NINE EXPERTS DESCRIBE THE ESSENCE OF RATIONAL-EMOTIVE THERAPY WHILE STANDING ON ONE FOOT

The purpose of this study was to determine the extent of agreement among a panel of rational-emotive therapy (RET) experts about the essence of RET. The panel of experts consisted of the 9 members of The International Training Standards and Review Committee of the Institute for Rational-Emotive Therapy in New York. The question that the experts were asked was an adaptation of a Talmudic story known in Jewish lore as “While Standing on One Foot.” Responses were assigned to either of 2 categories: general cognitive behavior therapy (CBT) or RET-specific. There seems to be a range of responses that capture the essence of RET. A strong case can be made for subsuming many aspects of CBT under RET because much of what is associated with CBT has its origins in RET. The confusion about where RET ends and general CBT begins goes to the very heart of RET’s status today. Reprinted from Journal of Counseling & Development, March/April 1996, Volume 74. ACA. Reprinted with permission. No further reproduction authorized without written permission from the American Counseling Association. Stephen G. Weinrach, who maintained a private practice in Havertown, Pennsylvania, was a professor of counseling and human relations at Villanova University, Villanova, Pennsylvania, and a Fellow of the Institute for Rational-Emotive Therapy in New York. The author was grateful to Michael Bernard, Raymond DiGiuseppe, Windy Dryden, Albert Ellis, Howard Kassinove, G. Barry Morris, Ann Vernon, and Janet Wolfe for their responses on which this article was based. The author expressed particular appreciation to Martin Gerstein, Jeffrey K. Messing, Ellen Finkelstein, Joanne Christopher, and Colleen Deeter, who provided valuable editorial assistance. Raymond DiGiuseppe and Windy Dryden made the publication of this study possible through their generous assistance and incisive knowledge of rational-emotive therapy.     

An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: a modified Delphi study

ABSTRACT

Designing new approaches to delivering cognitive behavioural therapy (CBT) requires an understanding of the key components. This study aimed to establish an expert consensus on the effective components of CBT for depressed adults. An international panel of 120 CBT experts was invited to participate in a modified Delphi study. Thirty-two experts participated in round 1; 21 also provided data in round 2. In round 1, experts rated the effectiveness of 35 content and process components. A priori rules identified components carried forward to round 2, in which experts re-rated items and final consensus items were identified. Consensus was achieved for nine content components (ensuring understanding; developing and maintaining a good therapeutic alliance; explaining the rationale for CBT; eliciting feedback; identifying and challenging avoidant behaviour; activity monitoring; undertaking an initial assessment; relapse prevention methods; homework assignments); and three process components (ensuring therapist competence; scheduling sessions flexibly; scheduling sessions for 45–60 mins). Five of the twelve components identified were generic therapeutic competences rather than specific CBT items. There was less agreement about the effectiveness of cognitive components of CBT. This is an important first step in the development of novel approaches to delivering CBT that may increase access to treatment for patients.     

First-Order and Second-Order Change in Rational-Emotive Therapy: A Reply to Lyddon

Lyddon (1990) claimed that rational-emotive therapy (RET) and other kinds of cognitive-behavior therapy (CBT) are in “the rationalist camp,” are realistic rather than constructivist, and focus on the elimination of emotional responses to irrational cognitions. His allegations about CBT practices are questionable, and he ignores the fact that RET is not merely realistic and empirical in disputing clients' irrational beliefs but is in several respects one of the most constructivist of the psychotherapies.     

Group rational-emotive and cognitive-behavioral therapy.

The theory of rational-emotive therapy (RET) and of cognitive-behavioral therapy (CBT) is briefly explained and is applied to group therapy. It is shown how RET and CBT therapy groups deal with transference, countertransference, levels of group intervention, process versus content orientation, identifying underlying group process themes, here-and-now activation, working with difficult group members, activity levels of therapist and group members, and other group problems. Although they particularly concentrate on people's tendencies to construct and create their own "emotional" difficulties, RET and CBT group procedures fully acknowledge the interactions of human thoughts, feelings, and actions and active-directively employ a variety of cognitive, emotive, and behavioral group therapy techniques.     

Cognitive Barriers to Successful Weight Management: 7 Stymie Beasts

This paper focuses on one of the most significant barriers, especially for teenagers and their families, to the effectiveness of cognitive behavioral therapy (CBT) for weight management: high rates of attrition. Cognitive barriers contribute to attrition and to decreasing commitment to full engagement in the process (deliberate practice). Excuses capture the essence of one type of those cognitive barriers. Excuses are defined as shifts in attribution from self-focused causes of struggles to achieve goals to more externally-focused causes—resulting in decreasing full engagement. Those excuses (shifts in attribution) do not just happen. People make decisions to implement those shifts away from personal responsibility. Ten cognitive biases lie at the heart of such problematic delusional decision making. This paper identifies seven excuses created by that biased decision making as anthropomorphisms called Stymie Beasts. Such unique simply worded visually distinctive creatures may help improve recall and focus on these powerful antagonists to successful weight control. Then, the use of two CBT techniques, Therapeutic Understanding of Science (TUS) and Rational Emotive Therapy (RET), illustrated with examples for all seven Stymie Beasts, shows how CBT may prevent and dismantle those Beasts (excuses). Ideas for future research using randomized controlled trials to test these notions are also presented.     

Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

A Model of Therapist Competencies for the Empirically Supported Interpersonal Psychotherapy for Adolescent Depression

In order to treat adolescent depression, a number of empirically supported treatments (ESTs) have been developed from both the cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT-A) frameworks. Research has shown that in order for these treatments to be implemented in routine clinical practice (RCP), effective therapist training must be generated and provided. However, before such training can be developed, a good understanding of the therapist competencies needed to implement these ESTs is required. Sburlati et al. (Clin Child Fam Psychol Rev 14:89–109, 2011) developed a model of therapist competencies for implementing CBT using the well-established Delphi technique. Given that IPT-A differs considerably to CBT, the current study aims to develop a model of therapist competencies for the implementation of IPT-A using a similar procedure as that applied in Sburlati et al. (Clin Child Fam Psychol Rev 14:89–109, 2011). This method involved: (1) identifying and reviewing an empirically supported IPT-A approach, (2) extracting therapist competencies required for the implementation of IPT-A, (3) consulting with a panel of IPT-A experts to generate an overall model of therapist competencies, and (4) validating the overall model with the IPT-A manual author. The resultant model offers an empirically derived set of competencies necessary for effectively treating adolescent depression using IPT-A and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines. This model, therefore, provides an empirical framework for the development of dissemination and implementation programs aimed at ensuring that adolescents with depression receive effective care in RCP settings. Key similarities and differences between CBT and IPT-A, and the therapist competencies required for implementing these treatments, are also highlighted throughout this article.     

"It's led me astray": How Cognitive Behavioural Therapists experience personal therapy in clinical practice

Personal therapy is considered to be an essential component of most psychotherapeutic training programmes. However, it remains peripheral to cognitive behavioural therapy (CBT) training courses. We present a subsection of results from a qualitative study that examines how CBT therapists use personal therapy in their clinical practice. Seven CBT therapists who have undergone personal therapy were interviewed. Participants were asked about how they used personal therapy in their clinical practice and their accounts were analysed using interpretative phenomenological analysis (IPA) to identify common themes. This article presents the results of the first master theme, “Personal therapy creates conflict”, which explores a paradox that arises between personal therapy and CBT clinical practice; participants suggest that personal therapy equips them with therapeutic tools that paradoxically hinder their capacity to practice a standardised protocol‐led CBT. Results show that participants found personal therapy created considerable internal conflict, where their use of technical evidence‐based treatment protocols as practitioners was experienced in tension with the relationally oriented therapy they had received as clients. We discuss results in the context of Gabriel Marcel's philosophical insights on the dehumanising effects of technology on human relationships. We conclude with a brief consideration of the current political climate that increasingly privileges short‐term technical solutions to psychological distress.     

A Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults With Generalized Anxiety Disorder

This randomized clinical trial compared cognitive-behavioral therapy (CBT), applied relaxation (AR), and wait-list control (WL) in a sample of 65 adults with a primary diagnosis of generalized anxiety disorder (GAD). The CBT condition was based on the intolerance of uncertainty model of GAD, whereas the AR condition was based on general theories of anxiety. Both manualized treatments were administered over 12 weekly 1-hour sessions. Standardized clinician ratings and self-report questionnaires were used to assess GAD and related symptoms at pretest, posttest, and at 6-, 12-, and 24-month follow-ups. At posttest, CBT was clearly superior to WL, AR was marginally superior to WL, and CBT was marginally superior to AR. Over follow-up, CBT and AR were equivalent, but only CBT led to continued improvement. Thus, direct comparisons of CBT and AR indicated that the treatments were comparable; however, comparisons of each treatment with another point of reference (either waiting list or no change over follow-up) provided greater support for the efficacy of CBT than AR.     

Cognitive-behavioral treatment with and without response prevention for Bulimia

We compared cognitive-behavior therapy (CBT) with and without exposure and response prevention (ERP) in the treatment of eating disorder patients who both binged and purged, and reported abnormal attitudes concerning body weight and shape. Both treatments produced significant and comparable reductions in binge-eating and purging, eating patterns, and attitudes about weight and shape at posttreatment. Treatment effects were generalized to improvements in different measures of general psychopathology, and were maintained over follow-ups of 3 and 12 months. The findings are consistent with prior research showing that CBT is an effective treatment for patients with the core features of bulimia nervosa. Furthermore, the data suggest that the addition of in-session exposure and response prevention does not enhance the effectiveness of the basic CBT program.     

Development and Pilot Testing of a Cognitive-Behavioral Therapy Digital Service for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.     

Examining Positive and Negative Affect as Outcomes and Moderators of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy for Social Anxiety Disorder

Traditional cognitive-behavioral therapy (CBT) for anxiety disorders has been designed to target reductions in negative affect (NA) associated with defense-related processes. However, a subset of anxiety disorders, including social anxiety disorder (SAD), are also characterized by low positive affect (PA) resulting from separate deficits in appetitive-related processes. In contrast to CBT, “third-wave” approaches, such as acceptance and commitment therapy (ACT), align more consistently with motivational processes and, as a result, PA. However, the differential effect of CBT and ACT on PA and NA has yet to be investigated. Using secondary data from a randomized controlled trial, the present study sought to compare CBT’s (n = 45) and ACT’s (n = 35) effect on PA and NA in SAD. Findings were compared to a wait-list (WL) control condition (n = 31), as well as normative data from a general adult sample. Baseline PA and NA were also examined as moderators and predictors of theory-relevant treatment outcomes. NA decreased significantly in both CBT and ACT from pre to posttreatment. Although ACT outperformed WL in reducing NA, this effect was not observed for CBT. PA increased significantly in both CBT and ACT from pre to posttreatment, with neither ACT nor CBT outperforming WL in increasing PA. Neither PA nor NA were found to moderate theoretically relevant treatment outcomes. Findings suggest that ACT and CBT share common treatment mechanisms, making them more similar than distinct. Further efforts should be focused on optimizing CBT’s and ACT’s influence on threat and reward learning, and elucidating common processes of change.     

Change in Dysfunctional Beliefs About Sleep in Behavior Therapy,Cognitive Therapy,and Cognitive-Behavioral Therapy for Insomnia

As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.     

A Randomized Trial of Cognitive Behaviour Therapy and Cognitive Therapy for Children with Posttraumatic Stress Disorder Following Single-Incident Trauma

The present study compared the efficacy of trauma-focused cognitive behavior therapy (CBT) with trauma-focused cognitive therapy (without exposure; CT) for children and youth with posttraumatic stress disorder (PTSD). Children and youth who had experienced single-incident trauma (N = 33; 7–17 years old) were randomly assigned to receive 9 weeks of either CBT or CT which was administered individually to children and their parents. Intent-to-treat analyses demonstrated that both interventions significantly reduced severity of PTSD, depression, and general anxiety. At posttreatment 65% of CBT and 56% of the CT group no longer met criteria for PTSD. Treatment completers showed a better response (CBT: 91%; CT: 90%), and gains were maintained at 6-month follow-up. Maternal depressive symptoms and unhelpful trauma beliefs moderated children’s outcome. It is concluded that PTSD secondary to single-incident trauma can be successfully treated with trauma-focused cognitive behavioural methods and the use of exposure is not a prerequisite for good outcome.     

University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal,social and religious values (a study from Pakistan)

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non Western cultures. Differences between Western and non Western cultures have been reported widely. Psychotherapy was developed in the West and is underpinned by many beliefs which might be specific only to the Western culture. However, in order to modify CBT, we need to understand whether the concepts associated with the CBT might cause conflicts among people who receive therapy. This study explored the beliefs of the university students in Pakistan to find out if the concepts underpinning CBT are consistent with the personal, family, socio-cultural and religious values of the university students. Discussions were held with University students in Rahim Yar Khan, Pakistan. Students were given information on various aspects of the CBT and were asked to rate their agreement with these concepts on a visual analogue scale. There was little disagreement for the principles of CBT for personal values, while some disagreement existed for religious values. This study highlights the value of assessing peoples’ beliefs about acceptability of CBT in non Western cultures. Students in Pakistan felt that the principles of CBT are consistent with their belief system in most areas. However, the value system of students might not be representative of the rest of the population.     

A Randomized Trial of Internet-Delivered Treatment for Social Anxiety Disorder in High School Students

Internet-based cognitive behavior therapy (CBT) has been shown effective for university students with social anxiety disorder (SAD) and public speaking fears. The aim of this study was to investigate whether the promising results can be transferred to high school students suffering from this condition. A total of 19 speech-anxious high school students with SAD were randomized either into 9 weeks of Internet-delivered CBT or to a wait-list control group. Significant improvements were found on measures of social anxiety, general anxiety, and depression. Effects were maintained at 1-year follow-up. The average within- and between-group effect sizes (Cohen's d) for the primary social anxiety scales at posttest were 0.98 and 1.38, respectively. However, the average number of completed modules in the CBT program was low. Although compliance can be improved, the results suggest that Internet-based guided self-help is effective in the treatment of high school students with SAD.     

Kognitive Verhaltenstherapie bei schizophrenen Psychosen

Cognitive behavioral therapy (CBT) can be regarded as an established intervention for the treatment of patients with schizophrenia. Based on randomized clinical trials and meta-analyses, which found evidence for the efficacy of CBT, almost all evidence-based treatment guidelines recommend CBT for routine treatment. This paper demonstrates that in psychoses CBT is a disorder-specific adaptation of general principles of CBT for the treatment of patients suffering from schizophrenia. The CBT procedure draws on cognitive models of symptoms for the identification of treatment targets and focuses on everyday problems of patients by implementing a self-management approach. Fostering motivation and the application of behavioral and cognitive treatment strategies characterize this approach. If the patients live in a family, other family members should be involved in order to improve crisis management and problem solving within the family. A major challenge for the future is to improve the availability of CBT under the German conditions of routine mental health care.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety

Internet-based cognitive behavior therapy (CBT) for severe health anxiety can be effective, but not all patients achieve full remission. Under these circumstances, knowledge about predictors is essential for the clinician in order to make reliable treatment recommendations. The primary aim of this study was to investigate clinical, demographic, and therapy process-related predictors of Internet-based CBT for severe health anxiety. We performed three types of analyses on data from a sample comprising participants (N = 81) who had received Internet-based CBT in a randomized controlled trial. Outcomes were a) end state health anxiety, b) improvement in health anxiety (continuous change scores), and c) clinically significant improvement. Outcomes were assessed at six-month follow-up. The results showed that the most stable predictors of both end state health anxiety and improvement were baseline health anxiety and depressive symptoms. Treatment adherence, i.e. the number of completed treatment modules, also significantly predicted outcome. Notably, health anxiety at baseline was positively associated with symptom improvement while depressive symptoms was negatively related to improvement. Demographic factors were largely without significant impact on end state symptoms or improvement. We conclude that baseline symptom burden and adherence to treatment have strong predictive effects in Internet-based CBT for severe health anxiety.