Clinical Applications of Cognitive Therapy

367 Pages·1990·11.778 MB·English

by  Arthur Freeman, James Pretzer, Barbara Fleming, Karen M. Simon (auth.)

Clinical Applications
of Cognitive Therapy
Clinical Applications
of Cognitive Therapy
ARTHUR FREEMAN
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine
Stratford, New Jersey
JAMES PRETZER
AND
BARBARA FLEMING
Case Western Reserve University
School of Medicine
Cleveland, Ohio
AND
KAREN M. SIMON
Center for Cognitive Therapy
University of Pennsylvania
Philadelphia, Pennsylvania
Plenum Press • New York and London
Library of Congress Cataloging in Publication Data
Freeman, Arthur M.
Clinical applications of cognitive therapy / Arthur Freeman ... let aI.).
p. cm.
Includes bibliographical references.
ISBN-13: 978-1-4684-0009-0 e-ISBN-13: 978-1-4684-0007-6
DOl: 10.1007/978-1-4684-0007-6
1. Cognitive therapy. 2. Personality disorders - Treatment. I. Title.
[DNLM: 1. Cognitive Therapy. 2. Personality Disorders-therapy. WM 425 F855c)
RC489.C63F73 1990
616.89'142-dc20
DNLM/DLC 90-6706
for Library of Congress CIP
2019181716151413 121110 9 8
The DSM-III-R diagnostic criteria are reprinted with
permission from the Diagnostic and Statistical Manual of
Mental Disorders, Third Edition, Revised. Copyright 1987
American Psychiatric Association.
© 1990 Plenum Press, New York
Softcover reprint of the hardcover lst edition 1990
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Preface
Since Beck and his colleagues (Beck, Rush, Shaw, & Emery, 1979) published
their classic work on the cognitive therapy of depression ten years ago,
cognitive therapy has come of age. From the early clinical focus on a single
diagnostic entity, the cognitive therapy model has been adapted to treat a
wide variety of clinical problems and populations. Thus, a number of clini
cians, including many trained at the Center for Cognitive Therapy at the
University of Pennsylvania, have developed applications for the treatment
of anxiety, personality, and eating disorders. They have adapted the model
to work with couples, children, adolescents, and families as well as with
schizophrenic inpatients. These clinicians have gone on to establish their
own centers and take responsibility for training and supervising others.
The present collaboration is just one result.
The title we have chosen for this volume is descriptive of the book's
development as well as its utility. The authors, who are all practicing clini
cians, have developed the theoretical and practical models found within on
the firing line of the psychotherapeutic interaction. When specific tech
niques did not work, consultation was sought. If the techniques still did
not produce the desired results, revisions were made again. The ultimate
results of this process were then tested and evaluated in terms of treatment
efficacy and practicality with other patients with similar diagnoses. This
volume, then, is written with the practicing clinician in mind. And,
whether the reader is a psychologist, psychiatrist, social counselor worker,
psychiatric nurse, or pastoral counselor, he or she should find principles of
case conceptualization and practical techniques which can be readily ap
plied in daily practice.
While each of the authors has his or her own idiosyncratic style of
therapy, all have maintained a fairly parochial view. We do not consider our
work to be eclectic; we have not attempted to establish "rapprochement"
with any other theoretical or practical model. Rather we view -cognitive
therapy as having boundaries that are elastic enough to allow the freedom of
creativity within the cognitive therapy model.
v
vi PREFACE
This book has grown and matured as new ideas were tried, devel
oped, and incorporated. We do not see it as the ultimate destination of
cognitive therapeutic treatment, but as a milestone along the path. Many
people must be acknowledged for their varied contributions to this vol
ume. First and foremost, we wish to express our gratitude to Aaron T.
Beck, M.D., director of the Center for Cognitive Therapy, and Professor of
Psychiatry at the University of Pennsylvania. Tim has been teacher, men
tor, colleague, and friend to all of us for many years. His contributions to
psychotherapeutic theory in practice have earned him a place as one of the
preeminant therapists of our time. Eliot Werner, medical and behavioral
science editor at Plenum, has left his mark on this book in terms of his
ideas, encouragement, and feedback. Our students and patients deserve
special thanks, for it is through our interactions with them that we con
tinue to learn, question, develop, and improve our therapeutic skills. Final
ly, Apple Computer deserves special thanks for its invention and
development of the Macintosh, without which this and other writings
might never have existed.
Our intention and hope is that our readers will be motivated to try
these ideas and develop them further.
Contents
I. Introduction
1. Cognitive Therapy in the Real World ......................... 3
A Cognitive View of Psychopathology ....................... 4
Principles of Cognitive Therapy ............................. 7
The Process of Cognitive Therapy ........................... 10
The Structure of a Cognitive Therapy Session ................ 16
The Complexities Encountered in Practice .................... 18
Misconceptions about Cognitive Therapy .................... 19
The Clinical Application of Cognitive Therapy ..... . . . . . . . . . . . 22
II. The Clinical Practice of Cognitive Therapy
2. Clinical Assessment in Cognitive Therapy ..................... 27
The Process of Clinical Assessment ..... . . . . . . . . . . . . . . . . . . . . . 28
Targets of Assessment . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 29
Assessment in the Initial Evaluation ......................... 30
Assessment during the Course of Therapy . . . . . . . . . . . . . . . . . . . 32
Assessment Techniques .................................... 34
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3. Cognitive and Behavioral Interventions ....................... 49
Cognitive Techniques ...................................... 49
Behavioral Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4. The Treatment of Depression ............................... 81
Assessment ............................................... 81
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Strategies for Intervention .................................. 90
Cognitive and Behavioral Techniques ........................ 91
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
vii
viii CONTENTS
5. The Treatment of Suicidal Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Assessment ............................................... 104
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Strategies for Intervention .................................. 109
Cognitive and Behavioral Techniques ........................ 111
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 118
6. Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Assessment ............................................... 119
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Strategies for Intervention .................................. 137
Cognitive and Behavioral Techniques ........................ 139
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
III. Personality Disorders
7. Paranoid, Schizoid, and Schizotypal Personality Disorders. . . . . . . . 155
Paranoid Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Schizoid Personality Disorder ............................... 169
Schizotypal Personality Disorder ............................ 175
8. Borderline Personality Disorder ............................. 181
Assessment.... .. . .. .......... .................... ...... . . 181
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Strategies for Intervention .................................. 191
Cognitive and Behavioral Techniques ........................ 195
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
9. Histrionic Personality Disorder ............................. 203
Assessment.. ..................................... ........ 205
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Strategies for Intervention .................................. 210
Cognitive and Behavioral Techniques ........................ 212
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
10. Antisocial and Narcissistic Personality Disorders ............... 223
Antisocial Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Narcissistic Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
11. Obsessive-Compulsive Personality Disorder. . . . . . . . . . . . . . . . . . . . 247
Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Conceptualization... . . . . . . . . . . . . . . . . . . . ... . . . ... . . . . ... . . . . 251
Strategies for Intervention .................................. 256
CONTENTS ix
Cognitive and Behavioral Techniques ........................ 259
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
12. Avo:dant and Dependent Personality Disorders ................ 267
Avoidant Personality Disorder .............................. 267
Dependent Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
13. Passive-Aggressive Personality Disorder ...................... 291
Assessment ............................................... 291
Conceptualization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Strategies for Intervention .................................. 296
Cognitive and Behavioral Techniques ........................ 296
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
IV. Conclusion
14. The Practice of Cognitive Therapy ........................... 307
Overcoming Stumbling Blocks .............................. 307
Polishing Skills in Cognitive Therapy ........................ 320
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Appendix
Cognitive Therapy Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Clinical Applications
of Cognitive Therapy