oliveira, MD, PhD - Professor of Psychiatry, Department of Neurosciences and Mental Health, Federal University of Bahia, Brazil

    TBCT is a new branch of Beckian cognitive-behavior therapy (CBT) that organizes known standard CBT and behavioral techniques into a step-by-step fashion.  In developing TBCT, my goal was to make CBT easily mastered by the therapist and more easily understood by the patients. TBCT should  also be simpler to be implemented and maintain CBT’s recognized effectiveness and transdiagnostic feature (de Oliveira, 2015; 2016). A detailed case illustration may be found on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012a).

    Inspiration for the development of TBCT came initially from the novel The Trial, by Franz Kafka (1925/1998). Although it was not the first time the courtroom metaphor was used in CBT – Freeman and DeWolf (1992), Cromarty and Marks (1995), and Leahy (2003) had already used this metaphor –, my idea was conceptualizing core beliefs (CBs) as self-accusations and giving all the columns of the traditional dysfunctional thought record (DTR) the courtroom connotation (de Oliveira, 2011). For instance, the column corresponding to the evidence confirming the CB would bring the prosecutor’s plea, and the evidence not supporting it would carry the defense attorney’s statements. The newly derived 7-column DTR, named trial-based thought record (TBTR; de Oliveira, 2008), contained several well-known traditional CBT techniques like the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). A more detailed case illustration may also be downloaded on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012b).

    Several studies conducted in the last decade support the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012). For instance, TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013). The conclusion reached by the above-mentioned studies was that TBTR might help patients reduce the credibility attached to the negative CBs and the intensity of corresponding emotions, regardless of the diagnosis.

    New techniques were progressively added to the TBTR, resulting in TBCT. Such techniques were modifications of standard CBT and other approaches. Consequently, TBCT is an example of assimilative psychotherapy integration (Messer, 1992), in which various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). From the time of its original development, TBCT relied on Beckian CBT as the organizing theory, and subsequently added technical interventions drawn from several other approaches. Among them were Gestalt, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell’s (1988) two-person relational model.

    TBCT has its own case conceptualization, which makes it an individualized approach. It is divided into 3 levels and 3 phases, and includes a cyclic interactional mechanism in which components in each level influence the others, and flexibly allow the therapist to adapt the treatment to the individual’s features (de Oliveira, 2016).

    Figure 1 depicts the three levels of information processing in the TBCT conceptualization diagram, and shows how a situation that is appraised in a biased fashion by the automatic thought (AT) elicits a dysfunctional negative emotion, which, in turn, produces undesired consequences in terms of behaviors and/or physiological responses. Figure 1 also contains arrows pointing back to the emotion, ATs and the situation, meaning that a confirmatory bias might preclude re-examination of the situation and replacement of the incorrect ATs with more functional and healthier perceptions (de Oliveira 2015; 2016).

    Figure 1. TBCT case conceptualization diagram, phase 1, and its 3-level cognitive components: ATs, UAs and CBs. Here, dysfunctional negative CBs are predominantly active.

    The TBCT case conceptualization diagram was also designed to help the patient realize that the behaviors that decrease anxiety and produce relief (e.g., avoidance) are little by little converted into coping strategies or safety-seeking behaviors, shown in Figure 1 as an arrow directed from the behavior and physiological response from the first to the second level on the right-hand side of the picture, meaning that situational perceptions in the first level (ATs) are progressively transformed into underlying assumptions (UAs) at the second level, which maintains and is maintained by the coping strategies/safety behaviors (de Oliveira, 2016). The table below shows the tools that were developed and are currently used during the TBCT therapy course.

    Table 1. TBCT techniques and its diagrams. Column 2 informs the cognitive levels and column 3 informs in which sessions they are usually used (de Oliveira 2016).

    The main TBCT technique used to restructure cognitions in the third level, namely CBs (Figure 1), is the TBTR. Besides including a courtroom metaphor, it introduces at least 12 known techniques usually used in CBT and listed below (de Oliveira, 2016):

    1. Socratic dialogue;
    2. Guided discovery;
    3. Imagery re-scripting;
    4. Empty chair or chairwork;
    5. Downward arrow technique (investigation);
    6. Evidence supporting the negative CB (prosecutor’s first plea);
    7. Evidence not supporting the negative CB (defense attorney’s first plea);
    8. Eliciting more automatic thoughts by discounting the positives (prosecutor’s second plea);
    9. Sentence reversal (defense attorney’s second plea);
    10. Upward arrow technique to uncover positive CBs (the defense attorney goes deeper);
    11. Identifying cognitive distortions (jurors’ phase); and
    12. The positive data log (preparation for the appeal), during which the patient summons the inner defense attorney as an ally to distance oneself even more and to collect daily elements that support the newly activated functional positive CBs.

    In summary, TBCT is an evidence-based, three-level and three-phase Beckian branch of CBT, whose main techniques use the courtroom metaphor, and designed to facilitate the work of the therapist and the client by means of a highly structured (although flexible) protocol.

    Burns, D.D. (1980). Feeling Good: The New Mood Therapy. New York: Signet.

    Cromarty, P. and Marks, I. (1995). Does rational role-play enhance the outcome of exposure therapy in dysmorphophobia? A case study. British Journal of Psychiatry, 167, 399-402.

    de Oliveira, I.R. (2008). Trial-based thought record (TBTR): preliminary data on a strategy to deal with core beliefs by combining sentence reversion and the use of an analogy to a trial. Revista Brasileira de Psiquiatria, 30(1), 12–18.

    de Oliveira, I.R. (2011). Kafka’s trial dilemma: Proposal of a practical solution to Joseph K.’s unknown accusation. Medical Hypotheses, 77(1), 5-6.

    de Oliveira, I.R. (2012a) Trial-Based Cognitive Therapy. Accepted entry in Common Language for Psychotherapy Procedures.

    de Oliveira, I.R. (2012b) Trial-Based Thought Record. Accepted entry in Common Language for Psychotherapy Procedures.

    de Oliveira, I.R. (2015). Trial-Based Cognitive Therapy: A Manual for Clinicians. New York: Routledge.

    de Oliveira, I.R. (2016) Trial-Based Cognitive Therapy: Distinctive Features. London:Routledge.

    de Oliveira, I.R., Duran, E.P. and Velasquez, M. (2012). A trans-diagnostic observation of the efficacy of the Trial-Based Thought Record in changing negative core beliefs and reducing self-criticism. NEI Psychopharmacoloy Congress, San Diego, October 18-21.

    de Oliveira, I.R., Hemmany, C., Powell, V.B., Bonfim, T.D., Duran, E.P., Novais, N. et al., (2012). Trial-based psychotherapy and the efficacy of trial-based thought record in changing unhelpful core beliefs and reducing self-criticism. CNS Spectrums, 17(1), 16–23.

    de Oliveira, I.R., Powell, V.B., Caldas, M., Seixas, C., Almeida, C., Bomfim, T. et al. (2012). Efficacy of the Trial-Based Thought Record (TBTR), a new cognitive therapy strategy designed to change core beliefs, in social phobia: A randomized controlled study. Journal of Clinical Pharmacy and Therapeutics, 37(3), 328-334.

    Freeman, A., DeWolf, R. (1992). The 10 Dumbest Mistakes Smart People Make and How to Avoid them. New York: HyperPerennial.

    Kafka, F. (1925/1998). The Trial. New York: Schoken Books.

    Leahy, R.L. (2003). Cognitive therapy techniques. A practitioner’s guide. New York: Guilford Press.

    Messer, S.B. (1992). A critical examination of belief structures in interpretive and eclectic psychotherapy. In J.C. Narcross and M.R. Goldfried (Eds.), Handbook of Psychotherapy Integration. New York: Basic Books.

    Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MP: Harvard University Press.

    Powell, V.B., de Oliveira, O.H., Seixas, C., Almeida, C., Grangeon, M.C., Caldas, M., et al. (2013). Changing core beliefs with trial-based cognitive therapy may improve quality of life in social phobia: a randomized study. Revista Brasileira de Psiquiatria, 35(3), 243-247.

    Stricker, G. (2010). Psychotherapy Integration. Washington D. C.: American Psychological Association.

    Published July 12, 2016

  • 07/03/2016 10:01 AM | Anonymous

    Donna Sudak, MD - Drexel University College of Medicine

    In the past twenty years there has been an enormous interest in the practice of cognitive-behavioral therapy (CBT). Substantial research has been conducted indicating that CBT is a significantly effective treatment for a variety of psychiatric illnesses. In 2001, the Residency Review Committee for Psychiatry adopted training requirements requiring competence in CBT for graduating psychiatry residents. In 2012, an inter-organizational task force produced guidelines for cognitive behavioral therapy training within doctoral Psychology programs in the United States (Klepac et al, 2012). Despite such requirements, dissemination of CBT remains poor (Shafran et al 2009) and training is lacking (Weissman et al, 2006). There is some evidence regarding specific methods of supervision and teaching that lead to effective application of CBT in clinical practice, but such evidence is even more poorly disseminated and inconsistently applied. Literature on the outcome of supervision is lacking. In spite of decades of emphasis on data-driven decision-making regarding the therapeutic process, there has been a relative lack of research to address questions of best practices in both training and supervision of CBT. Although dissemination of effective treatments for mental disorder is of paramount public health concern the field requires considerable progress to facilitate such dissemination.

    There are at least two distinct points of view regarding therapist training represented in the training and supervision literature. First, a commonly articulated evidence-supported position is that more training produces more competent therapists (McManus et al 2010). A further assumption derived from this point of view is that more competent therapists have superior clinical outcomes. Several studies (Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006) support this view and point specifically to the role of supervision in producing competent therapists. Another argument, advanced from the public health perspective, is that the process of training and supervision is far too resource intensive to be practical for illnesses such as depression (Fairburn and Cooper 2011), which will soon represent the largest global disease burden (WHO). This perspective argues for a larger group of therapists trained in low intensity interventions for specific disorders along with guided self-help and internet assisted interventions to produce the widest ranging impact. Both ideas have merit, and likely an amalgam of training strategies will continue to be developed and tested worldwide.

    Given the aforementioned scarcity of resources, identifying the most efficient strategies for supervision and training is imperative for the field. Regarding supervision, a small number of studies exist that indicate it improves therapist competence (Strunk et al 2010, Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006), but do not describe the most efficient and effective procedures to follow. Even more significantly, the elements of what constitutes “adequate” supervision are only recently described in the literature and have been determined by a combination of narrative and systematic reviews and expert consensus (Milne and Dunkerley). The importance of adequate training for supervisors has led to several professional organizations establishing criteria for supervisors/trainers (e.g., the Academy of Cognitive Therapy, the British Association of Behavioural and Cognitive Psychotherapy) and/or required continuing education credits pertaining to supervision.

    Key principles that are derived from CBT itself, because it is rooted in learning theory, are equally applicable to the supervisory process and facilitate therapist development. These include:

    1. Make the terms of the supervisory relationship explicit and clear. Foster a relationship that promotes frank disclosure by the supervisee. Specific tools that may assist are handouts that teach the supervisee about how to use supervision, supervision contracts and a clear and open discussion of expectations and evaluation methods. Engagement in supervision is improved by a clear understanding of expectations of tape review and how to handle confidentiality and patient emergencies. Keep detailed supervision notes.
    2. Structure supervision in a similar way to CBT. The process should reflect clinical practice because all the tools we use in therapy are designed to enhance learning. Supervision sessions optimally begin with agenda setting, check-in about last week’s session, then proceed to work on particular supervision questions, followed by summaries, feedback and homework. Socratic questions should be a mainstay of the work that you do. Require the use of rating scales to track patient progress.
    3. Conceptualize the supervisee regarding particular learning needs, attitudes about psychotherapy, and culture. This will insure interventions that are tailored and precise.
    4. Aim to use a variety of methods to promote learning in a supervision session. Keep your eye on the balance between challenge and support. The supervisee needs to have sufficient confidence in the relationship in order to frankly discuss patients and be sufficiently challenged to take the next learning step.
    5. Identify what skill level is present in the supervisee either with direct observation of patient care or role-play practice in supervision. Train skills when necessary. If skill-training is not needed, be Socratic and help the supervisee think through and make decisions independently.
    6. Examine actual work samples (therapy tapes) with a validated instrument, like the Cognitive Therapy Rating Scale (Young and Beck, 1980) to ensure progress is being made. Teach the supervisee to use the instrument as well. Such work provides valuable review of the key features of the session for the trainee.

    These practices in supervision will help you be more effective at teaching the skills of therapy and make the work interesting to you both!

    Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research,16(3), 317-331.

    Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6-7), 373-378.

    Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., & ... Strauman, T. J. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687-697.

    McManus, F., Westbrook, D., Vazquez-Montes, M., Fennell, M., & Kennerley, H. (2010). An evaluation of the effectiveness of diploma-level training in cognitive behaviour therapy. Behaviour Research and Therapy, 48(11), 1123-1132.

    Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516.

    Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We Don't Train in Vain: A Dissemination Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy. Journal of Consulting and Clinical Psychology, 73(1), 106-115.

    Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., & ... Beck, A. T. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751-756.

    Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429-437.

    Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & ... Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925-934.

    Published July 3, 2016

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