The Theory-Practice Gap in Cognitive-Behavior Therapy

This special series is devoted to understanding the theory-practice gap in cognitive-behavior therapy (CBT). Although CBT enjoys considerable empirical support, and is widely recognized as an efficacious approach to a diversity of psychiatric disorders and includes many different forms of treatment, it is unclear whether clinicians are familiar with the underlying theories of the treatments they are practicing. Moreover, it is unclear to what degree an understanding of the theory is necessary for effective practice. Gaining clarity on the role of understanding underlying theory and identifying potential disparities between theory and practice may have implications for the way graduate training programs are structured and current professionals approach continuing education. A brief exploration of these implications will be offered by introducing issues related to the scientist-practitioner model and dissemination of efficacious treatments, in addition to an outline of potential advantages and disadvantages of knowing underlying theory. This special series will then feature several major approaches to treatment wherein the role of theory and practice are discussed.     

Cognitive-Behavior Therapy for Reduction of Persistent Anger

Although persistent anger is not represented in DSM-IV as a psychiatric disorder, it is nevertheless a significant clinical problem. Based on our experience with both research and clinic patients from a diverse urban population, and drawing on methods utilized by others, we have refined and elaborated several treatment strategies that appear useful for anger reduction. The strategies derive from a counterconditioning treatment model: patients are exposed (either naturally or by design) to situations that may evoke anger, while they apply physiological, cognitive, and/or behavioral methods that can dampen the habitually angry response. The specific anger-reduction methods include: applied muscle relaxation, cognitive reappraisal, inhibition of overresponding, and reversal of underresponding (through acquisition of effective communication and problem-solving skills). Preliminary evidence is presented indicating that anger patients experience significant reduction in the intensity, duration, and frequency of anger reactions after completing 12 sessions of therapy utilizing these anger-reduction methods.     

Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example

Low self-esteem is a common, disabling, and distressing problem that has been shown to be involved in the etiology and maintenance of a range of Axis I disorders. Hence, it is a priority to develop effective treatments for low self-esteem. A cognitive-behavioral conceptualization of low self-esteem has been proposed and a cognitive-behavioral treatment (CBT) program described (Fennell, 1997, 1999). As yet there has been no systematic evaluation of this treatment with routine clinical populations. The current case report describes the assessment, formulation, and treatment of a patient with low self-esteem, depression, and anxiety symptoms. At the end of treatment (12 sessions over 6 months), and at 1-year follow-up, the treatment showed large effect sizes on measures of depression, anxiety, and self-esteem. The patient no longer met diagnostic criteria for any psychiatric disorder, and showed reliable and clinically significant change on all measures. As far as we are aware, there are no other published case studies of CBT for low self-esteem that report pre- and posttreatment evaluations, or follow-up data. Hence, this case provides an initial contribution to the evidence base for the efficacy of CBT for low self-esteem. However, further research is needed to confirm the efficacy of CBT for low self-esteem and to compare its efficacy and effectiveness to alternative treatments, including diagnosis-specific CBT protocols.     

Cognitive-Behavior Family Therapy: Contemporary Myths and Misconceptions

The field of couple and family therapy has grown in the direction of expanding its horizons by looking toward innovative ideas and whatever works to facilitate change. Despite its demonstrated track record with a broad range of behavioral and emotional disorders, the cognitive-behavior therapies (CBT) may have been underutilized by couples and family therapists unlike some of the more traditional and postmodern approaches. This article explores some of the basic tenets of the cognitive-behavioral approach with families and proposes it as both a useful intervention tool as well as a theoretically compatible model to systemic approaches. In addition, a number of contemporary myths and misconceptions are discussed that may be precluding CBT's utilization by therapists in the field.     

Cognitive-Behavior Therapy for Vietnamese Refugees With PTSD and Comorbid Panic Attacks

For Vietnamese refugees, we describe (a) how headache- and orthostasis-focused panic attacks are generated, (b) a culturally sensitive treatment for PTSD with comorbid headache- and orthostasis-focused panic attacks, and (c) the outcome of a treatment series. In a multiple-baseline, across-subjects design (N = 3), all patients demonstrated treatment-related improvement of headache- and orthostasis-associated panic attacks; and in the repeated-measures, within-subjects design, all patients greatly improved across treatment on measures of psychopathology. One treatment case is presented.     

Clinical Experiences in Using Cognitive-Behavior Therapy to Treat Panic Disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.     

Introduction to the Special Issue: Mechanisms of Action in Cognitive-Behavior Therapy

Research into mechanisms of treatment outcome in cognitive-behavior therapy (CBT), as work evaluating potential mechanisms through mediator and moderator analyses, has been increasing. In recognition of this growth in more refined analyses of functional components of treatment, this special issue highlights a diverse range of research-evaluating mechanisms, as well as mediators and moderators, of outcome. It is anticipated that the research described in these articles will stimulate additional investigations as well as provide important insights for clinicians in refining treatment programs.     

Commentary on the Current Status of Assessment in Rational-Emotive and Cognitive-Behavior Therapy

This commentary focuses on the current status of assessment in rational-emotive and cognitive-behavior therapy, in the context of making comments about three assessment articles published in the same journal issue. The commentary describes important characteristics of rational-emotive and cognitive-behavior assessment measures, suggests several avenues of psychometric research on behavioral tests of distress tolerance as clinical measures, reviews psychometric and other important properties of existing irrational belief measures, and endorses assessment related to newly proposed anger disorder diagnoses.

Symptom Severity at Week 4 of Cognitive-Behavior Therapy Predicts Depression Remission

Early response has been shown to predict psychotherapy outcome. We examined the strength of the relationship between early response and remission in 82 patients who received naturalistic cognitive-behavior therapy in a private practice setting, and 158 patients who received protocol cognitive therapy in a research setting. We predicted that the relationship between early response and remission would be substantial enough to guide clinical decision making in both samples, and that a simple model of severity at Week 4 of treatment would predict remission as effectively as a more complex change score. Logistic regressions showed that a simple model based on the Week 4 Beck Depression Inventory (BDI) score was as predictive of remission as more complex models of early change. A receiver operating characteristics analysis showed that BDI score at Week 4 was substantially predictive of remission in both the naturalistic and research protocol samples; the area under the curve was .80 and .84 in the naturalistic and protocol samples, respectively. To guide clinical decision making, we identified threshold scores on the BDI corresponding to various negative predictive values (probability of nonremission when nonremission is predicted). Our results indicate that depressed patients who remain severely depressed at Week 4 of cognitive therapy are unlikely to reach remission at the end of relatively brief (maximum 20 sessions) treatment. We discuss implications of our findings for clinical decision making and treatment development.     

Taking Cognitive-Behavior Therapy to School: A School-Based Mental Health Approach

This paper offers an overview using cognitive-behavior therapy (CBT) within a school system. In addition to providing services to individual students, this article provides an overview of implementing CBT into a system of school-wide mental health services. Interventions are discussed at three levels—universal school-wide interventions, target interventions with at-risk students, and intensive interventions with students in need. Examples of specific programs or intervention are given for each level.     

Introduction to the Special Issue: Integration of Technological Advances in Cognitive-Behavior Therapy

A wide range of technological approaches has been adopted in assessment and intervention using cognitive-behavior therapy (CBT). The articles that comprise this special issue cover a diversity of areas, including motion-tracking devices, ecological momentary assessment, facial recognition software to provide rapid feedback, audio and tablet-based CBT-administered procedures, web-based acceptance program for stress reduction, and videoconferencing for delivery of anxiety treatment in youth. It is expected that technological advances will continue to lead to additional advances in CBT delivery.     

Narrative and Clinical Change in Cognitive-Behavior Therapy: A Comparison of Two Recovered Cases

Psychotherapy research suggests that therapeutic change is associated with the emergence and development of innovative moments (IMs)—that is, exceptions to the problematic self-narrative that brought the client to therapy. This study compares two recovered cases of major depression, according to symptom measures, that presented contrasting profiles of evolution of IMs: one typical of successful therapy (Barbara), and another typical of unsuccessful therapy (Claudia). The core conflictual relationship theme (CCRT) was used to study narrative change independently of the innovative moments coding system (IMCS). The results suggest a high congruence between the IMCS and the CCRT profiles. Although Barbara presented changes in the IMCS and the CCRT in a similar way, Claudia's self-narratives (IMs and CCRT), despite symptom change, did not change. The results are discussed, considering the importance of narrative changes in recovery from depression and the maintenance of therapeutic gains.     

Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1 year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.     

Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group for Individuals with a First Episode of Psychosis

CBT for psychosis has recently been called a best practice, suggesting that studies have demonstrated its efficacy with many populations. Community settings are encouraged to implement best practices such as CBT yet many factors can make the implementation of CBT challenging. Issues such as clinician resistance, setting, as well as client variables (refusal, denial of symptoms, etc.) come into play. Examples of successes and challenges of a community based study of CBT groups for first episodes will be described. The strategies used to overcome these challenges and the successes of the program will be presented.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

Satiation Therapy and Exposure Response Prevention in the Treatment of Obsessive Compulsive Disorder

The purpose of present study was to test the comparative effectiveness of Satiation Therapy and Exposure Response Prevention techniques in the treatment of obsessive–compulsive disordered patients. Sixty self-referred male outpatient cases were investigated within a randomized controlled trial. Patients were allocated to Satiation Therapy, Exposure Response Prevention or wait-list control groups. Obsessive–compulsive symptoms were measured by the Yale-Brown Obsessive Compulsive Scale at baseline, post-treatment, and 3 and 6 month follow-ups. The therapeutic groups had more significant improvement than the control group. In addition, there was not a significant difference between therapeutic groups on post-treatment and follow-up assessments which showed that Satiation Therapy and Exposure Response Prevention were similarly effective in reducing obsessive–compulsive symptoms. Analyses revealed that therapeutic groups had improved significantly while the control group had continued unchanged. Finally, the present investigation supported both Satiation Therapy and Exposure Response Prevention in the treatment of obsessive–compulsive disorder.     

Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy

Among psychologically distressed Cambodian refugees, somatic complaints are particularly prominent. Cambodians interpret anxiety-related somatic sensations in terms of “Wind” (khyâl), an ethnophysiology that gives rise to multiple catastrophic interpretations; and they have prominent trauma-memory associations to anxiety-related somatic symptoms. In this article, we detail some of the common sensation-related dysphoric networks of Cambodian refugees, focusing on catastrophic cognitions and trauma associations. We argue that delineating symptom-related dysphoric networks is crucial to successfully adapt cognitive-behavioral interventions to treat panic disorder and posttraumatic stress disorder among Cambodian refugees, and that such an approach may be useful for the culturally sensitive adaptation of cognitive-behavior therapy for other traumatized non-Western groups.