Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be treated effectively with cognitive-behavioral therapy. When working with clients who have GAD, therapy can focus on four central areas that help to promote therapeutic change. The initial focus of therapy is on developing a sound therapeutic alliance and educating the client about anxiety symptoms. Skills training focuses on relaxation training and cognitive changes that can help clients confront their worries in a constructive manner. Then, exposure to internal and external aspects of the anxiety can help clients test and refine their coping skills. Finally, because of the chronic nature of GAD, relapse prevention strategies can be used to help maintain treatment gains over time. These strategies allow a broad but flexible treatment plan that can be adapted to the unique needs of each individual client.     

Behavior Treatment: General Considerations

The principal goal of behavior treatment for retarded clients is that of modifying behavior as it occurs in a given environment in such a manner that it becomes more appropriate to that environment. The therapeutic or change agents can involve a variety of persons other than the counselor, teacher, and client--this may include parents, peers, work supervisors and others who can provide supportive influences. Education and rehabilitation programs should be tailored to the occupational and social environment of the retarded client and designed to teach those behavior patterns that are relevant to that environment. Additionally, the work tasks for which retarded clients are trained should be highly structured and routine. Excessive demand for adaptability or decision making is a major cause of training failure for retarded clients.     

Cognitive-Behavioral Processes Based on Using the ABC Analysis by Trainees’ for Their Personal Development

As cognitive-behavior therapy (CBT) has proven to be an evidence-based intervention for many mental health problems, the requirement for training programs has increased. Although there is promising data on the skills outcomes of such programs, trainees’ affective/behavioral changes mechanisms and in their faulty thinking patterns during the personal development of such training are unknown. The aim of this study is to investigate which are the most common irrational/dysfunctional beliefs of trainees during a cognitive-behavioral intervention training and their maladaptive consequences, as well as the methods of restructuring that they prefer to change these beliefs into rational/functional ones and achieve more adaptive consequences. 94 participants in a cognitive-behavioral interventions training program filled out 340 ABC, forms related to negative events at work and in personal life, as part of the personal development component in the training program. The obtained qualitative data was coded by three trained ratters in accordance to the current cognitive model of CBT. Contingencies analysis showed that demandingness, awfulizing and global evaluation (GE) are most frequently associated with anxiety, while low frustration tolerance is associated with anger. Comfort, affiliation, achievement themes were most frequently associated with anxiety, while fairness was most frequently associated with anger. Pragmatic cognitive restructuring was the most frequently used by trainees. We found evidence that confirmed many of the theoretical predictions form the cognitive model of CBT in respect to the associations between irrational/dysfunctional cognitions and dysfunctional emotions as well as some particularities for this specific population.     

Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder

Cognitive-behavioral therapy can be effective for many clients who have obsessive-compulsive disorder. Despite its effectiveness, many treatment guidelines fail to describe cognitive-behavioral therapy procedures in adequate detail. The present paper will review the literature on cognitive-behavioral therapy for OCD in an attempt to provide concise, meaningful guidelines for the psychological treatment of this disorder. Cognitive-behavioral therapy includes four general components: initial preparation for therapy, development of applied coping skills, exposure with ritual prevention, and relapse prevention. The four general treatment components are described, and clinical examples are provided.     

Behavior treatment: General considerations

The principal goal of behavior treatment for retarded clients is that of modifying behavior as it occurs in a given environment in such a maner that it becomes more appropriate to that environment. The therapeutic or change agents can involve a variety of persons other than the counselor, teacher, and client—this may include parents, peers, work supervisors and others who can provide supportive influences. Education and rehabilitation programs should be tailored to the occupational and social environment of the retarded client and designed to teach those behavior patterns that are relevant to that environment. Additionally, the work tasks for which retarded clients are trained should be highly structured and routine. Excessive demand for adaptability or decision making is a major cause of training failure for retarded clients. Reprinted from Gardner, William I.Behavior Modification in Mental Retardation: The Education and Rehabilitation of the Mentally Retarded Adolescent and Adult. Aldine.     

Effectiveness of a Cognitive Behavioral Intervention for Young Adults with Cystic Fibrosis

This study examined the effectiveness of a cognitive behavioral intervention for young adults with cystic fibrosis (CF). Four young adults were referred for the therapy by medical staff because of perceived problems with anxiety, anger, or coping. Treatment impact was assessed on measures of anxiety, anger, perceptions of functional disability, and coping. A multiple baseline design across subjects was used. Overall, the impact of the cognitive behavioral intervention for young adults with CF was mixed. If participants had elevated baseline scores on anxiety, anger, or perceived functional disability, then some improvement was shown. However, only one participant had elevated baseline anxiety and anger scores, while two had higher functional disability scores. For coping, only one participant clearly displayed a greater use of approach relative to avoidance coping by the end of treatment. Results are discussed in terms of treatment implications, assessment, and coping issues.     

Self-control in hyperactive boys in anger-inducing situations: Effects of cognitive-behavioral training and of methylphenidate

The effects of cognitive-behavioral intervention and methylphenidate on anger control in hyperactive boys were investigated in two studies. The anger-inducing stimuli in both studies involved verbal provocation from peers. Study 1 assessed a brief intervention using self-control strategies, while Study 2 employed a longer training period and a control intervention that focused on enhancement of empathy. Both studies included methylphenidate versus placebo comparisons. Methylphenidate reduced the intensity of the hyperactive boys' behavior but did not significantly increase either global or specific measures of self-control. Cognitive-behavioral treatment, when compared to control training, was more successful in enhancing both general self-control and the use of specific coping strategies. There was no advantage for the combination of methylphenidate plus cognitive-behavioral intervention. Implications for intervention to ameliorate the social and interpersonal difficulties of hyperactive children are discussed.Major support for this study was provided by NIDA grant 01070. This research was also facilitated by a grant from the Spencer Foundation. The many training staff and raters, too numerous to mention individually here, are deserving of our special thanks. We also appreciate the cooperation of Marion Jacobs and the staff of the UCLA Psychology Clinic, where the first study was held, and of Howard Adelman and the staff of Fernald School, where the second study was housed; the clinical and administrative skills of Stephen Alkus, who organized the intervention program for the first study; the talents and diligence of David Neswald, who coordinated much of the videotape scoring; and the ever-present contributions of Doris Finck, who also edited and dubbed the video segments. Medication and placebos were supplied by CIBA-Geigy.     

A New Model to Facilitate Individualized Case Conceptualization and Treatment of Social Phobia: An Examination and Reaction to Moscovitch's Model

Moscovitch's (2009) model of social phobia is put forth as an integration and extension of previous cognitive-behavioral models. The author asserts that his approach overcomes a number of shortcomings of previous models and will serve to better guide case conceptualization, treatment planning, and intervention implementation for clients with social phobia. Here I respond to these claims and examine the new and not-so-new aspects of Moscovitch's model. Moscovitch provides creative ways of thinking about feared stimuli and maladaptive methods for anxiety management used by clients with social phobia, and these notions may indeed expand our horizons, linking cognitive-behavioral thought to literatures on emotional suppression and emotion regulation. Other aspects of Moscovitch's thesis do provide heuristic and useful approaches to the assessment and treatment of social phobia which may be of great utility to the cognitive-behavioral clinician, but they do not provide a truly new approach to understanding the psychopathology or treatment of social phobia.     

Effectiveness of negative-thought-reduction, meditation, and placebo training treatment in reducing anger

Twenty-nine highly angry subjects who obtained high scores on Spielberger's Trait component of State-Trait Anger Scale went through a thought-listing procedure to determine their negative self-statements in response to high, medium, and low anger-arousing situations. It was found that subjects made more negative self-statements in response to a high anger-arousing situation compared to the medium and low anger-arousing situations. The subjects were divided into four groups. Subjects in one group were trained to reduce their negative thoughts, subjects in a second group were trained to meditate, subjects in the third group were asked to imagine the high anger-arousing situations (placebo procedure), and subjects in the fourth group were given no treatment. It was found that the subjects in the Negative-thought-reduction, Meditation and Placebo groups showed improvement in trait anger, anger aroused through high-anger situations, anger scores across a wide variety of situations, unconstructive coping, and anger measured through physiological symptoms. The gains made through intervention were maintained at a 6-week follow-up. The No-treatment Group showed no significant change in anger scores across a wide variety of situations, unconstructive coping, and physiological symptom scores but showed a small but significant improvement in trait anger and in anger aroused by high-anger situations.     

Social Mishap Exposures for Social Anxiety Disorder: An Important Treatment Ingredient

Conventional cognitive-behavioral therapy for social anxiety disorder, which is closely based on the treatment for depression, has been shown to be effective in numerous randomized placebo-controlled trials. Although this intervention is more effective than waitlist control group and placebo conditions, a considerable number of clients do not respond to this approach. Newer approaches include techniques specifically tailored to this particular population. One of these techniques, social mishap exposure practice, is associated with significant improvement in treatment gains. We will describe here the theoretical framework for social mishap exposures that addresses the client's exaggerated estimation of social cost. We will then present clinical observations and outcome data of a client who underwent treatment that included such social mishap exposures. Findings are discussed in the context of treatment implications and directions for future research.     

Cognitive-Behavioral Self-Regulation of the Frequency, Duration, and Intensity of Anger

Within a self-regulation format, cognitive, behavioral, and (combined) cognitive-behavioral techniques were evaluated for effects on the frequency, duration, and intensity of anger. Twenty-seven subjects randomly assigned to three groups each received one of the three treatments after a baseline of self-monitoring and then completed another phase of self-monitoring. Results revealed a significant reduction in the frequency and duration of anger (but not anger intensity) under self-intervention, regardless of treatment type. These effects were preserved for a week following treatment. Thus, self-regulation may prevent incidents of anger and even cut short the persistence of anger, but once anger occurs, it tends to register about the same maximum intensity; this peak intensity is typically reached at the onset of the anger which then wanes at a decreasing rate over time. Further research is called for to determine the long-term durability of the treatment gains obtained and the generalizability of these findings in clinical populations.     

Compliance during sessions and homework in exposure-based treatment of agoraphobia

The relationship between compliance with cognitive-behavioral treatment instructions and outcome was examined for 56 agoraphobic clients treated with in vivo exposure and training in anxiety management strategies. Clients who complied more often with anxiety management instructions during treatment sessions tended to improve more on a behavioral avoidance test than those who were less compliant, but did not differ on three other outcome variables. Compliance with instructions for self-directed exposure between sessions was examined in a subset of 28 of these Ss. Clients who spent more time doing homework reported significantly greater decrements in fear of fear than less compliant clients and also tended to report larger changes on avoidance behavior. However, a quasi-experimental comparison of homework vs no-homework treatment protocols yielded no difference in outcome. Less compliant clients were more symptomatic pretreatment and rated their therapists as less caring and less self-confident.     

Comparison of Cognitive-Behavioral Stress Management Techniques With Adolescent Boys

This study examined the effectiveness of two cognitive-behavioral interventions to help adolescent boys cope with stress and other forms of negative emotional arousal. One group of youths, those receiving cognitive restructuring, learned how to identify and monitor stress-promoting cognitions, restructure these cognitions into more adaptive thoughts, and practice and apply these acquired skills. Another group of youths received anxiety management training, and they were taught to recognize cues that signal the onset of anxiety and to react to these cues using various relaxation skills to reduce the anxiety. The youths who received training were compared with a waiting list control group on measures of anxiety, anger, self-esteem, depression, and reports of anxious self-statements. Both groups that received the intervention showed significant reductions in levels of state and trait anxiety, state anger, anger expression, and depression. These treatment gains were maintained at an 11-week follow-up.     

Effects of coping skills training on generalized self-efficacy and locus of control

A number of studies have shown that mastery experiences strengthen self-efficacy expectancies that are specific to the mastery situation. In this study I assessed the effects of cognitive-behavioral coping skills training on generalized expectancies concerning self-efficacy and locus of control in test-anxious college students. Compared with a waiting-list control group, the trained subjects exhibited significant decreases on trait and state measures of test anxiety and a higher level of academic performance on classroom tests, as well as changes in specific self-efficacy expectancies relating to test-anxiety management and academic performance. Consistent with generalization predictions derived from self-efficacy theory, the coping skills group also exhibited decreases in general trait anxiety and increased scores on a trait measure of generalized self-efficacy. Locus of control was unaffected by the program, and changes in general self-efficacy were unrelated to changes in locus of control, suggesting the possibility that different parameters of experience are related to changes in the two types of generalized expectancies.     

STIMULUS OVERSELECTIVITY IN LEARNING DISABLED CHILDREN

Stimulus overselectivity, a phenomenon exhibited by autistic and institutionalized retarded individuals, was examined in mildly handicapped and nonhandicapped public school children. Subjects were 16 young, educable mentally retarded, 16 learning disabled, 15 nonhandicapped first- and second-graders, and 16 older, educable retarded students. The children were trained on a 3-component visual discrimination task and then tested on individual elements to determine which element or elements were controlling subject responses. Nine of the young educable mentally retarded children and eight of the learning disabled students showed some overselectivity. The majority of overselective retarded children were controlled by only one of the three components of the training cue, whereas the majority of the overselective learning disabled children responded to the discrimination task on the basis of two of the three components. No overselectivity was exhibited by the nonhandicapped students. All three cue components were also functional in controlling the responding of 14 of the 16 older retarded students, but two children were under the control of only one cue. The research indicated that in terms of overselectivity, learning disabled children respond more like young, mildly retarded children than they do like nonhandicapped ones. The demonstration of stimulus overselectivity in a sizable portion of a learning disabled sample may have implications for a more empirically based approach to this handicapped population.     

Coaching Clients to Manage Depression

The author presents a system of behavioral techniques that permits clients to manage their own depression. By coaching clients through the sequence of self-management procedures identified by Kahn (1976) and using the strategies offered by Lewinsohn (1975), counselors have an effective set of techniques to lead clients to successful coping with depression. The sequence of self-observation, self-mediation, and self-reinforcement activities is based on Lewinsohn's (1975) work and is effective with moderately depressed clients. This comprehensive treatment program requires a minimum amount of counselor intervention for a maximum amount of client gain.     

The use of self-disclosure among Swedish psychotherapists

Although self-disclosure, when handled with discretion, is often seen as an important intervention in many psychotherapy orientations, including psychodynamic as well as humanistic and cognitive-behavioral approaches, many psychotherapists seem reluctant to use it. The frequency and type of those interventions from psychotherapists of different orientations is less well known. In this study, a random sample of Swedish psychotherapists was asked about their use of different types of self-disclosing information. The results showed that therapists with CBT orientation told their clients more about their training and about their personal ways of handling affective-relational issues. It was apparent that the trend toward more use of self-disclosure in relational psychodynamic treatment has not been accepted among a large number of psychodynamic and psychoanalytic psychotherapists in Sweden. It is recommended that psychotherapists inform their clients more about their training and in appropriate ways share more with their clients about their own relational experiences. Doing so may help enhance clients’ hope and their ability to address their ongoing difficulties.     

Desensitization for the treatment of fear in the high level adult retardate.

Behavior therapy procedures, particularly desensitization procedures, have not been used with the retarded, perhaps due to the high demand for verbal skill implicit in the techniques. Twenty mildly retarded subjects who met criterion on a Behavior Avoidance Test for fear of heights or rats were randomly assigned to Contact Desensitization, Vicarious Symbolic Densitization. Systematic Desensitization, Placebo-Attention Control and No-Treatment Groups. Subjects were given up to fifteen sessions of treatment. Posttreatment data on the Behavior Avoidance Test, Fear Thermometer and Behavior Checklist showed that generally Contact Desensitization was most effective and most efficient with this population. Results show that the mildly retarded are able to follow slightly simplified desensitization procedures.     

A Model for Adapting Evidence-Based Interventions to Be LGBQ-Affirmative: Putting Minority Stress Principles and Case Conceptualization Into Clinical Research and Practice

The mental health field now possesses clinical trials attesting to the efficacy of affirmative practice with sexual minority individuals. With the goal of efficiently moving the results of these clinical trials into real-world clinical practice, this paper offers a model for adapting existing evidence-based practices originally developed for the general population to be lesbian, gay, bisexual, and queer (LGBQ)-affirmative. The adaptation model presented here guides clinicians to incorporate six LGBQ-affirmative transtheoretical principles of change into practice. These principles facilitate raising awareness of the impact of minority stress on sexual minority clients’ mental health and on client self-evaluation while drawing upon sexual minority resilience and intersectional experiences to build empowering coping skills and validating relationships. The adaptation model also provides a transtheoretical approach to case conceptualization that directs clinicians to consider the role of early and ongoing minority stress on sexual minority clients’ cognitive, affective, motivational, behavioral, and self-evaluative experiences that maintain current distress. This case conceptualization approach highlights common associations among these experiences, suggesting clear routes of interventions for many sexual minority client presentations. Case examples from recent clinical trials of LGBQ-affirmative cognitive-behavioral therapy illustrate how these principles and this case conceptualization can be effectively utilized in practice. While the principles and case conceptualization are meant to be transtheoretical and therefore applicable across therapeutic techniques, to date they have been tested only in clinical trials for cognitive-behavioral treatments. Therefore, this paper concludes with a call for future research to determine the effectiveness of implementing this adaptation model across diverse therapeutic modalities and client presentations.     

A Cognitive-Behavioral Educational Workshop to Combat Sexual Harassment in the Workplace

Various measures have been implemented for coping with the problem of sexual harassment in the workplace. Although much of the effort has been provided for special legislation, proper grievance procedures, or actions for organizational change, few attempts have been made to prevent sexual harassment through the application of appropriate training procedures based on effective psycho-educational methods. The author describes a workshop based on cognitive-behavioral techniques and is designed to provide women workers with understanding about sexual harassment at work and equip them with various response alternatives to sexual harassment attempts. Preliminary findings support the positive impact of the workshop.