THE EVIDENCE BASED PRACTITIONER

Zindel Segal, PhD - University of Toronto Scarborough

In 2015 Sona Dimidjian and I published a paper in which we examined the prospects for a clinical science of mindfulness-based interventions (MBIs).  We reported that the prospects looked good on the evidence front but were less promising on the public health front.  Some might say that mindfulness-based treatments have cleared the hurdle of efficacy only to stumble over the hurdles of reach and impact. Maybe this is a natural developmental trajectory for a set of treatments that have only been around for 20-30 years. One could even argue that it makes sense to demonstrate that a given approach actually works before investing too greatly in its dissemination.  But, this argument seems shaky when we consider that Kazdin & Blase made a similar point in 2011 regarding evidence-based interventions, such as BT and CBT, that have been around far longer than MBIs – strong on the data side but weak on delivery side.

I have experienced this phenomenon first hand in my own work with Mindfulness Based Cognitive Therapy (MBCT).  With our treatment manual now having been in print for close to 16 years, with a yearly slate of training workshops being offered and with MBCT being listed as a first line prevention intervention in a number of national Depression Treatment guidelines, it is still hard for most people to find an MBCT therapist.  This is perplexing.  I also know that I am not alone in asking; what good is a well-supported intervention if it sits on the shelf and fails to make it into the hands of those who need it most?  My response to this dilemma has been twofold.

One strategy has involved directly focusing on MBCT dissemination and quality by providing the public with a way to find MBCT therapists who have been trained to a recognized level of competence in this approach.  Willem Kuyken and I have launched a freely available, searchable, standards-based international registry of MBCT therapists that will allow members of the public to find MBCT therapists who practice in their community.  We have named this registry ACCESS MBCT www.accessmbct.com - you can search by either city or country and it will provide you with a list of registered MBCT therapists practicing in your area.  Also, if you know the name of a provider and want to see if they are listed on the registry, you can search by name as well.

In this way, ACCESS MBCT serves a quality assurance function.  All members of ACCESS MBCT will have to have been trained according to the steps outlined in the MBCT Training Pathway  oxfordmindfulness.org/wp-content/uploads/2018/02/MBCT-Training-Pathway.pdf . Adopting this document to set our training threshold reflects the recognition that our field has evolved from the days when having a personal mindfulness practice, a clinical background and familiarity with the contents of Segal et al., 2002 would qualify one to teach MBCT. It is increasingly clear to me that MBCT is not preferentially defined according to its mindfulness or cognitive therapy axes, but rather from the integrative embodiment of these perspectives in the act of teaching.  Not surprisingly, additional training experiences are required to develop this capacity and it is our intention that being a member of ACCESS MBCT will communicate this standard to the public.  Deciding on this particular framework for ACCESS MBCT was achieved via broad consultation and feedback.  We considered a variety of listing/registry models, with varying amounts of oversight and settled on a solution that relies on verifiable self-declarations provided by therapists/applicants interested in joining ACCESS MBCT.  Please take a few minutes to check out the ACCESS MBCT website and watch the brief video of the Digital International Announcement for the Registry that was held at the end of 2017 - you may recognize a few familiar faces at www.accessmbct.com.

The second strategy to increase access to MBCT has been to digitize the in-person 8 week program and make it available online so that people could access it from the comfort of their own homes.  The program is called Mindful Mood Balance (MMB) and takes a person through 8 separate sessions that present identical content to what folks attending the in-person groups are learning and practicing.  While we have some preliminary data indicating that this program is effective in reducing residual depressive symptoms (Dimidjian et al., 2014), we are completing an RCT with 460 patients that will provide a more definitive evaluation.  We have also adapted Mindful Mood Balance so that therapists interested in learning MBCT but who can’t find a group in their neighbourhood can complete the program online. MMBPro   www.mindfulnoggin.com/mindful-mood-balance   is now recognized as an acceptable format for both within the MBCT Training Pathway and is being used to supplement training programs in Canada, the US and the UK.

Needless to say, my graduate training never prepared me to address issues of dissemination and implementation, but it is increasingly clear that for our field to stay relevant in the provision of empirically supported treatments, these are pivotal issues that need to be addressed.

Dimidjian S, Beck A, Felder JN, Boggs JM, Gallop R, Segal ZV. Web-based Mindfulness-based Cognitive Therapy for reducing residual depressive symptoms: An open trial and quasi-experimental comparison to propensity score matched controls. Behav Res Ther. 2014 Dec;63:83-9.

Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-based intervention.  Am Psychol. 2015 Oct;70(7):593-620.

Kazdin AE, Blase SL. Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness. Perspect Psychol Sci. 2011 Jan;6(1):21-37.

Published October 26, 2018

Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine

Empirical Support for CBT with Suicidal Patients

There is a growing body of research suggesting that CBT-related approaches that specifically target suicidality lead to a reduction in suicidal behavior, at least during the critical period of time following a suicide attempt when the risk for further attempts is high (see Monti, Cedereke, & Ojehagen, 2003) and up to two years of assessed follow-up. Commonalities among the CBT-based treatment approaches reviewed below are more prominent than their relatively minor procedural and terminology differences. What they have in common is an assessment process that uses empathic interviewing, psychometrically supported measures, and a combination of functional analyses and cognitive conceptualizations in order to understand the chain reaction of external events (precipitants and consequences) and internal reactions (thoughts, feelings, physiological responses, and behaviors) that comprise the suicidal crises. Further, these approaches are alike in that they teach suicidal patients psychological skills such as self-monitoring, reflecting on their intended actions rather than responding reflexively, engaging in constructive actions, rationally responding to combat a sense of helplessness and hopelessness, reaching out to their social supports to counteract a sense of isolation, and contacting mental health professionals (including those by whom they are being treated, and others who are “on call,” such as those in hospitals and on crisis hotlines). These interventions can be used as part of a larger, general package of CBT for the full range of problems that patients bring to treatment, or they can be stand-alone treatments. When they are used as single-contact interventions in emergency departments (Stanley & Brown, 2012) or as brief treatments in inpatient facilities (e.g., Ellis & Ruffino, 2015), they can be learned and applied by well-trained mental health professionals regardless of their self-identified theoretical orientation.

A randomized controlled trial showing the efficacy of a brief Beckian cognitive therapy protocol in reducing suicide attempts in a high-risk population was conducted by Brown, Ten Have, Henriques, Xie, Hollander, and Beck (2005). The 120 patients in this study had presented with a suicide attempt in the emergency department, and were recruited within 48 hours for random assignment either to a treatment-as-usual condition or a 10-session cognitive therapy package (identified as Cognitive Therapy for Suicide Prevention, or CT-SP) in addition to treatment as usual (all of which was conducted post-discharge). Participants in the cognitive therapy group were 50% less likely to re-attempt suicide during follow-up, and they showed significantly lower depression and hopelessness. A very similar version of brief CBT was successfully tested in a military sample of active-duty Army soldiers who had made a suicide attempt within the past month or who had suicidal ideation with intent to die in the past week (Rudd et al., 2015). Half of the cohort (n=76) was randomly assigned to the treatment-as-usual condition, and the other half (n=76) was randomly assigned to brief CBT (12 sessions) plus treatment as usual. Similar to the Brown et al. treatment study (2005), the Rudd et al. (2015) program utilized a CBT approach that specifically focused on the symptoms of suicidality (including the patients’ belief systems pertinent to their thoughts about life and death), as well as on safety planning and relapse prevention. During the two-year follow-up period, those receiving CBT were 60% less likely to make a suicide attempt.

The Collaborative Assessment and Management of Suicidality (CAMS: Jobes, 2006; 2012) is a therapeutic approach that self-identifies as being applicable in conjunction with treatments across the theoretical spectrum but nonetheless borrows heavily from CBT methods. In a non-randomized control comparison study, CAMS was associated with reductions in suicidal ideation in comparison to treatment as usual, and was significantly linked to decreases in emergency department utilization during the 6-month follow-up period (Jobes et al., 2005). In a randomized trial, a brief course of outpatient CAMS was shown to reduce suicidal thinking and general symptom distress significantly, and to increase hopefulness and reasons for living at 12-month follow-up more so than an enhanced care-as-usual approach (Comtois et al., 2011). When provided to hospitalized patients in an individual therapy format, CAMS led to significantly greater improvements on measures specific to suicidal ideation and suicidal cognitions compared to inpatients who did not receive the CAMS interventions (Ellis, Rufino, Allen, Fowler, & Jobes, 2015).

Safety Planning Intervention (SPI: Stanley & Brown, 2012) consists of the same steps as described earlier, but in a condensed, written format that serves as a guide to aftercare and follow-up when suicidal patients exit the emergency department following a single contact. The basic elements of the written SPI are: (1) identifying early warning signs of heightened suicide risk, (2) employing prepared, internal coping strategies, (3) utilizing social settings and contacts to distract from suicidal preoccupation, (4) contacting friends and family members for support in times of crisis; (5) contacting mental health practitioners or agencies, and (6) restricting access to lethal means. Stanley and Brown (2012) report that SPI has been used as part of other evidence-based psychotherapy interventions in clinical trial research.

Another CBT approach that has been applied to suicidal individuals in inpatient settings is Post Admission Cognitive Therapy (PACT: Ghahramanlou-Holloway, Cox, & Greene, 2012). PACT emphasizes helping patients face the stressors that are often encountered following discharge from hospital; stressors that if not managed properly can easily trigger a relapse of suicidal thoughts, feelings, urges and behaviors. Indeed, the period of time when patients are re-acclimating to life outside of the hospital is a period of high risk for another suicide attempt (Ghahramanlou-Holloway, Neely, & Tucker, 2015). PACT has the same treatment objectives as outpatient CBT (e.g., identifying and modifying the cognitive, emotional, and behavioral factors that comprise the patient’s “suicidal mode”), but also helps patients develop the problem-solving skills they will need on the outside. The goals include improving the patient’s self-efficacy in dealing with the demands of their life situation and increasing their compliance with adjunctive medical, social, psychiatric, and substance abuse interventions both during and after hospitalization. In a highly related line of clinical research, a subset of problem-solving that focuses on emotional self-regulation and interpersonal concerns (Emotion-Centered Problem-Solving Therapy: EC-PST, Nezu & Nezu, in press) is also showing promise as a means by which to help highly distressed persons to feel more personally empowered, and to refrain from translating negative affect into self-harm.

It is also important to acknowledge the contribution of dialectical behavior therapy (DBT) to the treatment literature on suicide risk reduction (e.g., Linehan et al., 2006; Linehan et al., 2015). Although DBT is a distinct treatment that involves components of care that are not routinely included in standard CBT packages (e.g., a DBT skills group to go along with individual treatment; regular between-sessions phone contacts), DBT and the CBT approaches mentioned in this review have the same common theoretical roots. Brown et al. (2012) note that their CT-SP treatment and DBT both focus on preventing suicidal behavior by teaching high-risk patients specific coping skills. A noteworthy component of DBT is mindfulness, a self-regulation skill that itself has some empirical support as a method that reduces suicidal behavior in those at risk (see Chesin, Sonmez, Benjamin-Beeler, Brodsky, & Stanley, 2015).

CBT can be applied to suicidal children and adolescents. For example, a randomized controlled trial conducted by Esposito-Smythers and Spirito (2004) on hospitalized adolescents with a substance use disorder and at least one suicide attempt in the previous three weeks showed the superiority of CBT over enhanced treatment as usual on outcomes related to substance use, suicide attempts, emergency department visits, and arrests. The adolescents who received CBT also showed better treatment adherence. Another CBT approach currently being applied to the treatment of suicidal adolescents is the aptly named Treatment of Adolescent Suicide Attempters (TASA: Brent et al., 2009). The authors emphasize the importance of safety planning and increased frequency of therapeutic contact early in treatment. Additionally, a treatment model for young suicidal patients that includes working with the family -- called Safe Alternatives for Teens and Youths (SAFETY) – was shown in a randomized, controlled trial to reduce suicide attempts in adolescents presenting with recent self-harm (Asarnow, Hughes, Babeva, & Sugar, 2017). The authors describe the SAFETY program as a cognitive-behavioral, dialectical behavior-therapy informed family treatment.

Although the studies noted above suggest that even brief CBT interventions for suicidality can be efficacious, a longitudinal approach to the treatment of suicidality may be best. There is evidence that even when patients respond well to treatment they are prone to residual symptoms – including sub-optimally modified dysfunctional beliefs about suicide – that may keep them at elevated risk in the future. Also, in outpatient work with suicidal individuals, spotty attendance and early drop-out from treatment take on added significance. There is evidence that those patients who are most at risk (e.g., having a history of multiple suicide attempts) tend to be least likely to avail themselves of regular therapy sessions (see Berk, Henriques, Warman, Brown, & Beck, 2004; Joiner & Rudd, 2000). Similarly, suicidal patients who opt to discontinue therapy without having a formal concluding session to summarize their gains and formulate a maintenance plan, and/or while still demonstrating hopelessness (e.g., as assessed via their last-completed BHS) are at higher ongoing risk for suicide than those who complete treatment with a better sense of hope and direction (Dahlsgaard, Beck, & Brown, 1998). Thus, therapists cannot remain passive when their suicidal patients are absent from treatment in an unanticipated way. Instead, therapists would do well to try to reconnect with the patients, such as by calling and leaving caring messages that invite the patients to come in for an appointment as soon as possible (Brown et al., 2012). A randomized controlled trial by Motto and Bostrom (2001) also showed that even after therapy is completed, some simple acts of positive outreach (e.g., a birthday card with a pleasant message) can lower suicide risk well after termination.

Concluding Comments

Helping a patient to relinquish suicidal intentions and behaviors is a process. The CBT practitioner makes gradual inroads by establishing a genuinely caring therapeutic relationship, constructing a clear and comprehensive framework for the work of therapy, collaborating with the patient on a treatment plan involving skill-building and safeguarding, and offering a steady flow of words of empathy, support, encouragement, and hope. No single intervention in any given session is likely to put a definitive end to the patient’s risk for suicide. However, each intervention contributes to an incremental lowering of risk, especially if the therapist succeeds in motivating the patient to practice a range of self-help methods between therapy sessions for homework. In sum, the therapist offers the suicidal patient hope and a plan, bolstered by a healthy therapeutic relationship characterized by accurate empathy for the patient’s unique experiences, and ongoing positive reinforcement for learning durable psychological skills.

Asarnow, J. R., Hughes, J. L., Babeva, K. A., & Sugar, C. A. (2017). Cognitive-behavioral family treatment for suicide attempt prevention: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 506-514.

Beck, A.T., Brown, G. K., Berchick, R. J., Stewart, B. L., & Steer, R. A. (1990). Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. American Journal of Psychiatry, 147, 190-195.

Beck, A. T., Brown, G. K., Steer, R. A., Dahlsgaard, K. K., & Grisham, J. R. (1999). Suicide ideation at its worst point: A predictor of eventual suicide in psychiatric outpatients. Suicide and Life-Threatening Behavior, 29, 1-9.

Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47, 343-352.

Beck, A.T., Steer, R. A., Beck, J. S., & Newman, C. F. (1993). Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide and Life-Threatening, 23, 139-145.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.

Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142, 559-563.

Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, 499-505.

Berk, M. S., Henriques, G. R., Warman, D. M., Brown, G. K., & Beck, A. T. (2004). A cognitive therapy intervention for suicide attempters: An overview of the treatment and case examples. Cognitive and Behavioral Practice, 11, 265-277.

Brent, D. A., Greenhill, L. L., Compton, S., Emslie, G., Wells, K., Walkup, J., … & Blake, T. J. (2009). The Treatment of Adolescent Suicide Attempts (TASA) study: Predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 987-996.

Britton, P. C., Bryan, C. J., & Valenstein, M. (2016). Motivational interviewing for means restriction counseling with patients at risk for suicide. Cognitive and Behavioral Practice, 23, 51-61.

Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.

Brown, G. K., Jeglic, E., Henriques, G. R., & Beck, A. T. (2006). Cognitive therapy, cognition, and suicidal behavior. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 53-74). Washington, D.C.: American Psychological Association.

Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. D., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294, 563-570.

Brown, G. K., Wright, J, H., Thase, M. E., & Beck, A. T. (2012). Cognitive therapy for suicide prevention. In R. I. Simon & R. E. Hales (Eds.), Textbook of suicide assessment and management (pp. 233-249). Washington, DC: American Psychiatric Publishing.

Bryan, C. J. (Ed.) (2015). Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings. New York: Routledge.

Bryan, C. J., Rudd, M. D., Wertenberger, E., Etienne, N., Ray-Sannerud, B. N., Peterson, A. L., & Young-McCaughom, S. (2014). Improving the detection and prediction of suicidal behavior among military personnel by measuring suicidal beliefs: An evaluation of the Suicide Cognitions Scale. Journal of Affective Disorders, 159, 15-22.

Chesin, M. S., Sonmez, C. C., Benjamin-Phillips, C. A., Beller, B., Brodsy, B. S, & Stanley, B. (2015). Preliminary effectiveness of adjunct mimdfulness-based cognitive therapy to prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness, 6, 1345-1355.

Clemans, T. A. (2015). A cognitive behavioral model of suicide risk. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 51-64). New York: Routledge.

Comtois, K. A., Jobes, D. A., O’Connor, S. S., Atkins, D. A., Janus, K. I., Chessen, C. E., … & Yuodelis-Flores, C. (2011). Collaborative Assessment and Management of Suicidality (CAMS): Feasibility trial for next day appointment services. Depression and Anxiety, 28, 963-972.

Dahlsgaard, K. K., Beck, A. T., & Brown, G. K. (1998). Inadequate response to therapy as a predictor of suicide. Suicide and Life-Threatening Behavior, 28, 197-204.

Ellis, T. E., & Newman, C. F. (1996). Choosing to live: How to defeat suicide through cognitive therapy. Oakland, CA: New Harbinger Publications.

Ellis, T. E., & Rufino, K. A. (2015). A psychometric study of the Suicide Cognitions Scale with psychiatric inpatients. Psychological Assessment, 27, 82-89.

Ellis, T. E., Rufino, K. A., Allen, J. G., Fowler, J. C., & Jobes, D. A. (2015). Impact of a suicide-specific intervention within inpatient psychiatric care: The Collaborative Assessment and Management of Suicidality (CAMS). Suicide and Life-Threatening Behavior, 45, 556-566.

Esposito-Smythers, C., & Spirito, A. (2004). Adolescent substance use and suicidal behavior: A review with implications for treatment research. Alcoholism: Clinical and Experimental Research, 28, 77S-88S.

Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18, 156-172.

Ghahramanlou-Holloway, M., Cox, D., & Greene, F. (2012). Post-admission cognitive therapy: A brief intervention for psychiatric inpatients admitted after a suicide attempt. Cognitive and Behavioral Practice, 19, 116-125.

Ghahramanlou-Holloway, M., Neely, L. L., & Tucker, J. (2015). Treating risk for self-directed violence in inpatient settings. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 91-109). New York: Routledge.

Green, K. L., & Brown, G. K. (2015). Cognitive therapy for suicide prevention: An illustrated case example. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 65-88). New York: Routledge.

Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford.

Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42, 640-653.

Jobes, D. A., Wong, S. A., Kiernan, A., Conrad, A. K., Drozd, J. F., & Neal-Walden, T. (2005). The collaborative assessment and management of suicidality vs. treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behavior, 35, 483-497.

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Consulting and Clinical Psychology, 68, 909-916.

Joiner, T. E., Steer, R. A., Brown, G., Beck, A. T., Petit, J. W., & Rudd, M. D. (2003). Worst-point suicidal plans: A dimension of suicidality predictive of past suicide attempts and eventual death by suicide. Behaviour Research and Therapy, 41, 1469-1480.

Joiner, T. E., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd, M. D. (2009). Main predictors of the interpersonal-psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology, 188, 634-646.

Kuyken W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York: Guilford.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Hedard, H. L., … & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behavior and borderline personality disorder. Archives of General Psychiatry, 63, 757-766.

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A, Neacsiu, A. D., … & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. Journal of the American Medical Association, 72, 475-482.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press.

Miranda, R., Gallagher, M., Bauchner, B., Vaysman, R., & Marroquín, B. (2012). Cognitive inflexibility as a prospective predictor of suicidal ideation among young adults with a suicide attempt history. Depression and Anxiety, 29(3), 180–186.

Miranda, R., Valderrama, J., Tsypes, A., Gadol, E., & Gallagher, M. (2013). Cognitive inflexibility and suicidal ideation: Mediating role of brooding and hopelessness. Psychiatry Research, 210, 174-181.

Monti, K. M., Cedereke, M., & Ojehagen, A. (2003). Treatment attendance and suicidal behavior 1 month and 3 months after a suicide attempt: A comparison between two samples. Archives of Suicide Research, 7, 167-174.

Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of post-crisis suicide intervention. Psychiatric Services, 52, 828-833.

Newman, C. F. (2015). Cognitive restructuring / cognitive therapy. In A. M. Nezu & C. M. Nezu (Eds.). Oxford handbook of cognitive and behavioral therapies (pp. 118-141). NewYork: Oxford University Press.

Nezu, A. M., Nezu, C. M., & D’Zurilla, T. (2013). Problem-solving therapy: A treatment manual. New York: Springer.

Nezu, A. M. & Nezu, C. M. (in press). Emotion-centered problem-solving therapy. In A. Wenzel (Ed.), Handbook of cognitive behavioral therapy. Washington, DC: American Psychological Association.

Nezu, A. M., Nezu, C. M., Stern, J. B., Greenfield, A. P., Diaz, C., & Hays, A. M. (2017). Social problem-solving moderates emotion reactivity in predicting suicide ideation among U.S. veterans. Military Behavioral Health, 5, 417-426

O'Connor, R. C. (2007). The relation between perfectionism and suicidality: A systematic review. Suicide and Life-Threatening Behavior, 37(6), 698-714.

Peak, N. J., Overholser, J. C., Ridley, J., Braden, A., Fisher, L., Bixler, J., & Chandler, M. (2015). Too much to bear: Psychometric evidence supporting the Perceived Burdensomeness Scale. Psychiatry Research, 228, 554-550.

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., … & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266-1277.

Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., ... & Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172, 441-449.

Simon, R. I. (2007). Gun safety management with patients at risk for suicide. Suicide and Life Threatening Behavior, 37, 518-526.

Smith, J. M., Alloy, L. B., & Abramson, L. Y. (2006). Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: Multiple pathways to self-injurious thinking. Suicide and Life-Threatening Behavior, 36, 443-454.

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256-264.

Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal clients: Scientific and clinical applications. Washington, D.C.: American Psychological Association.

Woods, A. P. (2018, May). Problem-solving as a predictor of suicidal thoughts and behaviors. Unpublished doctoral dissertation. Drexel University, Philadelphia, PA.

Published June 25, 2018

Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine

Introduction

Suicide is a significant public health problem both at home and abroad, and therefore is an area of major importance for mental health intervention. Cognitive-behavioral interventions that specifically target suicidality are showing promise in significantly reducing potentially lethal self-directed violence in patients at high risk.

Assessment

When patients present with suicidal ideation, intent, and/or recent self-harming behaviors, the clinician conducts a comprehensive suicide risk assessment (Bryan, 2015; Wenzel, Brown, & Beck, 2009). An assessment includes interviewing patients about their suicidal thoughts, observing their behavior directly, obtaining information from other pertinent sources (e.g., medical records, verbal reports from others, family history), and using psychometrically sound assessment inventories (several of which appear in Box 1).

Box 1. Inventories to Assess Suicidality
The Beck Scale for Suicide Ideation (BSSI: Beck, Kovacs, & Weissman, 1979): The BSSI is an interview-based instrument that addresses multiple factors pertinent to a patient’s suicidality. The BSSI includes a section that inquires about the patient’s worst past episode of suicidality. This adds important information, as there is evidence that future risk for suicide is significantly linked to past severity of suicidality, even if the patient’s current risk level is low (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999; Joiner, Steer, Brown, Beck, Petit, & Rudd 2003).
The Beck Hopelessness Scale (BHS: Beck, Weissman, Lester, & Trexler, 1974): The BHS is a 20-item “true-false” self-report inventory that assesses patients’ views of their future, with such items as, “I might as well give up because there is nothing I can do about making things better for myself.” Hopelessness has been shown to be a mediator between depression and suicidality, and has predictive validity for deaths by suicide (Brown, Jeglic, Henriques, & Beck, 2006).
The Beck Depression Inventory-II (BDI-II: Beck, Steer, & Brown, 1996): This 21-item self-report measure of the severity of depression contains items pertinent to hopelessness (#2) and suicidality (#9). When patients fill out the BDI-II at each session, therapists can eyeball these two scoring items for a quick, concise understanding of the patients’ current level of suicide risk, and can ask the patients to discuss their inventory responses as part of the session agenda.
The Columbia-Suicide Severity Rating Scale (C-SSRS: Posner et al., 2011): The C-SSRS is an interview-based scale measuring patients’ past and current suicidal ideation and behavior. It addresses the four constructs of severity, intensity, behavior, and lethality.

The Suicide Cognitions Scale (SCS: Bryan et al., 2014): The SCS is an 18-item self-report instrument. Patients rate their strength of belief in each item on a 0-5 Likert-type scale. The two main constructs underlying the items are the suicidal schemas of unbearability and unlovability.

If a patient presenting for treatment has previously engaged in self-directed violence, the clinician inquires about the patient’s level of intent (e.g., impulsive versus planned; communicating the need for help versus wanting to die), degree of lethality of the method used (e.g., taking several pills or superficially cutting one’s wrist, versus trying to hang oneself), presence and extent of actual physical injury, whether or not the suicide attempt was interrupted (and by whom), and situational context and triggers. It is also important to determine if the current suicide attempt was the first time or the latest in a historical pattern, as patients who have a history of multiple suicide attempts are particularly at risk (Joiner & Rudd, 2000).

It is also advisable to construct a chain analysis that includes the sequence of events precipitating the suicide attempt, the patient’s resultant thoughts, emotions, and behaviors, as well as the consequences (Brown, Wright, Thase, & Beck, 2012). This process assists in providing patients with valuable psycho-education about their vulnerabilities and related targets for intervention. In terms of ongoing treatment, therapists can explain to their patients that they will ask about their suicidal ideation, intentions, and behaviors as a routine part of each session, because they will need to be vigilant for emergent recurrences of increased risk.

Unlike the more traditional syndromal model that viewed patients’ suicidality as secondary to their psychiatric diagnoses, current cognitive-behavioral approaches directly assess and target the suicidality as a primary issue. Therapists examine the antecedent and consequent contextual influences as well as the patient’s belief systems that interact to initiate and maintain suicidal feelings and behaviors (Clemans, 2015). For example, the therapist may hypothesize that a patient receives negative reinforcement for cutting herself in that she provides herself with a temporary distraction from her emotional pain that she considers much worse. She may also receive some positive reinforcement for her self-harming behaviors when people close to her increase their demonstrations of care and concern. In another case, the therapist posits that the patient’s suicidal ideation and intent are congruent with his stated self-punitive belief “I am a bad person who doesn’t deserve to live.” When other people (including the therapist) give this patient support and positive feedback, he has great difficulty believing it, thus he appears to be unresponsive to help. Exploring such factors contributes greatly to the formulation of a cognitive-behavioral case conceptualization (see Kuyken, Padesky, & Dudley, 2009) that can increase the practitioner’s accurate empathy, and guide the construction of a treatment plan for the suicidal patient.

Cognitive Vulnerabilities Associated with Suicidality

A CBT approach to the assessment and treatment of suicidality pays close attention to the cognitive characteristics associated with suicide risk. For example, hopelessness has been found to be a significant factor in differentiating non-suicidal persons from those who are potentially at elevated risk for suicide (Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck, Steer, Beck, & Newman, 1993; Beck, Steer, Kovacs, & Garrison, 1985; Brown, Beck, Steer, & Grisham, 2000; Brown, Jeglic, Henriques, & Beck, 2006; Smith, Alloy, & Abramson, 2006).    

In addition to general hopelessness, there are specific beliefs that have been found to be related to suicide risk. For example, suicidal patients have a tendency to believe that they are unlovable, that their problems are unsolvable, that their pain is unbearable, and/or that they are a burden to others (Ellis & Rufino, 2015; Joiner et al., 2009; Peak et al., 2015).

Cognitive rigidity or inflexibility has also been identified as a characteristic in suicidal thinking (Miranda, Gallagher, Bauchner, Vaysman, & Marroquín, 2012; Miranda, Valderrama, Tsypes, Gadol, & Gallagher, 2013). Suicidal persons are prone to evaluating themselves and their lives in all-or-none terms. For example, situational self-reproach becomes blanket self-condemnation, and/or an adverse event seems inexorable and devastating.

Perfectionism is also a cognitive risk factor for suicide (Flett, Hewitt, & Heisel, 2014; O’Connor, 2007). “Morbid” perfectionism goes way beyond just a stubborn desire to get things right. It entails a patient’s internal demand to have things be “just so,” and to be punitive toward oneself, excessively concerned about others’ negative judgments, and angry at the world if things turn out differently. Within this mindset, the minor setbacks of everyday life become triggers for emotional crises, and larger disappointments become reasons to want to die (e.g., “If I don’t pass the Bar Exam this time, I will kill myself”).

Interventions

It should be noted that the term “interventions” does not just mean “techniques,” as interventions are intertwined with and highly dependent upon the quality of the therapeutic relationship and case conceptualization (see Newman, 2015). Similarly, the term “interventions” goes beyond what transpires in the therapist’s office. It also refers to the patient’s homework assignments, in which they practice in everyday life what they learned in their CBT sessions. Homework assignments can also include self-help readings that supplement and are congruent with the treatment (e.g., Choosing to Live: How to Defeat Suicide Through Cognitive Therapy, Ellis & Newman, 1996). Several major areas of intervention are described below.

Safety Planning – “Safety planning” refers to formal methods for keeping suicidal patients safe between therapy sessions (Stanley & Brown, 2012; Wenzel et al., 2009).  Safety planning entails the implementation of good, standard risk management methods, including identifying, promoting, and utilizing the patients’ interpersonal and intrapersonal resources. The typical components of outpatient risk management include increasing the frequency of sessions, scheduling between-session phone contacts, making arrangements for the patient to spend time in public places around other people (e.g., cafés, bookstores, parks, sporting or community events, malls) and/or with selected others who can provide some measure of oversight (e.g., friends, family, support group cohorts), and doing advance problem-solving to reduce the likelihood of the patient’s being in situations that might increase risk. The risk management methods above involve a strong interpersonal component, in which the patient is prepared to reach out to (and spend time with) others. Patients should have ready access to important contact information, including phone numbers for their practitioners and suicide hot lines. The interpersonal part of the safety plan can also be utilized to enact a lethal means restriction – that is to say that important people in the patient’s life are enlisted to help remove whatever poses a potential danger to the patient. For example, a trusted family member can take possession of the patient’s firearm(s) for safe storage (see Simon, 2007), or a person in the patient’s household can take charge of doling out the patient’s medications in small increments to lower the risk of deliberate overdose. When patients do not wish to give up their instruments of self-harm (e.g., firearms, razors, pills), the risk of a power struggle can be lowered by adopting a therapeutic negotiating style known as motivational interviewing (Miller & Rollnick, 2002), which can be utilized to take steps toward reducing access to lethal means (Britton, Bryan, & Valenstein, 2016).

The intrapersonal piece in safety planning has to do with the patient learning to spot early warning signs of increasing suicidality and being ready and agreeable to use the full array of self-help coping skills he or she is learning in CBT. The key self-help skills, which can be used at times of acute need as well as throughout a course of treatment and beyond, are described below.

Building Psychological Self-Help Skills – In order to help patients make therapeutic gains that will be well-maintained for the long term, CBT helps patients develop and practice durable psychological skills. Some of these interventions include, (1) developing hopefulness and reasons for living, (2) rationally responding to suicidogenic beliefs, (3) constructing a compassionate narrative of one’s own life, (4) creating a “hope kit,” (5) improving problem-solving, (6) engaging in activities that bring a sense of accomplishment and enjoyment, and (7) preparing for potential high-risk situations to prevent relapse (see Ellis & Newman, 1996; Wenzel et al., 2009).

Developing Hopefulness and Reasons for Living – CBT therapists validate their patients’ experiences of subjective emotional pain, but also invite them to consider ways in which this pain may be eased within the scope of an improved life and a more hopeful future. A simple, straightforward technique that can be very enlightening is discussing and writing the pros and cons of dying by suicide versus investing in living (Ellis & Newman, 1996; Jobes, 2006; Brown et al., 2012). This method gives patients overt permission to identify the “advantages” of suicide that they have already been dwelling upon, and to talk about the topic openly with the therapist (see Figure 1). Often there are obvious cognitive biases that are identified in the course of fleshing out the “pros of dying” (e.g., “My family will be better off if I kill myself”), and these beliefs can be subjected to rational responding (see below). Meanwhile, the therapist engages the patient in a process of considering the advantages of investing in life going forward, something that the patient may have been discounting or neglecting. A further application of this technique involves discussing the pros and cons of the patient’s living versus dying for the patient’s loved ones. Doing so often motivates patients to think about the well-being of their family and other important people in their lives as a deterrent to suicide.

Figure 1. Advantages/Disadvantages Analysis

Rationally Responding to Suicidogenic Beliefs – Suicidal patients are taught to identify their beliefs that potentially support their suicidal feelings and intentions, and to use cognitive restructuring techniques (see Newman, 2015) in an attempt to modify these dangerous beliefs. Many suicidal patients evince rigid, maladaptive beliefs that are not easy to relinquish. However, therapists try to create “reasonable doubt” in the minds of such patients about their notions (for example) that death is the only “solution” to their problems, or that they are so bad that they “deserve” to die. Rational responding is not the same thing as “thought replacement.” The more apt description is that rational responding plants seeds of hope that can sprout over time with the help of a strong therapeutic relationship. Patients are taught that it is not necessary for them to fully believe their own rational responses – it is progress in itself if they can simply generate more hopeful, more constructive beliefs that can be tested, or if they are willing to partially believe their therapist’s attempts at hopeful reframing. Even tentatively believed rational responses can gain greater acceptance over time, as other interventions take hold.

Constructing a Compassionate Narrative of One’s Own Life – In order to gain a broader perspective on their lives, to escape the “time trap” of being unduly focused on the pain of the moment, to improve specific autobiographical recall, and to imagine a better future, suicidal patients are encouraged to write a compassionate narrative of their lives. It is best if this technique is done in stages, across sessions, so that it can grow into a detailed, thorough story, and so that it can become a useful, ongoing homework assignment. An additional narrative can be added that describes positive possibilities for the future. For example, the patients can be asked to list three positive and/or interesting things they might experience each year going forward – things that they would miss if they were to die by suicide (see Ellis & Newman, 1996).

Creating a “Hope Kit” – A hope kit (see Wenzel et al., 2009) is a compilation of positive memorabilia that patients can store in a shoebox, a phone app, or a computer file. Once patients do the work of putting a hope kit together (an excellent homework assignment), they can continue to add to it as new events come up that serve as reminders about what is valuable in their lives. The contents of hope kits typically include such items as photos of happier times and events, birthday and greeting cards that the patient has received over the years, personal archives that represent success experiences (e.g., awards, certificates, congratulatory notes), and mementos from favored activities (e.g., trips, clubs, organizations). Additionally, patients can add emotionally significant and meaningful things they have produced, such as artwork, crafts, and writings, including the best examples of previous therapy homework assignments. Consistent with the information used in a safety plan, the hope kit can also include a list of important people in the patient’s life along with their contact information. The main purpose of the hope kit is to produce evidence that suicidal patients do indeed have important attachments to life, and to remind them why their existence is worth preserving and nurturing.

Improving Problem-Solving – Suicidal patients sometimes feel overwhelmed by life’s problems (and/or by their perceptions of life’s problems) and see no way out other than escaping from life itself. This is where therapists need to teach their patients basic problem-solving skills, including describing problems objectively, brainstorming solutions, weighing pros and cons, implementing chosen methods, evaluating the outcomes, and beginning the process with another problem (Nezu, Nezu, & D’Zurilla,2013). Even when patients have bona fide crises and hardships, therapists offer empathy along with a lesson in the benefits of doing “damage control” to begin to turn things around for the better. There is evidence that the subset of problem-solving known as social problem-solving  (also called emotion-centered problem solving, see Nezu & Nezu, in press) – which pertains to interpersonal and emotional self-regulation skills – is particularly germane to suicidality in that deficiencies in this area are a risk factor (Nezu, Nezu, Stern, Greenfield, Diaz, & Hayes, 2017; Woods, 2018). Such findings suggest that treatment should teach patients to view their negative emotions and interpersonal concerns as problems that can be addressed constructively and with self-efficacy, rather than as indicators of uncontrollable, intolerable misery.

Engaging in Activities for Accomplishment and Enjoyment – Therapists help their patients brainstorm a list of activities in which to engage, particularly those that have the potential to be enjoyable and/or to provide a sense of accomplishment. Sometimes an excellent source of ideas for this list comes from a review of the things that the patient used to do and/or has been meaning to do. Deeply depressed patients are prone to minimizing the meaning or importance of such activities, and often assume that taking part in the activities will fail to make them feel better anyway. Practitioners of CBT encourage patients to increase their level of activity step by step as a therapeutic experiment to test hypotheses about the potential impact. When patients begin to do positive, constructive things, it often improves their morale, provides some hope, and helps in the process of connecting with others and/or solving problems. All of this serves as a counterweight to suicidality.

Preparing for Potential High-Risk Situations to Prevent Relapse – The skills described above require regular practice to minimize the risk of relapsing into suicidal crises. This involves such methods as reviewing and documenting the patient’s self-help strategies (e.g., drawing from earlier homework assignments), updating the safety plan to incorporate new material (e.g., new activities, additional people to contact), and organizing and assembling “coping cards” that contain the best of the patient’s rational responses to the re-emergence of old stress reactions. Coping cards can be index cards, or memos on the patient’s phone or other digital device. A particularly powerful relapse prevention method is the guided imagery exercise described by Green and Brown (2015), in which the therapist instructs the patient to imagine anticipated situations in the future that could have the potential to trigger suicidal ideation and intentions. Patients then have to provide a detailed account of the coping methods they would use in such situations. This method serves as an important measure of the patient’s preparedness for the maintenance and ending phases of a treatment trial.

Published June 25, 2018

Lynne Siqueland, PhD - Children's and Adult Center for OCD and Anxiety

It is useful to consider three levels of family involvement when conceptualizing and planning treatment of child and adolescent anxiety: education, coaching parents and other family members and caregivers, and improving family relationships.  This conceptualization has been useful for assessment of needs and clinical decision making by articulating levels of intervention for the treatment of childhood anxiety and related disorders.  These three levels of intervention have also been suggested by other clinical investigators who have written about family factors relevant in child anxiety (Rapee, 2012).  In what follows, straight forward language is offered that can be used by clinicians and other providers when speaking directly to parents and children in practice.  

Psychoeducation about anxiety

Cognitive-behavioral therapists overall rely on psychoeducation as an essential part of their work.  The first level of intervention then is psychoeducation about the nature of anxiety in children and an understanding of what ameliorates or exacerbates anxiety. This is the starting point and often essential for all families. It is useful to teach parents about what anxiety looks like in children and teens in terms of body reactions, thoughts and behavior. Many children and parents are not aware of the links between physical symptoms and anxiety. It helps for them to notice patterns.  If, for example, a child is complaining of stomach pain each school day morning but does not have difficulty or pain during the school day or after school in the afternoons or weekends then there is likely a link to anxiety or separation fears rather than stomach condition alone.  

Also clarifying for parents that the discomfort or pain is real but will often be relieved by managing anxiety rather than treating the stomach or other regions of the gastrointestinal system with medications can be helpful.  Or addressing anxiety first can help clarify physical symptoms that remain after anxiety is lessened.  Headaches and stomachaches are the most common physical symptoms reported along with vague physical complaints.  Finally sleep issues are common in anxiety, especially around falling asleep.  If sleep issues are caused primarily by anxiety then treating worry or separation anxiety in the daylight hours is often essential before there can be success in sleep difficulties.  Another important psychoeducation issue is the reverse.  Too little or disrupted sleep can cause anxiety and treating sleep issues may significantly reduce anxiety without formal treatment of the anxiety.  Indeed psychoeducation and information alone has been helpful in child anxiety (Ginsburg, Drake, Tien et al., 2015).  For some children and families education may be all they need to address concerns.

Cognitive-behavioral therapy (CBT) can be especially helpful in teaching youth and parents to recognize that there are thinking patterns that arise when anxiety is present, including beliefs that anxiety is problematic or dangerous.  The first reaction the child shows is the anxiety reaction – it is automatic and often inaccurate or “false alarm”.  For children and teens, that anxiety reaction is either a “freak-out” as kids often call it, or a “No” or refusal to do something or a combination of both.  It helps parents and other caregivers to recognize this first response as the anxiety reaction and not how their child thinks or feels when not anxious. While it is clear that the child may not be able to help the first reaction, the child is expected to learn, and the parents are to help their child cultivate, another more reasonable response.  It helps everyone to not be surprised or disappointed or to panic if the anxiety reaction occurs.  Instead they can respond by calmly saying, “We thought this might happen and we have a plan.”

Finally the major issue for parents to understand is how avoidance maintains anxiety.  Many parents understand this at higher levels of avoidance but not in the subtler versions of day-to-day living.  It really helps for parents to understand that it is true that the anxiety goes down in the short run if they take over for a child (contact a friend or teachers for them) or allow a child to not attend a planned activity or event. However, avoidance maintains and exacerbates the anxiety in the long-run. Both prevention and intervention trials have targeted working with parents alone and providing educational information with good outcomes (e.g. Ginsburg, Drake, Tein, et al., 2015); Thirlwall, Cooper, Karalus,, Voysey, Willetts & Creswell, 2013).

Coaching Caregivers to Coach Children

The second component of coaching children during anxious moments comes into the clinical plan and is usually needed to some extent for all child and teen clients and their parents.  If parents have a way to help their children rather than the past options of trying to force their child, getting angry, or letting their child avoid, then parents feel that they can do something.  Also kids feel empowered because they also have something useful and different to do in the moment so often they are more willing to approach situations.  The therapist reminds parents and child clients that humans forget or do not use their therapeutic strategies at first and especially in times of stress if the strategies have not been sufficiently practiced.  It takes repeated practice for new skills to become available in times of stress. So it is important to review tools non-reactively and before they are needed, including after stressful events in anticipation of the next time.  Overall, therapists want both kids and parents to know that anxiety disorders are no-fault conditions.  Everyone is doing the best they can but in treatment parents and kids are asked to do some things differently based on what mental health professionals know about the nature of anxiety.  

It is important to educate children, teens and their parents about the nature of exposures to feared situations and symptoms. There is no force involved but instead the therapist, child and parent are work together to make a plan to face fears step by step.  Children and teens should be told ahead of time what is going to happen, and informed that parents are going to do things differently.  Everyone in the family is told that it can be hard at first and uncomfortable but gets better with practice and time. One essential fact to learn about anxiety is that it often goes away on its own with doing next to nothing. The reaction to the anxiety is the problem more than the anxiety itself.  Parents and kids see that you often do not have to use all cognitive or behavioral approaches for anxiety to change if you just expose yourself to the feared situation and pay attention to the actual objective outcome.  The anxiety goes up and down on its own.  One of the pieces of coaching advice is that “this bad feeling will pass.”  Anxiety does not mean you have to do something.  This fact alleviates pressure on children, teens and their families alike.

Parents and their children have a role in CBT treatment.  Parents’ role in exposures is making time for exposures at home, taking kids places to do them and setting up plans like playdates.  In this new role, parents are limiting reassurance, working to stay calm, and encouraging a different way of asking for help.  Most importantly, therapists help parents pay a lot of attention to kids’ healthy coping responses and a lot less to anxiety. They can help their children use the CBT strategies or just simply help their children continue or return to what they would be doing if anxiety were not getting in the way.  Psychologist Deborah Ledley, Ph.D. describes the child’s primary instruction as “just do it”-  try the exposures planned, use your strategies and do not get too mad at your parents for taking you to treatment or asking you to do homework.

Many parents, with the psychoeducation and coaching, can do a great job and rather quickly take over the role as an encouraging side-by-side coach or background coach for their children. However some parents and families have difficulty doing this.  If one or both parents have significant anxiety, and especially if the anxiety is untreated, they may be modeling an anxious response in words or other behaviors or may not be able to complete exposures.   Many parents with anxiety who have formally received treatment or found their own ways to challenge themselves despite anxiety can be excellent coaches.  

Parents very appropriately model for their kids coping by speaking out loud in the moment how they cope or describe how they coped in past situations.  A parent might say, “I was pretty nervous to talk to someone at work about something I did not like because I did not want them to be mad at me or I did not want to look stupid.  So I thought about how I wanted to say it and looked for a good time to talk to my coworker.  It was hard because they were a little upset when I talked to them, but later at lunch we were able to talk again comfortably.”  Often parents who cannot manage their own anxiety particularly well can still provide support and coaching for their child.

Other parents with or without anxiety might have strongly held beliefs either about parenting or anxiety that make it hard for them to feel that it is ok or safe for their child to be anxious.  Oftentimes a session or two with parents alone focused on hearing their concerns with patience and understanding can lead these to be evaluated and challenged by attending to their child’s actual experience in treatment.   It can be really enlightening for a parent to see a child either do an exposure with the therapist or come back from an exposure and report to the parent what they did.  For example, parents will be surprised sometimes to hear the child did an exposure such as asking for a book in a bookstore or talking to another child in the waiting room.  Seeing their child actually competent in doing these tasks helps challenge the belief about the child or anxiety.  Also if there is one parent who is less anxious, that parent can do the exposures alone with the child first to help the child feel confident and competent and then transition to practicing with the more anxious parent.

Family accommodation has been well documented to directly relate to severity of OCD and anxiety symptoms.  Improvements in limiting family accommodation lead to improvements in OCD and anxiety symptoms.  Whereas in OCD family accommodation is often related to involvement in rituals, in the other anxiety disorders accommodation can take forms such as allowing avoidance or doing things for the child rather than promoting independence (Liebowitz, Scharfstein & Jones,2014; Merlo, Lehmkuhl, Geffken & Storch, 2009).

Improving Relationships with Caregivers

The third level of intervention is work on improving family relationships including improving communication, lowering conflict and promoting autonomy and independence.  In some families, the level of conflict or anger or difficulties in communication can really limit the ability to do the CBT treatment.  Therapists can decide if they have the interest in and experience working with families on these issues prior to or concurrent with CBT treatment.   Otherwise families can be referred to individual, couples or family treatment with another provider.  Both research studies and clinical experience show that many children and teens can make major improvements in CBT treatment even if their family does not change so it is important to keep offering the individual treatment option even in the family is not willing to engage in family work. The main difficulties that can arise when just an individual treatment model is used include therapy-interfering behaviors that take the form of parent accommodation, avoidance or parental difficulty helping children in anxious moments.

However other therapists can decide to take on the often rewarding and crucial work in some cases to meet with different family members to improve communication, lower conflict, increase closeness and attachment. Especially teens, but also younger children, are amazing at telling their parents how they feel when their parent reacts in a certain way.  They might be able to tell parents how they feel when their parent gets anxious, or how it feels when the parent is mad when the child cannot help their anxiety reaction.  For some families individuation and contrasting beliefs or choices are compromised for fear of conflict, hurting others feelings, or guilt.  This family work is best done carefully and thoughtfully and working with child, parents / caregivers or dyads separately to plan for different kinds of conversations.  Therapists can evaluate for kids and teens whether it is safe or useful for a child or teen to express their feelings and whether or not the parent is willing to listen and can be helped to hear.  Families can be helped to promote competence and independence in their children and to “enact” different conversations and interactions (Bogels & Siqueland, 2016). Parents also need a safe place to discuss any differences in parenting philosophy or beliefs about anxiety that are limiting their ability to help their child.  Therapists can often help parents to find a compromise approach or to respectfully tag team using different strengths and contributions of each parent.  This third level of intervention is not needed for all families.

Bogels, S & Siqueland, L. (2006). Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2) 134-141.

Ginsburg, GS, Drake KL, Tein JY Teetsle, R and Riddle, M.  (2015).  Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. American Journal of Psychiatry, 172:1207-1213.

Lebowitz  ER, Scharfstein LA and Jones. J. (2014). Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children, Depression and Anxiety, 31(12):1018-25.

Manassis K., Lee, T.C., Bennett, K., et al (2014). Types of parental involvement in CBT with anxious youth: a preliminary meta-analysis. Journal of Consulting and Clinical Psychology, 82 (6):1163–1172.

Merlo, L, Lehmkuhl, HD, Geffken, GR & Storch, E A (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive–compulsive disorder, Journal of Consulting and Clinical Psychology, Vol 77(2), 355-360.

Rapee, RM  (2012). Family Factors in the Development and Management of Anxiety Disorders, Clinical Child and Family Psychology Review, Volume 15 (1) pp 69-80

Thirlwall,  K, Cooper, PJ, Karalus, J, Voysey, M, Willetts L, Creswell C  (2013).  Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial. British Journal of Psychiatry. Dec; 203(6): 436-44.

Note: This article is based on the PBTA workshop entitled, “Family involvement in the treatment of children with anxiety disorders,” that was given by Lynne Siqueland, Ph.D. and Deborah Ledley, Ph.D. http://philabta.org/event-1878131

Published February 3, 2018

Joanna Kaye, MS - Department of Psychology, Drexel University

A large body of literature has determined that exposure-based cognitive-behavioral therapies are highly effective for a variety of anxiety disorders (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). Exposure therapies (ET) refer to a group of treatments that use exposure techniques to help individuals confront feared stimuli in a prolonged, repeated, and intense manner (Richard & Lauterbach, 2007). The various forms of exposure techniques include in vivo exposure (i.e., directly confronting feared stimuli in the real world), simulated exposure (i.e., confronting feared stimuli through role-play or “simulated” real-world scenarios), imaginal exposure (i.e., recounting anxiety-provoking thoughts or images verbally or in the form of written narratives), and interoceptive exposure (i.e., intentionally invoking feared body sensations). 

Meta-analyses have determined that exposure-based cognitive-behavioral treatments (CBTs) lead to symptom improvement with large effect sizes in the treatment of panic disorder, specific phobia, social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD; Bandelow et al., 2015; Deacon & Abramowitz, 2004; Mayo-Wilson et al., 2014; Olatunji, Davis, Powers, & Smits, 2013; Olatunji et al., 2010). Additionally, exposure to feared stimuli is widely considered an empirically-supported principle of behavior change for anxiety disorders (Lohr, Lilienfeld, & Rosen, 2012). Exposure techniques are the cornerstone of CBT protocols for anxiety disorders, so much so that many debate if other treatment components add any incremental benefit above exposure alone (Barrera, Szafranski, Ratcliff, Garnaat, & Norton, 2016; Olatunji et al., 2010). 

Given this evidence, why aren’t all mental health clinicians using exposure?

Despite the demonstrated efficacy of ET, many therapists do not use exposure therapy or use it only rarely (Becker, Zayfert, & Anderson, 2004; Freiheit, Vye, Swan, & Cady, 2004; Hipol & Deacon, 2013; Whiteside, Deacon, Benito, & Stewart, 2016). A key factor is lack of adequate dissemination of ET training. However, even when therapists indicate that they endorse a cognitive-behavioral orientation and have been trained in the use of exposure therapy methods, many report they do not utilize these methods or use them only infrequently. Given the established efficacy of exposure treatments for anxiety disorders, it is critical that we expand efforts to understand how to increase implementation of exposure techniques. 

Another concerning factor related to the implementation of ET is the research that has found that even among therapists who report using exposure techniques, many do not deliver them in an optimal manner. Therapists in community settings appear to utilize client-directed exposure substantially more than therapist-directed exposure (Freiheit et al., 2004; Hipol & Deacon, 2013), which is concerning given indications that self-directed exposure is less effective (Abramowitz, 1996). Additionally, although findings suggest that effective exposure treatment requires its delivery in a prolonged, repeated, and intense manner, many therapists also endorse promoting arousal reduction techniques (e.g., deep breathing exercises) during exposure, despite theoretical and empirical contraindications for doing so (Blakey & Abramowitz, 2016; Schmidt et al., 2000). For example, Deacon and colleagues (2013) found that many therapists delivering interoceptive exposure for panic disorder utilized controlled breathing strategies during delivery, which have shown no benefit in treatment and stand in direct contrast to the prolonged and intense delivery suggested by validated treatment manuals. 

Given the efficacy of exposure therapies for anxiety disorders, it is critical to examine the reasons behind underutilization and improper use of these methods. Many factors are likely to impede dissemination and effective implementation, including lack of adequate training, persistent beliefs that empirically-supported treatments conducted in research settings are irrelevant to clinical practice, therapists’ overemphasis on clinical intuition, and therapist concerns about exposure therapy (Deacon & Farrell, 2013). 

What do we do about this?

Research must determine how to improve the implementation of exposure therapy through clinical training. Further investigation onto the barriers to dissemination and effective training will provide guidance about how to achieve these goals. Mental health clinicians clearly desire more training in exposure therapy. However, the question remains: which training method will prepare clinicians to deliver the most effective exposure therapy?

Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600.

Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 30(4), 183-192.

Barrera, T. L., Szafranski, D. D., Ratcliff, C. G., Garnaat, S. L., & Norton, P. J. (2016). An Experimental comparison of techniques: Cognitive defusion, cognitive restructuring, and in-vivo exposure for social anxiety. Behavioural and Cognitive Psychotherapy, 44(2), 249-254.

Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277-292.

Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1-15.

Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60(4), 429-441.

Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In Handbook of treating variants and complications in anxiety disorders (pp. 363-373). New York: Springer.

Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J., Sy, J. T., Zhang, A. R., & McGrath, P. B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale. Journal of Anxiety Disorders, 27(8), 772-780.

Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive-behavioral therapy for anxiety: Is dissemination working?. The Behavior Therapist, 27(2), 25-32.

Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming A survey of practicing psychotherapists. Behavior Modification, 37(2), 170-188.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.

Lohr, J. M., Lilienfeld, S. O., & Rosen, G. M. (2012). Anxiety and its treatment: Promoting science-based practice. Journal of Anxiety Disorders, 26(7), 719-727.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91-110.

Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America, 33(3), 557-577.

Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33-41.

Richard, D. C. S. & Lauterbach, D. L. (2007). Handbook of exposure therapies. Boston: Academic Press.

Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424.

Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29-36.

Published September 2, 2017

Ronald S. Kaiser, PhD, ABPP - Jefferson Headache Center, Thomas Jefferson University

The American Migraine Prevalence Study (Lipton et al, 2007), the largest study of migraine in America ever conducted, found that 12% of Americans have migraine, and 90% of them can’t function normally on days when they have migraine.  30% of them are bedridden on those days.  Obviously, that level of impairment impacts quality of life as well as mood.

Working with migraine headache patients can be challenging, but it can also be one of the most rewarding therapeutic experiences that can occur for both the patient and the therapist – so long as each pursues the therapeutic process with the proper mindset.  Because of the size of the migraine population, there has been considerable research to provide guidance for understanding and treating migraine patients.

Reviews of the literature (Kaiser et al, 2015, Kaiser et al, 2016), as well as clinical experience, provide principles for psychotherapeutic effectiveness in treating migraine patients.

For the therapist, there can be no better patient than a motivated headache patient.  Regardless of the patient’s current means of coping, there usually is a history of success that can be called upon.  There is the probability of getting better, and there usually are some bad habits that can be changed to reduce the centrality of the headache.  When migraine patients feel they are being understood, they typically become willing allies in their treatment.  

If the patient is getting appropriate medical treatment, the therapist is part of a treatment team.  Long before integrated care became a buzzword, cooperation between physicians and mental health professionals was taking place in the field of headache medicine

There have been many psychological approaches to migraine treatment. Although some appear to be promising, such as acceptance and commitment therapy (ACT), mindfulness, neurofeedback, and yoga, there are four approaches that have attained an “A” rating from the U.S. Headache Consortium:  relaxation training; thermal biofeedback plus relaxation training; EMG biofeedback; and cognitive-behavioral therapy (CBT) (Silberstein, 2000).

Because of its focus upon the thinking process as an agent of change, CBT is particularly well-suited to working with headache patients whose typically good cognitive functioning enables them to be active participants in their treatment plans (Kaiser & Weatherby, 2009).  In addition, while both anxiety and depression significantly affect headache-related quality of life (HRQoL), catastrophizing has been found to be an independent and greater predictor of HRQol – as it intensifies the negative aspect of pain and exaggerates helplessness (Holroyd et al, 2007). Of course, a major focus of CBT is the reduction of catastrophic thinking.

The positive focus utilized in working with migraine patients has led to the widespread incorporation of positive psychology techniques in the treatment process.  Goal-Achieving Psychotherapy (GAP), a unique offshoot of CBT and positive psychology, was developed, based upon strategies that have been successfully implemented to promote positive behavior change at the Jefferson Headache Center in Philadelphia (Kaiser, 2012).

Certain principles have emerged in our work that can be helpful in guiding the mental health professional in working with migraine patients.

Despite all the progress that has been made, migraine is a stubborn disorder that does not always respond to appropriate medical treatment.  Treating migraine is a process.  Neither the patient nor the therapist can expect it to follow the type of predictable course that people have learned to expect from a bout with the flu or the recovery following a surgical procedure.  Patience is required, and sometimes it is required for a pretty long time.  Being active, however, reduces the centrality of the migraine in the patient’s life. Progress in making positive changes that affect body, mind, and character provide the evidence that change can occur – as can the recognition that, once the bad stuff has been ruled out, we are working on a potentially solvable problem.  The therapist’s role includes being a cheerleader for change because, indeed, MIGRAINE PATIENTS CAN GET BETTER.

Achor, S. (2010). The happiness advantage. New York: Crown.

Holroyd, K., Drew, J., Cottrell, C., Romanek, K., & Heh, V. (2007). Impaired functioning and quality of life in severe migraine: The role of catastrophizing and associated symptoms. Cephalalgia, 27(10), 1156-65.

Kaiser, R. (2012). Goal-achieving psychotherapy.  Retrieved from wwww.thementalhealthgym.com/goal-achieving-psychotherapy.

Kaiser, R., Kurzyna, A., & Mooreville, M. (in press). Psychological factors and headache. Medlink Neurology.

Kaiser, R., Mooreville, M., & Kannan, K. (2015) Psychological interventions for the management of chronic pain: A review of current evidence. Current Pain and Headache Reports, 9, 43. doi: 10.107/s11916-015-0517-9.

Kaiser R, & Weatherby S. (2009). Psychology in headache management. In: Kernick D, Goadsby PJ (eds). Headache: A practical manual. Oxford: Oxford University Press, 248-251.

Lipton,R., Stewart, W., Diamond, S., Diamond,M., & Reed, M.  (2001). Prevalence and burden of migraine in the United States: Data from the American migraine study II. Headache, 61, 646-657.

McCrea, S, Kaiser, R., & Young, W. (2014) The relationship between personality factors and perceptions of stigma in chronic and episodic migraine patients. Headache, 54, :59.

Silberstein, S. (2000) Practice parameter: Evidence-based guidelines for migraine headache (an evidenced-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology, 55(6), 754-762.

Waugh, O., Byrne, D., & Nicholas, M. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 1-10.

Young, W., Park, J., Tian, I., & Kempner, J. (2013). The stigma of migraine. Plos One. Retrieved from dxdoi.org/10.1371/journal.poneoo54074

Published August 30, 2016

Melissa Hunt, PhD - University of Pennsylvania Department of Psychology

People with chronic GI disorders fall into two large categories – those with functional disorders like Irritable Bowel Syndrome (IBS) and those with disorders in which tissue pathology and other pathognomic indicators can actually be identified, like the Inflammatory Bowel Diseases including Crohn’s and ulcerative colitis. Surprisingly, both groups can benefit enormously from cognitive-behavioral therapy.

IBS is characterized by recurrent abdominal pain that is relieved by defecation, and is accompanied by abnormalities in the frequency and/or form of bowel movements (i.e. characterized by constipation, diarrhea or an alternating mix of the two.)  In practice, individuals with IBS often experience urgency and develop a number of maladaptive coping strategies, most of which are designed to help them avoid visceral sensations and the possibility of needing to get to a bathroom urgently and not making it “in time.”  Many people with IBS develop catastrophic cognitions about pain, about the possibility of incontinence and about the potential repercussions, both socially and occupationally, of needing the bathroom both frequently and urgently and not being able to “hold it.”  Many people with IBS also develop considerable avoidance behaviors which can meet diagnostic criteria for agoraphobia.  Avoidance can include many feared “danger” foods which are believed to “trigger” IBS “attacks” and avoidance of situations in which getting to a bathroom quickly and unobtrusively might be difficult.  That includes numerous venues (malls, parks, stadiums, concerts, places of worship) and numerous situations (long drives, trains, planes, work environments that prohibit quick exits such as classrooms, reception, factory work, conference calls, and so on.)  In many ways, IBS falls at the intersection of panic disorder with agoraphobia and social anxiety disorder, along with significant health anxiety and catastrophizing about both pain and other visceral sensations.

Fortunately, CBT is very well adapted to tackle both catastrophic cognitions and maladaptive avoidance behavior.  Indeed, CBT is the intervention with the most empirical support in the treatment of IBS. With a little knowledge and minor adjustments, most CBT practitioners can probably address the concerns of IBS patients.  First, one should always start with a good assessment, including coordination of care with medical providers in order to review the patient’s medical history and the various diagnostic procedures they have undergone.  In most cases, the diagnostic tests will all have been negative.  If the patient has not been tested for celiac disease (an autoimmune disorder that leads to true gluten intolerance), they should be, as this is an important differential medical diagnosis to rule out.  However, extensive, invasive testing, including colonoscopy and endoscopy is not recommended by current medical guidelines , unless the patient has “alarm” symptoms (such as blood in the stool, inflammatory markers in the blood or stool, fever, nutrient deficiencies or unexplained weight loss) that may signal an underlying inflammatory process (Brandt et al., 2009).  The next step is psychoeducation about how stress can result in sympathetic nervous system arousal and reduced parasympathetic autonomic activity that directly affect the gut.  This is important because it provides the rationale for relaxation training and stress management strategies like cognitive restructuring and CBT more generally. Next comes relaxation training, especially deep diaphragmatic breathing, which has been shown to optimize GI motility, as well as sympathovagal balance and heart rate variability.

Once the patient has a better grasp on the relationship between stress, distress and GI discomfort and is using deep breathing (and/or other strategies including mindfulness, imagery, progressive muscle relaxation and so on) effectively, the therapist can move on to the basic CBT model, introducing the notion that beliefs (not situations) affect our emotions and that beliefs can be right or wrong.  This is all standard CBT fare (thought records, benign alternatives, evaluating evidence) but will often have to focus on situations in which the person’s gut is acting up.  Behavioral experiments are an important part of this process.  For example, send the patient to a movie theater or house of worship, have them sit in the very back, and count how many people actually get up at some point to leave and then come back.  They will be surprised by how often this happens and how little most people react.

Finally, in vivo exposure therapy that reduces behavioral avoidance is a crucial part of every successful treatment for IBS.  This may need to include food (hint – there are no “danger” foods), food-related situations, abdominal sensations, and any situation the person avoids for fear of not being able to get to a bathroom in time.  Using standard in-vivo exposure strategies (e.g. constructing a fear hierarchy and working up it using graded exposure) works quite well.  For example, if the person is afraid of long car trips, have them sit in the car in their driveway for 30 minutes.  Then progress to driving around the block near their home 20 times.  Then drive a mile away and drive back.  At home, when they feel the urge to defecate, see if they can delay going to the bathroom for 1 minute.  After mastery of 1 minute then try increasing the duration of time (2,3…5 minutes) so the person learns that they can indeed “hold it” without experiencing incontinence. Such exposure can be a huge confidence booster.

Another important area to target is “subtle” avoidance, especially use of a pharmacopeia of medications including anti-diarrheal agents, anti-gas agents and antacids.  Patients will often insist that it is perfectly rational and sensible to use these medications, but further probing will often reveal that they are using them in maladaptive ways that perpetuate the cycle of anxious avoidance.  For example, if the person knows they have a stressful day coming up at work, they may take one or two Imodium before they even leave the house just in case.  Many will recognize such safety behaviors as similar to those seen in people with panic disorder who use benzodiazepines PRN to fend off possible panic attacks.  Whether or not the person also meets diagnostic criteria for anxiety disorders, this safety utilization behavior will maintain distress if not targeted in treatment. Moreover, while anti-diarrheal medications are quite safe, they can cause constipation and bloating and thus also perpetuate further avoidance and distress and maintain maladaptive beliefs.  For example, people can become convinced that needing to poop is a catastrophe to be avoided at all costs.  Turns out that getting people to stop using these medications on a regular basis is an important part of reducing GI specific catastrophic cognitions and visceral sensitivity, and ultimately it actually leads to reductions in abdominal discomfort and urgency.

Many IBS patients can benefit from a self-help book that makes this entire protocol accessible and easy to implement on their own.  Reclaim Your Life from IBS: A Scientifically Proven Plan for Relief Without Restrictive Diets (available at Amazon or Barnes and Noble online) was tested in a randomized controlled trial and was shown to be quite effective (Hunt,Ertel, Coello, & Rodriguez, 2014). It can also be used as a treatment manual or guide for interested clinicians.

Unlike IBS, inflammatory bowel diseases lead to actual tissue damage and can have life threatening complications.  They are auto-immune disorders that have a genetic basis and are probably related in part to disruptions in both the immune system itself and the microbiome of the gut.  They are less prone to stress related exacerbations than IBS (Kovács & Kovács, 2007) but stress is still implicated in symptom exacerbation and relapse (Sajadinejad, Asgari, Molavi, Kalantari, & Adibi, 2002).  In addition, CBT for GI disorders can have a very positive effect on health related quality of life, catastrophizing, visceral sensitivity and the secondary depression and anxiety that accompany many chronic and serious health conditions.  CBT for IBDs varies somewhat from CBT for IBS, in that people may actually need to get to rest rooms urgently, may struggle with fecal incontinence, and may require significant medical management to target both the underlying inflammatory/auto-immune problems and the symptoms themselves.  For individuals with IBDs, it is important to learn to distinguish between abdominal discomfort that can be safely ignored and abdominal pain that signals either a flare or a serious complication like a small bowel obstruction.  There is a current trial ongoing at the University of Pennsylvania testing a self-help CBT protocol for IBD patients against an active psychoeducational control.  If you know an IBD patient who might benefit from a GI informed approach to CBT, consider encouraging them to enroll in the trial.  They can learn more at IBD-Study@psych.upenn.edu.

Brandt, L. J., Chey, W. D., Foxx-Orenstein, A. E., Schiller, L. R., Schoenfeld, P. S., Spiegel, B. M., & ... Quigley, E. M. (2009). An evidence-based position statement on the management of irritable bowel syndrome. The American Journal Of Gastroenterology, 104 Suppl 1S1-S35. doi:10.1038/ajg.2008.122

Hunt, M., Ertel, E., Coello, J., & Rodriguez, L. (2015). Empirical Support for a Self-help Treatment for IBS. Cognitive Therapy & Research, 39(2), 215-227. doi:dx.doi.org/10.1007/s10608-014-9647-3

Kovács, Z., & Kovács, F. (2007). Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease.International Journal Of Psychiatry In Medicine, 37(3), 245-255. doi:10.2190/PM.37.3.a

Sajadinejad, M. S., Asgari, K., Molavi, H., Kalantari, M., & Adibi, P. (2012). Psychological issues in inflammatory bowel disease: an overview. Gastroenterology Research And Practice, 2012106502. doi:10.1155/2012/106502

Published July 28, 2016

Michael Morrow, PhD - Arcadia University

Evidence-based practice (EBP) in clinical and counseling psychology is both an ethical and social justice imperative. Clients of all backgrounds deserve the psychosocial treatments most likely to benefit them and not cause harm (Lilienfeld, 2007). Accordingly, graduate programs are charged to provide students with sufficient preparation in EBP. Ideally, students should graduate their programs with a clear understanding of EBP, emerging skills in empirically supported assessments and treatments, and a firm commitment to maintaining an evidence-based orientation throughout their careers (Morrow, Lee, Bartoli, & Gillem, 2016). While graduates will undoubtedly require further training to master EBP, their education should plant the seeds needed to later bloom into competent evidence-based practitioners.

As a clinical psychologist (reared in a clinical science program) and a counselor educator, I am tasked with the privilege and challenge of helping MA-level counseling students begin their transformation into evidence-based practitioners, all in roughly three years of coursework and applied training. MA-level practitioners comprise the bulk of frontline mental healthcare in many communities (Weisz, Chu, & Polo, 2004); thus, it is critical to provide them with strong training in EBP. Over the past five years, I have learned that guiding students toward competence in EBP is no easy feat; in fact, simply helping them grasp the meaning of EBP is a major challenge, especially in light of the many misinterpretations that plague the field.

While definitions have evolved over time, EBP currently represents a broad framework for clinical decision making and service based on three key components: the strongest available research, clinical expertise, and client characteristics (e.g., preferences, strengths, and culture; Kazdin, 2008). When (and only when) these three components are thoughtfully and continually integrated throughout treatment, EBP occurs. Recent models also emphasize the role of the therapeutic relationship and other common factors (Ackerman et al., 2001).

Unfortunately, many students fail to internalize EBP as an overarching orientation and reduce it solely to using empirically supported treatments (ESTs): interventions supported by rigorous research for particular disorders (Norcross & Karpiak, 2012). While EBP involves using ESTs, it is a broader framework for decision making and intervention. This tendency to minimize EBP to ESTs is well documented (Luebbe, Radcliffe, Callands, Green, & Thorn, 2007) and poses a significant barrier to the proliferation of EBP. Creative teaching strategies are needed to ensure that students acquire a fuller and more accurate understanding of EBP.

Learning theory and research indicate that metaphors can be powerful teaching tools (Hansen, Richland, Baumer, & Tomlinson, 2011). Recently, I developed a metaphor to introduce EBP to counseling students. As a novice painter, I liken EBP to oil painting. I start by explaining that artists utilize a variety of tools (brushes, paint knives, and palettes) to mix and apply various materials (gesso, paint, and varnish); these tools and materials are analogous to practitioners’ knowledge and skills, including their competence in making evidence-based decisions, building strong therapeutic alliances, conducting and interpreting assessments, and delivering specific interventions (e.g., cognitive behavior therapy or exposure and response prevention).

I then add to the metaphor the adoption of an evidence-based orientation. Artists often begin oil paintings by covering the whole canvas with a wash of acrylic paint (e.g., a flat layer of light blue acrylic paint). While numerous layers of paint will be added atop, this wash provides an underlying tone for the entire piece (i.e., the blue wash will interact with each new layer of paint). This acrylic wash represents the adoption of an overarching evidence-based orientation, a guiding framework that colors key clinical decisions, such as choosing assessment tools, formulating conceptualizations, selecting treatment modalities, tailoring interventions, and monitoring progress. To illustrate this point, I ask students to visualize a blank treatment plan and imagine painting “EBP” in a light hue across the background (Figure 1).

Figure 1

Next, I add to the metaphor the process of utilizing research to guide treatment planning. Once the acrylic wash has dried, artists add their first layer of oil paint, which typically blocks out major forms (e.g., a flat grey patch denoting a mountain range) and creates a basic composition for the piece. Regarding EBP, this first layer reflects evidence from the best available research (Lilienfeld et al., 2013). When the research base is strong for treatments targeting a particular condition, it offers a very clear picture for treatment.

For instance, when working with a child with significant disruptive behavior, rigorous efficacy studies deem behavioral parent training a well-established intervention (Eyberg, Nelson, & Boggs, 2008). In this example, students can visualize themselves painting “behavioral parent training” atop a treatment plan already washed in a background of EBP (Figure 2). However, when research is lacking (e.g., ESTs for child Adjustment Disorders), it provides a much fainter picture of treatment. In these cases, practitioners must rely more heavily on the other components of EBP: clinical expertise and client characteristics.

Figure 2

I next introduce practitioners’ use of clinical expertise. Artists then add additional layers of oils and other materials (varnish, sand, stones) atop the previous layers to achieve various effects (detail, contrast, texture, depth, shine). Relative to EBP, these new layers reflect the integration of practitioners’ professional expertise to fill in any major gaps left uncovered by the extant research. In working with a child with an Adjustment Disorder, a practitioner could draw from her experience working with youth with this disorder or similar symptomology. If the child is presenting with a mix of internalizing symptoms, the practitioner could utilize well-established treatments (e.g., cognitive behavior therapies) for pediatric anxiety or depression.

Moreover, the final layers reflect practitioners’ efforts to incorporate client characteristics into treatment. In discussing this topic, it is critical to distinguish “modifying” and “tailoring” treatments. When modifying, practitioners alter treatment in a substantial way (e.g., removing elements or delivering components out of sequence). While such modifications can be justified (Lindhiem, Bennett, Trentacosta, & McLear, 2014), evidence-based practitioners are more likely to tailor by infusing client characteristics into the treatment framework (e.g., offering examples to match clients’ interests and building upon clients’ resources and values to help them reach their goals; Figure 3). This process reflects the notion of “breathing life” into an evidence-based protocol (Kendall, Chu, & Gifford, 1998), and, in my opinion, represents the precise point where the science and art of therapy intersect in the context of EBP.

Figure 3

Finally, I tack two remaining concepts onto the metaphor: progress monitoring and objective thinking. Artists frequently step back to view their work from afar (and from various angles). Similarly, evidence-based practitioners repeatedly examine clients’ progress by carefully monitoring changes in symptoms and behaviors. Stepping back to evaluate the full course of treatment offers invaluable information to further case conceptualization and treatment planning. Moreover, viewing a painting from different angles is analogous to considering alternate plausible hypotheses (e.g., reevaluating the primary factors maintaining a problematic behavior), which is critical to avoiding errors in clinical judgment (Spengler & Strohmer, 1994).

As paintings evolve with each brush stroke, the initial acrylic wash remains a unifying foundation for the entire work, just as an evidence-based orientation should guide the entire course of treatment.  While I have experienced some success with this metaphor, I encourage other educators to develop their own based on their personal interests (e.g., sport, dance, music, cooking). Further, it would be helpful to start a field-wide dialogue on methods for teaching EBP, perhaps via a dedicated listserv or even an edited volume of different pedagogical approaches. Finally, I challenge all graduate instructors to guide their students to practice teaching others about EBP in order to prepare them to “carry the torch” from their education into the mental health landscape and paint their own pictures of EBP.

Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C., et al. (2010). Empirically supported therapy relationships: Conclusions and recommendations for the Division 29 Task Force. Psychotherapy: Theory, Research, Practice, Training, 38, 495-497.

Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37, 215-237.

Hansen, J., Baumer, E. P. S., Richland, L., & Tomlinson, B. (2011). Metaphor and creativity in learning science. Paper presented at the annual conference of the American Educational Researchers Association, New Orleans, LA.

Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146-159.

Kendall, P. C., Chu, B., & Gifford, A. (1998). Breathing life into a manual: Flexibility and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5, 177-198.

Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Lilienfeld, S. O., Lynn, S. J., Ritschel, L. A., Cautin, R. L., & Latzman, R. D. (2013). Why many practitioners are resistant to evidence-based practice in clinical psychology: Root causes and constructive remedies. Clinical Psychology Review, 33, 883-900.

Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence-based practice in psychology: Perceptions of graduate students in scientist practitioner programs. Journal of Clinical Psychology, 63, 643-655.

Morrow, M. T., Lee, H., Bartoli, E., & Gillem, A. (2016). Strengthening counselor preparation in evidence-based practice. Submitted to the International Journal for the Advancement of Counseling.

Norcross, J. C., & Karpiak, C. P. (2012). Teaching clinical psychology: Four seminal lessons that all can master. Teaching of Psychology, 39, 301-307.

Spengler, P. M. & Strohmer, D. C. (1994). Counselor complexity and clinical judgment:  Challenging the model of the average judge. Journal of Counseling Psychology, 41, 1-10.

Published July 23, 2016

Irismar Reis de Oliveira, MD, PhD - Professor of Psychiatry, Department of Neurosciences and Mental Health, Federal University of Bahia, Brazil

TBCT is a new branch of Beckian cognitive-behavior therapy (CBT) that organizes known standard CBT and behavioral techniques into a step-by-step fashion.  In developing TBCT, my goal was to make CBT easily mastered by the therapist and more easily understood by the patients. TBCT should  also be simpler to be implemented and maintain CBT’s recognized effectiveness and transdiagnostic feature (de Oliveira, 2015; 2016). A detailed case illustration may be found on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012a).

Inspiration for the development of TBCT came initially from the novel The Trial, by Franz Kafka (1925/1998). Although it was not the first time the courtroom metaphor was used in CBT – Freeman and DeWolf (1992), Cromarty and Marks (1995), and Leahy (2003) had already used this metaphor –, my idea was conceptualizing core beliefs (CBs) as self-accusations and giving all the columns of the traditional dysfunctional thought record (DTR) the courtroom connotation (de Oliveira, 2011). For instance, the column corresponding to the evidence confirming the CB would bring the prosecutor’s plea, and the evidence not supporting it would carry the defense attorney’s statements. The newly derived 7-column DTR, named trial-based thought record (TBTR; de Oliveira, 2008), contained several well-known traditional CBT techniques like the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). A more detailed case illustration may also be downloaded on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012b).

Several studies conducted in the last decade support the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012). For instance, TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013). The conclusion reached by the above-mentioned studies was that TBTR might help patients reduce the credibility attached to the negative CBs and the intensity of corresponding emotions, regardless of the diagnosis.

New techniques were progressively added to the TBTR, resulting in TBCT. Such techniques were modifications of standard CBT and other approaches. Consequently, TBCT is an example of assimilative psychotherapy integration (Messer, 1992), in which various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). From the time of its original development, TBCT relied on Beckian CBT as the organizing theory, and subsequently added technical interventions drawn from several other approaches. Among them were Gestalt, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell’s (1988) two-person relational model.

TBCT has its own case conceptualization, which makes it an individualized approach. It is divided into 3 levels and 3 phases, and includes a cyclic interactional mechanism in which components in each level influence the others, and flexibly allow the therapist to adapt the treatment to the individual’s features (de Oliveira, 2016).

Figure 1 depicts the three levels of information processing in the TBCT conceptualization diagram, and shows how a situation that is appraised in a biased fashion by the automatic thought (AT) elicits a dysfunctional negative emotion, which, in turn, produces undesired consequences in terms of behaviors and/or physiological responses. Figure 1 also contains arrows pointing back to the emotion, ATs and the situation, meaning that a confirmatory bias might preclude re-examination of the situation and replacement of the incorrect ATs with more functional and healthier perceptions (de Oliveira 2015; 2016).

Figure 1. TBCT case conceptualization diagram, phase 1, and its 3-level cognitive components: ATs, UAs and CBs. Here, dysfunctional negative CBs are predominantly active.

The TBCT case conceptualization diagram was also designed to help the patient realize that the behaviors that decrease anxiety and produce relief (e.g., avoidance) are little by little converted into coping strategies or safety-seeking behaviors, shown in Figure 1 as an arrow directed from the behavior and physiological response from the first to the second level on the right-hand side of the picture, meaning that situational perceptions in the first level (ATs) are progressively transformed into underlying assumptions (UAs) at the second level, which maintains and is maintained by the coping strategies/safety behaviors (de Oliveira, 2016). The table below shows the tools that were developed and are currently used during the TBCT therapy course.

Table 1. TBCT techniques and its diagrams. Column 2 informs the cognitive levels and column 3 informs in which sessions they are usually used (de Oliveira 2016).

The main TBCT technique used to restructure cognitions in the third level, namely CBs (Figure 1), is the TBTR. Besides including a courtroom metaphor, it introduces at least 12 known techniques usually used in CBT and listed below (de Oliveira, 2016):

1. Socratic dialogue;
2. Guided discovery;
3. Imagery re-scripting;
4. Empty chair or chairwork;
5. Downward arrow technique (investigation);
6. Evidence supporting the negative CB (prosecutor’s first plea);
7. Evidence not supporting the negative CB (defense attorney’s first plea);
8. Eliciting more automatic thoughts by discounting the positives (prosecutor’s second plea);
9. Sentence reversal (defense attorney’s second plea);
10. Upward arrow technique to uncover positive CBs (the defense attorney goes deeper);
11. Identifying cognitive distortions (jurors’ phase); and
12. The positive data log (preparation for the appeal), during which the patient summons the inner defense attorney as an ally to distance oneself even more and to collect daily elements that support the newly activated functional positive CBs.

In summary, TBCT is an evidence-based, three-level and three-phase Beckian branch of CBT, whose main techniques use the courtroom metaphor, and designed to facilitate the work of the therapist and the client by means of a highly structured (although flexible) protocol.

Burns, D.D. (1980). Feeling Good: The New Mood Therapy. New York: Signet.

Cromarty, P. and Marks, I. (1995). Does rational role-play enhance the outcome of exposure therapy in dysmorphophobia? A case study. British Journal of Psychiatry, 167, 399-402.

de Oliveira, I.R. (2008). Trial-based thought record (TBTR): preliminary data on a strategy to deal with core beliefs by combining sentence reversion and the use of an analogy to a trial. Revista Brasileira de Psiquiatria, 30(1), 12–18.

de Oliveira, I.R. (2011). Kafka’s trial dilemma: Proposal of a practical solution to Joseph K.’s unknown accusation. Medical Hypotheses, 77(1), 5-6.

de Oliveira, I.R. (2012a) Trial-Based Cognitive Therapy. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2012b) Trial-Based Thought Record. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2015). Trial-Based Cognitive Therapy: A Manual for Clinicians. New York: Routledge.

de Oliveira, I.R. (2016) Trial-Based Cognitive Therapy: Distinctive Features. London:Routledge.

de Oliveira, I.R., Duran, E.P. and Velasquez, M. (2012). A trans-diagnostic observation of the efficacy of the Trial-Based Thought Record in changing negative core beliefs and reducing self-criticism. NEI Psychopharmacoloy Congress, San Diego, October 18-21.

de Oliveira, I.R., Hemmany, C., Powell, V.B., Bonfim, T.D., Duran, E.P., Novais, N. et al., (2012). Trial-based psychotherapy and the efficacy of trial-based thought record in changing unhelpful core beliefs and reducing self-criticism. CNS Spectrums, 17(1), 16–23.

de Oliveira, I.R., Powell, V.B., Caldas, M., Seixas, C., Almeida, C., Bomfim, T. et al. (2012). Efficacy of the Trial-Based Thought Record (TBTR), a new cognitive therapy strategy designed to change core beliefs, in social phobia: A randomized controlled study. Journal of Clinical Pharmacy and Therapeutics, 37(3), 328-334.

Freeman, A., DeWolf, R. (1992). The 10 Dumbest Mistakes Smart People Make and How to Avoid them. New York: HyperPerennial.

Kafka, F. (1925/1998). The Trial. New York: Schoken Books.

Leahy, R.L. (2003). Cognitive therapy techniques. A practitioner’s guide. New York: Guilford Press.

Messer, S.B. (1992). A critical examination of belief structures in interpretive and eclectic psychotherapy. In J.C. Narcross and M.R. Goldfried (Eds.), Handbook of Psychotherapy Integration. New York: Basic Books.

Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MP: Harvard University Press.

Powell, V.B., de Oliveira, O.H., Seixas, C., Almeida, C., Grangeon, M.C., Caldas, M., et al. (2013). Changing core beliefs with trial-based cognitive therapy may improve quality of life in social phobia: a randomized study. Revista Brasileira de Psiquiatria, 35(3), 243-247.

Stricker, G. (2010). Psychotherapy Integration. Washington D. C.: American Psychological Association.

Published July 12, 2016

Donna Sudak, MD - Drexel University College of Medicine

In the past twenty years there has been an enormous interest in the practice of cognitive-behavioral therapy (CBT). Substantial research has been conducted indicating that CBT is a significantly effective treatment for a variety of psychiatric illnesses. In 2001, the Residency Review Committee for Psychiatry adopted training requirements requiring competence in CBT for graduating psychiatry residents. In 2012, an inter-organizational task force produced guidelines for cognitive behavioral therapy training within doctoral Psychology programs in the United States (Klepac et al, 2012). Despite such requirements, dissemination of CBT remains poor (Shafran et al 2009) and training is lacking (Weissman et al, 2006). There is some evidence regarding specific methods of supervision and teaching that lead to effective application of CBT in clinical practice, but such evidence is even more poorly disseminated and inconsistently applied. Literature on the outcome of supervision is lacking. In spite of decades of emphasis on data-driven decision-making regarding the therapeutic process, there has been a relative lack of research to address questions of best practices in both training and supervision of CBT. Although dissemination of effective treatments for mental disorder is of paramount public health concern the field requires considerable progress to facilitate such dissemination.

There are at least two distinct points of view regarding therapist training represented in the training and supervision literature. First, a commonly articulated evidence-supported position is that more training produces more competent therapists (McManus et al 2010). A further assumption derived from this point of view is that more competent therapists have superior clinical outcomes. Several studies (Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006) support this view and point specifically to the role of supervision in producing competent therapists. Another argument, advanced from the public health perspective, is that the process of training and supervision is far too resource intensive to be practical for illnesses such as depression (Fairburn and Cooper 2011), which will soon represent the largest global disease burden (WHO). This perspective argues for a larger group of therapists trained in low intensity interventions for specific disorders along with guided self-help and internet assisted interventions to produce the widest ranging impact. Both ideas have merit, and likely an amalgam of training strategies will continue to be developed and tested worldwide.

Given the aforementioned scarcity of resources, identifying the most efficient strategies for supervision and training is imperative for the field. Regarding supervision, a small number of studies exist that indicate it improves therapist competence (Strunk et al 2010, Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006), but do not describe the most efficient and effective procedures to follow. Even more significantly, the elements of what constitutes “adequate” supervision are only recently described in the literature and have been determined by a combination of narrative and systematic reviews and expert consensus (Milne and Dunkerley). The importance of adequate training for supervisors has led to several professional organizations establishing criteria for supervisors/trainers (e.g., the Academy of Cognitive Therapy, the British Association of Behavioural and Cognitive Psychotherapy) and/or required continuing education credits pertaining to supervision.

Key principles that are derived from CBT itself, because it is rooted in learning theory, are equally applicable to the supervisory process and facilitate therapist development. These include:

These practices in supervision will help you be more effective at teaching the skills of therapy and make the work interesting to you both!

Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research,16(3), 317-331.

Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6-7), 373-378.

Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., & ... Strauman, T. J. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687-697.

McManus, F., Westbrook, D., Vazquez-Montes, M., Fennell, M., & Kennerley, H. (2010). An evaluation of the effectiveness of diploma-level training in cognitive behaviour therapy. Behaviour Research and Therapy, 48(11), 1123-1132.

Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516.

Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We Don't Train in Vain: A Dissemination Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy. Journal of Consulting and Clinical Psychology, 73(1), 106-115.

Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., & ... Beck, A. T. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751-756.

Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429-437.

Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & ... Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925-934.

Published July 3, 2016