CHAPTER 54

Cognitive Therapy
Stirling Moorey

WHAT IS COGNITIVE THERAPY? and how it is maintained is essential in constructing a treatment pro-
gram, which will help the person correct their distorted thinking and
The term cognitive-behavior therapy (CBT) refers to a broad range of
test the impact of their behavioral reactions. In depression Beck’s model
psychological approaches that have in common an interest in the role of
describes how negative thoughts about the self, the world, and the future
thoughts and behaviors in creating and maintaining psychological dis-
trap the depressed person in a helpless and hopeless view of the world,
tress. Problem solving therapies, stress management and coping skills
and result in reduced activity and social withdrawal that further deepen
training are all examples of cognitive behavior therapies which have
the depression. One of the important assumptions here is that although
been applied in cancer.– This chapter will describe a therapy for help-
the thoughts may be distorted, the emotional and behavioral responses
ing cancer patients cope which is based on Beck’s cognitive therapy.,
are perfectly natural given the interpretation of the situation: we are all
Cognitive therapy was originally developed as a treatment for depres-
doing our best within our view of reality. Therapy is about helping peo-
sion, but has since been extended to the anxiety disorders, eating dis-
ple to question whether their current view is accurate or helpful and to
orders, chronic fatigue, and psychosis.– One of cognitive therapy’s
explore alternatives.
strengths is its insistence on rigorous scientific investigation of its theory
In distinction from some of the other cognitive behavior therapies
and treatment; this has contributed to a large body of outcome research
mentioned already, Beck’s cognitive therapy pays attention to cognitive
supporting its efficacy.
factors that might predispose to mental distress. The underlying beliefs
Cognitive therapy is a structured, problem-focused treatment that
or rules we have about our self, other people, and the world in general
places cognition, or consciously accessible thoughts and beliefs, at its
make us vulnerable or protect us from emotional disorder. So, if we have
centre. A cognitive formulation of a problem will stress how thoughts,
strong beliefs that to be happy we have to be successful at everything
behaviors, emotions, and physical sensations interact together to main-
we do, we may feel fine until we fail at something, but once this hap-
tain the problem. For instance, in panic disorder the cognitive model
pens we may conclude that we are inadequate and become depressed.
asserts that normal autonomic arousal (often as a result of stress or
The cognitive model therefore allows therapists to understand both the
anxiety) is catastrophically misinterpreted as a sign of impending disas-
maintenance and predisposition to a particular disorder, and it allows
ter. There is a clear link between the sensation that is perceived as threat-
flexibility in deciding how “deep” you dig. For many problems the main-
ening and the catastrophic cognition—so a feeling of breathlessness may
tenance conceptualization and treatment is sufficient to effect significant
lead to a belief that one is about to suffocate, or tightness in the chest to
and lasting change, but at other times a developmental model focusing
a belief that a heart attack is imminent. These thoughts can then create
on core beliefs is required.
a vicious cycle of increasing fear, physical reactions, and negative cogni-
There are two ways in which cognitive therapy can make a contribu-
tions. The panic patient’s behavior is again in keeping with the meaning
tion to coping with cancer. Firstly, many of the psychological problems
ascribed to the situation; so a person who fears they cannot breathe may
experienced by people with cancer share similarities with problems for
open windows to get more air, or if they think they are having a heart
which we have effective cognitive-behavioral treatments. In cancer the
attack may sit down to rest. Another common behavioral reaction is to
prevalence of depression varies from % to % across studies. Nearly
avoid situations where the panic has occurred. These reactions are called
half of all cancer patients report some anxiety and this may be clinically
“safety seeking behaviours” and confirm the negative belief, because
significant in %., In addition to treatments for these syndromes of
they prevent the person from being exposed to the feared consequence
depression, generalized anxiety, panic, and health anxiety, cognitive
and so learning that their fear is misplaced. Similar maintenance mod-
therapy also has change methods for common cancer symptoms like
els have been applied to other anxiety disorders. They share a number
fatigue and insomnia., Second, the general theory and therapeutic
of features: a personal meaning of perceived threat, selective atten-
approach of cognitive therapy with its emphasis on normalizing stress
tion to the threatening stimulus, and safety behaviors that paradoxically
reactions, collaboration, and problem solving may be particularly help-
reinforce the anxiety. Although cognitive therapy is sometimes seen as
ful in understanding and treating adjustment reactions.
a cookbook therapy, the specific formulation of a presenting problem

“I can exert control” Fighting spirit

Challenge

Diagnosis of life
threatening illness Threat “I don’t know if I can Anxious
do anything about this” preoccupation

Harm, loss, Helplessness/

“No one can exert control”
or defeat hopelessness

“It’s in the hands of Fatalism

God or the doctors’’

Fig. 54–1. The appraisal of the diagnosis of life-threatening illness.

402
 COGNITIVE THERAPY 403

THE COGNITIVE MODEL OF ADJUSTMENT Experiences of illness, Early experiences and

TO LIFE-THREATENING ILLNESS bereavement, and key relationships
adversity
The personal meaning of illness and death. As we have seen, the
fundamental principle of any cognitive model is that our interpretation
of events determines how we feel and how we act. Lazarus and Folkman’s
model of coping is particularly relevant to the case of life-threatening
illness.– Many people, after an initial period of distress and confusion,
perceive cancer as a challenge, and are able to call upon a range of cop-
ing strategies. Others focus on the uncertainty inherent in the diagnosis
of a life-threatening illness and understandably feel anxious, while other
“Survival” schema “Self” schema
people may see the diagnosis in terms of loss of a hoped-for future. This Beliefs about illness, death, View of the self, the world,
broad appraisal of the diagnosis as a challenge, threat, or loss then leads and perceived control and other people
to a secondary appraisal of the resources available to the individual for
coping with the illness that is, what can be done about it? Fig. 54–2. Past experience and core beliefs.
If the diagnosis is seen as a challenge that can be met by the individual
with the help of health professionals and the prognosis is seen as hopeful,
a positive adjustment style that has been termed by some as a “fighting
Situation
spirit” develops. On the other hand, if the diagnosis is seen as a loss or
Terminal cancer of the lung with cerebral
defeat which no one has the power to affect and death is seen as inev- metastases and left sided weakness.
itable, a “helpless/hopeless” adjustment results. A person who focuses
on the uncertainty inherent in their situation and the unpredictability of
their future will become anxiously preoccupied with their disease and
how to deal with it. Two further patterns of interpretation and coping
may be found: fatalism and denial. People who respond to the question “My life is over
“what can be done about this?” by externalizing responsibility—giving I can’t do anything
it up to the doctors, fate, or God—will tend to have a stoic acceptance Why me?”
of their illness. For some people the threat may be so great that they Bad back
minimize or even deny its severity and so the response to the ques- Deterioration Angry
tions about how to cope and what the future holds become less salient. in ability to Depressed
Outright denial of the diagnosis of a life-threatening illness is relatively walk
rare these days, but the tendency to minimize the seriousness or the
impact of disease is quite common and many patients practice varying
Lie in bed
levels of avoidance. “Denial” is a complex psychosocial reaction which
is not always simply a defense mechanism; the effects of education and
knowledge about the disease, information received from health profes- Fig. 54–3. The cognitive model.
sionals, family influences, and adaptive decisions to be positive about
adversity all interact with minimization of threat to produce the overall
coping response. Fig. – shows these adjustment styles diagrammati-
cally. Studies have consistently found that patients with helpless/hope- Table 54–1. The interaction of negative thoughts and behaviors
less and anxious adjustment styles have greater emotional distress than
those who see their illness as a challenge., Unhelpful
A diagnosis of cancer not only challenges our hopes about our life Automatic thought behavior Consequence
and survival and our confidence in our ability to cope; but also may chal-
lenge our view of ourselves and our world. For instance, someone may “If I can’t do what Give up, Loss of pleasurable
be hopeful that they can be cured of their illness, but the side effects of I used to do, my ruminate activities, depression
treatment such as radical surgery may be so difficult for them to bear that life’s over.” about loss
they become depressed. Here again the cognitive model would state that it “I’m different.” Avoid people Reinforces feeling of being
is the personal meaning of symptoms, treatment, or side effects that deter- an outsider
mines the emotional reaction. And the reverberations of a serious illness “I’m no longer Neglect Confirms negative
do not stop with its physical effects. The reactions of others and the gen- attractive.” appearance self-image
eral social perception of the disease will also influence the person’s coping
behavior. A heavy smoker who develops lung cancer may be highly criti-
cal of himself for contributing to the development of his illness, but this
may be compounded by a partner who feels let down and blames him for
thoughts may lead to unhelpful behavior that often has the consequence
getting ill, not to mention the social stigma that may also be involved.
of confirming the initial negative appraisal (Table –). Effective
One important difference between cognitive therapy with people who
therapy breaks these vicious circles.
have serious physical illness and those with psychiatric disorders is the
reality of the dangers and disturbances they face. As we will see when we
The influence of underlying beliefs on adjustment. We often live
discuss therapeutic interventions, it is important to distinguish between
our lives with an implicit assumption that we are going to live forever
appraisals that are unrealistic (e.g., a woman with early stage primary
and that bad things will somehow not happen to us. Cancer challenges
breast cancer who becomes depressed because she believes she will inevita-
these implicit beliefs about invulnerability and immortality. It may also
bly die within a short time) and realistic ones (such as a woman with met-
challenge our beliefs that we are competent and able to cope, and that
astatic breast cancer who is sad about not living to see her children grow
the world is a predictable, fair, and controllable place. How someone
up). Where thinking is clearly unrealistic standard methods of challenging
appraises the impact of cancer will depend on their underlying system
negative thoughts can be used, but where thoughts are more realistic the
of beliefs about themselves, other people, and the world around them,
focus moves more to problem solving and coping strategies (Fig –).
as well as more specific beliefs about illness and its treatment. The cog-
When coping fails the person with cancer can become trapped in
nitive model proposes that early experiences shape our core beliefs. If
vicious circles of thoughts, feelings, and behaviors (Fig. –). Unhelpful
those core beliefs are overly positive and rigid they may be shattered by
404 INTERVENTIONS
the trauma of a diagnosis of a terminal illness. Beliefs that the world is
just and predictable make it hard for some people to accommodate their
beliefs in the face of trauma. For some people a life-threatening illness
may confirm their secret fears and so activate core beliefs like “I am vul-
nerable,” “The world is dangerous, unpredictable, hostile,” “Others are
abusive, unavailable.” The individual may have more conditional beliefs
and coping strategies to mitigate these unconditional negative beliefs.
With a diagnosis of a life-threatening illness the person will often try
unsuccessfully to use the same strategies they have used in the past. For
instance, someone who has had significant separations or abuse during
their childhood may have core beliefs that the world is a dangerous and
unpredictable place where they are helpless and vulnerable, and where
people let you down. To cope with this they may have developed a belief
like “If I can control my life I will be safe,” and used compensatory strat-
egies of perfectionism and self-reliance (Fig. –). With a diagnosis of
cancer their fears that the world is dangerous and unpredictable may
be confirmed as will their sense of vulnerability, but there may be more
limited scope to exert their usually controlling strategies; moreover, they
will be forced to become dependent on others for their treatment and
care. So their negative beliefs may be activated along with feelings of
anxiety and depression.
Adjustment and coping across the course of chronic illness. Most
people will have their positive beliefs challenged by the diagnosis
of a life-threatening illness and will feel vulnerable, unable to cope,
and hopeless about the future temporarily, but then find strength and
resources to deal with the stress. It may be that most people adapt by
integrating the news of their diagnosis into their preexisting belief sys-
tem and there is some evidence that cancer patients may actually be
more optimistic than healthy controls. This adaptation is not static
but will vary across the course of the disease. There is much more
uncertainty over the course of the disease and prognosis and there may
be periods of remission before a relapse. After the initial diagnosis and
treatment of cancer there may be a period of hope that the disease has
been cured which is then dashed if there is a recurrence.
Physical abuse, separation
I am helpless and vulnerable. People let you down.
The world is dangerous and unpredictable.
If I can control my life I will be safe.
Perfectionism, overcontrol
Diagnosis of life threatening illness
No longer able to exert control
Cognition Affect
“I’m out of control. I can’t cope.”
Anxiety
“What will go wrong next?”
“I must beat this at all costs.”
Behavior Physiology
Desperately try to regain control Tension
Obsessively read about the illness Palpitations
Fig. 54–4. Longitudinal or developmental model.
Basic principles of cognitive therapy in serious ill-
ness. Cognitive therapy encourages the patient to become their own
therapist by learning to identify and modify their unhelpful thoughts,
beliefs, and behavior. Therapist and patient work collaboratively to
agree a set of target problems and develop a shared conceptualiza-
tion of how the problems are being perpetuated. Patients are helped
to see their negative beliefs as hypotheses about themselves, their ill-
ness, and the world, which are then tested through the use of cogni-
tive and behavioral techniques. This reality testing approach has been
termed “collaborative empiricism.” Sessions usually follow an agenda
set by patient and therapist and will include the setting and review of
homework assignments to test beliefs and practice new ways of coping
(Textbox –).
Modifications of cognitive therapy in cancer. Because cognitive
therapy for life-threatening illness often addresses emotional problems
such as anxiety and depression it is very similar to standard cognitive
therapy for these conditions.,, However, a number of modifications to
therapy may be required to accommodate the effects of physical illness
and the process of adjustment that many patients will be going through
(Textbox –).
As with CBT for older people therapy may need to be delivered in
healthcare settings or patients’ homes rather than in the traditional
outpatient clinic. It is often difficult to pursue a typical course of
therapy with patients with active physical illness. Fluctuations in
the disease, demands of physical treatment may disrupt the flow
of weekly therapy. This means that therapy in this setting is often
shorter and has more circumscribed goals. The aim with ill patients
is to achieve the maximum change with minimum intervention and
wherever possible the therapist works to regain and enhance previ-
ous coping strategies.
While cognitive therapy always pays attention to emotional and
interpersonal issues, these considerations are particularly important
with this patient group. Many may be going through an adjustment
process and the therapist needs to achieve a balance between encourag-
ing and supporting adjustment and promoting effective problem solv-
ing. Identifying and managing maladaptive interactions with carers and
fostering adaptive social support is a significant factor in working with
these patients.
Textbox 54–1. Characteristics of cognitive therapy in cancer
• Based on a cognitive model of adjustment
• Structured
• Short-term (– sessions)
• Focused and problem-oriented
• Educational
• Collaborative
• Makes use of homework assignments
• Uses a variety of treatment techniques including nondirective
methods, behavioral techniques, cognitive techniques, and
interpersonal techniques.
Textbox 54–2. Modifications of cognitive therapy in cancer
• Sessions less formal, more flexible, and more supportive
• Sessions may be briefer and adjusted to patient’s physical status
• Therapy may need to be delivered in healthcare settings or
patients’ homes
• Techniques are adjusted to patients’ physical status
• Therapy includes family and health professionals
• Goals of therapy are more circumscribed
• Primary goal of therapy is to promote maximum change with
minimum intervention

Phase 1: Engagement and conceptualization. In the first session
the therapist will need to make a judgment about the length and intensity
of therapy and then establish a contract with the patient. In some cases
time may be limited (terminal illness, severe fatigue, time restraints of a
liaison consultation) and the aims of therapy will be consequently less
ambitious. In other cases (early stage disease, less debility) there may be
more time available which will allow a full course of therapy and per-
haps even time to work on underlying beliefs that have made the person
vulnerable. In the early sessions the therapist will also need to establish
rapport, engage and “socialise” the patient into the therapy, and develop
a shared conceptualization. These tasks are common to CBT in any set-
ting. With patients facing death there may also be a need to facilitate the
adjustment process. This can often be done simply by letting the patient
tell their story, including what symptoms first led them to seek help,
how the diagnosis was made, how treatment has progressed and so on.
The therapist may be the first person to listen in this way. Developing a
“compassionate case conceptualisation” helps this process and also helps
to make sense of the confusing set of feelings experienced by the patient.
At this stage a simple conceptualization using the “five areas model” is
very useful (Fig. –). Goals are established that are appropriate for
the stage and severity of disease. Some basic self monitoring of thoughts
and/or behavior can be set at this stage to clarify the conceptualization
and start to demonstrate the model to the patient.
Phase 2: Cognitive and behavioral interventions. These should
arise naturally from the conceptualization. In Fig. – we can see how
a woman with terminal cancer has become locked into a vicious circle of
negative thinking and withdrawal. Her ruminations about her disease and
death have led her to feel depressed, hopeless, and angry. She has physical
symptoms of weakness and pain and these together with the hopelessness
have led her to take to her bed. Unfortunately the consequence of this is
that she feels more isolated, and becomes more physically debilitated. The
five areas model or “hot cross bun” is an effective nonstigmatizing way of
showing the patient how these different systems interact. In the alternative
ABC model, which has a linear form situation → thoughts → feelings →
there is a risk that people with physical illness will feel that the seriousness
of the situation is not being adequately recognized. The five areas model
does not assume that any of the systems is primary. So in cancer it is possi-
ble to start with the physical state (e.g., fatigue or pain) as a given and then
examine the patient’s thoughts and behaviors in response to the physical
reality of the illness. Once this maintenance conceptualization is agreed,
the therapist now has a number of options:
. She could use emotional techniques to facilitate anticipatory
grieving.
. She could use cognitive techniques to test the patient’s belief that her
life is over and she can’t do anything.
. She could set up a behavioral experiment to test this negative belief.
This might involve the patient spending some time out of bed and
engaging in some small tasks which used to give her a sense of
achievement. She can then monitor her mood, fatigue, and pain.
This will usually demonstrate that these are not made worse by
activity but may actually improve and this may start to introduce a
more positive cycle.
COGNITIVE TECHNIQUES
The threat of cancer to survival generates many realistic and sometimes
catastrophic negative thoughts (Textbox –). The cognitive techniques
used will differ depending on the stage of the disease and prognosis.
Patients with early stage disease and a good chance of cure or remission
can be helped to see that their hopeless thoughts are unrealistic through
looking at the evidence for and against their beliefs that the future is hope-
less. Patients with a poor prognosis may be helped more by techniques
that address the usefulness rather than the rationality of their thinking.
A cost benefit analysis of realistic negative thoughts often reveals them to
be ruminative in nature rather than helpful in solving problems or mov-
ing anticipatory grieving forward. If the patient accepts that recurrent
thoughts about death are not productive it may be possible to schedule
COGNITIVE THERAPY 405
Textbox 54–3. Questioning automatic thoughts
• What is the evidence?
• Is there an alternative way of looking at the situation?
• What is the worst that could happen?
• What is the effect of thinking this way?
• What would I say to a friend if I were in this situation?
some worry time during the day when they can allow themselves to
ruminate, but at other times to schedule more constructive activities that
give them a sense of control over their life. Sometimes these apparently
realistic thoughts may overlie other fears for example, fears about what
will happen to your family when you die. Uncovering these fears may
allow the process of anticipatory grieving to take place or allow more
effective problem solving (see under behavioral techniques).
Many negative thoughts are centered not on death but on the impli-
cations of the disease, regarding a person’s self-esteem or competence.
People may feel stigmatized by their illness and so “buy into” perceived
social rejection. They may sometimes feel guilty and blame themselves
for developing their condition. Often their sense of powerlessness comes
from all or nothing thinking such as “If I can’t be the person I used to be,
I’m nothing.” This leads them to selectively attend to the areas of their life
they have lost rather than the areas where they still have some control.
These themes of guilt and shame, anger toward self or others, and per-
ceived helplessness are often distorted cognitions. Cognitive techniques
can be used to test the validity and functionality of these thoughts.
BEHAVIORAL TECHNIQUES
In cognitive therapy, behavioral techniques usually arise out of a cog-
nitive conceptualization and intervention. Negative beliefs are turned
into hypotheses. For instance the belief that “If I can’t do what I used
to do my life’s over” (Table –) can be rephrased as a prediction “If
I engage in activities I won’t get any pleasure.” The therapist asks the
patient to rate the likelihood that she will get pleasure from doing some
small things over the next week. In the following session the results of
the behavioral experiment are reviewed. In most cases, the patient finds
that she got more pleasure than she predicted, and the vicious cycle of
inactivity begins to be broken. For helpless/hopeless patients simply
scheduling activities can be very helpful in overcoming inactivity and
demoralization. For more depressed or more physically ill patients, large
tasks will need to be broken down into small steps (graded task assign-
ment). Some ingenuity may be needed to find activities that are mean-
ingful to patients who are very disabled or bedridden. Family members
can sometimes be recruited to make suggestions based on their knowl-
edge of the patient. For anxious patients behavioral experiments can be
set up to test feared situations. Much of this behavioral work centers on
establishing a sense of control. It is helpful to work within an individ-
ual’s value and belief system to find empowering behavioral tasks. The
message to the patient is to focus on what you can control, not what you
can’t (“you can’t control your death, but you can control your life.”).
Problem solving is another very powerful behavioral technique and
has been applied as a therapy in its own right., When the appraisal of
the stress is accurate, rather than trying to change the thoughts about it,
finding effective ways of coping or removing obstacles may be the best
policy. For instance, in the case of a mother worrying about what will
happen to her family when she dies, the problem solving may take the
form of discussions with her partner about how to plan the future. The
patient can make her own wishes for the children’s future clear through
writing advice to the partner on how to handle situations he may not
have had so much experience in managing. Other examples of problem
solving would be preparing and rehearsing how to talk to oncologists
and be more involved in your treatment; preparing puzzles, music and
so on to take with you during chemotherapy; making a will; working
out and rehearsing a way to tell people you have cancer. More detailed
description of cognitive and behavioral techniques for cancer can be
found in Moorey and Greer and Sage.,
406 INTERVENTIONS
Phase 3: Consolidating coping and ending therapy. The length
and form of this phase will depend on the nature of the therapeutic con-
tract. In liaison settings time is often scarce. If the therapist can see the
patient for  or more sessions it may be possible to do some work on
underlying beliefs. This can be an opportunity for psychological growth:
the impact of the illness on the person’s life can be more fully assessed,
the limitations of their more rigid beliefs and coping strategies evalu-
ated, and alternative beliefs generated and tested. Briefer therapies will
be more concerned with enhancing coping in the here and now. At the
end of any course of cognitive therapy the therapist develops a “blue-
print” collaboratively with the patient. This contains a summary of what
the patient has learned in therapy, what strategies he or she needs to
continue using, what might be factors that could cause a set back and
how they can be managed.
EFFECT OF CBT ON QUALITY OF LIFE
In cancer cognitive-behavioral approaches have usually been delivered
in a group coping skills format, though some researchers have applied
a more formulation-based individual treatment as described in this
article., The usual outcome measures have been distress, anxiety, and
depression. When CBT has been compared with no treatment or treat-
ment as usual all trials have demonstrated the superiority of CBT.,–
These differences have been shown to persist for at least a year. The
majority of trials have demonstrated a superiority of CBT over treat-
ment as usual when all patients are entered into the trial, but the effect
size of this intervention is small compared to that with psychologically
distressed patients. A smaller number of trials have compared CBT with
other treatments, usually nondirective therapy. Some of these found
CBT to be more effective at the end of therapy while others found the
two therapies to be equally effective.,,,–
A meta-analysis by Osborn et al. concluded that CBT was effective
for depression (ES = .; % CI = .–.), anxiety (ES = .; %
CI = .–.), and quality of life (ES = .; % CI = .–.).
Quality of life was improved at short-term follow-up and (ES = ., %
CI = .–.) but the effect size reduced to . (% CI = .-.) at
long-term follow-up. Reviews have tended to support the idea that indi-
vidual interventions were more effective than group, and that therapy
is more effective when directed at patients with high levels of distress
rather than all patients. Recently Lepore and Coyne have questioned the
methodological rigor of both the original studies and reviews., There
is a challenge to carry out larger, more methodologically sound multi-
centre trials that have sufficient power to establish the efficacy of psy-
chological interventions.
Trials have mainly used patients with early stage disease but three tri-
als using a cognitive therapy approach have now been carried out with
patients with advanced disease. Edelman et al. used a group approach
and Savard et al. used individual cognitive therapy, both for women
with metastatic breast cancer., Cognitive therapy proved more effec-
tive than a control group. Moorey et al. taught cognitive and behavioral
techniques to palliative care nurses and demonstrated an effect on levels
of anxiety in people with terminal illness treated in their own homes.
CONCLUSIONS
Cognitive therapy is a treatment that has substantial evidence for its
effectiveness with a range of psychological problems. Because it is brief,
problem-focused, and collaborative it has the potential to be a useful tool
for liaison psychiatrists and psychologists, and in a “first aid” form may
even be useful to nonmental healthcare workers., There are encourag-
ing signs from randomized controlled trials that it can be effective in
the cancer setting both for early and advanced disease. Most work so
far has been done on quality of life and emotional distress but targeting
specific cancer-related symptoms such as fatigue, pain, or insomnia may
help to refine the treatment in the future., As with all psychological
therapies, the challenge is to identify what works for whom, and to find
ways to disseminate skills so that as many people as possible have access
to evidence-based therapy.
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