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James Pretzer November 15th, 2004 10:51 PM

A unified CBT for emotional disorders?
The Spring, 2004 edition of Behavior Therapy includes an article in which David Barlow and colleagues propose a CBT model which they see as applying to emotional disorders in general. Barlow has spent much or his career developing empirically-supported protocols for CBT with various anxiety disorders. He has been quite successful in doing this but now he notes that this approach has drawbacks as well saying "these manualized protoccols have become numerous and somewhat complex, restricting effective training and dissemination." In recent years he has been working to understand general principles that underly the emotional disorders in the hopes of developing a single treatment approach that can be used with all of the emotional disorders.

He and his colleagues propose that three fundamental therapeutic components are generally applicable to the treatment of emotional disorders:
  1. "altering antecedent cognitive reappraisals"
  2. "preventing emotional avoidance"
  3. "facilitating action tendencies not associated with the emotion that is dysregulated"

By "altering antecedent cognitive reappraisals" Barlow is referring to the process of identifying dysfunctional cognitions and developing more adaptive alternatives for which CT is known. He offers a reconceptualization of this process as a response to Hayes, Strosahl & Wilson's (1999) criticsm of CT and cites several lines of research that support this process.

In discussing "preventing emotional avoidance" he suggests that attempts to avoid aversive emotional experiences play an important role in depression, anger and mania, not just anxiety disorders and cites research supporting this idea. Both exposure-based strategies and acceptance-based strategies are options for preventing emotional avoidance.

"Facilitating action tendencies not associated with the emotion that is dysregulated" isn't a phrase that rolls off my tongue easily. However, it makes sense. In discussing this, Barlow cites CT and CBT's use of behavioral activation in the treatment of depression, as well as DBT and ACT's use of strategies in which the individual intentionally engages in other (incompatible) actions rather than engaging in the actions associated with problematic emotions.

In discussing how these ideas apply to clinical practice, Barlow and his colleagues give examples which cover major depression and a broad range of anxiety disorders. He also describes some outcome research which is in it's initial stages but which is producing promising results so far.

At this point, it isn't clear (to me at least) whether the term "emotional disorders" which Barlow uses is intended to just include depression and the anxiety disorders, is intended to include all the Axis I disorders, is intended to include all psychopathology. It also isn't clear to me whether he would suggest that CT should make any substantial changes in it's approach or not (we already include all three of the therapeutic components he's advocating).

I'm interesting in hearing others' responses to Barlow's ideas. In particular, if anyone hears him speak on this topic at AABT, please post what he has to say since I won't be at AABT this year to hear him.

JustBen November 18th, 2004 10:49 AM

Re: A unified CBT for emotional disorders?
My understanding of CT is that identifying cognitive distortions and developing adaptive responses is the beginning of a process that eventually moves on to explore the client's attitudes, and finally their beliefs. I don't have a copy of BT handy, but based on your synopsis, it doesn't seem as if Barlow addresses these issues. If not, then I'd have to say that he is proposing a substantial change to CT -- not by addding anything new, but by removing something. Is this an accurate interpretation, or does Barlow go into this in his response to Hayes, et. al.?

James Pretzer November 19th, 2004 10:37 PM

Re: A unified CBT for emotional disorders?
My understanding is that Barlow would classify all of those interventions (identifying cognitive distortions and developing adaptive responses, exploring the client's attitudes, and finally addressing their beliefs) as "altering antecedent cognitive reappraisals." I don't think he's excluding any of them.

If he's proposing a change in CT, it would be an increased emphasis on "preventing emotional avoidance" and on "facilitating action tendencies not associated with the emotion that is dysregulated." However, these both already are important parts of CT (though the terminology is a bit different) and I'm not sure that there's a noticeable difference between what I do and what he's proposing.

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