James Pretzer

Cognitive Therapy with Children and Adolescents

To some, the idea of doing Cognitive Therapy with children seems absurd: “How are you going to get an 8-year-old to fill out thought records (TRs) and write rational responses?” Others might wonder why a separate discussion of Cognitive Therapy with children and adolescents is needed. After all, don’t the principles of Cognitive Therapy apply to children in the same way as they do to adults? The answer to both questions is similar. The general principles of Cognitive Therapy apply to children and adolescents in the same way as they do to adults. However, children and adolescents differ from adults in important ways and significant adjustments are needed if one is to intervene effectively.

Marital Attitude Survey: A Measure of Dysfunctional Attributions and Expectancies

The Marital Attitude Survey (MAS) was designed to assess potentially dysfunctional attributions and expectancies regarding relationship problems. The eight MAS subscales measure attributions regarding one’s partner’s malicious intent and lack of love, attribution of causality to one’s own behavior and personality, attribution of causality to the partner’s behavior and personality, perceived ability of the couple to change, and expectancy of change in the relationship. All subscales except the subscale assessing attribution of causality to own behavior exhibited adequate internal consistency and showed evidence of construct validity in relation to measures of marital dysfunction. Multivariate analyses indicated that considering subscales in combination increases the measure’s ability to discriminate between clinical and nonclinical samples. The results demonstrate the utility of the MAS as a measure of dysfunctional cognitions associated with marital distress.

Stress and Stress Management: A Cognitive View

Extreme variability has been observed in individual responses to stressors. It appears that a more detailed analysis of individual variation in cognitions related to stress may result in a greater understanding of their differential responses. An idiographic cognitive model of the psychological processes that mediate stress and that underlie stress management techniques is presented in the form of an illustrative series of hypotheses based on Beck’s cognitive model (Beck, Rush, Shaw, & Emery, 1979). The model is presented in detail and is applied to a clinical case example in which traditional nomothetic stress management techniques were ineffective. The advantages and disadvantages of a more idiographic approach to stress are examined as are the implications of the cognitive view of stress for research and practice.

The Final Stage

The cognitive and behavioral interventions introduced in Chapter 2 and applied throughout the remainder of this volume are quite useful in helping clients overcome their problems and work toward their goals. However, there is much more to effective treatment than simply applying an assortment of therapeutic techniques. This chapter will discuss how to handle times when progress in therapy slows or stalls, how to accomplish the “deep” changes often needed to produce lasting change, and how to end therapy in a way that maximizes the likelihood that improvements will persist.

Passive-Aggressive Personality Disorder

The nature of Passive-Aggressive Personality Disorder is obvious from its name. This disorder has been referred to in many ways including “negativistic personality” (Millon, 1969), “oral-sadistic melancholiac” (Men-flinger, 1940), “emotionally unstable character” (Klein & Davis, 1969), “oppositional personality,” and “active-ambivalent personality” (Millon, 1981). Whatever it is called, it is one of the most frustrating and aggravating personality disorders to treat. As Millon (1981, p. 258) describes: The passive-aggressive s strategy of negativism, of being discontent and unpredictable, of being both seductive and rejecting, and of being demanding and then dissatisfied, is an effective weapon… with people in general. Switching among the roles of the martyr, the affronted, the aggrieved, the misunderstood, the contrite, the guilt-ridden, the sickly, and the overworked, is a tactic of interpersonal behavior that gains passive-aggressives the attention, reassurance, and dependency they crave while, at the same time, allowing them to subtly vent their angers and resentments.

Antisocial and Borderline Personality Disorders

DSM-IV-TR (2000) categorizes Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders together as Cluster B, the “dramatic cluster.” Certainly, individuals who meet diagnostic criteria for these disorders can be quite dramatic. Interventions directed toward improving impulse control, increasing emotional stability, and replacing maladaptive interpersonal behavior with more adaptive alternatives can be useful with each of these disorders. However, there are important differences among these disorders as well. Therefore, each of these disorders will be discussed separately. To keep the chapter to a manageable size, Antisocial and Borderline Personality Disorders will be discussed in this chapter and Histrionic and Narcissistic Personality Disorders will be discussed in Chapter 9.

Histrionic Personality Disorder

The use of the term hysteria has varied widely over its 4,000-year-history and has often been a source of controversy (Vieth, 1977). Hysteria has at times been used to refer to conversion disorder, Briquet’s syndrome, a personality disorder, and a personality trait. Perhaps most commonly, it has been used pejoratively to describe hyperexcitable female clients who are difficult to treat. The concept of hysteria has been strongly rejected by feminists who view it as a sexist label due to the denigrating use of the term hysterical to discount the problems presented by the female client. Perhaps as an attempt to reduce the confusion regarding the use of the term hysteria, the American Psychiatric Association does not include hysteria in DSM-III-R. Instead, separate categories of Somatization Disorder, Conversion Disorder, Hypochondriasis, Dissociative Disorders, and Histrionic Personality Disorder have been designated.

The Mid-Stage

Once the therapist and client have jointly agreed on treatment goals, the therapist will need a range of skills and techniques to implement the overall treatment strategy. The goal of this chapter is to describe the wide range of techniques that are used in Cognitive Therapy. The techniques will be broadly categorized as “cognitive” and “behavioral.” However, it is important to remember that a “behavioral” technique, such as assertion training, can be used to accomplish cognitive changes (i.e., changes in expectancies regarding the consequences of assertion), as well as changes in interpersonal behavior. Similarly, cognitive techniques are often intended to produce changes in behavior as well as cognition. Therefore, in our descriptions of these techniques, we will distinguish between those that primarily produce changes in cognition and those that primarily produce changes in behavior.

Cognitive Therapy in Groups

In the preceding chapters of this book, we have discussed the usefulness of individual Cognitive Therapy in the treatment of a wide variety of problems. However, individual therapy is not always available and is not always the preferred method of treatment. Group therapy can reduce the cost of treatment and alleviate long waits for appointments when there are too few therapists to satisfy the demand for individual therapy. Beyond these pragmatic considerations, treatment for some problems may be facilitated by the social contact, interpersonal interaction, and social support that can be a part of group therapy. In these situations, group Cognitive Therapy may be an effective alternative or adjunct to individual treatment.

Histrionic and Narcissistic Personality Disorders

In keeping with the drama inherent in this personality disorder, Histrionic Personality Disorder, itself, has had a dramatic history. The use of the term “histrionic” is relatively recent. Originally, the term used to describe this disorder was “Hysterical Personality.” The use of the term “hysteria” has varied widely over its 4000-year history and has often been a source of controversy (Vieth, 1977). Hysteria has at times been used to refer to conversion disorder, Briquet’s Syndrome, a personality disorder, and a personality trait. Perhaps most commonly, it has been used pejoratively to describe hyperexcitable female clients who are difficult to treat. The concept of hysteria has been strongly rejected by feminists who view it as a sexist label due to the denigrating use of the term “hysterical” to discount the problems presented by the female client. Perhaps as an attempt to reduce the confusion regarding the use of the term “hysteria,” the American Psychiatric Association did not include it in either DSM-III-R (1987) or DSM-IV-TR (2000). Instead, separate categories of Somatization Disorder, Conversion Disorder, Hypochondriasis, Dissociative Disorders, and Histrionic Personality Disorder have been designated. This chapter will focus on the treatment of people who fit the DSM-IV-TR criteria for Histrionic Personality Disorder (Table 9.1). Table 9.1. DSM-IV-TR Diagnostic Criteria for Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following : (1) is uncomfortable in situations in which he or she is not the center of attention (2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior (3) displays rapidly shifting and shallow expre ssion of emotions (4) consistently uses physical appearance to draw attention to sel (5) has a style of speech that is excessively impressionistic and lacking in detail (6) shows self-dramatization, theatricality, and exaggerated expression of em (7) is suggestible, i.e., easily influenced by others or circumstances (8) considers relationships to be more intimate than they actually are