Karen M. Simon

Comprehensive Handbook of Cognitive Therapy

Theory and Research: The History of Cognition in Psychotherapy (A. Ellis). Cognitive Therapy (A.T. Beck & M. Weishaar). The Measurement of Cognition in Psychopathology: Clinical and Research Applications (J.O. Goldberg & B.F. Shaw). rocess and Outcome in Cognitive Therapy (E.E. Beckham & J.T. Watkins). Cognitive Therapy and Cognitive Science (D. Tataryn et al.). Constructs of the Mind in Mental Health and Psychotherapy (R.S. Lazarus). The Role of Cognitive Change in Psychotherapy (L.E. Beutler & P.D. Guest). Clinical Applications of Cognitive Therapy: Clinical Assessment in Cognitive Therapy (T. Merluzzi). Combined Cognitive Therapy and Pharmacology (J. Wright & R. Schrodt). Cognitive Restructuring through Guided Imagery: Lessons from Gestalt Therapy (D. Edwards). Cognitive Therapy with the Adult Depressed Patient (C. Perris). The Treatment of Suicidal Behavior (A. Freeman & D. White). Cognitive Therapy of Anxiety (A. Freeman & K.M. Simon). Cognitive and Behavioral Approaches to the Treatment of Anorexia Nervosa (S. Edgette & M. Prout). Treatment of Obesity (M. Cramer). 16 additional articles. Index.

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.

Cognitive therapy of anxiety.

Anxiety is among the most common of human responses. When experienced in moderate quantity, it can serve to motivate, energize, and mobilize the individual (Izard & Blumberg, 1985; Lindsley, 1952, 1957, 1960). Many people maintain that they “work best under pressure,” that is, when their anxiety level is high enough, they are motivated to do their best, or only, work. On the other hand, the anxiety level may be so high that it can debilitate the individual and cause both emotional and physical discomfort and pain (Lindsley, 1952, 1957, 1960). Although the particular permutations of cognitive and behavioral anxiety symptoms differ from person to person, the basic physiological concomittants of the experience are common to all people. We experience the emotion of anxiety because of the physiological correlates (Gray, 1985; Schacter, 1964, 1967; Spielberger 1966, 1972; Stokes, 1985; Weiner, 1985). These physiological sequalae can affect every system of the body causing dermal, respiratory, circulatory, gastrointestinal, or muscular systems. In some cases, the problems can be severe enough to cause health problems, that is, ulcers, hypertension (Agras, 1985; Dimsdale, 1985). Given the potentially life-threatening impact of anxiety, it has persisted as a human response throughout human existence. Some authors have speculated that anxiety as a response mechanism has had survival value for the race (Plutchik, 1980), or a “significant evolutionary advantage” that “must have contributed in significant ways to adaptation to a dangerous environment” (Beck, 1985, p. 185).

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