Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges PDF
Preview Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges
COGNITIVE-BEHAVIORAL THERAPY FOR ANXIETY DISORDERS Guides to Individualized Evidence-Based Treatment Jacqueline B. Persons, Series Editor Providing roadmaps for managing real-world cases,volumes in this series help the clinician develop treatment plans using interventions of proven effectiveness.With an emphasis on systematic yet flexible case formulation,these hands-on guides provide powerful alternatives to one-size-fits-all approaches.Each book addresses a particular disorder or presents cutting-edge intervention strategies that can be used across a range of clinical problems. Cognitive Therapy of Schizophrenia David G.Kingdon and Douglas Turkington Treating Bipolar Disorder:A Clinician’s Guide to Interpersonal and Social Rhythm Therapy Ellen Frank Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders Bruce F.Chorpita Cognitive-Behavioral Therapy for PTSD:A Case Formulation Approach Claudia Zayfert and Carolyn Black Becker Cognitive-Behavioral Therapy for Adult Asperger Syndrome Valerie L.Gaus Cognitive-Behavioral Therapy for Anxiety Disorders:Mastering Clinical Challenges Gillian Butler,Melanie Fennell,and Ann Hackmann The Case Formulation Approach to Cognitive-Behavior Therapy Jacqueline B.Persons Mindfulness- and Acceptance-Based Behavioral Therapies in Practice Lizabeth Roemer and Susan M.Orsillo Cognitive-Behavioral Therapy for Anxiety Disorders MASTERING CLINICAL CHALLENGES Gillian Butler Melanie Fennell Ann Hackmann Series Editor’s Note by Jacqueline B. Persons THE GUILFORD PRESS New York London © 2008TheGuilfordPress ADivisionofGuilfordPublications,Inc. 72SpringStreet,NewYork,NY10012 www.guilford.com Allrightsreserved Paperbackedition2010 Exceptasindicated,nopartofthisbookmaybereproduced,translated, storedinaretrievalsystem,ortransmitted,inanyformorbyanymeans, electronic,mechanical,photocopying,microfilming,recording,or otherwise,withoutwrittenpermissionfromthePublisher. PrintedintheUnitedStatesofAmerica Thisbookisprintedonacid-freepaper. Lastdigitisprintnumber: 9 8 7 6 5 4 3 2 LIMITEDPHOTOCOPYLICENSE Thesematerialsareintendedforuseonlybyqualifiedmentalhealth professionals. ThePublishergrantstoindividualpurchasersofthisbooknonassignable permissiontoreproduceallmaterialsforwhichphotocopyingpermissionis specificallygrantedinafootnote.Thislicenseislimitedtoyou,theindividual purchaseronly,forusewithyourownclientsandpatients.Purchasebyan institutiondoesnotconstituteasitelicense.Thislicensedoesnotgranttheright toreproducethesematerialsforresale,redistribution,oranyotherpurposes (includingbutnotlimitedtobooksandhandoutsorslidesforlecturesor workshops).Permissiontoreproducethesematerialsfortheseandanyother purposesmustbeobtainedinwritingfromTheGuilfordPress. LibraryofCongressCataloging-in-PublicationData Butler,Gillian. Cognitive-behavioraltherapyforanxietydisorders:masteringclinical challenges/byGillianButler,MelanieFennell,AnnHackmann. p.;cm.—(Guidestoindividualizedevidence-basedtreatment) Includesbibliographicalreferencesandindex. ISBN978-1-59385-830-8(hardcover:alk.paper) ISBN978-1-60623-869-1(paperback:alk.paper) 1. Anxietydisorders—Treatment. 2. Cognitivetherapy. I. Fennell, MelanieJ.V. II. Hackmann,Ann. III. Title. IV. Series. [DNLM: 1.AnxietyDisorders—therapy. 2.Cognitive Therapy. WM172B985c2008] RC531.B882008 616.85′2206—dc22 2008014217 About the Authors GillianButler,PhD,aFellowoftheBritishPsychologicalSocietyandaFoundingFellowoftheAcad- emyofCognitiveTherapy,worksfortheOxfordCognitiveTherapyCentreintheUnitedKingdom.For 10yearsshedidresearchinOxfordhelpingtodevelopandevaluatecognitive-behavioraltreatmentsfor anxietydisorders.Dr.Butlerhasaspecialclinicalinterestintheuseofcognitive-behavioraltherapydur- ingrecoveryfromtraumaticexperiencesinchildhood,andrunstrainingworkshopsintheUnitedKing- domandinternationallyonawidevarietyoftopicsrelevanttopractitionersofcognitive-behavioral therapy.Sheisparticularlyinterestedinmakingtheproductsofresearchavailabletothegeneralpublic, andherbookOvercomingSocialAnxietyandShyness(1999)isnowavailableasaself-helpcourseaswell. Dr.Butleriscoauthor,withTonyHope,ofManageYourMind:TheMentalFitnessGuide(2ndedition;2007) and,withFredaMcManus,ofPsychology:AVeryShortIntroduction(1998).Sheisalsocoeditorofthe highly successfulOxford Guide to Behavioural Experiments in Cognitive Therapy(2004). Melanie Fennell, PhD, is one of the pioneers of cognitive therapy in the United Kingdom. As a researchtherapistinOxfordUniversity’sDepartmentofPsychiatry,shehascontributedtothedevel- opmentofmodelsandtreatmentprotocolsfordepressionandforarangeofanxietydisorders.Dr.Fen- nelliscurrentlyamemberofateam,ledbyProfessorJ.MarkG.Williams,developingmindfulness- based cognitive therapy for people suffering from recurrent depression and suicidality. Afounding memberoftheOxfordCognitiveTherapyCentre,Dr.Fennellhaswrittenwidelyoncognitive-behav- ioral therapy for depression and low self-esteem, including the books Overcoming Low Self-Esteem (1999)andOvercomingLowSelf-Esteem:Self-HelpCourse(2006).WithcolleaguesfromtheOxfordCogni- tiveTherapyCentre,shewascontributingauthorandcoeditoroftheOxfordGuidetoBehaviouralExper- imentsinCognitiveTherapy(2004).Dr.Fennellhascontributedtoconferencesanddeliveredworkshops inmanycountries.In2002,shewasvoted“MostInfluentialFemaleUKCognitiveTherapist”bythe membership of the British Association of Behavioural and Cognitive Psychotherapies at their 30th anniversaryconference. AnnHackmann,PhD,isaclinicalpsychologistwhohasworkedforover20yearsinaresearchgroup thatspecializesinthedevelopmentofcognitivetherapyprotocolsforthedifferentanxietydisorders. Shehasworkedasatherapistinalargenumberofrandomizedcontrolledtrialsandhasdoneresearch onphenomenologyofanxietydisordersandrefinementoftreatmentstrategies.Dr.Hackmann’sspe- cialinterestisinimageryanditsrelationshiptomemoryinpsychopathology,andwithEmilyHolmes sheeditedaspecialeditionofthejournalMemory(2004)onthistopic.Shewasalsooneoftheeditorsof the Oxford Guide to Behavioural Experiments in Cognitive Therapy (2004). Dr. Hackmann has also pro- videdteachingandtrainingincognitivetherapyinmanysettingsintheUnitedKingdomandinterna- tionally,andisaFoundingFellowoftheAcademyofCognitiveTherapy. v Series Editor’s Note Oneofthementalhealthprofessional’smostchallengingtasksistousefindingsfrom theresearchliteratureinawaythatisthoughtful,theoryguided,andresponsivetothe needsofthecaseathand.ThiswonderfulbookbyGillianButler,MelanieFennell,and AnnHackmannprovidesbothconceptualandpracticalguidancetotheclinicianfacing this task. The evidence base underpinning treatment of the anxiety disorders has exploded inrecentdecades.Researchershavedevelopedeffectivetreatmentsforalloftheanxiety disorders,andtheyarebeginningtodescribethepsychologicalmechanismsunderpin- ning the symptoms and disorders, and the process of change during effective treat- ment. As a result, the clinician can easily have the sense that work with individuals withanxietydisordersshouldproceedsmoothlyandquicklytoasuccessfulandlong- lastingconclusion.However,thisisfrequentlynotthecase.Thedisorder-focusedpro- tocols of the empirically supported treatments simply do not provide all the answers for all of our patients with anxiety disorders. Thisbookfillsinmanyofthemissingpieces.Evenmoreimportant,itoffersprinci- plesandillustratesawayofworkingthatcanhelpcliniciansgeneratetheanswersthey need when the protocols come up short. The authors assume that most readers are familiar with the diagnosis-specific cognitive-behavioral models and therapies. They gobeyondtheprotocolstoaddresscommonobstaclesthatimpedeworkwiththecom- plex patient with an anxiety disorder. They focus particularly on difficulties that arise whenavoidance,especiallyavoidanceofaffect,isextensive;whenlowself-esteemand comorbid depression are present; and when tolerance for uncertainty is low. The authors help clinicians accomplish thoroughgoing change that pervades cognitive, behavioral, and emotional systems. They describe how to end therapy in a way that helps patients consolidate and maintain their gains. Although the book focuses on the complex anxiety disorders, it also provides a modelofclinicalworkthatwillbeusefultoclinicianswhoworkwithabroadrangeof symptomsandproblemsinoutpatientpractice.Itoffersamodelforusingdataandthe- ory and idiographic conceptualization to guide clinical decision making. It helps the clinicianworkinafullycollaborativewaywiththepatienttodevelopanduseaformu- vi Series Editor’s Note vii lationofthecasetoidentifytreatmenttargetsandcarryouteffectiveinterventions,and to problem-solve when initial success is not forthcoming. Theseauthorsaretrulyremarkableintheirabilitytoteachandmodeltheintegra- tion of science, theory, and clinical experience in their clinical work. They are clearly masterclinicianswhoareatthetopoftheirgameandareworthymodelsforanyofus. This material is particularly useful for Americans and others outside of Great Britain becauseitbringsusuptodatewiththelargebodyofimportantandinterestingworkin theanxietydisordersintheUnitedKingdomthathasnotbeendisseminatedaswidely as its importance merits. I am delighted to include this book in the Guides to Individualized Evidence- BasedTreatmentseries.Iamcertainitwillmakeanimportantcontributiontothetreat- mentofanxietydisordersinparticularandtotheintegrationofscienceandpracticein cognitive-behavioral therapy more generally. JACQUELINE B. PERSONS, PhD San Francisco Bay Area Center for Cognitive Therapy Preface Thisisabookforcliniciansaboutworkingwithpeoplewhosufferfromanxietydisor- ders. Cognitive-behavioral models and treatment protocols have now been developed for a range of anxiety disorders, and proved effective. This might lead clinicians to anticipatethatthetreatmentofanxietywillbetroublefree.Inpractice,however,even skilled and experienced clinicians experience difficulties in applying what they know, sometimes encountering problems in the application of standard methods to appar- entlystraightforwardcases.Sometimestheyfindthatestablishedprotocolscannotsat- isfactorily address difficulties that arise in treating atypical or complex manifestations of anxiety. Written from a cognitive-behavioral perspective, this book addresses prob- lemsanddifficultiesthatcommonlyariseduringtreatmentandprovidesawiderange of practical solutions to these difficulties. We link these solutions to the theoretical foundationsofcognitivetherapy,andtoresearchfindingswhenthesearerelevant,and we provide illustrative examples from our experience of clinical practice. We focus on solutions that our patients have found helpful, and we attempt to explain clearly the underlying clinical principles that give them a wider applicability. Our main aim is therefore to help clinicians to solve problems that arise in the treatmentofanxietydisorders.Asecondbutperhapsequallyimportantgoalistohelp readers to draw on theoretical knowledge when seeking solutions to problems they havenotpreviouslyencountered—toprovideasyntaxforclinicalproblemsolvingand notjustacollectionofunconnectedtechniques.Inabooksuchasthisitisimpossibleto addresseverysingleproblemthatislikelytoariseduringthetreatmentofanxietydis- orders.However,itispossibletosystematizesolutionseeking,andthustoenableprac- ticing clinicians to use their creativity in a theoretically sound way. STARTING POINTS:BACKGROUND KNOWLEDGE REQUIRED Weassumereadersalreadyhavesomeexperienceintreatinganxiouspeopleandhave come across at least some of the difficulties that arise in clinical practice. Other books havefocusedonthebasicmethodsandtechniquesofcognitivetherapyforanxietydis- viii Preface ix orders,andwereferreaderstotheclassics,suchasBeck,Emery,andGreenberg(1985), andlatervolumesthatspecifyfurtherdetails,suchasWells(1997)andBarlow(2002). For those seeking an introduction to the methods of cognitive therapy in general therearemanyexcellentbooksavailable—forexample,Hawton,Salkovskis,Kirk,and Clark(1989);J.S.Beck(1995);PadeskyandGreenberger(1995);Simos(2002);Bennett- Levy,Butler,etal.(2004);andWestbrook,Kennerley,andKirk(2007).Thosewhowish to encourage their patients to explore self-help materials about cognitive-behavioral therapy will find many useful ideas in Greenberger and Padesky (1995) and in Butler and Hope (2007). Self-help books and workbooks focusing on single disorders, which canalsobeusedtoguidetherapy,includethoseintheexcellentOvercomingseriespub- lished by Constable & Robinson (e.g., Overcoming Social Anxiety and Shyness [Butler, 1999b]andOvercomingLowSelf-Esteem[Fennell,1999])andintheseriesofworkbooks on Treatments That Work edited by David Barlow and published by Oxford University Press (New York). ORGANIZATION OF THIS BOOK Thebookisorganizedintofivemainparts.PartIreviewscurrentideasandresearchon treatinganxietydisorders.PartsIIthroughVmirrortheorderinwhichtherapyusually progresses, with each part designed to address the specific difficulties that commonly arise during that phase. Intheopeningchapter,“TreatingAnxietyDisorders:TheStateoftheArt,”weset thescenebysummarizingcurrent,research-basedmodelsforthespecificanxietydisor- ders.Thesemodelsprovidethebasisfortheempiricallyvalidatedtreatmentsforthese conditions,andforthespecifictreatmentprotocolsthatarecommonlytaught.Indeed, thesemodelsreflecttheenormousadvancesthathavebeenmadeintheeffectivenessof anxietytreatmentsinthelast25years.Butthisdoesnotmeanthatnoproblemsremain. Although treatment effectiveness has improved hugely, there is still some way to go. Forexample,until3or4yearsago,atleastonethirdofthepatientsinresearchtrialsfor generalized anxiety disorder gained little if anything from treatment. Additionally, in mostresearchtrialsahighdegreeofpatientselectionisnecessarysothatresearchfind- ings relate to a specific, clearly defined condition and can be compared worldwide, across centers of study. In clinical practice it is not usual to apply such rigorous selec- tioncriteria,andanxiouspatientsmaycomefortreatmentwithmixed,comorbidcon- ditions involving different types of anxiety, anxiety and depression, or anxiety in the contextofone(ormore)ofthepersonalitydisorders.SoChapter1alsoidentifiesissues and questions arising about the models. It ends with a summary of the problems to which solutions will be sought in the rest of the book. Part II (Chapters 2, 3, and 4) addresses issues related to “Deepening Understand- ing and Securing Engagement.” Chapter 2, “Assessment: Investigating Appraisals in Depth,” takes the reader immediately to the heart of the cognitive approach. Current models for the anxiety disorders focus largely (and usefully) on the specific maintain- ing factors for each condition (e.g., catastrophic misinterpretation of symptoms in the case of panic disorder; fear of negative evaluation by others and self-consciousness in thecaseofsocialphobia).Inthischapterwediscusssomeoftheunusualcognitivefac- torsthatmaybemissedinaparticularpatient,andwhichmaythereforeinterferewith
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