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  #1  
Unread March 20th, 2006, 09:38 PM
James Pretzer James Pretzer is offline
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Default Misconceptions about CBT with anxiety

One of my pet peeves is that professionals who aren't very familiar with CBT read Cognitive Therapy of Depression and assume that we treat all problems exactly the same way as we treat depression. Please note that the book is called Cognitive Therapy of Depression, not Cognitive Therapy of Everything.

It galls me even more when professionals who should know better make it sound as through we use thought sheets and rational responses for every problem. Sometimes I wonder if they're trying to make CT sound dumb so that they can make the approach they're promoting sound good, but maybe it's that they just don't understand CT.

Anyway, this tirade was prompted by a review of Acceptance and Committment Therapy for Anxiety Disorders: A Practitioner's Guide to Using Mindfulness, Acceptance and Values-Based Behavior Change Strategies in the Behavior Therapist in which the author says "Conventional CBT generally teaches anxious clients that thoughts and feelings cause suffering, and that controlling thoughts via CBT methods such as disputation, distraction, or mastery is the best way to ensure optimal health" (Moran, 2006).

Wrong! Conventional CBT generally teaches anxious clients that dysfunctional thoughts and dysfunctional behavior (i.e. avoidance) typically play an important role in anxiety disorders. However, I spend a lot of time helping clients realize that their attempts to control their thoughts and feelings are counterproductive. When clients try to use CBT techniques to control their thoughts and feelings, this is just as counterproductive.

In terms of the last sentence in our quote from Moran's article, disputation of dysfunctional thoughts can be very helpful with some problems (such as depression), disputation of anxiety-provoking thoughts usually has little effect on the client's anxiety. Distraction techniques were quite popular in CBT 25 years ago but have very limited utility with anxiety disorders and easily can be quite counterproductive. If by "mastery" he means having the client face their fears in manageable steps and discover that they can cope, this is very much what we spend our time on. If by "mastery" he means having the client control their thoughts and feelings, that is not at all what we focus on.

In CBT for anxiety disorders, the essential component is getting the client to face their fears, tolerate the anxiety, and refrain from engaging in the avoidance or escape behaviors that they normally use in an attempt to avoid experiencing anxiety or to avoid the disasters they anticipate. This key component takes different forms with different anxiety disorders. With many phobias we focus on in-vivo exposure. With OCD we use Exposure and Response Prevention. With panic attacks we teach clients to let the panic peak and subside without fighting it or trying to control it.

In particular, with the many anxious clients who fear their thoughts and feelings, we work to get them to accept their thoughts and feelings and cope with them rather than trying to control them or escape them. We often use acceptance-based strategies and mindfulness-based strategies in doing this. The book that Moran was reviewing sounds quite good and I may well pick up a copy. However, mindfulness-based strategies and acceptance-based strategies are frequently used in CBT these days (we tend to use values-based strategies implicitly, not explicitly the way ACT does). Techniques such as "thought stopping," aversive control through snapping one's wrist with a rubber band, distraction techniques, etc. may have been state-of-the-art in the 1970's but we've learned a few things since then.
Moran, D. J. (2006). Book review Eifert, G. H., & Forsyth, J. P. (2005) Acceptance and Committment Therapy for Anxiety Disorders: A Practitioner's Guide to Using Mindfulness, Acceptance and Values-Based Behavior Change Strategies. Oakland, CA: New Harbinger, the Behavior Therapist, 36-37.
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  #2  
Unread March 21st, 2006, 10:05 AM
James Pretzer James Pretzer is offline
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Default Re: Misconceptions about CBT with anxiety

Note: I don't intend to blast Moran who wrote a perfectly fine book review and who says reasonable things about CBT in the rest of his review. I want to address some widely held misconceptions about CBT with anxiety.
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Unread March 27th, 2006, 01:11 AM
Michael Vurek
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Default Re: Misconceptions about CBT with anxiety

I agree, and it's all quite unfortunate as there is so much to contribute without having to "push off" of prior approaches. I notice this in Marsha Linehan as well, whose material I like and use extensively. I'm just learning ACT, and already find much that I can use in my "traditional" CBT approach. What it offers is a persistent emphasis on becoming aware of and shifting from control strategies, as well as the great values piece. It's also unfortunate that CBT often uses terms like "mastery" because it leads clients (and therapists) to believe that it is about controlling and overpowering anxiety. ACT strategies and explanations help me and my clients watch for the mind's attraction to relating to and controling states of mind, and to frequently lose sight of what's really important and occuring in the present moment.
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Unread March 30th, 2006, 01:57 AM
Wayne Froggatt Wayne Froggatt is offline
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Default Re: Misconceptions about CBT with anxiety

I have to agree with Jim. The research seems very clear that exposure is the first line in treating anxiety. Cognitive strategies do have an important place, but primarily in supporting the exposure work (i.e. dealing with the client's fears about exposure, and coping with the exposure work itself using techniques like cue cards etc.). It is very doubtful that anyone is going to learn to manage their anxiety by simply changing their thinking - you need to walk the talk. Incidentally, I think it is very important to help the client see that we are aiming for management, not cure, otherwise we set them up for disallusionment.
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