Cognitive-Behavioral Therapy for Anxiety Disorders: Mastering Clinical Challenges

241 Pages·2010·3.04 MB·English

by  Gillian Butler PhD

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
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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