The impact of cognitive behavioral therapy on post event processing among those with social anxiety disorder

Individuals with social anxiety are prone to engage in post event processing (PEP), a post mortem review of a social interaction that focuses on negative elements. The extent that PEP is impacted by cognitive behavioral therapy (CBT) and the relation between PEP and change during treatment has yet to be evaluated in a controlled study. The current study used multilevel modeling to determine if PEP decreased as a result of treatment and if PEP limits treatment response for two types of cognitive behavioral treatments, a group-based cognitive behavioral intervention and individually based virtual reality exposure. These hypotheses were evaluated using 91 participants diagnosed with social anxiety disorder. The findings suggested that PEP decreased as a result of treatment, and that social anxiety symptoms for individuals reporting greater levels of PEP improved at a slower rate than those with lower levels of PEP. Further research is needed to understand why PEP attenuates response to treatment.     

Laying mother to rest: Working with grief-related nightmares through exposure therapy and imagery

Cognitive behavioural therapy of unresolved grief is usually presented as a fairly rapid approach for reducing psychological problems. The present case study shows how behavioural cognitive and symbolic approaches can be integrated to foster griefwork at several levels. The counselling adopted a behavioural exposure technique specifically for eliminating a significant anxiety-provoking obstacle to mourning, namely the experience of recurrent death-related nightmares that surfaced every time the bereavement was recalled in depth. The client was also encouraged to explore the symbolic meaning of the dream images and in drawings modified these images in ways that helped to alleviate her feelings of long-standing guilt. Drawing as well as verbal representation could also be regarded as an effective form of exposure therapy, helping the client to stay with the anxiety-provoking death-related images. The client once relatively free of nightmares could mourn the loss of the mother more deeply in subsequent less directive counselling sessions.     

Cognitive-Behavioral Treatment of Panic Disorder: Confronting Situational Precipitants

Panic Disorder is a common, debilitating psychological problem which is often effectively treated through cognitive behavioral approaches. Cognitive-behavioral treatment incorporates education, relaxation training, cognitive therapy, behavioral exposure, and relapse prevention treatment strategies. A case illustration demonstrates how cognitive-behavioral treatment facilitated a client's ability to identify and confront situational precipitants to panic in a gradual and systematic manner. A therapeutic and collaborative relationship provided the foundation for treatment, while education helped the client to understand the vicious cycle between somatic symptoms, catastrophic thoughts, and anxiety. Passive relaxation training incorporated deep breathing, muscle relaxation, and positive imagery generated from the client's own experience. Cognitive restructuring involved identifying automatic thoughts related to panic, challenging dysfunctional beliefs associated with the client's depression and low self-esteem, and generating alternative ways of thinking. Behavioral exposure (e.g., imaginal exposure, behavioral rehearsal, in vivo techniques) helped the client gain a greater sense of mastery over panic attacks triggered by his fear of hypodermic needles. Over the course of treatment, the frequency and intensity of the client's panic attacks decreased. Furthermore, the client's sense of mastery over panic had beneficial effects on his mood and self-esteem. Treatment gains were maintained at one-year follow-up.     

Cognitive and emotional covariates of violence exposure among former prisoners: links to antisocial behavior and emotional distress and implications for theory

In this study, formerly incarcerated men (N = 123) were assessed for their experiences with violence in the community as well as their current behavioral and mental health status (antisocial behavior and emotional distress). Participants also completed measures of two constructs theorized to moderate relations between exposure to violence and outcomes: cognitive beliefs supporting aggressive responding and negative emotional reactivity to witnessed violence. Data on key social-demographic background factors affecting outcomes were also collected. Analyses showed that, after controlling the effects of background factors, relationships between experiences with violence in the community and behavioral/mental health were moderated by cognitive beliefs and emotional reactivity. At high levels of support for aggressive responding, significant positive links were observed between exposure to violence and antisocial behavior as well as emotional distress. At high levels of negative reactivity to violence, a significant positive link was observed between exposure to violence and emotional distress (but not antisocial behavior). Findings are discussed with respect to research and theory on the effects of exposure to violence in high-risk adult populations.     

"Dwelling in the Past": The Role of Rumination in the Treatment of Posttraumatic Stress Disorder

Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an "optimal dose" of exposure during treatment.     

Collaborative Empiricism in Cognitive Therapy for Psychosis: A Practice Guide

We outline our understanding of collaborative empiricism (CE) as used in cognitive therapy (CT) for psychosis. We discuss how CE can be thought of as a technique for facilitating cognitive change in the service of a client's goals, but also as an expression of respect for client autonomy, recognizing the ethical imperative to empower clients by involving them in decisions about their care. Taking a CE approach is therefore consistent with user-led conceptualizations of recovery, and the related movements of “shared decision-making” and “evidence-based patient choice.” We discuss how CE can aid with engagement, assessment, formulation, and intervention in CT, illustrating this with case material. We focus on how CE can help with distressing intrusive experiences and beliefs, and also consider its role in helping clients achieve wider life goals. Adaptations to CE for working with people with problems with learning, attention, and memory are discussed, as are considerations for working with high conviction and conceptual disorganization.     

Helping Clients Move Toward Constructive Change: A Three-Phase Integrated Counseling Model

This article presents a 3-phase integrated counseling model that draws from object relations and attachment theory for assessment and uses cognitive behavioral techniques to promote constructive client change. A case vignette is presented to illustrate implementation of the model.     

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.     

The Revolution in Counseling: A Sociological Perspective

Revolution, from a sociological perspective, requires more than a full acceptance of behavioral techniques and applications by counselors. What the behaviorists have contributed is not a revolutionary stance but a newly coherent set of strategies for dealing with client problems. It is still the client who is encouraged to acquire behaviors more consistent with the immediate social milieu rather than the reverse—It is easier to fit the individual into the existing social order than to confront and change the social order. A revolution would entail taking on society as the client, and then developing and applying efficacious change strategies to social structures.     

Does any aspect of mind survive brain damage that typically leads to a persistent vegetative state? Ethical considerations

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness.     

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.     

‘The Nowness of Everything’: A mindfulness-based approach to psychotherapy

Current levels of mental distress are of great concern to those of us working in the therapeutic setting. Many people today are discontented and unhappy with their lives. Success fails to bring fulfilment and with alienation from self and others, an inner numbness can become established. When working with troubled individuals or participants of groups, I believe by remaining with a mindfulness-based here-and-now approach, levels of depression, anxiety, narcissistic conceit and acquisitiveness become diminished. At the same time, I feel peace of mind increases when in-the-moment experiences are the focus of attention. It would seem that a mindful approach which involves circumventing client history and concentrating on current feelings and experiences can effectively facilitate psychic change. This paper considers some of the literature of mindfulness, in an attempt to validate my observations and determine if there is a satisfactory evidence base for a mindfulness-based psychotherapeutic approach to the ills of contemporary life.     

Positive living with anxiety: A morita perspective of human agency

Morita therapy, a Japanese cognitive behavioural approach, is applied to a Western context. This paper intends to focus on one of the Morita key concepts, namely the positive acceptance of social anxiety, and its underlying meaning of human agency that can be interpreted in daily life and counselling situations. Some similarities and differences between Morita philosophy of human anxiety and Western therapeutic conceptions of anxiety feelings are highlighted in order to clarify Morita principles as they are incorporated into counselling process in Western society. Suggestions for counselling, with special focus on counsellor attitude, client cognitive behavioural transformation, and client existential meaning making, are provided.     

Educational advocacy for children with autism

There exists a great divide between parents' demands for intensive behavioral interventions for their children with autism and the public education system's reluctance to support early intensive behavioral intervention programs. More and more, professionals with expertise in applied behavior analysis are being asked to advocate for effective, early behavioral intervention for autism in education litigation brought about by frustrated parents. The progress made in recent years in the behavioral treatment of children with autism and the schools' lack of adherence to the requirements of IDEA have made it possible for educational policy change through effective advocacy by behavioral interventionists. This paper discusses preparing for educational advocacy on behalf of young children with autism. We explore the personal and emotional reasons why parents choose to engage in the financially risky endeavor of educational litigation. We then outline an approach to developing expert testimony based upon evaluation of the target child and his/her educational history. Issues related to assessment, training, and ethical practice are addressed. Copyright © 2002 John Wiley & Sons, Ltd.     

Contemporary Perspectives on Stress Management: Medication,Meditation or Mitigation

Stressful life events can increase the risk for developing a variety of physical disorders and emotional problems. A biopsychosocial approach can help mental health professions to better understand and more effectively treat disorders that are related to severe negative life events. Biological approaches focus on suppressing emotional reactions, usually through a reliance on psychopharmacological interventions. Psychological approaches usually focus on the cognitive processes that translate stress into distress. Psychological interventions focus on changing the negative attitudes and maladaptive behaviors that aggravate most stressful situations. Social interventions focus on improving social support and involvement with agencies to confront limited finances, unemployment, and housing problems. In these times of economic crisis and severe financial hardship, psychological and social intervention strategies appear more useful than biological treatments.     

Affective and Behavioral Changes Following Exposure to Traumatic Events: the Moderating Effect of Religiosity on Avoidance Behavior Among Students Studying Under a High Level of Terror Event Exposure

The goals of this study were to examine the development of affective and behavioral changes following exposure to traumatic events among Israeli students studying under a high level of terror event exposure and to assess the effects of religiosity on those changes development. A questionnaire was administered to 770 students in the Ariel University Center in Judea and Samaria. Higher levels of terror exposure were associated with higher levels of avoidance behavior, subjective feelings of insecurity, and emotional distress. Higher religiosity moderated avoidance behavior, even when controlling for the level of objective exposure to terror events exposure, but had no influence on subjective sense of insecurity, or the level of emotional distress. These findings suggest that religiosity moderates behavioral changes development after traumatic event exposure mainly by reducing avoidance behavior.     

Treatment preference and acceptability: Epistemology and locus of control

Abstract

Treatment preference and acceptability were investigated in 397 female university students. Three audiovisual vignettes depicting a client and therapist discussing a body image disturbance problem were presented to subjects. Predictions were that subjects would prefer one of three therapy approaches—behavioral, cognitive—rational, or cognitive—constructivist—as a function of personal epistemology and locus of control. Overall, subjects rated the constructivist therapy approach more favorably than either the cognitive—rational or behavioral approach. Similarly, subjects evaluated the constructivist therapist more positively than either the rational or behavioral therapist. After degree of subject identification with the target problem was controlled, results indicated that matching subjects who had an external locus of control orientation to a behavioral or cognitive-rational therapist resulted in more favorable assessments of that therapist. Matching subjects who had an internal locus of control orientation to a constructivist therapist resulted in more positive assessments of that therapist. Implications for matching in clinical practice are discussed.     

School-based discussion groups for children of divorce: A pilot program

This paper describes a pilot program for school-based discussion groups for children of divorce. Relevant literature is reviewed and a model for a semistructured discussion group for latency-aged children is presented. Particular techniques used to engage children in discussion of relevant issues are described. While we have not conducted a systematic outcome study of these groups, our impression is that while some definite concrete changes have occurred for several children, for others, change has been located more in the representational than behavioral world. Children may remain unable to communicate angry feelings to the absent parent but as a result of the group experiences may be able to stop thinking of themselves as bad for harboring such feelings in the first place.Formerly an Elementary Guidance Counselor in the Brookline Public Schools, currently is an Educational Consultant in the Philadelphia area.     

The spirited, the observant, and the disheartened: social concepts of optimism, realism, and pessimism

The social concepts of optimism, pessimism, and realism were investigated by assessing the prototypical acts (thoughts, feelings, goals, and actions) that laypersons assign to optimists, pessimists, and realists responding to a controllable and an uncontrollable situation. Optimists and realists, but not pessimists, were seen as adjusting their behavior to the situation. However, whereas optimists were characterized by flexibility in thoughts and feelings but invariance in goals and actions (i.e., they pursued their goals in both controllable and uncontrollable situations), the act profiles assigned to realists varied on all of these dimensions. The profile assigned to pessimists was characterized by cognitive, affective, motivational, and behavioral invariance, encompassing negative construals of the situation, giving up, and a focus on distress.