Estrategias metodológicas

The first reported case of CBT for schizophrenia occurred in 1952 when Aaron Beck described successful treatment of delusions in a patient with schizophrenia (A. T. Beck 1952). However, systematic exploration of the possible role of CBT in treatment of schizophrenia and other psychoses did not begin until the early 1990s (Kingdon and Turkington 1991, 1994; Tarrier et al. 1993).

Over the past two decades, several books have been published that detail methods for performing CBT with psychotic patients (Chadwick et al. 1996; Kingdon and Turkington 1994, 2002, 2005); numerous outcome studies have been completed (reviewed in Chapter 8); and CBT applications for schizophrenia have been gaining increased acceptance. In the United Kingdom, where much of the research on CBT for psychoses has been conducted, the National Institute for Clinical Excellence (2002) guidelines for treatment of schizophrenia recommend a course of CBT for all patients who have this condition.

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CBT methods for schizophrenia use the same basic strategies used in treatment of nonpsychotic Axis I disorders. However, modifications are made in the therapeutic relationship, the pace of therapy, targets for interventions, and implementation of techniques. Because patients with schizophrenia often have difficulty engaging in therapy and can be stigmatized by this illness, considerable effort is expended early in CBT on building a collaborative therapeutic relationship. The therapist uses a gentle, nonthreatening questioning style to try to set the patient at ease.

Psychoeducation and the "normalizing rationale" are key elements of the beginning stages of CBT for schizophrenia (Kingdon and Turkington 1991, 2005). One part of this process is for therapists to ask patients to give their explanations of symptoms.

Often the responses reflect dysfunctional beliefs and thus offer useful opportunities for educating and destigmatizing (e.g., "The devil is talking to me," "I have done something terribly wrong and deserve to be punished," "Nobody else hears voices," "All doctors want to do is push pills—I won't take them").

The normalizing rationale can be a centerpiece of efforts to help patients understand their illnesses in more rational and affirming ways (Kingdon and Turkington 1991, 2005). The cognitive-behavioral therapist explains that experiences such as having paranoia or hearing voices are very common and can be induced by lack of sleep, sensory deprivation, medical illnesses, and other stresses. The discussion can then lead to presentation of a stress-vulnerability model for symptoms. The goal of this process is to help patients develop a conceptualization that has these core elements: 1) psychotic symptoms can occur in a wide range of people and thus can be a part of "normal" experience; 2) stress can interact with a biological vulnerability to produce or worsen symptoms; and 3) problems can be reduced or solved by learning ways to manage symptoms and cope with stress. If this conceptualization is understood and accepted, therapeutic work on reducing delusions and hallucinations and reversing negative symptoms is more likely to succeed.

CBT for delusions relies primarily on the use of Socratic questioning and guided discovery to gradually help patients see different perspectives. Examining the evidence can be a quite useful specific technique. For example, a patient might be asked to list the evidence for and against a belief that his food is being poisoned, people are following him, or microphones are hidden in the heating ducts. After the evidence is examined in a therapy session, homework assignments may be developed to test out the belief or to obtain further information. It is important for therapists to maintain an empirical stance when doing this type of work. Instead of trying to persuade the patient to give up a delusion, the therapist works with the patient to function as an investigative team. Together they explore evidence and attempt to draw the most rational conclusion.

An example of an examining the evidence exercise for a woman with paranoid schizophrenia is shown in Figure 7–4. As often happens in performing this type of exercise, the "evidence for" the delusional belief contains numerous cognitive errors that can be discussed in the therapy session. The intervention plan developed with this patient used graded exposure in a manner similar to the stepped approach used for anxiety disorders. This patient had been isolating herself in a darkened house with all of the shades drawn. Thus, a combined cognitive and behavioral intervention was used to decrease the intensity of her delusional belief and help her resume normal activities.

Figure 7–4. Examining the evidence for a delusional belief: people in red cars are trying to get me.

The CBT approach to hallucinations uses the educating and normalizing process outlined earlier to help patients understand these symptoms in the most adaptive way possible. The patient's attributions (explanation of causality) about these perceptions are elicited and discussed with the goal of developing an explanatory model that assists with coping. For example, a patient who first explained his auditory hallucinations as "coming from the devil" was eventually able to articulate and accept a much more adaptive construct: "I have an illness that affects my thinking and makes me hear voices . . . I don't need to pay attention to the voices or do what they say . . . The voices get softer and less bothersome when I pay less attention to them."

Therapeutic work with hallucinations also may involve developing lists of behaviors that either aggravate or reduce the intensity of the symptom. For example, a patient might note that lack of sleep, arguments with parents, and spending time alone with

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nothing to do may make her voices worse. Conversely, listening to soothing music, socializing with a friend, working on crafts projects, and going out to eat may reduce the hallucinations. Behavioral plans can be made to cope with aggravating influences and to use identified coping methods more frequently. If patients have difficulty finding ways to reduce hallucinations, it can be helpful to provide them with a list of commonly used strategies (see Kingdon and Turkington 2005, p. 123 for examples of coping methods).

Cognitive and behavioral interventions for negative symptoms are less direct than techniques for positive symptoms. Kingdon and Turkington (2005) recommend a "go slow" approach for negative symptoms. Instead of trying to aggressively push patients to break patterns of social isolation or apathy, therapists gradually build the therapeutic relationship and assist patients to meet their goals for change—even if these goals are rather modest. When patients are ready to begin changing negative symptoms, therapists may suggest techniques such as graded task assignments to help them take sequential steps toward improvement.

Eating Disorders

As noted in Chapter 8, CBT has been shown to be effective for bulimia and binge-eating disorder. Cognitive therapy for these conditions focuses on maladaptive beliefs about food, weight, body image, and self-worth and associated dysfunctional behaviors (Fairburn et al. 2003; Garner et al. 1997). Treatment plans typically start with behavioral interventions aimed at normalizing eating behavior, progresses to cognitive interventions aimed at underlying beliefs and maladaptive cognitions, and then concludes with relapse prevention strategies (Wonderlich et al. 2004).

Self-Monitoring and Meal Planning

In the first phase of treatment, patients create a self-monitoring form and use it to record everything they eat and any associated eating disorder symptoms. Patients record the time of day; the content of the meal; where the meal was consumed;

whether it was a snack, binge, or meal; whether it was a planned or an unplanned meal; whether it led to associated purging, use of laxatives, or exercise; and associated thoughts and feelings.

A collaborative meal prescription can be used for some patients who require more structure (Garner and Bemis 1982). The eating prescription is a detailed written meal plan instructing patients when to eat, specifying the foods to be consumed, specifying where the meal is to be eaten, and indicating the duration of the meal. It temporarily takes "the decision" out of eating behavior. Meal planning can be implemented incrementally, with the initial focus on spacing meals throughout the day, lengthening the duration of eating within the meal, and eating foods the patient considers safe. After the early stages of meal planning are mastered, the therapist and patient can increase the quantity of food eaten and the range of food consumed.

Cognitive Restructuring

Individuals with eating disorders are taught to examine their cognitions carefully, identify instances of maladaptive thinking, and attempt to identify a more adaptive response to the cue or situation. For example, a person with an eating disorder may be trying on some clothes (stimulus) and have the thought "I look like an elephant." This thought is associated with disgust and sadness (emotional response) and may increase the likelihood of dieting or purging. Table 7–7 displays the five key cognitive constructs found in persons with eating disorders (Cooper et al. 2004).

Table 7–7. Cognitive domains and cognitive-behavioral therapy methods for eating disorders Cognitive domain Typical automatic

Graded exposure experiment with analysis of feared outcome Meal prescription

Decatastrophizing Thought change records

"I have to be thin to be successful."

Survey others to gain more realistic view

"If I don't exercise 2 hours a day, I'll get fat."

Gradually decrease safety behaviors and monitor frequency or effect of feared outcome; analysis of the advantages and disadvantages of change

Mood (emotion) intolerance "I can't take this." Gradual elimination of safety behaviors that allow patient to avoid mood states

Graded exposure to distressful feelings

"When I am upset, I have lost all control."

Thought change records (challenge dichotomous reasoning) Survey on the meaning of emotions or feelings

Low self-esteem "If I am not perfect, I'm nothing."

Cognitive rehearsal (practice being not perfect and monitor for feared outcome)

"I'm no good. . . stupid. . . ugly."

Thought change records (distill vague statements about self into specific beliefs to make the distortion highly apparent)

Practice tasks or situations in which belief will be challenged

Perfectionism "I must do things perfectly." Activity scheduling/planning (reduce checking of performance with specific activities or increase activities with the specific purpose of pleasure) Interpersonal difficulties "I can't let anyone down

(they are counting on me)."

Exposure to putting own needs first, with analysis of feared consequences

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Cognitive domain Typical automatic thoughts

Cognitive or behavioral methods

"I will upset them if I tell them what I really think."

Role-playing/assertiveness training in sessions; graded practice of expressing emotions and feelings

Source. Adapted from Cooper M, Whitehead L, Boughton N: "Eating Disorders," in Oxford Guide to Behavioural Experiments in Cognitive Therapy. Edited by Bennett-Levy J, Butler G, Fennell M, et al. New York, Oxford University Press, 2004, pp. 269–272. Used with permission.

If possible, the therapist helps the patient to move toward examining deeper self-schemas and their linked behavioral patterns (Garner et al. 1997). For example, patients with eating disorders often have poor self-esteem and devote a considerable amount of time to keeping a "balance sheet" of daily accomplishments and shortcomings. The technique of decentering can be used to look at the patient's approach to self-worth and need to maintain perfection. Decentering involves asking patients if other individuals are considered less worthwhile if they make mistakes or do not perform well on a particular day. Would they consider the therapist "a loser" or less worthwhile if an appointment started 5 minutes late? Decentering and a variety of other cognitive restructuring techniques discussed earlier in this chapter can be used to help patients modify rigidly held schemas.

Bipolar Disorder

The primary emphasis of CBT for bipolar disorder is on helping patients learn to monitor symptoms effectively, identify potential triggers for relapse, and develop skills for halting escalation into depression or mania (Basco and Rush 2005). Because patients with this condition often downplay the significance of symptoms of hypomania or mania, or may completely deny that they have a problem, the opening phase of treatment is often devoted to developing an effective working relationship and providing psychoeducation. Readings such as An Unquiet Mind (Jamison 1995) are typically suggested for both patients and family. Later, if patients have an improved understanding of their illness and accept treatment, The Bipolar Workbook: Tools for Controlling Your Mood Swings (Basco 2006) can be a very useful tool for learning CBT skills for managing this disorder.

Mood graphs are a frequently used tool for increasing patient awareness (Basco and Rush 2005). Another helpful method suggested by Basco and Rush 2005) is a symptom summary worksheet. This exercise assists patients with identifying early warning signs of impending mood shifts, in addition to the more pronounced signs of full episodes of depression or mania. In the example provided in Figure 7–5, a middle-aged man with bipolar disorder was able to spot several indicators of possible

switches to hypomania or depression. His worksheet could be used to plan interventions to decrease the risk for an escalation of symptoms. He could agree to curtail his Internet research to no more than 30 minutes on weeknights and 1 hour during the day on weekends. Another intervention could be a CBT exercise to list advantages and disadvantages of trying again to start a home-based business. During past episodes of hypomania, he had made unwise financial decisions about starting businesses that ultimately failed. A fully developed relapse prevention plan for this patient would include various coping strategies for limiting the development of both hypomanic and depressive symptoms.

Figure 7–5. A symptom summary worksheet: early warning signs of hypomania and depression.

Other common targets for CBT interventions in bipolar disorder are 1) sleep disruption, 2) pharmacotherapy nonadherence, 3) cognitive distortions and automatic thoughts in mania, 4) stress, and 5) lack of a daily routine. CBT methods for insomnia have proven to be quite effective (Edinger et al. 2001; Sivertsen et al. 2006) and are used routinely in the treatment of bipolar disorder (Basco and Rush 2005). Adherence is promoted by use of behavioral reminder systems and by eliciting and modifying dysfunctional attitudes about taking medication. Therapists may help patients identify barriers to adherence and then design plans to overcome these obstacles. CBT for automatic thoughts and cognitive errors in hypomania or mania can use standard interventions such as thought change records and examining the evidence exercises. However, the focus is on positively distorted cognitions, underestimates of risk, and externalization of blame.

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The importance of following a daily routine has been confirmed in research on social rhythm therapy for bipolar disorder (Frank et al. 2005). In CBT, therapists inquire about habits of sleep and wake times, mealtimes, work schedules, and other activities that define patients' daily schedules. If significant irregularity occurs in the daily schedule, changes are recommended to reduce this variability. CBT methods for bipolar disorder also may include work on building stress management skills. For example, relaxation training, breathing exercises, or imagery could be applied to reduce tension; pleasant event scheduling could be used to provide healthy distractions from stressful situations; or efforts could be made to enhance problem-solving capacity.

CONCLUSION

CBT methods are based directly on core theories of altered information processing and associated maladaptive behavior in psychiatric disorders. Therapists select techniques on the basis of an individualized CBT formulation, the patient's diagnosis, and the objectives or agenda that is collaboratively set during each session. General or nonspecific features of all effective

psychotherapies are also important in CBT. Thus, therapists work to promote understanding, trust, genuineness, and accurate empathy. The CBT relationship is highly collaborative and active. Specific emphasis is placed on psychoeducation, structuring sessions, and enhancing learning and skill acquisition. A variety of cognitive techniques such as thought recording, examining the evidence, and rehearsal are used to modify dysfunctional automatic thoughts and schemas. Also, behavioral methods such as activity scheduling, graded task assignments, and exposure and response prevention are used routinely in CBT sessions.

CBT has been studied extensively in randomized controlled trials, and detailed treatment guidelines and techniques have been described for most psychiatric conditions. Future challenges for CBT include the study of methods to further enhance treatment results, detailed examination of predictors for outcome, incorporation of new developments in computer-assisted learning or other technologies, and research on best practices for dissemination of CBT methods to trainees across health care disciplines and in various health care settings.

KEY POINTS

Cognitive-behavioral therapy (CBT) methods are constructed from the basic theories and experimental findings on cognitive and behavioral pathology in specific psychiatric disorders.

Prior to the selection and implementation of specific CBT methods, the patient's unique history is understood through the lens of cognitive and behavioral theory. Specific methods are then selected that match the patient's problems, symptoms, assets, and potential.

General CBT methods such as the collaborative-empirical therapeutic relationship and structuring procedures are used across sessions and are incorporated into the treatment of all disorders.

All CBT treatment plans aim to modify patients' maladaptive automatic thoughts and schemas. Various cognitive methods enable patients to engage in this process.

Several methods target problematic behaviors associated with depression and anxiety. These methods include activity monitoring, behavioral activation, and exposure and response prevention and are also incorporated into the treatments of other disorders.

CBT methods for schizophrenia include many of the typical procedures for depression and anxiety conditions. However, the "normalizing rationale" is central to assisting patients to understand their illness in a more rational and affirming way.

CBT methods for eating disorders focus on maladaptive beliefs about food, weight, body image, and self-worth and on dysfunctional behaviors.

The primary emphasis of CBT for bipolar disorder is on helping patients learn to monitor symptoms effectively, identify triggers for relapse, and develop skills for halting escalation into depression or mania.

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