An Introduction to Cognitive Behaviour Therapy, 2 edition

15

Wider Applications of CBT

Introduction

Over the past 25 years, CBT has been applied to an ever-widening range of psychological problems beyond anxiety and depression. This chapter will briefly review the application of CBT to some of those other problems. Our intention is twofold:

 

  • to highlight salient aspects of the disorders to help you recognise them;
  • to outline what might be involved in the management of such problems so that you can decide whether to refer on or to take a client yourself. Remember that additional training and supervision may be required to manage these disorders.

At the end of each section, we will refer you to further reading.

We will review:

 

  • eating disorders
  • trauma
  • anger
  • psychosis
  • relationship difficulties
  • substance misuse.

Eating disorders

CBT has been the most exhaustively researched form of treatment for eating disorders, particularly bulimia nervosa. Over time, cognitive therapists have developed a trans-diagnostic understanding of the eating disorders (Waller, 1993; Fairburn, Cooper & Shafran, 2003). Nonetheless, there remain distinct differences in the presentations of the separate conditions, differences that must be taken into account in their understanding and treatment.

 

  • Anorexia nervosa (AN): the DSM-IV (APA, 2000) criteria for anorexia include low weight (with cessation of menstruation in women), an over-concern with weight and shape, and a disturbance in body image. There is a sub-classification of restricting AN (pure restriction of caloric intake) and of binging/purging AN (episodes of over-eating with extreme compensation for this). Excessive exercise is not uncommon in AN.
  • Bulimia nervosa (BN): DSM-IV criteria include an over-concern with weight and shape, but an essential criterion is recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time, experienced as being uncontrollable). In BN, there is significant compensation for binge eating – for example, self-induced vomiting, purging, fasting or excessive exercise.
  • Binge-eating disorder (BED): this is a provisional category in DSM-IV and describes binge eating without extreme compensation. This may or may not be associated with being overweight.
  • EDNOS: this category of ‘Eating Disorders Not Otherwise Specified’ has only one positive criterion (that an individual should have an eating disorder of clinical severity) and one negative criterion (the disorder should not fulfil criteria for AN or BN). It is notable that this can be the most common diagnosis in eating-disorder services (Palmer, 2003).
  • Obesity:although often included in psychiatric conditions, obesity refers only to a medical state of overweight – a state that can result from psychological or non-psychological factors.

Eating disorders commonly occur in young women, but take care not to overlook them in men and older women, and take care not to confuse them with other disorders such as the ‘true’ anorexia of depression or high anxiety, or OCD which focuses on excessive control of food intake.

In clinical practice, body mass is estimated by using the body-mass index (BMI = kg/m2). Classification of under- and overweight can be seen in Table 15.1.When working with someone with an eating disorder, it is usually necessary to keep track of their BMI, especially when it is low or particularly high. Some clients weigh themselves excessively, and this should be tackled as a form of reassurance; others are reluctant to do so – a potential obstacle to treatment, which needs early intervention. The use of behavioural experiments is limited if a client is unable to weigh herself, the therapeutic alliance can be compromised, and, most importantly, extreme weight carries health risks and must be monitored.

Table 15.1    Body-mass index

BMI (kg/m2)

WHO classification

<18.5

Underweight

18.5–24.9

 

25–29.9

Grade I overweight

30–39.9

Grade II overweight (‘obesity’)

> = 40

Grade III overweight (‘morbid obesity’)

 

 

This can be done by you as therapist, by a GP, or by another member of a multidisciplinary team. Do not be persuaded that your client can make an accurate estimate of her size – felt sense of fatness is notoriously unreliable.

Features shared by the eating disorders are summarised below.

1 Interplay of cognition, emotion and behaviour

Identifying such patterns is fundamental to helping clients with eating disorders, whatever the diagnosis. This includes the person categorised as EDNOS, when a cognitive behavioural maintenance cycle will be your guide. Three examples are illustrated in Figure 15.1: (1) a cycle of self-starvation, (2) a cycle of over-compensation for eating, (3) a cycle of over-eating.

2 Common core themes

NATs often beg the question, ‘What is so bad about that?’ As eating disorders are unlikely to be driven purely by concerns about shape and weight, we have to ask, what’s so bad about being normal body weight/being overweight/being top-heavy/and so on. Themes that emerge from clinical report and research include:

 

  • Social and interpersonal issues: these include fears of being abandoned, of social evaluation, shame and low self-esteem (see Waller & Kennerley, 2003, for a review). Thus, systemic (particularly family) factors need consideration at assessment, and partners or parents might be usefully involved in treatment.
  • Control: This has long been recognised as a powerful factor in the aetiology and maintenance of eating disorders, and its role has been elaborated (Fairburn, Shafran & Cooper, 1999).

Figure 15.1    Maintaining cycles in eating disorders

3 Cognitive process

Extreme cognitive processes are as pertinent to the development and maintenance of eating disorders as they are to other psychological problems. Specifically, perfectionism and dissociation have been identified as playing a powerful role in their maintenance.

 

  • Dichotomous thinking, the ‘all or nothing’ view, is common and tends to be expressed as perfectionism. This is apparent in extreme goals for thinness and in extreme over- or under-eating, for example. It is often underpinned by negative self-evaluation, which drives a compensatory behaviour of attempting to overachieve. When a client succeeds, this usually fuels the belief that performance equals worth, and the negative self-view is unchallenged; when a client fails, this feeds the low self-esteem (see Figure 15.2).

Figure 15.2    Perfectionism maintaining an eating disorder

 

  • Dissociation, namely mental processes of ‘tuning out’ or disassociating from current emotional or cognitive experience, has been linked with eating disorders, as it can be induced by self-starvation or by over-eating (Vanderlinden & Vandereycken, 1997). Repeated dissociation in the face of perceived negative emotions results in a person failing to learn that the emotions can be tolerated; and thus dissociation through misuse of food remains a major coping strategy.

4 Affect

There is now substantial evidence for the role of emotion in driving eating behaviours (e.g. Waters, Hill & Waller, 2001). This is relevant to both over- and under-eating, and research suggests that sensations of hunger or satiation are overridden by emotion. The precise role of emotion in your clients will be identified through close analysis of automatic thought records which incorporate descriptions of affect, but put simply, you need to look out for:

 

  • Mood or affect intolerance: where bingeing or restrictive eating serve to moderate emotions clients find intolerable. This can be a very effective and therefore compelling reason for extreme eating behaviours.
  • Emotions overriding the sensations of hunger or of satiation: high arousal in the form of anxiety, anger or excitement can interfere with awareness of both the need to eat and the need to stop eating.
  • Emotions being mistaken for hunger: clients who mislabel anger, anxiety, thrill or misery as hunger typically eat in response to this. As eating has a soothing effect, they experience the sensations diminishing, which then reinforces the belief that they were, indeed, hungry.

5 Motivation

Clients with eating disorders often show an ambivalence about, or even overt resistance to, change, with therapists often having to focus on enhancing motivation. This costs time, and currently there is little evidence that adding a motivational element to CBT improves outcome (Treasure, Katzman, Schmidt, Troop, Todd & de Silva, 1999). However, clients with eating disorders – particularly those with restricting anorexia nervosa – can be very ambivalent about changing their behaviour and this has to be acknowledged. Waller et al. (2007) have set out clear guidelines for understanding the client’s position and helping them through their ambivalence in a compassionate and effective way.

6 Health risks

Severe physical consequences are possible with both acute and chronic eating disorders. Thus, clients should be taken on with caution and managed in consultation with a physician. For most therapists practising in the UK, this will be your client’s GP. The main concerns include:

 

  • Anorexia and bulimia nervosa: malnourishment and its consequences, cardiovascular complications, gastrointestinal problems, deficiencies in the immune system, biochemical abnormalities, central nervous system changes, amenorrhoea, osteoporosis, renal failure.
  • Obesity: metabolic complications, cardiovascular complications, respiratory problems, osteoarthritis.

Using CBT with the eating disorders

Whatever the diagnosis, you will need to carry out a thorough assessment. Your resulting formulation will guide you towards appropriate cognitive and behavioural interventions. This is especially important if you discover that your client does not fit one of the established models relating to DSM diagnoses. The characteristic dichotomous thinking style of those with eating disorders can be addressed using continuum work (see Chapter 8), and relapse management is particularly relevant in helping clients manage powerful cravings and the absolute thinking style that can put them at risk of binge eating or self-starvation (see Chapter 6).

There has been a long behavioural tradition of working with AN, BED and obesity. These interventions have been relatively effective in achieving weight reinstatement and stability in those with AN and reduced binge eating in those who binge. However, gains are poorly maintained, and in the past two decades, emphasis has switched to modifying cognitions.

As with other problems, treatment involves breaking the cycles that maintain the problem. The most prominent CBT protocols for managing eating disorders are based on very specific ‘maintenance models’ (see Vitousek, 1996); generic models and models that encompass schema-level meanings are gaining ground (see Waller & Kennerley, 2003, for a review). Clinically, you need to be aware of the particular needs of eating-disordered clients and to ask yourself if you are sufficiently resourced to help them.

Treatments for AN need to take into account:

 

  • the consequences of prolonged low body weight – there is general agreement that those with anorexia should have regular medical screening (Zipfel, Lowe & Herzog, 2003);
  • the effects of starvation – including behavioural and cognitive changes that reduce motivation and impair the ability to engage in cognitive therapy;
  • a client’s denial or lack of an appreciation of the medical dangers of anorexia – reducing her ability to engage in treatment.

Engagement is further undermined when sufferers feel that their behaviour is appropriate and not dysfunctional.

Treatments for bulimia nervosa need to take into account:

 

  • the medical risks of extreme compensation for perceived over-eating (vomiting, purging, etc.).

Treatments for binge-eating and obesity need to take into account:

 

  • the medical risks of over-eating and being overweight.

Recommended reading

Treasure, J., Schmidt, U., & van Furth, E. (2003). Handbook of eating disorders (2nd ed.). Chichester: Wiley.

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioural therapy for eating disorders: a comprehensive treatment guide. New York: Cambridge University Press.

Trauma

Psychological trauma can be evoked by many incidents: for example, witnessing atrocities, being in a natural disaster, sexual assault (in childhood or in adulthood). DSM-IV (APA, 2000) defines traumatic stressors as events involving actual or threatened death or serious injury or a threat to the physical integrity of self and others. Without this, the diagnosis of PTSD cannot be made, regardless of how distressed a person appears. None the less, we see clients who have not experienced trauma as defined above and yet who struggle to cope with the psychological consequences of trauma. We also see clients who do not fulfil other DSM criteria, such as re-experiencing the trauma and emotional numbing, but who appear to suffer from the psychological legacy of trauma.

Terr (1991) distinguished two types of trauma victim:

 

  • Type I: who have experienced a single traumatic event
  • Type II: who have been repeatedly traumatised.

Terr originally made this distinction with regard to children, but the division has been applied to adults. Rothschild (2000) has suggested further refinements to the adult Type II classification, in order to distinguish those with and without stable backgrounds and to distinguish those who can recall discrete traumatic events from those who have a generic recall of trauma. Scott and Stradling (1994) have proposed a further category, that of prolonged duress stress disorder (PDSD), which describes the client who has experienced ongoing stress such as chronic illness or emotional cruelty during childhood, rather than specific trauma.

These distinctions remind us that trauma survivors are not a homogenous group and that PTSD is not the only clinically significant response to trauma. However, research cognitive therapists have tended to focus on trauma victims who have PTSD, and for this population there are well-developed treatments (see Chapter 14). If you are working with survivors of trauma who do not fulfil criteria for PTSD, you will have to work from first principles: formulation leading to intervention, rather than assuming that PTSD protocols fit all trauma survivors.

It is now well established that those who have suffered childhood trauma are more likely to experience psychological difficulties in adulthood (Mullen, Martin, Anderson, Romans & Herbison, 1993). Survivors of childhood trauma can present with any combination of psychological problems, such as eating disorders, depression or interpersonal difficulties. Thus, many of the presenting difficulties of survivors of childhood trauma are familiar to cognitive therapists, and a cognitive understanding of the problem(s) already exists.

There are several key issues that need to be considered when working with survivors of trauma. These are discussed below.

1 Interpersonal issues

Many survivors of interpersonal trauma have difficulty in developing a trusting relationship with others, including you as therapist. It is not unusual to have to ‘invest’ in sessions to build up your working alliance in preparation for the CBT per se (see Chapter 3). Survivors of accidents, impersonal attack and natural disasters may, however, find it much easier to establish rapport.

Survivors of interpersonal trauma often develop difficulties in their real-life relationships, and a systemic overview of your client’s situation can be helpful. This means frequently updating your understanding of their relationship with their children (Are the children at risk of neglect or abuse?); or with significant others (Is your client at risk of harm? Is their partner at risk?). Repeated early life trauma has often been linked with personality disorders (Terr, 1991; Layden, Newman, Freeman & Morse, 1993; Beck et al., 2004), and, as a clinician, you need to be prepared for this possibility.

2 Memory of trauma

As we have already said, presentations of non-PTSD trauma are diverse. One manifestation of this is the range of available memories of traumatic experience(s).

 

  • Lack of memories of trauma.Some clients do not have accessible memories of trauma. Sometimes a victim is so distracted or dissociated that full memories are never laid down. Clients will say things like ‘My mind froze, I don’t remember what he said/did’, or ‘I can see the knife but I can’t recall anything else’. In such cases, there might be no more memory to retrieve. You should not try to force recall because of the danger of creating false memories (see below). It has also been suggested that traumatic memories can be repressed (British Psychological Society, 1995): there will be stored recollections of the trauma, but again, do not force recollection because of the danger of encouraging distortions.
  • Intrusive memories.Although it is not inevitable, many survivors of trauma have intrusive memories that can involve any, or all, of the senses. For some, these memories will have the quality of flashbacks. Some memories will reflect specific incidents reasonably accurately, some will have become inaccurate, while some will be a composite of several events. The empirically based methods of managing intrusive memories in Type I PTSD (Ehlers & Clark, 2000, for example) may not be the best option for managing Type II trauma intrusions – we do not yet know.
  • False memory has been well-researched, and is recognised to exist (British Psychological Society, 1995). All memories are vulnerable to distortion, as they are not stored in the brain like a video-recording, but more like a collection of jig-saw pieces which are reformed each time a memory is recalled. However, we know that while memory for detail is rather unreliable, general memories are not. Thus, we might accurately recall that we enjoyed or hated a holiday, but our recollection of the detail of it would be considerably less reliable. Clinically, the guideline is not to get too obsessed with the detail in remote memories as it can be inaccurate.

3 Schema-level work

Childhood trauma, especially if chronic, can impact on a person’s fundamental sense of self, of others and of the future, which can result in the development of powerful belief systems (or schemata) which, by adulthood, can be both rigid and unhelpful. Schemata and schema therapy are described in Chapter 17, so suffice to say that you need to hold in mind the possibility that your client may express a wide range of difficulties underpinned by inflexible belief systems.

4 Complexity of presentations

Sometimes, when working with survivors of complex or chronic trauma, you may find that the client presents with a combination of problems or lives in a dysfunctional environment, which undermines therapy. In short, the picture can be complex, possibly involving co-morbid problems, or multi-impulsive behaviours (including self-injury). You are again reminded to formulate the ‘bigger picture’ for such clients by asking questions that will elicit more information – ‘Is there any thing else that you do that might affect this …?’; ‘Are there other occasions when …?; ‘And in your work life …?’; ‘And in your home life …?’.

CBT with survivors of trauma

With the exception of research focused on PTSD, evaluation of CBT with survivors of trauma has not been systematic, and there is a paucity of RCTs. However, guidelines from highly experienced practitioners exist to help you develop your approaches to working with survivors of trauma who have personality disorders (e.g. Layden et al., 1993; Beck et al., 2004). There is increasing research supporting the theory behind Gilbert’s compassionate mind therapy (CMT) and it may be an effective intervention with those who have been left with fixed self-blaming and self-attacking beliefs (see Gilbert & Irons, 2005, for a review). There is also evidence that supports the use of cognitive techniques for specific aspects of a client’s presentation (for example Arntz & Weertman, 1999) and for interventions for particular categories of trauma (for example Resick & Schnicke, 1993).

In summary, with Type II trauma there are no well-established protocols to follow, and you will have to call on the generic skills of cognitive therapy. However, we would promote the following guidelines:

 

  • Formulate the bigpicture.
  • Remember the qualities of memory.
  • Focus on the accessible Axis I problems as far as possible, using treatment protocols where appropriate.
  • Bear in mind the possibility of your having to accommodate interpersonal difficulties, schema-driven problems and multi-problem presentations.
  • Keep risk assessment on your agenda.

Recommended reading

Beck, A.T., Freeman, A. and associates (2004). Cognitive therapy of personality disorders (2nd ed.). New York: Guilford Press.

Grey, N. (2009). A casebook of cognitive therapy for traumatic stress reactions. Hove: Routledge.

Layden, M.A., Newman, C.F., Freeman, A., & Byers-Morse, S. (1993). Cognitive behaviour therapy of borderline personality disorder. Needham Heights, MA: Allyn & Bacon.

Mcnally, R.J. (2003). Remembering trauma. Cambridge, MA: Harvard University Press.

Petrak, J. & Hedge, B. (2002). The trauma of sexual assault: treatment, prevention and practice. Chichester: Wiley.

Anger

Anger is an emotion, and, like other emotions, it is not necessarily a problem. However, anger may become a problem when it is excessive in frequency or severity and when it leads to behaviour that is dangerous to self or others, or that hinders rather than helps people in achieving their goals. It can be at the heart of a range of interpersonal problems such as domestic violence – physical or emotional – or aggressive outbursts in the workplace, on the road, in social settings and so on.

Although anger has received less attention than other emotions, there is evidence that CBT can be an effective treatment for anger problems (Beck & Fernandez, 1998; Naeem, Clarke & Kingdon, 2009). The Beckian approach sees anger as arising in situations where people feel that important ‘rules’ about how others should behave are violated, or as a defensive reaction when there is a perceived threat (Beck, 1999). However, the best-known CBT approach to anger control was developed by Novaco (1979, 2000) and derives more from Meichenbaum’s (1975) stress inoculation training than from Beckian cognitive models. In brief, the therapy typically consists of three stages:

 

  • Preparation: the client is helped to identify patterns of anger, including triggers and typical thoughts, feelings and behaviours, through the usual assessment and formulation.
  • Skills acquisition: the client learns techniques to help him lower his arousal when provoked. These may include relaxation, and ‘self-instructional techniques’ (see below).
  • Application training: the client rehearses the techniques in progressively more difficult situations, perhaps starting off with practising in imagination and progressing through role play to in vivo application.

The self-instruction which is central to Novaco’s approach teaches the client to manage different stages of a potentially anger-provoking situation. These stages include:

 

  • preparing for the provocation (e.g. recognising situations that may be difficult; reducing excessive expectations of other people);
  • coping with physical arousal (e.g. through relaxation and/or breathing control);
  • coping with cognitive arousal (using self-instruction statements such as ‘Getting angry won’t help me’);
  • post-confrontation reflection (evaluating the outcome and working out how to move forward).

Apart from the need for careful risk assessment, the main difficulty in therapy for anger is that clients are often not well engaged. Anger has often been perceived as useful to them in the past, is often rewarding in the short term, and clients may have been referred to therapy because someone else thinks their anger is a problem (e.g. their families or the courts). Also, many people are reluctant to look for alternative perspectives when they are angry. Engagement in a collaborative relationship and careful assessment are, therefore, crucial, and as therapist you also need to consider carefully whether you may be at risk.

Recommended reading

Beck, A.T. (1999). Prisoners of hate. New York: HarperCollins.

Novaco, R.W. (1979). The cognitive regulation of anger and stress. In P.C. Kendall & S.D. Hollon (Eds.), Cognitive-behavioral interventions: theory, research, and procedures. New York: Academic Press.

Novaco, R.W. (2007). Anger dysregulation. In T. Cavell & K. Malcolm (Eds.), Anger, aggression, and interventions for interpersonal violence. Mahwah, NJ: Erlbaum.

Psychosis

Most of the work on CBT for psychosis has focused on medication-resistant symptoms in schizophrenia, although there has also been some interesting work on CBT for bipolar disorder (see, for example, Basco & Rush, 1996; Lam, Jones, Bright & Hayward, 1999; Scott, 2001). Within schizophrenia, the most common symptoms that may be amenable to CBT interventions are:

 

  • hallucinations, particularly auditory hallucinations (i.e. experiencing unusual or distorted sensory perceptions which do not seem to exist outside one’s perception);
  • delusions (false beliefs that persist despite a lack of evidence and which are not explained by cultural norms);
  • problems of mood such as depression or anxiety;
  • other related problems such as low self-esteem, relationship problems and social withdrawal.

In addition, there may be an important role for working with families or other carers – Pilling et al. (2002) have reviewed CBT and family therapy for schizophrenia.

In principle, CBT for psychosis is like CBT for any other disorder: your task is to build a formulation and apply CBT therapeutic strategies to the maintaining factors in that formulation. Nevertheless, working with psychosis has sufficient risks and complications that we would urge you to make sure you are familiar with using CBT in more straightforward problems before you try to use it with psychotic symptoms and that you have recourse to suitable supervision. It is also important to note that almost all trials of CBT for psychosis use CBT as part of a care package which also includes anti-psychotic medication and mental-health team support, rather than using CBT as a stand-alone treatment.

CBT theories of psychosis are less well established than in other disorders, and the field is still being actively developed. However, most current models suggest that hallucinations are a product of cognitive processes which include disturbances of attention, perception and judgement, including the misattribution of one’s own thoughts to an external source; and, furthermore, that delusions may represent attempts to make sense of the anomalous experiences that can result from these processes, with the delusions then being maintained by biases in reasoning and attention (see, for example, Fowler, Garety & Fowler, 1995; Chadwick, Birchwoord & Trower, 1996; Garety, Kuipers, Fowler, Freeman & Bebbington, 2001; Morrison, Renton, Dunn, Williams & Bentall, 2003).

The aims of CBT for psychosis are usually to help the client manage psychotic symptoms better, to reduce the distress and disability caused by those symptoms and to reduce the risk of relapse. Some of the standard features of CBT described earlier in this book are particularly important in psychosis. Building a collaborative relationship and a formulation that can give an alternative, non-threatening and non-stigmatising account of the symptoms is vital. The formulation is then used to identify and test cognitions about the source, meaning and controllability of symptoms. BEs can be a key part of this exploration (see Close & Schuller, 2004) but need to be planned and carried out with particular sensitivity.

Other factors that may need special care include engaging clients who may be suspicious and who sometimes perceive themselves, rightly or wrongly, as having been abused by psychiatric systems; the pleasurable experience of mild mania, which can prevent a sufferer from wanting to manage it; idiosyncratic thought processes, which may make it difficult for you to keep track of the client’s thinking; and the sometime neediness of the client’s family or carer.

All these complications mean that CBT for psychosis often needs to be a longer-term treatment, taken at a relatively slow pace; and that you need skilled supervision and support.

Recommended reading

Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia. Chichester: Wiley.

Kingdon, D., & Turkington, D. (2004). Cognitive therapy of schizophrenia. New York: Guilford Press.

Lam, D., Jones, S., & Hayward, P. (2010). Cognitive therapy for bipolar disorder: a therapist’s guide to concepts, methods and practice (2nd edn). Chichester: Wiley.

Larkin, W., & Morrison, A. (2006). Trauma and psychosis. Hove: Routledge.

Morrison, A.P., Renton, J.C., Dunn, H., Williams, S., & Bentall, R.P. (2003). Cognitive therapy for psychosis: a formulation-based approach. Hove: Brunner–Routledge.

Relationship difficulties

Difficulties in relationships are common in clients who ask for help. This is true for people with Axis I disorders, as well as with people with long-standing problems typified as personality disorder. For example in Axis I disorders, a client with social anxiety may have difficulties in asserting himself, someone with low self-esteem may be overly dependent on others, and a depressed client may have become socially withdrawn. A cognitive behavioural formulation allows issues such as these to be approached in similar ways to other problems, by looking at the inter-linkages between cognitions, and emotions, behaviours, and physical state, where the cognitions will be concerned with relationships.

A woman who had been depressed for a number of months had gradually reduced the amount of time she spent with her friends. If she were invited to see someone, her automatic thought would be, ‘I am boring and have nothing to say. If I see my friends in this state, I shall lose them’. She therefore turned down most invitations with the result that her friends made less contact with her.

With a client like this, where the automatic thoughts were typical of her depressed state, but not of her thinking in general, the problem could successfully be approached at the level of automatic thoughts. For people with a personality disorder, the difficulties in relationships are likely to be more pervasive and enduring, and a central feature of the disorder. However, the CBT approach still emphasises the central role of cognitions about self, other people and relationships, and their linkages with behaviour and emotions, though it is likely to be more necessary to also tackle underlying beliefs.

A man with a history of emotional neglect had a powerful and pervasive belief that ‘No one is there for me’. In response to this, he had developed a rule that ‘If I am honest about my failures, I shall be rejected’, and as a result, frequently chose lying as a way of protecting himself. In the short term this allayed his fears, but in the medium term presented him with real difficulties as he had to weave more and more complicated stories to cover his lies. Treatment partly involved experiments with confessing to small failures, and keeping careful notes of the responses that this drew from others, particularly from his wife

One setting where relationship problems can be viewed as they occur is the therapeutic relationship. Safran and Muran (1995) have written about how interactions in the therapeutic relationship can be used to invalidate unhelpful beliefs about relationships (see Chapter 3). Safran and Segal (1990) proposed that the ways that other people respond can play an important role in the maintenance of dysfunctional thinking about relationships. They suggested that a client’s interpersonal behaviour towards others may ‘pull’ a predictable response from the other person, which then confirms the client’s original belief.

A woman who was bullied at school had a belief that she was not easy to be with, and that if she tried to join in, she would be rejected, and feel isolated and desolate. As she assumed that she would not be welcome in groups, she acted in an aloof and arrogant manner when she was in group situations (for example, at professional conferences), on the basis that ‘If you don’t want me, I am not going to demean myself by looking as though I want you’. Her colleagues responded to this by turning to others who were easier to approach, thus confirming her belief that she was not welcome in groups.

If an unhelpful belief has been identified, then in the therapy setting the therapist can experiment with not being ‘pulled’ into responding in the predicted way, and therapist and client can reflect on the impact that this has on the client’s beliefs. The client can then experiment with using different interpersonal behaviours based on his modified belief.

A therapist needed to change the regular time for appointments because of a teaching commitment, and as the client interpreted this as indicating that the therapist was trying to find a way not to be with her, she became aloof and rigid about alternative dates. The therapist rejected the ‘pull’ to respond with ‘Well, suit yourself!’, and instead was warm and concerned about their difficulty with rescheduling, and showed non-verbally that she very much wanted to find a solution so that she could see the client. After the practical problem was dealt with, the therapist asked the client to reflect upon how she had construed the situation, and what implication the therapist’s response had for her original belief (which in this case had been extensively discussed in earlier sessions).

Beck et al. (2004) and Young, Klosko and Weishaar (2003) have also written creatively about ways of dealing with interpersonal problems (see Chapter 17), and Linehan and her colleagues (1993) have developed a group programme called Dialectical Behaviour Therapy (DBT) for helping clients with borderline personality disorders (see Chapter 16). The programme is lengthy, taking up to a year, but the outcome data so far are encouraging, with significant impacts on interpersonal and social adjustment.

Finally, there are many useful ideas about working with relationship problems incorporated in Dattilio and Padesky’s (1990) work with couples.

Recommended reading

Dattilio, F.M., & Padesky, C.A. (1990). Cognitive therapy with couples. Sarasota, FL: Professional Resource Exchange.

Safran, J.D., & Segal, Z.V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.

Safran, J.D., & Muran, J.C. (1995). Resolving therapeutic alliance ruptures: diversity and integration. Session: Psychotherapy in Practice, 1, 81–92.

Substance misuse

When people talk about substance misuse, they are generally thinking about misuse of alcohol, psychoactive drugs, and possibly smoking. It is worth bearing in mind that other behaviours such as gambling, overeating and compulsive spending have also been viewed as ‘addictive’, so may be amenable to the management outlined for substance misuse. This section will focus on the substances covered by DSM-IV (APA, 2000), namely alcohol and drugs, where:

 

  • Substance abuserefers to a maladaptive pattern of use leading to significant impairment or distress (e.g. failure to fulfil responsibilities, legal or interpersonal problems).
  • Substance dependenceis more severe, and includes increased tolerance, withdrawal, use of increasing amounts of a substance, and a persistent desire for the substance even though the person recognises the negative consequences of its use.

Why misuse substances?

In the face of the negative consequences, why do people misuse? Among the most common reasons are:

 

  • mood regulation – either to control depression or anxiety, or to enhance positive moods like happiness;
  • to cope with adverse circumstances, e.g. abusive relationships, poverty;
  • to contain severe psychiatric symptoms.

It is very difficult for people to stop misusing substances, partly because they often report that nothing competes with the positive effects of the substance (mood enhancement, blanking out problems). This is exacerbated by physical dependence, where withdrawal symptoms are experienced if the individual does stop using the substance. Some of the people who are misusing substances can be helped with short-term interventions, but many of those who are dependent will require longer-term input. Ideally, treatment should address the client’s associated problems, and not just the substance misuse. Many programmes involve more than one treatment modality, typically medication and psychosocial help, as well as psychological input. There is then good evidence of effectiveness (see, for example, Hubbard, 2005). The CBT approach to substance misuse emphasises the additional role of dysfunctional thinking in the maintenance of the behaviour (Beck, Wright, Newman & Liese, 1993; Marlatt & Gordon, 1985) and this will now be considered.

The cognitive behavioural approach to substance misuse

Liese and Franz (1996)’s developmental model for substance misuse is similar to the general CBT model of development (see Chapter 4), with the specific addition of exposure to, and experimentation with, addictive behaviours (e.g. family members who use drugs, friends who encourage drug use), and consequent development of drug-related beliefs (‘If I use drugs I shall feel less anxious’, ‘I will fit in more easily if I use drugs’.

The general CBT approach is similar to that used with other kinds of problems, including socialisation to the model, structured sessions, and the range of cognitive, behavioural and physical techniques described in Chapters 89 and 10; there are useful clinical examples in Daley and Marlatt (2006). However, with this group of clients there is a very strong emphasis on a non-blaming conceptualisation. Given the challenges of working with these clients, it is particularly helpful to emphasise assets such as an adaptive coping style or strong social supports. A collaborative therapeutic alliance is clearly important in this area, and relates to compliance in treatment (Petry & Bickel, 1999). This can be difficult in the face of frequent relapses, anti-social and illegal behaviour, dishonesty, and so on; but one of the challenges of working with clients with problems of this kind is to maintain a genuinely compassionate and empathic stance. This is facilitated by framing difficult behaviours in terms of the formulation.

An important concept, highly relevant for this group of clients with marked ambivalence about change, is that of preparedness for change (Prochaska et al., 1994) (see Chapter 11), and the importance of working with them to change their position on the continuum. This readiness to risk changing behaviour can fluctuate, depending on the level of craving a client experiences. Powerful physiologically driven urges to engage in misuse can undermine commitment to therapy, and you need to anticipate this and to encourage clients to develop substitute behaviours that can help take the edge off the craving: for example, monitoring internal and external triggers for craving, and then using forms of self-soothing or distraction, physical activity, social interaction or ‘urge surfing’ (Daley & Marlatt, 2006).

The issue of whether you should encourage your client to aim to control his substance misuse, or to become totally abstinent (advocated by major influences such as Alcoholics Anonymous) has continued to divide people who work in this area. It is possible that controlled misuse is more relevant for the very large group with less severe problems, (Sobell & Sobell, 1993). The harm reduction approach is one attempt to circumvent this issue, while accepting the need to take account of the stage that the client has reached. The goals of therapy are to limit the impact of substance misuse rather than aim for total abstinence (Marlatt, Larimer, Baer & Quigley, 1993).

The cognitive behavioural approach emphasises the individual’s capacity to exercise control. Another important aspect of this is relapse prevention (Daley & Marlatt, 2006), including the identification and avoidance of high risk situations, exploration of the decisions that lead to substance use, life-style changes, and learning from relapses in order to reduce future ones (see also Chapter 6).

Some of the problems of working with substance misusers have already been identified – marked ambivalence about change, and difficult behaviours such as non-compliance and dishonesty. Substance misuse may also be difficult to identify because the manifestations may be subtle (e.g. sleep disturbance, panic attacks). It is important to bear it in mind as a hypothesis when clients present for help with other problems.

Recommended reading

Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy of substance abuse. New York: Guilford.

Daley, D.C., & Marlatt, G A. (2006). Overcoming your alcohol or drug problem. Effective recovery strategies: Therapist Guide. Oxford: Oxford University Press.

Liese, B.S., & Franz, R.A. (1996). Treating substance use disorders with cognitive therapy: lessons learned and implications for the future. In P.S. Salkovskis (Ed.), Frontiers of cognitive therapy. New York: Guilford.

Other applications of CBT

Clearly, the application of CBT extends beyond the few described here. It is used with diverse clinical populations: children and adolescents, older adults, those with learning disabilities, or sexual problems, in settings that are forensic, physical health, occupational – and so on. However, interesting as these applications are, it is beyond the scope of this book to describe them, though we want to alert you to the versatility of CBT. There will be training events, specialist supervision and textbooks to guide you if a client has specialist needs, and we strongly urge you to make use of them. However, remember that the principles described in this book are relevant to every CBT intervention, and the methods that we have described will be useful across client groups. The foundation set out in Chapters 1 to 11 will stand you in good stead for carrying out a cognitive assessment, offering a formulation and, where appropriate, beginning work with a range of clients.