Cognitive Behaviour Therapy for Psychiatric Problems A Practical Guide PAUL M. SALKOVSKIS Research Clinical Peychologist, Department of Psychiatry, Uni JOAN KIRK Top Grade Clinical Psychologist, Warneford Hospital, Oxford AND DAVID M. CLARK Lecture in Psychology, Department of Psychiatry University of Oxford: Fellow, University Coleg, Oxford Oxford New York Tokyo OXFORD UNIVERSITY PRESS 1989Supe se yp se Cresson t soauodee porns ‘wean ou fae these inoy jo auouneon un ae 9 ep Su goad BuOD:O80 Stent moge sap fonoesdypnus sprout ayy pe “one sn 0 corns fy pa mum ipeap a tunosoe 2, NST pe “taunsosoe set seq eos uo sss yi Eu Plepues Toga sup pes topo» pare oy say Yon Kea our “rq santufoo yo suovenyade asewodwr ap ye sive Suyop. sodeyp Sttenoo ooq ny 0 un Sure ut pu sh POS ose tng dso tomtypg sannuon moge 2jespaymoty AMO 304 9 OM Src jo dod Poguosse one A om Maura popssons 2x4 uf aripouor 0 motos pur dda Snwtaespg aaneo vo suns dui fovapyop sip pogauapr yoog, sf Jo sroupe 24. sonpaoud 3g ano anes ov oy pub lear anosnepg axnsSo> 2 ARGEHNS SShoned seve o1 oy ano ply o SeEN Poms UE 2) 3M Sihr'uosen ang 10g uounenn Jo soodke[eotnesd yh iim Pow 5} umes sin yo ed yous faba e uo oxaMoyy “Ade sno Sus ano Sapa pu soy tq om Hy SE | or 0 jeu pUE [enXas Se |ppm Se SssoUI yeruEW aTUOIYD yaa si sonmigesip ayp Jo swsadse ‘surzjgoid onewos ureu29 ‘siopiosip Sune> sopa0sip [euorssosqo pur AIDIKUE apnpput suONIPUOD IsO4L],“SKEA 2940 ‘ur Afpansoyja pur Ajiseo parean aq 1ouNueD ayo Yprya suoNIpuoD O2 aYef> piqis jo Aueus ‘suoneayidde s9pim ysnus sey Adesaup anoiaeyaq aanUs0> Saxomop “Suapuosip aalssaidap Jo wow8euew oy ut suersiurp rsou Jo uonuane atp 01 aure> A\geqoid yuouneon or saxpeoudde aansutioy “sjeun yeotuy ur us ppue paseq Aijeaynuaras axe quounean Jo spoyoui somou soup “Ades2ys coypisd siureudp ayqun ‘Kypayy saidersypoypssd ouweukp ay pur spoypou jesnoweysq Ajsund usdaiog aareoied suecmum> uous yey) ded P sily Adesoyp snoteypq aantuson ‘Aypuosag ‘siaprosip sinenpésd [JE UE juetiodun Ajsnotaqo os 238 wip supa) pue swySnowp ayp ym poUs2DU09 Aqoouip aze spoysou jeunoracyaq-2antuo> ‘Adesoy anorey>q Jo sut0} sbipo 20s ayyjun ssl “ISo19TUE Sup 20J suOseas fedioutad 2974p ze 23941] ‘suepjuy Suowe assur yonu pasyose Apeosje sey at nq wounean ro1ojorpAsd ut suouido}2aap ausd91 © st Adesoy) anoweyaq aantuiion plofxo Jo kissoaiupy “Kapeagpksg Jo s0ssafoug PPD ‘DW aq promaioy 119099 sz Mas sonny am) ‘pind povead bsg 99 wo posodas Bog won pus arias» oxi pus psn 3 0 Spay fo so “yD W para, reno Ped OLE gH) Yok mon seg Kesey poofsc 6 mt wd pio a igouen, ocqat oy Baty debs of SaHowever the account in this book will ensure that learners treatment with clear ideas about the proceduces that they wr and supervision sessions will be the more frui issues have been understood ‘The chapters in this book contain the basic information needed by Preface How to use this guide book is appro Cognitive behaviour therapy is developing rapidly, has been introduced by this book to the basic and practical aspects of cognitive-behavioural techniques should have no difficulty in adapting hs or her practice to other conditions for which cognitive-behavioural trent, | iment may be shown to be of value. In short, the book is undoubtedly 2 ‘most important addition to the literature on cognitive behaviour therapy, and it isa pleasure to introduce it to the reader. This book has been compiled for therapists who already have some experience ical management of patients with psychiatric dis. s to help them to start using cognitive behavioural al work. While there are many academic reviews Afcacy of this approach, there are few guides suff low practitioners to work in this way in their every. de scribed in subsequent ch: is read before turning to the ch: in each of the succeeding chapters the authors have adopted a standard format, ou, ing the nature of each disorder and the development of current treat, i approaches, and then detailed practical account of how to carry out treatment. tion is paid ro dealing wit sulties encountered during treatment and reasons for treatment fai Research evidence suppor where appropriate, but way of structuring the diagnostic scheme. The bi any rigid is that a treat- ized packages for particular con; aim of each chapter is to provide the reader carry out an assessment and plan i presenting with the wide rangeres fjawanxa a1€ aM YY Jo} 2DUESISE pues genoa popunud sport pel pu ‘wrypng afen) uu’ "9 sentry up swing Jo} MopuEHL mp ue 2 Popa re9-c9-19 ah y9-¢9 ¢9-19 IgE 29 MBAS Sue ouuay a1uepyy “76 198 30) Kasergaksy Jo jousnof 4 Pag pue EID Woy F¢ AGEL 30} PuE (S61) HELD WOH TE SSong towredog:[euDvew 14—14kdoo sonpoxds 01 uossiusad 20) Sutsoyoy yp ues 02 2 oj pur iuoddns 35]8 Plnom 3, “sxOUpa anoy ing ‘suo 10u yatm dn Zunand ej9]OUss sToyp 40J SHOANIGUIUOD ayp YEU Or YstA Ip sjuaaspaymouxyry 8861 paofxo poudde 2q Kew auouneon yorys ut sem aytoods spun 01 sH9pear 2S1SSE 01 AJparsuoix9 pasn ud>q aaey suoMEN enw “Adesa4p 01 sasuodsas ,stuoned Jo 1484] ay UE Aaesso00u se Payipour axe pue pa aye qwusunean pue enUs0gContents List of Contributors 1b The development and principles of cognitive-behavioural treatments The Editors Cognitive-behavioural assessment Joan Kirk Anxiety state: panic and generalized anxiety David M. Clark Phobic disorders Gillian Butler Obsessional disorders Paul M, Salkouskis and Joan Kirk Depression Melanie Fennell Somatic problems Paul M, Salkouskis Eating disorders Christopher Fairburn and Peter Cooper Chronic psychiatric handicaps Jobs Hall 52 7 ns 169 2s a7 us‘vsn ‘2uripayy Azores1ds9y ounwuy 30} 4919 ystaDf jeuoNeN HaqUIDWY JIS IWESISY pl ant “Kavenpp4sy Jo 20882j024 WHEISISSY Buprugag “q uawy 20 “PHO pues SIYSAOYPS “W Prd 0) ‘PHONO “eNdsOH projousey, “wuounsedaq MBojoyssy “siBoqoyr4sq EMMI) 2px doy pany, uvof -ysn uoxdunyse 9, rex feonuy Jo sors9.C1 pur AIOIOY>AS| Jo 10559}014 1405402 °§ [!2N ¥n ‘pu0}Xo Jo AassontU “Kaerypdsg Jo auounsedoy Wisop4 puoyuse gy “sano [EON pue asMneNYpssg aUerOsUED MoImwyy quay A *pIOXNO Jo Auss9AIUP| “AnewPAsg auounsedog pure ndsopy projaure, “s2nnI59] [eu puE rS!FOIOY>A5y [EDM NSIC eH gol “yn ‘uoxfunyseqy 30 Aas:99tUp ‘sdiysuone|ay Jo png 242 30} 492 -uap ‘Jowurpsod} ypseasay pur *4Bojoyp4sy [eD1UHP) Ut AUapMG [e300 morenig “7 uryy 10 “P2050 jo Asisamuy, “knenypAsg jo aupumsedaq siBojoypésy [e1U) PIES anna anucjoy 11 “PHOHKO JO Joysioatup, “Aanerypdsy jo wuounsedsq Yasmox] 201095 3804. 91U09]}99 dingiwy 124dosug 4p ‘sipuques jo Aasiastup, “4Bojoypésg jewsu sundxq pur Anewpésy jo siuaunsedog “ASojoqredoy>Asg. ut 393mD9] Jadoo 190d “n ‘pu9yxo ‘a¥aqjo9 Auss9A1U “Mo|Py pue Spuo}xo Jo Ausioatu, “anenjpisg yo wusunzedsg “ABojoypsg ui 191M] oI W Plaeg 11 “P203x0 quip) Y>Ie2s9 42yng wor) Jo Assan, ‘Anneupisg yo auounsedag asiBojoypssy ye yo Axsiastup) “Buy pue Jo Ausioatun, “anenpAsg Jo maunzedog ‘asf8oyoup4sq sJOINQIIIUOS JO ISI] Isp oy oF one ere xapuy sanuai9jay ee Surajos-wayqosg “71 omieyy quay suonounysép [enxag “11 uosqooe| an pun ‘mnaz2nug 3 unpy rages “Haury suajqoad penseyy “OT swuaqu0) x1 The development and principles of cognitive—behavioural treatments The Editors ‘The empirical foundations of cognitive-behavi psychological problems can be traced back to century. The Darwinian view that there is cont the lower animals allowed ‘animal models’ of bel ral approaches 10 carly part of this could be generalized 0 man, Early work identified two principles of animal le ple was based on the work of Pavlov and other Russian physi ‘They conducted experiments with dogs where first a bell was rung, and then food was given. After this sequence of events had been repeated a number of times, the dogs began to salivate as soon as the bell was rung, before the food was given. This phenomenon became known conditioning. As food automatically produces salivation before (conditioning) has occurred, it was termed an unconditioned stimulus; the response of salvation to the food was termed on unconditioned response. Before any learning had taken place the bell did not elicit salivation However, after several pairings of the bell and food, the sound of the bell (the conditioned st ioned re- sponse). This paradigm is represented in Fig. 1.1. Pavlov also investigated what happened ro a conditioned response when the bell ceased 10 be followed by the uncon ioned stimulus (the food). After a number of ned response gradually extinguished. 8 also found that emotional response wed. For this reason the classical conditioning para- implications for the understanding of psychopatho- al phenomena. In an unconditioned state, for example, an animal respond emotionally to an electric shock, with an unconditioned response including an increase in heart rate. It wil this wayor sjdud Wide yn Jo 4duiex> sn un seg sojdiounsd jean jo suonvondde peor nuns 9 uowo}o5 Ae St 209} se weyp pue “A ns sypads yo se2} 1eyp parssf8ns FY “snoILEYy>q sDuEpIONE pUE 10} 1uno92e 0 (siusUEdwOD 1ueIado puE JEDISSeP y10q FuIssedu09 “Lb61) 224MOWY JO 20M ‘ip sem 2oueniodust seynonze: >qqeH|eAU! 239M IDIMOPY PUE 2soui ‘uoMDomp pasisop oy2 ut amorAeyaq 28ueYP 0: aid aney ypiy siuoa> 94p stonioyuray se Suish pouue|d axe siuouncan ‘siuoned djoq 01 sojdound Su1uonipuo> qwesado Jursn uy “(posted 8u2q Sunejndiuew Aq ( }) 28e2109p 30 (|) asea10u1 1 spew 2q ues fousnboy} 24 ur stem oq ZH (uauiaoioyuies sane$oy) | (wueunysiung) — | aatteon 4 + saau0yuyps gordi |pvemas-uow aanessnag) | (ususas0yurs anmtsog)| aansoa t 4 pam, pausaid aasu0yuPy, € sadiouud pue mowdoaaaq wou aanpaysneg “(9poys auw2p> ‘F asnesag Aousnbasy ur saseasz0p anoun we4aq_P yo Aouanbaxy aya ut 595% je a2uanbasua jo sodAs 224) 9g. s,.enpi Suruyap 44 nes Aq pomoyfoy st y>Iya smorsEyog. ‘se UMOU aureI9q UOUDWOUDY St, 249q atp Puesmau € Aq pamoljoy Aur ety punoy Aoyp stusuitisdx> Jo s WBNS pue “uEWIOY ‘OANPUIOYL 4q YSN DYp UI peut suoNEALDSqo wo4y panuap “Sumorpuor zuiado se umouy ‘2ydouud puor2s 241, 400) (snus ‘Suuompuos s9yy pose 3said Kdesoqi snownqaq aanior zt4 Cognitive bebaviour therapy extended (generalized) to similar stimuli such as the experimenter’s white hair and cotton wool, but not to dissimilar stimuli. This work was adopted by Jones (1924), who applied Watson's recommendations for treatment; she discovered that only two treatment methods were consis. fective, one being to associate the feared object with an native pleasant response (eating), the other being to expose t the feared stimulus in the presence of other children who were not fearf notable that these methods closely resemble those later adopted Wolpe (systematic desensitization) and Bandura (participant model (see below) ‘The next major development was the work of the Mowrers in the late 1930s on enuresis. They regarded enuresis as a failure of the p: respond to bladder distension by waking up. They associated distention (onset of urination) with wakening and consequent sphincter trials bladder distension should result in sphincter contraction on its own, thus preventing urination. Treatment utilizing an electrical ‘bell and pad’ device proved effective (Mowrer and Mowrer 1938). The work of the Mowrers was important not only be- cause of this impressive outcome, but because the behavioural formu. lation and treatment of enuresis were novel. This work was significant in the later development of behav nd Developments in the 1950s ‘concepts from outside the behavi . the work of Dollard and Miller (1950), who conceptualized psycho. analytic theory in learning theory terms,’ and included factors such as cultural influences within a behavioural framework. This work demon~ strated the broader explanatory power of behavioural theory, and laid the foundations for subsequent cognitive-behavioural formulations which in- corporated findings from cognitive and social psychology research. In South Africa during the early 1950s, Joseph Wolpe began to report work on ‘experimental neuroses’ in cats. This work was similar to pre- vious research, for example by Masserman (1943), except that Wolpe emphasized new techniques for the elimination of experimentally induced fear and avoidance. He became particularly interested in the production Of conditioned fear. Thus if an animal experienced a small shock when it approached food, subsequently the fear could be elicited by other situa- tions which were similar to the situation in which the shock had previous. ly been delivered. Wolpe proposed a neurophysiological explanation to account for this phenomenon. Since feeding was inhibited by conditions antagonis- tic or reciprocally inbibiting. This led to the idea that feeding might be used to reduce the anxiety elicited by specific situations. Wolpe success- fully demonstrated this in his experimental animals by feeding them in Development and principles 5 ly closer approximations to the setting in which they had een shocked. He proposed that fear reduction could generally ed by th stimuli and stimuli ), Provided of the two. In order imultaneous present Wg a response anta; tthe antagonist of anxiety. conger, the were presented in a graded way, on a hierar- , and progressive muscular re adopted of these was a modified and shor (1938) relaxation procedure, which Wolpe bel Physiological correlates to the effects of eating, In Wolp Patient was taught relaxation, then encouraged to progress step-by-step through a hierarchy situations while maintaining the relaxation in order to reciprocal fe) expos Presentation because of the greater controllability and ease of presentation this offered. This Procedure, which became known as systematic desensitization, was care fully elaborated in Wolpe’s influential book Psychotherapy by reciprocal where itis made clear that patients were expected 0 in vivo homework between therapy sessions. Wolpe's vise a clearly specified treatment but also in his description of the inical application of this therapeutic technique. Howev theoretical basis of reciprocal ink : because it has been established that exposure in real-life situations is the most effective way to bring about reductions in con that neither grading the exposure nor the use of reciprocal as relaxation are necessary. Nevertheless, systematic. dese vided the practical foundation and the theoretical which has led to the development of current exposure-based therapies. Wolpe was reporting his work at an important time, when the efficacy of psychoanalytic approaches was undergoing critical appraisal, fo ing Eysenck’s (1952) controversial review in which he argued that the improvement rates achieved by psychotherapy were no higher than the rates which would be expected if treatment were not given (spontaneous the Maudsley Hospital in London, Eysenck, Jones, Meyer, Yates, and Shapiro became interested in the application of conditioning ories to psychological problems, and held a series of seminars on this ic. From these discussions emerged a treatment approach exemplifiedJo a2uvuayitpue 243 pue (sBumas 22410 01 uorsuaIxa) 101 109 01 pre ue se Aejn: posouad wo souevodut siyj, “soypeosdde uaaydoziyps 214Oa4> YL ojoyed ysiy sem om sIyL “(896I ay Y>ys wos} S98: ‘woos Sumuip a4 ut swuoned 4940 4) 1 Supsojurss aq Aews a1 qusned ssypoue 10) 2[1ya “OOS 2fBuIs e UI UOTE 189 01 Supiojuoy 9g eur a waned ou0 405 ‘sy “(Z “d 928) snorseyaq two 1949 S11 Jo StwI2 UI pouyDp 2q Pinoys aUoUIZD.0jUIEX eK 2YdIoUEAd sa2uuryg Jo 2oueniodw aya paresasnyyt 440% sit “uaespypN sem wu -So10jur31 20 paoi0juras Sem IMOIABYPA >Kp s9yI>YM 01 BuIpsos.e ase—199p 420 38e3:9UI POM sInoIAEYaq PAqAnISIP IeYp aTeNSUOUDP 01 {qr SEM 9} ‘uonDunxa Jo sueaw e se uated sip woxy UoRuane jo Jemespy 241 pur ‘suxsi0jupy se asteid pue sanaiesio Sussn ‘siusned ‘uy (mmorseysq Suneo seudorddeur pur * joypad“ se yons) snoiAeypq 2Hoy>dsd FuBuey> uo prx0m uoI|Ay ‘su[gord >101 \dde Aqsea uy “uaapjyp Sunod pu ajdoad poddes Suuey> pur Suunseaut uo ‘sonbuuypar auesado yo suoneaydde assy a4 Mn ano Pauue> SEM om audUNEDN OU Ing “42|SpurT pur ouurys q paquasop 239m (sis4jeue anolaeyoq poydde se umouy) qpeoidde auezado o1p jo suoneaydde jenuaiod yp ‘spggt a1e] axp Burn, sisdqeue anoravysq poydde :sonbiuysai suesodo Jo suonvonddy suoudoppaap si ur 2jos Suinun wos v skejd pur “y>eosdde yesmoreysq-aanruiioy 242 jo us oy uw pareposse AjrewNUT ouod9q sey at ‘siuoUNE= jemoIAEyaq muBo> 01 pauyuor 20 Ayesnaioayp st AFojopoyou siyp ysNO\pTY “(p861 UosppN, pur ‘sa4e}y “mopeg 99s) padopsaap 210m an1z20d [e: ausmnos Jo upd s0 sonst ypaeaso1 pur [e21uIp Jo aBue1 opr © 01 a 24 02 stuauituadxa ase>-2fduis pamoype Ypiya suRtsop xajduio> ‘sare “Lem Siyp ur parenjeas ag ue> soiSarens uonuaxiaiu Jo ADuEA e Jo siD2y}9 YL, ‘yqeues oun ur soBueyp 01 Suypsos0e passosse st uoKUDAL2IUT siMp JO 129}}9 yi pue ‘paonponuy s} uonuaaraiut ue ‘91295 sup uF auiod pounwad.op ‘oad v ae *(sauas auay p) sjeasaiut sejnfox ae 9]qeueA rueadx AqjeotuN> P Jo soinseau pareadas Jo sous e Suiuteiqo sajoaut stusuusdxs ase> ‘ sajdiouud pur mowdoxsaeq oudeys souls wpeoudde | sey pi “suisap 950. sem Uo|suedxo sty “uo! ‘onur siuouneon esno1aeyag Jo worst 241, “Aiaixue pouompuo dip Aq paonposd asuodsax aures ay ay ‘sfuuted yons yersaas soy “~poys ‘snymuns aajsioae ue gaia posted 219m asuodso1 ponsopun 242 yum pare NUS [PUIDIy “snoIAeYog [ernxas 2UEIAaP s10aP po UE D4} IseDHDUF JO Bonu 01 SistdeIO4p aT0 aduone ayn ‘sem wononpas 3e3y 1 auauidoppaap parejas Atjemdaouo> pur jpyjesed y “(6261 SUEW '9961 [Ned #9) sje pojjonuo> ut pred cnsoaur AqjeomeuisAs sem ssousanoayja Oy vey sea [et pues -3q uorinpas 463) 0) sayseordde Jesnoleysq AYR UoseD2 ouO “APPIN ‘510W yoru spaa2oad a1 ‘uoneznIsuDs9p SneUIDIs4S O1 AUT st anbIUYD=1 simp yBnowsyy “ampap or suaq GaruE jun aseay re anunuO> Pinoys aansodyg “un8aq sey aansodxa 20u0 (aznsodxo piose Aqpsoq) pu) adeso (01 20u pue tnuns poseay ayp 01 pasodxa aq 01 sey quand ayy “ysinunxa 433} 40} 29p10 uJ “tauins pores} 241 02 pasodxo Aynj BuIq wHoxy enpiaipur 2yp qusxo1d yoiym sunosavyag adease pun aourproan pack 9p sey auoned ay asne22q ysindunxe or payiey sey 363) pauoH aq ey) pue “(yeas pauompuo) pouontpue> swos9q sey ADIUE Y>ry for qjnuias 23¢ sisalgo pases} aeyp st ypeoudde ainsodxo 242 Jo siseq |e nasoatp ay, "us!pox8us 2an>9}p9 [ENUDsso O42 sem osnsodxD Oaya ur Ley. porensuowsp’ pue ‘sonbiuyso1 uononpas se2j a2qpo pue ysudsop Jo ssavoud 241 16 yeiap ur Buryoo] osje 19m “(g961) vosiaeg se Yon SsuYsOM UEDHOUIY JUIN sues ay IY “SI9pIOSIP rIgoyd 40} sMHaMPaW nsodxa paresoge|> pur padopaxp sjewdsoy] proouse ay pue A2jspneyy 8 SanBe2|jo> JoYLO pur ‘smouIEYY ‘SLEW HOPI “S19ps uoIs JO quauneDN jesnoreyog 2 ‘Suprpaus jeano1sey, 9g ‘kdeaaya wojss94e jo auauidojasap 941 ul jerusunsIsU! sem WeLYDEY ‘adjom yum payiom A[snorsaad pey oy ‘ueuIy>Dey Jo iuoUIDAJoAuT yt pum papuans sem jenrdsoyy Aoyspneyy 242 ae auouneas paseq-Buruze>| Jo uoneoydde ayy, “suiaiqoud je>tuy 01 paride Ayyssanons 19m sajdound puo> YoY UF suoREIsoauL ase>-9(8UIS poyersp Jo souas © ul Addesoqy snowanqaq aamuioy 98 Cognitive behaviour therapy desired or acceptable behaviours. More recent work has cast doubts on the theoretical basis of the token system: for example, Hall and Baker (1986) indicated that the feedback and specific guidance about perform ance at the time the tokens were given were the most important factors in such programmes. Nevertheless, the development of token economies was hiehy significant in terms of encouraging 2 general approach o treatment gs. The use of structured social reinforcers (praise by the therapist) was more widely adopted than the use of tokens, and the emphasis on altering and structuring social interactions (cg. Falloon, Boyd, and McGill 1984), Consolidation and elaboration of the behavioural approach ‘The 1970s saw the full emergence of behaviour new techniques being developed and experimental validated. By the end of the decade there was general acceptance of these treatment approaches. Behaviour therapy became the treatment of choice for many disorders, such as the use of in vivo exposure with phobias, obsessions, and sexual dysfunctions, and operant and goal-setting tech Sex therapy developed from Masters and Johnsons” pioneering work into the physiology of sexual responses rather than from behavioural research into sexual dysfunction. However, the emphasis on the empirical evalua- by Bick disorders, ith a purely physical origin (e.g. to those with a possible psychological actiology (© syndrome, psychogenic chest pain) and to the modifica (eg. smoking). This period was also marked by the techniques (such as reducing the time required f ar reduction and the development of abbreviated forms of and the introduction of novel approaches (such as anxicty 1g and social skills training). pment was the ado approach. Lang, Rachman, and others proposed Jems could usefully be conceptual a ‘three systems? psychological prob- din terms of loosely linked response Development and pr The systems prc "These systems, the same way, of even they are said to be desyn: reason (0 specify three systems as ‘more, and indeed it is probably useful to di ive and ever, this symptom Ited in more systematic own to have specif effets for instance, likely to affect physiological aspects of problem more than behavioural or cognitive aspects " ‘The late 1960s and early 1970s also saw the beginnings of disc the strict behavioural notions which dominated majority of behavioural treatments could not be conceptualized simply in learning theory terms, and proposed the adoption of ‘broad spectrum behaviour therapy’, in which techniques of empirically established effic- acy are employed regardless of theit theo! In pract approach was increasingly adi though the research literature did: not systema ms of behaviour was a tendency to apply treatment in a prescr echniques were mechanistically applied to pai regard t0 a , discontent approaches resulted in attempts to add cognitive components techniques, opening the way for the systematic developme cation of cog proaches. 1970s, there was general accept- apy. No longer faced with the acy of behaviour therapy per se, some of began to turn their attention 10 those im behaviour therapy even when it was rated in Foa and Emmelkamp’s book ireasingly clear, for example, problems :jpuodxo ase2-2ffuis pue dnos8 yioq Suns nua ay Uo UE stuZ>) fe id ‘uo povejd st siseyduio 2]qesoprsuo y>eoudde jesnoiseysq-oatitSo> atp tp quounean Tesnoraeyaq—oantu8o9 Jo sajdioutsd yesouasy -sonpeid ounerppsd ur pasnunosus sraps0sip 3sour 20) padojeaap u99q, mou aaey siuzunivan jemoreysq—oanruBo> ‘sarensuowap Ape>}> 4004 siqi sy “siseydwo aanqufo> soieo48 e sroqpo pur siseyduia jesmorseysq sateoii ancy auzunean Jo spadse awog ‘sunoraeypq feuon>unysép s1oIp PUE sygnowp pauoisip 21241 qiog Aptpour pur arenjeas stuaned djay 03 pasn uaup are squouufisse jesmoraeyaq pormonns A|jry>ie> pue uoIssnosIp 2neuraASKS “mmomaeyaq [euoNDunjsip pue Bur{uNA pouoasip yo suzmed szuH0901 oy padjay st qwuaned ay iuouneon jo ad snp uy “Adeioy anoweyoq ‘2anmufioo pauuay st a1 uoseas stip aoq -soypeoudde yemowaeysq pue yoo jo uonexauur ue sivasoxdax Yoog swyp u paquDsap mouNeN ay a -wonowsa jo a8ues apis ¥ of Adesoqp 2antuo> jo wont (9260) Pea "9 sexdeyD “Uap jo MaIA aaneB2u a soned ‘durexo 10) ‘pou Sip Uyexutew seus SoBe aanmufoo 22xp0 “samany puE SoUDUEdx> yu2sIn> ‘Jps Jo moIA aaneou ‘pou annus 2xp se soptuews axe 2894] “Butuon>ury Kep-or-Kep s,uossad 24p 2240 aouanyul yesous! v U9xD suortiogsip aaysudo> yo 398 & ‘passaud “2p 22uQ ‘wosssoidap ayp uyeIMeM 0} spua) ypiy apsH sno}ta e Sut -onpord no00 yu sayshoyp sHewome aneBou JoWRITY VoIP ALgegord ap sosearour us ‘pou s9m0} ju sydnowp png e's ammreyv wn , “SS]4UOM te], ‘se Yons “4n042 aAPULOIND an jo uorsnposd ays ot pe] pur ss0f zoleu © se paraudiaiu 2q prom nuo49 Ue Uns 9q 1YSHW UOREUIUNEXD Ue Buype) ‘uonduInsse 240qE 342 JO uD4o Jeonu> wlew29 02 2[qesaulNa enplaypus ay3 2xBuH SUR amo} “AtaHDe axnsod 2igesaprsuo> ateatots oF A st cuysssoons 9g asnut | 2] yiatpIOM 9q oj, se Yots uorduinsse ue ‘afluIExD og “mnoreypq api pur “iaydjoq aq ued suondunsse asoyp suoKenais ‘sa1B| PUE pOOUPLYD UI UiRop pre] 236 IY (suoHRduss) sopm cme uy ssyeulBu0 dosssoxdap ut Bupjunp sanedou weyp posodosd >poq -siginowp aateRau sayy 4jpou pt 01 stuaned Sundjoq 4q poweonn aq ue> uorssoudap ved Saxfdust jssoudap yo soueuayureM 2g ul jor fesu2> © sey anq Worduu4s oypeoudde aanuBo> yp Jo iueuoduit ysour 242 aW0s9q MoU Sey iq ‘Ayojs a10ur Yonus pardope sem ‘Adeioy] aanourg jeuoney (7961) u s2jdiousd pur wowdozsa2q. (oy sxadso1 uous ut aeyruns s1 Yorn (9261 “OL6T) 9PM 44 pEqU>sIP. ins uiMequayp!a}y “£04 sswei9a0o, Jo wd2>u0> 24 ‘wonngune Suypnpur ‘sionuisuo> aantuoo Ypryse Ur wo} YPse9501 Jo yeop woul © paseioua’ jppousiyy “iwou>o20}uBr js pur “spiepuens Bum25) uuonenjeao-yps “uoneaxosqo,s Jo jopous aBers-oas1p © uo poseq ‘Jou140? 2f5 30 rdaou0> 2yp uy asasai Busseasour ue soda 2bipouy “vonsanb ut morseypg 24p wo}z0d 02 8 Aq parerpaus sea 28 pq AaeaUnos je aeyp eapr ay HO ovr fas paqye> © [ppow v podoppaap eanpueg pus Asess320U @ 30U S sonb ur snoraeypg 2ep stu20}s0d mibasqns s94r98q0 2p | St snoweyaq a4p NOMAeYOG guuopod asip auoowos Sunpiem Aq suseo] jenpiarpur ue ypeoxdde -Aderaip sno1seypq, Ur s10198} aanmufio> 01 uonuoNe SuuMexp Ut -jsod yeotusqod ayn pur “uomsadsoniut yo Uon2a[as §,uosteq\ Jo aunt fiuinunuos ayn or paves Aigeqoxd Adesoys anomeyoq wig smote aan sides yo soutndooge somos a4, ‘paruoney AfHutsraxou 940099 APES ey sojqeten aanmudoo yo soueodun ay) nowy. 03) ‘Afoqoxpésd eanotaeyaq Jo 1xa1U0> ayp Uf “ypeoxdde fesno1Ney “29 248 upHA suonoU axRMUBOD Jo aouEIdssoe ayX 20) suOREPUNOS ayp rey pey stoi asuodsos wuapuodapur APanejss 3xtp Jo wonow 5 3uey soypeordde jesnoreyq pure sanrufoo jo wonesBo1ut ay.f, Advzoyp us woup ss2uppe 02 pou ay pue s101>e} axmruBo> Jo aoueUodut yo sisidesayp Aue £q soueidasoe auanbasqns ay 03 paanguiuo> s1usut -doypnap om: 2sou,audueas1 [eanoraeyaq 2[dusss 01 puodsa1 20u pip oy ‘wuanied 2soy2 Ul paafoaut 229m s201>e} 2AntUO> yelp qUapraa AYsuIseDI> ul aures9q it snyjj “22ueWLO}Iad |ryss99INs UMO I1DyI Pue aojuray Aqjenuctod {yo 2481 poonpas e or anp st uorssoudop 1 uyosuuaay worssoudap Ajejnonsed ppisd 12410 0b Kdosaqy snowangaq 2anudo3, ormeasures are also here-and-now, and there focuses on the opport changes outside the is chapter we have summarized the earlier developments which sd to the acceptance of the applicability and usef reatment approaches for many psychit designing treatment programmes. Recommended reading Barlow, D. H, Hayes, S.C, and Nelson, R. ©. (1984) The scent practitioner. Pergamon, New York. Davison, G.'and Neale, J. (1984). Abnormal psychology (3rd edn). Wiley, New York. Kazdin, A. E. tions of contemporary research. University Pa 178). History of behavior modification: ‘perimental founda- Press, Baltimore 2) Cognitive—behavioural assessment Joan Kirk Introduction Cognitive-behavioural assessment is based on simple principles and has clearly defined aims. These can be readily understood by therapists ne this approach, although they may need two or more assessn with their first patients in order to achieve the aims of the These are to have agreed a formulation of the target probler Patient, and to have sufficiently detailed information about fa taining the problem to be able to design and present a treatm addition, the thera psychological mode. The first, and perhaps central principle of cognitive-behavioural assessment is that the ways in which an individual behaves are determined by immediate situations, and the individu therefore becom specific problems rather than global entities. ‘The characteristics of therapists which are believed to be important in cother kinds of therapy are likely to be just as relevant in cognitive behavioural treatment. The patient needs to fel safe to disclose important stressing information. This will be facilitated if there is a and trusting atmosphere, no risk of censure, and if the therapist is ic and clearly committed to helping the patient overcome current ies. lan. In t should have begun to educate the patient about the Goals of cognitive-behavioural assessment he assessment takes assessment process continues throu; make the error 0 “height phobic exposure)uuejd auounean pur us uB0> 242 Jo Jeo ur syd Jo Aay 9ssDsse 9q 18 ‘ojduiexo 404 ~AousGuowa ue se soUPouy ysH|qeIsD 09 $1 UDUASs% se ‘ssaj2doy 20 ‘Aayin “possesiequis snowuou2 2pisoid eur sup ‘ssansip pur su: wed ayp anoge lwzaou0> pur Aqpeduiss jeiuauo§pni-uou say pjnoys asidesayp 94 ‘payout 24p sey Jo UONerozdio.U! J94 pue siuDs9 pareRosse ay Aq poUe|dx> 24, 4Aupess pynos anq par>rpaidun 20u sem sworduids 394 ut aseasour a4 ey) 398 02 394 pad}ay ButuoHsang urese 1yBnoug s,2eyA MOU! [>peq Sunuo> powers aaeq swiordurss ‘Suyp99} uo9q 20, dea 01 pue “umop 24039 31 2518299 38: {Hom or Sos wes o pey | UOIP “Ypeap sJoyiou hw Jo AessoATIUE 24p moge s>ypo1q Au 1 4p9% rppeoap & pey Aifeas 94, S9Q, ‘pres quand v ajdurexo 104 ns pue stuordunds uooiiag s snl you a¥E pi Teusoix9 pue jeussiur Jo sua) ur a]qeioipasd axe ssansip Jo. 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Modes of assessment Physiological measures allows the therapist to educate the patient about the treatment approach, ‘and to begin the process of change. It also allows emergency factors to be assessed, Modes of assessment 1 part of the behavioural assessment takes the form of i is only one of the modes of assessment in any given case. When assessing problems, itis four different of response— behavioural, ph procedures gi may be useful to assess a problem in more than one way, cure of change following treatment. This is lack of synchrony between the different measures 1974), For example, a patient may change behaviourally, but still feel sed and experience physiological uations. Thus, assessing only the p: self-report of distress would mask progress ani rented by a behavioural test (see asked to carry out problem behaviours. Table modes of assessment which may be considered when assessing problems. 1¢ major part of the behavioural assessment takes the form of an by information collected and recorded ing problems in the kind of de les of measuremer the other aspect + the principles of which are relevant to self-mor fof assessment summarized in Cognitive-behavi ral assessment 7 will be presented here, before the behavioural interview and of assessment are discussed. Hother modes Measurement in cognitive-behavioural assessment and treatment The application of the experimen patients, as advocated by Shapiro approach: a formil the effects of particular interventions these ae then tested out in treatmes h any one can be Seen aa single-case experiment, and much of teatient reccoee round measures taken both during treatment eee 8 sessions, and between situations, Advantages of measurement 1, Retrospective 2. Measurements durin sions, allow the patient an For exampl "9 a well as berween ses treatment if necessa ¢ the patient focuses on a distrest. Selo re and 22" Ratings of the thoughts con during treatment sessions, but daily rat Fe was ictasing Irom day to day Gen the tring sessions, this deterioration would han day tong, agoraphobic patient reported, Teouldn'e do anything Exam trips from home (see Fig, 2. slipped back from the pre 7 ‘more and fecling less anxious than a mJo Aousnbayy a auoned ayp 9809 sp ep aspaid ay apraoud rou pip Suluonsanb jo yunoure siqp uasa cskep sow uo, od .2ep st Yoyo Moy Puy, “YL 281 peau | s34202y44 "YO, Md OU st quoted ay asmesoq om r0u Aeur (f soidey>) 995) 2u1 -uesBoid sansodxo ue ‘2|durexa 205 tpopusiut se posaaifap u99q sey WU won ay saqpoyas yst|gerso oF asiderayp ay sMmo|je auDuDINsEAY “p ‘[eo8 auunean poosBe op uo pasnsoy Uurews uaned pue asidesoyp ayn weyp aunsua ospe siuswasnseau sen2oy 328) wiajgoad aoleu v u2ag pey 2eyin 3 pIOAE pur ‘Suyuutoq, "1 SI2OYS uos>1 Ape 01 IUDID}Y "pla 1 uoupyiyp ay Sunpuey s, ianed e ‘3]durexs 104 “$89 z] $89] pue snomue 2x0w 9q 03 papuot 24s 1e4p pare>tput s enasuaward so\po jo ma1aar ¥ pur “Pouad jenusuous 134 yp Ur S299 eprouios ed eyo Ged +z BL o1duymos owes Pd = Ol 09 OF_CONT_ WIZ adn swpastig = § 09 OL say 01 poe pu snoqutou Au pauoyd sro ovo pq aw09 01394 480 ‘1 soyious Sw pauoud | se SrOr_ ozol HWE oro) oaf auoyo Suioq oy | nym padoo nos nop Grarruy donwy wads own 210 6 duowssasse peanosanqaq—aaytudory jewom argoydesode ue 4g awoy woay sda jo Leip pee x + oo ox om x Fe oo oF x KAKA Dv auoqy sdoys aug awa Jeuosssasqo ue Jo) 2e08 Hunes-uorsunn Apep-soun-s90yL 77 “Bg 8 L 9 mat z ’ s az “ 9 8 oat ® s z AON OF t 5 t ON 6 Bumag— woouy — Sumo a0 132) Kiqssod p1no 1 st pog se sua ua “psuar Apu Ayprepow rw wN, OU Ge Ge ee ec aa ceae la) 3895 Buta ‘241 Butsn “Kap ayp Jo used y>e9 Tutmnp 329 MOK passansIp ned yeuorssosgo 784 Adesoqy snomangeq aay st20 Cognitive behaviour therapy In summary, measurement has a central role in co} assessment and treatment, and may occur in different assessment modes. ‘The behavioural interview is generally the starting point for assessment, and this will now be discussed in d Behavioural interviewing rote to me about the problems you would like help wi feeling tense and anxious most of the time, and drinking. Apart from that, I do not have a, you to tell me briefly how for a quarter of an hour #0 how the problem developed. And then we will go So can you begin by telling me briefly {eis useful simply to listen to what the patient has to say about the Problems. He or she has probably spent a great deal of time t about them. On the other hand, communicate thatthe problems are understood, For example, afer ing to a lengthy description of a patient's problems, the therapist said, "fT am right, you are saying that you try very hard to please other people, and to put their well-being before your own, but it sounds as though this makes you feel very worked up at times. Is that right?’ The patient can be encouraged to expand in relevant areas if increased interest is shown, both non-verbally with nods and eye contact, as well as verbally through rents and questions. However, therapists should ensure that theit preconceptions about patients’ problems do not excessively in luence either their questions, or their interpretations of the patients? replies. Some patients find it difficult to describe their problems, or give only ‘vague descriptions. It may then be to ask questions such as, “Can you describe to me what happened last time you were upset?", ‘When was Cognitive-behavioural assessment a1 "What was the fi ing you not what way has your life changed since you developed these problems?", “What does the problem you doing?’, ‘What have you had to give up because of the The use of paraphrasing may then help the patient expand on spect. lasts five or 10 minutes, only a gener 1e of, The therapist picks up clues about possible use later in the to provide the patient with a obtain feedbac accuracy. The example, *You seem to be saying that your major and your worry about them. But in additi ’s current relationship, as wel Are there any other problem is palpi that, you are wor problems we have missed out ‘When there is more than one presented problem, the therapist and patient should work out together which problem should be the initial focus of intervention (see p. 416). ‘The assessment then moves on to look at cach problem began and sd analysis of the current situation is made. Each identified problem is analysed in turn, covering. the steps summarized in Table 2.2. Development of problem This part of the assessment is considerably bri psychotherapeutic assessment, si lected if it is of direct relevance Onset There may have been a very clear onset for a proble driving phobia may develop immediately after a car a. even in such apparently straightforward cases, the therapist understand the problem and the driving phobia may be maintain avoidance, and, disfigurement remaining from thei For many patients, the problem succession of events contributing to the p a problem. These events may be di identified as the problem; for exar before recognizing that he has difficulty dealing with aut work. The patient on the other hand, may real which is geting worse, but be unclear about ho igus that there is a problem ted, oF whysuonsodxe Aqua] 10 nour, 248 Sys 5 8 poprone ‘urajqoad 2123939 24 jews 3q MoU Kew SI019E} \ypiyat suoseas 104 podo oa0p aaey Aeus wo}goud e rey ano Sunuiod apymyiom aq ospe AEw yy _sfueyp ue> 2m yeys uo aun sno Jo wou pusds on paou am ‘padoyarop woqqoud ‘Moy Jo aupno ue pasu ax yBnoyply ‘>Bury pur Ay o1 3ulod axe am 1eyH eyo asnes2q ‘mou Suyuoddey si 1eyy Uo au ano 3 asou pudds 01 paoU 2A, wonepouos9e ‘ées pynoo asidesoyp ayy, “souersuunos9 Sduysuoneps jemxasoy>tsd arerpaunuy vo st iwounean jo snoo} sofew ayp vey siuatied yons purus (01 Gsessanau aq eur 3] “snySnoys atoup xeys 01 YSU pue suID}qoId TOY anoge Stusopuod sanoy auads axey Aoqp asneD9q 0 ‘mo1AoIUt 242 nOqe jnadxa areanaoeut Jo asnen9q 94 APU st “Si2}qoud Jo muowidoppxap quDs9p stun daissanxa ue puods o1 IueM jp1m sitoned JWOS “yBnonp) Aue pynoys se Sinoge oy (a3 ‘saypanqp ‘sa1poq Aseaunyoa ‘sdnos8 "uuojUt 20 feuuzo} s9qpI9 “suoRUDAs posinbu> 2g pynoys pow ut soBuey> ‘Aauoaas su | ua & Jo apis 240 UMP auin-uass ue 2044 02 jrydppy stat uayp “Burpuers-Buoy pur ‘w}goad ayn jo suonemony usaq axey 2194p] “uoaiue> jeis o4p Sursn 494 aud,01d plnom uoneUIUIEIUE> Jo sie9} IY sonde>] jo> 041 01 Bururejdxo aoey 10u pno> pue sqot pauey> ays voy diay 20} paiuasoid {quo Aarue JeD0s HuIseaxDUF YL ueWOM e jdWIEXD 10, ‘sonmoyyp s0410 Days deur sup Se ‘OWN se|MonAed su 1 djoK 30} parUDs -aad uated aya Ayo ysrqeaso 01 ynyasn st a] -poreniony 20 paresou21p E ea Buneynpou pue sxavo-) ‘aney deur af 40 ‘Kypeais parsisiod ancy ‘ojduexs 103 ‘ews wiojqod ay] | [Paysqeiso aq pynoys z9su0 sit aours padojaxap sey waqgoud ay. Kes aL pssn0y) ue ‘pene squed yum quaned & 40} puowy 40 aaneps © ur ssouy jeoistyd Suaned possoudap v 40} rwEA2q= Aqjerradsa 2q pynom ss 1ex 20} tura|qoad Uaai8 Aur 40} 20ues2p>s sejnonied Jo svaxe aq [jue 194, "239 ‘98ueyP qo “ssnoy Sulaow “diys suonejaa © ur dn-yeaig ‘spuayy 20 Ayjurey ur ssuy 40 ypeap ‘9|dusexo 40} “swuoaa agp yeoida awsos jo asi © yBnosyp una on |ryasn aq deus 3] ~AysuaIUE ‘uy ut soflueys pue wisjgosd ay2 yo a2suo ay yplm pareposse soBuEyP a oles 20 siu9ad oj [ryssons 2q eur axoyp ‘sase9 ypns up “Sunes0UDIp mOMDIU] fesmoWNEY IB SANG TZ aIgEL, & uouss2ssp jeanorangaq-2ai B09, Adesoqy snorangoq 2arS0-) zw4 Cog ive behaviour therapy Occasional anxiety —__gp |= — Lt college sradualy disappeared | Uncte died aged 40, heart attack Severe generalized 1970 —¢— Separated from pariner anxiety increasing Night panics _ | 44__ Began oxazepam | ton insceuriy “rapped” by children |< stopped oxazepam; began to take iron Daytime panics _p | Rapid improvement —__ | in symptoms 1980 |< Mother died |< Younger daughter let home, no longer “trapped, began totravel Slightly ‘upaight’ | Panic attacks rapidly increased —__ | Began trip © America Fig. 2.5. Time-event chart for a pa ith anxiety symptoms about the origins of the problem in terms of lay psychology. Questions such as, ‘What was difficult for you about that situation?" or, ‘How did you stay calm in that situation?” on the other hand, produce more detailed information about factors currently maintaining the problem Predisposing factors Information is sought about anything in the background which made more likely that the patient would develop the target problem. specific information about background factors relevant for specific corders is available in the subsequent chapters. For example, if so Cognitive-behavioural assess ‘were depressed, then the pat tory of depression and childh questioned about em would be questioned about se: depressed and anxious patients tudes, even though it could be argued understanding of the patient as awh seeks information which makes it more likely be changed. Behavioural analysis ‘This stage, during which problems are reviewed in det: tmajor part of the interview. The aim is to discover ho ‘curently maintained, in what way itis interfering wi and whether the problem is serving any useful purp ‘There are two commonly used approaches to this. Each problem can be analysed in terms of what O'Leary and Wi (1975) termed the A-B-Cs—the Antecedents, Bebaviours and Consequences, Each of these factors may increase or decrease ability that the behaviour will occur. For example, a common antecedent to smoking cigarettes is ha cup of coffee the antecedents are altered (immediately moving away from the tab the end of the meal, drinking tea instead of coffee), then the likelihood of smoking is reduced. On the other hand, changing behaviour by deliber- ately smoking cigarettes too rapidly can help bring smoking under con- trol. Finally if there are positive consequences, for example, money saved by not smoking put aside for a specific activity, smoking is less likely in the future. For any given problem, changes may be possible in any or all of the tecedents, behaviours, or consequences; the assessment aims to what might be maintaining the problem and what can be ard way of carrying out a behavioural analysis isto describe the contexts in which the problems arise, to look at the factors which modulate the intensity of the problems, and to assess the consequences, including avoidance, of them. This scheme will be less complex but allows an adequate analysis of most sk the patien the problem. This gives in describing a recent ‘may be helpful for them to close their eyes and imagine the scene, as420} ponionns Ajuofoyjns 2g pynoys sorAaiU! ayp ‘sops0 ul 2894p YBnosp (8 01 Aavssanou 10u st 31 YAS £7'7 91g, UE PaIst] se Sp219A09 24 plnoys seane peoaq, xis ‘ase surojqord y>iym Ur s¥xa1Uo> BuL2pIsuOD Udy 97 “ity uy umoys st {aeip sty woxy ajdwies y “uonensniy jenxas 01 AjJeu0Ise50, {quo put “uossua pur “4 ‘wopaiog 01 parejas sem snoiaeyog 24) 2e4p 295 01 wy padjay Sunonuou! 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Apuonboxy qusunean “uonippe uy ‘sdoys pooy poruaauinou1> yoryme sainos Suruue|d fq SumBuIg, sey 2onpor Ayentur pjno enutNg YK UEWOM a4p ‘>jdurexs 404 fn200 swipjgozd ypryas ur sixaiuos atp Jo uone|ndiuew apnpsut uayo surjd usu ‘avon osnezaq, pasmbos st sio831n pemxaiuod Jo auouIssasse po[eI2p “sedoys sejnonsed ut snorxtee dys aj} 24s 2eyp parou ergoyderoe yum uewom v ‘sdoys poo} 219m 21941 21aym umor Jo seare Ul sem ays Uy Bug 01 sa84n 2x0u KuEW peY 24s DeIo> jenxasowoy Jense> Jo FuNOMUOW.yPS 9°7 Hy suse ues 01 paoqiog 29 Ol PA GOE_—1, ue DHE] oon PAYOM —¥}SL PHO UNE ZI — Nase 908 dn pag. sung 6 St A OL_—_BurYooq a8 oF IQeUN] yO9.LTUY aUNG g OZ AOL HPSKUL AG AL SOMITE 34OL PAHOA 2UNF wouf— apow mouoteg 13010 ona a ‘pousea| udDq sey snowaryoq euoUge wetp st Azoayp esmotaeyaq jo uondwnsse ue “| amidey ut paulpno sy Yi IpIM pur “uayO Moy 24 ey yo suMo1d E axey pjnoys asidex94p 9p sou ue IYpe! aypads amy 02 Bu uw “iupigosd 942 0 ano of pyno: op paris nod | tw001 anoK ur fers Bod pap So] MOH Aue a1041 91294 “uo 05 pue Atoms pur Sup ue op 02 2ygeun aq pur da uox peuioss Au pur apm sopsus Apy iysindn Aue woge spaydas waned ay“ 1 hvoas pur 194 108 | Due ‘sown asoqp 1 asp fu IP ay ey Fuiquosap ino 24 Moy uo pasnro) ajduiex> aaoge 2471 say 28 Sea TEMA “UO 08 pre roy ano Yoon Buyo8 asow sysnoys Leys oy “pouaddey rey our 241 Bun} pwotsdyd pue ‘sBuyjaay ‘sy lupjqoid ay1 30 wonduosop ay Kdosogy snowangaq anusuio 9%28 ive behaviour therapy each to be discussed: a major go: view of the problem, to one in whi predictable. Situational cues Problems are often worse in some si ‘Therapist ‘Right, that’s a prety clear pictute of how things are when they are bad. Now let’s look at the sorts of things which make the problem more likely to occu the time, I never stop thinking about ke that. But you've mentioned th ro the back of your mind and get on with in the morn “Oh yes, mi Th, ‘And which people make it worse anybody or are some people Pr “'m not too bad at home with my family, because they know froblem and eave me alone. total strangers in college, sa dificult, ne Fa Pe aui ‘Th. “What's so bad about quietness?” Behavioural cues Symptoms may be precipitated by a wide range of behaviours. For example, an obsessional woman was not troubled by the presence of knives in her kitchen, but became very distressed whenever she used them; an obsessional man found going through doorways or over steps very difficult; a man concerned about his health found that any mildly strenuous activity resulted in anxious thoughts. Cognitive factors Patients may believe that problems occur unpredict- ably because they pay litte attention to what thoughts are goin their minds at the time and immediately beforehand. At th it may be difficult for the patient to identify the to focus on thoughts at the appropriate level of speci because the thoughts were not attended to; or it may portant step in Chapters 3 and 6. ‘may introduce the patient to theit rol example, one patient said: Biz ic, typing away, and suddenly I Pp Th 0 you often feel bad in your office? Pe said, [usually feel OK when I'm at work.” Th were you actually doing on this occasi Pe w Th. typing the annual review, was anyone Pe and 1d been left with a hugh pile of t nd can you think what actually went through your mind at th Pe thought, I shall never get state for this evening.” the presentation of sy talk themselves control about having gy bility for in a very strong position, having, how you feel” ns when she table and whether this can be changed. It would also be useful to discuss whether she attributes her physicalspores ‘ue> 4 “dn &ejd days pue “peg Sy 28 uaappyp ayp uayp wooussepp ayn SHowxue ABB NO J EIp Kes desu soypear e sv 320m xe ado> or Aayqe 394 noqe paLZIOM AfBulseo.9U Sem 9Yg uoneMNs Ajuuey ajnoyzip w Jo asneraq, aWN atp Jo Y>MUT snore -ue Suyoy sem uewom v ‘2jdurexs 104 “suonsonb aypads pur pa[iep ‘yum poruawioyddns 2g 01 paou asayp ng suawssasse ayp Jo sued ao1]369 Suunp ssomey Summewutew anoge sanp> 9418 Apuonboyy [1m usted ay, s3y {aduso 01 ge sta ays Se woos 41 mou oof a4p 01 OB 01 Buso8 104 NOK ay, 24 ‘due 20} ‘s2ouanbosuo> yeuosiodsa1u ose 219 2104“ se paseaibur Ypiyye ‘suon, ‘urpuog ‘eau Bune> ‘ze> 20 sng -popur ‘sinowseypg pue suonenys Aueus yeax8 w Aq passin 213m suONeSURs 2p -PeIg ze4p puno woMn>nw Jo ouanboxy poseasour yuu uewOM TT AGEL Ut UMOYS se ‘BuIdnos# peorg x15 o1 payisse> 2q we suonpear asoyn ‘s3988in oy IM sy s22uanbosuo> 2qvipouul] “huowsey dures pue siradsord uouiXojdurs 40g Surzpredoat ‘uu 3uo] 941 ut yBnoyp uoAo sjenaus umwnsuo>-owN Yau 21 waned yeuorssasqo ue ‘2]durexs 10) ‘jd und auesado >1Seq 241 ~enuoa 01 svadde Lew! paoput pue “1ueAs{ox sso} 1s8uoy “ws|gosd ay UrEUTEU YoY s9PID st sso] s1 Ssoueiswinos qweseajdun 4q dey ur paquosap se ‘suns -25u09 areypouiunt 24 UO st rey ie uauussasso poanoianqoq-2as180) JaUssasse a4 OF WS 46 38941 JOY “Sond SwUBpoAUE yp YsHIgEs? ayzoads uy an320 4 dip asoye dour ‘ssounfeaa fesous 9]q@esn>u! se ujqoud ayp 398 ays soynayys uo Suspuadap ueArdya4 ose axe sioquisu Ajuuey JO S9q ay woned >1goyd e ur sasuodsos 3 ‘Aew ply © Jo aoussosd ayp tsjenau feuorssasqo sarequa9ex9 uosiod sqnoue awos ways “Garxue o1 swords, Kdesaqs snomngaq annoy of2 Cosy ive behaviour therapy ‘of an example of when that happened, as 7 z usenet ee eee i sheet we avoided. The discussi 1. : ee 4 Ae ce roel dang or nha pace veo Te ce etree ee eae per eprom phere Pe “Oh yes, I spend have started doing, or are doing differently, because of oth ooo ee a oi E Gr pull myself togetk the problem?’ or ‘What could you stop doing if the problem went away: ? Sean aes mca down! Th howl be supplement by eat then gave the patient a summary, so that she could begin which may be affected by avoidance. If the pr he patient to see which factors might be changed, and could provide feedback on the become unaware of the extent of the avoidance, and ques accuracy of the summary: “How we your life be differ if you did not have an ideal you be doing that you the literature can guide 5 ‘Therapist “So what you seem to be saying i th if the problem disappeared, what would the then you i efen aoe ina, sod any mildly strenuous activity ch eating disorders may avoid a wide range though you just until you can the classroom. And I supp ythening your phobic woman continued to avoidance of eye-contact ‘Th. ‘So we'll need to work our what you can do that would build up your people interacting, self-confidence about coping at work.” ugh the problem appears a woman with a phobia about vomit- hher work as a nursery nurse where she iren. Specific questioning revealed a much ‘This summary has raised the possibility of ing factors—nipping ud, we felt unable to deal wi improved without ‘escap- i a + pattern of avoi 4 confident in the classroom, ly rapist "You sa relevant, and necessary t0 ask o Richer situations. General descriptions of behaviour, le information; nor do phrases ly Patient them. I won't go to pubs when they phobic woman gave much more useful informati iy he evening when people may have drunk questioned et drunk.” th The low did your husband respond when you went red2" Pe know the people, b Patient ‘Oh, he never says anything really, he's not much help.”‘wjgoad ayp jo sumeu 24) asideoyp agp yproudde ap jx auaunean ut a8e8u> 02 suowaaus pup uioyqoud agi moge sfon2q ‘4 eowojoypsd aye deur ypryar (stuau aaypo ose ang ‘sidonoypésd Apey uzun) ‘2suodsox snotsaad Jo puodsos p19 3,uptp ( s12jqe) 01 papuodsos a}, padojxap aaey Mew wuoned ay: ‘uomppe uy luonewioyu 2418 ay8iur ‘au1o>In0 200d Jo ase suiodsey quo4un9 o4paad Kew 31 asne20q suurd st auauneon snomaid 01 asuiods9y Jo Atrejnonaed “Azoasty snoxsasd yo pauteiqo 2q prnoys suouenans pur K103s14 po2qpotu puv auswqpksd sHorna4d auous0y 3) ‘ynosyp paseo 2q Ila suonsaaiins wounean vey 4 ay oyeur ypiyan “que Jeuosiodsowur ‘sousisisiod “120;UI00s ‘oy ssoufluyiae “anowiny Jo 2s ‘syiguans pue Jo aamos v se Suidao¥-204 drenpoe) Ayes2uod deur yyy S|EAS ep © Buiney ‘gol Sur4ysnes v ‘asnods oansoddns e -r9j ewusuiuostaus apnpul asoyy, “sipsuans pue ‘i Jo woIssnasip J9pIm e O2 2AOW WED IOMDNA ‘wo -sip sem ypiq Bu ‘nox uayar 391] anOK UF 2uu datexo 40g “pasn 2390 ajqensuowp Aue aysyysiy jeap sey auaned ayp moy ssnosIp or [nydjpY os|e uno} 2ary nok y>tyse re4p ‘240 j9q uaa IuND PUE WOOs 24) ‘ue> nok rey potd! 2q dew i 34 plniom |, “yse ueD asides Suydoo ae porsauip 2q ue> Bu Ssonsip ae2quNWUIOD 0} st9) Uy SI9p|OYS 2 IE $34] pu suojgosd yum Suido> yo spoypou 324) sassp 40430 pu sa2unoso1 Budo: se suoussasse pounosary2q, niiog auey> ‘anyea a5ej si 1e uaxfer aq ues (01 paieanous 4ijeoa st jut suiajqoad pareisosse 0 pur “(oe “a ayp sdans-apis popun a 8 Aaepuoras, se yans St 2104 SoADMO} “Aa|NOYpIP JOPINs 124m Jo Uonsanb ayp astes APU LUD uot 3U0] 1 yo ued 51 wajqoud powuasaid sed © Aq poquosap aouepione 40 usterview so that infor- ined, and so that patients ural approach, nevertheless pist about their per example, whether of the patient's ‘One woman wi tunable to give a coherent desct down during the interview. It woul problems was subtle effects; Patients can provide detailed information about their problems, but reveal nothing about their gen had described a cancer phobi chondriacal ideas had died aft psychiatric hospi the same fate, evil day. Patients with physical symy physical condition which wi oms frequently hey have a ly be helped by physical treatment, and this is also true for some depressed patients. While some beliefs require immediate intervention, others can be d in subsequent sessions. Many change spontancously during treatment; for example, a belief about the hopelessness of a condition may begin to change 28 soon as any improvement occurs. Ways of questioning and challenging beliefs are described in detail in Chapters 3 and 6. It is preferable for the patients beliefs to be el interviews, but occasionally the patient may be u at this stage, or even be unaware of them. As assessment continues throughout treatment, further discussion of beliefs may arise when there is a block in progress. Engagement in treatment ‘Most cognitive-behavioural treatments demand a high level of commit: ‘ment on the patient's part, and many treatments fai does not apply the agreed procedu people who are mo: would be worthwhile cont or inconvenience associated distress and inconvenience li lance is likely to change during cally reassessed. The pat above) should be explored, and erron« involve providing new come); or by getting the patient to quest example, that the right ta problem useful to discuss whether changes on a broad front, the target problem, would, on balance, be pos unlikely to energetically pursue treatment suggestions wife will leave home once she is sure he can cope. progress and then discontinue homework ccan be associated with the homework 's percep- tions of the homework. Since les apply whether engage- ‘ment is an issue at the assessment or subsequent stages, the general principles will be reviewed here, The homework task ‘The patient and therapist should focus on what prevented completion of the homework. Was the homework merely sug gested rather than explicitly planned? Was it too vague? Was it recalled accurately? Homework tasks should ideally be written down by therapist and patient. Had the therapist routinely reviewed homework on previous viewed, usually at the start of each session, patients come to perceive it as unimportant. Was the rationale for the homework understood? The patient shouldbe asked to samen the homework for the therapist, thus identifying gaps and misunderstandings. Were there practical difficult ich interfered with the homework? (c.g, diary forms were not accessible, patient had insufficient funds to ‘complete the task). casks were set up foadly that the patient lp achieve the goals for or that other factors (eg. prevent progress. This may be because levant, perhaps revealing new facets of the problem; orbq su auayp 9154 a.oqRKUE fe 958 nok aun yped aetp st suaddey weyA “PUNY sD ‘a a8y 8 05 “spt ‘85 HK 9uN PED 109} yt PUodsD! O1 pouse>, pry Apoq ano ~fiorcue pur spaiq aaqueq pus ano ur YOREDOSSE 24) paUDK SL, "9pisut eq paysta pur snonue AA9s sure>9q nok popeoudde symp ‘ay sy “avepyel ayp yo nok Huypunuiss “slut sap Buiddey Sea ap 25942 0 200 aged Buryfem Sy>np Jo Duy] E MES NOK TINO HoH MEK LOY A “aulegosd pyoos sig “pag 248 ‘an suue29q nok spunoie Suddey mepypel © punoy pue Suus0M v0 wo ‘Susy a9 otut ump aise nok uatyn ati912x9 auve>9q wojqoxd a4p LHP PUY, gays aeqn st "9sua) Arey Ayes2us% nok apews pey re 0 9 ut spus4y OU pey NOs pue axou ayp ynoge UrELD.UIN s>qpE ok yBnoupje “Anno ayp 01 paxow pey nox “Asnotsaid pey nok se “day 0} tuo 1/82 4upino> nos aeyp asurs ayp ur AaypOW INOk wos} AEE ssi 242 sem sty “4824 jo 2jdno9 © 20} pow U22q P,n0s YBnoMy nt ey NOK Kes NOA EH dos pute ‘auionxa 21me2oq A]: 5 ‘tu 9) 01 uo 08 5,327, *»,gAeununs 2]qeuoseas © 1p pur “ump 01 Afuons Aras sioeo1 oy ‘Uo Shemje anty N04 Aes os|e NOK *, SPM DL, JO WY 24) MES NOK Uo4o SUD InOd an swwopout Suuuorysiyy asou! ou 219m S194, “JONES ay Peguis,, awnwONed fut paiq anueSid v mes nok ua poylis) Sam nox pur “jews 212m nok fem Bu © eq a1eP Sputg YI puesiopun | se ‘os, ssiderqy -urgygoad ay Jo 1usuidoppaap ay) 01 uo [peAow oq uolssnasip ay “pasmunosua 2q 1yBiU sparg 2:04 sareid Jo Soulepioae Buisvasout Jay pur (1Palqo Axaype9} 42420 10) pug & Aq paIUuoy, “o> sem ays uaya uaned ayp Aq pasusuiadxa sworduds oy Surziseyd ws “upjgoid ayy jo Aseuuns joug © Sura ‘spuauadxa queseajdun yo suouou asiy snod 6 uawssasse poanowanqaq-2anti50D pay ut iwupad © ponuasoid asidesoyp ay ‘motaroiur uaUIssasse axp Jo pud 2xp spremoy “eiqoud eigoyd pg © Jo Aaorsty 194-904 & yum poruasaid ueWwom pjo-se24-g7 v ‘9jduexa 404 ‘Aoeano9" sit uo y>"qp2: ‘ut yo Azwuiuns © pue uous pue si012ty Susodsipoad Susp) jeueydx> we “wojqoad russsn> ayp 4 id ay2 Jo uone|muNI0} AseUK sod & ut ag plnoys isidesoya alg “aotazaiut 24p sonb aydnjnus HU SsouuNt6% 89] st 21942 pue “Buon 10U st SSOUINIsM nOMOH, idf, put ejaine-y) souorsiy yeuone> Suros09 eiep punosiyeq pur sn ayy aziseyduso feIap E aNOYM “ZZ euL0}4 posognnsy, ue asodas S11 UEUOWY “fa 2IqeL UF pozeuuns se “puis 394 30) 07 pue Suouufisse ysomous nurBeus 01 payse 9q po: PS MOU B Jo Uo! cd ‘9]duuex> 4044 ned ay} asne29q Aiieiaqy snomogaq aay 8¢40 Cognitive behaviour therapy is what happens when you are actus re of y response ike your heart pounding, feeling cold; you get anxious pass 04 thoughts rapidly increase your anxiety level, so your physical symptoms increase” is kind, which increase your fear ‘This means ‘nother thing we ip you learn ways to you have to do next. down when you are bird being trapped and sion of the treatment plan followed on from The presentation of the formulation generally highlights the need for further information, whi other sources, descri ing data is avai ft t0 prepare the mn between sessions, and to incorporate the information from ther case the form ent blocks may arise at any stage, and may in the formulation. For example, ways of responding to this range of that another major factor was her mi a au The revised formulation was discussed wi planned and new interventions around which there are agee and the ways of doing this, areas which are g¢ setting up intermediate sub-goals. Many of the principles involved in goal se for devising measurement, as the measures are ing goals at the assessment stage. 1 patient can expect from treat (0 expect never to have an at id not feel ics addressed istorical antecedents for her pai reducing the frequency of her p: requited: the pi Defined goals help to impose structure on treatm presenting problems to be addressed, with less ris prepares the pa therapy will be terminated when goals are achieved; or that therapy will be discontinued if there is little progress towards them. This is not to say that goals cannot be re-nego ment, but that this should be done expl thus reducing the risk thar patient and ther agendas. are pursuing different 18 goals provides the opportunity for an evaluation of ‘outcome related directly to the individual’s presented problen How to set goals08e s1pok aso4 Aun passed |—umo Aus uo uyddoys ayp op pue ssw daup pyno> | :su0r ‘us MoUs 01 uii0q plnom | “op s953U | a5neD9q AuUNY 429 sn {94 —sa4}09 20} ut sInoguiou Awl yo 2408 ‘pase sem 20upyuoo-s9s tur Bupppey sea oys auoned e ‘s|durexs 204 “soussIN990 Sif MOge IaHFe (01 staazosqo auar9yp1p mole plnom y>iya sem ‘ur pauyap 2q pynoys posnseaut oq 01 1u949 40 s1me9j ay], *2>UDpYyUO-y]>5, aH] sidaou0s onsen yo auowomnseow >jgeyja1 2As1yPE 1 yIROYHP St 4] s1aBir4 pauop Kuna ‘sy2eds -s ‘s0uvaapos Huyseosout yo sXem smote aye 23941 ‘oy Jo uno39e quaIsIsuo> A\qeuoseas v OpIA ey D4NsEOWW PINOYs ‘poyse wonsonb 24 o1 aueazjss 9q,plnoys aunpaooid ausuouseau y J011UOULJ]95 01 MOH, asnods Aq pazonuow aq osfe pyno> auaned jeuorssasqo ue Aq Surysempuey sj9 auosuios £q parouuoul 3q lue> siuo4o ayp Jt Sp>ouIp Sous paasIy>e 9q ueD Inq uayo st SY “(FZ6L HOSA, puE 1ysutdry) passasse 2g eq azeme si auoned oy jt s9seax5u SuOMUOUL-Jps Jo AresNaIe ay, -poutego 2q plnoys soxuour or wowoDiBe EL uEYP A9qIEF “yeuatew 242 uo sn20y I] suorss9s auaunean auonbosqns 1% $Buroq at ‘paziseyduro ag pynoys Buizouow-y2s Jo 2ouesoduat 2 aq Suuapangiano anoyatm ‘parsanbar aq pjnoys oneuoyUt injure pur aiviidordde so [exouail ay & yt pasesiour st uoneWojUr paxouuoUj2s yo Aovana>e ay, ‘Auysoruou-y]9s Jo Koesns>y jusudunseau! a1eIND9e UleIgO 0} U>x81 21”9 puE PastAap Samowaeysq a 14 o8eIs oMD are 22042 1 & uowssasse ppanowo4aq-2ainudo3) parepar sounseau jo Aay [e08 yp jt saute syeo8 Se “pasouype seat poseayd aq pynoys 324 01 punos spuaiyy aney or ‘spi 2snoy 242 ut aysIUADKO AeIS 02 !5193 (01 :ypasiay 20} seo Burm spoydas yp 01 Surwos yBnoayr anaqyse or 241) plno%m ays 2eyIN PIYSE > ayn ways ‘3jdurexo 104 2q 01 94H Koy Moy 3 yesousa UF azeane ayo axe siuaneg ‘paprerep pup 2ysads aq pynoys sjeoy “7 ‘Azessa0ou jt 2sey1 Jo waned ay puruisa pue pes 2a ads 20 panos spy ots uex2 20)) a2iAzaIUT ayp wnoYHORp pou dn pid 01 rydpay osye st and 2M pom sons 5,1 05 "82200 Jo 2ouapi4a “Buidoo 33,n04 teya 29UDpIAd [3 Suuream eis 01 nod quem | “st lwo Sursnooj 1e pod aoa axe y>uyn sass Futseam 4294 In ey ae9p aie 9 2tued ou 9Acy 2g Pinos ypuya rey se , sep “gpomasnoy SuNp Kdosaqy snorangeq any44 behaviour therapy Further discussion elicived amenable to self-monitorit refer to events which are observable but it may be po: external effects of an internal For example, it would be easy to disagree about ‘Mr G was ang easy to agree about a more detailed ‘Mr G shouted’, "Mr doorifurniture’. This could be supplemented by Mr G cou ber of angry thoughts, and giving self-ratings of anger. In general, the instructions about what to record should include re- quests for information about the frequency, intensity, and duration of the targeted problem where these are relevant. Aids to recording ‘The therapist should provide the patient with a form or recording device which allows easy record keeping, Patients usually cannot draw up record forms for themselves until they have become skilled at recording. The patient should be clear about what and how to record information. This is best achieved by going through a worked example with th Meaningfia and sensitive measures The most meaningful measures are often different from the most sensitive ones. For example, a gitl was being trained in assertiveness skills as 2 way of increasing her self-esteem. The most meaningful measures were sel ratings of behaviours associated in her mind with self-esteem (eg, being able to initiate social contacts), and questionnaires related to sellesteem (Rosenberg 1965). However, these indices would be insensitive to small daily changes during therapy and could only be used, say, monthly. In order to look more immediately at whether changes were occurring, more sensitive measures (such as the number of times each day that she said ‘sorry’) were also used. le measures for each problem since there weasure of a problem which will adequately reflect all However, patients should not be bombarded with in record-keeping, » particularly at the beginning of treat. be collected if the patient an pist are 3 used for. Patients are much less likely to keep they appear irrelevant. aspects (see p. demands for inform: Timing of measurement Recordings should be made as so thought, oF feeling) has occurred possible after an event (behaviour, he patient stores up examples and 8 of achievement or coping, It is important, therefore, recording is easy to carry and use—a notebook, ‘There are many data which can be monitored. Specific examples are given in the subsequent chapters, but a broad ion follows to allow the reader to design the most relevant selt- 8 for specific problems. Frequency count If there is a relevant and meaningful aspect of the ited, then this will provide the is worthwhile tying to problem to count; for example, number of week, number of self-critical thoughts, number of haits pul ber of panic attacks, number of arguments wit easier t0 use a mechanical counter (for example, a ing counter). Duration of problem It may be appropriate to measure the duration of behaviour. Exam how long an agoraphobic idwashing, down after an episode o information can be recorded in a diary lapsed time indicator is available: d time elapses whenever a switch i Self-ratings ‘These are used when information is required about a subjective state, and are frequently obtained in ai to the frequency and duration measures described above. They are less reliable th direct measures, and ‘anchor points’ may change as the p. unless great care is taken to specify what the points on the meaning of ange as the patien ly distressing experiences. Ratings are more reliable if they are made at the ‘vent occurs discretely andJomuour Kew ‘pamoraroiut 2g Aew (dood Aoy ‘sn 3e} 0s possnosip sear ip Jo ypee uy ‘ajdoad soy10 wou pourergo ag Aew woneuofut feuoRIPpY ajdoad zo woy uoneuLOsUT ) uosio}] pue pe] pue dusexo Jo 33uea 9pim E ang aff siaidey> auonbasqns (9261) 22ddp, pur eames ut 24q ‘soutewuonsonb wes9ppu anoge uk JPA pur ‘seq yea!So] uewp z2yres jeoutdura ue UO a11EUU sioypne 2q1 Aq pouiwusorep u9q axey plnoys sty “eaxe pasedto aq ue> sow eqs aBeyuRApe ay) DACY 4 nqie 1eywouio# est 2D sosreuuonsonb 130d21-4[95 (£¢ 4 998) aoueydn ‘Bums ut a1e9 avenbape ue auauss2sse uss soxamoy SHeUIa|GoId 230u asowe aye sauey> ayp sv yryssn aq ues 1 “4 ‘sey uosiad 249 40} fsnunuo> 01 Jay !24m apHap oF uosiad yp s a uowssassp ppanorangaq-aniniuB03 -no9e st Suyor1uoU! >xp 10U 30 2945 Aaynoess ay poy! uoususougd stu, Ch sum us xe on gps 9 Ge gpg 24 ew yunowe aseA e asimsoyLO ‘pasINbox st Uo! {goods or queviodunt sty -pouin220 au9A2 aip Y>iyon ut ss2uEIsu: PE ut ang ‘sSuned-y]9s pue ‘saanseout sour, (ajduiexa ue 20} 1-7 “Ry 228) 1e9 asuodso4 1ounsip pue aiesedas Jo 428 © Yano sajens feauauumu or *(a}dusex> Ue 404 2-7 “ALy 295) Aue ae peur og ue> sseu! ¥ pur papisoad st au] ypua] parpuers e 2x94 sojess andoyeue jensia woyy 28ues pur “w0) 4 up saje3s 3uney Aep yp yo s9pun siya ysinSunsip 02 ‘Sep op Suunp 8 sttuaned aqp jt pasosdun ag deus A>ean3 30 *kep © 4940 ‘ajduexa 404 ‘paesoae areas aanoalqns ¢ Jo Zunes e 3{0UL ‘on auaned a1 4se 01 ryasn ax0u 3 deus ss9] yBnowpy “[eass1u aun Sues 0 paxy ere s9y19 ‘pasinbos st Buypsoroz e aye zznq ypiya soo14ap Suntan 21qeusod gue 2301 10291 Punuuos o1 sano afueae o1 Asessaoou 3q deus y “Aep 34) JO 2A 34 01 324 sta asme2aq 20 “(jeow! © BUIMO}[o} sNoY a4R UI SIYNOYA .Ss>UTE], Jo ssonisip Supsosar ‘ayduiexd 103) wojqoud 241 40) souesyudis sepn> used sey 1 asne29q uasoy> s9y11 “ep ap Jo pousd poxy e 40) pl0d9s (01 payse aq Aews auoned a4: uoip “ 02 an, Jo ANsuDINT 242 99 pytiom 2}durex2 ue ‘sans20 1 aun y>ed axes 01 payse aq ueD aUaned Aq umoys a ew “KOON, awa Adosagy anoravgaq aayriory oFthe nature of the it; and to engage problem and the psychologi them in treatment if this is relevs -w what impact the pr at person's beliefs are concerning th sponds to, or copes with the problem, also be available about avoidance which had not been mentioned by the part of the assessment may be the husband of a woman wi was suffering from madness, and th: treatment was to keep this distressing fact from her as long as possible. The husband's beliefs only became clear after a lengthy interview in which his pessimism about therapeutic o ‘cussed. Further examples of the central role of informat are given in Chapter 9. Its important to check whether the relative or other person wishes the therapist to keep any of the information confidentially (and to have made a similar check with the patient before interviewing the other person). If is worthwhile discussing whether the request is based on unreason- abie fears. mn from others Monitoring by key others This may be used to enhance the accuracy of self-monitoring, but it can also provide specific information ab. lem he impact ofthe patient’s prob ly relevant where other people are involved in the problem; for example, a spouse reassuring. a hypochondriacal patient, or relationship problems (including those with children). The general principles for obtaining accurately monitored data are exactly the same as for sef-recorded data, and it should be set up with similar attention to det Observations by staff in therapeutic environments are discussed in etal in Chapter 9. others. This will be p: Direct observation of behaviour I is often useful to have direct observation of a problem beh: patient may broadly ot ion in natu igs. One examy describes gross inadequacies in social skills, an these represent deficits oF anxiety about Observation of naturally occurring behaviours rant behaviours occur with the therapist, then measures can be taken at the time, provided that the situation can be standardized. Such Cognitive-behavioural assessment 49 ‘measures can include frequency cour For example, with a patient who compl: counted the number of burps per sessi the therapist counted the number of the length of frequency count calculated on the basis of a constant se With a depressed patient, ratings of made for the patient's response lard 4 things been this week?” Another example of useful made by a therapist of the amount of eye contact made by a socially withdrawn patient in each session, the visual analogue scale shown in Fig. 2.7 being used for this purpose. If the target behaviours do not occur spontaneously in the clinical setting, it may be possible to contrive the situation so that the behaviour can be observed by the therapist. Two common examples are role-play and behavioural tests. Role-play If the problem involves interactions with other people, then role-play with a stooge allows direct observation of the problem behaviour, and can be repeated pre- and post-treatment to assess change. Where possible, the role-play should be videotaped, and then rated on relevant dimensions by independent observers who have practised using the rating this. method has been used to assess the efficacy of social skills training ower, Bryant, and Argyle 1978). In another study, couples with mari- I problems were asked to discuss problem topics, and thei ideotaped and subsequently coded (Bornstein, Bach, Heider, “How have were those cannot be assumed, however, that there isa high correlation between performance in role-played situations and tha example, assertiveness may vary according to whether a good friend ot acquaintance makes a request and whether or not a reason is given for the request. When ratings ‘changes, treatm: have focused specifically on the ierwise be impossible to determine whether ie improvement has generalized beyond those specific tasks. Behavioural tests of a wide range of problem behaviours, subsequent chapt“204, Man SuoureRs2g “(up2 p2e) "y009 puny peonsoud » :juoussosse poanosangeg “gR61) ‘W “HSH PUE'S "V SPCP A ‘plojxc) “vowed “aeuonnzesd 1511205 941, “(¥861) “OW “UOSPN PUES SORE HG “MOLE, ‘Surpvos popususwi0s9y “suiajqoid 2ypads 01 soypeordde nnadesoup 242 uo sasnooy 400g atp Jo 3804 a4 i299 a4p JoMUOUT O1 puE [su anoraeypg 2yp 40 ‘s2ouanbosued ‘siuapardiue o4p ul ssBuey> 2yEUI Or uonisod v ut ze 1uoned pue asidesoip ayp ‘storey Humtesureur ayqeqosd pur wojgoad ayn Jo aumeu ayp asypaior paoaife Suse} -wogosd oy) Jo Suipuersiopun aienbape ur pey waned pue asidesoup yp a10Jaq sorBorenns aeudosddeus Supnponut 4q sip szzusun o1 axeumuejuN aq pynom 1 ue ‘suowss2s auounean 2) 183g oy2 ZuuNp sand00 aBuey> Jo oleus 24 eWp Puno} aaey soIpmas AUEY “UORE]MULIO 942 I 9ALUIE PUL IUDLssDsse Aaeuiumsid sip 212]duo> 01 suorss9s so1y} uda2 40 oma 98) ALU! a ‘auoned ay) Aq sfunes ojdusexo 105 ‘spampur ag uoyo ye aso ng ‘pa1s9}J0> aq Au! evep yeo!Soyorsiyd ‘sase9 awios up “sisoi Jesmoreypg 40 s45e1 Aejd-2jox da 19s 01 Aaessonou aq deus Is muowssasse peanoranyaq—oanyul 24 ‘Sumas je>tuyp ayp ur Afsnoaueiuods sanao0 snotAeyag 942 S89}UP)“s8288e (01 ynoyyip 2q 9staU24I0 plnom a1 Y>Iyas wHD]goud a4p Jo SD") IYSH|YIY uayo anotacyaq wa|goud Jo suoneasssqo w23Ic] “|R}djay 94 APU $1340 40 Soanejos wos} uoReWO} ue posinbas aq éijesauat “101 s2qpany ulErgo o1 AaPss999u aq SKEM|E SOLUTE I ay aiayduoo or “oramopy “motassIUL [eHIU! 3% suoisnpuog (157 °d) snewos 48:0] a16 swaqqesd oy 21944 Ase|moned “301 -deyp wonbosgis ut uoaif aie sydurecy “oygepeae Apurstonur ose sora “ap tso2-mo] pur (qs afdurexo 10) “8049 Joly apanand Leu ssBueyo.yeoyersiydoypied voudinb yo Aanigeiese pre aso aya Aq pov st aorzead eon sunos i 990 Su iupusunseatsyeoojrsAydoypasd uo aunvezn austoox et 230) inowply “suonenus eos uw poudsiod runowe dy) a1 pyno> iuaned Digoudyesor © 30 "soepeay Jo. Zouonboxy sonour sp pyno> won “ed '2jduieea 20} “spoon posonout a Ker sosson0nd eonopossd sounseau eorojorsktg ruewoyoypin yum sumed 44 ano pond suey Jo soquinu 242 pue “suaned jeuorssasqo Aq yaam 49d posn deos Jo wunowe 241 28urg oym swuaned Aq poy uo uads AauOUW Jo UnoWe ay) apnjour sajdurexa 2940 “siopsosip Sunes yum swuaned yuu pasn Funes Jo ionposd-dq v se ayBiom st adwreXs uOUNUOD y “seIq 394195q0 Ws} doy Appaneyps pur aanoalgo aur Aayp weyp aBerueape ays aaey Ay y]95%1 anolaey>q uo]gord 24 Uo sn20j 104 OP PUE IDoupUL a¥e souNseoUH 9Sy], sionposd-4q jeanoraeyog plow-ued yo aseo yo sBunes isidexoyp pur Suned ay) Aq uoywoosip yo sBunes yaa ‘poioqduio> spuow Jo saquinu pue u>{er umn yo qiua} aqp papnppur soanseaur ayp ‘aflessed parpueis © yno 214M oF poyse sem ous ‘dured> szoiim yatm usted v 404 2801 fexnoraryag >4p Sem a}durexa aoqpouy “doys 24: ut stu1od snowses ae fears 02 aun yo Sune: pue ‘(sotpopp wuasoyp Suuesm “seq wuas9yIp Busse uayor “2) 2]0r 23yS 1unouse ayp papnppur soanseau 34 “SX Bunfeaug jo ume ay) yar posnooy a>yseun poo} ayp Jo ysnu pa Adeiaqy inoranyaq aanyuo3, os3 Anxiety states Panic and generalized anxiety David M. Clark The nature of the problem ‘The term ‘anxie refers to pervasive anxiety which is not restricted to specific external situations and is not associated with the consistent and extensive avoidance behaviour which characterizes phobias. Because many anxiety state patients appear to be pervasively anxious in the absence of any obvious danger, anxiety states have sometimes been described as examples of ‘free-floating’ anxiety or “anxiety the source of which is not recognized’ (Lader and Marks 1971, p. 29). Howevet 8 Beck 1976) have challenged this point of view, ing that the notion of free-floating anxiety is based on the viewpoint server, not that of the patient. When interviewed, anxiety state frequently report thoughts and images which suggest that they ive considerable danger in their current circumstances and their seems to be an understandable response to these misperceptions Laude, and Bohnert 1974; Hibbert 1984). This observation has led development of cognitive behaviour therapies which attempt to tes by helping patients to identify, evaluate, and modify ic appraisals of danger and the behaviours which may be these appraisals. The present chapter briefly discusses the tes and then provides a detailed description of f anxiety state can be Blanchard, Vermilyea, Vermilyea, he predominant prob cks which can occur unexpectedly and in almo situation. A panic attack consists of an intense feeling of apprehensi impending doom which is of sudden onset and is associated with 2 vi range of distressing physi ions. These sensations lessness, palpitations, chest hot and cold flushes, . The unexpected and ind feelings these sensations often Anxiety states 33 link they are in danger of some physical or mental 2 heart attack, mtrol, or going mad. ly calm However, the majority remain somewhat anxious between attacks, often because they are anticipating another second form of anxiety. st or excessive anxiety and worry which stances and is not concerned with the anticipai A wide range of physical symptoms may be associated wi These ching and shaking, disaster such as When not experiencing panic ing, feeling on edge, diffu Thoughts associated around the theme tion from oth However, patients experience types of anxiety. As we sedures used for the two types of ih types of anxiety often require both types of general practice 8 per cent of all Surveys of th ingas 1986) suggest that the ‘One recent panic disorder are s (Rape 1985). Some genet but many have a‘pene oqed pue Aiorue pozyes2uad jo aoucumurew pue wawidoppaap axp 02 aunguiuo> 01 pres axe stioHN09 {yoiyas ut seas aypads ayp uo sayesiuaou0> uons9s 2xoU oy “AiorxuE 4 sppow aannuior o1 uonsnponut jesus aoge ay SuIMoH[os ‘uo1yse) a4Monseie> © ul suonesuas épog snonsouut Smad -anwuisia dyjouewiis4s pur aoueansseay feotpaus Sun{o9s Ayporeod>s “yijeoq J04 ‘yum potdnd30oud 210229 01 J9y Supe oq 24) a1eANDE oY pynod suonEsLDs sau, “so8uey> jeuoutioy 0: anp ssauizIp pe ssoUIUHE} 30 “YuoMII90 wos} UOTE Pung se yons UoResuas ensiun ue sapussdx. ays jun anolAeyPq 40 suonoWD 234 uo SounyUt pa] aney Ke Jang SIP DADO} “YBEEP UOPPNS o1 Ped} PInoy worduuis jeo1skyd parodxoun pue Suons Aue yews Jpg 24p dojarap deus stored lod snewios pasouerpsius pue yensnun Jo A2oIsIy UOYS ¥ A2ye pF yo a8e 241 te fipatzadxoun pur Ajuappns sop saype] asoya. wewom Sunod e *9\JWeX> 104 ‘uray ypim soysous yoiyas auaaa aypoads e Aq pareanse juun aueuwop Ae] ‘Aew pue soaustiadxa uwuseo] 4pe9 woosy ast4e 01 p9rst|aq a3e sojns pur suonduinsse jeuonsunysiq ‘Buuog st ay uIya S224) ue Se uonesisauo9 ut sjjads auops z2sdaaxt 0 Aja ue seu! yf (s0]y 90M w,] suOaA2 Aq POYLl UL ss9[UN,) [epos Yu yuOAps Jo uoHENb swNx Ue Tulajoaur I[n3 e “apduse "x9 204 “Wowyse) feuon2unysip pure raneHou Apparss2>x9 ue UF suoREMS aypads raadiaut 01 suosd wy 2yeu 01 ples xe YpIya soaypsuayp puE liom ay anoge pjoy sjenpisipur y>rys sjayfaq [es9usH axe s2ymu pup suo dunssp jouor>unfsiq“ssouewurenbse jo dos8 e 01 Buryjer aya S109, uA yuma 4p, AyNOW neWoINE aAneBou ay Davy IYsHH OLENA? [eos inoge pauis>u0> auoawos ‘sjduiexd 104 "snorxUE St jenprapul ue lay suonenais 2yisods ul quasaad aze ypiyae soBews! 0 SYSMOB sour aie s1q3nog) 2HeWOMD aaneBaN “poysinunsip ae SuPUNB paqimasip 40 sono] 24239}31p oma “S39pu0sIp [euOHOWD Jo s[ppour aAnmUBOD Uy sworudo> Jo 52427] -Qprcue jo swordwés aannuBo> pue jeanor.eypg ‘1ewI0s ay) anoge sseay yun Buleop 01 parorap st Adesay. amolseyaq 2a11U%09 jo ued yenurisqns v ‘diaixue yo sworduiks 242 pue aofuep pasiariod ‘uaoaiaq diysuoneps jesord1oa1 sp Jo asnesog “swords Jeipse> pue Ararxue sotpuny Supnpord ypene 1eay Suypusduss ue so aooprso se wafer 2q eu weoy dupes & 20 “Surfeys pur Ar>txUe a10U1 01 BuIpe>| jon1U0> jo sso] lurpuadunt jo uoneoipur ue se uaxer aq Aew puey Turfeys © sur ystyg, pue auauussessequid soyuany 01 BuIpedy jJasou0 yo joo} v apew sey ‘Uo Jey) UOHeDIpur ue se uDxer 9q Aew ZuIysMyg ‘ajduiexd Jog “uoNDeD ‘Aorxue ue axeqs9ex9 40 uEIUTEML 62 PuDL Y>IYN S9]911 sNOIIA Jo Sods ‘0) Suspeaj avaayp Jo saoanos soquny se porsudionur uayo axe Aotp “uoroUny ryasn e Sursa9s jo peaisuy “uonems ayp 204 axerdosddeut av aunwesB01d ‘Aorxue an hq pareande sosuodsos ayp ‘uondaouodsiw © wosy sosise reas ee sows haoreuy 2p uoya SaA9M0f{ “(2144 Suypaads e jo yred 2yp jo ano Suna8 se yPNs) aeouyp [ear © Sutajoaur suonenass AueUI UL YORU {rjasn E ansDs A[pE|LUIS ues Garxue ‘941 wispou uy sfuep wosy Arme a 10 soajssuraqp naioad 02 2jdood Surdypy Jo uonsuny ajqenyes 24 28195 pjnom auntuesiiosd Aaarxue 2x2 ‘(aorepasd © Aq poy>ene Aulag “¥9) Suuoreasyp 3yH] Pue eo1sdyd 910m SusSuEp AueUL 9194) tu: > oaruad © uy ‘ailuep Jo saoznos ajqissod 40} iuowuomsua a4 Suiuueds ApamDaps (J ue ‘unoiseyoq Su 1) ‘ayy Aysig soy uonesedoid se jesnowe snuouome ul sofuey> (1) opmpur Koyy, “uouuosaUD danwuird © uF tu wos povoud os pauap puso sion gory pue sed sewn -nJora sno wo3y pooyut ancy dm Yoryas sasiodsa3 jo 196 & St siq -,9u cwe8oid Axe, 2yp SteanDe Ayxo4jan pu Ajjeonewo.ne Sore 11501940 $png “uonemts uaald ut wuozaqut aofluep ap atewnsos940 AqjeoneurarsKs sjenpiatpur ‘soreas Aaaixte ut ) yp9q “9A9MOpY “IwOsIp Jo sjesteadde onsipeas uayo aze |ENpIAIpUL ‘SuoRERAIS 9s942 UY ‘snoso8uep ‘Aueus axe ouoyp ‘99 AepAs9A2 ‘up sasuep oad © Jo sso] pa smnu a4 woissaudap uy “ss ue se ypns suonowa ysuodsay are ypryas sauos2 jo suoneiaid aawu pur suoneradxo s.ajdoad soyzex ang as 4ad siugAD 10U st 31 rey 9p! ayp st siapuosip jeuonow Jo sfapow! aanUHO> UF oHOU [esIua> a4 soreis Aia}xue Jo sjapour aantusoy, skyd poatsound 0} ayejos (c amdeyy, fosje 298) Adesoyy ut pa8eBua Saansayja aq ura auaned 941 340}0q p> -ssomppe 2g 0} poou soy, pue sworduids stays Jo samew je>rBojoyésd ay moge Sqnop ules Kpuanboxy Koy) so>HAIOs sunENPAsd ay peas Ajjeuy siuaned yans uayy “21uH]> zorestds>x 40 “ABojorpie> “ABojosnou & 01 20 “uersiskuyd pessuae ‘pads 1s1y ay) pue s9U0R, suoead [e22ue © yum uoneyynsuo> feniut ue UF passnosip swordulds 4[uO yp ag eur asayp) joad Spejnonaed axe (Suumoypeas Aanayyip son, -euidjed se yons) stworduids snewos usygy “Aorxue Jo sus4o1 ut stu9}qoad oip azyjenidoou0> Ayjentur rou op saieis AaarxKue yim suoned auH0s ‘uonenussoad jo poms (1861 wnoug pue souof-ceyu1g) sso] yo auduIa}> fosje uayo siuaaa ayn saves aaissoudop pue Ai2ixue paxil Adpiay, snosavqeq aayn80ry +s56 behavio ions in a threatening fai functional assumptions, which are involved highly varied. Howe petence, responsil to please others’. ‘Assumptions related to competence ing only winners and losers in li ity include, enjoyment when they are with me’, “I am m: ‘my children turn out’. Assumptions related let someone get too clo ed to anxiety include, dangerous to show signs of anxiety’. Once an individual has developed generalized anxiety, atte behavioural changes further contribute to the maintenance lem. In situations which are perceived as threatening, pat attend to aspects ofthe situation which to them appear For example, an individual who is anxious while talk people may be more likely to notice that ne looks out of the window and then interpret this as a is bored. By definition, patients with generalized anxiety do not show consistent avoidance of specific external situations. However, they ‘engage in mote subtle, or less consistent, forms of avoidance which in their negative beliefs (Butler, Gelder, Hibbert, Cullington, and Klimes 1987). For example, an academic who believed that everything he Published must be outstandingly good, frequently put off writing because hhe was not sure that he was ready to write an outstanding art Procrastination then became an additional source of anxiety as his fa to produce anything reinforced his doubts about his own ability and produced negative comments from colleagues. Similarly, a man who found social situations anxiety-provoking listened to others but avoided talking so as not to expose himself to the possibility of er ridicule. This avoidance made it dfficul for others to include him in the conversation, which reinforced his fear that he was not interesting, Anxiety states 37 ‘Trigger stimulus (Goternal or external) | fo tna ae Apprehension Sstopie \ body / scnatoas ‘The suggested sequence of events in a panic attack (reprinted with jon from Clark 1986, p. 463), panic (Clark 1986a, 1988) states that individuals s because they have a relatively enduring tendency ly sensations in a catastrophic fashion. The preted are those which can be in- and consequent death: accompanies anxiety as evidence tions as evidence of a heart attack; of ps thoughts as evidence of impending loss consequent insanity. The specific sequence ‘occurs in a panic attack is shown in Fig, 3. Provoke attacks. These stimuli can be ig of faintness which ing palpita- and racing 4 state of apprehensi a wide range of bodily sensations. induced sensations are interpreted in a catastrophic fashiOt pUE 0m joss ae 3suar Huq uuondupsap Joug © up ApEUON “M218 quWssassy ‘suoneiaidiout sydonsee> ,s1u9n jey> jo Kea jrydjay © aq ue> xpene snooueruods v 30 swap Inuspt ‘saprosip jea!sAyd sniouss awios o1 anp axe Sy2ENE ‘dy yp aouapiad se SPENE 35941 10} sIaBHiN snolago kUE Jo sDU95qe 381009 PUE 1980) (8) (oreudasdde a1oyn) stusuuadse jesnorseypg (2) tajgjoad jo sasne> inoge s>H>a (9) saxo Jo anorae4pq PueS2pt (ossom 20 soq 3 Bupyeus sSun4p) S300 (assed pur aance _aroaos 380ud 99/30220 01 poyiew ae semypousnare wia}goad ay uorse3s0 au2091 € jo wond49s9p Pp (s)wajqoud Sunuasasd ee 1uauussasse ut pazaa0d aq o1 soidon yo AewUUNS 1°¢ >IGEL, 6s sams Kyarxuy ayy aye vayo stoned sy «ang Sunuoo pur osne> ou se yptie ah anoiad os pu pen i ae ‘poq wpe rou ae BEM SPI se ypns “sued 01 suatunize Arsixue 2Wos a Ie uDyM any aI Jo fe pouaryioy Jo pousd © dq poparosd aie sysene ued awo0s ouued Jo sadks muouafficy despues woyy 3 ced v ‘3]duexo Jo, Uurewuteus or puar souepioae jo su 10 [esd shou sues Jo 260. Cognitive bebaviour therapy was typical. If not, further descriptions of other recent occasions should be elicited to provide a complete picture. Next a list of the situations in which the problem is most likely to occur or is most severe is elicited (‘Ate there any situations in which you are particularly likely to have 4 panic attack/feeltiredhave difficulty coping?) Avoidance behaviour is identified by asking questions such as: ‘Are there any situations which you avoid because of anxiety, ‘Are there any things which you used to do before you developed the problem but don’t do any longer?, ‘When you notice the symptoms, ate there any things thar you won't do, "When you notice the symptoms, are there any things that you do in order to protect yourself (from fainting, ‘going mad, losing control)?” Modulators are identified by asking questions such as: ‘Are there any things which you notice make the symptoms stronger/more likely to occur?, ‘Are there any things which you have noticed help you to control the symptoms/make them les likely to ‘occur?’. As well as identifying the things which the patient does to con. trol oF exacerbate a problem, it is also important to identify the atti tudes and behaviour of significant others such as the patient's spouse and close friends (‘What does X think about the problem?, ‘What does X do when you are particularly anxious?’ Patients’ own beliefs about the cause of the problem as some beliefs may make it difficult for patients to engage in therapy. For example, someone who believes that their social anxiety is due to their personality, and that personality cannot be changed, is unlikely to show much learning ansciety management strategies until his belief is at least partly modified. When somatic symptoms are prominent, and patients are scep. tical about the ides that these may have a psychological cause, behaviow. ral experiments can be a particularly convincing way of determining whether psychological factors are important, In a behavioural exper. ment, the interviewer manipulates a factor which he’she supposes may be responsible for producing the patient's symptoms and observes whether it does indeed reproduce the symptoms. Several examples of behavioural experiments are given on pages 83-85. Finally, a brief description of the onset and subsequent course of the problem is obtained. This descrip- tion should particularly focus on factors which may have been responsible for the initial onset and for fluctuations in the course of the symptoms. Itis not always possible to obtain from the assessment interview all the information needed for a cognitive-bchavioural formulation. Sometioes it is necessary to follow up the interview with homework assignments in which the patient is asked to collect more information which will clarify the formulation, For example, if tis unclear whether symptoms vary with time of day and the situation that patients are in, they may be asked to keep a diary recording what they are doing and how anxious (0 10-poine scale) they feel each hour. Figure 3.2 shows an extract from a monitoring Fluid produced (approx. in pins) 12 m2 12 6 6 16 us n Urge to Urinase as) Anxiety (0-10) Back from shops Pre formal lunch Post lunch Pre formal meeting Reading ‘About 1 go out Reading ‘Activity Getting up Time 30am, 1030.a.m, 12.15 pm. 115 pam, 2.00 p.m. 3.50 p.m. 5.00pm, 6.10pm, Drink Teup wea 2 glasses water 22 pint ica Anxiety states ssegee a8 2 3 Bag tleaai 2eg523 gidees 228838 : a Fig. 3.2. Extract from a self-monitoring sheetmunis ‘jdurexa swuoned 20) BuKjpow poo sew “Swed teas kixue 'sour 30) ages st AGED ANOIAEYDG 2 auounvan 305 Auiqesins SHU 2p UF Se pm ‘se suonems pazeay ur sjayfaq paonpas sey wuouneas 1eyp 3p24> sisidez>q yelp auruodunt st 11 ‘uoseas siyp 404 -uorsses Adesoy) e Ut uissnostp Ajupe> aie doqp usya wey wordunds Sumuarysiy eH 20 uonenas Fupjors-s034 e UL a1e siuoNEd uoym aoysiY oxE (,osdeyO> (on py we | UL 2y pue snorxue we | w>yM, wrdn yeods [1 prdmas ulus 14 ajdoag, *,adoo 02 ajge aq 3,u0m soydonseie> pored uv 30) Sunes j>yfaq uIWO “suHo|qoud J1oyR JO DouEUAUTEM ayy UF ey sjoyjaq 2ybads aeqp s9]or 1ueuodusl 241 Uo UonuIne ,siuaned sno} dj (01 osje pur ‘Suo|ssas UadMIng PUL SUOISSIS UNI ssos80ud 11 3q Uap UeD sures Jo4]2q pareaday| “,poourAuo> Ay ‘01 ‘je 28 af asa1}9q 2,uop |, 9 wos} BuLBues 27e98 UO at 21E3 01 1 te Buryse Aq passasse 9q ued poaayag st ayBnowp e YSU HO} Aqpaeadas 21e siySnoup poynuop! 494, ut ed nyssazons uaaq axey AOKp 294ROyN aUTUIRIP OF 29P: Snoauou pur spoyg jeuoHeRt sour auD}[ey> 02 SUN soxp anotaeyaq aantloa Ul SUIIE UTeM! ayp Jo 2UQ “SSE forag ‘afin oyp yo yi8uans amp jo siueurmaiap ureu axp 919m SiON -oiskyd sou 16 BuneoIpur (zo) s9ysIy AyjeueEIsqns sem uo ‘yp 1u2unvan Jo pus aip Aq -s201>8) jea¥BojoypAsd saxpo jo aflues v Aq osfe ang s9ppeyq yp Ur pny Jo runoure ayp Aq pourwsor9p 2 ‘01 a84n aun jo Suns ayn rep Buneoyput (F°-F"0) 0] Sem VORE|>I0> 9 sammis krorxuy Jo Gysuiuy uesus pur oom aad Arorxue aie Aaeip sip “pe Avixue due poousudxs aney, Aay neg “Aisixue poz we stsoBns (8861) 180) “Ps np pu0294 4p puosas 02 isanb poziparpuvis “| ‘ue Samp potuouraydust ag 02 poou poou Se 94 s9yIDy p40 ut A ‘pours sey 1uWEON UG) ssoitioud SuoMuoyy, junuuo> asous mau s0/pue ‘areuun o1 afin ay Wea} 1eyp BunsoFns ‘snorxUe sem pur Asowae] 241 01 o8 01 ayR>YpP 3q PInom m ayno4p ay a19qo% © UL Aqjensn sem auoned 24) ‘suo1se>20 sane] a4 UC “paoNpord 4494 Su9q20 uo ‘poonposd sem piny jo unowe afae] ev 33n Buons © sem o10q1 UDYN sUOISeS90 2uI0s UC “paonposd pl au pue areussn ot ys a4 uDaati9g diysuonejaa 2paty A494 sem a12qp 2eyp pajtoras Aavip siqp yo uondadsuj “papio91 219m past gun jo anowe pur “Buneuun 230409 1801 sewn or a8un 0 yisuons NDE *AIDINUE ‘YEIUE PIN} “UOREULIN Jo AduaNbox} YAY ApaaIs599 ed v Jo stueunuoip oy) aeBs9AU! OF pasn sear YLYA 19945 SurAjsuorur sem axeutsn © 21qr But>q 104 Ades2qy anosaeyeq antnuiog, 264 Cognitive behaviour therapy Anxiety states IE sine | Week commencing. | | 3] et Hal le Hl el 4 el} ls | uate] 2) ol i 5) (E} Vel! (izle @] 4 rowcaroons [ol] Fel Hale LAE) 5 I ccarnon ALE Heal Kztels &| pescnirrion or |g] | af] else} 3] =| MAIN BoDy wy] srruaron were RUEUTCEISTERIEHER) 2} SexsaTions |__| ranicocconen BBE EBIEEISIELEI3] 5] 2 At home Ha m4 |4, 70 [Prntationd fam having [he gitens Bs socens > cause lien omet { eee ep har Tyerore : egae A Fy P Me attacks ‘ : i= 2 Toiag the bathroom |b [4 [4 : , fpanee Dodane Pp lunrend, 70%, Je preactre F Jom f>venchdnssd Sseberary alg enraotad } : ered Shopping | loves Receren tetera 234, ~ , feeeranici a 3 2| 2 Boney eee erge oe Fig. 33 Example of a panic-attack diary Fig.3.3 (Cont'd)fox auanxa ay, “guoddey 14S aySnoyp nok Bun as10%m yp sem ey Ssnorxue woul 319M nok U>y, ye afew ue aaey nos Su aoun 29 “ace sem siya Uonety 30 nuon an88 © year oy poype ave se souaundzs puonoun zie SussIong“T 1 pasn sIp poser sour 3111 “sHyFmowp sHeWOINE tusoq 94ey sonbyuy>on [210405 {Aygegosd st ayBnoyp pawn ppoaatjaq pu aysinoyp sdou Agnuept s1Ua yp s2se> yons uj “siysno 30 uIP UIDU0D PY s1dor ays ‘peaisuy “faapxue Jo sopost Jo syleiop 19ex2 a4 ssnosip pur [e224 01 mens aze Swuaned suvow s98uep por saynoyp J0 saya Supnp 10 mod (88 ID sy “Aisixue aup pasoSiin pet saySoyp aip Jo [8292 yum paxojraiut osje ing Aia1XUE paonpat Bh auf, 2Alewt Fupjosoud-Gorcue ue poousuadxs 24 se uoos se IXUE yatm doo Or paduone oy ruaned e aquDs9p 1p 79 ypoq‘9|durexs 404 “Suonruo9 pareyas-Aaa1xu DexD 24 Jo auemE 9q 01 SUDHEd 40} ynIYIp 1 S9xEUL 2xp jo Bupsooosd poperp sword say so 2A 02 30 0) = lue> s2@uep Yala pousoouo> siyn 9 auaumuedwoo>e jeuoU e ae ssdeU 10s SI. (19 Epasmuaq Yo oo} $1210 Hao ur Sung seo unos) assez 29 ue K0KUe (BM o sais Koruy 3 yiomauoy sv sader desu spomouoy se 01 u ayy or ader ayy Fumi pur ader-orpne uo uorssos 241 Supsos2s 1 axe Kaya sv SIYBNO suomsue umop 2 9q ue yor sanbruypa om | (661 7 “oyu atp Jo vorzodoid jJeuis © Aju ut 2q Avus Siysnoys aanedou o1 fe Sy “woIssas ayy Huuunp passnosip nw 2o.uEsen 0 post asaad atp Jo sno} ure pry swaqoud ssjpam snowasd nefou ,siuan (01 S19MsUE 24p sosaypod ky ap Ups pue awuaned pur ‘sasoyodty se poreon Dy we: som up 03 sas0pp st Adesoip peaasuy 21342 01 20U PI jueagjau a20w aup sanbIuyo1 aW0g “MO}>g P>X jo fuvur pue wire siyp aaamype of past ae sonbu Adesoqs oq 2anusiory 99.68 Cognitive bebaviour therapy Table 3.2 Examples of specific links between sensations and thoughts Sensation ‘Thought (interpretion) Palpi Breathlessness Tam going mad which patients belicve anxiety-related thoughts often varies with their vel of anxiety. When calm, patients can sometimes see that their thoughts are irrational and so attempt to discount and ignore them. For panic patient who is concerned with the idea that there may be something wrong wi the question, ‘What are y saying, 'l used to think | would have a ck. However, my doctor has reassured me that my heart is OK and now I'm just wortied about the anxiety.” However, if asked the ,n, “Right in the middle of an attack, what is the worst that you think cou ?, Despite what my doctor says, in the about to have a heart When listing the cogni with panic attacks, therapists should try to help patients to see berween specific sensations or can be achieved by it experiences in a joughts which occur in an sks which thoughts go with which sensations and suggests the possibility that the thoughts may be interpretations Of the sensations. Examples of specific links between sensations and thoughts are given in Table 3.2, 2. Using imagery or role-play to relive an emotional experience by either rerpersonal ‘ing an emotional experience for you to remember exactly what was happening and yur mind in the siuation. When this problem occurs, times useful to get peopl to try to produce a clear image of Anxiety states 69 dew on the petals? Are they cus producing clear images, ai what was going through your mind?” ‘When the event that is being discussed is an interperson: confrontation with someone at work), using role-play to reinact the interaction is often mote effective than reliving it in imagery. After obtaining a detailed description of how the other person in the interaction behaved, the therapist plays the other person while patients pl selves’ 3. Shifts in mood during a session Mood shifts during therapy sessions can be part automatic though vent, ‘What went through your mind just lustrated in the following transcr anxious patient who was preoccupied with the idea that her headaches indicated a serious brain abnormality thaemorthage or tumour). Pt the start of the transcript, the therapist had drawn a picture of a blood vessel and noticed the patient became very tense while looking at the picture. ‘What went through your mind when I drew that picture? Patient ‘1 w: bout “About the blood coming out.” ‘Did you have a mental picture?” oa you had that picture, how did you f “Horrible. Where did y “In my head. “Did you have d "No. you had the image” weaver de ee aeasa8ins ‘siynoys soy Woy paenstp St sip aeyr 295 wo4p soonpou uayo SIL “Uh “ul 3q_we> ayp ‘uoIssas v Jo [pour aannuioo ax2 Jo woneasuoWp uDI0d © eNSIC] “sUCUIIO}IOd UA 394, 3 ueiuawour 219m Aoyp 9sT829q yssod 20u mens ur anbruy: ee 2q WED UOIDENSIp ‘hdeiay1 ul 31e] “harxue stoyp 1900 jonuo> ou oaey Aoxp reIp spppq .siuaNed TuneqwOD yo dem jryasn Kaa e oq ueD uomensip ur Suuen ‘Ades ur dpey ‘sorfaieis iuowsfeurw woxdusAs aveipaunut se pasn 2q ue> sonbu 2s2y °g~Z81 Safed uo paquosep are sanbruypar uompensip yo AIA y wonseasi “Aiarxue yo simeu 242 mnoge suond22uo2siw Kue 3323109 03, pur ‘Goncue jo p pueisiopun 01 siusned Ayarxue mnogo uonprusoua Buaaigy “hope Gordonue 89] poououndxa ancy pjnom ay sonzed soup as0jaq sxysnoKp 240 asaqp Jo aUIOs $S99I" 01 21g UD>q PEY 94 sUOISED9 snoLArd UO 31 3eyp 995 01 a1ge ospe Sem 9}{ “SI 10) UAIY auEIq A[ESsIDAU 10U PINOM. dood “iow aim days jt uos> ‘oouoyuny pue uy 219m sonaed s1y aeys azyjeor 0 uny padjay ‘saajasuiaip polus Aaqp aeyp 2ouapiaa anuyep Aue pey oy soy124% pur AuoWKolUD YP ouIME aonop afin epryar anoraeypg sty UeY 22410 HODEY am 2341 DYDYR ‘quoudolua atoxp 204 aqqysuodsay 4jjex01 sea a4 ro\pay ‘sonaed soMUIp siq Suunp soapsunys SurXolus axom dyn yBnowp se poroo] Ajpes9u8 spusiy sty s0yoym moge Buluonsongy “wy aure|q UDKp pur s94]>sUH vou uw sais Kroreuy soup 240 ayp se tpns ajdusex> -aeyaq pu ‘Buy99y “Buy auauine an 10) ayy Suurerutews sossao0sd jean 1oge podojaaap 2ys 10 24 y>Iym so ul ‘pue motariut ausussasse ays Aq papind 4 eynonied Isooyp weBou 2194 Ajipour pue dy 01 pasn ase ssunpaooid jo 2Sues api y “30} Sujoo} 2q stu A>yp eqn sxyBinoyp yo 308 a4 soni z2y.nj aprsoad 01 poou deus isides2qp 349 ey ‘aiou yb 18 y>eq uIyOo -[uoREMIS ay) no uoqp purus anos ysinoays Buto¥ stim Yen 93ns 9 uaned 241 40) 1u949 a4p Jo Sulueaus 2y!20ds ay) ‘Buonsonb ySnosyp ‘uradsIp or adwane uy. yssaaonsun ase says ‘wos ured ap syeu 1-Pe>y ano ut wo uayi pue aimoid yeuow © pey nog {rep jo aru mod Kdesaqy snorangaq antnudo) 06n Cognitive bebaviour therapy Ansiety states 2B ing that thoughts play an important role in the maintenance of their symptoms, ime management GOALS. Decide what you w: secretary suddenly became an eatment session, hher mind, she ince we have been hhead and os isa brain that case, the room and describe to you can all the objects you see?" Initially, the found i difficult to do this. However, with gentle encourageme rapist, she eventually became absorbed. After thre of and things decide on PRIORITIES. ‘What do I want to disappear so si : the symptoms were produced by her fear thé 7 Try todo ONE TASK AT A TIME aod ty p from one task 0 ano 1 same task and uncompleted tasks remain on Activity schedules the present task schedule (sce page 190 for an exampl y-hour rating them (on 0-100 scal ue, pleasure, and mastery. Acti inning on from one task fatigue and increases perceived time pressure). Table 3.3 outlines the themselves as being under con- Time pressure and other anxious concerns can lead some patients to stop engaging in leisure and so they previously enjoyed. Often these act of worth and perceived control over 1 ping activities often increases anxiety and perceived this problem is identified, the therapist and patient can use schedule to reintroduce pleasurable activities. Inspection of a‘ dules can also help to identify periods of anxious rumination, th perfectionism (suggested by highly polarized mastery and pl iings—everything is either rated 10 or 0) and go for a jog. This was an Since becoming anxious Verbal challenging of automatic thoughts A series of que ised to help patients co evaluate negative do sul patient and therapist sessions, ively to identify ween sessions patients attempt t0 pt. they have learned in the sessions by thoughts as they arise. One parti rnvenient way of doing this is to use the daily record of dys ts reproduced in Fig. 3.4 or (if panic attacks are the problem) the panic diary reproduced in Fig. 3.3(pawoy) we sayBnoys euonsunysip yo prooss Ape ¥e HL |pomcloay-voernd x Kok re peof pow hoes Gro hey) peyee) wane rey we frny smyen pay ee v6) TD pon eeu pral wnt) el wos ores] Loge Gh are 5 per on 2 en en Aaswousny TWNOILYa souoy aun SL sas Kyapeuy Adeuogt snosavqaq 2ansu80ry ve76 Cognitive behaviour therapy Some of the questions which are particularly useful for examining and testing the reality of negative automatic thoughts are: have for this thought?” ‘Is there any alternative way of situation?” ‘Is there any alternative explana tion?” These questions, which are among the most commonly used, are illustrated in the transcript below, which also highlights the value of providing information about anxiety. 1, ‘What evidence it “In the middle of a panic attack, 1 usual collapse." “Therapist ‘How much do you bel ‘would you believe ink Lam going to faint oF right now and how much as you get in an attack?” re nd 90% in an th i atthe evidence you have for this thought, Have you in an aac re : Th then that makes you think you might fain? re od the feling can be very song" ‘Th. ‘Santo summarie, your evidence tha you ae ging f faint isthe fact that you fe fait? nes Th. ‘How can you then acount fo tandreds of ines and ave m RS tm that you have always done someting to save you r cernative explanation is that the feeling of m th mR 'Non Th. "Your blood presure needs to drop. Do you know what happens to your blood pressure during a pane attack? " reel, my pss racing gest my lood presure must be Th “That's nght In annety, heart rate and blood presure tend to #0 topsther So, you are actualy less ikely to fine when you are anxious then when you ae ® ng and help ™ inmess is & Anxiety states 7 Pr Th. lean check out whether 1 mal, or quicker than how ‘panic attack? you were experiencing the sensations? 25%." In this example, the patient had never fainted. However, some panic patients have fainted in the past. Then the line of argument outlined above needs to be slightly modified to take this into account. First, the therapist should enquire whether the patients were anxious when they fainted. Usually, they were not and in fact the faint occurred very early on in the development of their panic attacks. It was probably produced by a variety of common physiological changes (such as hormonal shifts, a virus) but the patients were not aware of this and so subsequently wh ever they were anxious and felt faint, they erroneously interpreted this feeling as evidence that they would faint. The misinterpretation then produced more anxiety and a more intense feeling of faintness. The only anxiety condition in which fainting actually occurs is blood injury phobia. thes, the therapist should explain that they are only likely to faint atthe sight of blood and injury and also invite the patient to compare the feelings that precede an actual faint with those expe he same. Before actual away. Ina pa lly aware of their intense feelings of faintness, 2. ‘How would someone else think about the situation?” 1s ex aggerated perceptions of danger usually do not extend to other people (Butler and Mathews 1983). For 1 asking how someone el ‘would view the situation can be a particularly helpful way of res perspective.PIP APY pur Kofus ayShar 94 y>tyia BuIOp s9pIsH09 Sipw 3334p "sayera! aq) Sse JOU pip 94 jt DAD ‘Gon 2g plnom ay Kes jeusou siy ut Apmas gs SWIEXD sty >4E11 01 2IGe 24 $89] 20 pared 22119 saA02sIp. nue wet snonsestp $59] 2q 01 woyn sdjpy usyo usddey, Burgsn 0) ey id Bursn Aq poytpow 3q uayo ul -uodsa1 10 Jonuo> [euosiad Jo suonou 9a1ss29x74 “20 3992309 4 yey poo8 ur uoyed aaey nod rey uoIsHap e J94!DyM soURApE (01 2Iqissod sdempe S11 etp uoNdunsse smosuoND 24) UO p2seq 249m A>4p n pawoop 219% ang Avuteua9un sty aonpod O1 siduin ny auanbay} J9}{ “JOoy>s a4 Wo4y 1y9U9q pu AolUD P| luos 204 1eip 2o1UEIENS 20U pip asiNoD Jo siyp ang “D}qELFeAE HORE 21p Jo Siseq ayy Uo uoIs1rap is9q ay Sem IYSMOKR dys IeYs ape PeY Wp pafeaaas SuIUONsaNg “JooyDs sejnoNIEd ¥ O1 UOS 494 BiIpUds UE 1p Sts yp pew pey 24s 49494m NOge PatLIO% ApULISUOD Jo4yrOUL \dwexd 404 “siusao 10) aaeq Koyp Aujqisuodsos 40 yor1Uo> Jo unowe 242 a1ewNs2-s040 soumN>WOs SiuaHed sORUY sBigt arog 1200 anvq | Jo1yH09 qanu m04 Suypusysa-s9a0 | wy, yoo sBiunys Kem ayn 40) wo J 2yqisuodso4 moy Susyouaysa-s900 | wy flues 39x09 peaisut ing 2fe2s 242 Jo spu oxp 2 soIsn> asnt 10u op 2jdoad aeyp auapine souios2q uoos 1 “Sassaifload as1o29x9 SIyp SY “3[226 94p Uo UOSIad ype aoejd pue mouy four ajdoad ayp ype anoge ur 0 pox inom Aayy,“9A0] AiSuons, “py ‘parpeqe} jppius ayp * axey Asuon seep 01 payse 2g auf NOK parey 20 NOK poyp| s24p19 a|dood 4p PaAtfq 6L somis Krareuy Inysso2ans snotaoid 0 40 spay junnapa4 tue9 s1sa1 [P9 -aBequeape ue aq ue> ayy] Aep&unan yo used Aavssadou v st AirxUE 24 pp Aq oun ay sparpucis pasod janbouy Aiquatrgur age Aa 128 369 34 25U0) “POOIG 3h ‘Bonysean jeg de aq) s2pun yo afin © 3p} 945 "IP pytom Aoyp sey. poreoipur pue 21 aaijeas uoyo £4) ‘poxcyoq D4 Ur snorxue [p9} Aaya asne>2q Adeszqy anosaryeq sano) son ugh ue ip u9y payoiesns pue pouuinbs 19 24 cypene ys yo pusuy v ip © yin pare \duiexo 40g 35120/ suo) nok ay, °S yd ays ap poysna “Aiixue80 Cognitive behaviour therapy ‘Whether guest happens like the food and dink provided (i may be imposible to Guests soca skills AA pie chart representing the factors which might themselves at one of your dinner parties bute to guests 9. “How will things be in X months'Iyears' time?” This can be a useful way of putting ich as the breaking up of a re ship, in perspective. Often when thinking about the possibilty of such a loss, patients exclusively dwell on the immediate impact of the loss. However, after the break-up of a reati distressed for several months but this will gradually decline in intensity; slowly ly. For ‘example, someone who is excessively frightened about the prospect of a ionship breaking up may become excessively attentive and com ‘making the partner feel smothered and more likely to end the ship. Forward time-projection can then be used to help reduce the pa- tient’ fear of a break-up, pethaps increasing the patient's confidence to such an extent that he or she ceases to engage in the behaviours which were interfering with the relationship. Anxiety states 1 10. ‘Are you over-estimating how likely an event is?” Anxious patients frequently over-estimate the probability of feared events (B Mathews 1983) and their over-esti unrelated to objective probabilities. For ins. anxious about flying may rate the prob: ast ey, 1 1 in 20 after seeing ig take-off. Discussion of patients’ inflated lity estimates and provision of data on objective probabilities can be a helpful way of reducing anxiety. However, some patients find that they remain anxious even when they are able to acknowledge feared outcome has a very low probability. This is usually because the perceived consequence of the event is very severe. In such cases, it is Important to decatastrophize the event by looking at how the person could cope with it and what would be so bad about it, as well as dealing with inflated probability estimates 11, “Are you underestimating what you can do 10 deal with the problemisiuation®” Anxious patients often underestimate. tl skills and resources for dealing with a problem, For this aso useful to review how they have dealt with similar problems in the past, how other people view their coping skills and rehearse ways in which they might cope with forthcoming difficulties. So far the discussion has concentrated on the verb ever, as noted earlier, sometimes odin anxiety are images rather than thoughts. Often images can be dealt with by challen, ig the meaning of the image with verbal questioning. On other oces- ions, itis necessary to work in imagery as well as using verbal quest i. This is particularly likely to be the case when patients experience vivid and repetitive images. For example, a young woman was disturbed by a recurrent image in which she visualized having. been sexually assaulted when a child. Verbal discussion did litle to reduce the distress provoked by this image. However, visualizing herself back in the situa tion, growing to her present size and dealing with the relative who assaulted her in an adult and assertive fashion was highly. effect Modifying images was similarly useful for a woman who feared fainting in public and often had images of doing so. Her images normaly stopped at the point where she fainted. However, disc cl her to see that get up and thoughts. How- ly produced by The examples given above have all cos cognitions. However, anxiety state patients are often depressed as well as anxious and one of the great advantages of the cognitive approach tonow pur 2s0 ‘ysnomp Surin “wi2]goad ayp anoge s10w Jaa0ss1p asidesoys 24 4 asiouox9 ousoudelp v se pasnpont woarsday, ‘duiks 4upoq ayp aonpas sdjpy Suignesig pojjosiuos ut Suiures s9q!9yH pue aqued yo swordws 4yppoq ayn s2onposd jaarndy A2erUnjor Hopoyn Sururunaiap asjoaut sisaxpoddy sty uo paseq siusuodxo eopr oy aouiotzadxa ue> Aaip ssajun UoH aie day, ‘seuoyL Sunqnog 24 J2yEI a1e siwoned o1urd ‘9sUIs © UY ‘poonpas soypue psonposdas axe swuoiduiAs say y>iyes ur stuswtzadx9 [es -noineypq 4q paresisuowap 2q ue> Aupyyea si jt woyp 02 soxjdde uoneraad 4aiu! aaQtewioye ue aeyp 249tPq [uo souautos stuaned *|njdoy 3q UeD jexoadiowut a1ydonseie9-uou ‘saneusaye ue 30} 20uD4 P Ydno\pry “spene sued Sump souarsadxa ays pry su ‘Aupog a4p jo stoneisadssaut aydonsrie> ,suaned Aptpour 02 st 21ued Jo juauneas} 9p ul ute ureW 24, 2HPd quim pasn syuouusadxa jpanoangag 5 ‘0 3ap S838 uoresuas a4 ‘aowstosip 294u4n} Bulang -piey a3esUa9U0 0 PEASE J! UNO 324 0 138 01 P: Coanau snouas 2400s axe>qpur asnun sIy2 2eYp p2%2}9q 24 fq pasos juo seo eprie sisfuy Joy ur Suyplun sex swordaks Sus £8 says Garay paidepe uos 494 7d Buwwow Aye2 124 4 of, 380 fue ssydesoqy 242 “1980.04 “JonU09 Jopt sueyd 204 wopuege 02 ey nl pjnow 9g EY} p2ratoq pu ‘aaa auads pey 2 tue se anc ous fe pue ajimosnoy a on aie siusuiuodxa [esnoweypg pur sjaiaq Jo S128 St at 2e42 sjarfaq ayboads ayp uo spusdap uasoy> “oq seynonaed ayy. Azatxup pa2ypesauad ur pasm sauouasodxo [4 ‘moj2q uani8 a4e sjaneq BuBuey> yo sem asayj, “saysnowp aaneou 31oMp JO A pry stusuuisse ssuynoys aartefou su: yansodxo jeanoineyaq Jo SU ‘ap Jo 9u0 94 2up ano »po4p> red asulede pur 103 a>uapine Sut syuouusiadxo youn pup jo Lucy ‘prog yum Bupeap 2 parepE-Gaixue pues ppasn 9g, ue> sonbiuypor Adouoqa ani yoq 2anuB0y 884 Cognitive behaviour therapy minimize the patients’ prior expectations and to prevent difficulties id ists should encourage patir between effects of hyperve Such differences can then be discussed. For example, the patients may say the physical sensations are very similar to their panic attac were less anxious. The therapist could then ask, sensati you have thought and how would you have fe see that they would have jumped to a catastrophic hhaving a heart a 1g attacks. hyperventilation plays a role in panic, this lowed up ing in controlled breathing. Such training has two aims. Fi ley (1985) found that a convenient way of teaching patients con- trolled breathing is to use pacing tapes. On these tapes the pacing consists for two seconds (12 breaths/min) or three seconds then ‘out’ for the same period; after a b ‘on. Therapists choose the pacing rate he shacp tas ing starts by asking ps are comfortable ‘When they are able to-do this, they led breathing to reduce the sensations which occur in pani done in a graded fashion by asking sessions and then to return to thi order to ally extends over a period of two to three sessions and associated home- work, smal focus of attention sometimes accounts for the bodily sen: which panic pat Anxiety states 85 For example, a 42-year-old housewi 1 disease ( ance from her physicia sh roneously believed she was suffering et 60 Pt sem). Negative medial sked what evidence she noticed her to her body, ‘When asked what she though very good at thinking of clever exp some people, but I'don't think that the argue wi “You may be right. But peshaps to get more information we did minutes, she ceased to be av belie that she had cardiac = 30 per cent the alternative explanation, and encouraged het to use technique when she subsequently felt panicky. A further experiment strating the role of thoug! hich can be used involves directly demon. by trying to produce a panic attack in which‘onaype 02 uoueanow saseazouyssa0ans Huunjes ysnowpye wep 39s 01 wy pargeus jayaq ayp Bupjoy Jo safeueapesip pur soBerurapr ayqwssod ays Jo YoRstosic] Jpipq 34 Woy) ouEIIP wos ure or uy podjay aysUE Si, Aaorsty wwouro2x0ju198 eo sty Jo as94 € Aygeqoud sem uondUNssE Dip ey 298 02 ajge sea aWaHed ay aaiaas pesio}sig e BuyNo|}O4 “UOR “duwnsse 242 Ajpow pur 28uaqfe4> dy 03 psn 210% sonbyuypar [es9505 ges ay) ut wavoys uorduinsse ayp wos} sue 01 poseadde sous0M asoy tow souewuo}sed pas8iin suonens ay fe wsowe 14) poo Appnb ay ‘snorxue aue>9q 94 UIA ut suo 1p uy “ep ‘Gaana Jo 1429 sod og 1869] 18 20} pu SuoneMIs Jo a8ues apim e UI STONE Se jpsumiy paquosop woned 2y], "wondumsse rey) 03 sasuodso2 punysxp s,usned ADmue (ag61 Pea pue se] wos uoye) ¥’¢ Tae {3 0} UESW 24 pjnow aeyn onan sea aysinoyp sip jh, Bunyse Aypareadas 4g aysinoys 4p png Jona agp AJnuap! ov wre suoned SyBnowp sHewoane we ZuuoMsuE Jo pensut onbiuypox sone] ayp up “(sez “4 “ORGL sug Ose Spor “A os) anbiuypos mone paexunop atp Sutsn pu siyflnogp euoH>uNsAP Jo poses ep ayp ut sowayp 205 Surfoo] :aze sonbruypor uowuo> 2s0W 24 Jo om "9 Joidey Ui uaaid age suonduunsse sjenpiaspur ue Burgjnuop! jo $m yexo19g “suondwinsse jeuon2unyskp yuu Bumeap 40} posn 216 Piya sonbiuypar ay) Jo aos uo saienua>uo> Atjeogads uondes jong si, sonbyugp2y worsdunssy njdoy 2q spe wea (zp aaideyD 29) sppps Sursjos-wajgoad wi Sues jog ‘sulaigoid 2y1)-Je2s moge SuosPap Buyeur ur Aajnoyyip q dpued poonpur 9q 01 sieadde Aarxue assy “urywads kypouorsnsioquor “Yooq ‘jot, ys aka|oxa (Og61) $,s9uIeD UE|Y Jo SuoND9s Buipess wosy 1yTu2q Aeus uj08 suonessoauo> dovy 01 Moy pue suonemis utE2> ut Aes oF ein Suimoury Aaynaypip avy oym siuaHeg “(S29 JOyLINY 305 “y soIdeKy “6261 sIaIseA puE WIUTY 30 $576] UEDA pur “Ishy aq “Bury “weus 15g] 998) suonemas 91-99 ut sare] pure uoIssas Adezoyp ap ut Aeyd-2}03 eyo Aapyes op ut ‘uaned 94 esd uayp pur asidesoy) ip 4g pajpapow “parssiins are soanewsaye ‘paynuapr usaq aaey sunoIsey 99 2891p 29 “SunoWAeyq areLdoddeu! 4NuEp! or posh aze uoNEMAIS 2g) Ur pip Ayjemse ausned oy wey yo uoIssnosIp pue sdeyd-ojo3 ‘pare| 081 uaaq sey uonEnIs snewa}qosd e aauQ “IHjApy aq ULD siPyS POs arendoudde us Suyuyen jog ‘9se> 942 St SIE UOYAA “S|IPIS jeuoHEssAUO pue jeoos Buren Ayroyyp aaey 40 Spey soya ays aeys st ajnoyjp Suonems jemos puy Aay3 Kya Uoseas a2 Jo ued ‘Siuoned wos 104 S18 pup sunotarqaq arou Sunny ‘ae9} ypns inoyIN sjenpraiput ‘ur uana Buryeys Supnpoad 20) auo jeapy ayp seat aumasod siya weys p2ye2Aa1 8 saws Kyoncuy undxg “uede paypions sisfuy sy yt jor, a aysiaye 229m spuey siy dey payPay> yporvador ay smyp Suse “oyqnd ur ayeys aysiu spuey sty wey pat auoned e jo gpipeq ay SuureueM ut lurypay> pue jonuo> re siduony 1 pasvadde siynoyp sty jo ye39428 1e4p parnow diqei siy Jonuo> 01 paduone sy sum y>e> asnevaq Joyjoq sty FuDsOyUIDS tu2oq poy saysnoys sty jonue> or siduione siy ‘peu! HuIo# uny uuddors lueys Joqiex reyp popnppuod Ajjeuy ay ‘paspuy ENE ue BuUNP signoW siy jonue © adwone ou 9peu! 24 UDyK UDAD ssoupru oF per] 10 ‘op sypene o1wed rey pasax0zsip ay ‘si Jo 2ouanbasuoo e sy “aysnoyy iy jonuos pue 4x 01 r0u uy pur sulorduds siy uo Surg oF pose JoDuD Sea 94 $aH]9q SIYP 1892 01 49pIO UL "uM PIRES :snl Kempe JoIOD ye sidwone asoqp 164) pas31}>q pur pene ue Hump siysnoys sty yox1UO> (02 poun sKemje poy 94 rey poure|dxs auoned ay]. ce} os peur Huo’ nok paddos sey reyqh, “uNY payse asidesoyp sty ‘syPene suEME po2u> jodxo Apeasqe pey ay sy pene sted eB Som a4 4p pos21pq OYM iuoned owed & Aq PA ¥ "85 aed uo andl 219m sanoIAEYpg ypns Jo S9pduUIeXD [e10K Sppsaoyes) snozsiiuep éyysiy suv sworduds wreua> reyp soyaq sauoned fe ulewuteas pue payers aary swordusés 2>u0 pasn axe yPIYm s4noIAeyaq Aypou or uevodut osje $1 a1 “uproar ae days yorys sontanre 30) suonemis 01 soapsunyp 2s0dx9 01 siuoned Suisleanoaus or uoIppE Up spauio> jase aie soydonseie> povedonue jo suonoipoad s19y Ing 462) paououadxo ip. ‘oad Aypreanose stuoned uy4O, Aamxue 241, spon 01 21g 29 2,u0m “aute} im J, (9PENE Meay e 2A JOW' puB) sje Ing *s2] 49} parypoxd soy duo 0 AJoods siuaned ‘suonsipaid Supfeu usyqy -parrposd wey aaneSou (s10U 30) ss9}_ st twoamo ayp 424412424 998 01 uDKp Pur as!H9x9 sansodxo ue Buumnp uoddey, im yung Aoys dey 2DUEApE U poyse are Zowp ‘uomppe up soidet) 298) uorysey pope’ v ut pur Aypareadau san pases) 02 Soapaswiayp asodx9 01 pafeano9u> a1e siuaited “sn290 Aypen>e Jo pieae axe Aoup sump agp aaypoqs 32s 02 29ps0 ut poprone Aysnoinasd aney, ays yptyse ‘Santanpe ut a¥eud 01 40 ‘suonems o1ut of 01 swoned 28e Cinoot ssidesaqp 94p 2e4p) 1eNoduN StF ‘uOseaL sup 404 “sJorfoq anne (siuaned ufequiEW 02 pudy souEpIoae Jo suOY 29142 [TY “CIES [29} 02 Hunsers uoya sivalgo pyos o1uo Suipjoy >) pauers rary surordunss 2540 pasn 216 y>iym safiarens sourpiose “Appar “(as1019x9 “3'2) suonestDs poveay uo Suizq yu yor soMiaNde Jo 2ouEpIOae ‘Appuosg -(dunddoys ‘spmoup ‘uodsuest ayqnd uo Buyjanes) suonemis ad4a-s1goydeso3e pioar auao sad gz Ajaewixordde pur “(sufuens yuu Suneo ‘siueaneisoa uw Bu aa ‘syjgnd ul Sunjjer) suonemns aanenjess-feoos plone sitoned o1xuE ‘oes ox aejiuuts © padryd sanowegoq Kdeszqy anosaryeq m0 9888 Cognitive bebaviour therapy ion of a dysfunctional assumption, rational responses and a plan for change (from Clark, D. M. and Beck, ibook of anxiety disorders, because in the past my parents but instead always suggested that there is another unseen ck However, this bei re because there are things about me from my past which are good and which nobody can take away ‘same person when have to work hi 40 to help change of his assets and discussed his perceived deficits. sumption. In this way he ife even when adopting a p: that implied by the assum found to do because whenever he tried to act agai assumption he experienced a series of automatic thoughts and became anxious. To help him continue to act against the assumption, he wrote the assumption and arguments against it on a flash-card (Table 3.4) Anxiety states 89 advantages (it produced consider le anxiety which prevented her from Relaxation techniques Relaxation can be an effective way for pat selves that they have control over their symproms may have broader cognitive effects. Peveler and Johnston (1986) found that relaxation increases the accessibility of pos and hence makes it easier to find ‘One of the simplest ways of achieving some relax planning enjoyable and relaxing activities and planning breaks in busy routines. In addition, some patients beneii ining in relaxation techniques. This may be particularly relevant for individuals who report finding it extremely difficult to relax or who repor continually tense. A range of relaxation techniques are a stein and Borkovec 1973; Goldftied and Davison 197 impor presented as a skill ro be learned through repeated practice with the aim being n lax in an armchair at home, but also to be able to use relaxation during everyday a One of the most plausible types of relaxation relaxation method devised by Ost (1987). The va the Appendix to this chape is advisable to demonstrate each of the stages in applied relaxation during a treatment session rather than just giving tapes of each set of relaxation exercises, as studies indicate that audi effective is through ing is the applied us stages in applied e's body which is involved in ice sensations which they are first pras for reatprostag “(S260) “WY “HEIN pu “La IS 2M AN HOR MON INH -MeAPWY Buyrads Apouonvszaau0r (R61) "V IBUIES “Yuox, MON “uoUNaLD4 “sIsPHpuogpodKy Wor) “95014 ts) “Wd HOA, MON "SyOOH DEG 'sHHgo4d sepionp Karsny “(soi “TY SusquIN pur D “KouRy NL -V SPOR Sutpeos popuswiwossy “(uonexejas appsnun aayssoiSosd) uonexeyas jo Woy eu aou e ual siuoned ueyp a10ul Kpue>yrus porosduur (roidey> yeu ‘iyi 01 xtpuoddy 995) uonexejau porjdde waar siwoned Konue poztyes2ua8 pur sued .eqn punoy (3861) 150 “A1Jeurg“2aMDay> a10W AjeurBueUs Bug Adesay2 moweypq aaniuSoo yuu “Aiarxue pszyesoue® ut suonsnpot POUCU YuIN parePosse asam dessyp anorseyaq sANNUHOD pur AdesOKp eq yi0g deMp punoy (Zg61) AAIN pue WeYNeY dn soy}o} yiuOLL “x16 16 pouteiuteut 19m Sule aso4p UE “Sjonuo> ast] em UeyD azoUL Spuesyuuais pasoadus (uonexejy pur ‘uonsessip “Suunsnaisos santo snjd ausunean aanrufo: 198 pur s9puosip atued rep punoy (pR61) “PP 12 wed Aroixue opseg “sompasoid jeanoiseyaq pue 2anuo> Jo suoNEUIGlOD snoLEA Jo ssoumanooyo oy poreSinsoauy aavy s[ein poyjonuo> 29yumNy day {puDd>y, AdesaxpoypAsd aansoddns aansoup-uow jo woy © wold siuoned ueKt au0u Kpueoyiudis paroudus “(¢g61) ‘70 12 9815 Aq pasn qusunean ay) OF Aes st Pry SuoUNEIN snp Us siuoneg “swUDHed s9puosip 21ued Ut ‘Adesoup aatnuo> Jo wuoy © JO ssoupanrayy> 2yp pareSinsaaur (8861) 2d sje pojjosiuo> quso91 Aq Pauuyuos st Y>iys uonsans v “uoIssIMDD SHY Jes ouyseg oy ueYP aUIN Jo poued saUOYS E UT porlosqo 219m aurpseg rey Woy siuowonosduy ueDyiuBs puE iuouREaN Jo UES ayt 240}9q paystqerse sem auraseq 2]qeIS E (O9RGT TP 19 SIASAOHTES *S86I TP 12 e|9) SouDs ase yp Jo oma uy “syso1 BurstwOAd pauteqo Y>rKo JO |e $8861 29H ‘9861 ED Pues “1ppPe AL {0861 UOIIOH) $9u95 3se> ays ur pasn usaq axcy aoidey> Sty} UL paquosop asoyr o1 aejumts sounpaooad auouneasy -poyst|gnd u99q, ‘ney soxpmas owiozno may Aoaneyos ‘uoseas sty 404 "oHeAOUUE 142091, ‘eae saieis Kiaixue jo tuaunean ayp 02 soypeordde jeanorseyaq—aarmuslo5, 2u031NQ, 16 sows Koreuy 9 UH pouyuoD 2q 01 sposu apTs91 styD “39A9MOHY ]ayjns swuaned ur syene sued Jo soyiany ‘2>u9pt asm uia1-Buo] 1eyp wopIAd MoU St tuonippe uy -sourdazerpozung vai asoyp se anosdun 01 AIoy se asnl 930m soutdazeipozung wat 10u siuoned ‘syuowl x18 2XoU 941 49AQ,“ADEKUE s9se> Sow! ul ‘Si9piosip aamDayje IasuO wuD291 YK HunUDSad siuoned (0 sourdozerpozusg Suiquosaid tou siguonnyead [essus8 Jo ssouanbssuo> ay2 poredussaut (}g61) stuua pu ‘spuowp| “per ‘uejerey ~AorUE auarsisiad aout ur anjea api Jo 94 02 aeadde sBrup asoyp ainoe ue Sueurw 40) jrydjpy 9q Kew soutdazeipozuag Jo 9sn wHs91-1104S 3p [yg “Tuaunan [eanK 109 01 soARUIN|E pasn fj sour aip aze siuessaudopniue © Ss19990]4 CIP “S9U siuaunean aaneuyy -padoppaap uy. ase sosuodso1 Supusauo> s10ur ‘aanewsoye “paynuspr aue s2ssauyeom J] “sasuodsau [euoned soy 40 sty Ur sassoueom aUIoduld 1 auaned 2y1 sdjpy ssoo0sd si “sosuodsax [ouone ay asutede andie 01 Sunda £q 1uodioiunos ayp sind asidesays ayp uaya pue ayginoyp sane Bou aejnoused v 01 sosuodsas jeuones 134 10 siy soieas ausHed ap Ae|d-3]03 uy “sip Bulop yo em jryasn e aq ue> jodiayuno2jui0g -s2suodso Teuones umo s1oq2 ax2¥aq suaned AyBuons moy SuDpoy> UO poreyd st syseydum sejnonsed ‘siyfinoy: aaneGau asurele stuauinaae yo dses® maid osu! ue 99 pjnos asdejpu v 10) suo: ppow aannifo> ay sy “Aispxue yo sopo ry due luejd e asiaap 01 pue Adeaap Sutinp pourra} aavy daup sunp jo 1m 01 Payse axe stuDNed ‘siya axeANpDE] Of “wayqoad sou v 01 poydde 9g 109 Adesaqp ut pasinboe usaq APEDs|e AAeY Y>Ilp SIPS soy BUISSNDSIP >AONUE [Im A]fensn si “3nd50 pip AayD Jt YIM aJeop 2q plno> Ady OY ssmostp 02 jnjasn stay “und90 eur siuaa> 2soys 1eyD UIEHD9 JOU SLM JE UDA “diysuonv}o4 Jo dn ya1q 40 go! e yo sso] se ypns “sypequas aanany Aue a1ed piue 03 2pew aye sidwoue ‘pasea:out Ajjenpesd st suorssos Adesoqp uo9¥et -9q [rasmiut ayp ‘s0ueya1-9s a10word 01 Jopi0 uy -asdepr Sunudaaid o1 wousnpas wordwés wox siyiys siseyduu> oyp Adesoy) Jo pus ap spieMoy asdeyou Busguoa24g aso 01 sansodxe popes Buipiosd Aq suonesuss ureris9 yo Kdesaqy anoraryag 2annior) 062 Cognitive behaviour therapy . and Maser, J. (1988). Panic: psychological perspectives. Laweence sd 83). Life after stress. Contemporary Books, Chicago. Young, J. E, (1981). Cognitive therapy and loneliness. In New directions in cognitive therapy, (ed. G. Emery, R. Bedrosian, and S, Hollon), pp. 139-59, Guilford Press, New York. ines, depression and cognitive therapy: theory and application, In Lonelines: a’ source book of current theory, research and ‘therapy, (ed. L. A. Peplau and D. Peslman), pp. 379-405, Wiley, New York APPENDIX STAGES OF APPLIED RELAXATION TRAINING ‘The main stages of Os’s (1987) applied relaxation training are briefly outlined below, with the expected time it should take a patient training programme given in parentheses, In most of the con ating its effectiveness, the applied relaxation training progt ‘over 8=12 sessions and it is unlikely thatthe full training pr delivered in less than seven sessions. However, when that the number of sessions available for training is less that this, it may be Possible to obtain worthwhile reductions in anxiety by teaching subsets of the training programme. Within a treatment session, training in applied relaxation can be easily combined with many of the other cognitive and behavioural proce dures outlined in the present chapter. Rationale mportant that patients understand the jonale should rationale for include the fol 2 behavioural ‘person to person but ii common for people Physiological change, followed by 2 negative thought, which increases, oducng 3 vic m build up ery relaxation technique th teaching y cen through 2 series of traning exe progressively less and less te, Throughout the pe 1 10 use the relaxation Anxiety states 93 gach as riding a bicycle, applied relaxation requires lt of practi rmework practice is necesaty throughout the traning ® Recognizing the carly signs of anxiety In order to increase patients’ awareness of the ealy signs of an anxicty reaction, they ate asked to keep a record of anxious episodes, The record includes infortna fom in which raged 10 the different stages of relaxation training. Progressive relaxation (15~20 min.) ‘The frst stage of relaxation training involves the progres in whieh the bod series of large Br 0up is tensed ar ly alternating tension and relaxation patients are taught to di te between these two ind to become mote aware ‘of the parts of the body in which they are part ‘anstion to natural situations, patents donot relaxation Instead, they are asked to the therapist models how the different groups of mu relaxed. The patient does the va ion-release exercises at the same time, with the therapist checking that these are done correctly. Then the hisher eyes and the therapist takes him/her through te different muscle groups in the right order and at the normally t tempo. Tens tained for about five seconds, with the subsequent relaca laxed only once. After going through all muscle groups in this way the Patient is asked to rate the degree of relaxation obtained using 1 0-100; sale ‘The same is later used to monitor progress dui tice. Therapists should check whether patents ate experiencing any problen felaxing particular muscle groups and help deal with these. For the purpose Progressive relaxation, the body is divided into two parts. In the fest ee felaxation of the hands, arms, face, neck, and shoulders is practiced. In second session, the test of the body is also included. The main muscle groups involved in each session and inst ing them ate as follows: Session 1 Clench the right fist, feeling tension in the fst and forearm clench the left fist, feeling the tension im the fist and forearm bend the elbow and tense the biceps, keeping the hands relaxed straighten the ares ard Ps leaving the lower arms supported by the chair with the hands inkle the forchead by raising the eyebrows. bring the eyebrows (as in a frow ongue hard and flat against the tension in the throat. press the lips the head back as far ay (against a the chest... hunch the shoulders up towards 5 towards the ears and circle the shoulders,voy Sys agiuds 5 20) Ap ip Buyuado “aie “saouun jo suis st 9ys1q ug, dooid © uo Buna 914s px ‘aug, "Tusudzout a4 Ut paBeu> iow Kpog 249 JO (spuoses g¢—9z) uonexeyas pidey, sou nop aso Sng ansend SoM EL in ‘Areurpuo ue ut 3 "pune ue ut Sunnis Aephson9 ut poBeBuo apy xeps oF Moy Use| 1 St ‘afleas 1xau 94) 02 Supaav0xd 210)2q Jo 999m 7—1 “uy "uorses90 ped Uo parawype UOEXe xeps on u>ye1 Saajoaut ypomowoy “Ses om apap uo %peqp asnl pue 2704 sauatied 941 01 pan> ‘S400 56 (spuosas 96-09) uonexejas 2yp Suppsoso1 “kep w aouma wonexe} ipansaad ay ut sy “2ouewsopiad Bursordust 3} siupned >ai8 01 pue xe! 01 uayer own >4p shes saqwrs Kyareuy ‘UILE ¢~Z) UOHEXe]>s payjosU0s-In7) pur 4 pues sa39p saqje9= + sonny Dy xeps--ypeq_pue sien. Dy. BY“ ypeUOIS NOs 4p non (1 pue Ajuje> aynea3q 01 payse Sumivo eq Xess 02 = ypewors ut aes ye pinoys96 Cognitive behaviour therapy an be used t0 remind the ‘every time one looks loured tape patient relax 15-21 When relaxing he/she is instructed to: ing after each breath; ‘Once patients have practised rapid el relax in 20-30 seconds the final stage of race 1 become complet " ly control tt sure to a wide range of lanxiety-arousing ‘show the patient that hhlshe can cope wi In order to promote control, the p: Jawation as soon as the first sign of anxiety is noticed and earlier fare reviewed to remind patients of their typical early si ch fairly easy t0 identify a range of anxiety-ci ns and pa may woke Sanig and ty arousing events can be used to prod) iment ‘during homework practice. Maintenance programme 1-10 help maintain the improvements made ng pt a encod develo the habit of ein ‘once 9 day 3 4 Phobic disorders Introduction Such fear results ina strong desire to avoid phobic even though patients often recognize th: ‘They may be able to dismiss their fears when in a ‘safe’ place, bi believe they are in real danger when faced with the thing that they fear. other fears, phobias are disabling and not adaptive, as they inter- h ordinary activities. ‘Types of phobia rypes of phobic disorder: simple phobia, social mple phobia ). Simple their symptoms if they are neither in nor mn. Social phobias are more complex, as they uunobsery teractions, such as speaking, ase they resemble simple phobi: not so easy 10 is determined by ‘They may also ps pse if unable to escape.“Ayernoraeyeg “Ay av ‘19} ypns Suryonoud su somes pur ep Jo 21s yt ruyap 44 “snoss8uep Uy aandepejew pur aandrusip 2110999 Suojoid uana Avu pur ‘]gisuas ase soyjeméel ayp Jo suonseos 94]. ‘purLy e (0 Supyjer 3143 0s Hop prone or au0 Funypear 30 ‘aun wxau peos aya But -sso19 Uays Rysue> aio 9u0 Supzeut :s9ouanbasuo> ‘aandepe “Jeoyouaq avy ayfHty soustiadxs ayp pue ‘Keme a1p ppinb pynom 29} Jo swI01 duis ayn ‘389 © 4q UNOP payDoUry BuIpg passiM ApROUEH pey (b261 vosspoy] puE uewEpEY) rou Kew 30 Kew suroiduiss aamoalqns pue ‘yemorryeg 39} Se []9M Se ‘uaBue pur “WuouisseAIEquID ‘oureYS Se Y>ns suonoUD puE § sapere AjsnoraBuep ane ajdoag, «ui payry aaey ayshUn ey, :sAyHO\D Spnpur Aayy “snomeyaq pur suiodox jeqiox sivoned wosy pousoyur 29 (01 axvy Aisnoiago sworduks annz2lqns ods 2yp 01 poi001 AyjrewaUI04 Burg 30 dem ay Jo ano Ajpaods ursow $,8urz991), 30. IuWwoy, oe swiosducs jpinoriegag snotago sous 2yf ‘AqyesauDe “Bunutey 01 ped] WED {pny aves aae9q ut ep uappns e st axoqn uay ‘Asn 20 poo|g jo seiqou uur aupsoud st swordwks yo waned 1iaiayyip reyxawos Y “sypene owed {yum parenosse aq ew asaip “(ager 248825 pue mopsEg) e1goyd yo sod ipo ut ueyp eIgoydesofe ul uayo a10w Soumowos “x9 ‘ssoussopyreoNq ‘easnew *.ypewors ayp ul SoqjioNNG, ‘Ss9UYyeDM JO/PUE UOIsUAL ze|MOsTIL Burgreaaq poypouy u19q passiun asm! pey 2u0 “jdurexo 205 dep suonesuds ayp Ife apnppur suosduds poorSoqorskad 241, “(g961 ue) ‘anbalqns pue “jeanoraeyaq “e>1Bojoskyd :s9d4 sax owt pozLO82I€9 99 ‘Aqjyosn ued paseay Suypowos yuu aeru0s 4q paxOsoud sworduaks a4 suordurks -Ayoyssanons eiqoyd € 38a 01 J9ps0 ut asne> 19ex9 say mouy oy Gaessas0u ou AqurEUR> st 3 “1p10 ‘3sin02 aonb “2sqns ap 01 diysuone>s snotago ou axey si01>e} id Jo sxmew ps02>¥ “(9961 49PI°D PUE SEIN) Jou auo294 01 patrodxa axe UwOM uanbayy sou wers 01 sxeodde eigoud ep ued ays 20 94 YpIY 02 “uaNg Bulag se ys 'p aquosap 01 waned >1goyd e 40} [ensnun ‘19A2M04, seunen 38 66 stapsosip 21404 Suunp Suuse>] yo wo} e st Suuompuos, ‘uewypey) suonsnnsur 10/pue UOREWOJUT Jo u 4o 49} ayn Butatosqo 4g pouser| st seo} 243 Uoy) 3 mpuo> asamp ysnosyp posinbse ‘sivay pauses] 2q 01 pa1opisuor joud8 are days ‘umouy 10U st seiqoyd Jo asne> 1>eX9 axp YNOYTY £61) weWEHIS pue uEWPEY hq par ypns ‘suon Se qpns ssouy ui pare voy 242 01 Ade osje Ker au pur ‘ood ape © lou Ame 2) unix 4q {dood sayzo Aq porratos BuDq ‘yp ut poazasgo st se! aysinoya 9q 02 pst a} sun bos pur ‘soigoydesode axe uonedino uy us9s stusned >1qoyd ayn Jo aua> 49d gg anogy “eiqoud [eos uF papi Ayjenba are saxas ayp LYM udWOM ae Jo aux sod 9g tnoge ‘s9A2moy ‘usu UL HEY uDWOm Is ae seigoyd synpe uayys 10 ‘snun ue> Kap suodwos Aq paruedutorre Kde1oqy anorangaq am100 Cognitive behaviour therapy and subjectively, and these reactions prevent the symptoms from dying away. They maintain the problem because they prolong and increase distress, and also because they produce new symptoms such as anti- jon, and dread. In many eases the most dis the reactions is avoidance. Subjective rea and include thoughts such as ‘Here I go agai ‘am shaking and everyone wil avoid, and a variety of fear and dread. Depres phobias which interfere with daily a are also am going 10 a Strong desire 10 stressing emotions such as frustration as well as. become a problem in persistent les (see below). The interaction between symptoms and reactions igure 4.1 shows how the reactions to symptoms maintain the phobia by creating vicious circles that perpetuate fear. Avoidance mai because it makes it difficul not in fact dangerous, or is not dangerous in the way, or to the extent that the patient thinks itis. Other important maintaining factors include thoughts, for example about the meaning of the symptoms of anxiety (‘I'm going to faint, “There's something really wrong with me’), or about ct and loss of confidence. External ns of people close to the patient, for example when they do things for them so that they do not have to face the things that they fear, also maintain phobia absence of treatment, pho- bias are extremely pe (Marks 1969), and precise identifica maintaining factors is necessary in order to plan effective treatment. ‘of this chapter is concerned with the treatment of phobias. The background to treatment is presented first and more prac factors, such as the The chapter ends with a brief treatment, of procedures for the maintenance of change, and of alternative treatments. The theoretical background to treatment Behavioural treatment for phobias developed directly out of the findings Pho! disorders SITUATIONAL TRIGGER | Behavioural running. SYMPTOMS REACTIONS. a heart thumping, ete fatigue Fig. 4.1. A vicious circle model of phobic anxiety hhas the opportunity to learn that the situation is not in fact ‘The child who never goes near a dog again may remain ‘one who approaches them to regain confidence requires that patients repeatedly make contact with iey fear, and remain in contact with them fear Exposure breaks the vicious circles that maintain sym toms, and facilitates new learning. By facing the things that are feare: patients re-learn how to deal with them ly.aus aup se yons rep yuu uosiod on 2yeur lajqoad sign pey 428 ue ,@8u1op nod auanoad eiqoyd ayp soop reyay, “9 =Shem up 01 dpoy, Aes 3p “sdiyst ‘Aannge ay: Suipapsur sugpaiuy Aq porewinso 9q ue> eigoyd ayn jo Aauaaas suoudeas moge pue ‘suorduds aansaiqns pue anoge Ajjeoneuinsés Burjse Aq paimanns 2q pynoys suaussasse uy siuod yoiowas) Aquqenns 1usunesn pur eiqoyd ayp jo sumeu asiza3d oy ‘yewoneust 30 snojnoypia spunos 11 uray) or asne22q iqoyd ayp aquosap 02 ruesonja1 9g eur swusHed aeys saquioWDd nb wzoddes dn pying 03 1we1sodum a20}o4041 st “1qo4d [EOS ns © 01 BuryJe1 20 1goydeo8e Ue 20} Uy 242 02 Suaren venus siqoyd eas v Owus uaned ap s9210) IUdUHssasse a5me30q 430 ‘papioae Ajjeuniou st pue AIDIxUE soseas5UT [eNEp UF a1 Inoge SuryUIE ‘asmepaq 9q AeuH Siy] “op 2 1IM>yjIp si Puy 2>UD4 pue “eIgoyd DM anoge Sunjjea uaya passansip pur snorxue aworaq siuaied s1goyd Auepy ‘Avaixue 21qoyd Jo sounseous arendosdde 4y 20} Auyjiqeuns pue eigoyd ay) Jo sumeu asira1d ays su2%p or ssunre doa sey au9U -ssossy “ABovenis wounean 91grxay pue 2anD2J9 Ue seq o1 YPIYs Uodn uoneuuoyut axp apiaoud aonread Jo spo2a1 pur 482} 0 saunseau asne> -9q 81 SIU “dn-moyjoy pur auouNeaN inoysnONp s9MuiBUOD PU *KoIss9s say 2up Ut sutaq s1aps0sip a1qoyd Sunean yo as0dund 3yp 10} wowissassy quouIssassy od s9Adua yp | Avpsaaa onut paresodioout pu ‘uo ise990 parvado3 24 P| souo so1pse9 ay], ;paseannap sey 940 01 stoptosip 214044 1861 SEW 32) payrrads Aje>}> 2q pinoys syse2 aonpead put ‘poSuojoad pur ‘poreadas ‘parenpesd 2 ssausansoyj9 jtuindo soy wey sUs9Hns yoseos2q asneooq paproar us2q sey rey Sumypowos Huey se p- S804, “viqoydesole pur ‘er luo ypuvasa1 aaIsunx9 WOH} PA Adesaqy snowangaq aanmio3104 Cognitive behaviour therapy under furniture. This is particularly clear in the case of social phobics, in whom the pattern of avoidance may be determined by the personal meaning of the situation to them, for example that they are being criti cized or that they will never be able to form close relationships. Maintaining factors Assessment of background factors need not include a detailed history of the development of a phobia. It is more useful to identify mainta sctors, because they may interfere with progress. Avoidance is usual jin maintaining actor. Cognitive factors dangerousness of the phobic nt, or about having the at it through. The assessment should clarify whether other p generalized anxiety and depression, warrant specific attention (: ind whether there are reasons why 1¢ phobia than to struggle against ‘young person would be expected to move away from home ‘once the phobia had improved, or if the greater independence achieved by an agoraphobic after treatment was perceived as threatening to her mar- riage. The therapist should try Existing coping s ‘The therapist should ask about which methods of coping the pati tried in the past, because those which appear to be adaptive (such as keeping busy so as not to brood too much on the problem) might useful be incorporated into the treatment programme. Others, such as spora attempts to face difficult situations, may have been unsuccess could lead to reservations about the methods to be used in ti reasons for failure (such as insufficient, un; ) are discussed. Alcohol and tranqui ness, However, they are both likely to lead to depender long periods, and the patient may need other methods of control, of more long-term value, to take their place (see p. 11 Resources resources will influence factors such as their abil uations, and their readiness to accept the rationale of a cognitive-behavioural approach. Resources in and aspects of life that are relatively unaffected by the phobia, sources of pleasure and success, help es and friends, and personal charac- long-standing personality excessive dependence on oF hi id take longer to treat. Determining the goals of treatment disorders, itis important to discuss the ‘may not correspon There are many sources of difference. Expecting the imposs , a social phobic might wish never to feel anxious in ince some degree of social anxiety is probably achieved, and it might be what extent others feel during a difficult interview, or Patient and therapi precise goals, a5 these set new goals by finding 01 uumstances, for instance unexpectedly criticized, may also place differing degrees of emphasis on ‘may be more important, and indeed mB ings alone. Agreement about ‘engagement in treatment, ult to know how wide ranging goals for pl hee is some disagreement about wl Measuring the phobia Measures ate needed to provide i plan Id beuy ayedionaed o1 Suyjim 220m [99j uayo swung “sunsodx9 se Bo4 Jo ssoU -a4o ploae 01 ‘2yieoiqioa0 01 Aouspuar v se Ys ‘pouiodss Surpawos 22A0281p pue auoned ay1 axsasqo pjnoo wsidesoys o4yp yp we spunw sup Yom o8 rey sYFAOYE Aue dn y>1d 01 20 st Gapcur usyys 4p>ex9 ano puy 01 ‘uonenws Zunsor ayp ut age Kou UOyIN suaddey rym [21 ul aquds9p 01 poyse 2q ‘22UEISUI oy “UED siUaHeg 1 pazeasiout dem siyp ur pue “Go1xXue so amnseaut & jueyp Jo sounseoui wuapuodopur se pasn pu poreados {prog rouue> s10yoro42 pue ‘paajoaut sansodxo ayp Jo astezaq ‘snnadesoy) 3q Aeus Aogy reyp st ‘Moxa Jo aulod auowoanseaur © wos *S 94 Jo aSeiueapesip 2uQ) “poureiutew! us0q aaey awounean Suuinp apeut sue aaypayas ano puy 02 Luo 194m SuIpHop way (01 Ay age sassand se “x -Avaixue Giored!onue uo paseq 2q NS © peq Moy ssond 01 sey auaned 2uo[e uy) pu “suosu0s yu i a ‘ur mopar pr (01 munazyax s4s01 Jo Kroon 0 3 oot somo]. 204}0 3804 Ut [EU IE 06 sayeay ON wt 9 “speos urexunow Buoye a9 p> Buoje pea, OL 43001 evo ano pur OF woos jo anu ut yng x ‘01 da ‘soyjo ur mopurm ssept ‘Sinoplll 200 pur + "350 mopuym 3004 381 uipuey sesdn ayes Haney, sayfing yo 2e9p 10) Apres Lp MITEL, zor stapsosip 214044 aya {ue yo wnowe 243 Sunes etp Bunyauios Bulop Jo sistsuo> saso1 jesmorsey>q popucdxs re 1aeL “pour Sunr9pisuor 20 © 30 21095 pInoM NOK YDIYH UO W for dn 0m Ayjenpest ue 209 © OU! 3eyR Deu PJnom EYAL Jo yun No Ue} “sou0 prey y¢ ey 0S “SIppruu ayy Ut study padd 3x8 UDUL ON “001-06 ‘typ 108 94,9 pue “5 pares oxey nok yor 208 94,994, "21 "UIDYR 2]e95 UOIP ue swan ayes 8 Uo swan Ut yed soy Jo1se9 2q Aout jose 01 A pjnoam aunowe 241 ed ay YonUL Moy J0ypue) asne> PnOM 1 (01 Surps09>e 91298 (001-0 40) 01-0 & UO aUaned ayp 4a, ‘ua ypeg 2yosoud Aoyp Aappxue ays yo susan ut paveds Squdsa.2q sv aby se “plnoys pue aie aeyp eigoud yp Jo sisadse 12yox pynoys ‘pouyap A ‘sowoxixo soup uuzpatiog Ur SwoM 24 ic auasoid ed yh pi -oydeso8e ue yo ase> 241 ut {quo 2yonoad ep Bump tp jo 28uer ny oy D9y20 pl digoyd jo si] pos9p20 ue st Ay>uEIOIY popesd y soxppumiay pop | 169) Jeanolaeyaq pue y>ses214 popes ayn aie Aauiaays s1qoyd Jo soanseaus pasn Adpuagy snoswogaq 2:Cognitive behaviour therapy this difficult test if its fact-finding function is emphasized when i is explained to them: ‘In order to find out more about what it’s like for you in real life, it would be very useful for you to go into one of the situations that you find difficule itoring A daily record of exposure practice and of the level of anxiety experi- ‘enced encourages patients to self-monitor and reminds them to complete homework assignments. It can also provide evidence to counter the tendency to remember failures rather than successes. Feeling panicky on a crowded bus may seem more important, and be more readily me than routine trips to the local shops. Written records are part ick or relapse, when they provide a context ely assessed. They can help ind keep track of progress. Symptoms of particular concern (e.g. sweating rated separately. An exat in Table 4.2, and further information is given in Chapter 2 (p. Measures of cogn Accurate assessment of cognit and to the benefits of exposure. For example, a identify what he she predicts will happen when entering a feared situation (‘Anxiety wi reach 7 on the 0-10 scale, and These predi fects of iden (Gee also Chapter 3). Standardized rating scales ‘These are useful for assessing the relative severity of phobias, for measur- ing the extent of genera Phobic disorders 109 Table 4.2 Practice record for an agoraphobic patient TARGET: Go to NB Decide what to do before after each tip. Day Task Expected Actual Shaky Tablets Anxiety Anxiety legs 1 4 ere) 2 5 a ) 3 hops, and back + chemist 3 1 0 0 4 to town, and back can't get lift int) 4 sm ++ 0 5. 5 4 ood 6 ino bus) 5 2 09 0 joing out. Met S, could 2 6 2 00 Survey Schedule (Wolpe and anxiety developed by Watson a y for Agoraphobia (Chambless, Capu 5). Treatment in practice Introducing treatment In theory, phobias can be s. For example, an agoraphobic p and faint in a bus one day (a phy: the next week for fear‘spodse soqpo 01 azyesous8 yim eigoyd ayp yo 1adse au0 ut wuouano3d sm s01De} 1uELOdust auaproe Joquiou! ¥ 02 paxuno30 a4ey ay erey e aeyp 204 2%] B10W 94 Aeme sem aYS 398 ‘spousd Suo] Aron 40} auoy woxy keme azNIUdA 02 >]qeuN sem “H spinb ut siuauraneasog Jo Soups e paouauadxa pey oys waned >1qoyd -B108e UY “(ZR6T adja, Os[e 228) jonuo> Jo $804 pur ‘2}doad Surpudyo anoge {atom “A ofo4 apnpput soway1 uouUOL -kyDues afduts © uo woup yssod 2q Aew 1 ‘podden Burs se yons ‘owioyn 2fBuls e Aq paisouuon aie siea} ay 2sn 01 30 uoneMs qpe> Sunppeosdde 40} so1y>ze3244, soy22y% apHap 01 sey 2UO aseD styP U] “Jom Ie UDsIUED ay) UI BUND pUE ‘aassouparey yp 01 Sulo3 ‘2uoydaja1 atp uo Burfeads ajdurexa s0y *parsou suooun aq 01 seadde sproae auaned © ey) suonenus 24) sowmotos reudosdde 39 I sjser aonzead yy sunuoiap 01 sday (sJf9q pur sigsnomp apn ply) ssowey yous Burdgnuspy -asu 241 J! uaspyp a4p 02 uaddey pjnom rey anoge Burjunp aq eur ays wooo 2y3 ur anya “(98761 UEUN|DeY) Uosiad JoxpoUe 404 IuHzeD Jo 1949 Bupnpor-arxue ap wou Sumyoudg aq Aru >1GoydesoHe ay 38¢9 1814 2y2 Ul "yn2yjIp a40W sty puy SH>yI0 pue “U>spHIYD AIP yaLse ano O3 OF ose sigoydeso8y [pM mouy Aay2 9jdood 1 oy 9! mou uno} Or yRoyyIP 11 puy pue (01 Sunyjer u2y a[qeuojw0s ax0N a1 SIBIRO areunU! 2104! ayp snorxue 210W! au10299 PUE uy ajqeuojwios as0us axe siqoyd eos awog “sow Aava Aiqeqoid sa1qoud Tebos pue “sons pjnom uontUYap sy) Ley repUNS ss] 3B seIGOUg ‘opaey ieymauos sonoead ayeu Aqueioduion dew poo peg v HulAcy yeoods> Suysay se ypns sio1e} punosBy>eq Wei SuudquoUL nok 20} Japreyraises sip 24EW Jom reyA, BUASE YOM ‘Suneams se ons swordus Susssonsip 4jeDos ay0A01d ue> ‘woos 104 Y “SuoRIpUoD auaique 40 ‘ep Jo awn ‘uonenns ayp Jo AujeUI0y up se tpns sojqentea or Surpioa.e 40 fuaned 2) 03 WoREpPE UE AOYNe Jo 2019p pur *xa5 ‘fie spp Suasaid ajdoad yo squnu 24) 02 Buspronse ‘Aaqnoyyip ut Avex Kew suonemis Dos *2|durexa 104 ‘posusuadxa Arsixue Jo pA] ay arexs7pour yIYR sHOIDe} AjUDp: ‘Aoiens soouy ‘uo 08 pue ‘souuuesSosd oxpes 01 Buruarst, Aq 30 ‘suyy 40 soumresford woisiaaja1 iueaayas Sunyprem £q “0Igo a1goyd 24 anoge Sunyjes 40 ‘Suny “Buppeas Aq sysen yo aBues ayp pustxo 03 2Iqe 2q ‘sup dew auanied ax “2on>esd 405 siseq e Se pasn aq We? UoReDIUNWILHOS Jo Sueow Aue *s2ssauyp! oyrsods jo suv2y 10 seiqoyd Jeunue Ur se ‘poquas ut swapsosip 219044 -wno11 st eiqoyd >t iaquuinus Y "S4sE JO. suoddey supp uy 2qqr) | parenpesd e de esp 0} ‘auaune>ai jo spoyaur jryasn poqudsop aze asoqp pur “sansodxa snoue, “2194, yeKolud 40 seo puy s1aqp Poads> ‘peas oats 2g tue> auaned oip dquo “eigoyd a4 auH0939 idesoyp ay) 1 2y"suoneisodx> uLyuodsIp 01 pue 2: readas 01 1nq 198 oF ou st doys 24) 4J2p4m 21U0S 10} 10U PUL 24S UNO Sut JO} |ry>sH 1 nfs yeotskyd w Buruze>) uoyon i 1 pur ‘ssasosd JonuoU! 02 tog siys 2s (01 pue “2onsead Jo puooss e dooy 02 Azesso29u1 241 ‘9san09 Jo pue 95" UMO Jy] 40 IY 02 Soi ay 01 Aaessa2ou uoneuopU! anoge pue “pour 42 anoge uoneut: “uoy}9 aanesoqryjo> e Jo 3]Ns91 24 24 apjnffas dq dn payaeq 2q az0j21042 suadapur pue Appandoya wajgoad 241 uo > ausuneas reyp urejdxo pynoys asides24) 2441, U9 DaNDE 242 nOYUA udx}019 9q 1oUNED 9 ‘woxy saoqjoy paruassad st ‘suonesodxa a1oyt ang Sop 01 veya anoge Apoanse > @ ‘oy 395 MOK UE) “3ppuld lute ay 0, ‘Bunfse yusom a10}9194p up rey ssond ew usted 24s 1uIod siya ae og “apis ‘sdais ajqeatieueu ul *éyjenpesd ‘pasaaaaa st 2oueproae oy) 41 24 ‘un smoyjoy ¥essour ureur ay1 “pouaddey sey eyo un souanbas sip J] “(2SuepIONe say pouteIUIEUE S39qjI0 FO NOIAEYDA Kdesaqy anomaeqaq anno ou12 Cognitive behaviour therapy fom waiting in the queue at the supermarket, to waiting in the waiting room, and waiting for someone who is late returning also be used to break tasks down into smaller steps when the next item on the hierarchy is too difficult. An agoraphobic patient who is unable to make the step from the small supermarket to the superstore may be able to do so if friend waits in the car park, if she goes at a time when it is unlikely to be crowded, or if she visits it first just to look round, Encouraging patients to search for ‘opportunities to approach instead of avoid helps them to adopt an ‘ever- ready’ attitude, and to overcome some subtle, but just as disruptive, types of avoidance. These include feeling reluctant to do something, postponing activities, prevarication, not thinking about the phobia, and giving ex- ‘cuses or rationalizations: ‘It would be better to stay in today in case my inthe coalman calls’ ‘I can't carry all the shopping I someone can’ come with me.’ The therapist should make this point quite clear: eg “Watch out for feeling that you want to get out of doing something. Try thinking instead about how you could do it’ Conforming to the guidelines for exposure ‘The main guidelines suggest that exposure should be graduated, repeated, and prolonged, and tasks should be clearly specified in advance. In practice this is not always easy to achieve (Butler 1985), and three of the ain difficulties are discussed her asks cannot always be clearly specified in advance, repeates graduated, because phobic situations are variable and unpredicta never knows who will be at the party or when a big dog bounding down the road). One strictly to a hierarchy, and to practise a variety of tasks of difficulty in the same week. Another is to analyse the si Of practising elem control, such as asking, al signs of commu sk for social phobics attention i focused upon them, away from the speaker and on answer the question. Questions can also the motions a 2 wher for instance. F internal sens: ing, etc.) Us than to reduce sy Methods of applying exposure Exposure as described above can be applied in many ways. As treatment 's needs, phobics are frequently treated sted t0 review progress and to ted. ide mH of the patient is also taught api 10 extremely economical ing results having been obtained during Real-life exposure A major goal of treatment is to give pa confidence to face the things they have been avo fis is crass laced ow homenonhy and an the begin with, This may reduce anxiety andlor make pth each. femay a advisable for patient phase out accompaniment w: agoraphobic pat the busod ap souuts s94p0 2 “(071 “d “MoD 225) ja sawinawos pue “sunsodx> Aq poonpa ynpoxdsaiuno> st 2oUeytSta ‘d10w pasnou are ssp nf 904 es ound ulog ay St SIL“ jor e aaey 2fdoad snoreuy 20urpSiaadky “1 guasoud ag) Suyyaffo s2s01g soupsaud a4p 01 aejmonued & 01 Proyse4 wee 10m 01 peau Keur INOyp!P iy Op ued OYM ISO, “SOS5aDDNS “syuaaa aejmonued \dxo Buryse 10) uouiaaaype JO ast2s 24p soDnpay jajqoad, oyp surevurews se1g st, i ayp RurweapS inaud aya Jo UK 24) qUDSP sop ue> seiqoyd {jsnotsoad sem 2u0 1uaa9 soquiswas o1 pou! au0 Aue ut 4se9 Apaneps ‘suonows Suons yim pare0sse uued 24ey youn siu9A2 peed ays Supaffo soscig sas01q possue8 Suyros9pun0r saquauas or Ase2 Af pe ‘doug pag u puny 29 veo ansesd pue {20>41 pany pue “topsonip srgoyd yo auounear 3p ut [280 ye 5 pur ¢sialey) th Paqintp soy Sp ave snp puri 20 seme > ‘eur -woyp spt apn mod pues AAT lous aos pls 1 wo 4908 ue “po rewew dew pus sonyeoyyp Hayy moge U5 Suongur ay soseigyessusd ono UONSRENP © rwounean jo sodse ‘] jadse aantuo> oy1> ‘yoy jt swiordusds 1 suapiosip 219044 soflueg> 11 oy pur Aonxu souaos [eure 9y2 Umop ssi0U waned ayp j} pur uoUEIN ay Jo ued ausunean oy a10jaq Sunduroad pay © pasu ke yp UF uoneueR ypu! st 239q, d10j9q “Kianxue ‘Aaarxue aun a1q\ssod se pue ‘io1xue aonput 02 Uf BILL “(€6 “Ad 998) Aaesso99u 34 a]ya Aypacsany >1g04d soajoaur sunpasoad prepurss ayy Ajjensn pue ‘suope 0} 1yBiy noge Buyer 10 Suspess wiosy aydudg ospe yu ang uy Aouanol e 30} a1edo1d 01 aaey Aw a1goyd SuIKy ayp og ~2IqHSS0d 1049 -uay pauiguio> 9q pynoys oma ay pur ‘sunsodxo ay-jea1 sv Aum owes 2y2 ut parenpesd aq pinoys ainsodxo jeusfeuyy “peasut pasn aq 02 sey ‘ansodxo jeurew pur ‘sunsodxa sauisy yo 209] 20 eigoyd J9punqp ajdurex> ‘wusuudisse spomauoy pouBtsop Ajjenpisipur quum dn poypeq sxe Koy Jt paoueyua, 39 |] suorssas usuneaN ZuuNp spew sues sose> yroq ul pur “UdW ean dnosd wosy ayausg osje Kew Soiqoyd jeHos “siaquidu door wos} ayqejear aq eur y>iyss a1syp uo Suppo anu Sdueyjouug *226' ayns ways axeU! os[e ss1goyd usDmI0qCognitive behaviour therapy phobic situation, and avoiding full exposure (e.g. by glancing at the newspaper but not reading it or thinking about it). In this case appro: priate, engaged, exposure should be planned in the usual way. 2. Misinterpretation Anxious people tend to interpret events in a threatening way, especially if the events are ambiguous (Butler and ‘Mathews 1983), Ambiguous events can be either external or internal. So when an agoraphobic notices her legs ‘turn to jelly” she thinks she is about to collapse, and when a friend fails to return a telephone call a social phobic thinks he or she has been rejected. In both cases. the interpretations should be identified, and then re-examined to find out whether there are alternative, and more plausible, explanations (methods for finding and examining alternatives are described in more detail in Chapters 3 and 6). Alternative explanations can then be tested during ‘exposure. For instance, the agoraphobic may find that thinking she is about to collapse makes her legs feel wobbly, but that they feel stronger after starting a distracting conversation with her companion. She may therefore be able to accept that the feeling may be a symptom of anxiety rather than of imminent collapse, thus increasing the potential for her to important to ask patients to find their own alternative so that they learn how to do this, although initially the will often have to make suggestions. ‘An example may help to this point: ss in a lft and became panicky when she thought ss, and thought you might suffocate because there ‘Th, Might there be any other reason why you felt breathless just then? Pe rean’t think of one. Th. Well, had you been hurrying to get the lift? Pe No. Th. Were you worried about geting into it? Pe Th did you have? Pe sweaty, had to hang on tight to my bag, breathing Th wxious breathing and feeling tense can make you feel breathless? Pe T think I had been tol idn’t occur to me just then. Pethaps the lessness was another sign of anxiety ily could be. How could you find out whether that was what was happening to y The next step would be to instance noticing what happe session (See also Chapter 3), t some relevant evidence, by for ime, or by overbreathing in also there the degree of anxiety experienced by phol fect their Not only wi ‘may not help.” Once agai hhas been identified, and phrased in and cognitive factors and only did I pick up a spider, but also ‘managed not to scream). In fact aspects of phobias has obvious ive components: e.g. th patients are 1g “When you are this may be the sort of exposure th: the course of everyday life, and which appears not order to be made useful it should be set in the ci return, and if they they may end up sta original expect procedures ange, or even prevent the patient jing engaged in treatment at all. Two examples should make thisauiey Supa} 30} suoseas pue sworduis yo woned arseydip ay], Bunurey pur aunssasd poojq ut dosp ‘paxejad tou anq pasuoi die osior pur ‘say ‘sue 2up yplyas ur “uorsuar poydde joap deys uapp' sd pooq pu aye 11e9q ut 2seas>u tue ypiyas ul woned worduis jedAe ue st osoys eigoyd Aanit uy wossuay payddy oyd Aun{ur-poojg Jo uondaoxs ayy yum 'sase> ynexeja1 pordde pue aunsodxa jo uoneuiqwos 24) sno 4eapp sKeasje OU ase SBuNpUy 2K 161 wossuEyo! pUE susjeuniof -og are stwordiuds yucuruopaad asoys asoya pur ‘uonexep ul Bul {guim ainsodxo sourquioo yptyn ‘uonexeppa paride 01 189q puodsos [P31 -orshyd 218 suiorduids aueunopaid asoya stuaned, rey) “eigoyd pur eiqoydonsney> uo yom siy Jo siseq ay2 Uo ‘porsailins sey 350) 08 je> dooy,) s140w2uu 20 UoHaNNSULs|96 jeuosiod dn oyew ot put ‘guoyjdajo0 aya ‘suoastur “ypaeaastim © UO) 298 99, {ysse9 te Koyp 2224 YoU 0% stop Jaded pamnojo> ajduzexd 205 “Y9puruIOs aqqysta Aupeas e asm 03 jryd}ay m puy uayo siuoney “(9-Z6 ‘68 “dd e JeuLioU tpim uo Surkuze> pur “Surpuers ‘Bumis aa pue ‘spouad soz04s Apaissooons ur Busxeppr asnoead pynoys day, “xE}a1 02 sand se aso4p as Due ‘Ararxue jo suis Apre> ays 29now 01 uae} plnoys siuaned 20)919111, opsou uy Appinb paydde aq ue> m ssayun dy ysnul 9q 20U | sn © Buuanp 3sio19x9 mau YDED YAHON UuD{ER Pinoys su su! papaooo4-ade) Bush 2104, noead 9q ue> sonbmuypar ayy “(E saxdey) 298 s[reI9p s>yINy 40}) Uunouy 1999 31 948 onexepps poyfdde pue uoNeXejar sejnasmus A193 “Bod ypiym jo ‘xepps 01 Buusea} Jo shem snowes a1 e194], uOMPXDpPY ‘mo st Aaorxue uaysa asay paydde 2q pinoys pur “Garxue Jo sI>49] {ySiy ve asm on rapzey axe sanbruypar ayp {TY “THya>4 punoy Aysnorsoad 100 sey awaned e ey) poyous wv asn or wouneaN SuuNp uLEse Burk YOM Sshempe st 1108 ‘yryasn aurosaq or age Aoqn # Aeynox pue Ajjeoneuioshs patdde pue pasioead aq 01 pasu Aoyp “Ajoan294J9 way asn 01 MOK, ‘1 Ase9 10U st 11 ang ‘asus uouTHIe>, Aq papuautu0s92 sonbIUyPo oy juts Axoa ane Aatp “paopuy ‘uaunes2 40) BuiwH09 210494 (Iam Se ‘iotno pur) spoyro asayp asn 01 parduone ancy sorgoyd Aueyy ‘siqnogt Suuiomsup pue ‘uorpousip “uowexeyze axe sonbruypay LIEW 294) 24. ‘uonezies2u38 pue aouapyuoojjas yioq Suiseaxur smyp ‘sunny 2y2 UF snorxuE p>} Aowp roaauDyp s|ppjs asa4p_Ajdde 02 2pge aq. q]uW pue “aorUE Loved Chue apm [eop 01 9]qe J9N9g 9g yee “Ky>seIaIy papess op dn sosey daout jjue swords stp onWOD UeI oye siuaHEd “suoNEMHS 2104s eu suapionp Md ainsodx> Suisueyus 10 ‘40) 3ui ‘Agarxue Suyjonu0> 40} sanbruy>21 :pox Asd Jo spury om, “paquDsap Apeasqe Spoyrous jeamorneyaq-> {yuu uonounluos uy pasn aq Ue? UoHD9s siyp uF paqUosap spoyRou! 242 [TV ausunesn Jo spoyow jnjasn jeuonlppy Buyouy ry mod 2e42 Ue: sno4seysg 1 ‘ue 2iqoyd djjebos e pawiasoid siygnoys aneuKsorpr ‘ose puod2s 24) up ‘aioue yo dy 34p tp uarsks wojgoad ay) sutUeXD id op unity 24 20) & pe “Hoq]09 01 9M 24s pue 3 tygnosg,SUPlHog. Joy Jo VOREUK yqosd asoqp s90289 Duwo29q 0} 23I89p Sows & yulM Jouodor ip ye28 Jo 4aquin © pyeanas 3Aaq}o> “uzoy Suro} moge Apcue (01 Tulo8 Jo suo pur sord 24) Sem ays parsons sromstie 29}4 2004Cognitive behaviour therapy should be expl xed and the treatment presented as a coping skill that can be applied quickly and easily in almost any situation. Fist, patients learn, through modelling and practice, to tense gross body muscles for 10~13 seconds at a time, releasing them so as to return to “normal to a relaxed state. Then they are exposed to a series of increasingly threatening blood/injury stimuli, so that they become skilled both at ig the early signs of a drop in blood pressure and at reversing this snsion. This treatment is described in detail by Ost and Di raction Paying attention to symptoms of anxiety perpetuates the ous circle, and makes the symproms worse. Distraction can reverse . rerm strategy, but can be unhelpful in long term if used as a way of avoiding symptoms, or of disengaging ‘om exposure. There are many distraction techniques, most of which wolve focusing on external factors, and many patients like to devise their own, Distraction is discussed in more detail in Chapters 3 and 6. Identifying thoughts and fir es The cognitive techniques for identifying and then examining the thoughts associated wi can be used to control symptoms, for example of panic, as well as to lenge thoughts about the phobia. They are particularly useful for dealing with worries about future events or anticipatory anxiety, during their capacity for coping, and over: lihood of disaster (see Chapters 3 and 6). ‘Additional behavioural techniques |, and modelling are the most frequently used behavioural adjuncts to exposure. All of them can be seen as ways ski Whatever the n skills are particularly useful in the case of social phobias, and applied tension, as mentioned above, in the case of blood/injury phobia. playing and rehearsal are more often used phobias than of other phobias, and a rol tself be a type of exposure. For example, a patient who finds say no, oF {0 be assertive, can pract fe therapist. This has many advanta co knowledge, such as to be ass aggressive. The role-play can then be re peated in various ways, until the pal to change. The technique can be q boss, and you show me how you responses, disorders off.’ Reversing the roles, so that the therapist plays the role alerts the patient to the effects of unasse the advantages of being more assertive. change. Role-plays are p: as interviews. Video (or audio make the most of this type of pr accurate feedback as well as new inform feel much worse than they look. Rebearsal This is a way of preparing for exposure. Many phobics find that their minds go blank when they are faced with phobic situations, or when feeling panicky. Techniques for managing the symp- toms of intense anxiety, especially panic attacks, should therefore be rehearsed. When this ‘blankness’ occurs in soci awkwardness, which rapidly increases anxiety. appropriate strategies are rehearsed, and appropr such as lists of questions to ask, oF topic be separately rehearsed and may improve with practice (Trow and Argyle 1978). Rehea such as speaking in public, ‘making a request, or introducing someone, both increases confidence and reduces anticipatory anxiety. Lastly, detailed rehearsal helps to reveal “blocks? that might prevent exposure: ‘What wi there isa queue in the post offce?’, ‘How will you explain your trip to your edge of a high building, while being observed by the patient. Mi ‘most effective when the model exhibits, and overcomes, anxiety, and itis suggested that observation of such a ‘coping model facilitates the pa tient’s own coping skills. These might be poor either because patients do not know what t0 do, or because they are unable to think what to do at the time, fects of expo- izers are used at the same time. 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They remembering that this lepend, should encourage patien takes much courage. Sometimes patients do seem to them to be une department store to everyday life, or unnecessary. Explaining exercises that physiotherapists teach people after sports A they have served their pu In general, when diffcul is arise in treatment, the therapist shoul (1) establish that the ly understood; determine whether symptoms can be explain that they are therefore potent (3) together with the patient, look for evidence that exposuire has bene- ficial effects, noting that the biases described above may make it hard for the patient to find such evidence without help; and (4) expect progress to be slower than otherwise. ale and treatment model have been adequate- ‘Maintenance of change the lessons learned during treatment are made expli 0 learn how to deal with the problem again shoul. inthe phobias can be reduced by approaching rather than avoiding the phobic object oF situation, ‘One advantage of the cognitive-behavioural approach is that structure discussion about reasons for improvement, The active, self-he rationale, and the emphasis on independent homework, strongly sugges that change results from the patient's work. So when started the therapist should make su bie disorders rationale. Examples would be: ‘The more | pra an go to the supermarket without having a pani these symptoms after practise exposure tasks, they fesponsible for improvement, and they may not make best use of this oppor ‘evidence in front of them in the form of re discussed. Conclusions can be w ‘A number of other strategies will be maintained. Expectations for the future should always be discussed, in phobic anxiety are common, and minor set-backs are be distressing if not expected, so warning pat good way of helping them remain hopeful and active when they occu, Most patients are aware that the amount of phobic anxiety experienced varies not only with the difficulty of the phobic situation, but also with indices of stress, such as fatigue, physical health, and the number of problems in their lives. So relapses are more and it may be unrealistic to expect a ‘phobi less, a relapse, whether or th using the same methods, prevented if action is taken ea elapse wi ly if ‘regular exposure is planned, even though this may have to be contrived, for instance by becoming a blood donor or by choosing to stand in the longest instead of the shortest queue at the supermarket. -atment ends it helps specifying how to handle the strategies that were ful. As well as reminders about exposure and conclusions discussions about improvement mentioned above, it should inuoussoidun rey) pue *(gg6t S#922q PuE > BPP pue ‘samy “Kqunyy, *) apng) ssinpavosd 9An 20 wouDSeueW! A2KUE HuIppe Aq p: 3q ue MOUPEWY “ELL MCYS PuE ‘sMOUPEYY “UoIsUYOL 2e si904}9 942 I pur ‘som aunsodxa wey MoYs sHuIpuy urEUE uf, “ypseosa4 [eotUp atSuoax9 wos} p9AuDp ud%q aAey ps2r0x0 01 Kem. 4834 2\p anoge Souljppin@ payteisp as0ur pur “Asooyp Suruseay ut papunoss jp pur ajduis dpaneps st paseq axe Aoy yoy uodn jopou aq, ‘pouspyuod-y]9s paoueyuo pur uaupaoidu se ysns ‘siyouaq pozi[tiound 2x0 2Aey ojoypasd o1 saypeosd aansodxa Jo SsauDsN39459 91,1, safuoy 2481 Adesoyn eojutouos> Aaa st yo suiz0j s9430 2qry4 au ‘yp sey aunsodx2 yp aBeuew or soy Bunusea} 40 5 dup Burprone yo Kem © 2g osje Aen Apeynfos worp Susp, “(pg6t UO pue 2914) soouonbasuos jnjuuzey ws91-3uo] oxey dew pue “dn 2688 02 nogyp 34 ew Aoyp wey aBeveapestp ays ancy exOUdB Ut 0 yey) suodusds xp fosu09 0% sp jixue asuewuopod 30) auouneo vg “(6861 um pouiquo> st 342 Jo vor onposd 01 sivadde Sdrup jo ssep) 424uU ‘SaxoM0H “wa 04 jy 9q 01 puno} uooq ancy “2sop [jews ur Ajjensn “uone>tpou re pur 22440 ncue fog ‘parsjdiloa u2d9q axey sje aanexeduos so4 “Adesoypoy>ésd Jo io) sour pue desaypooeuseyd ‘soancusmye uiew Ona 278 2324), stsnuy jeuorssajoxd q se pasn 44 pue soy pea] fas auouneon 2an2sqyo mam stopsosip 219044 panewsny pposea> sey ape nexepay se yo [euonppe pur ‘sauzeip pue spsosss Surdaoy se yons sonbruypar Suoiuow ‘Suwupddey 564s sem ue> nok 210}9q una oF 4 up 2pp982 “2uin ype9 ap} Nos Moy Wop axtZm “2U0 Ka >t vsdons ut asusead 01 soy ‘no« aans ayeus pu “umoy “spun peg atios Suiney noyquss 2jH| Yoon 28 .ueD NOX DuOKIDAD o1 Uaddey 5924-128 JoquioND ane rou 108 Baga fp ‘0s op “ques 291 ya 08 seme a,uogy“ssun2wos auofe aoqsewiodns 9 -2 108 a1 230}2q op 01 pey | sonzeid gnu MOY Pe "10434 any 2p. oH mo LL SpE HO a PEN TOOT 5 1 a4 WHO 914, 7 . ary 104 220}0q “AppInb wioyD og. “yoy axe eK sun Fulop wos Aeme Aus ALO “T aundomq jo adwexa p 219¢4 Adpiogs sno.angaq aa sz128 Cognitive behaviour therapy ne for many years (Munby and Johnston 1980). Other findings t variations in the level of anxiety during ex fence to outcome, and th: nl prolonged’ ve than brief exposure (see, for example, Stern and Marks 1973), However, we not understand exactly how exposure works. When a patient improves, changes are observed in both behaviour and thinking. Exposure has cognitive as well as behavioural effects and, as has been described above, it frequently incorporates a variety of cog procedures. Distinctions between cognitive and behavioural proce have only recently been clarified. Some of the aspects of exposure t used to be described as ‘non-specific’, such as arriving at a realistic interpretation of the week’s events, or at accurate expectations for the future, or dealing with reservations about treatment, are now described in cognitive terms. Cognitive therapies are sufficiently well developed, and the theories upon which they are based are sufcienly well worked ou Nevertheless, the simplicity of the theory should not tempt therapi working mechanistically, or suggest to them that therapy will be easy. No two people are ever exactly the same, and working with phobic patients requires much creativity from the therapist. Because these treatments have 4 high chance of being successful, i is both rewarding and interesting, Recommended reading G. and Greenberg, R. (1985) Anxiety dion 78), Fear and courage. W. H. Peace from nervous suffering. Has ‘The systematic desensitization treatme Nervous and Mental Diseases 132, 189-203, 5 Obsessional disorders Paul M. Salkouskis and Joan Kirk Obsessive-compulsive disorders are not a new phenomenon; the notable fictional example is Lady Macbeth. John Bunyan and Cha amongst the many prominent people afflicted in the past by disorder. Many of the early descriptions emphasized ‘of obsessions, which provides an important clue to the nature of the disorder. The content of obsessions reflects the pri time, whether these are the work of the des and radian the risk of acquired (AIDS). Daring the nineteenth century, obsessions ceased to be regarded as the work of the devil and were seen as part of depression. Aft the century, obsessions began to be viewed as a syndrome in their own right. In his early writings, Freud proposed that obsessional sym represented regression to a pregenital anal-sadistic stage of development with conflicts between aggressiveness and submissiveness, dirt and cleanli ness, order and disorder. Subsequent psychodynamic formulations imply that obsessional patients have ‘weak ego boundaries’ and may therefore be ‘pre-psychotic’. Such views may result in inappropriate treatment (such as the prescription of neuroleptics) and opposition to behavioural treat- ‘ment on the grounds that this will undermine the patient's defences and precipitate psychosis. Prior to the 1960s the prognosis for obsessional disorders was poor, with recommended treatments being support, long-term hospitalization, and psychosurgery. Against this unpromising background, Meyer (1966) reported the successful behavioural treatment of two cases of chronic ob- sessional neurosis, followed by a series of successful case reports. Meyer's work heralded the appli to obses- 5» He took as imal models of compulsive behaviour (see, for exam: 7 which proposed that ritualistic behaviours were a form of learned avoidance. Behaviour therapy for phobias, based on similar models, had in the treatment of phobic avoi- dance through ization, but attempts to generalize these methods to obsessional rituals had been unsuccessful. Meyer argued that it wasplone uayo tuzeq 1uasoid 02 paudisap sinotaeyaq 2oueprone as0ur YN pue ,spalgo poreulweuoa, yo 28ur1 ssreai8 © Aq pozuomeseyp axe pur “eeigoyd ajquiass suorssasqo Tia) ‘uewy>ey) anorsrypq Suppso4> qIYX> A &q potuedwoose Ay apsosip 2aisjndwo>-oaissosqo qm siuaned AUeU! or oUWOD 9W24 anoraeyoq 2aisyndso> jo sodA “suno1aeyoq yo soda 2up Jo sajdurexo yam so4p9801 Jo} seaxe WigUOD UOUIWOD OU 24 ‘ey ous 2oyoUr pau2dU0D ayp 40 sas]nd asyped ayp *Ajsn0 suaydseyg Syuryp oy asoud agp Jo xopest yp sureydxa sing, enpuaipur ue ajqeuoyiosun a20u suosiad auoui af 1ueusndas sofleun pur ‘sosjndun ‘siysino swoyssosqo yo 142100) uswo> s194p Ut Jury ut posayyip YpIym sIyBMoYp Jo ureYD e ural “uo os pu jnau-uoisnnut-Surzyexinou-uorsnsiut Jo s2ouanbas nod sty, “senq 99} 02 JOps0 ut (sou jo JaquiNU_U9RD f2noys ay ancy Jsuany 2YeU OF aAey Pjnom 24 ‘PaxsNID0 spiemon 1s[o1A 9q pjnom souens e rey wysNOys ned v sem ajdurexo uy “siyinoys ]pt aq UED snoineyq BUrZ pryar anoreypg Cuerumjon "909 pure 13940) Surzyfezinou seadoya “Aiarxue paseaxout Aq patedusoade dre pur Crjunoau ase yous sosndut pue ‘soBeun ‘siynowp oarsnzzut dup 316 suoIssasqo ‘seq StI, UO \weypq SuZENMU se UROL) suoysjnduioa 2,09 pup 19K0 Jo soueDyIUS feUOHUN] axR soziseydD “(rgz61 wewy>ey) suorssasqo Jo Jopour yeorBojoysésd ayy, vsoutenb uoHDUNy queued seu KeUL Ing “Buypeadde Ajperoyzodns st su juew 129400 pue 11940 owt euauOUayd >ass|ndwo>-—oaIss2sqo Jo UOISIAIP ayduas sq “(0861 wosSpoyy pur weMNpey) (Sut 7ew018895q0) suorsjndwos avo yum sUoIssasqo pu (SuorPumuns fouorssasqQ) sj9q anisjnduso> stoiago nous saYBMoYA [eUOIss2sqo O1UI poptAlP luaoq Ajjesote8 aney euaiuoudyd 2x15jndusor-peuorssasqo ur puey 0 sem Buses 23H, ‘3p ule ays pyno> Suaysem opmprur DN “paseaiout 9 dm Antu “no pouse> potest aoe jpuoa3e 30 Kem pod “ats on SUES Jo aston aanDalgee ug (uD204> 40 Bunsen se yon} Duh oye uae ways Goon soo a (1) ano ob sun ayy pu dra 0 s3un39) Aq poueduonse 8 Suio8Bua Jo ues pum y : etueands see ens 36 ayy (estan ssid pun nou) set “ayfooys ausnatuy pue powemun ase wssr70, wajqoad ayp jo asmeu ayy yensn axe sanoreyaq Su D yn Butuuojod Oy132 Cognitive bebaviour therapy ‘Table 5.1 Principal content areas with examples of obsessions and ed compulsive behaviour SSS Example of obsession Example of compulsive behaviour ee ae eee Contamination (ideas of being harmed by contact with substances believed to be dangerous, e.g. dirt, germs, urine, fasces, blood, radi “The hai 'scomb had AIDS ings which others may touch Physical violence to self or others, by self or others Twill harm my baby ‘Won't be alone with the baby; seeks Death Images of loved ones dead [Imagines the same people alive | harm (not due to contamination or physi violence, eg. accident, xy have hit someone with my car Telephones hospitals, pol route driven; checks eat for marks ly unacceptable behaviour (eg. shouting, swearing, losing control of le sexual acts) ‘Avoids being alone with womer to keep mind off sexual though ligious helpvconfession; offers other things to God Onderiness (things being in the right place, actions done in the right way, accor 4 particular pattern or number) the right Repeats action times; repeats ‘good’ number of “Yels right’ meaningless phrases, images, tunes, words, strings of numbers) Hears (in head) tune of a TV sports Repeats action programme while reading. anages to read the same passage without the tune ‘occurring er ee ee 13 the patient ‘puts things right’ by washing ot cleaning, Thus, a patient who was worried about bringing germs into the house avoided buying things from particular shops; when she bought groceries, she washed ven times so that germs were 10 himself or others. Jing to harm because ficance of the compulsive identical. A similar di c¢ cleaning) and verification (like checking) The psychological model of obsessive avoidance of objects or obsessions; and ive behaviours and thought rituals ions which trigger obsessions; obsessions by keeping away from m. For example, a patient with violent impulses rade sure she was with only left the house if someone else locked the door and kept the key for ‘When, despi ccularly when they are reper icf oF the expectation that ‘worsened, As the obsessions pe neutralizes before the obsession occurs, and thereby prever ence. For example, a patient checked her door $0 or 60 times she used itso that the obsessional thought of occurred.foam ase] 94) 4940 auoned we 20} Buryse £4 ayy st auawissasse Dy smonzou uoyp JoMD14N0 dy anoge aus |}22 nod Pyne, “se Yons ‘sous sz saideys us pa pluo} [e9us8 2p) SK0 sou pjnoys pur a>edu Aue aavy 02 A} “seg pue shxSAo¥]eS) soH0m PUE st quounean ul panse aedinied 02 ‘yp ssonbuypar aantuion ied 344 quatussassy suaddey Ajjemoe rou op e2y Koy yoy sBuiyp a4 yr sox0ss1p susned rey ay “sansodxo sip dreuuaar 40 wdaaid yoiyy sinoreyaq Aue Y>0Iq o2 WYP FulesNODUD any wuouneay | ayy acy jem>e 10u op Jo presje st a4, ssaaoosip (ays 40) ay ‘sano1aeyag 2soy. Sd auoaaad snip a0uepioae pue suoisjndisor) “suo! siy (01 pasodxs Suiaq) Sunuoyuo> wos auoned 241 wudacud snoiacy -2q) Jo sodAa tpg tainsodxo ateutunar (119209 40 4940) aunber pue uipjgosd Aaewud oy Jo uo! 9s Se pauyap U99q ACY YPIYAL SUOISSISGO ‘Aueynonsed) payer app: yarun padojaap wojgoud unas ut 2Be8u9 o1 ss2u Suuinp 40 29su0 ep 30u9pH yuedo 40 “s98qo 9p 394124 UO sn20} A suousnean Joy Aayigenns uwpjgosd jeuo's yoge suoIstD9q, yus299p $401264 ‘9pdut0> auouissosse poqieiap ay suo preMuopysiens Ajaneps s} ‘onus ‘omt ayy Uo poseq “wouneas jex ue> quaned pue asidesoyp 942 24v 2ouepiose pul nou “SIyBnowp “S128 ‘uagaiaq ul] a4p 25u0 ‘9smeD0q yy aaideyp sty ur resp Spteaif ul poias0d st 1Uaulss9sse a4], "SuoISSas yomauoy pur Ades>ys lusamioq pue wiyiia yuoq (Zurzpesinau anoypu) aunsodxa or asuodsos 1 suapiosip ou01s95q0, Kdeingy mosaoyag sentry eetms is obtained, the focus moves to recent examples of the problem, ‘The therapist should look for clues about possible funct ¢ intrusive images. (1m es) and impulses (‘feeling an urge to do something you don’t to do’), and the patient should be questioned about assessment procedures is presented in Table 5.3, Detaled behavioural analysis Once the general picture has been obtained, the interview progresses to a detailed analysis, using specific examples which typily the problem can be structured in terms of response systems (pp. 8-9}, therapist enquires about cognitive, subjective/emotion and behavioural aspects of the problem. Direct question £0 go over the type of things which you do int formation is sought about the obsessional thou 8¢F3, avoidance and ritualizing in each response system, At each step, the accuracy of the assessor’s understanding is checked by the use of the behaviour of an obsessional washer, f /ou do when bothered by the obs ‘of things which you do because of your problem; you where dirty people may have been. If you can't avo thing you think ditty people may have touched, en You usually wash your hands a number ey feel can take berween half an hour and two hours. If you have touched Win your house before you washed, you have to scrub it until you are For example, wi 10 avoid going to places ces, then you avoid Table 5.3. Summary of assessment procedures 137 Table 5.3 (Co Content of obsessions (see Table 5 Which are intended to co king others to carry out tasks which w th the obs ial changes consequent on obsessions Background to the problem History Development of the problem and ps Benefits and costs of change behavioural by-productsin poy A194 Buiag 24 $19 ‘somojeue 2s or sypads ‘osu jeuonow ay odor stuoied Aue ‘s9A2K0y paystiqeass aq_pjnoys sqo 24} JO soUDs3ND90 oy IM parEDosse sa#ucy> Poop suopon] jpuoous {Ajysiy 242 1eyp rusu90x%e uo spuadap ua} poiessiexs Tex2ua8 snp dso “sofeu © ut siadead Sunvadas yo Aayjeuonesst ayp szquBo221 © ajqe sem UCU v ‘adurexs 204 “4arXue Jo uoRDuRY e Se aBueyD ssoussappsUDS Jo sIUDU! tea pue aanaaiqns (zor °d) anoqe yun fun uo syznoys ‘aaoge oq) p se yesvesddeas 01 SuL4n Ajpesnueyy 20 sBunyp uN ‘uonse paeodss Apunnos 2ys yey sou UowWNOD S53] yon ‘sem ang ‘Bor21 94 1 posuateds> Apuanboxy pey ays 2uo se ayfnoyp yt poz ‘uw 94e3{ prom vee, aynoys 242 4 pEmOHOH oe siopiosip ouorss2sqc) or auaned yp Buryse £q pos 9K0 &q paunosqo 9q ued su aquory> sous up ays ays esiyfnoyp soypo due 198 Appreraquap 442 ypiys uoned ayy safeut 40 IYo UO SuOISeDD0 sUID21 IMO PU auaned ay. “passasse aq osye plnoys sje 2kom siyy ur siySnoys ay Yo 398 ED Yorn 2y “uaapyiyp 424 pareansiur pey oy s24pour e mnoge sade ue Suipeas dq yo 198 us9q pey siyznoys ays ‘Kep, nowy 24 Xq jw! NOA, “payse sem 1uoHed wou apnpsur ur> sieBy -siyBnoyr ay1 Jo audUOD se > a4 We possosse 2q ueD siygtowp [ouoIss9sqo 241 30} 5428311) aAx1>9/qng pomoljoy uayp renner asn{ syfnowp 9504) “payse st auoned ayp 404 “sured 9soy1 18 pausddey rey moge a: Apejnonaed i sdi 40 pawensip Hunwos9q) so10I0 siyginoyp jeuorssasqo Supusnadx> jo suis moys suoned Auepy pa|qnon 219m nox own ase] axp aquasap nos pjnor), ‘cassia axe siyinoys unas an0€ ouy poutaulUn auL0> sazmadid feat 30 "SoA yanoyy Sumdsdn oq, ‘se ypns suonsonb payse st auotied yp ossasse aq pjnoys pue onedsuésorpi 9q [Ja wa¥u09 ay, “suoIsNN ‘uzquo9 pus (asjndust 10 frou. soyoys) wex0f ay) Uo st s “sasqo Jo s2uauadx9 24n jenjead uaya sno} jedoud a4 fqns oy «gino Sunpiue possi anepy 20 39401 3 Adesoqy anosarqog aansuiory ser140 Cognitive bebaviour therapy whether mood changes precede or follow the obsessional thoughts and behaviours. Behaviours The assessment of behaviours is crucial. Any behaviours. whi trigger the obsessional thoughts, prev terminate them, or prevent reappraisal are exami Behaviours often serve as triggers, because the harm to oneself or others is considerable. A common example is driving a one patient had the thought that he had knocked someone over whenever he turned left, and would often turn round and drive back to make sure that no one was hurt. Turning left thus served as a trigger for the obsessional thought and the urge to check. Active and passive avoidance are both investigated by asking, ‘Are there any things you do to prevent the obsessions occurring?’ and, ‘Are there any things you don’t do because they might set the obsession off? ‘Overt rituals are readily elicited by asking ‘When you have one of these thoughts do you do things to put things right or stop things going “Do you ever feel that you should do things of this type, even if you seldom actually do?” Covert rituals (neutralizing) sometimes take the place of overt ritualizing at times when the patient is prevented from using overt behaviours. Patients should be routinely asked about these. ‘An additional neutralizing behaviour often prominent in obsessional pa- tients is the seeking of reassurance. This serves two functions: first, a checking function (‘Do my hands look clean to you?"); secondly, reassur- ‘nce allows the patient to spread responsibility to trusted individuals—if there truly were a problem, the other person would take action of otherwise comment. Reassurance thus terminates exposure to the upset- ting thought and affects the degree to which reappraisal can take place. Neutralizing behaviour (including reassurance) can be stored up and carried out some time after the occurrence of the initial obsessional thoughts. fs unable to ‘up’ the washing until the For example, when her hands for eight hours accidentally harmed some- spond she began to ask asked on a clear day) ‘no! responses and used them later when she was filed with obs about another issue For each behaviour, detailed information is sought abo it takes and its duration, frequency and consistency ( you always do ). Factors making behavi behavioural test includin the spoken rat come this overt rating of he igs would have provided feu jons may trigger obsessional thoughts and beha ‘example, a patient had the thought that he was contaminated a to wash whenever he detected feelings of sweatiness. Bo result from obsessional behaviour, as for example, when by excessive washing, or when severe and pe constipat from cbse the use of toilets. Some patients with health-related obsessions c areas by feeling them repeatedly and thereby make them swell up (p. 243) am pay 7 Other aspects of assessment The more general assessment of history follows the lines discussed carliee in the book (Chapter 2). The circumstances surrounding the onset of the problem are important. Onset in early adolescence may have tion and general ability to c ies in traction may have to be dealt with along with the obsessions if evident. Involvement of other in the patient's compulsive behaviour needs to be asses- ‘of the problem on work, sexual functioning, and home life the behavioural alue of the symptoms, and Patient on the relative costs and benefits of‘oy wow ay powsey 24 2569 uF Keme mos 200 PIOM 24 You ‘sHpoP Jo ‘Soxoq poje2s Ajsjase> yo [ys sem axed ayn sou0 wou Burdng éypareodas sy pur ‘boys pur ssqnop pyo Aeme mou or Jeuonippe jo s9quumu © paquosep Dy "2sn0y yo 98n8299, yrdesayp 24 uy “2429 4, (02 01 da spuey sty Stuysem sea 2q 2242 pov0d2s ‘ase Aue ut papuatuusodss st simp ‘oatsuanxa st adoos ayy 2204 40 ‘perap ur surzjgoid siays Suigunssp Ayroyyp aaey oy siuoned UL -Aaesso20U isla 2uoy © Zurfeu Ajuey pue 2WIOY UO anu surajqosd 24) Apuanbax axopy ‘20gjns Aeus 904s Jo sojos ayp ynor o1 uated aya TUIySE ajOaur st SUIS 20 uIp Aq uoneurTE oD jt *2jdurexd 2 Ayise upp a4p UF ano paLe> 9q AEUL saa JeANOIAEH|q IULL punipe joy v 2q Kew sBurpsosa1-o9pia ‘soumowos tpasn udyp st 3 98 paperq “Aarxue ssonpos ysidesoy oyp jo soursoad yp jeivadso ‘2fqussod 20u st sup saunouiog “urazasqo asidesoyp Im ano pose $94 SMP Ue sisa1 anomey>g_ "uoHeUNUEE ‘Sursn) deat jensnun ue ur dn sung poxord uous 20U pip quaned e “jdurexa soy SXdex9qp JOU 0 [PIAL UWD9$ Yor syerap a4wHO ABUL AD Aq paotiongur axe swojgord s1a41 yo suonduosop siuaned ‘sououinan0 alayp ausaaud sjenais padAaoasays asne2aq says Sumosda s1oya jo azescun sue ys Siuoned 2qU014> 2101 as0K sewuoyut Apejnonsed axe But oq ‘ponaljo> os[e 919m szyenNoU oF sain pue wo}Worstp/fiarxue JO no Asze9 01 pjjaduo> a>} 24 530 yp ‘sIySnoyp siy aqussap 02 payse usyp sem 3% “woo otp axpuey or poyse sem s129/qo popu: somsom pia quaned & ‘3jduexo 104 “4: ue ayeur 02 10u pur prose 30 s3u9 01 payse 21e stuaned -goid ay: yo spenop axp Aue a 4893 PINOIAEYIq © SUOISS2SGO out uf 182) eanonaogag, yp Jo AupquoIy> pur 419428 ay) uo (02) tuounean porluny-sumn © paisyo st iuaned ay) seDueisut 3 jon 40 3834 Aue ssoidxo Inoyjip ASOUr SAE BE st wHo]gosd ays 194 st padsa ‘nod Aq 2woy 3 auop st yom Adesoup yuEUodu semis 24 eel siapiosip Jou01ss25qQ) sou ay “awoy Ie s2H>eId OnE and aq o1 dary assy Ing “wo}gord jp 9 U! snoY 69] 324X 24 suoissas Adesoyp ang, “ews paziseyduua st yy Ades ue Jonu0s-yps yiog JO a>ueUOduN ay ssazIs pynoys duos 24 ur 25n9q [29 ypreunojun ISSUED yt pa!>UUOD 2g ays AYsMOYE NOK YI anppdue popiose pue ‘bun € 2e andy We o2 dn 20) spury snos Suysem pOuers Kdosaqy smosanqeq tl144 Cognitive behaviour therapy collected the rubbish. He agreed to a behaviour test, which involved across and touching with his hand a nearby patch of grass he knew had sprayed with weedkiller the previous year. His ratings of discomfort and his com ments are shown in Fig. 5.1. At the end of the behavioural test, he reported strong urge to wash. For a previously agreed period of 30 minutes he discussed with the therapist the thoughts he was experiencing and then demonstrated the way he washed his hands. This involved stripping to the waist and washing his hhands in a stereotyped fashion; if he was not satisfied, then he would have to times. The handwashing included his arms up to his elbows; sit would include virually his entire body. A single wash at 15 minutes, which was slightly quicker than normal. He usually took longer if he was in a hurry. The behavioural test thus quickly revealed a great deal of information which extended far beyond the Interviewing relatives When there is extensive involvement of the family in the patient's thoughts or rituals, it is important to involve chem in treatment. Usually the relative is interviewed in the presence of the patient. Considerabl sensitivity may be required because of the unusual nature of the be- hhaviours involved. For example, the parents of a 17-year-old patient reported that he gor his family ro sit on the kitchen table with theit legs up for 15 minutes at a time while he carried out cleaning and checking. Questionnaire measures Questionnaire measures of obsessional behaviour are principally used as a shorthand way of obtaining repeated measures during treatment. Most useful are the Maudsley Obsessive-Compulsive Inventory (Hodgson and Rachman 1977) and the Compulsive Activity Checklist (Freund, Stekete, and Foa 1987), both of which focus on rituals Self-monitoring Self-monitoring begins as carly as possible in assessment and treatment. This introduces regular homework, provides detailed information about the problem, and is a useful indicator of treatment progress. Patients can be asked to self-monitor a variety of variables, depending on their specific problems. Common measures include: Diaries of obsessional thoughts In its simplest form this isa frequency count. A golf counter (availabe from sports shops) isa useful adjuncts the Patient presses a button each time the thought oce records the totals at agreed inter spent on rituals) These are Diaries of compulsive behaviour (e. a stopwatch can be helpful if ‘often combined with thought recordin NAME DATE /2-2-e8 best describes how if 501s too low and 60 is too high, Do the ig the cross underneath the number which ive your rating by circling ices between numbers if ‘ating inthe situation itself. NOT later when you For each situation listed, ‘YoU Want, such as “5S think back, {feel at thar time. Use spa Obsessional disorders 145 3 ris! iy Ni ay aft de fue x ae a 8 ui q # i g 3 3: P 27 18 3 & E 5 By z z eel the most ncampontable Thave ever felt allunsampertasle e nay J[#ildasd = £4 TH lth $4 aa +y PEE RERERE ft dette 22 acl ass 5 asl a faye FERRE | | {]5]8]2] 2/2) ef. © including discomfort ratings Fig. 5.1. Record sheet from a behaviour test,su 01 Keo PIMP, P snyBao pe Aouy iq“ ROA Tey ‘nok op >qiep ous au09M0S NOE AU, uajors inoge rsdn 39 joe nok apo Aa>4 216 no! “aydseyq dq 28dn 298 0 AIpyyy 210W a2e NOK sj 1 wou 40} 2]dood 24p 23 ised © anoge s9kdA sou! 138 oye ajdood ay) suysnoyy Tnoge s9quiu2s oF Sun welodun G2 e st 294, “ssouuaiy say) Su Uy se wyp 01 suon>e24 pur -tundx ayginoyp yo sada 2yp jo sofdusexa 243 jo auos ySnostp so08 aside sey aydoad “ua4jo Sunzsdn Ajeradso a3e yptyn siysnoyp Jo Puy Dap ssnaep 0} 3]toypp 4394 9q wea 2noyyp pue N04 30) Bumnpsdn 4194 axe sxginoy in sem 24s aeyp ples 24s yBinow 108 Ais Kina SE ays MDIALIUL as Sem wewiow snoypisd-uow Sunos e *2jdWsexd 204 ‘snyBnoup 2941 30 sty an0qe sgye1 01 oueronjas sauaned 942 404 auno2s" Y>Iym SUOSEDS 204 20 “AINDYHEP Jo seaxe aqqiss0d anoge sonp 20) ape 2q plnoys asidesoys ayy “sidesoKR ayp jo ued ay uo Aredia pur UDs pulewop SON|NoYHIP 25214, ssnynoyp Jo woned pareisosse Juonied 942 ae4p a4isu31x9 08 2110994, idio> “stuajgoud a1u0y> Yara Aysnomaad aup Jo azeme s28u0] ou avi] Aru S0UepIOAE pue snoIAEYD Kapmosyy, ant siapiostp [pu01ss25q0) ussnied ayads 5, Surpsos9y “7101 a4 jeuo1ssasqo jo 1 upuHss9sse UF SIMOY;LCL pom ype> aypFn0q,148 Cognitive behaviour therapy Th, ‘One of the most important features of these kind of thoughts is how ‘upset they make the person having them. It might seem odd, but very iehts happen because you are trying hard right now NOT to think about ag) ‘away from them bec them?” “That's just what Ido. 1 patient's worries abo appear to have some patient's own di the assessment will have to be spread over two or even in dorder to complete it thoroughly. Treatment of obsessions with overt compulsive behaviour Exposure and response prevention ‘The principles of treatment are derived from the psychological model lined carlier. The procedures are: deliberate exposure to all previously avoided situations; (2) direct exposure to feared stimal this chapter aims at the highest possible level of ing of any kind taking place. Otherwise, neut- ing exposure without full confront 's fears. Therapy is collaborative with the target b ts to take responsibility for planning and carrying out th ‘treatment as quickly as possible as treatment proceeds. The therapy are achieved more quickly and generalize more y for implementation and planning of h Presenting the rationale ing of treatment the prel ns makes it easier patient with fears al comb out of a lavatory. Ex; anxiety ‘without switchi ferwhelming when exposure is carried by the therapist. Bland reassurance worry’) ean be unhel the patient. Instead, the therapis anxiety will not decline nt could be que longest period for which the compulsive behaviour was resisted, and how certain it was that the anxiety would not have declined. Asking about possible ways of discovering whether the worries are true or not can be used to lead into a behavioural experiment. Th what happens (both in terms ies about the feared consequences) ent is able to resist neutralizing for a preset period, usually two hours. This is then used as the basis for further sessions of exposure with response prevention. Formulation of treatment the patient ‘The treatment plan is negotiated with the patient by agreeing short-, advance, and For the -ferm target was hands afterwards weeks was to be able to handle packets of weed couch objects around « etm target for the frst week was to remove the newspaper from the house fl out handwashing for ai is designed to investigate it is emphasized man with obs to put weedkipe suorssos ye uj asides ufisse jomauoy ano Surdaze> auaned 1un pauojosd aq pinoys uorssas ays Syead e ed atp uDy UOIsss e Ystuy or 21qEAIS9pun I woIssos (01 a]qe 3q 02 A9pI0 uy afles siyp we sanoy sDIp idesaya 242 ang ‘sanoy Jey © PUE BuO Or 240 29° 98 aansodxa oma uj "safeas Ajied ayp Suunp pider uayo \ydnouyp worssasogg "2am Yea sown 2ostp 30 Oma Uads st waTEd yp Jt 1njdypq 2q Kou a1 auouRVIN wonedino Jo S220 OM > uotueaaid asuodso4 pup aunsodx2 jana} yy som jpouad poumussiep-aad v 404 asnoy 24) 2ae>] oq U>YP Sgjo payouuns st woat ayp ayes Suyprea asidesoy axp anoupuo) awsES 94D ‘op of pauaut st waned aq] “BuNp>y> noyIN woos ap BuIAeD] PUE YO a1 Bumypiums uayp “QAYa v A6) UO UOT ue BuNINd japour dew rsides>qp 94 ‘ajduiexo 404 -soapsulayp ausned ayp Jo suonse aif uo paneyd st siseydua ayou ang Sues ayp st Aorens yexousd ay Spay oy swuoned Uy -anorneyog 3h jpouinas0 youyie ysea oF aun ayp Jo Ae>9p ay pUE uor Sip 0} umeip uonuane 424 pue pastesd Ayporeodss sem waned 243 anoyoo.yy. 1a ye sea 2 2830 PUE HO} WO>sIP Jo 3 pur sino 32. us pazeauss uoqg waned Du ‘puEY SY PP PUT 22") PUE spuEY LAOS Bie] e paseaus asidesoyn oy) “isu “Pury 294 Jo PEG ‘or noned ayp Sunjse Aq aansodxo paonponiu sidessip ay ‘5yuaHourze9 2q pjNo> {pm sionpoad uooaypeq Aq voneuruewe> poseay oy wwred e jo 2369 ay U ‘aoueansseas Jo wo} sey auownean 20u0 ano pape) ‘yim pur suoissos auounean Suunp amsodxe Aq potuedoare st suauqv94) ui uo Kine Suijapour *AIpu03 ye Fuyfoo} inoypm Soop Susop ‘sivas nso spuey Susuuns “3'2) ensnun uayo axe asaqp Se Ayjeads> “uonuaaaid asuodsar pu aunsodx> Suunp pornbss az sinoiaeyaq yy Sunensuowisp yo kvm 3s2109)> yamod © se 94:98 ED a! a5meD9q partes S34 uo 29U9p149 ypueasoa 3ylyay 01 payse st waned ay uey azoue ynusns poses} ay) 01 pasodxo fesoyp 242 3! paseasour st aouerjduio> tos soop awaned 24} 230)99, ser porinbor agi ino Sudiae> asidesaip yp sosjoaur sw, 5um7/oPOW, (uyyppow) auoned axp 01 anovaey aq pasinbas 2p 0 jouap © Aq paonposiur 1594 youuie> auoned 942 aeyp aUese2[dumn os se pasuauiedxo 1 Adesoy ep) Ist stopsosip oU0Iss25q0) ‘jeuones aunsodx aqp Jo paputt: auoned oy, -s01e] 2221109 01 In>y; 9q pinoys styp ae yproadde payusiz0 yo Surpueassapun past Aaqp Jt ss suadxo ew auoned ay asneroq Moy 38ers su Puy aunsodx2 ano pay0m 194 you aAEY am Y>IYIE UOIS swodse ausuayip snl aue da awo> ypiya stwojgoad ayy Yayo “saNIn} UL Aste Aoyp uayss stuajqoad aejuns Yara som9q Yeap uL> am dey os pauaddey yey anoge saIoU payrElep s1M NOK jt seueus 01 {ge OU aye NOX JL Ang “a1He 2m SoMa a s9psE4 anof An no aeip wueuodust $3] "no sbaye at Aem ayn pur woigord ayp anoge 210m ws: Wau £1989 asneroq ‘9UY SeULL, “upp aeyr sureydxo 1 40) pasedaid 9q ues152 Cognitive behaviour therapy homework the patient rates discomfort and urges to improves compliance and helps identify difficulties which arise. Ratings lustrating, the session session. , self-directed response prevention for any avoidance or ncutralizing is crucial. Such behaviours may not be immediately obvious to cither therapist or patient. Useful questions for patients to ask them- selves are: ‘If I didn’t have an obsessional problem, would | be doing this?" (identifies neutralizing and avoidance), ‘What extra things would | be doing if I didn't have the problem?" (identifies avoidance). As treat- iment progresses, the intensity of self-directed exposure and response prevention is built up as rapidly as possible. In many patients (especially checkers) anxiety about being respons for harm to self or others is prominent. In order to reduce respons should anything go wrong, the patient may seek frequent reassu from the therapist or carry out homework literally as directed. This is a form of avoidance and indicates the need for direct exposure to respon- sibility as part of the treatment programme, after a discussion about the role of worries about respor “This involves the patient being given homework in which the entire assignment is self-initiated and the details not discussed with the therapist. The therapist says: ‘I would like you to plan this week's homework yourself; it should be the normal type of assignment, but I don’t want you to tell me any details of what you do. I ‘want you to record, as usual, how uncomfortable you get. It is important that you set things up so that you become uncomfortable but don't check, avoid, or neutralize. Try not to tell or even hint to anyone what you have done. Next session we will discuss how you felt but you and only you will be responsible for the assignment. So, without telling me any details of what you will lave unchecked, can you outline what the homework is for this week?” Reassurance Reassurance seeking is a prominent feature of obsess Iways involve the fear of respon: 1 oF omitted (Salkovskis 1985). pass on the road, ght that not picking up pieces of glass badly cut. Asking for reassu attempt to ensure that harm has not been caused to self or others; it also has the effect of sharing or passing on responsibility. Its tempting for the therapist to reduce the patient's anxiety by providing such assurance, but the enterprise is doomed to failure: proving that harm has not and’ wil ‘not be caused is an impossibility. For example, a patient told her therapist Obsessional disorders 153 tha she ha nor checked er rubbish bint see if there were any ales and asked whether the therapist thought that was alight the therapist provided suff ce regardless of whether an answer was given; the dherapst had the opportunity to suggest corrective action and the patient could gauge the therapist's eacion. The repent, Persistent, and stereotyped way in which reassurance Fesembles other forme of i atonal for ths problem, whether the relict obtained from and compare reassurance w therapy ian blocks other usefu i ion “Theray ng over your worries about cant you wanting me t0 respond 50,1 just need to know th finding that out, sly shoal it wil help the pro now. How much Id Ihave pickin Pe “The rest of this month?” Th “Yes, ve gor for the rest of the for tha Pe It doesn’t work like that. another two hours now. hI should tell you The therapist can go on to discuss how ress from confronting the anxiety about being rap that selimposed response prevention free brook 1987). ement of other family members is help. tending esr prevention an in suming he pati sD when the patient is having dffculty Sometimes i asl for the therapist ve df f t mice prevents the patient le for harm, and hence lospital instruct 81), If the pau practise helpful to € resp play further diffiuoywoosig (8 sey FR s1aplosip [DU018595q0) 24geuoywooun ‘sou 240 193) ORL OL as 09 ss uojwoasig (sresvehssajea 119} 1999 ane | 6 OF O81 OCI 06-09 SE OF SH OF SE OF ST OT St OL ¢ uojwo>siq Kdesaqy anosaryaq aannuior) rtrapy patient walk away from ly used as a back-up if it the onus for response prevention remains Difficulties encountered in the course of treatment In the maj of cases, exposure and response prevention are successful. three major patterns of difficulty may arise during homework (anxiety reduction) may not occur during sessions; fall compliance, little progress may occur between sessions; severe concur: ‘may demand fre are two ways of considering your problems with germs, and need to be of 3 you have an obsessional problet to protect being kept going . How could we decide hese two possibilities?” The discussion of the e: 's beliefs (again, based on quest arguments) proceeds on that basis, using other cog appropri Lack of progress from session to session, despite repeated expos ‘more common, even when there has been a decline in discomfort during the course of exposure. The decline in exposure can be the result of two processes: leading to a decrease in the power of the stimu patients can distract themselves from the an ‘or decrease their anxiety by neutralizing, For exat ‘exposed to being in the same room as a kri kknife would reduce ratings but would n« in anxiety between sessions. Any neutralizing which the ‘out during the session (including reassurance seeking) can h Reassurance secking Transfer of responsibility Exposure and response Prevention too) «circumscribed Avoidance of situations which trigger thoughts Reasons not clear