Handbook of Cognitive-Behavioral Therapies (2)

I’ve finished the book.

I almost didn’t. A few of the chapters were quite awful. Here’s what I wrote on goodreads:

“Much closer to one star than three – I was very close to giving it one star.

It starts out not terrible, but then gets worse and worse as it moves on. Some chapters are almost hilariously bad. Often all that’ll be worth knowing about a given method is one or two key ideas; you quickly realize that most of the rest is just crap and/or speculation. Some chapters have more than this, but not many, and frankly a lot of this stuff is pure bullshit.

Many of the chapters are written by partisans who don’t even try to pretend to be impartial.

I was very disappointed by this book.”

I wrote this review after having just read the last two chapters, the first of which was far from great and the latter of which was simply spectacularly bad. So I might have been a bit harder on the book than I should have been. The ‘it progressively gets worse’ model is also on second thought perhaps not completely fair. Either way I don’t think you should read this book. At least not all of it. Some chapters were not bad, it’s just that others broke the scale and tempted me to give the book a negative goodreads score. This makes it somewhat hard for me to say good things about it in general.

Actually I have been tempted while reading this handbook to add another star to Leary & Hoyle‘s work. If that’s the kind of stuff which is out there, perhaps I was too hard on those guys.

In some of the chapters of this book you’ll have to look really hard to find any formal tests of whether it even makes sense to think about the problems in the manner proposed (you’ll see lots of words spilled, but words are cheap); some of the therapy approaches have assumptions underlying them which are not flexible at all and are simply taken for granted – in some cases they’re arguably not even testable in theory. To take an example it’s always theoretically possible for you to blame your parents for your problems, and it’s not hard to come up with a therapy approach which helps you feel better by enabling you to evade responsibility for your problems by blaming your parents for them. Parent-blaming is a frequently encountered component in so-called schema-therapy approaches, though of course they don’t call it that in the book. Other times the therapists get even more creative; for example did you know that marital discord may be partly due to (societal) racism? I didn’t, I’m glad they included this important variable in their coverage. In one case I considered the proposed theoretical framework underlying/justifying the therapeutic approach frankly inconsistent – it simply makes no sense to me even in theory. Some approaches have proposed mechanisms of actions which remain either completely unexplored or at the very least seriously underexamined – the proponents seem to feel fine justifying the treatment approach solely by reference to various outcome variables arguably completely orthogonal to the methodology applied. They sometimes have no clue why it works, when it works (…if it works?). Ideas like selection bias and selective attrition naturally spring to mind, as do (as always) underpowered studies of questionable validity and publication bias, but they pretty much don’t talk about stuff like that at all. It should be noted that problems such as these are quite important to address if you want to argue, as some indeed implicitly do, that ‘regardless of whether it works ‘the way it’s supposed to’ or not, if it does work then that’s the important part.’ If the methodology is questionable it gets a lot harder to ‘just accept that it works’ because that conclusion might be wrong – and if you as a contributor to a handbook like this just choose to pretend specific problems don’t exist by not talking about them, that does not make you look good. There are a lot of problems meta-analyses do not solve.

In the coverage below I’ve tried to stay away from the low quality material and focus only on the stuff I can justify sharing here – don’t take the passages below to be representative of the book in general.

…

“The case formulation is an element of a hypothesis-testing empirical mode of clinical work […] The therapist begins the process by carrying out an assessment to collect information that is used to develop an initial formulation of the case. The case formulation is a hypothesis about the psychological mechanisms and other factors that cause and maintain a particular patient’s disorders and problems. The formulation is used to develop a treatment plan and to assist in obtaining the patient’s informed consent to it. After obtaining informed consent, the therapist moves forward with treatment. At every step in the treatment process […] the therapist returns repeatedly to the assessment phase; that is, the therapist collects data to monitor the process and progress of the therapy and uses those data to test the hypotheses (formulations) that underpin the intervention plan and to revise them as needed. Thus, the four elements of case formulation-driven cognitive-behavioral therapy (CBT) are (1) assessment to obtain a diagnosis and case formulation; (2) treatment planning and obtaining the patient’s informed consent to the treatment plan; (3) treatment; and (4) continuous monitoring and hypothesis-testing. […] A case formulation is important, because interventions flow from it […] a complete case formulation describes all of the patient’s symptoms, disorders, and problems, and proposes hypotheses about the mechanisms causing the disorders and problems, the precipitants of the disorders and problems, and the origins of the mechanisms. […] To understand the case fully, the therapist must know all of the problems. […] the therapist who simply focuses on the obvious problems or those on which the patient wishes to focus may miss important problems. Patients frequently wish to ignore problems such as substance abuse, self-harming behaviors, or others that can interfere with the successful treatment of the problems on which the patient does want to focus”

“numerous studies have now shown that CT (Cognitive Therapy) is associated with reductions of negative cognitions […] Garratt, Ingram, Rand, and Sawalani (2007) concluded in their review that the empirical literature is generally consistent with the hypothesis that CT results in cognitive changes that in turn predict reductions in depressive symptom severity. […] although the research designs and statistical techniques employed in most of these studies are appropriate for testing whether reductions in depressive symptoms and negative cognitions covary during CT, they do not allow for rigorous tests of the causal relations between symptoms and cognitions […] Notably, relatively few studies have included multiple assessments of both symptoms and plausible mediators […] In summary, given the research designs and data-analytic strategies employed in the majority of studies to date, only tentative conclusions can be drawn from the literature regarding the role of cognition in mediating therapeutic improvement in CT. […] Even though CT is somewhat more expensive than antidepressant medications in the short run, cost–benefit analyses to date have indicated that it pays for itself within a short time following treatment termination considering its potential to confer resistance to relapse and recurrence (Antonuccio, Thomas, & Danton, 1997; Dobson et al., 2008; Hollon et al., 2005).”

“Much of what distinguishes CT from other cognitive-behavioral therapies lies in the role assumed by the therapist and the role that he or she recommends to the patient. In the relationship, which is meant to be collaborative, the therapist and patient assume an equal share of the responsibility for solving the patient’s problems. The patient is assumed to be the expert on his or her own experience and on the meanings he or she attaches to events […] cognitive therapists do not assume to know why a certain thought was upsetting; they ask the patient.” [Other approaches don’t.]

“The purpose of scheduling activities in CT is twofold: (1) to increase the probability that the patient will engage in activities that he or she has been avoiding unwisely, and (2) to remove decision making as an obstacle in the initiation of an activity. Since the decision has been made in the therapist’s office, or in advance by the patient him- or herself, the patient need only carry out what he or she has agreed (or decided) to do. […] Since tasks that have been avoided by the patient are often exactly those that have been difficult to do, modifying the structure of these tasks is often appropriate. Large tasks […] are explicitly broken down into their smaller units […] to make them more concrete and less overwhelming. This intervention has been termed “chunking.” “Graded tasks” can also be constructed, such that easier tasks or simpler aspects of larger tasks are set out as the first to be attempted. […] Though chunking and graded task assignments may seem simplistic, it is often surprising to both patient and therapist how these simple alterations in the structure of a task change the patient’s view of the task and, subsequently, the likelihood of its being accomplished.”

“Problem-solving therapy (PST) is a positive approach to clinical intervention that focuses on training in constructive problem-solving attitudes and skills. […] Problem solving should be distinguished from solution implementation. These two processes are conceptually different and require different sets of skills. “Problem solving” refers to the process of discovering solutions to specific problems, whereas “solution implementation” refers to the process of carrying out those solutions in the actual problematic situations. […] Problem-solving skills and solution implementation skills are not always correlated; some individuals might possess poor problem-solving skills but good solution implementation skills, or vice versa.”

“A major assumption underlying the use of PST is that symptoms of psychopathology can often be understood and effectively prevented or treated if they are viewed as ineffective, maladaptive, and self-defeating coping behaviors that in turn have negative psychological and social consequences […] The most important concept in the relational/problem-solving model is “problem-solving coping,” a process that integrates all cognitive appraisal and coping activities within a general social problem-solving framework. A person who applies the problem-solving coping strategy effectively (1) perceives a stressful life event as a challenge or “problem to be solved,” (2) believes that he or she is capable of solving the problem successfully, (3) carefully defines the problem and sets a realistic goal, (4) generates a variety of alternative “solutions” or coping options, (5) chooses the “best” or most effective solution, (6) implements the solution effectively, and (7) carefully observes and evaluates the outcome. […] When the situation is appraised as changeable or controllable, then problem-focused goals are emphasized […] On the other hand, if the situation is appraised as largely unchangeable, then emotion-focused goals are emphasized (e.g., acceptance, making something good come from the problem).”

“a number of studies have suggested that an accumulation of unresolved daily problems may have a greater negative impact on well-being than the number of major negative events”

“Problem-solving ability has been found to be positively related to adaptive situational coping strategies, behavioral competence (e.g., social skills, academic performance, job performance), and positive psychological functioning (e.g., positive affectivity, self-esteem, a sense of mastery and control, life satisfaction). In addition, problem-solving deficits have been found to be associated with general psychological distress, depression, suicidal ideation, anxiety, substance abuse and addictions, offending behavior (e.g., aggression, criminal behavior), severe psychopathology (e.g., schizophrenia), health- related distress, and health-compromising behaviors. These results have been found using different measures of social problem-solving ability in a wide range of participants”

“compared to happy couples, distressed couples are characterized by a high frequency of reciprocal negative or punishing exchanges between partners, a relative scarcity of positive outcomes that each partner provides for the other, and deficits in communication and problem-solving skills […] Research has also demonstrated that partners in distressed relationships are more likely to notice selectively or “track” each other’s negative behavior […], make negative attributions about the determinants of such behavior […], hold unrealistic beliefs about intimate relationships […], and be dissatisfied with the ways that their personal standards for the relationship (e.g., regarding the amount of time and effort that they should put into their relationship) are met […] [However] some studies have indicated that increases in partners’ exchanges of positive behavior and improved communication skills have had limited impact on relationship satisfaction […] the degree of improvement in communication is not correlated with level of improvement in relationship adjustment”

“distressed couples commonly exhibit a pattern in which one partner pursues the other for interaction, while the other partner withdraws […] Females are more likely to be in the demanding role, whereas males more often withdraw”

“individuals often have strong standards for how partners should behave toward each other in a variety of domains. If these standards are not met, the individual is likely to become upset and behave negatively toward the partner. Likewise, one person’s level of satisfaction with the other’s behavior can be influenced by the attributions that person makes about the reasons for the partner’s actions. Thus, a husband might clean the house before his wife arrives at home, but whether she interprets this as a positive or negative behavior is likely to be influenced by her attribution or explanation for his behavior. If she concludes that he is attempting to be thoughtful and loving, she might experience his efforts to provide a clean house as positive. However, if she believes that he wishes to buy a new computer and is attempting to bribe her by cleaning the house, she might feel manipulated and experience the same behavior as negative. In essence, partners’ behaviors in intimate relationships carry great meaning, and not considering these cognitive factors can limit the effectiveness of treatment. We have described a variety of cognitive variables that are important in understanding couples’ relationships […], including the following:

Selective attention—what each person notices about the partner and the relationship.
Attributions—causal and responsibility explanations about marital events.
Expectancies—predictions of what will occur in the relationship in the future.
Assumptions—how each person believes people and relationships actually function.
Standards—how each person believes people and relationships should function.

These cognitions help to shape how each individual experiences the relationship. […] therapy at times will not focus on behavioral change but will help the partners reassess their cognitions about behaviors, so that they can be viewed in a more reasonable and balanced fashion.”