Cognitive-Behavioral Treatment of Social Phobia

Social phobia can be a chronic disorder, capable of restricting a client's social and occupational functioning. Cognitive-behavioral therapy can help many clients learn to overcome their social inhibitions, and make lasting changes in their interpersonal style. Cognitive-behavioral therapy for social phobia includes four general components for helping clients learn to manage their social anxiety. First, therapy begins with the establishment of a sound therapeutic alliance, a focus on assessment, diagnostic interviewing, and education regarding anxiety symptoms and their treatment. Second, the therapist helps clients to develop competence in social skills, relaxation training, and cognitive restructuring. Third, therapy uses exposure to social situations in order to help clients confront their fears and refine their coping skills. Fourth, relapse prevention strategies are used to help clients learn to tolerate feelings of discomfort and confront challenging social interactions. This treatment framework can be adapted to the specific needs of different clients.     

Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.     

A Case of Premature Termination in a Treatment for Generalized Anxiety Disorder

In this paper we present a case of failure in an integrative treatment for generalized anxiety disorder (GAD) combining cognitive-behavioral therapy, an empirically supported treatment for GAD, and interpersonal-emotional processing therapy. The client of focus dropped out of treatment after the eighth session. Based on our analysis of this case, we discuss the participant, technical and relationship factors that were likely implicated in this case of premature termination in both of the cognitive-behavioral and interpersonal-emotional processing segments that comprised the treatment. Implications for practice, training and future research are also discussed.     

Managing Anxiety: A Therapist Common Factor

In this paper, we propose that therapist anxiety in the therapy room, especially anxiety stirred up by difficult or triggering clients, represents a challenge to effective therapy, and that effective management of this anxiety be considered as a necessary therapist skill for conducting quality couple and family therapy (CFT). We propose that effective therapists need to be able to manage their emotions, especially their anxiety, in order to truly help their clients. The failure to do this can lead to break downs in the alliance and the flow of therapy, and these deleterious effects can be prevented when therapists actively navigate their internal states through self-awareness and ongoing introspection. Bridging psychotherapy literature, we discuss specific strategies to this end, and make clinical recommendations for CFTs and CFT training programs.     

Treatment of Comorbid Pica and Generalized Anxiety Disorder: A Case Study

This case report describes the assessment and treatment of a treatment-naïve 36-year-old Hispanic/Latina female with comorbid pica and generalized anxiety disorder (GAD), and iron-deficiency anemia. At the onset of treatment, the client consumed chalkboard chalk and vermiculite from potting soil approximately three times per week and presented with moderate-severity GAD. Assessment and treatment occurred over 24 weekly outpatient individual sessions. Treatment was delivered in concert with medical intervention to address anemia. A cognitive-behavioral case formulation was developed from multiple assessment sources. A process-based cognitive-behavioral therapy (CBT) intervention approach was used to target GAD and pica simultaneously, which included psychoeducation, self-monitoring, arousal reduction skills, cognitive training (reappraisal, distancing), and behavior modification/stimulus control techniques. Barriers to treatment and their solutions are discussed. At the end of treatment, the client demonstrated increased insight and understanding of her worry symptoms and pica behavior, acquired cognitive skills and arousal reduction strategies for managing GAD, and reported less than one episode of pica per week. The identified assessment and treatment approach is worthy of future investigation to inform empirically based treatment development efforts, especially for pica.     

A solution-focused approach to working with clients who are suicidal

Self-harm and suicide are amongst the most challenging and frightening problems that therapists and counsellors can encounter in the course of their work. The risk of clients harming themselves in the course of treatment can debilitate the therapists from acting creatively and collaboratively, and make their actions defensive, focused solely on risk assessment rather than therapeutic change.Yet it is precisely a creative and collaborative response, such as that engendered by solution-focused therapy and other models, that is the most likely to facilitate change and re-empower clients to take back charge of their lives. This article describes a solution-focused approach to working with suicidal clients that can be used in conjunction with traditional approaches and which focus on establishing safety as well as assessing risk.Working from this model the clinician shifts to identifying client strengths and coping skills, to collaborating with the client to establish meaningful goals and to helping the client envision a positive future. Arguably, such an approach can increase collaboration between therapist and client and lead to a more client-centred safety plan.     

Generalized Anxiety Disorder: Connections With Self-Reported Attachment

Even though generalized anxiety disorder (GAD) is one of the most common of the anxiety disorders, relatively little is known about its precursors. Bowlby's attachment theory provides a framework within which these precursors can be considered. According to Bowlby, adult anxiety may be rooted in childhood experiences that leave a child uncertain of the availability of a protective figure in times of trouble. Furthermore, adult “current state of mind with respect to attachment” is thought to relate to adult anxiety. Both attachment-related components were assessed with 8 subscales of the Perceptions of Adult Attachment Questionnaire (PAAQ). Clinically severe GAD clients who were about to begin therapy reported experiencing less maternal love in childhood, greater maternal rejection/neglect, and more maternal role-reversal/enmeshment than did control participants. In keeping with a cumulative risk model, risk for GAD increased as indices of poor childhood attachment experience increased. GAD clients, in contrast to controls, also reported greater current vulnerability in relation to their mothers as well as more difficulty accessing childhood memories. Logistic regression analyses revealed that elevations on PAAQ subscales could significantly predict GAD vs. non-GAD status. Results and the implications for advancing the theory and treatment of GAD are discussed.     

Treatment of Excessive Interpersonal Dependency: A Cognitive-Behavioral Model

Clients with excessive dependency often seek treatment for an Axis I anxiety or mood disorder. Simply providing treatment for the Axis I disorder may fail to address the long-standing personality factors that may underlie the acute anxiety and depression. A four-stage model has been proposed for the treatment of excessive interpersonal dependency. This model describes strategic ways therapy content and style should change over the course of treatment. Despite the apparent utility of the four-stage treatment model, it may be difficult to apply in many sites that now emphasize short-term approaches to treatment. In many cases, therapy can be designed to address themes that are relevant to both dependency and the Axis I syndrome. Therapy can be focused around helping clients make improvements in stabilizing emotional reactions, enhancing views of the self, and improving social functioning. Treatment focused on stabilizing emotional reactions can help clients confront and develop tolerance for feelings of depression and anxiety. Treatment focused on enhancing views of the self can help clients improve their self-esteem, self-reinforcement and reduce self-criticism. Treatment focused on improving social functioning can enhance social skills, reduce social anxiety and challenge feelings of loneliness. In addition, treatment can focus on reducing specific aspects of interpersonal dependency and confronting developmental antecedents that may underlie the dependency.     

The Relationship Between Momentary States of Therapist Self-Awareness and Perceptions of the Counseling Process

To investigate the role of momentary self-awareness, beginning therapists and their volunteer clients participated in a postsession process recall in which therapist helpfulness and momentary self-awareness were assessed along with client reactions. Therapist anxiety levels and strategies used to manage hindering self-awareness were also examined. Results suggest that momentary states of heightened therapist self-awareness may be hindering. Specifically, when therapists rated themselves as more self-aware from moment to moment during counseling sessions, they also rated themselves as more anxious before the session and their clients rated them as less helpful during the session. In addition, therapists reported using a variety of strategies to manage distracting self-awareness, including focusing on intervention planning and focusing on the client. Implications for therapist training are discussed.     

When Words are not Enough: Psychotherapy with Clients Who are Living Below the Poverty Level

The present article describes six strategies found useful when working with depressed clients who are struggling with severe financial limitations. First, it is important to help clients maintain an attitude of hope for a better future, so they remain as positive yet realistic about their current options and future goals. Second, empathy is considered to be a central component in all psychotherapy sessions, helping therapists to understand their clients’ life experiences and ongoing struggles. Third, clients can learn to develop more adaptive perspectives about life, family, and friends, trying to focus on the positive events they have experienced and the supportive bonds they have developed. Fourth, clients can develop new specific coping skills that may help them to manage the problems they encounter. Fifth, many clients can better utilize the social support that is often available, starting to ask family members and friends for assistance and support when help is needed. Sixth, an interdisciplinary treatment team is often optimal when the treatment plan integrates the potential benefits derived from psychotherapy, medications, and social service agencies. An effective psychotherapist respects the limits of psychology while consulting with colleagues from other health care professions. These six strategies can help guide therapists when working with clients who are struggling with persistent depression in the face of adversity.     

Short-term desensitization therapy

R has raised the possibility that behavior therapy procedures can benefit from even further departures from traditional psychotherapy formats. Although behavioral approaches such as desensitization therapy are distinctive departures from the verbal psychotherapies, there is still an implicit commitment to one traditional approach: the reliance upon one or two weekly appointments. Clients being treated for phobias, for example, are typically seen for desensitization sessions twice weekly. Yet, both theory and current research argue for more frequent meetings as being more effective. Robinson and Suinn (1969) saw clients with spider phobia daily for five consecutive days, meeting one hr per day. Clients were tested on a behavioral task prior to and following massed treatment. Results showed that prior to therapy, none of 20 clients were able to place their hands near the spider; following massed treatment, all clients improved, 13 clients placed their hands within 12 in. of the spider, 2 touched the spider and 1 client stroked the 4 in. spider twice as it moved across the cage. Suinn and Hall (1970) relied upon an even shorter treatment period: students with test-taking anxiety were desensitized completely within 24 hr. These clients were trained to relax and exposed to hierarchy items from 1–4 p.m. on Friday and 8–12 noon the next day. Results showed that the marathon treated clients showed recoveries to the same degree as that achieved in a group treated over a course of 4 weeks. Theoretically, massed treatment should be more effective than spaced treatment. This is based on the view that massed practice would lead to the extinction of fear or anxiety responses since this method capitalizes upon two factors: (1) counterconditioning, whereby the fear stimulus becomes conditioned to relaxation instead of anxiety, and (2) conditioned inhibition, whereby the anxiety responses become ‘fatigued’ and non-responding is reinforced. Implosive therapy (Stampfl and Levis, 1967) appears to be basically a type of massed practice in which the client is continuously exposed to extremely frightening scenes to extinguish the fear. In implosive therapy the client is kept anxious during the treatment; in massed or marathon desensitization, the client is relaxed throughout the sessions. The purpose of this report is to summarize some results achieved through massed desensitization.     

An Acceptance-Based Behavioral Therapy for Individuals With Generalized Anxiety Disorder

In response to clinical observations and research findings that individuals with generalized anxiety disorder are reactive to their internal experiences, avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities, an Acceptance Based Behavioral Therapy (ABBT) was developed to specifically target these responses. ABBT incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT uses mindfulness and acceptance approaches as an alternate response to the rigid, avoidant responses characteristic of GAD. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client rather than engaging in actions that are motivated by avoidance of anxiety. This article provides a case conceptualization from an ABBT perspective for “William,” the composite client presented in Robichaud (2013a--this issue). The article goes on to demonstrate how an ABBT approach to treatment may unfold session-by-session for “William.”     

Guided Discovery

Guided discovery involves a therapeutic dialogue that is designed to assist clients in finding their own solutions to their problems. An integration of problem-solving therapy and the Socratic method can help clients to develop their own coping skills. Problem-solving therapy provides a useful framework for helping clients to manage many of the problems they typically encounter. The Socratic method provides a useful therapeutic style to promote self-guided discovery and self-regulation. Strategies from the Socratic method can be used to guide the process of the therapeutic dialogue, while the stages of problem-solving serve as the structure for the content of therapy sessions. Therapy can be structured according to five main stages: (1) Help clients establish a realistic and adaptive attitude toward common life problems; (2) Define problems in terms of specific and realistic goals; (3) Help clients to generate a wide variety of coping options; (4) Guide clients through a process of rational decision-making in order to select the best coping options, and (5) Implement the plan and evaluate its effectiveness. A systematic series of questions can be used to facilitate the client’s self-evaluation of different problems, goals, and coping efforts. The process helps to promote client autonomy and self-guided action. When problem-solving therapy is integrated within the Socratic method, clients can learn to approach most problems in a logical, thoughtful, and self-directed manner.     

An empowerment model of memory training

The authors outline an empowerment model of memory rehabilitation. Unlike conventional cognitive rehabilitation methods, clients' plan and control the treatment process from the earliest stages of therapy. The client identifies functional goals and the therapy is geared to achieve those goals. The empowerment model also emphasizes domain-specific compensatory training. Memory strategies and prosthetic devices are chosen so as to maximize transfer of training in the workplace, training programme, or in the client's activities of daily living. Group therapy involves clients teaching their newly learned skills to other clients. The authors present research findings to document the efficacy of the empowerment model, describe its limitations, and discuss how the model can be implemented effectively.     

Therapeutic Alliance,Interpersonal Relations,and Trauma Symptoms: Examining a Mediation Model of Women With Childhood Abuse Histories

The current study explored the dimensions of the early therapeutic alliance (tasks, goals, bonds, and other-therapist [people important to clients who support their involvement in therapy]) as mediators between clients’ interpersonal relations problems and outcome measures of trauma symptoms (dissociation and total trauma symptoms). Seventy-six female participants who were receiving treatment for posttraumatic stress due to child abuse (CA), were recruited from a university training clinic. The bond and other subscales mediated the association between interpersonal relations problems and dissociation. The element of client trust associated with the alliance bond, as well as clients’ sense that people who are important to them support their involvement in therapy, should be focal in treating CA survivors. Clinical implications revolve around developing, maintaining, and repairing the therapeutic relationship, especially the bond, within the context of dissociation, as well as exploring clients’ views of important others and its impact on their therapy.     

正式反馈的发展与临床应用

摘要:正式反馈通过系统收集当事人的效果反馈来追踪其治疗进展,进而识别缺乏治疗进展的个案,并通过促进治疗策略的调整来阻止治疗失败。正式反馈是近20年来发展出的一种循证治疗手段,其目的为进一步提高当事人的咨询效果。正式反馈的发展大致经历了临床有效性检验和实用性发展两个阶段。正式反馈可用于促进个体、夫妻和团体咨询的效果,也可用于评估临床督导效果、确定督导个案和指导临床督导。未来研究可探讨咨询师对待正式反馈的态度,拓展正式反馈的使用价值,建立正式反馈系统的本土化常模。     

Influence of Counselor Spirituality and Training on Treatment Focus and Self‐Perceived Competence

Spirituality is a potential area of concern for counseling clients. This study presents the empirical results of a survey completed by 572 counselors to determine if counselors' spiritual beliefs, experiences, or training had an impact on their focus of therapy or self‐perceived competence. A counselor's personal spirituality, spiritual experience, and spirituality training did significantly influence treatment focus as well as self‐perceived competence to counsel a client with spiritual concerns.     

Cognition About Cognition: Metacognitive Therapy and Change in Generalized Anxiety Disorder and Social Phobia

Metacognitive theory and therapy views the persistence of negative beliefs and thoughts as a result of metacognitions controlling cognition. This paper describes, with reference to the treatment of generalized anxiety disorder (GAD) and social phobia, how metacognition contributes to cognitive stability and to change. Metacognitive therapy offers a level of formulation and intervention that does not focus predominantly on challenging the content of negative thoughts and beliefs that are emphasized in traditional cognitive therapy. The focus of treatment in GAD is on erroneous beliefs about worry and unhelpful mental regulation strategies. In treating social phobia, a greater emphasis is placed on modifying attention and worry processes and on configuring processing during and after behavioral experiments.     

Honoring Protective Responses: Reframing Resistance in Therapy Using Polyvagal Theory

Therapists often conceptualize resistance as client behaviors that impede progress; this perspective threatens the therapeutic alliance, especially in couple and family therapy where increased resistance and multiple alliances are present. Polyvagal theory reframes and normalizes resistant behaviors as preconscious, protective responses emerging from our autonomic nervous system. The theory also explains how humans reciprocate safety cues to connect with each other; therapists can use concepts of polyvagal theory to manage their own emotional regulation and foster safety and connection in therapy. Polyvagal concepts deepen our understanding of protective behaviors presenting in couple and family therapy; therapists can help couple and family clients to recognize protective behaviors in their own relationships and facilitate safer connection and engagement. Clinical implications are presented: psychoeducation can help clients normalize and understand their protective processes; therapist presence and immediacy acknowledges and normalizes protective behaviors as they arise; therapist and client self-regulation skills support connection; therapist genuineness is a precondition to client safety; and understanding of polyvagal theory enhances assessment of conflict and enactments in couple and family therapy.