Simple Treatments for Complex Problems A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy 9780805846430, 0805846433, 9781410610232, 1410610233

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S im p Ic Treat m en ts for C om plex Problem s A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy

Psychology Press

Kimberly A. Driscoll Kelly C. Cukrowicz M aureen Lyons Reardon Thomas E. Joiner, Jr.

Simple Treatments for Complex Problems A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy

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Simple Treatments for Complex Problems A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy

K im b erly A . D r isc o ll K elly C. C u k ro w ic z M a u re en L yons R eard on T h o m a s E. Joiner, Jr. The Florida S tate U niversity

In collaboration w ith the staff o f The Florida State University Psychology C linic Ginette C. Blackhart L eonardo Bobadilla A ndrea B. Burns Keith F. D onohue Rebecca R. G erhardstein Annya H ernandez Therese Skubic K em per D onald R. Kerr, Jr. Rita L. K etterm an

Jennifer A. M innix M arisol Perez Scharles C. Petty M ark D. Reeves L orraine R. Reitzel Karla K. Repper Sarah A. Shultz Sheila L. Stanley Bradley A. W hite

V p Psychology Press JL

Taylor & Francis C roup NEW YORK A N D LO N D O N

First published 2004 by Lawrence Erlbaum Associates, Inc. This edition published 2014 by Psychology Press 71 I Third Avenue, New York, NY 10017 and by Psychology Press 27 Church Road, Hove, East Sussex, BN3 2FA Psychology Press is an imprint o f the Taylor & Francis Group, an informa business

C opyright © 2004 by Lawrence Erlbaum Associates, Inc. All rights reserved. N o part o f this book m ay be reprinted or reproduced or utilised in any form or by any electronic, m echanical, or other m eans, now known or hereafter invented, including photocopying and recording, or in any inform ation storage or retrieval system , w ithout perm ission in w riting from the publishers. T radem ark notice: Product or corporate nam es m ay be tradem arks or registered tradem arks, and are used only for identification and explanation w ithout intent to infringe. Cover design by Kathryn H oughtaling Lacey

L ibrary o f Congress C ataloging-in-Publication D ata Sim ple treatm ents for complex problem s : a flexible cognitive behavior analysis system approach to psychotherapy / Kimberly A. D risco ll. . . [et al.) in collaboration w ith the staff o f the Florida State University Psychology Clinic, p. cm. Includes bibliographical references and indexes. ISBN 0-80 5 8 -4 6 4 3 -3 (cloth : alk. paper) 1. Cognitive therapy. I. Driscoll, Kimberly A., 1972University. Psychology Clinic. RC489.C63S565 2004 616.89' 14 — dc22

II. Florida State

2003049294

Books published by Lawrence Erlbaum Associates are printed on acid-free paper, and their bindings are chosen for strength and durability.

ISBN-13: 978-1-410-61023-2 (ebk)

Contents

About the Authors Preface Chapter 1

vii ix

The Cognitive Behavioral Analysis System of Psychotherapy: Modifications and Applications for a Variety of Psychological Disorders

1

PART I Personality Disorders Chapter 2

Schizotypal Personality Disorder

15

Chapter 3

Borderline Personality Disorder

33

Chapter 4

Passive-Aggressive (Negativistic) Personality Disorder

49

Chapter 5

Personality Disorder Not Otherwise Specified

67

PART II Anxiety Disorders Chapter 6

Social Anxiety Disorder and Avoidant Personality Disorder

81

Chapter 7

Generalized Anxiety Disorder and Panic Disorder

101

PART III Parents, Children, and Couples Chapter 8

Parents of Children Diagnosed With Behavior Disorders

Chapter 9

Children With Social Skills Deficits

Chapter 10 Couples

119 139 153

PART IV Other Issues and Groups Chapter 11

Anger Management Problems

169 v

vi

CONTENTS

C hapter 12

C orrectional Settings

187

C hapter 13

T he C ognitive Behavioral Analysis System o f Psychotherapy: Future D irections

207

References

225

A uthor Index

235

Subject Index

239

About the Authors

K im berly A. D riscoll, Kelly C. C ukrow icz, a n d M au reen Lyons R eardon are d o c to ra l c an d id ates in clinical psychology at F lorida State U niversity, w here T h o m a s E. Joiner is th e B rig h t-B u rto n P rofessor o f Psychology a n d D irecto r o f th e U niversity Psychology Clinic. D riscoll’s w ork has focused o n c h ild h o o d d epression, the assessm ent o f A D H D a n d child externalizing disorders, a n d a d h ere n ce in ch ild ren w ith type 1 diabetes; C ukrow icz’s, o n p re d ic to rs o f tre a tm e n t o u tco m e , evalu­ a tio n o f p re v en tio n m e th o d s fo r anxiety a n d d epression, a n d a d u lt a n d child p sychopathology; R eard o n ’s on substance use a n d schizo p h ren ia, m ech an ism s u n d e rly in g acute alcohol tolerance, substance use in special p o p u la tio n s (e.g., c o rrectio n al in stitu tio n s, hom eless), evaluations o f c o m ­ p e te n cy /c rim in al responsibility, a n d p re d ic to rs o f p sy ch o th era p y ou tco m e. Jo in er’s interests include the psychology a n d n eu ro b io lo g y o f depression, suicidal behavior, anxiety, a n d eating disorders. H e earn e d a P hD in clin i­ cal psychology at th e U niversity o f Texas at A ustin. A re cip ie n t o f a G u g ­ gen h eim Fellow ship a n d th e A m erican Psychological A ssociation D istin ­ guished Scientific Aw ard fo r Early C areer C o n trib u tio n to Psychology in th e area o f psychopathology, a m o n g o th e r aw ards, he is th e c o a u th o r o r e d ito r o f six books a n d the a u th o r o f m o re th a n 200 jo u rn a l articles a n d chapters. H e has also served as Associate E d ito r o f B ehavior Therapy a n d as a m em b e r o f the edito rial b o a rd s o f nine o th e r jo u rn als.

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Preface

T he p rim a ry goal o f psychotherapy is to help patients get better. As a result o f m anaged care and lim itations set fo rth by insurance com panies, it has becom e increasingly im p o rta n t for therapists to quickly facilitate the p a tie n t’s process o f getting better. T hus, there has been a m ovem ent tow ard developing psychological treatm en ts th at can be easily and effi­ ciently im plem ented. M oreover, it is incu m b en t on therapists to provide patients w ith treatm en ts th at w ork. M cC ullough (2000) developed such a treatm ent; his C ognitive Behavioral Analysis System o f Psychotherapy (CBASP) is a technique th at has proven to be efficacious in the trea tm e n t o f chronic depression. In addition, the highly stru ctu red nature o f the technique allows for ease o f learning and im p lem entation. T he underlying concept o f CBASP is sim ple. T he therapist assists the p atient in discovering why he o r she did n o t obtain a D esired O utcom e (D O ) by evaluating the p a tie n t’s problem atic thou g h ts and behaviors. In o th er w ords, the th e ra ­ pist helps the patien t to d eterm ine w hat th o u g h ts and behaviors got in the way o f getting a DO. Because there is often a m ism atch betw een a p a tie n t’s goals and w hat is actually happ en in g in the p a tie n t’s life, CBASP’s tech ­ nique can easily be adapted and used in the trea tm e n t o f o th er psychologi­ cally distressing problem s, including anxiety, p ersonality disorders, m arital conflict, and child behavior problem s. Sim ple Treatments fo r Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy dem onstrates the w ider applica­ tio n o f CBASP to a variety o f psychological disorders. F u rth erm o re, the chapters in this book provide clinicians and patients w ith valuable in fo r­ m atio n regarding the im p lem en tatio n and m odification o f CBASP th ro u g h a b u n d an t clinical case exam ples and in-session tran scrip ts.1 T his book should prove valuable to academ icians, researchers, clinicians, o ther 'All names in case examples were changed to protect patients’ identity. ix

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PR EFACE

service providers, and the general public, particularly those interested in conducting trea tm e n t research and those interested in providing o r receiv­ ing efficient and effective trea tm e n t. CBASP, as presented in this book, is sim ple to teach and im plem ent and provides both professionals and the general public w ith an efficient and effective m eans to im prove psycho­ logical functioning. T he idea for this boo k was suggested by the d irector o f the Florida State University (FSU) Psychology Clinic, T hom as E. Joiner, PhD. O ne m o rn in g d u rin g o u r weekly staff m eeting, Dr. Joiner stated th at it w ould be a good idea for som eone to w rite a boo k applying M cC ullough’s CBASP tech ­ nique to o th er psychological disorders. As the assistant d irector at the tim e, I gave Dr. Joiner’s idea som e th o u g h t and then asked him if we as a clinic could w rite the book, especially since we used CBASP to trea t a variety o f disorders. At first he was skeptical; he was n o t convinced that the therapists w ould be enthusiastic ab o u t joining him in w riting a book given th at they already had m ultiple clinical-related, research-related, and course-related responsibilities. D espite the a m o u n t o f w ork th at the project represented, all o f us were enthusiastic, and as a result this boo k is a ra th e r unique c o n trib u tio n to the field. N ot only does it describe how to apply a single innovative and effective psychological trea tm e n t to a variety o f psycho­ logical disorders, it was the p ro d u c t o f a collaborative w riting effort by the therapists at the FSU Psychology Clinic. As one o f the coordinating a u th o rs (and I speak for the o thers and for all o f the co n trib u tin g a uthors), I am extrem ely grateful for Dr. Joiner’s generosity and m en to rsh ip at the clinic, w hich has resulted in the acquisition o f w hat we feel are superior clinical and research skills by us, his m entees and in w hat we hope will be a widely influential and widely used trea tm e n t technique th at will help patients get better fast. — Kimberly A. Driscoll

Chapter

The Cognitive Behavioral Analysis System of Psychotherapy: M odifications and Applications for a Variety of Psychological Disorders*

The introduction will provide a comprehensive review o f the dis­ orders that are discussed in subsequent chapters. In addition, the C og­ nitive Behavioral Analysis System o f Psychotherapy will be described, and general guidelines for m odifications are proposed.

Recently, th ere has b een a m o v em e n t away from the tra d itio n a l a p p ro ac h to p sy ch o th erap y (a p a tie n t sittin g o n a couch as th e th e ra p ist m akes in te r­ p re ta tio n s co n n ec tin g the past to th e p re sen t) to a m o re tim e -lim ite d , g oal-directed ap p ro ac h , w ith a p a rtic u la r em p h asis on the present. T his m o v em e n t tow ard the m o re efficient delivery o f p sy ch o th erap y serves sev­ eral p u rp o ses. First, it helps p a tie n ts recover in a sh o rte r a m o u n t o f tim e, w hich has im p lica tio n s fo r decreasing th e negative im p a c t o f psychological distress in a variety o f areas, in clu d in g in te rp e rso n a l relatio n sh ip s, e m p lo y ­ m en t, a n d p erso n al finance. Second, it decreases th e cost o f psy ch o th erap y w hile at th e sam e tim e p o ten tially in creasing th e n u m b e r o f p a tie n ts w ho receive services. Finally, as researchers a n d clinicians c o n tin u e to refine and ‘The primary authors contributing to this chapter were Kimberly A. Driscoll, Kelly C. Cukrowicz, and Thomas E. Joiner, Jr.

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im p ro v e p sy c h o th era p eu tic tech n iq u es, it reinforces the scientific bases o f p sy ch o th erap y a n d enhances credibility. T he m o v em e n t has resulted in th e estab lish m en t o f a v a rie ty o f tre a t­ m en ts as efficacious (i.e., sh o w n to w o rk for a g ro u p o f p a tie n ts w ith a sp e ­ cific psychological d iso rd e r u n d e r well c o n tro lled co n d itio n s). For exam ple, the c u rre n t tre a tm e n t o f choice for a p a tie n t diag n o sed w ith obsessivecom pulsive d iso rd e r is th e c o m b in a tio n o f p h a rm a c o th e ra p y w ith e x p o ­ sure a n d response p re v en tio n . In so m e cases, th ere exists m o re th a n one em p irically s u p p o rte d tre a tm e n t fo r a specific psychological d iso rd e r (see C ham bless & O llendick, 2000, for a co m plete review o f c u rre n tly e m p iri­ cally s u p p o rte d th era p ie s). M any d ifferent th e ra p e u tic tec h n iq u es have b een d e m o n s tra te d to be equally efficacious for depression. For exam ple, im p ro v e m en t in fu n c tio n in g is seen in depressed p a tie n ts w h e th er the p r i­ m ary tre a tm e n t m o d ality is p h a rm a co th e rap y , psychotherapy, o r a c o m b i­ n a tio n o f the two. Recently, Keller et al. (2000) d e m o n s tra te d th a t the C ognitive B ehavioral Analysis System o f P sychotherapy (CBASP), p a rticu la rly in c o m b in a tio n w ith p h a rm a co th e rap y , is efficacious in the tre a tm e n t o f c h ro n ic d e p res­ sion. CBASP is goal o rien ted , efficient, a n d sim ple to im p le m e n t.

T H E D E V E L O P M E N T OF C B A S P M cC u llo u g h (2000) developed CBASP specifically fo r the tre a tm e n t o f c h ro n ic d epression. T h e a p p ro a c h co m b in es b ehavioral, cognitive, and in te rp e rso n a l tec h n iq u es to teach the p a tie n t to focus o n th e c o n se­ quences o f behavior, a n d to use p ro b lem solving to resolve in te rp erso n al difficulties. T h e stu d y th a t lau n c h ed CBASP as an efficacious tre a tm e n t to o k place at 12 academ ic centers a n d inclu d ed p a tie n ts w h o m et criteria for a c h ro n ic u n ip o la r depressive d iso rd e r (i.e., M a jo r D epressive D iso r­ der, re c u rre n t o r D ysthym ic D iso rd e r). P atients w ere ra n d o m ly assigned to o n e o f th ree tre a tm e n t groups: m e d ic atio n only (N efazodone), p sycho­ th e ra p y only (CBASP), o r c o m b in e d tre a tm e n t o f N efazodone a n d CBASP. E xtrem e care was taken to e n su re th e q ualifications a n d tra in in g o f the th e ra p ists a d m in iste rin g psychotherapy. In a d d itio n , tre a tm e n t fidelity was carefully m o n ito re d a n d co n tro lled . R esults in d ic a te d th a t p a tie n ts in all th re e tre a tm e n t g ro u p s im p ro v e d substantially. H ow ever, th o se p a tie n ts w ho received the co m b in e d tre a tm e n t o f N efazodone a n d CBASP m ad e even m o re significant im p ro v e m en ts on p o sttre a tm e n t ratings, c o m p a red w ith th o se p a tie n ts in e ith e r the m e d ic a tio n -o n ly tre a tm e n t

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g ro u p o r th e p sy c h o th era p y -o n ly tre a tm e n t g roup. T h u s, th e a u th o rs c o n ­ cluded th a t th e ir results c o n trib u te to th e ex tan t lite ratu re, suggesting th at th e c o m b in a tio n o f m e d ic atio n a n d p sy c h o th era p y in th e tre a tm e n t o f dep ressio n is su p e rio r to e ith er tre a tm e n t alone.

C O M P O N E N T S OF C B A S P T he p rim a ry exercise o f CBASP is S itu atio n al A nalysis, o r SA, in w hich th ere is an elicitatio n phase a n d a re m e d ia tio n phase (M cC ullough, 2000). SA first requires th e p a tie n t to verbalize his o r h e r c o n trib u tio n in a d is­ tressful situ a tio n at th ree levels: interpersonally, behaviorally, a n d co g n i­ tively. SA is accom plished in five steps: describing the situ atio n , statin g the in te rp re ta tio n s th at w ere m ade d u rin g the situ atio n , describing the beh av ­ iors th a t o ccu rred , sta tin g the desired o u tco m e , a n d sta tin g th e actual o u t­ com e. W h en first b e g in n in g CBASP, th e C o p in g Survey Q u e stio n n aire (C S Q )1 sh o u ld be used b o th in session a n d as assigned h o m ew o rk (see Fig. 1.1). T he CSQ is in tro d u c e d in th e first session as th e to o l w ith w hich CBASP is co n d u cted . T he overall goal o f th e tre a tm e n t is to d e te rm in e the discrep an cy betw een w hat th e p a tie n t w an ts to h a p p e n in a specific s itu ­ a tio n a n d w h a t is actually h a p p en in g . By e x am in in g the specific situ atio n s, the p a tie n t g radually uncovers p ro b lem atic them es a n d ways in w hich he o r she can get w h a t is w anted. T h e p a tie n t is told th a t he o r she will co m plete CSQ s a b o u t stressful o r p ro b lem atic in te rac tio n s. T he p a tie n t is also to ld th a t th e situ a tio n will be discussed in session, along w ith w h a t th e p a tie n t th o u g h t, ho w he o r she acted, a n d ho w th e situ a tio n tu rn e d o u t c o m p a red w ith h o w the p a tie n t w anted th e situ a tio n to tu rn o u t. Finally, th e p a tie n t is to ld th a t this m e th o d will allow him o r h er to d e te rm in e ways in w hich th o u g h ts a n d b ehaviors are in te rferin g w ith his o r h er ability to get the d esired ou tco m e. As n o ted , th e CSQ is th e p rim a ry to o l o f SA, a n d we have m ad e m o d ifi­ c atio n s to M cC u llo u g h ’s o riginal CSQ to facilitate th e efficient use o f this im p o rta n t to o l, w hich is reflected in th e d e sc rip tio n s o f each o f th e steps. T h e CSQ is in tro d u c e d in th e first session. P ro v id in g th e p a tie n t w ith sev­ eral b lan k copies o f th e CSQ establishes th e e x p ectatio n th a t at least tw o CSQ s are to be c o m p leted betw een sessions, w hich m ean s at least o n e CSQ

'We recommend several modifications to McCullough’s CSQ; therefore, we refer to our version as the Coping Survey Questionnaire Used in the FSU Psychology Clinic’s Adapta­ tions of CBASP.

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Coping Survey Questionnaire Used in FSU Psychology Clinic's Adaptations of CBASP Select a stressful situation that has occurred in your life during the previous week or two. Please describe this situation using the steps indicated below. 1. In three or four sentences, describe the situation. 2. W hat was your interpretation of the situation? W hat did this situation mean to you? a. b. c. d. 3. W hat were your behaviors in this situation? a. Eye Contact— b. Body Posture— c. Gestures— d. Tone of Voice— e. Tim ing— f. Other behaviors— W hat did you say? How did you say it? 4. State what you wanted to get out of this situation. W hat was your desired outcome? 5. W hat was the actual outcome o f this situation? RATE: Did you get what you wanted? Yes_________ N o _________

FIG. 1.1. Coping Survey Q uestionnaire used in Situational Analysis. Adapted from McCullough’s Coping Survey Q uestionnaire by Maureen Lyons Reardon.

will be reviewed in session. Initially, com pleting one CSQ will probably take a full session; however, as the patient becom es m ore succinct when com pleting the individual steps and m ore efficient w ith using the CSQ, it is likely that several CSQs can be com pleted in one session. Eventual mastery o f the steps o f the CSQ is expected; however, patients should be required to com plete a paper version o f the CSQ as hom ew ork between every session to ensure consolidation o f therapeutic gains. A graphical depiction o f the CSQ can be found in Fig. 1.2, which can also be used as a patient handout to explain the process.

Ask yourself: Did I get what I wanted? Com pare the Actual and Desired Outcomes

GREAT! Ask yourself: How did my behaviors and/or my interpretations help me to get what I wanted'! Anything that might have hurt me that 1 may need to improve/alter?

FIG. 1.2.

Ask yourself: How did my behaviors and/or my interpretations hurt me or prevent me from getting what I w anted in this situation? How could they be improved/altered to help me get what I want the next time should such a situation come up again?

G raphical d ep ictio n o f CSQ fo rm at used to facilitate discus­

sion o f the conn ectio n s betw een th o u g h ts, behaviors, a n d consequent outcom es. A dapted by M aureen Lyons Reardon.

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In Step 1, the p a tie n t succinctly describes a p ro b lem atic o r stressful situ ­ a tio n in an objective m an n e r. T he goal d u rin g this step is for the p a tie n t to provide a situ a tio n w ith a b e g in n in g , a m iddle, a n d an en d , w ith o u t e d ito ­ rializing o r m ak in g in te rp re ta tio n s a b o u t w h a t h ap p en e d . We refer to this as a specific slice o f tim e, a n d o u r goal is for p a tie n ts to describe very specific situ atio n s. T he th e ra p ist m ay p h ra se the elicitation o f Step 1 as “If I was a fly on th e wall, w h a t w ould I see?” T h e in fo rm a tio n presen ted in Step 1 needs to be b o th relevant a n d accurate. Because p a tie n ts often pro v id e irrelevant, e x tra n eo u s in fo rm a tio n , in stru c tin g th e p a tie n t to d e ­ scribe a discrete in cid e n t in th ree o r fo u r sentences is reco m m e n d e d . D u rin g Step 2, th e p a tie n t learn s to identify th e specific in te rp re ta tio n s th a t w ere m ad e d u rin g th e situ atio n . D ep ressio n -related in te rp re ta tio n s te n d to be global a n d negative in n a tu re . T he goal o f th e seco n d step is for the p a tie n t to c o n stru c t relevant a n d accu rate in te rp re ta tio n s, a n d the m ost effective in te rp re ta tio n s are those th a t c o n trib u te directly to th e a tta in m e n t o f the D esired O u tc o m e (D O ). T his step tends to be the m o st difficult for p a ­ tie n ts to com plete; th u s, in stru c tin g th e m to describe tw o o r th ree th o u g h ts th a t p o p p e d in to th e ir m in d often helps w ith identifying in te rp reta tio n s. S om etim es it is necessary for th e th e ra p ist to p ro m p t th e p a tie n t by stating, “At th e tim e, w hen you w ere in th e situ atio n , w h a t did it m ea n to you?” D u rin g Step 3 o f SA, th e p a tie n t identifies th e specific b ehaviors th a t o c ­ c u rre d d u rin g the situ atio n . P articu lar a tte n tio n is p aid to th e co n te n t o f the conversation, th e to n e o f voice, b o d y language, eye c o n tact, a n d an y th in g else th a t th e p a tie n t did (e.g., w alking away). W h en identifying behaviors, th e p a tie n t sh o u ld a tte m p t to use the to n e o f voice o r facial expressions th a t occu rred in th e situ a tio n so th a t th e behav io ral details are accurately re p li­ cated. T he goal o f Step 3 is for th e p a tie n t to focus on th e aspects o f his o r h e r b e h av io r th a t c o n trib u te to th e a tta in m e n t o f th e DO. Iden tificatio n o f th e D O is accom plished in Step 4.2 A rticu latin g th e D O is im p o rta n t because all steps are a n c h o re d o r related to the a tta in m e n t o f th e DO . T h e D O is the o u tco m e th a t the p a tie n t actually w a n ted in the given situ atio n . To facilitate the expression o f the D O the th e ra p ist can ask, “W h at w ere you try in g to get in th is situ atio n ? ” o r “H ow did you w a n t this

2It should be noted that in McCullough’s (2000) original conceptualization of CBASP Steps 4 and 5 are reversed; the AO is determined in Step 4 and the DO is determined in Step 5. However, given that all steps are anchored to the DO, it is the opinion of these authors that the DO should be emphasized before discussion of the AO. Therefore, these steps have been reordered throughout the remaining chapters.

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situ a tio n to tu rn o u t? ” It is im p o rta n t for th e p a tie n t to identify a single D O p e r CSQ . M oreover, th e p a tie n t’s goal in Step 4 is to c o n stru c t D O s th a t are atta in a b le a n d realistic, m ea n in g th a t th e o u tco m e can be p ro d u c ed by the e n v iro n m e n t a n d the p a tie n t has the capacity to p ro d u c e the ou tco m e. P atients often have difficulty d e te rm in in g the a p p ro p ria te D O because th ey begin by ch o o sin g an o u tc o m e th a t requires change in a n o th e r p erso n o r a change in th e ir e m o tio n s. T h e p a tie n t m u st always focus o n how his o r h e r ow n th o u g h ts a n d beh av io rs influence situ atio n s, a n d , w hen focusing o n ho w so m e o n e else reacts, th e p a tie n t sh o u ld be re m in d e d th a t o th ers can be in fluenced b u t n o t co ntrolled. Lastly, th e id en tific atio n o f th e A ctual O u tc o m e (AO) is accom plished in Step 5. T he p a tie n t’s goal d u rin g Step 5 is to c o n stru c t an AO u sing b e h av ­ ioral te rm in o lo g y th a t describes exactly w h a t h a p p e n e d in th e situ atio n . P atients usually do n o t have any difficulty statin g the AO; how ever, for p a tie n ts w ho have difficulty a rticu la tin g this step, asking the q u estio n “W h at did you really get?” m ig h t help. O n ce Steps 1 th ro u g h 5 are c o m ­ plete, th e p a tie n t co m p ares th e AO to th e D O , answ ering th e m o st im p o r­ ta n t q u e s tio n — w h e th er o r n o t he o r she got the DO. T his com pletes the elicitation phase. D u rin g th e re m e d ia tio n phase, beh av io rs a n d c o g n itio n s are targ eted for change a n d revised so th a t the p a tie n t’s new beh av io rs a n d cog n itio n s in the situ atio n c o n trib u te to the DO. T h u s, d u rin g th e re m e d ia tio n phase, each in te rp re ta tio n is assessed to d e te rm in e w h e th er it aided in o r h in d ere d th e a tta in m e n t o f th e DO. T he re m e d ia tio n step focused on b ehaviors is sim ilar to th a t d o n e in th e re m e d ia tio n step focused o n in te rp reta tio n : Each b e h av io r is evaluated as to w h e th er o r n o t th e b e h av io r aided in o r h in d ere d the a tta in m e n t o f the DO. If in te rp re ta tio n s o r b ehaviors are seen as obstacles to a tta in m e n t o f D O s, th e so lu tio n is sim ply to alter th em so the in te rp re ta tio n s o r b e h av ­ iors are m o re likely to lead to D O s. R epetition o f these steps in a variety o f specific life situ atio n s is the core o f the CBASP tec h n iq u e (M cC ullough, 2000).

A P P L I C A T I O N OF C B A S P TO O T H E R PSYCHOLOGICAL DISORDERS A lthough M cC ullough (2000) originally developed CBASP for p a tie n ts w ith c h ro n ic depression, th e general p rin cip les o f CBASP can be applied to

DRISCOLL, CU K RO W ICZ , JO IN ER

a variety o f psychological disorders, a n d in som e cases only m in im al m o d ific atio n s to th e orig in al tec h n iq u e are necessary. As n o te d previously, th e p rim a ry exercise o f CBASP is SA, in w hich th ere is an elicitation phase a n d a re m e d ia tio n phase. T his is accom plished using the CSQ . SA first req u ires p a tie n ts to verbalize th e ir c o n trib u tio n in a social e n c o u n te r at th ree levels: interpersonally, behaviorally, a n d cognitively. D u rin g the re m e d ia tio n phase, beh av io rs a n d c o g n itio n s are targ eted for change a n d revised so th a t th e p a tie n ts’ new beh av io rs a n d c o g n itio n s in th e situ atio n c o n trib u te to a desirable o u tco m e . Because m o st psychological diso rd ers result in som e form o f in te rp erso n al difficulty, the use o f SA across a v a ri­ ety o f d iso rd ers m akes intu itiv e sense. F or exam ple, p a tie n ts w ith p e rso n a l­ ity d iso rd ers u n d o u b te d ly have in te rp erso n al conflicts, p a tie n ts w ith social an x iety d iso rd e r m ay experience su ch ex trem e anxiety w hen conversing w ith o th e rs th a t the possibility o f fo rm in g a n d fostering relatio n sh ip s is im p a ired , a n d p a tie n ts w ith im pulse co n tro l diso rd ers, p a rticu la rly anger m a n a g em e n t p ro b lem s, m ay alienate o th ers to the p o in t th a t th e re la tio n ­ ship is left in ru in s. T h u s, SA via th e CSQ can be used to address o n e o f th e c o m m o n features in each o f these d iso rd e rs— in te rp erso n al difficulties.

P erson ality D isord ers A p e rso n ality d iso rd e r is d efined as an e n d u rin g p a tte rn o f th in k in g , feel­ ing, a n d b ehaving th a t m ark ed ly deviates from th e exp ectatio n s o f o n e ’s c u ltu re (A m erican Psychiatric A ssociation, 1994). T his p a tte rn o f e x p eri­ ence a n d b e h av io r is pervasive, inflexible, a n d stable over tim e and leads to significant distress o r im p a irm e n t in th e indiv id u al. T here are th ree clu s­ ters o f p e rso n ality d isorders. C lu ster A consists o f p a ra n o id , schizoid, and schizotypal p e rso n ality disorders; ind iv id u als diag n o sed w ith a perso n ality d iso rd e r in th is c ategory are often described as o d d a n d eccentric. C lu ster B consists o f antisocial, b o rd e rlin e, h istrio n ic , a n d narcissistic perso n ality disorders; ind iv id u als diag n o sed w ith a p e rso n ality d iso rd e r in this cate­ gory are described as d ra m a tic o r erratic. Finally, C lu ster C consists o f avoidant, d e p e n d e n t, a n d obsessive-com pulsive p e rso n ality disorders; ind iv id u als diag n o sed w ith these d iso rd ers often a p p ea r a n x io u s o r fearful. Relatively few tre a tm e n ts have b een d e te rm in e d to be efficacious for p e r­ so n ality disorders. In fact, a ccording to N a th an a n d G o rm a n (1998), th ere are sta n d a rd psychosocial tre a tm e n ts for B orderline P ersonality D iso rd e r (BPD ) a n d A voidant P ersonality D iso rd e r (A PD ) b u t n o n e fo r o th e r p e r­ sonality disorders.

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T he a pplication o f CBASP to personality disorders is described in C h a p ­ ters 2 th ro u g h 5, w hich cover Schizotypal Personality D isorder (STPD), BPD, Passive-Aggressive Personality D isorder (PAPD), and Personality D isorder N o t O therw ise Specified (PD N O S). STPD is characterized by a pattern o f m aladaptive interpersonal behavior and by specific cognitive and behavioral sym ptom s (e.g., stereotyped thinking, m agical thinking, o d d/eccentric dem eanor, tangential speech). Previous studies indicate this disorder can be successfully treated w ith cognitive behavioral therapy. C hapter 2 describes m odifications o f CBASP th a t apply the use o f this technique to STPD. BPD consists o f sym ptom s such as instability o f interpersonal relation­ ships, self-im age, and affect and a p attern o f m arked im pulsivity. T his dis­ o rd er traditionally has been considered am ong the m ore difficult to treat, in p art due to the interpersonal deficits these patients exhibit. C hapter 3 sum m arizes the application o f CBASP to BPD and suggests ways in which it com plem ents existing treatm en ts for the disorder. PAPD is described in C hapter 4. T he disorder is characterized by a p attern o f negativistic attitudes, passive resistance to the dem ands o f o th ­ ers, and negative reactivity (e.g., hostile defiance, scorning o f auth o rity ). This disorder is cu rrently described in the appendix o f the Diagnostic and Statistical M anual o f M ental D isorders-Fourth Edition (D S M -IV ; A m erican Psychiatric A ssociation, 1994), as a result o f controversy su rro u n d in g the validity o f the diagnosis. T here is currently no em pirically validated trea t­ m en t for this disorder; however, CBASP seems to be a prom ising new fro n ­ tier in reducing the attitudes and behaviors associated w ith PAPD. PD NOS is the diagnostic label applied to patients w ho present w ith a com bination o f pathological personality sym ptom s th at com prise the oth er personality disorders b u t do n o t present w ith sym ptom s th at m eet the full criteria for any o ne personality disorder. These sym ptom s m ay also include m ore th an one personality disorder cluster (i.e., odd/eccentric, anxious, o r dram atic/erratic). C hapter 5 presents CBASP as a m eth o d o f treating the m ultifaceted p resentations th at m ake up this disorder. A case exam ple describes the im plem en tatio n o f SA for a patien t w ith PD NOS w ith avoidant and schizotypal features.

A n xiety D isorders Anxiety disorders are the m ost heterogeneous o f all the diagnostic cate­ gories (m o o d disorders, substance-related disorders, etc.) in the D S M -IV

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(A m erican Psychiatric A ssociation, 1994). T he sym ptom s o f som e o f the disorders are p rim arily physiological (e.g., breathing difficulties), others are characterized by avoidance (e.g., p hobias), a nd others p rim arily consist o f cognitive sym ptom s, such as w orries and obsessions. A large n u m b e r o f efficacious treatm en ts for anxiety disorders are in use, a nd a review o f these is beyond the scope o f this in tro d u c tio n . A lthough there are treatm ents th at have been dem o n strated to be efficacious for the anxiety disorders covered in this boo k (Social A nxiety D isorder, Panic D isorder [PD ], and G eneralized A nxiety D isorder [G A D ]), few focus as m u ch as CBASP on the consequences o f the p a tie n t’s behavior o r the interpersonal difficulties that arise from the disorder. CBASP em phasizes social problem s and interpersonal re lationships— realm s o f functioning specifically com prom ised in persons suffering from social anxiety. C hapter 9 d em onstrates how CBASP can be easily in co rp o ­ ra te d — and in fact dovetails nicely— w ith existing em pirically validated treatm en ts for Social A nxiety D isorder (e.g., exposure). M oreover, the increm ental efficacy o f integrating the present a pproach is depicted in the transcripts o f actual th erap y sessions. CBASP effectively targets the specific behaviors and cognitions th at co n trib u te to long-term avoidance o f social interactions, such th at en d u red o r thw arted anxiety is regularly attained across a variety o f interpersonal contexts. Little m odification o f the CBASP approach is actually needed to effec­ tively target the m aladaptive cognitions and behaviors th at m ain tain both PD and GAD. C hapter 7 d em onstrates th a t CBASP’s em phasis on specific situations enhances CBASP’s use as an in-session m eans to m anage the often diffuse, unfocused anxiety sym ptom s associated w ith each o f these conditions.

Parents, C hildren, and C ouples Parents o f children w ith behavior disorders often focus on the need to change the child’s behavior, w ithout fully recognizing the role that their ow n th o u g h ts and behaviors play in the p erp etu atio n o f family conflicts. C hapter 8 sum m arizes existing em pirically validated treatm en ts for exter­ nalizing b ehavior disorders, and the a u th o rs argue for the in co rp o ratio n o f CBASP into these treatm ents. T he u nm odified use o f CBASP w ith parents in a g roup therapy setting is a dem o n strated , effective m eans for positively changing p aren ts’ thou g h ts and behaviors, resulting in im provem ent not only in children’s behaviors b u t also in overall family functioning.

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C O G N I T I V E B E H A V I O R A L ANA LYSIS SYSTE M

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Social skills deficits are c o m m o n a m o n g ch ild ren w ith a variety o f b ehavioral p ro b lem s, in clu d in g A tten tio n -D efic it/H y p e rac tiv ity D isorder, O p p o sitio n al D efiant D isorder, a n d C o n d u c t D isorder. C h ild re n w ith these d iso rd ers often engage in negative beh av io rs th a t m ay be in te n d e d to gain a tte n tio n b u t actually result in a lack o f peer acceptance a n d , ultim ately, p eer rejection. C h a p te r 9 d e m o n stra te s ho w CBASP can be m od ified for use w ith ch ild ren in b o th the indiv id u al a n d the g ro u p th era p e u tic setting. T he m o d ific atio n o f CBASP is described w ith p a rtic u la r em phasis on the analysis o f the behav io ral aspects o f th e tre a tm e n t. C o n sid e ra tio n o f ch il­ d re n ’s ow n th o u g h ts and feelings as well as th e th o u g h ts a n d feelings o f o th ers is also stressed in th e m o d ific atio n o f th e tec h n iq u e. T reating couples in p sy ch o th erap y presents u n iq u e challenges, p a rtic u ­ larly because th e couple is generally seeking tre a tm e n t fo r relatio n sh ip difficulties; how ever, these pro b lem s m ay be c o n fo u n d e d by o n e — o r b o th — p a r tn e r’s ow n psychopathology. A lthough th ere is n o t yet an official diagnosis assigned to couples w ho seek tre a tm e n t (th o u g h th ere m ay be in fu tu re ed itio n s o f th e D SM ), they are categorized as h a ving a p a rtn e r-re la tio n a l p ro b lem , w hich is defined as a p a tte rn o f in te rac tio n betw een spouses o r p a rtn e rs characterized by c o m m u n ic a tio n pro b lem s. C h a p te r 10 p rovides a review o f th e available tre a tm e n t a p p ro ac h es fo r d is­ tressed couples. A lthough the prin cip les o f CBASP are consisten t w ith already available trea tm e n ts, this c h ap ter d e m o n stra tes the u n iq u e use o f th e tre a tm e n t, in w hich couple distress is the p rim a ry focus a n d indiv id u al distress is addressed indirectly.

O th er Issu es an d G rou ps A lthough it is n o t an in d ep e n d en tly d iagnosable c o n d itio n , excessive o r u n c o n tro lle d anger c o n stitu tes a critical feature o f m an y a d u lt a n d c h ild ­ h o o d p sychiatric d iso rd ers a n d can significantly interfere w ith several d o m a in s o f life fu n c tio n in g . C h a p te r 11 explores the p h e n o m e n o n o f anger a n d briefly su m m ariz es existing an g er m a n a g e m e n t tech n iq u es. T he com p arativ e use o f CBASP is h ighlighted by its a tte n tio n to th e cognitive, e m o tio n al, a n d behav io ral experience o f anger, its stra ig h tfo rw a rd in te g ra ­ tio n o f relaxation, a n d its in h ere n tly n o n c o n fro n ta tio n a l a p p ro ac h , w hich m akes it p a rticu la rly am en ab le to clients p ro n e to anger. T he successful a p p lic atio n o f CBASP to an g er m a n a g em e n t is illu stra te d in tw o case exam ples d raw n from vastly different p o p u latio n s: an o u tp a tie n t u n iv er­ sity clinic a n d a residential juvenile d e te n tio n facility.

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T he use o f CBASP is certainly n o t restricted to the o u tp atien t clinic; rather, CBASP m ay be effectively applied w ithin o th er settings, including correctional settings. C hapter 12 describes the interpersonal, em otional, and behavioral problem s often en countered by prison inm ates and fo r­ ensic hospital inpatients and dem onstrates, via session transcripts, how CBASP m ay be effectively applied to address the issues un iq u e to incarcer­ ated populations. A b rie f discussion o f potential barriers to the im p lem en ­ tation o f m ental health trea tm e n t in general, and CBASP in particular, w ithin correctional settings is also provided.

T he p u rpose o f this book is to provide clinicians and o th er m ental health care providers w ith a practical fou n d atio n for im plem enting CBASP w ith patients diagnosed w ith a variety o f psychological difficulties and d iso r­ ders. T he m odification and a d ap tatio n o f CBASP is described in a stra ig h t­ forw ard fashion so th at it can be easily used by those w ho lack form al train in g in its im plem entation. CBASP has been show n to be a tim elim ited, efficient trea tm e n t for patients diagnosed w ith depression; h ow ­ ever, in this book, we d em o n strate its p o tential w ith a variety o f disorders.

PART

I

Personality Disorders

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Chapter

Schizotypal Personality Disorder*

Schizotypal Personality Disorder is identified by a pattern o f m al­ adaptive interpersonal behavior, characterized by specific cognitive and behavioral sym ptom s. Previous studies indicate this disorder can be successfully treated with Cognitive Behavioral Therapy. This chap­ ter describes m odifications o f CBASP that increase the use o f this technique to Schizotypal Personality Disorder. A case is presented that illustrates the application o f specific com ponents o f this treatment (e.g., Situational Analysis) for reduction o f these sym ptoms. A tim elimited application o f this treatment led to a significant reduction in sym ptom expression despite the long-standing nature o f these sym p­ tom s in the patient.

Schizotypal P ersonality D iso rd e r (ST PD ) is a p a tte rn o f m aladaptive in te r­ p erso n al behavior, characterized by c ertain cognitive (e.g., stereotyped th o u g h t, m agical th in k in g ) a n d b eh av io ral (e.g., ta n g e n tia l/c irc u m stan tial speech, o d d /ec ce n tric ) sy m p to m s. T hese sy m p to m s m ay result in extrem e d isc o m fo rt a n d a d im in ish e d capacity to form close relatio n sh ip s, b e g in ­ n in g in early a d u lth o o d a n d ev id e n t across v ario u s situ atio n al contexts (A m erican Psychiatric A ssociation, 1994). D espite th e seem ing a m e n a b il­ ity o f STPD sy m p to m s to c o g n itive-behavioral in te rv en tio n , this m o d e o f tre a tm e n t has b een largely neglected. T his a p p a re n t oversight m ay ow e to the resem blance o f STPD sy m p to m s to S chizophrenia, a d iso rd e r generally accepted as biologically based a n d o p tim a lly trea te d w ith m ed icatio n . A lthough o th e r p sy ch o th erap y ap p ro ac h es have trad itio n a lly been applied, th ere is as yet no em p irically valid ated tre a tm e n t for STPD (N a th an & *The primary authors contributing to this chapter were Maureen Lyons Reardon, Scharles C. Petty, and Thomas E. Joiner, Jr.

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G o rm a n , 1998). H ow ever, th e stru c tu re in h e re n t in th e C ognitive Behav­ io ral Analysis System o f P sychotherapy (CBASP; M cC ullough, 2000) m akes it especially well suited to address ST PD sym ptom atology.

H I S T O R Y OF S T P D T R E A T M E N T STPD has lo n g b een co n sid ered a S chizo p h ren ia sp e c tru m d iso rd e r (B en­ ja m in , 1993), and p ro v id in g so m e s u p p o rt fo r this view, th e D iagnostic and Statistical M a n u a l o f M en ta l D isorders-F ourth Edition ( D S M -IV ; A m erican Psychiatric A ssociation, 1994) C lu ster A p e rso n ality d iso rd ers (i.e., STPD, schizoid, p a ra n o id ) are freq u en tly p re sen t in th e first-degree relatives o f schizo p h ren ics (K endler, M asterson, U ngaro, 8c Davis, 1984). In view o f this a p p a re n t relatio n sh ip , it p e rh ap s com es as little su rp rise th a t STPD has b een successfully trea te d w ith low -dose n e u ro le p tic a n tip sy ch o tic m e d i­ cations. T h o u g h n o t effective for all STPD p a tie n ts, several studies have sh o w n th a t antip sy ch o tic m ed ic atio n s can be m o d era te ly effective in re d u cin g ST PD sy m p to m s, such as ideas o f reference, o d d c o m m u n ic a ­ tio n , social isolation, suspiciousness, a n d anxiety (G oldberg et al., 1986; H ym ow itz, Frances, Jacobsberg, Sickles, & H oyt, 1986; Schultz, Schultz, 8c W ilson, 1988). A lthough psychodynam ic a p p ro ac h es have also been trad itio n a lly a p ­ plied, th ere exists little s u p p o rt for th eir clinical effectiveness w ith STPD (Siever 8c Kendler, 1986). Som e clinicians believe th a t p e rso n s w ith STPD can b enefit fro m dynam ically o rie n te d p sy ch o th erap y th a t focuses n o t on in te rp re ta tio n o f conflict b u t o n the in te rn aliza tio n o f a th era p e u tic rela­ tio n sh ip (G ab b ard , 2000; Sperry, 1995). In o th e r w ords, th e th e ra p ist w orks to dissolve th e rigid, in tern alized m aladaptive a tta c h m e n t w ith early caregivers by p ro v id in g an a p p ro p ria te a n d corrective em o tio n al e x p eri­ ence in therapy. O th e rs (W ainberg, Keefe, & Siever, 1995) c o n te n d th at su ch e x p lo ra to ry psy ch o th erap ies are ineffective fo r STPD , arg u in g for m o re stru c tu re d a p p ro ac h es (i.e., p sy c h o e d u ca tio n , reality testing, and in te rp e rso n a l b o u n d a ry re in fo rc em e n t). Based o n M illon’s (1981) view th a t STPD m a y b e considered an ex trem e form o f Schizoid P ersonality D iso rd e r o r A voidant P ersonality D isorder, so m e have a rgued th a t th e re c o m m e n d e d in te rv en tio n s fo r these d is­ o rd e rs also m ig h t be th e ra p e u tic for p erso n s w ith STPD (e.g., F reem an, Pretzer, Flem ing, & S im on, 1990). T hese a p p ro ac h es generally involve social skills train in g (e.g., role play) a n d g rad ed exposure to social in te r­

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actions (C rits-C h risto p h , 1998), w ith the goal o f e n co u ra g in g a m o re p o si­ tive view o f social in te rac tio n s th ro u g h practice. F u rth e rm o re , the c h ara c ­ teristic features o f STPD, such as m agical o r illogical th in k in g , m ay require in c o rp o ra tin g tec h n iq u es successfully ap p lied w ith sc h izo p h ren ic patients. Som e exam ples m ay include in te rv en tio n s aim ed at e n h a n c e m e n t o f social skills, re d u c tio n o f anxiety, a n d the im p ro v e m en t o f p ro b lem -so lv in g skills. O nce im p ro v e m en t in beh av io r a n d th o u g h t o d d ities is achieved, these tre a tm e n ts for schizoid o r avoidant p e rso n ality d iso rd e red p a tie n ts can th e n be effectively used in th e tre a tm e n t o f STPD. In terv e n tio n s for STPD have b een m ainly b eh av io ral in focus, w ith a p rim a ry em phasis o n skills tra in in g ra th e r th a n th o u g h t m o n ito rin g and d e v elo p m en t o f a p p ro p ria te responses to th o u g h ts (Bellack & H ersen, 1985). T he a p p a re n t em phasis o n b ehavioral tec h n iq u es is consisten t w ith the n o tio n th a t the b izarre th o u g h t processes associated w ith STPD m ay m ake pu rely cognitive tec h n iq u es difficult a n d im p ractical (F reem an et al., 1990). N onetheless, several recen t ra n d o m iz e d a n d c o n tro lled studies lend s u p p o rt fo r th e use o f cognitive th e ra p y in th e tre a tm e n t o f S chizophrenia (see Beck & Rector, 2000). T he m o st successful th era p ie s use a c o m b in a ­ tio n o f cognitive a n d b eh av io ral tec h n iq u es to address distress associated w ith positive (e.g., h a llu c in a tio n s, delusions) o r negative (e.g., flat affect, social w ith d raw al) sy m p to m s, c o ping skills a n d sy m p to m m an a g em e n t, a n d the sense o f alien atio n a n d stig m a associated w ith m en tal illness (H a d ­ d ock et al., 1998). T h u s, it co u ld be a rg u ed th a t if such in te rv en tio n s c o n ­ stitu te efficacious tre a tm e n t for a d iso rd e r as serious as S chizophrenia, sim ilar tec h n iq u es sh o u ld be at least as effective in trea tin g the relatively less severe b u t fu n ctio n ally sim ilar sy m p to m s associated w ith STPD. In this vein, CBASP a p p ears to be a p a rticu la rly p ro m isin g a p p ro ac h to th e tre a tm e n t o f STPD sy m p to m s. First, p e rso n ality d iso rd e red p a tie n ts repeatedly e n c o u n te r situ atio n s th a t result in u n d esirab le o u tco m es, a n d CBASP is designed to assist p a tie n ts in identifying th e th o u g h ts a n d beh av ­ iors th a t are c o n trib u tin g to the u n w a n ted o u tco m e s in specific situ atio n s. Second, CBASP involves regular co m p le tio n o f th e C o p in g Survey Q u e s­ tio n n a ire (C SQ ), w hich aim s, th ro u g h detailed e x am in atio n o f stressful situ atio n s, to increase p a tie n ts’ c o n tro l over life events to b e tte r m anage th e ir in te rp erso n al e n v iro n m e n t. T he CSQ su m m ariz es th e CBASP steps in sim ple form . Separate e x am in atio n o f beh av io rs a n d th o u g h ts, co n n ected to specific o u tco m es, can m ake com plex a n d a b strac t life events sim pler a n d m o re concrete; th is m e th o d b e tte r acco m m o d a te s th e im p aired th o u g h t processes (i.e., stereotypic, rigid) c o m m o n to ST PD pathology.

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M ore im p o rta n t, the CBASP m eth o d s o rganize th e th e ra p y session, w hich helps to co m b a t sy m p to m a tic tan g en tial th o u g h t processes.

TH ER AP EU TI C STRUCTURE: APPLICA TION OF A M O D I F I E D C B A S P A P P R O A C H F OR S T P D We re c o m m e n d several m o d ific atio n s to th e general CBASP a p p ro ac h to address th e ch aracteristic sy m p to m s o f STPD. First, ST PD p a tie n ts should be e n co u rag ed to select a p a rticu la rly specific a n d b rie f slice o f tim e for each CSQ . To evaluate a d h ere n ce to this d irec tio n a n d co rrect any lapses thereof, p a tie n ts can be asked to reco rd th e d u ra tio n o f selected situ atio n s (in m in u te s). Sentence lim ita tio n s can also be im p o sed to reduce the n u m ­ b er o f loose associations gen erated for each item . A d o p tin g a directive, so m e tim es in te rru p tiv e , th e ra p e u tic style m ay help to focus th e session a n d reduce irrelevant co m m en tary . Second, because som e ST PD p a tie n ts m ay be inclin ed to m u d d le th e D esired O u tc o m e (D O ) w ith th e d e sc rip tio n o f th e situ atio n , th ey sh o u ld be specifically directed n o t to do so. Such explicit in stru c tio n a n d se p a ra tio n m ay help to m in im iz e ST PD p a tie n ts’ c o n fu ­ sion. T h ird , a re stric tio n on th e to tal n u m b e r o f c o g n itio n s can be im posed to effectively reduce tan g en tial th o u g h t processes. Also, to em phasize th a t n o t all th o u g h ts equally c o n trib u te to the p e rce p tio n o f a situ atio n , p a ­ tie n ts can be asked to rate each th o u g h t o n a scale o f 1 (least applicable) to 10 ( m ost applicable). F o u rth , th e ch aracteristically o d d , eccentric b e h av io r sy m p to m a tic o f ST PD often c o n trib u te s significantly to STPD p a tie n ts’ ineffective n avigation o f social situ atio n s a n d sh o u ld be afforded a p ro m i­ n e n t role in tre a tm e n t. A dditionally, q ueries c o n ce rn in g c o m m u n ic a tio n beh av io r in each situ a tio n can be sep arated in to verbal a n d nonv erb al beh av io r to m ake these q ueries especially concrete. W e find it helpful to in q u ire specifically a b o u t nonverbal b ehaviors identified by A lberti and E m m o n s (1995) as critical to assertive c o m m u n ic a tio n (e.g., eye contact, b o d y p o stu re ). A dditionally, th era p ists sh o u ld co n sid er th e relative degree to w hich th e ST PD p a tie n t’s beh av io rs a n d th o u g h ts c o n trib u te to his o r h e r m a l­ adaptive in te rp e rso n a l style a n d accordingly afford g reater initial focus to th e ra p e u tic in te rv en tio n s addressing th e m o re severe d o m a in o f p ath o lo g y (i.e., beh av io rs o r th o u g h ts). Setting a tim e lim it for th era p y m ay also help set b o u n d a rie s fo r therapy, increase m o tiv a tio n fo r change, a n d encourage g en eralization o f th era p eu tic gains o u tsid e the th era p y setting. Such tim e

2.

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SCHIZOTYPA L PERSONALITY D ISO RD ER

lim its m ay be helpful n o t only for STPD p a tie n ts w ith long tre a tm e n t h is­ tories b u t also for th o se in early tre a tm e n t. O f course, tim e lim its sh o u ld n o t be rigidly enforced b u t revisited p eriodically to e n su re sufficient p ro g ­ ress has been m ade to justify te rm in a tio n . Finally, ST PD p a tie n ts sh o u ld be en co u ra g ed to seek feedback from o th ers in term s o f th eir im p ressio n s o f c o m m u n ic a tio n s after c o m p letio n o f a CSQ . In-session c o m m u n ic a tio n s w ith th e th e ra p ist m ay be used as m aterial for CBASP, th ereb y p e rm ittin g im m e d ia te feedback. T his affords th e o p p o rtu n ity to explore, in session, th e effectiveness o f p a tie n ts’ c o m m u ­ n icatio n s, an d , if ineffective, how th ey could be im proved . T he use o f the th e ra p e u tic rela tio n sh ip is c onsidered p a rticu la rly im p o rta n t in th e tre a t­ m e n t o f STPD , h elping th e p a tie n t to foster g en u in e co n n ec tio n s w ith others. T he follow ing case d e sc rip tio n illustrates th e th e ra p e u tic p o ten tial o f applying these CBASP m o d ificatio n s in the tre a tm e n t o f STPD.

-— -^> C a s e E x a m p l e

c—

Stan is a m id d le-ag ed , n e v er-m arried , self-em ployed W hite m an , w ho has lived alone for m o st o f his a d u lt life. H e has a long h isto ry o f m ental illness d a tin g back to his ch ild h o o d , d u rin g w hich tim e he was re p o rte d ly sub jected to u n im a g in ab le physical a n d sexual abuse by several close relatives. As a result, Stan has suffered from sy m p ­ to m s o f P o st-T rau m atic Stress D iso rd e r (PT SD ), p a rticu la rly n ig h t­ m ares, off a n d on for th e past 20 years. W h en Stan c o m m e n ce d th e th e ra p y described here, h e held a stro n g co n v ictio n o f inferiority. H e insisted, “ [I] am defective,” a “sm ashed p erson,” u n w o rth y o f m o st o th e rs’ a tte n tio n . T hese o p in ­ ions a p p ea red to h old, especially fo r th o se p erso n s w h o m he p e r­ ceived as attractive, ed u cated , a n d “together.” Stan c o m m o n ly categ o ­ rized p eople in this fashion, p e rh ap s p ro m o tin g a sense o f sep a ra tio n a n d differentness from o th ers. H is social n e tw o rk was largely re stric te d to a few co-w orkers a n d a fem ale frien d fo r w h o m he re p o rte d only p lato n ic interests. H e fu rth e r show ed little reco g n itio n o f th e im p a c t o f his b ehaviors o r sta te m en ts o n his associates. His a p p ro ac h to m eetin g w o m en was ra th e r h a p h az ard a n d alm o st acci­ dental, b u t he idealized these e n co u n ters as m agical. T his is certainly consisten t w ith cog n itio n s typical o f STPD (e.g., “T h ere are reasons fo r everything, th in g s d o n ’t h a p p e n by c h an c e ” [Beck & F reem an,

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1990, p. 140]). M oreover, his description o f his relationships was noticeably absent any d epth o r intim acy. Persons w hom Stan id en ti­ fied as friends were typically m ore characteristic o f acquaintances or casual contacts, suggesting a ra th e r superficial u n d erstan d in g o f w hat co nstituted closeness w ith others. Stan also exhibited noticeably o d d behaviors th at com prom ised his c om m unications w ith others, characteristics quite typical o f STPD pathology. For exam ple, Stan tended to vocalize every th o u g h t th at occurred to him w hen explaining a situ atio n , as if each were equally im p o rta n t to the com m u n icatio n . He show ed particular difficulty staying focused and generally responded to questions in a ram bling, tangential m anner. His speech had the quality o f a radio announcer, and, in fact, Stan later adm itted th at he had attem pted to m odel a local disc jockey’s pattern o f speech. Stan also referred to him self pluralistically, as “w e” o r “ourselves,” and described ostensible feelings o f social discom fort as being “o u t o f [my] body.” Stan offered little eye contact and initially sat h im self in a position perp en d icu lar to the therapist. D ue to p o o r d o c u m e n tatio n and co m m u n icatio n betw een various trea tm e n t providers, the details o f Stan’s extensive e ncounters w ith the m ental health system are sketchy at best. A review o f his file in d i­ cates he first entered treatm en t in 1979, at which tim e sym ptom s o f depressed m ood, frequent crying spells, low self-im age, sleep d istu r­ bance (insom nia), im paired concentration, suicidal ideation, and parental conflict do m in ated his clinical p resentation. O ver the next 3 years, Stan p articip ated in b o th individual and group therapy and was prescribed A m itriptyline (an antidepressant) and M idrin (for m igraines). D u rin g this tim e, Stan’s sym ptom s o f depression im ­ proved, and he finished ju n io r college and was accepted to a m ajor state university. Stan im m ediately sought trea tm e n t on arrival at the university and was seen by several therapists in the com m unity. A p re d o m in an tly psychoanalytic approach had been used to com bat his recu rren t depression and anxiety sym ptom s as well as to im prove his socialization. Stan was first seen by o u r train in g clinic in 1985. A lthough the p re ­ cise targets o f intervention were inadequately reflected in his chart, the approaches to trea tm e n t over the next 3 years were identified as cognitive restructuring, system atic desensitization, relaxation tra in ­ ing, stress m anagem ent, and social skills training. In 1988, Stan was

2.

SCHIZOTYPA L PERSONALITY D ISO RD ER

d iagnosed w ith M ultiple P ersonality D iso rd e r (i.e., D issociative Id e n ­ tity D iso rd e r), a n d an age-regression a p p ro ac h was used to w ork th ro u g h his su p p ressed tra u m a tic ch ild h o o d . O ver th e 13 years Stan received tre a tm e n t, he was tra n sfe rre d 12 tim es d u e to his th e ra p ists’ c o m p letio n o f th e ir g ra d u ate clinical tra in in g re q u ire m e n ts. By 1991, the ap p ro ac h to his sy m p to m s was again identified as cognitivebehav io ral w ith a re la x a tio n -tra in in g c o m p o n e n t. Stan was n o t diag n o sed w ith STPD u n til 1994. O ver th e next several years, Stan was trea te d by fo u r th era p ists w ho focused on e n co u ra g in g h im to o p en ly express e m o tio n s a n d to gain insight into his im p a c t o n others. A lth o u g h a p p are n tly helpful in c o m b a tin g his depression a n d overt anxiety sy m p to m s, n o n e o f these th era p ie s a d e ­ quately addressed th e features o f ST PD th a t c o m p ro m ise d his social fu n c tio n in g . Indeed, a p ro lo n g ed reliance on th era p y as th e p rim a ry fo ru m for em o tio n al expression a n d social in te rac tio n m ay have served to fu rth e r isolate h im from social c o n tacts o u tsid e the th era p y setting.

C o u r se of T r e a t m e n t : Sy m p t o m s a n d O u t c o m es

A 6 -m o n th tim e -lim ite d , m od ified CBASP a p p ro a c h was selected to address the a p p a re n t sh o rtc o m in g s o f his prev io u s therapies. We first targ eted S tan’s u n u su a l n o n v erb al p re se n ta tio n a n d its im p a c t o n his c o m m u n ic a tio n skills. As an a d ju n c t bib lio th erap y , Stan was e n co u rag ed to read p e rtin e n t sections o f Your Perfect R ight (A lberti & E m m o n s, 1995), w hich describes th e role o f n o n v erb al beh av io r in c o m m u n ic a tio n . As he achieved su b sta n tia l progress in b e h av ­ ioral d o m a in s (i.e., c o m m u n ic a tio n skills), we increasingly e m p h a ­ sized th e role o f his m alad ap tiv e co g n itio n s in his lim ited social in te ra c tio n s o u tsid e th e th e ra p y setting. T his was co n sid ered p a r ­ ticularly im p o rta n t to his tra n s itio n from a lo n g -te rm reliance on th e ra p y as th e p rim a ry avenue o f social expression to m o re a p p ro ­ p riate, o u tsid e in te rp e rso n a l contacts. Finally, issues p e rtin e n t to his te rm in a tio n w ere actively addressed in session, n o t only to firm u p b o u n d a rie s a n d increase m o tiv a tio n fo r change b u t also to offer h im a chance to practice expression o f e m o tio n s w ith th e th era p ist. T he th e ra p e u tic re la tio n sh ip h olds th e p o ten tial to m o d el a p p ro ­ p riate social in te rac tio n a n d also can help foster in te rp erso n al c o n ­ nectedness.

21

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It sh o u ld be n o te d th a t a lth o u g h we p re sen t S tan’s th e ra p y in term s o f these th ree targets o f in te rv en tio n , th ey sh o u ld n o t be c onsidered separate phases o f tre a tm e n t. T h at is, despite grad u al shifts in the em phasis o f CBASP in te rv en tio n , as progress in each d o m a in becam e evident, his o d d behaviors, m aladaptive cognitions, a n d te rm in a tio n issues w ere addressed th ro u g h o u t his therapy.

Em p h a s is : C o m m u n ic a t io n Skills

As stated previously, Stan initially sat h im self in a p o sitio n sideways relative to th e th era p ist. Stan readily p ro v id ed a ra tio n ale for this b e h av io r by stating, “I guess I’m used to m y h o u se . . . I always sit on th e rig h t side, I’m left-h an d e d . I guess I d o ju st a b o u t every th in g th a t way.” He fu rth e r in d icated th a t he needed to have a desk a n d used the w indow sill o n th e o p p o site side o f th e th e ra p y ro o m for this p u rp o se . T his beh av io r p ersisted in the next session, despite th e th e ra p is t’s e x p erim e n t in w hich a th e ra p y ro o m w ith o u t w indow s was selected. In a d d itio n , Stan rarely offered reg u lar eye c o n ta ct w hen speaking w ith others, in clu d in g th e th era p ist. R ath er th a n th e th e ra p ist a d ju s t­ ing to S tan’s m aladaptive behaviors, these b ehaviors w ere regularly addressed in th e co n tex t o f CBASP using S tan’s D O o f c o m m u n ic a t­ ing effectively w ith the th era p ist. R egular feedback c o n ce rn in g the effectiveness o f his in te rac tio n s was pro v id ed . T hese efforts w ere m et w ith som e resistance at first, a n d Stan arrived a few m in u te s late for th e next several sessions. D u rin g his fifth session, th e follow ing d ia ­ logue o ccurred: Therapist: For example . . . if you take you and me. I would find it easier for

Stan:

us to relate and for me to relate to other people when they’re fac­ ing me, looking at m e, and engaged with me. That’s why I brought up the chair thing. Yeah I had others ask about that, or they say “you don’t look that much,” and it’s hard to . . .

Therapist: ( interrupting) What do you think that means? Stan: W hen they ask or what does it mean for me? ( some cognitive dysregulation here) Therapist: What it means for you. Stan: What do I think it means to m e or what do I think it means for them?

SC H IZ O T Y PA L P ER SO N A LITY D ISO R D E R

Therapist: ( make specific) W hy d o n ’t we take it w hen they say it. H ow does that m ake you feel then? Stan: I w ould say t h a t . . . th at w ould m ake you feel in control and m aybe superior in a way. M ore skilled, aware o f social things, a n d ... Therapist: Well, how does it? I m ean, I can see w hat you see it can do for you. B u t. . . Stan: No. T h at’s w hat it m eans for you. Therapist: W hat do you m ean? I’m not following. ( clarification i f thought processes are unclear) Stan: I always have th o u g h t o f a counselor {i.e., therapist) as real socially skilled, polished, in control o f th em selv es. . . Therapist: So w hat does it m ean w hen people tell you that you’re n o t doing those things? Stan: I guess that I have a lot m ore to learn a bout m yself and that I still have good little habits to overcom e. Just a lot o f w ork to do. Therapist: (therapy relationship as model) Right now you’re looking at me. We’re talking. W hen you’re looking at m e, w hat’s going on . . . how do you feel? Is it uncom fortable? U ncom fortable, maybe, (pause) Challenging I guess. Stan: Therapist: Because you’re really trying? Stati: Trying to. It’s real h ard to get m yself to feel together and orga­ nized, engaged w ith som eone, to feel equal. T h at’s the hardest part, just feeling equal. Therapist: You feel som eone has the u p p er edge on you in som e way? Stan: I’ve got that, no d o u b t a bout that. Therapist: W hat w ould it take for you to start to do those things, like o ri­ enting yourself to oth er people, looking at them w hen they talk to y o u — w hat w ould it take? Stan: Wow. (pause) I guess reading m ore about it, practicing it. Therapist: Practice. Yeah, th a t’s the big one. Sounds like you know w hat it could do for you. Stan: Yeah, th a t’s n o t easy stuff to do, b u t . . . Therapist: I’m no t saying that. Stan: N ot m uch tim e to get all th at stu if together. Therapist: W hat do you m ean “n o t th at m uch tim e”? Well, tim e w ith us is ru n n in g out. Tim e goes so fast. Stuff w ith the Stan: book, th a t’s the k ind o f stuff— and m y little assignm ents here. You d o n ’t w ant to just say,“O h, I’ll do it later.” T hat m eans do it now as best you can. A nd I got to m ake tim e. T h at’s hard to sit dow n with (Ms. X ) and say this m ay sound really w'eird, b u t let

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m e go over this list o f stuff to talk about. ( chuckles) I’ll just have to make time to do it and present it to somebody. And (grabbing his completed CSQ JI found som eone I could do it with.

T he preced in g exchange n o t o n ly illustrates ho w S tan’s core co g n i­ tio n s o f in ferio rity are closely linked to his o d d ities o f b e h av io r b u t also s u p p o rts o u r c o n te n tio n th a t o u r im p o sitio n o f a tim e lim it help ed to m o tiv ate change. In th e follow ing session, Stan arrived p ro m p tly an d stated , “I was th in k in g a b o u t w hat you said, a n d so this w eek . . .” He pro ceed ed to pick u p a ch air from the o p p o site side o f th e ro o m a n d sat h im self face to face w ith th e th e ra p ist for th e first tim e. T his b e h av io r change persisted th ro u g h o u t th e re m a in d e r o f his therapy. By his 1Oth session, it becam e clear th a t these CBASP in te rv en tio n s h a d resulted in significant im p ro v em en t: Stan evidenced an increased aw areness o f th e c o n n ec tio n betw een his behaviors, th o u g h ts, and c o n se q u en t o u tco m es. D u rin g this session, Stan p re sen te d a CSQ in w hich he was able to achieve his D O reg ard in g a renew al o f a prev io u s frien d sh ip w ith a m ale friend. In discussing his n o n v erb al c o m m u n i­ catio n in th e situ atio n , he acknow ledged th a t he n o ticed his eye c o n ­ tac t was fleeting at tim es. Im p o rta n tly , how ever, he stated th a t he paid p a rtic u la r a tte n tio n to his p re sen ta tio n because, he stated, “the b e tte r [my] eye c o n tact, the m o re h o n e st an d sincere [I] can be w ith h im .” In a d d itio n , the stru c tu re im p o sed o n the th era p y sessions a p ­ p eare d to im p ro v e S tan’s ability to stay focused o n th e c o n te n t o f th e session, a n d his tan g en tial c o m m u n ic a tio n s w ere greatly reduced. Indeed, Stan was increasingly able to identify w hen a p a rtic u la r th o u g h t was n o t im p o rta n t to his c o m m u n ic a tio n s a n d sto p h im self from p u rsu in g in ap p ro p ria te , u n h e lp fu l lines o f discussion. At one p o in t, in Session 14, fo r exam ple, Stan cau g h t h im self w ith o u t th e r a ­ p ist d irect in te rv en tio n , “Yes, well. We can talk a b o u t th at later. T he im p o rta n t th in g is . . In-session im p ro v e m en ts in nonv erb al c o m ­ m u n ic a tio n grad u ally generalized to social in te rac tio n s o u tsid e o f therapy, as he increasingly began to achieve his D O s related to taking a p p ro p ria te social risks. He consistently com pleted CSQ h o m ew o rk th a t illu strated th e successful in itiatio n o f a p p ro p ria te conversations w ith o th ers a n d was b e tte r able to follow th e c o n v en tio n s o f social in te rac tio n . A ccordingly, the focus o f th e ra p y shifted to addressing the m aladaptive c o g n itio n s th a t im p e d e d his progress in this d o m ain ,

SC HIZOTYPAL PERSONALITY D ISO R D ER

w hile c o n tin u in g to m o n ito r his b e h a v io ra l g ain s in th e c o n te x t o f CBASP. Em ph a sis: C ognitions

To so m e e x te n t, th e im p ro v e m e n ts in S ta n ’s b e h a v io ra l p re se n ta tio n g en eralized to his m ala d ap tiv e c o g n itio n s, p ro v id in g h im w ith a new sense o f self-efficacy fo r effectively en g ag in g in social situ a tio n s. E a r­ lier in tre a tm e n t, Stan re la te d su c h core th o u g h t processes as “ I feel w ay to o self-co n scio u s,” “ I d o n ’t b e lo n g here,” “ T h is [social in te r ­ a ctio n ] isn ’t easy for m e,” a n d “ I c a n ’t c o n fro n t s o m e o n e if h e ’s a n g ry w ith m e.” T h ese c o g n itio n s w ere sim p ly a d d ressed in th e c o n te x t o f CBASP as u n h e lp fu l in a tta in in g his re p o rte d D O s to c o m m u n ic a te effectively in v a rio u s specific situ a tio n s. C o n tin u e d p ra c tic e a n d re h ea rsa l o f th ese c o g n itio n s in specific social in te ra c tio n s , a lo n g w ith m o re fre q u e n t a ch iev e m en t o f his D O s, re su lte d in sig n ifican t im p ro v e m e n t in S ta n ’s p re v io u sly “s m a sh e d ” self-im age. O v e r th e c o u rse o f h is th era p y , S tan g e n e ra te d a list o f p o sitiv e th o u g h ts th a t facilitated effective social in te ra c tio n s o u tsid e o f th e th e ra p y se ttin g (see Table 2.1). TABLE 2.1 Summary of Revised Cognitions of Self-Image and Self-Efficacy

Self-Image

Self-Efficacy

“Other people report that I am normal.”

“It’s not hard to communicate well.”

“I’m desired and valued from people.”

“I’m not always focused, but I am learn­ ing and improving my ability to be focused and orderly.”

“I treat people with respect.” “I’m knowledgeable and generous.” “I am a good listener.”

“I’ve learned to pay attention to what (my) self is telling (my)self and not to just do nothing.” “I’m going to be myself, be the best me that I can be, and will try to be aware, as much as possible, of other people involved.” “I’ve improved a lot over the years; I’ve fought for it, fought hard and will continue to fight.” “Whatever his attitude is, good or bad, I can handle it.”

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As an example o f this progress, while reviewing his CSQ assign­ ment during his 14th session, Stan generated several alternate inter­ pretations that clearly would have helped him achieve his DO in an interaction with several women during a business-related exposition where he presented his work. The therapist jotted down his thoughts and repeatedly tied them to his DO to demonstrate a good social interaction: Therapist: Well, okay, so you got a couple o f th oughts here that sou n d a whole lot better than the ones on the previous page ( the original CSQ homework) that you m ight just w ant to consider changing to, o r at least trying to th in k of, w hen you are about to approach som eone and m eet w ith them . T hey are ( reviewing notes): “O th ­ ers rep o rt th at I am n o rm a l” and “I am desired and valued from people.” Stan: Yeah. A nd they said th at I had obviously studied that stuff for years— w hich 1 had, like 30 years already— an d that they were glad th at I take tim e to go see them . Because there’s one guy there th at I know very well th a t’s a brilliant m an b u t also a very arrogant m an. [They said] they felt really p u t off by him , in tim i­ dated, an d not at all able to be themselves. Therapist: H m m . . . T h a t . . . that doesn’t seem to fit w ith your last one here, an d th a t’s p robably why you got the 50% one here. ( rating o f degree o f thought applicability to the situation) Stan: W hich one was that? Therapist: (reading) “I am an extrem ely self-centered person.” Stan:

Well, there’s a good exam ple o f how you can tu rn exactly that into som ething positive. W hich is a fine line, because I have been real self-centered and a lot o f it is from learning all that stuff and kind o f doing m y ow n PhD w ith learning inform ation, w riting it, and sharing it. T here’s been a lot o f being self-centered, b u t if you take tim e for s o m e o n e . . . Therapist: (interrupting) Sounds like to m e what they were saying is “you’re a pretty know ledgeable p erson in this area, seems like you’ve studied a lot, and you took the tim e to com e o u t and help us.” Stan: T h at’s the key. Therapist: Well, w hat w ould you say about som ebody w ho’s knowledgeable and willing to take the tim e to help oth er people? Stan: You treat them w ith re sp e c t. . . d o n ’t talk dow n at them . Make them feel like any counselor w ould, like they’re the m ost im p o r­ tan t person right then. Therapist: (writing) “I treat people w ith respect.”

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Stan: And “importance,” too. Therapist: “I treat people with respect and importance.” Does that thought

Stan:

help you get what you want, which is to have a good interaction with people? That’s what I got from them, yeah.

By his 18th session, Stan h a d fu rn ish ed a c o m p leted CSQ in w hich h e described a c o nv ersation w ith a w aitress at a local re stau ra n t. He n o ted his D O as “I w a n ted to have a casual b u t friendly conversation w ith her.” P articu larly n o tew orthy, arguably all o f his in te rp re ta tio n s in th is situ atio n served to help h im achieve th is desired e n d — for exam ple, “she d o e sn ’t m in d m y being here,” “sh e ’s m o re a p p ro a c h ­ able,’’“ it’s okay for m e to sit dow n w ith her,” an d “ I’m feeling together, real together,” “I’m prep ared .” H is n o n v erb al b ehaviors w ere also c o n ­ sistently likely to help h im get w hat he w a n ted in this situ atio n . Im p o rta n tly , Stan perceived this in te ra c tio n as successful, a n d feed­ b ack th a t he su b seq u e n tly solicited from th e w aitress su p p o rte d this in te rp reta tio n . D espite his a p p a re n t im p ro v e m en ts in b ehaviors a n d cognitions, how ever, Stan c o n tin u e d to categorize people in term s o f th eir perceived value in relation to him self, c o n te n d in g th a t m o st o th ers w ere u n a p p ro ac h ab le . T hese in te rp re ta tio n s m ay have caused Stan to avoid social in te rac tio n s w ith those p e rso n s he perceived as som ehow m o re valuable th a n h im . In the context o f CBASP, these th o u g h ts can sim ply be considered a c o n trib u tin g facto r in his failure to achieve his D O s o f social in te rac tio n . A lth o u g h these c o g n itio n s w ere addressed repeatedly in th e context o f his CSQ assignm ents, it was n o t u n til his 2 2 n d session th a t Stan re p o rte d a p a rticu la rly en lig h ten in g e x p eri­ ence. H e to ld th e th e ra p ist th a t he h a d recently seen a speed tra p , a n d no so o n e r did he say to him self, “Boy, am [I] glad [I’m ] n o t o n e o f those p eople w ho gets p ulled o v er” th a t he “saw blue lights in [his] rearview m irro r.” Stan re p o rte d th a t he su b seq u en tly began m a in ­ tain in g a log o f how m an y tim es he m ade negative a ttrib u tio n s ab o u t p eople in an effort to d ifferentiate h im self fro m th em , observing th a t he did so at least 10 tim es p e r day. H e fu rth e r estim ated th at he h a d m ade “a b o u t 14,000 negative a ttrib u tio n s in 40 years.” Stan c o m m e n te d th a t replacing such th o u g h ts w ith positive a ttrib u tio n s w ould be a slow process a n d w o u ld “n o t be a m agical change.” In c o n ­ nection w ith the cog n itio n s ch aracteristic o f STPD , in w hich such

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experiences are likely to be view ed as h a ving m agical im p licatio n s (Beck & F reem an, 1990), S tan ’s practical a n d realistic view o f this change process w as considered to m ark significant progress. U lti­ m ately, Stan co n clu d ed th a t he w ould use his “sp e e d o m e te r to re m in d [him ] o f ho w [he is] like o th e r people.” T his d e m o n stra tes S tan’s increasing reliance on him self, as o p p o se d to therapy, as the resource for a lterin g his m aladaptive cognitions.

Em ph a sis: T erm ination

W h en the issue o f te rm in a tio n w as readdressed in Session 18, Stan re sp o n d ed in a m a n n e r c o n sisten t w ith th e in te n d e d goal o f this tim e -lim ite d th era p e u tic ap p ro ac h , “It’s tim e to n a rro w d o w n to w ork th a t w ould be risky.” A lthough tim e -lim ite d , stru c tu re d th era p y m o tivates su b stan tial change in a s h o rt p e rio d o f tim e, som e regres­ sions are to b e expected. For exam ple, Stan arrived early for his 23rd session, using his tim e in th e w aiting ro o m to organize his th o u g h ts. H e initially tu rn e d his ch air away from th e th e ra p ist b u t th en re arra n g ed his ch air stating, “ [I’m ] n o t d o in g th is rig h t. We w orked o n this in th e beg in n in g . [I’m ] n o t c o m m u n ica tin g .” A lth o u g h he was speaking co h eren tly from th e th e ra p is t’s sta n d p o in t, he repeatedly stated th a t he was n o t. H is ap p ro ac h to this session did n o t ap p ear to be reflective o f a defensive effort to avoid te rm in a tio n b u t ra th e r o f an active, albeit so m ew h at rigid, effort to m ake h im self feel less scattered. Such aw areness a n d effort could be view ed as progress, d e m o n s tra tin g his increased reliance o n him self, ra th e r th a n the th era p ist, to im prove his focus and c o m m u n ic a tio n . Indeed, som e d isc o m fo rt can be expected, c o n sid erin g th e significant a d ju stm e n ts he h a d m ade in his life. T he e m o tio n s su rro u n d in g his te rm in a tio n as well as p erso n al loss o f th e ra p ist w ere addressed in session using CBASP. Such an ap p ro ac h affords th e th e ra p ist the o p p o rtu n ity to explore, in session, th e effectiveness o f S tan’s c o m m u n ic a tio n s an d , if ineffective, provide im m e d ia te feedback o n ho w th e c o m m u n ic a tio n could be im proved. In a d d itio n , by m ak in g th e loss o f his th era p ist perso n al, the th era p ist h o p e d to u n c o n stric t S tan’s affect a n d pro v id e h im w ith a sense o f in -th e -m o m e n t in te rp erso n al connectedness. N o t surprisingly, Stan initially struggled to c o m m u n ic a te negative e m o tio n s c o n ce rn in g this loss. He often avoided discussion o f losing th e th era p ist by refer­

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rin g to h e r as ju st one o f m an y th era p ists o r referrin g to th e clinic in general. In keeping w ith the general a p p ro ac h to his therapy, Stan was redirected. Perhaps d u e to his p rio r ro u tin e tran sfers in therapy, he struggled to u n d e rsta n d th e con cep t a n d value o f active te rm in a ­ tio n a n d o f saying good-bye. Also, p e rh a p s n o t unex p ected , Stan cancelled his last session by leaving a m essage to in fo rm the th e ra p ist o f his th an k s a n d w ell­ being. W ith som e p e rsu asio n , how ever, he agreed to com e in for a final session. E m phasis was placed o n th e im p o rta n c e o f saying good-bye, despite its b u ilt-in c o m p licatio n o f e m o tio n s, a n d the th e r ­ apist h ighlighted ho w a p h o n e m essage w ould m ake su ch im p o rta n t c o m m u n ic a tio n s im possible. D u rin g his te rm in a tio n session, S tan’s affect was less restricted. H e asked a p p ro p ria te q u e stio n s w ith m in i­ m al digressions a n d d e m o n s tra te d excellent eye c o n ta ct a n d a p p ro ­ p riate nonv erb al behavior. At th e session’s con clu sio n , th e th era p ist offered Stan a h a n d sh ak e, to w hich Stan looked directly at th e th e ra ­ p ist (i.e., g o o d eye c o n ta ct), w ith so m e tearfulness, th e first e m o tio n s su rro u n d in g te rm in a tio n yet expressed, he gestured fo r a hug. From a p rofessional sta n d p o in t, th is p ro v id ed a m a rk o f su b sta n tia l progress for this p a tie n t in term s o f his capacity for p erso n al co n n ectio n . Stan w as able to achieve significant progress in his n o n v erb al social p re sen ta tio n , as evidenced by his im p ro v ed eye c o n ta ct a n d p e rm a ­ n e n t behav io ral a d ju stm e n t in seating p o sitio n . H is c o m m u n ic a tio n skills w ere vastly en h an c ed by im p ro v e m en ts in his th o u g h t processes (e.g., tangentiality, loose associations). M ost im p o rta n t, after ju st 24 sessions o f CBASP, Stan was able to m ake a successful tra n s itio n o u t o f therapy, w hich to this p o in t h a d served as his p rim a ry o u tle t for social in te ra c tio n fo r m u c h o f his a d u lt life.

P O T E N T I A L O B S T A C L E S TO C B A S P A P P L I C A T I O N S TO S T P D A lth o u g h th e p ro p o se d changes to CBASP are likely to greatly im prove the focus a n d stru c tu re o f sessions w ith th e ST PD p a tie n t, successful im p le ­ m e n ta tio n o f this a p p ro ac h m ay req u ire som e a d ju stm e n t to o n e ’s typical th e ra p e u tic style. As in th e p re sen t case, a directive, so m e tim es interruptive, style m u st be a d o p te d early in tre a tm e n t to reduce sy m p to m a tic tan g en tial th o u g h ts. Such efforts m ay seem aw kw ard a n d at tim es u n c o m ­

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fo rtab le for th era p ists n o t accu sto m ed to c o m m u n ic a tin g w ith th eir p a tie n ts in this m an n er. It is im p erativ e th a t th era p ists a d o p tin g this a p p ro ac h carefully balance directive efforts to focus sessions against th e critical efforts to pro v id e th e p a tie n t w ith an in-session m odel o f c o m m u ­ nication. In o th e r w ords, th era p ists m u st be careful n o t to suggest th at in te rru p tio n o f o th ers is socially a p p ro p ria te . Instead, the th e ra p ist’s d irec ­ tive d isru p tio n o f th e p a tie n t’s loose associations sh o u ld be c o n d u cted only w ith m in d fu l in te n tio n o f ed u ca tin g th e p a tie n t a b o u t w hat is essential to th e d e sc rip tio n o f a p a rtic u la r situ atio n . CBASP is helpful in d e lin e at­ ing this subtle d istin c tio n , m ak in g it im m ed iately clear ho w tan g en tial th o u g h ts o r c ertain social b ehaviors m ay be o n ly rem o tely related, o r at tim es com pletely u n re la te d , to th e D O s a n d th u s n o t helpful in th e context o f m o st social c o m m u n ica tio n s. As sy m p to m s im prove, a less directive a n d in te rru p tiv e style m ay be n eed ed to focus the th e ra p y session. O ver tim e, th e p a tie n t sh o u ld be e n co u rag ed to take m o re o f th e lead in session. Initially, for exam ple, the th e ra p ist read a n d review ed S tan’s assig n m en ts in session. Later, Stan was asked to review th e a ssig n m en t as th e th e ra p ist to o k notes. T his tra n s ­ actio n w as th e n explored as in-session c o m m u n ic a tio n , subject to CBASP a n d feedback from th e th era p ist regarding th e effectiveness o f Stan’s c o m ­ m u n ic a tio n . To effectively use th e th era p e u tic rela tio n sh ip in this context, g e nuineness on the p a rt o f the th e ra p ist is n eed ed to m ake the relatio n sh ip b o th im p o rta n t a n d re a l— a challenge for STPD p a tie n ts, w h o m ay n o t readily view any p e rso n s in this m anner. A dditionally, b e co m in g a cq u a in te d w ith th e o d d m a n n e r in w hich STPD p a tie n ts c o m m u n ic a te th e ir th o u g h ts a n d beh av io rs m ay pose an ad d itio n al challenge for th e inexperienced th era p ist, p a rticu la rly early in tre a tm e n t w hen idiosyncrasies o f beh av io r can seem q u ite foreign. To ensure p ro p e r u n d e rsta n d in g , th e th e ra p ist sh o u ld a tte m p t to s u m m a r­ ize the p a tie n t’s c o g n itio n s using m o re c o m m o n w ording. T he th era p ist m ay also w ish to co n sid er offering feedback on these tran sla tio n s o f th e p a tie n t’s se lf-re p o rted co g n itio n s, p a rticu la rly if they are th o u g h t to im p e d e effective c o m m u n ic a tio n . A n o th e r issue th a t m ay em erge in th e tre a tm e n t o f ST PD is th e use o f p sychiatric m ed icatio n s. As n o te d previously, m an y atypical n e u ro le p tic m ed ic atio n s a p p e a r to be effective fo r som e o f th e p se u d o sc h izo p h re n ia sy m p to m s o f STPD. T h u s, along w ith a psy ch iatrist a n d th e STPD p a tie n t, th era p ists sh o u ld afford psychiatric m ed ic atio n s d u e c o n sid ­ e ratio n as a viable a d ju n c t tre a tm e n t. In the p re se n t case, Stan sto p p ed

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tak in g his p re sc rip tio n s fo r R isperdal (a n tip sy c h o tic ) a n d Im ip ra m in e (a n tid ep re ssan t) in th e m o n th s p rio r to the sta rt o f c u rre n t tre a tm e n t. A ccordingly, m ed ic atio n c om pliance was e n co u rag ed as an a d ju n c t to his therapy, h elping him to clear his th o u g h ts. By Session 4, Stan h a d begun tak in g R isperdal again a n d re p o rte d im p ro v e m en ts in sleep a n d fewer n ig h tm a res a n d intrusive th o u g h ts o f his past abuse h isto ry (how ever, we believe it w ould be an in ferential m istake to a ttrib u te S tan’s success to his m ed ic atio n s because m ed ic atio n s taken before CBASP h a d n o t resulted in m u c h im p ro v e m en t). In fact, few p a tie n ts p re sen t w ith STPD sy m p to m s in isolation; m o o d , anxiety, a n d o th e r p e rso n ality sy m p to m s c o m m o n ly c ooccur w ith this c o n d itio n . In th e p re sen t case, S tan’s PTSD re m a in e d in p a rtial rem ission th ro u g h o u t m u ch o f his tre a tm e n t. Like m any d iso rd ers w ith this clinical status, occasional relapses o f sy m p to m s can a n d did occur. W henever p o s­ sible, CBASP was used at these tim es, p a rticu la rly if th e sy m p to m s were situ a tio n specific a n d th u s readily am en ab le to this a p p ro ac h . T his is the p referred a p p ro a c h to addressing c o m o rb id p ath o lo g y because, as n o te d elsew here in this text, CBASP is q u ite flexible fo r m an y psychological c o n d itio n s a n d everyday pro b lem s. O th e r tim es, how ever, a m o re general c o g n itive-behavioral in te rv e n tio n was em ployed w ith Stan to address these sy m p to m s. A d e sc rip tio n o f these in te rv en tio n s is clearly b ey o n d the scope o f the p re sen t discussion, b u t the interested reader is referred to Resick and C a lh o u n (2001) for in fo rm a tio n o n an effective tre a tm e n t for PTSD. Given th a t STPD p a tie n ts m ay n o t be aw are o f th e im p a c t o f th e ir o d d beh av io rs o n th e ir life situ a tio n , it is likely th a t th e ir p e rce p tio n o f progress in th is regard m ay vary w idely from th a t o f th e th era p ist. For exam ple, d u rin g S tan’s 10th session, he w as asked to rate his progress in his n o n v e rb al beh av io rs o n a scale o f 1 = I need w ork to 4 = okay to 7 = excellent. In c o n tra st w ith o b serv atio n s o f his im p ro v e m en t by his th e ra ­ p ist a n d su pervisor, Stan ra te d all b u t gestures as in n eed o f so m e w ork (ran g e 2 .5 -3 .5 ). T his discrep an cy was th o u g h t to reflect S tan ’s m a la d a p ­ tive self-cognitions, w hich had , by this p o in t, only recently c o n stitu ted the em p h asis o f CBASP in te rv e n tio n . As can be seen in Table 2.1, how ever, w ith repeated practice and m o re freq u e n t achievem ent o f his social D O s, S tan’s self-efficacy had a p p are n tly cau g h t u p to his beh av io rs by th e c o n ­ clusion o f his therapy. In th is c o n n e c tio n , it sh o u ld be reiterated th a t th era p ists sh o u ld m ake n o te o f changes in observable b ehaviors a n d p ro ­ vide regular, in-session feedback c o n ce rn in g c o m m u n ic a tio n im p ro v e ­ m ents. O f course, th e process o f CBASP yields successful in te rp erso n al

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o u tco m e s o u tsid e o f th e ra p y th a t even th e least insightful c a n n o t d eny as progress.

T he preced in g case d e sc rip tio n clearly illustrates how the im p o sitio n o f a directive, tim e -lim ite d , stru c tu re d CBASP p ro to co l n eed n o t be im p e r­ sonal a n d m echanical b u t q u ite th era p e u tic for p e rso n s w ith STPD. A lth o u g h STPD p a tie n ts m ay n o t be aw are o f th e ir od d n o n v erb al social p re sen ta tio n , CBASP can enable th e ir su b stan tial progress in this regard (e.g., increasing eye co n ta ct). M oreover, im p ro v e m en ts in th o u g h t process­ ing (i.e., lo o sen in g o f associations) are also m ad e possible by th e stru c tu re in h e re n t in the CBASP m eth o d . U ltim ately, th e collaborative e x am in atio n o f in te rp re ta tio n s in the co n tex t o f CBASP serves to e ncourage the g en eral­ ization o f social experiences o u tsid e th e th e ra p y session. A lthough CBASP clearly aw aits form al em pirical evaluation as an ST PD tre a tm e n t, it appears to be a q uite p ro m isin g a p p ro a c h for p e rso n s w ith STPD, re g ard ­ less o f th e d u ra tio n o r severity o f p e rso n ality d y sfunction.

Chapter

Borderline Personality Disorder*

Borderline Personality Disorder has traditionally been considered am ong the m ore difficult disorders to treat, in part due to the inter­ personal deficits patients with the disorder exhibit. This chapter summarizes the application o f the Cognitive Behavioral Analysis System o f Psychotherapy to Borderline Personality Disorder and sug­ gests ways in which the approach com plem ents existing treatments for Borderline Personality Disorder. The use o f Situational Analysis is presented as a means o f identifying and correcting maladaptive patterns o f thinking and behaving that typify this disorder. A case example illustrates the im plem entation o f this treatment and associ­ ated sym ptom reduction.

B orderline P ersonality D iso rd e r (BPD ) has b een p a rt o f psychiatric n o so l­ ogy since th e 1930s (G reen, 1977). T h e D iagnostic an d Statistical M a n u a l o f M en ta l D isorders-F ourth Edition {D S M -IV ; A m erican Psychiatric A sso­ ciation, 1994) conceptualizes BPD as an eclectic set o f observed signs a n d re p o rte d characteristics th a t are derived from clinical re p o rts an d , to a lesser extent, from em pirical research. In th e D S M -IV , BPD is defined as “a pervasive p a tte rn o f in stability o f in te rp e rso n a l relatio n sh ip s, self-im age, a n d affects, a n d a m ark e d im pulsivity b eg in n in g by early a d u lth o o d a n d p re sen t in a variety o f c o n tex ts” (p. 654). T he p a tie n t m u st satisfy five (or m o re) o f n in e possible criteria to receive a diagnosis o f BPD. T he p rev a­ lence o f BPD is a p p ro x im ately 2% in th e general p o p u la tio n a n d m ay be up to 30% to 60% in clinical p o p u la tio n s w ith p e rso n ality diso rd ers (A m e ri­ can Psychiatric A ssociation, 1994). In a d d itio n , 75% o f p a tie n ts d iagnosed *The primary authors contributing to this chapter were Sarah A. Shultz and Keith F. Donohue.

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w ith BPD are fem ale (A m erican Psychiatric A ssociation, 1994). A lthough the D S M -IV approach has im proved the d iagnostic reliability considerably, the validity o f the approach and its use in identifying p atients w ith BPD has n o t gone unquestioned. L inehan (1993a) has advanced her ow n co n ce p tu ­ alization o f BPD based on a biosocial th eo ry o f the disorder. T his con cep tu ­ alization stresses the im p o rtan ce o f the interactio n betw een biological and social learning influences on the etiology and d evelopm ent o f BPD. L inehan’s (1993a) conceptualization uses the D S M -IV criteria b u t orga­ nizes the sym ptom s into a set o f dysregulated behavioral p attern s th at arise w ithin five basic systems. E m otion o r affective dysregulation refers to affective instability due to a m arked reactivity o f m ood and inappropriate, intense, anger o r difficulty controlling anger. Patients w ith BPD are likely to experience highly reactive em otional responses, w ith periods o f depres­ sion, anxiety, a nd irritability, as well as intense anger. Behavioral dysregula­ tion refers to im pulsivity, including suicidal behavior and self-m utilating behavior. M ore specifically, im pulsivity m ay include excessive spending, shoplifting, prom iscuous sex, substance abuse, reckless driving, o r binge eating. T hat patients w ith BPD are m ore likely than patients w ith o u t the diagnosis to injure, m utilate, or kill them selves highlights the often ex­ trem e n atu re o f im pulsivity am ong those w ith BPD. Interpersonal dys­ regulation refers to a pattern o f unstable and intense relationships and frantic efforts to avoid real o r im agined a b an d o n m en t. Patients w ith BPD are likely to be involved in chaotic relationships, find it extrem ely hard to let go o f relationships, and often go to extrem e lengths to avoid p e r­ ceived a b an d o n m en t. Self-dysregulation includes identity d isturbance and chron ic feelings o f em ptiness. Patients w ith BPD often re p o rt having no sense o f self, feeling em pty, o r n o t know ing w ho they are. Finally, cognitive dysregulation includes p aran o id ideation or dissociative sym ptom s, u su ­ ally related to stress. U nder stress, it is n o t u n c o m m o n for p atients w ith this disorder to experience m ild psychotic form s o f th o u g h t disturbance, including depersonalization, dissociations, and delusions; however, these sym ptom s are generally tran sien t and less severe w hen com pared to sym p­ tom s o f frank psychotic disorders (L inehan, 1993a).

TRE A T ME N T OF B O R D E R L I N E PERSONALITY DISORDER T herapists have em ployed a variety o f trea tm e n t approaches w hen c o n ­ fronted w ith the varied an d often severe features o f BPD. C entral to early

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id en tific atio n a n d c o n ce p tu a liz atio n o f th e diso rd er, p sychoanalytic a p ­ pro ach es to th e tre a tm e n t o f BPD have enjoyed an extensive h isto ry o f a p p lic atio n (fo r a review, see L inehan & Kehrer, 1993). Psychoanalytic a p p ro ac h es generally seek to expose a n d resolve late n t psychic processes a n d help p a tie n ts to b e tte r to le rate a n d m anage th e ir em o tionality. W ith in session, the th e ra p ist observes a n d c o m m e n ts on th e e m o tio n al to n e o f his o r h e r in te rac tio n s w ith th e p a tie n t a n d offers in te rp re ta tio n s o f th e late n t processes th a t m ay u n d e rlie these e m o tio n s (M asterso n & K lein, 1989). T he p a tie n t m u st c o n fro n t these in te rp re ta tio n s a n d e ith er agree o r revise th e m w ith th e th era p ist. T his process allow s p a tie n ts to gain in sig h t in to th e source o f th e stro n g e m o tio n a l re ac tio n s th a t th ey ex perience a n d to develop m ec h an ism s fo r to le ratin g a n d c o ping w ith these reactions. D espite extensive clinical w ritin g , relatively little research has been d o n e to s u p p o rt the efficacy o f psy ch o d y n am ic a p p ro ac h es to tre a tm e n t for BPD (L inehan & Kehrer, 1993). M any o f these tec h n iq u es w ere developed p rio r to th e estab lish m en t o f D S M criteria fo r BPD a n d are based o n a p sycho­ analytic m odel o f th e d iso rd e r th a t includes a b ro a d e r range o f features th a n th o se in clu d ed in th e D SM . As a result, th e sam ple o f p a tie n ts treated w ith p sychodynam ic a p p ro ac h es m ay be c onsidered p a rticu la rly h e te ro ­ geneous a n d difficult to specify for research. In a d d itio n , p sychodynam ic a p p ro ac h es to tre a tm e n t are designed to take place over several years o f tre a tm e n t, a span o f tim e th a t m o st p a tie n ts fail to com plete. T hese factors help to explain why, despite th e considerable influences th a t they have had o n th e o ry o f BPD, psy ch o d y n am ic a p p ro ac h es to tre a tm e n t o f this d iso r­ d e r have n o t been rigorously exam in ed by em pirical research. In te rp e rso n a l ap p ro ac h es to tre a tm e n t o f BPD em p h asize th e in te r­ p erso n al contexts in w hich th e c en tral features o f BPD o ccu r (B enjam in, 1993). T hese contexts in clu d e a h isto ry o f tra u m a tic a b a n d o n m e n t, a chao tic lifestyle th a t involves rep eated crises, experiences o f a tte m p ts to exert a u to n o m y th a t w ere m et w ith attacks, a n d the a ssu m p tio n o f a sick role th a t elicited n u rtu ra n c e . B en jam in ’s (1993) S tru c tu ra l Analysis o f Social B ehavior trea ts BPD by h e lp in g th e p a tie n t to b e tte r u n d e rsta n d a n d m an ag e th e p a tte rn s o f in te rp e rso n a l in te ra c tio n in his o r h e r life. O ver th e course o f tre a tm e n t, th e th e ra p ist helps th e p a tie n t to gain in sig h t in to these p a tte rn s o f in te ra c tio n a n d encourages th e p a tie n t to give u p th o se th a t lead to destru ctiv e o u tco m es. D u rin g this process, the th era p ist m u st be sensitive to the p a tie n t’s fear o f c h an g in g a n d to his o r h e r sense o f loss w hen giving u p old p a tte rn s o f in te rac tio n . A lthough in te rp erso n al a p p ro ac h es have in fluenced the c o n ce p tu a liz atio n a n d tre a t­

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m en t o f BPD, they are relatively new and have n o t been exam ined by em pirical research. D eveloped initially by Beck (Beck, Rush, Shaw, & Emery, 1987; Young, Beck, & W einberger, 1993) as a trea tm e n t for depression, cognitive therapy has been applied to the trea tm e n t o f personality disorders, including BPD (Beck & Freem an, 1990). T he cognitive conceptualization o f BPD includes bo th the negative cognitions th at patients with BPD hold about them selves and their interpersonal relationships and the d istorted processes o f th in k ­ ing in w hich they engage w hen evaluating situations. Together, these two broad features are th o u g h t to underlie and m aintain the m aladaptive p a t­ terns o f e m otional reactions and behavior th at characterize BPD. Patients w ith BPD are th o u g h t to have negative cognitions th at include the belief th at the w orld is essentially dangerous and m alevolent, th at the patien t is powerless and vulnerable to harm , and th at the p a tie n t is inherently unac­ ceptable o r unlovable to others. Perhaps the m ost significant cognitive d isto rtio n from this perspective is dich o to m o u s thinking, in w hich the patien t tends to in te rp ret experiences in term s o f extrem e, m utually exclusive categories. For exam ple, the patient m ay in te rp ret an interpersonal en co u n ter as either an unqualified success o r an u n m itigated failure. Because d ich o to m o u s thin k in g underlies m any o f the BPD p a tie n t’s difficulties and serves to m aintain his o r her negative cognitions, the central focus o f cognitive therapy for BPD is the reduction o r elim ination o f this d isto rted process o f thinking. T he tendency to engage in d ich o to m o u s thinking (the very target o f trea tm e n t) m ay lead BPD patients to alternately view the therapist as a supportive ally and as an u nsupportive enemy. To overcom e this difficulty, the therapist m u st first ac­ know ledge the p a tie n t’s difficulty in tru stin g him o r h er and then engage in a p attern o f consistently tru stw o rth y behavior. T hat is, the therapist m ust take extra care to be responsive to the patien t and m u st respond consis­ tently and patiently to his o r her concerns. O nce a tru stin g relationship is developed, the therapist m u st balance the need to respond to the p a tie n t’s acute concerns (and thereby m aintain the p a tie n t’s tru st in the th era p ist’s responsiveness) and the need to focus on the long-term goals o f therapy. Beck and Freem an (1990) suggested th a t cognitive th erap y for BPD p a ­ tients m ay be effective over the course o f 1 to 2 years in decreasing d ich o to ­ m ous thin k in g and the negative cognitions th at characterize BPD. Al­ th o u g h they offer case exam ples o f successful treatm en t, this approach to therapy has n o t yet been rigorously evaluated by em pirical research. Young, Beck, and W einberger (1993) have expanded the basic principles o f cognitive therapy to develop schem a-focused therapy, w hich proposes

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th a t th e c o g n itio n s th a t characterize p e rso n ality d iso rd ers are elem ents o f m o re b ro a d a n d stable p a tte rn s o f th in k in g th a t arise from early life e x p eri­ ences a n d ex p an d over th e course o f developm ent. N ine o f these early m a l­ adaptive schem as th a t characterize BPD include a b a n d o n m e n t/lo s s (“no o n e will care for m e ”), unlov ab ility (“if people really knew m e, th ey w ould n o t love m e ”), d ep en d e n ce (“I n eed so m e o n e to take care o f m e ”), su b ju g a ­ tio n (“if I express ho w 1 feel, peo p le will a b a n d o n o r attack m e ”), m istru st (“people will h u r t m e, if I let th e m ” ), in ad e q u ate self-discipline (“I am u n a b le to c o n tro l m yself” ), fear o f losing e m o tio n a l c o n tro l (“if I lose c o n ­ trol o f m y e m o tio n s, so m e th in g terrib le will h a p p e n to m e ” ), guilt (“I am a b a d p e rso n ”), a n d e m o tio n al d e p riv a tio n (“no o n e is ever th ere for m e ”). Schem a-focused th e ra p y proceeds in a sim ilar fashion to o th e r form s o f cognitive ap p ro ac h es to tre a tm e n t. H ow ever, th e th e ra p ist is directed to explore the o p e ra tio n o f the characteristic BPD schem as b e h in d the s u r­ face-level cognitions. T he th e ra p ist th e n identifies these schem as for the p a tie n t a n d encourages the p a tie n t to challenge a n d revise th em . A lthough it e x p an d s o n th e tra d itio n a l m o d el o f cognitive therapy, sch em a-fo cu sed th e ra p y has n o t yet b een rigorously evaluated by em pirical research. D ialectical B ehavioral T h era p y (D BT) grew o u t o f th e a p p lic atio n o f co gnitive-behavioral a p p ro ac h es to th e tre a tm e n t o f BPD, p articu larly th o se p a tie n ts w ith BPD w h o engage in c h ro n ic suicidal b e h av io r (L inehan, 1993a; L inchan & Kehrer, 1993). A lthough b o th therapies address th e in flu ­ ence th a t c o g n itio n s have o n e m o tio n al processes, DBT ad d s ad d itio n al em phasis o n co rre c tin g th e core d y sfu n ctio n in e m o tio n al reg u latio n th at is th o u g h t to u n d e rlie BPD. A ccording to a diathesis-stress m odel, d u e to an u n d e rly in g d iathesis m ak in g th e m v u ln erab le to stro n g em o tio n al responses a n d stressors from in te rp erso n al e n v iro n m e n ts th a t invalidate th e ir feelings, p a tie n ts w ith BPD are p ro n e to ex trem e p a tte rn s o f e m o ­ tio n al resp o n d in g . DBT uses th e c o n stru c t o f th e dialectic (i.e., th e balance betw een o pposites) to o rganize tre a tm e n t. At its m o st general level, DBT balances radical acceptance o f the p a tie n t’s c o n d itio n against the need to seek change. To help th e p a tie n t achieve this balance, th e p a tie n t and th e th e ra p ist engage in o ther, m o re specific dialectical processes, such as b alan cin g valid atio n o f th e p a tie n t’s feelings against a p ra g m a tic ap p ro ac h to p ro b lem solving a n d b alan cin g reciprocal c o m m u n ic a tio n against irrev ­ e ren t c o m m u n ic a tio n b etw een th e ra p ist a n d patien t. DBT is d ivided in to th e follow ing c o m p o n e n ts: indiv id u al sessions betw een p a tie n t a n d th era p ist, skills tra in in g g ro u p s for the p a tie n t, a n d tele p h o n e c o n su lta tio n s betw een th era p ist a n d p a tie n t d u rin g crises. (L inehan, 1993a, suggests a g ro u p c o n su lta tio n for the th e ra p ist as a fo u rth

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c o m p o n e n t.) In d iv id u al sessions b etw een p a tie n t a n d th e ra p ist involve explicit teaching o f skills related to e m o tio n re g u la tio n a n d im plicit tra in ­ ing in th e form o f chain analysis o f events. In this latter elem en t, the th e ra ­ p ist a n d p a tie n t d ism an tle a distressing event th a t resulted in se lf-h arm in g behavior. C h ain analysis is designed to help detect p o in ts o f in te rv en tio n th a t can be used to avert se lf-h arm in g behavior. T his serves to validate the p a tie n t’s experience, w hile also d e m o n s tra tin g th e c o n n ec tio n betw een th o u g h ts a n d actions th a t lead to se lf-h arm in g behavior. In this way, chain analysis reflects th e overall dialectical balance betw een accepting the p a tie n t as he o r she is and enab lin g change. G ro u p sessions for th e p a tie n t are designed to consolidate th e gains m ade in in d iv id u a l sessions by re la t­ ing th em to skill m o d u le s for core m in d fu ln ess, e m o tio n regu latio n , d is­ tress tolerance, a n d in te rp erso n al effectiveness (L inehan, 1993b). In a d d i­ tio n , p a tie n ts are en co u ra g ed to c o n ta ct the th e ra p ist d u rin g crises th at o ccu r betw een sessions to gain s u p p o rt a n d e n co u ra g em e n t for the use o f th e skills ta u g h t in session. DBT is an intensive a p p ro a c h to th e tre a tm e n t o f severely d iso rd e red patients. A lth o u g h its overall effectiveness and th e relative c o n trib u tio n s o f its elem en ts to tre a tm e n t have b een q u e stio n e d (Scheel, 2000; T urner, 2000), it is th e m o st rigorously evaluated tre a tm e n t for BPD. T reatm en t stu d ies indicate th a t BPD is effective in red u cin g som e o f th e features asso­ ciated w ith this disorder, p a rticu la rly se lf-h arm in g beh av io r (W esten, 2000). A lthough it is n o t yet a w ell-established tre a tm e n t, at this tim e th e m o st em pirically validated tre a tm e n t for BPD is DBT. How ever, th ere are several aspects o f DBT th a t m ake it difficult to c o n d u c t o u tsid e o f a clinic designed for th e im p le m e n ta tio n o f DBT. For exam ple, o n e o f the essential c o m p o ­ n e n ts o f DBT is skills train in g . It is re co m m e n d e d th a t skills tra in in g be c o n d u cted in a g ro u p fo rm a t to reserve tim e in in d iv id u al th e ra p y for crisis in te rv e n tio n a n d a tte n tio n to o th e r issues (L inehan, 1993a). T his is often difficult in sm all clinics, p rivate practice e n v iro n m en ts, a n d in hospital se t­ tings. In a d d itio n , m any o f the c oncepts o f DBT m ay be difficult to learn a n d in c o rp o ra te in to tre a tm e n t, especially for b e g in n in g therapists.

A P P L I C A T I O N OF C B A S P TO B O R D E R L I N E PERSONALITY DISO RD ER In review ing the lite ratu re on tre a tm e n ts for BPD, it is clear th a t the clin i­ cian has m an y o p tio n s b u t no clearly preferred choice. Given this situ atio n ,

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o u r attem pts to advance a n o th e r approach to trea tm e n t m ay seem ques­ tionable. However, o u r clinical w ork suggests th at a trea tm e n t based on elem ents o f the C ognitive Behavioral Analysis System o f Psychotherapy (CBASP; M cC ullough, 2000) m ay hold significant advantages for w orking w ith patients w ith BPD. T hese patients often represent a challenge for th e r­ apists, one th at is c o m p o u n d e d by the challenge o f m astering com plex th erapeutic m odels and applying them across often tu rb u le n t and in co n ­ sistent sessions th at are typical o f treatm ent. T he CBASP approach to trea t­ m en t offers a degree o f sim plicity while also in co rp o ratin g m any o f the elem ents found in o th er form s o f treatm ent. T he m ajor th erap eu tic tool in CBASP is Situational Analysis (SA), a p ro ­ cess th at is recorded by the p atient on the C oping Survey Q uestionnaire (CSQ) an d th en reviewed by the therapist in session (M cC ullough, 2000). Sim ilar to the interpersonal m odel, CBASP is based on the assum ption that the defining feature o f BPD is a p ersistent p attern o f unsuccessful in te rp e r­ sonal interactions. T he m ain tool for correcting this p attern is the CSQ technique for SA, w hich is used in three distinct ways. First, the CSQ can be used to identify and m odify m aladaptive cognitions. T he patien t com pletes the CSQ for hom ew ork, w hich is then reviewed w ithin session. Second, the CSQ can be used for crisis intervention betw een sessions. Finally, the CSQ can be used to u n d e rstan d an d m odify conflicts occurring betw een the therapist and the p atient w ithin session. In the first case, special em phasis is placed on elem ents th at have been gleaned from cognitive approaches to treatm ent. O u r clinical w ork sug­ gests th at patients w ith BPD tend to evaluate D esired O utcom es (D O s) and Actual O utcom es (AOs) for interpersonal situations in ways th at reflect the dich o to m o u s th inking proposed by the cognitive m odel o f BPD (Beck & Freem an, 1990). W hen asked to com plete the CSQ, patients w ith BPD tend to identify entirely positive D O s for interpersonal interactions a n d tend to re p o rt AOs th at they see as entirely negative. By encouraging the patien t to reflect on the discrepancy betw een the D O and the AO, the therapist is able to challenge the p a tie n t’s dich o to m o u s thin k in g in a way th at is non ju d g m en tal and tied to a concrete exam ple. In addition, o u r clinical w ork suggests th at patients w ith BPD tend to hold interp retatio n s o f interpersonal encounters th at are sim ilar to the early m aladaptive schem as identified by Young (1987), particularly the schem as for loss, m istrust, and guilt. T he therapist is directed to attend to these w hen review ing a p a tie n t’s CSQ. Using the CBASP approach to treatm ent, these in terp retatio n s can then be challenged by questioning

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w hether they seem ed to help o r h in d er the p a tie n t’s progress tow ard his o r her DO. In o u r experience, this form o f challenging is relatively n o n judgm ental and less likely to elicit negative reactions from the patient, com pared w ith a m ore direct challenge to the rational validity o f the in te r­ p retation. T his form o f challenging also validates the p a tie n t’s experiences by allowing him o r her to honestly express the th oughts th at occurred d u r­ ing the situation, while encouraging the patien t to consider revision o f unhelpful in terpretations. We feel th at this balance is sim ilar to the one suggested by the dialectical approach to trea tm e n t o f BPD. T he second application o f the CSQ occurs w hen the patien t and th e ra ­ pist use it betw een sessions to respond to crises. D raw ing insp iratio n from the chain analysis used in DBT, this application focuses alm ost exclusively on the in terp retatio n s th at the p atient had du rin g a crisis and the specific behaviors in which he o r she engaged. W hen dealing w ith a m ore dysregulated p atient, the therapist is encouraged to focus m ore on overt behaviors, w hereas w ith a less dysregulated p atient w ho is better able to reflect on his o r her in n er state d u rin g a crisis, the th erap ist can focus m ore a tten tio n on interpretations. In this m anner, the CBASP approach can help teach the relationships betw een the elem ents th at escalate a crisis for the patien t and help illustrate p o in ts for intervention. In the early stages o f treatm en t, the patien t an d therapist m ay struggle together to use this application o f the CSQ, b u t as the patien t becom es m ore fam iliar w ith this technique, he or she should be able to apply it w ith greater autonom y. T he final application o f the CSQ occurs w hen the therapist and the p atient use it to u n d e rstan d conflicts th at occur d u rin g the session. Here, the goal is to use the CSQ to highlight disruptive interp retatio n s, behav­ iors, and D O s d u rin g a real-tim e interpersonal encounter. This is the m ost challenging application for the patient, w ho m u st deal w ith the strong em otions elicited by interpersonal conflict, and therefore it is recom ­ m ended for the later stages o f treatm ent.

-— -^> C a s e E x a m p l e

Ben is a 26-year-old, single, W hite m ale. He did n o t graduate from high school; however, he subsequently earned a general equivalency diplom a (GED). He has w orked a variety o f jobs th ro u g h o u t his adult life an d is cu rrently em ployed through a tem p o rary agency as an office assistant. He was referred to the clinic by a local hospital fol­

BORDERLI NE P ERSONALITY DI SORDER

low ing a free m en ta l h e alth screening. At intake, Ben c o m p la in e d o f a variety o f sy m p to m s, in clu d in g m o o d sw ings, low self-esteem , diffi­ culties in b o th fam ily a n d d a tin g relatio n sh ip s, anxiety a n d w orry, guilt, substance abuse, sleep difficulties, a n d c h ro n ic feelings o f sa d ­ ness a n d lack o f m o tiv atio n . H e re p o rte d suicidal ideatio n d ating back to age 16, w ith at least five suicide a tte m p ts, in clu d in g c u ttin g his w rists, sw allow ing pills, a n d ju m p in g off a tw o -sto ry b uilding. At th e tim e o f referral, Ben m et D S M - I V criteria for BPD (A m erican Psychiatric A ssociation, 1994). In th e in itial stages o f tre a tm e n t, an a g reem en t w as reached betw een th e th e ra p ist a n d Ben th a t the p a tie n t w ould n o t engage in any self-in ju rio u s o r suicidal behavior. Ben agreed th a t if he becam e suicidal, he w ould call th e th era p ist before he engaged in such behavior. T he follow ing tra n s c rip t is from Ben’s eighth th era p y session; p rio r to this session, no suicidal gestures h a d b een m ade. T h e course o f tre a tm e n t involved weekly m eetings in w hich a co m p leted CSQ was review ed. Therapist: Okay, Ben, I see that you’ve brought in your homework assign­ m ent for today. Why don’t you go ahead and tell me about the situation that you outlined in Step 1 of the CSQ. I’m going to write it down here as you’re describing it so that I can make sure that I get all of the details. Ben: My girlfriend and I had an argument about her going back to Mexico for that missionary work that she does. W hen we were done arguing, I tried to hold her hand, but she said wouldn’t let me because she said it’s against her religion. Therapist: Okay, let me make sure I have this rig h t. . . First, you and Andi had an argument. Following the argument, you tried to hold her hand, but she would not allow you to do that based on her reli­ gious beliefs. Do I have that right? Ben: Yes, that’s basically what happened. Therapist: Okay, now let’s go on to Step 2. Tell me your thoughts and inter­ pretations of that situation. One way to do this is to fill in the blank: “When I was there in that situation, it meant blank.’’Tell me what this situation m eant to you. Ben: Well, I thought to myself, “Why can’t I show affection?” Therapist: So, to you, holding hands would be a sign of affection. Ben: Yeah, holding hands is a sign of affection, and what’s wrong with that? Therapist: Ok, good, that’s a good one. Did you have any other interpre­ tations?

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Ben:

Yeah . . . I kn o w she’s kissing o th e r m en in Mexico.

Therapist: Okay, you th o u g h t to y ourself, “I kn o w she’s kissing o th e r m en in Mexico.” W h at is y o u r in te rp re ta tio n o f th a t th o u g h t? W hat does th a t m ean to you? Ben:

She’s cheating o n m e.

Therapist: Okay, so w hen you w ere in th e situ atio n a n d A ndi refused to ho ld yo u r h a n d , you th o u g h t to yourself, “ I kn o w she’s cheating on m e in M exico a n d kissing o th e r m en.” D id you have any o th er th o u g h ts o r interp retatio n s? Ben:

W e’ve kissed in the past, b u t everything h as changed since she re tu rn e d from M exico the first tim e.

Therapist: Okay, so th a t’s good. N ow we have th ree in te rp re ta tio n s to w ork w ith. Let’s go o n to Step 3. W h at w ere y o u r behaviors? W h en you trie d to h old A n d i’s h a n d a n d she w ould n o t let you, w h at did you say a n d do in the situation? Ben:

I told h e r to go and kiss h e r M exican friends!

Therapist: A nd how did you say that? W h at was yo u r tone? Ben:

I d o n ’t know . I ju st said it.

Therapist: If I was a fly o n the wall, w hat w ould I have seen an d heard? Ben:

I guess I so u n d e d so rt o f sarcastic o r cocky, like, f in e . . . w hatever . . . go kiss w hom ever you w ant. I d o n ’t care!

Therapist: Okay, I th in k I can p ictu re it. W h at else did you say a n d do? Ben:

I tu rn e d away fro m her.

Therapist: D id you say a n y th in g else? Ben:

Well, w hen she got up to leave I said, “ If you leave now, th en it’s over for go o d !” I also to ld h e r th a t if she left, I w ould kill myself.

Therapist: A nd w hat w'as y o u r to n e w hen you said that? Ben: T he sam e as b efore, I w asn’t really yelling, b u t I w as lettin g h e r know th a t I was angry. Therapist: Okay, so y o u r to n e was an g ry a n d forceful. Ben:

Yeah, I w an ted her to k n o w th a t I w as serious.

Therapist: So, let m e m ake sure I have all o f this dow n. A fter you a n d A ndi had an a rg u m e n t, you reached o u t to h e r a n d trie d to ho ld her h a n d , b u t she w ould n o t h o ld y our h a n d because she felt it was against h e r religious beliefs. You re sp o n d ed by tu rn in g away from h e r an d telling h e r to go kiss h e r M exican friends. W hen she got up to leave, you told h e r th a t if she left it w o u ld be over b etw een you for good, a n d th a t you w ould kill yourself. Ben:

Well, w hen you say it like th a t it so u n d s bad.

Therapist: I’m n o t try in g to m ake it so u n d bad o r good. I ju st w ant to m ake sure that I have an accurate account o f the facts.

B O RDERLIN E PERSONALITY D ISO R D ER

Ben:

Yeah, I guess th a t’s w hat h a p p en e d . . . b u t it w asn’t m y fault.

Therapist: N o on e is assigning b lam e here, Ben. Let’s go o n to Step 4 an d see how th is situ atio n en d ed up. W h at w as the actual o u tco m e in th is situation? Ben:

She left and I got drunk and went to the store and bought a bot­ tle of sleeping pills.

Therapist: D id you take the pills? Ben:

No.

Therapist: W hat kept you from taking th e pills? Ben:

I passed o u t before I had a chance to take them .

Therapist: So, it so u n d s like there w ere som e o th e r th o u g h ts g oing o n in Step 2 th a t w e m issed th e first tim e th ro u g h . Ben:

W hat do you m ean?

Therapist: H ow did y ou get from her getting up to leave to telling h e r you were going to kill yourself? W h at w ere you thinking? Ben:

“If I tell h er I ’m going to kill m yself, she’ll stay.”

Therapist: Let m e w rite th at d o w n ___ Okay, we’ll com e back to th a t in a few m in u tes. Before we do th at, w hat did you w ant to happen? W hat was y o u r desired outcom e? Ben:

T h a t she w ould have stayed to discuss it.

Therapist: So w h at y ou w anted w as for A ndi to stay and discuss w hat had ju st h a p p en e d , an d w h at actually h ap p en e d was th a t she left w ith o u t discussing it? Is th a t a b o u t right? Ben:

Yes.

Therapist: So you k now w hat com es n e x t . . . did you get w hat you w anted in th is situation? Ben:

No!

Therapist: Okay, now let’s look at each th o u g h t a n d in te rp re ta tio n to see w h eth er it h elped you o r h u rt you in getting y o u r desired o u t­ com e o f A ndi staying to discuss th e situ atio n w ith you. T he first th in g you told m e was th a t you th o u g h t, “W hy c an ’t I show affection.” D id th a t th o u g h t help y ou o r h u r t you in achieving y o u r desired o u tco m e o f A ndi staying to discuss the situation? Ben:

I d o n ’t know . I d o n ’t really th in k it h u rt.

Therapist: I’m n o t sure either, let’s p u t it this w a y . . . do you th in k it h elped you to get A ndi to stay? Ben:

I guess not. Therapist: I d o n ’t th in k so either. W h at do you th in k you could have

Ben:

th o u g h t instead? I d o n ’t k n o w . . . m aybe, “I really w ant to show h e r how m u ch I care a b o u t her.”

Therapist: G ood! I th in k th a t’s a great th o u g h t! C an you th in k o f any m ore?

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Ben:

H old in g h an d s is a sign o f affection . . . I ju st still d o n ’t u n d e r­ stan d w hy we are n o t allow ed to to u ch each other!

Therapist: W hat co u ld you have th o u g h t th a t co u ld have h elped you u n d e r­ sta n d h e r beliefs? Ben:

M aybe . . . I d o n ’t know , m aybe I sh o u ld ask h e r to explain h er religion to m e.

Therapist: G reat! It seem s to m e th a t th in k in g , “ I really w an t to show h er h ow m u ch I care a b o u t h e r” a n d “ I sh o u ld ask her to explain h er religion to m e” w o u ld have h elped you to get y o u r d esired o u t­ com e o f A n d i staying to discuss th in g s w ith you. Now, since w e’re ru n n in g low o n tim e, let’s lo o k at y o u r th o u g h ts “ I know she’s cheating o n m e a n d kissing o th e r m en in M exico” an d “w e’ve kissed in the past, b u t e v erything h as changed since she re tu rn e d from M exico” together. D o y ou th in k those th o u g h ts helped you o r h u rt you in achieving y o u r desired o u tco m e o f A ndi staying to discuss the situ atio n w ith you. Ben:

I th in k th o se p ro b ab ly h u rt. T hey ju st pissed m e off.

Therapist: I agree w ith that. W h at w ould have b een a m o re helpful in te r­ pretation? Ben:

(pause) M aybe th a t’s the way p eople greet each o th e r in Mexico.

Therapist: Okay, th a t’s great! W h at are som e o th e r helpful thoughts? Ben:

I tru st A ndi. She loves m e.

Therapist: Beautiful! It so u n d s to m e th a t if you w ere th in k in g those th o u g h ts, it definitely w ould have h elped you to achieve your d esired ou tco m e. Now, let’s look at th e th o u g h t “If I tell her I’m going to kill myself, she’ll stay.” D o you th in k th a t on e helped you o r h u rt you? Ben:

I guess it h u rt.

Therapist: You d o n ’t so u n d convinced. Ben: It’s ju st h a rd to give th a t on e up. Therapist: I know , Ben, th a t’s been an effective strategy for you for a long tim e now. But I agree w ith you. It d id n ’t h elp y ou to achieve y our d esired o u tco m e in this situ atio n . W h at d o you th in k you could have th o u g h t instead? Ben:

I d o n ’t k n o w . . . I d o n ’t th in k th ere was an y th in g I could have th o u g h t th a t w ould really have m ad e h e r stay.

Therapist: I k now th is is h ard . Just try to th in k a b o u t som e helpful th o u g h ts th a t m ay have h elped you to regulate y o u r em o tio n s a n d the way you w ere in te rac tin g w ith her. Ben:

M aybe ju st th in k in g , “I really w ant h e r to stay a n d talk to m e.”

Therapist: T h a t so u n d s good. Is th ere an y th in g else? Ben:

H ow a b o u t “I w ant us to w ork this o u t!”

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Therapist: I th in k th a t’s a great one! You are really getting better at this! I know it is hard to generate these kinds o f thoughts, especially in the heat o f the m om ent, b u t you are doing a great job so far, and it’s only going to get easier the m ore we practice! Let’s move

Ben: Therapist:

Ben: Therapist: Ben: Therapist: Ben: Therapist:

Ben:

on to your behaviors . . . you said th at you told her, “W hy d on’t you go kiss your Mexican friends!” I th in k th at we can agree that th at w asn’t a helpful thing to say. W hat could you have said to help you get your desired outcom e o f Andi staying to talk w ith you? Maybe I could have asked h er to explain why she doesn’t w ant to hold m y h a n d . . . to explain the rules o f her religion to me. I th in k th at w ould have been a helpful thing to say. I know w e’re sort o f rushing th rough this, b u t I thin k you are getting the hang o f it. Let’s m ove on to the last thing you said. “If you leave now, then it’s over for good and I’m going to kill myself!” D o you th in k that one was helpful o r hurtful? We b oth know it was hurtful. W hat could you have said instead? A ndi, I just really w ant you to stay and talk to me! G ood. Is there anything else? I could have told h er that I love her, I guess. I agree, Ben, I th in k th at w ould have helped you get your desired outcom e. Now, let’s w rap things up . . . w hat have you learned from this situation? I guess that, if I w ant to w ork things o u t w ith A ndi, I need to be honest a bout how I feel and to be respectful to her. T hreatening to kill m yself is not fair to her and, at least in this situation, d id n ’t get m e w hat I w anted.

Therapist: G ood w ork today. I know this isn’t easy for you, b u t you are m aking a lot o f progress. Keep w orking on these hom ew ork assignm ents and it’s only going to get easier!

The case described here illustrates the possible use o f CBASP with pa­ tients meeting criteria for BPD. Although this case was in the early stages of treatment, using the CSQ proved an effective strategy to help Ben regulate his emotions, develop effective problem-solving techniques, stabilize his in­ terpersonal relationships, and understand the link between his interpreta­ tions and behaviors and the way people respond to him. It is important to note that following this interaction a detailed assessment o f his current sui­ cidal ideation and safety was conducted. It was determined that he was at moderate risk and a revised plan was developed to maintain his safety.

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O n e o f the in h e re n t stre n g th s in CBASP is its relative sim plicity. T he very n a tu re o f th e CSQ allows for tre a tm e n t o f th era p y -in te rferin g b e h av ­ iors, re p air o f rifts in the th era p e u tic re lationship, p ro b lem solving, a n d skills train in g . In a d d itio n , using th e CSQ requires th e th e ra p ist to focus on acceptance a n d valid atio n . T h e first stage o f th e process allows th e p a tie n t to describe his o r h e r th o u g h ts a n d b ehaviors as they actually h a p p en e d , w ith o u t b eing ju d g ed o r evaluated. T he p a tie n t feels accepted a n d vali­ d ated th ro u g h the th era p ist listening a n d taking n o tes on th e details o f the situ atio n . It is n o t u n til th e rem edial phase o f CBASP th a t th e th e ra p ist a n d th e p a tie n t evaluate th e effectiveness o f his o r h e r th o u g h ts a n d b ehaviors in achieving th e DO . Again, th e th e ra p ist is n o t m ak in g ju d g m e n ts a b o u t th e p a tie n t’s th o u g h ts a n d b ehaviors b u t is help in g th e p a tie n t to m odify th o se th a t are d e em ed d ysfunctional. As w ith DBT, CBASP pro v id es a b a l­ ance betw een acceptance a n d change th ro u g h the use o f the CSQ. In a d d itio n , as in d ic a te d previously, th ro u g h o u t tre a tm e n t, CSQ s m ay be used in session as an effective way to deal w ith in te ra c tio n s b etw een the th e ra p ist a n d th e p a tie n t th a t m ay be in te rferin g w ith th e course o f tre a t­ m e n t (e.g., th e p a tie n t consistently m isses sessions, th e th e ra p ist is p u sh in g to o h a rd , th e p a tie n t becom es hostile).

O B S T A C L E S TO T R E A T M E N T A lth o u g h CBASP is likely to pro v id e an a d d itio n al o p tio n for th e effective tre a tm e n t o f BPD, th ere are certain aspects o f th e d iso rd e r th a t are likely to be obstacles to a successful ou tco m e. R ecu rren t suicidal th reats, gestures, a n d beh av io rs are p a rticu la rly prev alen t a m o n g p a tie n ts w ith BPD (L ine­ han , 1993a). If, at any p o in t in tre a tm e n t, th e p a tie n t is at im m e d ia te risk for h a rm in g h im - o r herself, th e focus o f th e ra p y m u st shift to e n su re the p a tie n t’s safety. H ow ever, once the p a tie n t’s safety has b een established, the CSQ can be an effective to o l for help in g the p a tie n t develop m o re effective c o ping strategies. In a d d itio n , th ere are a variety o f th era p y -in te rfe rin g beh av io rs th a t m ay be obstacles to tre a tm e n t. For exam ple, th e p a tie n t m ay fail to a tte n d ses­ sions o n a regular basis. O bviously, it is im possible to c o n d u c t effective th e ra p y if th e p a tie n t is n o t atte n d in g . A dditio n al b ehaviors th a t m ay in te r­ fere w ith th e ra p y include refusal to w o rk in therapy, lying, refusing to do h o m ew o rk , c o m in g to sessions u n d e r the influence o f d ru g s o r alcohol,

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47

a n d failing to w o rk to w ard tre a tm e n t goals a n d co m p ly w ith th e tre a tm e n t co n tra ct. T hese beh av io rs are c o m m o n a m o n g p a tie n ts w ith BPD a n d in so m e cases m ay be diagnostic. T herefore, it is essential to establish, u p fro n t, a tre a tm e n t c o n tra c t a n d th e goals for therapy. O nce th e p a tie n t has agreed to th e c o n tra c t a n d goals, th e CSQ can be used w ith in session, as well as on the telephone, to help the p a tie n t a b a n d o n the th era p y -in te rferin g b e h av ­ iors a n d replace th em w ith m o re adaptive, fu n c tio n al behaviors. An a d d itio n al obstacle is th a t the th era p ist m ay have a difficult tim e g etting th e p a tie n t to c o n fo rm to th e stru c tu re o f th e session. T he tre a t­ m e n t focuses o n review ing o n e o r tw o CSQ s in session. T herefore, it is necessary fo r th e p a tie n t to b rin g in co m p leted h o m ew o rk assignm ents to be analyzed in session. It m ay be difficult for p a tie n ts w ith this d iso rd e r to co m plete th e h o m ew o rk assignm ents o u tsid e o f th e session a n d b rin g one in each week. In a d d itio n , th e lives o f p a tie n ts w ith BPD are often rife w ith in te rp erso n al difficulties a n d crises. As a result, these p a tie n ts often com e to the session w a n tin g to discuss the latest crisis, instead o f w orking on the h o m ew o rk . In som e cases, this m ay be a p p ro p ria te ; how ever, th e th era p ist m u st be careful to be c o n sisten t in th e im p le m e n ta tio n o f the tre a tm e n t plan a n d resist th e urge to follow th e p a tie n t’s lead in all cases. T h ro u g h th e use o f c o n su lta tio n , th e th era p ist can w o rk to follow th e tre a tm e n t plan, w hile b alancing an a p p ro p ria te level o f crisis in te rv en tio n .

T reatm en t for BPD is often a challenging end eav o r fo r b o th th era p ists and patients. In the face o f this challenge, several m ajo r a p p ro ac h es to tre a t­ m e n t have b een developed, an d , a m o n g th em , DBT has show n som e efficacy for the tre a tm e n t o f this disorder. C B A SP-inspired techniques, p a rticu la rly th e use o f the CSQ , m ay be valuable tools for tre a tm e n t. T hese tec h n iq u es are relatively sim ple, c o m p a red w ith those associated w ith tr a ­ d itio n a l p sychoanalytic a n d m o re c o n te m p o ra ry co gnitive-behavioral a p p ro ac h es to tre a tm e n t. T his relative sim plicity m ay offer tw o im p o rta n t advantages fo r tre a tm e n t. F or th erap ists, these tec h n iq u es m ay be m o re easily m astered d u rin g tra in in g a n d executed d u rin g th e ra p y sessions. For patien ts, these tec h n iq u es m ay seem less ab stru se a n d m o re p ro b lem focused. T hey im plicitly validate the p a tie n t, m odel careful analysis o f d is­ tressing situ atio n s, a n d o rie n t th e p a tie n t to w a rd concrete strategies for fu tu re situ atio n s.

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Clearly, th e value o f any ap p ro ac h to tre a tm e n t is m easu red by its d e m o n s tra te d efficacy in re d u cin g sy m p to m s a n d im p ro v in g fu n c tio n in g in patients. For th is reason, th is c h ap ter advances CBASP as a com pelling avenue for evaluation by clinicians a n d researchers. H ere again, th e relative sim plicity o f C B A SP-inspired tec h n iq u es m ay be an im p o rta n t advantage. O u r clinical w o rk suggests th a t they can be in c o rp o ra te d in to existing p ro g ram s o f th e ra p y th a t are based o n co gnitive-behavioral o r in te rp e r­ sonal a p p ro ac h es to trea tm e n t. T his suggests th e possibility o f tre a tm e n t studies th a t evaluate th e in cre m e n tal inclu sio n o f these tec h n iq u es in tre a t­ m e n t for p a tie n ts w ith BPD. In a d d itio n , th e CSQ m ay offer a rich b u t rela­ tively sta n d ard ize d d ata source fo r m o re fin e-g ra in e d analyses o f tre a tm e n t m echanism s.

Chapter

Passive-Aggressive (Negativistic) Personality Disorder*

Passive-Aggressive Personality Disorder is characterized by a pattern o f negativistic attitudes, passive resistance to the dem ands o f others, and negative reactivity (e.g., hostile defiance, scorning o f authority). There is currently no empirically validated treatment for this disorder; h ow ­ ever, the Cognitive Behavior Analysis System o f Psychotherapy seems to be a prom ising new frontier in reducing these attitudes and behav­ iors. This chapter includes several examples o f the application o f Situ­ ational Analysis to the problematic thoughts and behaviors expressed by a patient with this disorder.

Passive-Aggressive P ersonality D iso rd e r (PA PD) is ch ara cte riz ed by a pervasive p a tte rn o f passive resistance a n d negative reactivity. The D iag­ nostic an d Statistical M a n u a l o f M en ta l D isorders-F ourth Edition (D S M -IV ; A m erican Psychiatric A ssociation, 1994) notes th a t this p a tte rn begins by early a d u lth o o d a n d is p re sen t in a variety o f contexts. To be d iagnosed w ith PAPD, an in dividual m u st m eet at least fo u r o f the follow ing criteria: passive resistance to co m p le tin g ro u tin e social a n d o c cu p a tio n a l tasks, co m p la in ts o f being m is u n d e rs to o d a n d u n a p p rec ia ted by o th ers, sullen o r a rg u m e n ta tiv e , u n reaso n ab ly criticizes o r scorns au th o rity , expresses envy a n d re se n tm e n t to w ard th o se m o re fo rtu n a te , exaggerated a n d p e r­ sistent co m p la in ts o f p erso n al m isfo rtu n e , a n d a lte rn a tio n s b etw een h o s ­ tile defiance a n d c o n tritio n . If present, th e criteria c a n n o t o c cu r exclusively d u rin g a m ajo r depressive episode a n d sh o u ld n o t be b e tte r a cc o u n te d for by D ysthym ic D isorder. *The primary authors contributing to this chapter were Mark D. Reevesand Marisol Perez.

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T he validity o f PAPD is a m atter o f som e controversy, and the d isorder is cu rrently listed in the appendix o f the D S M -IV (A m erican Psychiatric Association, 1994) as a disorder requiring fu rth er study. T he diagnosis was classified as a personality disorder in earlier versions o f the D SM b u t was n o t included in the D S M -IV because the a u th o rs felt th at the scope o f the disorder was too narrow . T he D S M -IV com m ittee also concluded th at the PAPD diagnosis involved too few dom ains o f functioning, displayed unacceptably high com orbidity rates w ith o th er personality disorders, and was too situational to m eet the general personality d isorder criterion o f p erva­ siveness (M illon, 1993; M illon & Radovanov, 1995). Despite this criticism , there are those w ho argue for again including PAPD in the personality dis­ orders section o f the DSM . These p ro p o n e n ts claim th a t the narrow b readth o f PAPD is actually an asset, yielding diagnostic consistency and thus clinical use (W etzler & M orey, 1999). Specifically, VVetzler and M orey (1999) argued th at o th er personality disorders c an n o t always be reliably diagnosed due to considerable w ithin-diagnosis heterogeneity, which does n o t occur in the PAPD criteria. W etzler and M orey (1999) also observed th at the c o m orbidity rates o f PAPD are n o t any h igher th an the c o m o rb id ­ ity rates o f o th er personality disorders. These a u th o rs n o ted th at all p e r­ sonality disorders display high c om orbidity rates and concluded th at it is illogical to apply a higher stan d ard to PAPD alone. Lastly, W etzler and M orey (1999) provided evidence th at PAPD is n o t situation specific, arg u ­ ing th at patients diagnosed w ith PAPD display passive-aggressive behav­ iors in a variety o f contexts, including personal relationships, work, and school. For exam ple, a college stu d e n t diagnosed w ith PAPD m ight refuse to com plete a hom ew ork assignm ent th at he o r she views as unfair, m ight “forget” to show up for w ork, and m ight neglect to re tu rn a bo y frien d ’s or girlfriend’s ph o n e calls. Joiner and R udd (2002) fo u n d th at the in crem en ­ tal validity o f PAPD (defined as its ability to predict functioning c o n tro l­ ling for all oth er p ersonality disorder syndrom es) exceeded th at o f all o ther personality d isorder syndrom es. They concluded th at passive-aggressive sym ptom s display high validity and th at PAPD, in som e form , m ay deserve reinclusion on Axis II o f future editions o f DSM . Regardless o f this controversy, there are patients w ho seek trea tm e n t in clinical settings th at w ould clearly m eet the diagnostic criteria for PAPD (A m erican Psychiatric A ssociation, 1994). For these patients, passiveaggressive tendencies are d etrim en tal and interfere w ith their in te rp e r­ sonal, social, and occupational functioning. O thers m ay reject people w ith passive-aggressive tendencies in personal relationships o r term in ate them

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from w o rk p o sitio n s d u e to th e ir o p p o sitio n a l behavior. If rejections and te rm in a tio n s b ecom e freq u e n t, the p a tie n ts’ fu n c tio n in g m ay d e te rio ra te significantly. For this reason, passive-aggressive tend en cies c a n n o t be ig n o red o r go u n trea te d .

H I S T O R Y OF T R E A T M E N T OF P A P D Very few tre a tm e n ts have b een developed fo r PAPD, a n d th ere is n o e m p ir­ ically validated tre a tm e n t fo r th e diagnosis (C rits-C h risto p h , 1998). Beck a n d Freem an (1990) developed a cognitive a p p ro ac h to trea tin g PAPD th a t consists o f identifying a n d evaluating negative a u to m a tic th o u g h ts. T he cognitive d isto rtio n s associated w ith PAPD ten d to revolve a ro u n d them es such as rebelling against a u th o rity a n d p re d ic tin g negative outco m es. O ften th e a u to m a tic th o u g h ts reveal the an g er a n d rigidity th a t p a tie n ts w ith PAPD experience. For exam ple, in th e case exam ple described later in this chapter, th e p a tie n t held rigidly to his b elief th a t a rb itra ry a u th o ritie s w ere forcing h im to co m p lete w orthless tasks. H e experienced this a u to ­ m atic th o u g h t frequently, a n d it often resulted in his feeling aggravated. T his p a tie n t w ould often re so rt to seem ingly passive-aggressive m aneuvers, su ch as avoiding these tasks, to express his anger. T h e u n fo rtu n a te result o f this p a rtic u la r p a tte rn was th at th e p a tie n t ultim ately h u r t h im self m ore th a n the a u th o ritie s. Beck a n d Freem an (1990) suggested th a t th era p ists could challenge su ch cognitive d isto rtio n s u sing collaborative em p iricism a n d costb enefit analyses to assist p a tie n ts in evaluating th e validity a n d effective­ ness o f th e ir th o u g h ts. T his m ean s th a t th e th e ra p ist a n d th e p a tie n t col­ lectively evaluate b o th th e evidence th a t su p p o rts th e d isto rte d belief and evidence th a t refutes it. In a d d itio n , the th e ra p ist helps th e p a tie n t evalu­ ate the costs a n d benefits o f m a in ta in in g b o th the d isto rte d a n d the p o ten tially m o re adaptive beliefs. A ccordingly, Beck a n d F reem an (1990) re c o m m e n d e d th a t th era p ists help p a tie n ts to see th a t passive-aggressive beh av io rs usually result in situ a tio n a l o u tco m e s th a t c o n tra d ic t the p a tie n t’s stated goal. A n o th e r aspect o f Beck a n d F reem an ’s (1990) c o n ­ c ep tu aliza tio n is th a t PAPD p a tie n ts re so rt to passive-aggressive strategies because th ey te n d to have tro u b le expressing an g er a n d o th e r negative e m o tio n s directly. T h u s, Beck a n d F reem an (1990) re c o m m e n d e d te a c h ­ ing assertiveness skills to en co u rag e p a tie n ts to express them selves m o re clearly a n d directly.

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M O D I F I C A T I O N S OF C B A S P F OR P A P D T he five-step C ognitive B ehavioral Analysis System o f P sychotherapy (CBASP; M cC ullough, 2000) ap p ro ac h is ideally suited to the tre a tm e n t o f PAPD for a n u m b e r o f reasons. For exam ple, Step 2 o f the a p p ro a c h — W h a t did the situation m ean to y o u ?— focuses th e p a tie n t on the th o u g h ts th a t o c cu rre d d u rin g discrete situ atio n s u n d e r analysis. T his tec h n iq u e helps th e p a tie n t identify passive-aggressive in te rp re ta tio n s (e.g., “I d o n ’t have to do w h a t a u th o ritie s tell m e!” ) th a t w ere m ad e d u rin g specific s itu ­ ations. Iden tificatio n o f these th o u g h ts a n d in te rp re ta tio n s is h elpful b e ­ cause PAPD p a tie n ts m ay n o t have b een aw are o f th e m o r ho w freq u en tly th e y occur. P atients also m ay n o t k n o w ho w th e ir passive-aggressive th o u g h ts lead to b o th passive-aggressive beh av io rs a n d unfavorable situ a ­ tio n al o u tco m es. Step 2 o f CBASP illustrates these c o n n ec tio n s explicitly, thereby yielding even g reater use w hen the th e ra p ist helps the p a tie n t to reflect back on a series o f analyses o f v ario u s situ atio n s. T he th e ra p ist is th e n able to p o in t o u t th e freq u e n t re cu rre n ce o f certain passive-aggressive th o u g h ts a n d m ake generalized con clu sio n s a b o u t ho w such th o u g h ts typically lead to passive-aggressive beh av io rs a n d negative situ a tio n a l o u t­ com es. Likewise, Step 3 o f CBA SP— W h a t did you do in the situ a tio n ?— helps p a tie n ts to identify p a tte rn s o f passive-aggressive beh av io rs a n d to recog­ nize ho w these b eh av io rs lead to negative results. T his step is especially well suited to PAPD because passive b ehaviors m ay n o t be readily a p p a r­ e n t to th e p a tie n t o r even to o th ers w ith w h o m th ey in teract. Specifically, it is often w h a t th e p a tie n t is n o t d o in g th a t is o f m o re significance th a n w hat th ey are doing. T h o u g h th is p o in t m ay seem oversim plified, c o m ­ p re h e n d in g th is p a tte rn can be a very p ro fo u n d ex perience for PAPD patien ts. It m ay seem overly o bvious to ask p a tie n ts w h e th e r th e ir in ac ­ tio n help ed them to get w h a t they w a n te d — the D esired O u tc o m e (D O ) in Step 4 — yet it is precisely this q u e stio n th a t creates a feeling o f d ish a r­ m o n y in p a tie n ts a n d th a t ultim ately m o tiv ates th em to change th eir b e h av io r to m o re active ap p ro ach es. P atien ts c a n n o t help b u t see how th e ir lack o f actio n m ay be h in d e rin g th em from reaching th eir goals. T he CBASP a p p ro a c h rests o n th e a ssu m p tio n th a t as p a tie n ts repeatedly m ake this type o f co n n ec tio n over several S itu atio n al Analyses (SAs), th ey b ecom e increasingly m o tiv a te d to reduce th e u n c o m fo rta b le feeling th a t accom panies it.

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T hese realizations are often m ad e d u rin g th e elicitatio n phase o f CBASP, w hich helps p a tie n ts w ith PAPD to u n d e rsta n d th a t th e ir passiveaggressive th o u g h ts a n d b ehaviors are actually q u ite ineffectual. In the re m e d ia tio n phase o f CBASP, on th e o th e r h a n d , th era p ists direct th eir p a tie n ts to generate alternative th o u g h ts a n d b ehaviors th a t are m o re h e lp ­ ful in achieving th e ir D O s th a n th e passive-aggressive th o u g h ts a n d beh av ­ iors th a t they used ro u tin e ly b efore seeking tre a tm e n t. T his aspect o f th e CBASP ap p ro ac h p rovides an excellent o p p o rtu n ity for PAPD p a tie n ts to learn new th o u g h ts a n d b ehaviors th a t w ill im p ro v e th e ir quality o f life. R epeated experiences w ith the re m e d ia tio n phase o f CBASP should e ncourage PAPD p a tie n ts to increasingly apply alternative th o u g h ts a n d b ehaviors to situ atio n s o u tsid e session, ultim ately enab lin g th e m to change th e ir ch aracteristically passive-aggressive strategies. Insofar as CBASP seem s well su ited to th e tre a tm e n t o f PAPD, th e ra ­ pists n eed n o t m od ify th e tec h n iq u e m u c h for p a tie n ts p re sen tin g w ith these p e rso n ality features. H ow ever, th ere are a few issues th a t are w o rth c o n sid erin g w ith this p a tie n t p o p u la tio n . First, th e ra p ists sh o u ld direct th e p a tie n t to d escribe situ a tio n s (Step 1) in w hich he o r she was asked to m ee t so m e reaso n ab le re q u est a n d failed to do so. D u rin g Step 2 o f CBASP, th era p ists sh o u ld p ro b e for, a n d pay special a tte n tio n to, the negative a u to m a tic th o u g h ts th a t Beck a n d F reem an (1990) associated w ith PAPD. T hese include th o u g h ts o f rebellion, b ein g m isu n d e rsto o d , a n d the a rb itra ry requests o f a u th o ritie s. As m e n tio n e d previously, analy­ sis at Step 3 usually reveals b eh av io rs such as inactivity, p ro c ra stin a tio n , a n d o th e r passive m an eu v ers th a t are designed to express h o stility in d i­ rectly. T he th e ra p ist sh o u ld h ig h lig h t these b eh av io rs fo r PAPD p a tie n ts d u rin g SA. Lastly, th e th e ra p ist sh o u ld be aw are th a t a PAPD p a tie n t’s D O is ty p i­ cally to co m p lete som e task o r fulfill som e request, th o u g h th e p a tie n t m ay initially state som e o th e r goal, such as refusing to co m p ly w ith seem ingly u n reaso n ab le d e m a n d s. In a d d itio n , the th era p ist m ay n eed to em phasize th a t a lth o u g h reach in g specific s itu a tio n -b o u n d goals o f c om pliance m ay seem d e m e an in g a n d u n re aso n a b le, c o m p letin g these sh o rt-te rm goals is often necessary fo r th e p a tie n t to o b ta in th e DO . P atients w ith PAPD fea­ tu res often d e m o n stra te considerable difficulty in c o m p letin g requests to achieve th e ir D O s d u rin g the initial sessions o f tre a tm e n t. T his difficulty likely stem s from the fact th a t such b ehaviors c o n tra d ic t th e ir strongly held re sen tm en t o f au th o rity . If these p ro b lem s occur, th e th e ra p ist sh o u ld e ncourage the p a tie n t to h a n g in there, re m in d in g the p a tie n t th at learning

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any new skill takes tim e a n d a great deal o f practice. T he th e ra p ist m ay also need to hig h lig h t repeatedly th a t a lth o u g h c om pliance m ay seem d istaste ­ ful, th e p a tie n t m u st decide w h e th er com p lian ce is m o re distasteful th a n failing to achieve D O s (i.e., cost-benefit analysis). In the re m e d ia tio n phase o f Step 2, th era p ists sh o u ld en co u rag e p a tie n ts to replace negative th o u g h ts w ith th o u g h ts th a t em phasize c o m p letin g tasks th a t th ey m ay n o t find enjoyable b u t w hich they m u st co m plete to o b tain som e greater DO . In a d d itio n , re m e d ia tio n o f beh av io rs at Step 3 sh o u ld em phasize th e use o f assertive c o m m u n ic a tio n a n d efficient c o m ­ p letio n o f tasks. In th e case o f p a tie n ts p re sen tin g w ith PAPD features, it is especially im p o rta n t for th era p ists to explain th e ra tio n ale for u sing the C oping Survey Q u e stio n n a ire (CSQ ; M cC ullough, 2000) a n d illustrate ho w it can prove helpful to p a tie n ts’ p resen tin g problem s. T h era p ists also sh o u ld m ake clear th a t th e fo rm a t o f th e CSQ p rovides an org an ized a n d consis­ te n t way to view situ atio n s a n d increases the likelihood th a t the p a tie n t will get w hat th ey w a n t o u t o f a specific situ atio n . P ro v id in g such ratio n ales can d im in ish som e o f th e characteristic resistance to a seem ingly im posed stru c tu re , w hich PAPD p a tie n ts m ay exhibit w hen e n c o u n te rin g the CSQ. In a d d itio n , as p a tie n ts w ith PAPD features can be o p p o sitio n a l a n d often seek the p a th o f least resistance, it is im p o rta n t for th e th e ra p ist to be c o n ­ sisten t in a d h erin g to the CSQ fo rm at a n d in all o th e r aspects o f th e th e ra ­ peu tic re lationship. T his m ean s th a t if a p a tie n t “forgets” to co m plete CSQ h o m ew o rk o r a tte m p ts to steer co nversation away from th e situ atio n being e xam ined, the th era p ist m u st address th e n o n c o m p lian c e directly a n d assertively o r steer co nversation back to SA.

—

C ase E x a m p l e

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Jerem y was a 24-year-old stu d e n t w ho re p o rte d experien cin g a 4m o n th m a jo r depressive episode d u rin g his 1st year o f g ra d u ate school. He re p o rte d th a t he rem ain ed isolated in his h o u se for m u ch o f this tim e and rarely a tte n d e d classes, ultim ately resulting in his expulsion from his p ro g ram . H ow ever, after som e discussions w ith faculty, Jerem y was g ra n te d a seco n d chance. In intake sessions at o u r clinic, Jerem y was described as angry, a rg u m en tativ e, a n d so m etim es lacking em pathy.

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T h o u g h initially it ap p eared th a t Jerem y’s p rim a ry diagnoses were M ajo r D epressive D iso rd e r a n d N arcissistic P ersonality D isorder, later re ex a m in a tio n o f his case suggested th e possibility o f PAPD. In p articu lar, Jerem y’s tend en cies to resen t a u th o ritie s a n d see th em as arb itrary , p ro c ra stin ate o n assigned tasks, m ake m an y false starts w ith o u t c o m p le tio n , a n d express re se n tm e n t a n d anger th ro u g h p a s­ sive-aggressive beh av io rs stro n g ly im plicated PAPD. Jerem y re p o rte d several prev io u s tre a tm e n t experiences d u rin g the intake interview , m o st o f th e m q u ite negative (e.g., he recalled a th e r ­ apist he saw as a child w h o m he felt forced h im to decide w ith w hich p a re n t he w a n ted to live). It could be a rg u ed th a t by relating these negative im p ressio n s d u rin g his first session, Jerem y a p p ea red to be c o m m u n ic a tin g to th e th e ra p ist th a t he was w ary o f psychologists a n d th u s m ig h t be on the defensive. F ortunately, Jerem y h a d recently h a d a positive experience w ith a co u n se lo r after h e was a rrested for an offense related to substance abuse. Jerem y a ttrib u te d his c o m fo rt to this c o u n se lo r’s d o w n -to e arth and h u m b le a p p ro ac h . Jerem y n o ted th a t since th e c o u n selo r h a d suffered from su b sta n c e-re la ted p ro b lem s, Jerem y view ed h im less as a cold a u th o rity a n d m o re as a w arm , u n d e rsta n d in g h u m a n being. Jerem y a tte n d e d ju st over 20 sessions at o u r clinic. M uch o f his th e ra p y was d irec te d to w ard th e tre a tm e n t o f sy m p to m s associated w ith N PD , M ajor D epressive D iso rd e r (M O D ), a n d G eneralized A nxiety D iso rd e r (G A D ). T he th e ra p ist used elem ents o f Beck’s cog­ nitive th era p ie s fo r N P D a n d M D D a n d B arlow ’s tre a tm e n t for GAD for th e first several sessions. CBASP was only used sy stem ati­ cally to specifically targ et Jerem y’s passive-aggressive sy m p to m s for th e last seven sessions. T his w as d u e in p a rt to in itial d o u b t a b o u t w h e th er PAPD was a suitable, p rim a ry diagnosis fo r Jeremy. A lthough he ultim ately te rm in a te d against the th e ra p is t’s advice, Jerem y m ade su b sta n tia l progress d u rin g sessions in w hich the th e r­ apist used CBASP. A lth o u g h th e th e ra p ist only used the CSQ for seven sessions, Jerem y clearly learn ed d u rin g th is tim e th a t his th o u g h ts a n d b eh av io rs w ere key to his repeated fru stra tio n in achieving D O s a n d yet also held th e p o ten tial to b rin g in g th o se o u t­ com es w ith in reach. T his was clearly th e m o st p ro d u c tiv e th e ra p y experience o f Jerem y’s life.

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TABLE 4.1 CSQ Illustrating Jeremy’s Passive-Aggressive Pattern o f Thoughts and Behaviors

Step 1

• I sat down to do my homework. • I thought about how unfair the assignment was. • I decided to do other things.

Situation

Step 2 Interpretations

Step 3

• This assignment is unfair because it requires a special program only available on campus that I can’t dow n­ load for use at home. • I shouldn’t have to do this assignment. • There is no value to me for doing this assignment. • I’m being made to do som ething I don’t want to do.

Behaviors

• Sat down to do homework • Got up to do som ething else

Step 4

• To complete my homework

Desired outcome

Step 5

• Did not complete my homework

Outcome

Step 6

• Did not get what 1 wanted

Comparison o f Actual and Desired Outcomes

When com pleting CSQs with Jeremy, the focus was on his ten­ dency to avoid working on homework in certain classes. Table 4.1 presents a CSQ from one session with Jeremy and what follows is a partial transcript o f the session. Therapist: Okay! So, we k n o w th a t you have had this assignm ent a long tim e a n d th a t it’s overdue. H ow a b o u t we look a t on e tim e w hen you w ere w orking o n th e assignm ent? Jeremy:

Well, a couple n ights ago I finally sat d ow n at m y desk an d looked at th e assignm ent. I sp e n t a couple h o u rs try in g to get a free copy o f the stu p id c o m p u te r p ro g ra m we have to use, an d I c o u ld n ’t find it on th e In tern et. T he w hole assignm ent is a w aste o f tim e because it’s n o th in g like w h at I’ll actually be doing.

Therapist: Okay, I w rote th a t you sat d ow n to do y o u r h o m ew o rk an d decided it w as unfair. W h at else h a p p en e d in th e situation? Jeremy:

(silent, staring intensely at the therapist) I d id n ’t do it.

Therapist: Okay. You d id n ’t do it. So you did so m e th in g else instead, right? Jeremy:

Yeah. I w ent a n d w atched TV.

PASSIVE-AGGRESSIVE PERSONALITY D ISO RD ER

Therapist: T h a t’s Step 1. We m ade a very brief, b u lleted d e sc rip tio n o f the situ atio n . N ow let’s go to Step 2. W hat did th e situ atio n m ean to you? W h at w ere you thinking? Jeremy:

I was th in k in g how s tu p id th e assig n m en t was. I c o u ld n ’t u n d e r­ stan d w hy I h a d to go a n d use this p ro g ram w hen th ere are o th er m ore c o m m o n p ro g ram s th a t I w ould actually use in real life. 1 was th in k in g th is assig n m en t w as useless to m e since it’s artificial an d d o e sn ’t relate to m y w ork. O verall, I w as th in k in g th a t I was being forced to d o so m e th in g th a t I really d id n ’t w an t to do.

Therapist: Okay. G ot th a t dow n. T h a t’s Step 2, y o u r th o u g h ts. N ow let’s go to Step 3, y o u r b ehaviors. W hat did you do in the situation? It so u n d s like you sat d ow n to d o y our h o m ew ork, d id n ’t do yo u r ho m ew ork, th en got up to d o so m e th in g else. W h at d id you w ant in the situation? Jeremy:

To finish the assignm ent.

Therapist: H ow did things tu rn o u t in the situation? Jeremy:

W hat d o you m ean?

Therapist: W hat was th e end result o f th e situ atio n , the outcom e? Jeremy:

I d id n ’t do m y hom ew ork.

Therapist: Okay, so like we said before: You d o n ’t like this assignm ent, bu t you kn o w it will help you pass this class so you w o n ’t get kicked o u t o f y o u r p ro g ra m again. D id you get w hat you w anted? Jeremy:

( long silence: stares intensely a t ground, then at therapist) No.

Therapist: Now, let’s look b ack a t y o u r th o u g h ts a n d behaviors to see if they w ere helpful o r h u rtfu l. D id th in k in g to y ourself, “T his assign­ m e n t is u n fa ir because it requires a special p ro g ram on ly avail­ able o n cam p u s th a t I can’t d o w n lo ad for use at h o m e ” help you o r h u r t you to get th e assignm ent done? Jeremy:

I guess it d id n ’t help.

Therapist: M akes sense. If you feel th e assig n m en t is unfair, you’d p robably feel k in d a u p set a n d n o t w a n t to do th e th in g . H ow a b o u t the o th e r th o u g h ts, “ I sh o u ld n ’t have to d o th e assignm ent,” “T here is no value to m e for d o in g this assignm ent,” a n d “I’m being m ad e to do so m e th in g I d o n ’t w a n t to do.” D id th o se help or h urt? Jeremy:

T hey d id n ’t help. T hey ju st m ade m e m o re pissed off at th is s tu ­ pid assignm ent.

Therapist: Okay. H ow a b o u t y o u r behaviors? D id sitting d ow n at th e table help? Jeremy:

No.

Therapist: Well, okay. B ut, at least y ou’re sittin g d o w n to w ork o n it, right? Instead o f totally avoiding yo u r desk?

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Jeremy: I guess. Therapist: So, th a t’s a tough one, b u t I’d say it actually helped. H ow about getting up to do som ething else? Jeremy: O bviously th at d idn’t help. Therapist: Right. Let’s go back over this situation to see if you could have th o u g h t o r done anything differently to get w hat you wanted. So, w hat else could you have th o u g h t to get w hat you w anted? Again, I’m not trying to tell you w hat you should w ant, and I’m n o t arguing th at you have to do w hat oth er people w ant. I’m assum ing th at you w anted to get the assignm ent done. W hat else could you have thought? Jeremy: (silence) I d o n ’t know. I d id n ’t w ant to do it. Therapist: Okay, how a b o u t “I really d o n ’t w ant to do this stupid assign­ m ent, b u t I have to if I w ant to pass this stupid class. I guess I’d better just do the stupid thing so I can m ove on.” Jeremy: (laughs) Yeah, I guess that w ould help. But it’s hard to think those things. I know I should th in k them , b u t I d on’t. I keep thinking how stupid the assignm ent is. Therapist: T h at’s totally norm al, and it’s why you’re here. Listen, if you practice this thing we’re doing, you will eventually com e to think and do things that will at least help you get w hat you w'ant in every situation, at every m o m en t in your life. The thoughts here on the paper are knee-jerk for you. You autom atically think them every tim e you get w hat you see as a d u m b assignm ent. If you keep practicing the helpful thoughts, though, they will hopefully becom e autom atic and replace the hu rtfu l thoughts. Okay, now' let’s look at y our behavior. Jeremy: Well th a t’s obvious. N ot doing the hom ew ork d id n ’t help m e do the hom ew ork. Therapist: Yeah, this stuff is k ind o f com m onsense, b u t it helps to really look at w'hat you’re doing in each situation to see if it’s helping you o r h u rtin g you. Well, okay. So w hat else could you have done? Jeremy: Just do the d am n assignm ent. Therapist: Y eah. . . I th in k th at w ould help. (smiles) Jeremy: You know, I have all these different thoughts. I think about try ­ ing to change the system. I think a bout w hat else I could be doing. I think about w hat I’d do if I were in charge. I w onder if things from m y past are m aking m e not do this stuff. I’m not sure w hat the right thing is to think! Therapist: Yeah, we could com e up w ith all kinds o f ways o f looking at this, right? We could com e up w ith lots o f different theories and spec-

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ulate about why you do these things. You know what, though? It really com es down to one simple question: Does it help or does it hurt? Is thinking this helping me to get what I w'ant, or hurting me?

As can be seen from this tra n sc rip t, Jerem y’s in te rp re ta tio n s from Step 2 w ere actually q u ite sim ilar to those described by Beck and F reem an (1990) as ch aracteristic o f those w ith PAPD sy m p to m s a n d seem ingly led Jerem y to refuse to co m p ly w ith d e m a n d s th a t he perceived as u n fa ir a n d co m in g from a rb itra ry a u th o ritie s. T he e n d result, how ever, was to take Jerem y o n e step closer to again being expelled from his p ro g ram . H e stated th a t he w a n ted to co m plete th e p ro g ram , w hich no w re q u ire d o b ta in in g a high grade in all o f his classes to m ake u p for his p o o r grades. E xam ining the th o u g h ts a n d b ehaviors Jerem y chose in this situ a tio n revealed th a t n o n e o f th em h elped him to co m p lete his h o m ew o rk , a n d all o f th em h u r t h im in achieving this D O . H ow ever, Jerem y was able to u n d e rsta n d th a t ch o o sin g o th e r th o u g h ts and b eh av io rs could help h im achieve his DO. Jerem y’s p a tte rn o f passive-aggressive b e h av io r was a p p a re n t in his beh av io r w ith the th e ra p ist (see Table 4.2). At first, Jerem y arrived late TABI.F. 4.2 CSQ Illustrating Jeremy’s Passive-Aggressive Pattern with the Therapist Step 1

• I came to session without the book.

Situation Step 2

Interpretations

Step 3

• 1 don’t have to bring the book. • There will be no negative consequences for not bringing the book. • 1 don’t have to do what my therapist tells me. • 1 left home without the book.

Behaviors Step 4

• Bring the book to therapy

Desired outcome Step 5

• 1 arrived at therapy without the book.

Outcome Step 6

Comparison of Actual and Desired Outcomes

• Did not get what 1 wanted

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to session o n several occasions. H e explained th a t he was ru n n in g late for class a n d den ied any aggressive m otives. Later, th e th e ra p ist len t Jerem y a boo k , a n d Jerem y fo rg o t to b rin g th e b o o k for five c o n se cu ­ tive sessions. Jerem y again d en ie d any m otive for this b e h av io r a n d repeatedly p ro m ised to b rin g th e b o o k at the follow ing session. T he th era p ist finally c o n fro n te d Jerem y w ith the possibility th a t these beh av io rs w ere in fact p a rt o f a passive-aggressive p a tte rn o f resisting external d e m a n d s. T h e follow ing CSQ was th e result o f th e th e ra p ist’s p ro m p tin g Jerem y to lo o k fo r th e passive-aggressive th o u g h ts he had reg ard in g re tu rn in g th e boo k . T he follow ing tra n s c rip t elaborates the details o f th e discussion. Jeremy: I forgot the book again. I’m really sorry. Therapist: H m m . I have an idea. 1 wonder if you’re trying to tell m e som e­ thing by not bringing the book. I wonder if this is part o f the passive-aggressive pattern we’ve been talking about. Jeremy: Really, I just forgot it. There’s nothing more to it. Therapist: Hypothetically, what m ight you be angry with me about? Jeremy: Look, there’s really nothing to this. I just keep forgetting the book. Therapist: Well, that’s the thing. You’ve forgotten it four, five times now. I have a hunch that this is an example o f passive aggression. Jeremy: I really don’t know why you’re insisting on this. Why don’t you just drop it? I apologized.

Therapist: Okay. I know you forgot it. But w e’re more likely to forget certain things. For instance, if you had tickets to a concert o f your favorite rock group, how likely would you be to forget the concert? Jeremy: Hell, no. I wouldn’t forget that. You couldn’t stop me from get­ ting there. Therapist: Okay. Well, but what about a m eeting o f a group that you really feel is a waste o f your time but that you said you’d make. D o you think it’s possible that you’d be more likely to forget certain things, even though your ability to remember things is really intact? It seems that people may remember things they want to remember and forget things they want to forget. Jeremy: Yeah, but I really do feel sorry for forgetting the book, and I really do intend to bring it. There’s really no hidden agenda here. Why are you pushing me? I feel like you’re making m e do som e­ thing I don’t want to do!

Therapist: I’m trying to dig a little deeper here because I think there’s som ething to this. I wonder if you might really be angry with

PASSIVE-AGGRESSIVE PERSONALI TY DI S ORDER

m e a n d are try in g to c o m m u n ica te this an g er in directly by n o t b rin g in g th e b ook. Jeremy:

Well, I can see th at. It m akes sense.

Therapist: Okay. So let’s try again. W h at do you th in k you m ig h t be an g ry w ith m e about? Jeremy:

(long silence) You know , I’m never really sure if y ou’re acting in m y best interest. I never really k now w h a t y ou’re doin g , an d som etim es I w o n d e r if y ou’re ju st p laying w ith m y m in d for y our ow n enjo y m en t. O n th e o th e r h a n d , I d o n ’t w a n t to ask you a b o u t this because it m ay be th a t th e tre a tm e n t o nly w orks if I d o n ’t really k now w h at you’re doing. M aybe it w ould stop w orking if you told m e e v erything you are doing.

Therapist: A hh, th a t’s interesting! Okay. So you w ould like m e to be m ore clear w ith you a b o u t w hat I’m d o in g an d why. I th in k th a t’s totally fair an d it’s actually w hat cognitive-behavioral th erap ists are su pposed to do. I believe th at it’s perfectly okay an d actually qu ite helpful if you know w hat I’m doing, why I ’m d o in g it, and how it sh o u ld help. So you w ere ju st assertive w ith m e right then. You told m e flat o u t a b o u t so m e th in g you were kin d o f pissed about! H ow did th at feel? Jeremy:

Okay. I m ean , I ’m assertive. I speak u p against p eople w hen I th in k th e y ’re do in g so m e th in g really w rong. Like th a t racist boss I to ld you ab o u t. I to ld h im off!

Therapist: Yes. You w ere assertive then. But th a t was k in d o f an extrem e case. W h at a b o u t w hen it’s so m e th in g m o re m in o r th a t kin d o f has y ou m iffed, a n d y ou’re n o t really sure a b o u t saying so m e­ th in g a b o u t it? H ow a b o u t w e d o a CSQ a b o u t this situation? T he situ atio n is th a t you cam e to session w ith o u t the book. W h at w ere you thinking? Jeremy:

I d o n ’t know.

Therapist: Take a m in u te. W e’re n o t in a rush. Jeremy:

(silence) Well, I guess I w as th in k in g th a t th e re ’s no conse­ quence.

Therapist: W h at d o y ou m ean? Jeremy:

Well, it’s n o t like I ’m going to get in tro u b le if I forget the book. You d o n ’t have any c o n tro l o ver m e.

Therapist: Okay, I’ll w rite th a t dow n. W h at a b o u t y o u r behaviors? I ’ll ju st w rite th a t you d id n ’t b rin g the book. W h at d id you w ant? Jeremy:

I guess I w an ted to b rin g the book. I d id n ’t get that.

Therapist: Okay. W h at else could you have th o u g h t and done? I guess I could have th o u g h t th at it’s really n o t th at h a rd to find Jeremy: the book. I could have fo u n d it an d b ro u g h t it.

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Therapist: That’s fair. You know, you’re right. It’s not like the world will com e to an end if you don’t bring it. I have no control over you. But that’s a different issue than sim ply what you want. It sounds like you wanted to return the book. Look. I’ll bring it next time.

Jeremy: Therapist: Okay. (Jeremy brought the book to the next session.)

N ote again th a t th e th o u g h ts a n d b ehaviors Jerem y displayed in this situ atio n are very sim ilar to th o se described by Beck a n d Free­ m a n ’s (1990) d e sc rip tio n o f PAPD sy m ptom atology. Recall th a t one o f Beck’s fo rm u la tio n s a b o u t p eople w ith passive-aggressive features is th a t th ey have difficulty b ein g assertive. W orking w ith in this fram e ­ w ork, the th era p ist suggested th a t th ere m ig h t be so m e th in g th at Jerem y was try in g to c o m m u n ic a te to the th era p ist indirectly by fo r­ g etting to b rin g th e b o o k so m any tim es. Jerem y was defensive a b o u t this suggestion at first. N onetheless, the th e ra p ist suggested th a t for Jerem y to practice c h an g in g his b e h av io r from passive aggression to active assertio n , Jerem y w ould have to identify w hy he was a n g ry w ith th e th e ra p ist a n d c o m m u n ica te th is directly. A fter th e th e ra p ist gave this ratio n ale, Jerem y eventually revealed th a t he believed th e th e ra ­ p ist w as try in g to m an ip u la te his m in d in devious ways for his ow n pleasure. T his th era p e u tic b re a k th ro u g h m oved Jerem y from in d ire ct c o m ­ m u n ic a tio n to direct assertion. H ow ever, th e e n c o u n te r also revealed th e first o f m an y p a ra n o id p e rso n ality features th a t Jerem y eventually disclosed a n d w hich th e th e ra p ist was ultim ately n o t able to address d u e to Jerem y’s u n ilateral te rm in a tio n from tre a tm e n t. T h u s, as b o th th e critics a n d su p p o rte rs o f th e PAPD diagnosis have agreed, p a ­ tie n ts w h o display o n e constellation o f d iso rd e red p e rso n ality fea­ tu res alm o st always display features from o th e r p e rso n ality d isorders. At th e least, features o f PAPD, N P D , a n d P a ra n o id P ersonality D is­ o rd e r w ere a p p a re n t in Jerem y’s p re sen ta tio n . Im p o rta n tly , th o u g h , his th e ra p ist m ig h t n o t have u ncovered the p a ra n o id features if he had ig n o red Jerem y’s passive-aggressive p e rso n ality features. T his an ecd o tal evidence p rovides m o re su p p o rt fo r th e place o f PAPD in th e psychiatric nosology. As Beck a n d F reem an (1990) n o te, it is best practice for th era p ists trea tin g passive-aggressive p a tie n ts to be com pletely explicit in ex­ plain in g the tre a tm e n t a n d ratio n ale, even m o re so th an is sta n d a rd

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practice in c o g n itive-behavioral therapy. In fact, Jerem y resp o n d ed well w hen th e th era p ist began to explain every m ove he m ad e in session. For exam ple, th e th e ra p ist w ould preface a d iscussion o f the evidence for a n d against a th o u g h t w ith th e follow ing: “I ’d like to take a look at the th o u g h t you ju st m e n tio n e d by co m in g up w ith evidence th a t su p p o rts the th o u g h t a n d evidence th a t goes against the th o u g h t. I th in k th a t lo o k in g at this evidence w ould help you decide w h e th er th e th o u g h t is realistic a n d ultim ately decide w h e th er the th o u g h t is h e lp in g you o r h u rtin g you in gettin g th in g s you w a n t o u t o f th e situ atio n . Is th a t okay w ith you?” P ro v id in g these k inds o f e x p lan a­ tio n s is vital w hen using th e CBASP a p p ro ac h w ith PAPD patients. In the absence o f specific rationales, such p a tie n ts are likely to view the a p p ro ac h as sim ply a n o th e r a u th o rita ria n stru c tu re im p o sed by an a rb itra ry a u th o r ity — th e th era p ist. T ran sp aren cy also m akes the th e ra p ist ap p ea r like less o f an a u th o rity a n d m o re o f a h u m a n being w ho is sh a rin g a helpful solution.

O utcome

A lthough Jerem y seem ed to appreciate this m o re explicit a p p ro ac h , he u ltim ate ly te rm in a te d th e ra p y against the advice o f the th era p ist. H e called to explain th at he h a d decided to d ro p o u t o f school and could n o longer afford therapy. T he th e ra p ist felt it was im p o rta n t to have a form al te rm in a tio n session w ith Jerem y to a tte m p t to change his p a tte rn o f e n d in g re la tio n sh ip s passively, w hich he h a d re p o rte d d u rin g tre a tm e n t. A fter several weeks o f failed a tte m p ts at scheduling a te rm in a tio n session w ith Jeremy, th e th e ra p ist d ecided it was b e tte r to term in ate w ith Jerem y by p h o n e th a n to have no te rm in a tio n at all. He reached Jerem y at h o m e a n d explained th a t he felt it was in Jerem y’s best interest to have a form al te rm in a tio n so th a t this th e ra ­ peu tic episode w ould e n d in an active a n d clear way. Jerem y agreed a n d listened as the th era p ist review ed the c o n te n t a n d process o f his course o f tre a tm e n t a n d m e n tio n e d his p e rce p ­ tio n s o f Jerem y’s stre n g th s a n d w eaknesses. T h e th e ra p ist explained w hat he had learn ed from Jeremy, su ch as the im p o rta n c e o f explicitly ex plaining a n d giving a ra tio n ale fo r tre a tm e n ts, a n d m ade re c o m ­ m e n d a tio n s in th e event th a t Jerem y d ecided to rein itiate tre a tm e n t in th e fu tu re. Lastly, th e th e ra p ist stated th a t Jerem y was w elcom e to re tu rn to the clinic at any tim e.

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OB S T A C L E S TO T R E A T M E N T As w ith th e case exam ple, th e m o st c o m m o n obstacle e n co u n tere d w hen c o n d u c tin g th e ra p y w ith PAPD p a tie n ts is resistance. W hen p a tie n ts p a s­ sively refuse to co m p lete reasonable a n d a g re e d -u p o n th era p e u tic tasks in session, the th e ra p ist can use CBASP o r m o tiv a tio n a l interview ing te c h ­ n iq u es (M iller & Rollnick, 2002) to evaluate th e effectiveness o f the p a tie n t’s passive b e h av io r in reach in g his o r h e r ow n stated goals for th e r­ apy. For exam ple, th e th e ra p ist can guide the p a tie n t th ro u g h a c o n sid era ­ tio n o f th e p ro s a n d cons o f actively engaging in therapy. A related c o m m o n obstacle w ith this p a tie n t p o p u la tio n is failure to co m plete h o m ew o rk assignm ents. If a p a tie n t com es to session w ith o u t having c o m p leted assigned CSQ h o m ew o rk tasks, the th era p ist sh o u ld em phasize th a t th e p a tie n t will reach goals m o re quickly if he o r she c o m ­ pletes h o m ew o rk regularly. T h e th e ra p ist sh o u ld th en p roceed to co m plete a CSQ in session o n e ith e r th e failure to co m plete h o m ew o rk o r so m e s itu ­ a tio n from th e prev io u s week. W h en th ey do co m p lete CSQ h o m ew o rk assignm ents, p a tie n ts w ith PAPD features often initially exhibit characteristic p ro b lem s in learning the m eth o d . For exam ple, a c o m m o n p ro b lem for these p a tie n ts involves Step 1, describing the situ atio n . In Step 1, the p a tie n t is to provide only objective facts related to th e event a n d avoid e m o tio n ally laden d e sc rip ­ tions. How ever, PAPD p a tie n ts m ay have a h a rd tim e d istin g u ish in g th o u g h ts from e m o tio n s a n d u n d e rsta n d in g th a t p a rtic u la r th o u g h ts c o n ­ trib u te to c ertain e m o tio n al experiences. It often takes p a tie n ts w ith PAPD several sessions o f c o m p letin g CSQ s before th ey u n d e rsta n d th e d istin c ­ tio n b etw een th o u g h ts a n d e m o tio n s. L earning this difference, however, enhances th e p a tie n t’s ability to o rganize in fo rm a tio n d u rin g stressful s itu ­ a tio n s a n d facilitates su b seq u e n t th o u g h t analysis. PAPD p a tie n ts m ay also have difficulty w ith Step 5 o f the CSQ , d e sc rib ­ ing how the situ atio n tu rn e d o u t. In co m p le tin g th eir first few CSQ s, these p a tie n ts often fail to n otice th e e m o tio n al consequences th a t result from failing to o b ta in th e ir D O s. T h ey have difficulty u n d e rsta n d in g th a t failing to get w hat th ey w a n t can lead to feelings o f sadness, anger, o r guilt, w hich can c o m p o u n d any c o m o rb id m o o d a n d anxiety disorders. For exam ple, w hen Jerem y described the o u tco m e o f the situ a tio n in w hich he failed to re tu rn the boo k , he neglected to c o m m e n t o n any feelings o f guilt he m ig h t

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65

have experienced as a result o f n o t com plying w ith his th e ra p is t’s sim ple request. T h u s, Jerem y’s in te rp re ta tio n s indicate th a t he believed th a t there w ere no consequences to his fo rg ettin g th e book. A lth o u g h th ere m ig h t n o t have b een any externally observable consequences to his in ac tio n , failing to re tu rn the b o o k likely caused u n p lea sa n t e m o tio n s th a t Jerem y failed to identify. If p a tie n ts w ith PAPD features display this k in d o f difficulty, th era p ists sh o u ld explicitly m ake the co n n ec tio n betw een failing to get o n e ’s D O a n d re su lta n t negative e m o tio n s, in arguably an u n d esirab le o u t­ com e. Such in te rv en tio n s can help PAPD p a tie n ts u n d e rsta n d ho w th e ir p a tte rn o f passive aggression can m a in ta in c o m o rb id diso rd ers, such as depression. In Jerem y’s case, it seem s plausible to co n clu d e th a t conse­ q uences associated w ith his passive-aggressive p e rso n ality features c o n ­ trib u te d to his 4 -m o n th depressive episode.

It is im p o rta n t to re m e m b e r several things w hen im p le m e n tin g CBASP w ith p a tie n ts p re sen tin g w ith PAPD features. First, th e CSQ is used w ith in th e cognitive fram ew o rk o f Beck a n d F reem an ’s (1990) c o n ce p tu a liz atio n o f PAPD to identify ch aracteristic negative a u to m a tic th o u g h ts a n d replace th em w ith m o re effective th o u g h ts. Second, PAPD p a tie n ts ten d to resist tre a tm e n t o r h o m ew o rk assignm ents, such as the CSQ. W h en this occurs, th e th e ra p ist can actually co m p lete a CSQ o n the p a tie n ts’ resistance to do th e ir h o m ew o rk , as w hen the th e ra p ist in the case exam ple used the CSQ to u n d e rsta n d w hy Jerem y w o u ld n o t re tu rn a b o o k th e th e ra p ist len t him . T h ird , it is especially im p o rta n t to keep a collaborative stance w ith p a tie n ts w ith PAPD features a n d provide an explicit ra tio n ale for all th era p eu tic in te rv en tio n s. Last, it sh o u ld be n o te d th a t use o f the CSQ n o t only can help reduce passive-aggressive tend en cies b u t also can address o th e r c o n d i­ tio n s such as depression a n d anxiety th a t often co o ccu r w ith PAPD. As n o te d previously, CBASP is ideally suited to trea tin g PAPD. T he tre a tm e n t effectively uncovers passive-aggressive th o u g h ts a n d b ehaviors th a t m ay n o t be readily a p p a re n t to th e p a tie n t o r to others. CBASP also u n iq u ely high lig h ts ho w such th o u g h ts and beh av io rs are c o u n te rp ro ­ ductive th ro u g h repeated ev aluations o f th e ir effectiveness in achieving situ atio n al D O s. Lastly, a th e ra p ist using CBASP is able to assist p a tie n ts diag n o sed w ith PAPD in g e n era tin g a n d p racticin g active th o u g h ts a n d assertive behaviors. In the co n te x t o f a w arm , tra n s p a re n t th era p eu tic

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relatio n sh ip , CBASP offers a p ro m isin g so lu tio n to this in sid io u s p e rso n a l­ ity disorder. T he e n d result is th a t PAPD p a tie n ts can beco m e active p a rtic ­ ip an ts in life, able to o b tain directly a n d assertively th a t w hich th ey tru ly desire.

Chapter

Personality Disorder Not Otherwise Specified*

Personality Disorder Not Otherwise Specified is the diagnostic label applied to patients who present with a com bination o f the pathologi­ cal personality sym ptom s that com prise the other personality disor­ ders. These sym ptom s may also include more than one personality disorder cluster (i.e., odd/eccentric, anxious, or dramatic/erratic). This chapter presents the Cognitive Behavioral Analysis System o f Psychotherapy as a m ethod o f treating the multifaceted presentations that make up this disorder. A case example describes the im plem enta­ tion o f Situational Analysis for a patient with Personality Disorder N ot Otherwise Specified with Avoidant and Schizotypal features. Obstacles to treatment, as well as possible m ethods o f resolution, are presented.

T h ere are few em p irically v alidated tre a tm e n ts available fo r p e rso n ality disorders, w hich leaves clinicians g ra p p lin g w ith decisions on how to best tre a t these patien ts. F or p a tie n ts w ith P ersonality D iso rd e r N o t O therw ise Specified (PD N O S; A m erican Psychiatric A ssociation, 1994), tre a tm e n t decisions can be even m o re co m plicated d u e to th e presence o f different c o m b in a tio n s o f sy m p to m s fro m several p e rso n ality d isorders. T his c h a p ­ ter focuses o n th e tre a tm e n t o f p a tie n ts w ith PD N O S using the C ognitive B ehavioral Analysis System o f P sychotherapy (CBASP; M cC ullough, 2000) tec h n iq u e, m o d ific atio n s to th e tec h n iq u e, obstacles to tre a tm e n t, a n d a case exam ple. ‘The primary authors contributing to this chapter were Therese Skubic Kemper, Annya Hernandez, and Leonardo Bobadilla.

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P ersonality d iso rd ers are a m o n g th e m o st p e rn ic io u s m en ta l illnesses, given th e ir n a tu re as lo n g -stan d in g , in g rain ed p a tte rn s o f beh av io r th a t are often resistan t to tre a tm e n t a n d th e high rates o f c o m o rb id ity w ith Axis I d iso rd ers (C rits-C h risto p h , 1998). T h e clinical p ictu re is p e rh ap s m o re com plicated for PD N O S. PD N O S n o t o n ly shares th e p reviously m e n ­ tio n e d characteristics o f o ther, b e tte r d elin eated p e rso n ality d isorders, b u t it also is often com plicated by vexing c o m b in a tio n s o f p a thological perso n ality sy m p to m s from m o re th a n o n e perso n ality d iso rd e r cluster (i.e., o d d /ec ce n tric , d ra m a tic /e rra tic , o r a n x io u s /d e p e n d e n t). T his v a ria ­ b ility in sy m p to m expression m akes it im p ractical to develop a tre a tm e n t strategy specific to each c o m b in a tio n o f sym ptom s.

T R E A T M E N T OF P D N O S Even as research o n th e tre a tm e n t o f Axis I d iso rd ers c o n tin u e s to grow and tre a tm e n t o p tio n s b ecom e m o re effective, th ere re m a in few e m p iri­ cally validated tre a tm e n ts for p e rso n ality disorders, w ith th e exception o f D ialectical B ehavior T h era p y (D B T ) for B orderline P ersonality D iso rd er (L inehan, H u b e rt, Suarez, D ouglas, 8c H eard , 1991). T he p a u city o f research on the tre a tm e n t o f p e rso n ality d iso rd ers has left clinicians g ra p ­ pling w ith tre a tm e n t decisions a n d ch o o sin g tre a tm e n ts th a t have n o t been em p irically validated. Som e have suggested th a t research o n th e tre a tm e n t o f p e rso n ality d iso rd ers sh o u ld p roceed in the d irec tio n o f m atc h in g p a tie n ts to tre a tm e n t m o d alities based o n th e ir p e rso n ality sy n d ro m e (B arber 8c M uenz, 1996) o r salient p a tie n t variables th a t are n o t necessarily sy m p to m s o f th e p e rso n ality d iso rd e r (e.g., ex ternal c o ping style, resist­ ance; Beutler, M ohr, G raw e, 8c Engel, 1991). A lth o u g h these alternatives m ay be feasible d irec tio n s fo r research o n th e tre a tm e n t o f specific p e rso n ­ ality diso rd ers, it is m o re difficult to delineate g ro u p s o f perso n ality sy m p ­ to m s o r p a tie n t a ttrib u te s for a g ro u p o f p a tie n ts w ith PD N O S because th e ir sy m p to m s often fall in to several d iagnostic categories.

M O D I F I C A T I O N OF C B A S P F OR P D N O S CBASP a n d th e C o p in g Survey Q u e stio n n a ire (C SQ ) offer tre a tm e n t strategies th a t n eed n o t fu n d a m e n ta lly differ d e p en d in g o n th e p e rso n ality sy n d ro m e o r specific sy m p to m s. T h o u g h p a tie n ts w ith w ell-delineated d is­

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o rd ers, su ch as M ajo r D epressive D iso rd e r o r Panic D isorder, are likely to p re sen t w ith a core set o f sy m p to m s p e r the p a rtic u la r disorder, p a tie n ts w ith PD N O S m ay ap p ea r co m pletely sy m p to m atically d istin c t from one an o th er. D espite this circu m stan ce, the stru c tu re a n d process o f th e CSQ rem ain s relatively co n sta n t across clinical p re sen ta tio n s, allow ing for a d a p ­ tatio n o f the c o n te n t to address p ro b lem areas specific to each individual. T herefore, th o u g h ts a n d b ehaviors specific to each in d iv id u a l’s sy m p to m p re sen ta tio n m ay be targeted as p o in ts o f in te rv en tio n . T his a d a p ta tio n enables th e use o f CBASP in th e tre a tm e n t o f sy m p to m s th a t are specific to p a rtic u la r types o f features o f PD N O S. For exam ple, th e tre a tm e n t for p a tie n ts p re sen tin g w ith p a ra n o id o r schizotypal features could focus on th o u g h ts a n d b ehaviors associated w ith u n su b sta n tia te d p a ra n o ia a n d suspicio n o f others. Sim ilarly, tre a tm e n t focusing o n the th o u g h ts a n d b ehaviors associated w ith p o o r im pulse co n tro l w ould be a p p ro p ria te for p a tie n ts diag n o sed w ith PD N O S w ith antisocial o r b o r ­ derlin e features. Likewise, CBASP tre a tm e n t for a p a tie n t diag n o sed as h a ving PD N O S w ith d e p e n d e n t features can cen ter o n th e th o u g h ts a n d beh av io rs associated w ith unrealistic fears o f a b a n d o n m e n t. D ysfunctional p re o cc u p atio n w ith p erfectio n ism , a feature specific to PD N O S w ith obsessive-com pulsive features, can also be a focus o f CBASP tre a tm e n t.

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C ase E x a m p l e

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Sam w as a 28-year-old W hite m ale w h o so u g h t tre a tm e n t for p ro b ­ lem s o f loneliness, social isolation, a n d feelings o f sadness th a t w ere in te rferin g w ith his m o tiv a tio n , e nergy level, a n d ab ility to c o n ce n ­ trate, causing him to fall b e h in d in his g ra d u ate school p ro g ram . At th e tim e o f the intake interview , Sam ’s th o u g h t process a n d speech c o n te n t w ere logical a n d c oherent; how ever, he freq u en tly did n o t answ er q u e stio n s directly a n d spoke p h ilosophically a n d in the abstract. Sam re p o rte d th a t he could n o t re m e m b e r a tim e d u rin g w hich he felt a social c o n n ec tio n w ith o th ers, even as a child, a n d re p o rte d never having close frien d s o r a ro m a n tic relationship. He spoke freq u e n tly o f his desire for in tim ate social re la tio n sh ip s b u t re p o rte d social anxiety a n d a fear o f negative evalu atio n by o th ers th a t in h ib ited fulfilling this desire. Sam also expressed a sim u lta n eo u s d isin terest in social in te rac tio n s d u e to the im m o ra lity a n d c h aracter flaws in th o se he w as likely to e n co u n ter. Specifically, Sam fo u n d

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negative e m o tio n s, such as sadness, anger, a n d sexuality, intolerable in h im self a n d o th e rs a n d felt ex trem e guilt as a result o f th e presence o f these e m o tio n s. As a result, Sam fo rb ad e h im self from expressing th em o u tw a rd ly a n d rarely m ad e efforts to in te ra c t socially for fear th a t he m ig h t find these e m o tio n s in others. Sam often stated th a t he strived to reach a m o re e n lig h ten e d a n d m o ral state in w hich he w ould be free from anger, sexuality, a n d sadness. Sam was initially d iagnosed w ith D ysthym ic D isorder, a n d a diag ­ nosis o n Axis II was deferred. Later, a diagnosis o f PD N O S w ith A voidant a n d Schizotypal Features was given o n Axis II. H is G lobal A ssessm ent o f F u n c tio n in g ra tin g was 43 at intake. Sam ’s th era p e u tic goals in clu d ed re d u c tio n o f dysthym ic sy m p to m s, d e v elo p m en t o f social skills, a n d e m o tio n al reg u latio n focused o n in creasing aw are­ ness o f a n d c o m fo rt w ith e m o tio n s he labeled as negative. T h e p ri­ m a ry tre a tm e n t a p p ro ac h was CBASP. F orty-six CSQ form s w ere c o m p leted in session, a n d he c o m p leted several p e r w eek o n his ow n. Initially, Sam expressed skepticism at th e tre a tm e n t ap p ro ach ; how ever, from th e first session, he consistently com pleted h o m ew o rk assignm ents. Significant diificulties e n co u n tere d d u rin g sessions in ­ cluded p ro b lem s staying focused o n the event described in the CSQ, difficulty g en eratin g specific th o u g h ts a n d b ehaviors related to the event, difficulty g en eratin g th o u g h ts n o t p h ilosophically o rie n te d o r a b stract, a n d difficulty g e n era tin g D esired O u tc o m e s (D O s) th a t did n o t conflict w ith his m orals. O ften, Sam fo u n d h im se lf statin g two D O s th a t he believed conflicted. For exam ple, o n e p a ir o f D O s was “I w a n t to lo o k at an attractiv e girl,” w hich he saw as im m o ra l, and “I w a n t to be c onsiderate to w ard others.” A n o th e r p a ir o f D O s was “I w a n t to avoid a negative display o f e m o tio n ” a n d “I w a n t to express m yself [because I was a n g ry th a t I was b eing c harged for a cancelled session].” Sam also h a d difficulty g en eratin g D O s because he felt th a t if he did n o t attain w hat he w an ted in a situ atio n , it was because he d id n o t tru ly desire it, n o t because o f w hat he th o u g h t o r did. H is re cu rre n t ex p la n atio n o f th is was “M y beliefs create m y reality.” A ccording to Sam , th is sta te m en t im plied th a t he held beliefs, desires, and ideas th a t ultim ately gov erned th e o u tco m e o f situ atio n s, regardless o f w h a t he stated he w anted.

As a result of these obstacles encountered early in treatment, much of the initial work in completing the CSQ was in generating specific

5.

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a n d concrete th o u g h ts, behaviors, a n d D O s. For instance, Sam p ra c ­ ticed c h an g in g th o u g h ts such as, “I hypothesize th a t th ere is a p a rt o f m e th a t w ants to be close to so m e o n e a n d a n o th e r p a rt o f m e th a t d o e sn ’t let m yself get close to so m e o n e because th e usual series o f events is a so rt o f ‘split d ecision’” to “I th o u g h t 1 sh o u ld ask h er o u t, b u t I w as nervous.” Sam also p ra ctic e d chan g in g D O s su ch as “I w a n t to successfully achieve m y desires,” “I w a n t to successfully c o n fro n t m y fears,” a n d “I w ant to behave in a m a n n e r th a t signifies th a t I have resolved m y in te rn al conflicts” to situ atio n -sp ecific goals, w hich in clu d ed “I w ant to show u p for m y a p p o in tm e n t,” “I w a n t to spend som e casual tim e w ith friends,” a n d “I w a n t to express m y anger in a way th a t does n o t h u rt anyone.” Sim ilar obstacles w ere e n c o u n te re d w hen th e th e ra p ist e n c o u r­ aged Sam to replace h u rtfu l th o u g h ts a n d b ehaviors w ith helpful th o u g h ts a n d behaviors. O n e obstacle was th a t Sam w an ted to change his u n d e rly in g beliefs b efore chan g in g his th o u g h ts a n d behaviors. H is ra tio n ale for this was if he replaced his a u to m a tic th o u g h ts a n d beh av io rs w hile still m a in ta in in g his beliefs and values, w hich he often believed conflicted, he w o u ld be deceiving h im self a n d others. For instance, he often d ecided n o t to a p p ro ac h a w o m a n to sta rt a co nversation because he w as nervous, a n d he believed this reflected th at he d id n o t tru ly w a n t to in te rac t w ith her. A fter a p proxim ately 4 m o n th s o f tre a tm e n t, Sam acknow ledged th a t his c u rre n t th o u g h t a n d b e h av io r p a tte rn s w ere n o t help in g him m eet his goals. T h e re ­ fore, he decided to m ake a tte m p ts at g e n era tin g “sim p le ” th o u g h ts, su ch as “I w a n t to say ‘h ello’ to her,” challenging th e idea th a t his feel­ ings o f anxiety reflected th a t he did n o t desire a p a rtic u la r ou tco m e. D ue to these efforts, Sam began to sp o n ta n eo u sly generate specific, concrete, a n d sim ple th o u g h ts as well as D O s after an ad d itio n al m o n th o f trea tm e n t. In c o n ju n c tio n w ith this practice, tw o p a rtic u la r them es o f th o u g h ts a n d b ehaviors w ere addressed on a regular basis d u rin g the course o f c o m p letin g th e CSQ: th o se related to social anxiety a n d avoidance a n d th o se th a t w ere od d a n d abstract. Specifically, his fear o f rejection was ev id en t in m an y th o u g h ts a n d was targeted by developing social skills to help p re v en t rejectio n , developing skills to help accurately d e te rm in e w h e th er he was tru ly rejected, a n d challenging th o u g h ts related to th e severity o f th e consequences if, in fact, he was tru ly rejected. T h e latter strategy was essential to S am ’s discovery th a t the

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actual consequences w ere n o t as dire as he h a d im ag in ed , giving him n ew fo u n d confidence a n d th e desire to p u rsu e social contact. T his, in tu rn , enabled h im to practice social skills an d gain experience in social settings, th ere b y decreasing th e freq u en cy o f tru e social rejections. S am ’s a b stract a n d p h ilosophical th o u g h ts w ere seen as an im ­ p o rta n t p o in t o f in te rv e n tio n because they often p re v en ted th e fo r­ m a tio n o f concrete a n d logical c o n n ec tio n s b etw een his th o u g h ts, e m o tio n s, a n d behaviors. T hese th o u g h ts w ere targ eted th ro u g h a c o m b in a tio n o f a pp roaches. First, d u e to th e stru c tu re o f th e CSQ, Sam was n o t req u ired to challenge the validity o f his p h ilosophical th o u g h ts; he o n ly n eed ed to d e te rm in e w h e th er th e th o u g h ts h elped o r h u rt h im in achieving his DO . T his was a key advantage for Sam because challenging beliefs he held d e ar was d e em ed very p ro b le m ­ atic. A fter several m o n th s o f tre a tm e n t, Sam was able to acknow ledge th a t m an y o f his th o u g h ts d id n o t help him achieve his outco m es, a n d so m e o f them h u r t by eliciting anxiety o r leading h im to act in a m a n n e r c o n tra ry to th e DO . Second, w h e n Sam g en erated a b strac t o r ph ilo so p h ical th o u g h ts, he was asked, “W h at does th a t look like in th is p a rtic u la r situ atio n ? ” o r “W h at did th a t m ean , specifically, w hen you w ere in th e situ atio n ? ” T his led Sam to p ro d u c e m o re concrete th o u g h ts th a t w ere directly related to his behaviors. T hese th o u g h ts, in tu rn , h elped him discover th at instead o f b e co m in g overw helm ed o r a n x io u s as a result o f these th o u g h ts, he co u ld relate th em to his beh av io rs a n d change the beh av io rs directly to a tta in his DO . T h ird , Sam was responsive to e n co u ra g em e n t by his th era p ist to practice these strategies despite his skepticism a n d d isc o m fo rt a n d m ade m u c h progress d u e to his w illingness to em p lo y strategies w ith w hich he did n o t im m ed iately agree o r u n d e rsta n d . T hese aspects to th e r ­ apy, in c o m b in a tio n , led to Sam ’s sp o n ta n e o u s fo rm a tio n o f m ore concrete a n d specific D O s. As Sam becam e b e tte r able to specify desired goals, as well as the th o u g h ts a n d beh av io rs th a t w ould help him achieve th em , he re p o rte d feeling m o re in c o n tro l o f his e n v iro n ­ m en t. He began a tte n d in g classes o n a m o re regular basis to achieve his D O o f passing th em . H is w illingness to in te rac t socially also increased, an d , as a result, he began developing a social n e tw o rk and fo rm in g friendships. A lth o u g h positive e m o tio n al experiences a cc o m p a n ied these im ­ p ro v em en ts, Sam was faced w ith his a n d o th e rs’ tro u b le so m e n eg a­ tive e m o tio n s on a m o re regular basis. For exam ple, he fo u n d h im self

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PERSONALITY DISORDER NOT OTHERWISE SPECIFIED

becoming frustrated with others’ inconsideration, he felt angry and sad when he was rejected after requesting a date, and he continued to grapple with his discomfort with sexual desires. Sam’s discomfort with these emotions then became a therapeutic focus, incorporated into the CSQ. After several weeks of discussing social norms regard­ ing the expression o f these emotions and allowing Sam to rehearse them in session, he began to practice them on his own and incorpo­ rate his experiences into the CSQ. Specifically, Sam practiced em o­ tional regulation (i.e., anger management, self-reminders that intense emotions would subside) and engaged in more socially appropriate expressions of anger, sexual interest, and interpersonal frustration based on the in-session role plays. As he more frequently achieved his DOs and was able to recognize the role that his thoughts and behav­ iors played in attaining them, Sam was able to identify thoughts about his negative emotions that were hurtful in achieving his DOs (“I feel guilty for finding her attractive”) and DOs that were impossi­ ble (“I wanted to not be angry”). The following section contains a sample CSQ from the first month o f therapy and a form completed after several months of treatment. Transcript 1 Step 1. Describe w hat happened: I was in m y class w hen an o th er student sat dow n near m e, sm iled, and waved. After class, I struck up a conversation with her. She declined to get together w ith m e at the tim e b u t said we could study together closer to the next test date. Step 2. Describe your in terpretations o f w hat happened: My beliefs create m y reality, literally. I had to struggle against feelings o f helplessness to a degree. I feel that p art o f m e was holding m yself back to a degree. I’m not sure w hat I’m su p ­ posed to learn from this situation. W hatever the outcom e, it will reflect w hat is going on inside o f me. Isolation is reflected by the outcom e: I w ould have approached som eone w ho w ould have accepted or som eone w ho w ould have accepted w ould have sat next to me. Step 3. Describe w hat you did du rin g the situation: W hen she sat dow n near m e, I noticed that she was n o t sitting in her norm al seat. I began to check her out. W hen she sm iled

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a n d w aved at m e briefly, I n o ted h e r b ehavior as well an d d ecided to ap p ro ach h e r a fter class. D u rin g class, I felt a little anx io u s a b o u t m y fu tu re course o f action a n d tu rn e d m y a tte n ­ tio n inw ard to grow m o re q u iet inside. A fter class, I lingered briefly un til 1 cau g h t h e r a tte n tio n . She asked if 1 h a d a n o th e r class in the sam e ro o m afterw ards a n d 1 resp o n d ed th a t I d id n ’t. I asked h e r how she liked th e class so far. I listened attentively to h e r answ er, asked h e r m ore q u e stio n s as she to ld m e a little a b o u t herself, a n d resp o n d ed to h e r questions. W hen she m e n tio n e d th a t she h a d a lo t o f stud y in g to do for the class, 1 asked if she’d like to get to g eth er to stu d y so m etim e. W hen she declined, saying th a t she w as v ery b usy rig h t now , an d d escribed th e things th a t w ere keeping h e r b usy at the tim e a n d causing h e r som e stress, I offered to get to g eth e r w ith h er so m etim e, if she ever w an ted to unw in d . W h en she said th a t she was to o b usy at th e tim e b u t w o u ld n ’t m in d getting to g eth e r to study so m etim e closer to the test, I agreed. I offered to exchange n u m b ers, b u t she said we could wait u n til closer to the test. We said goodbye, an d I left. Step 4. D escribe how th e event cam e o u t for you: T he in te rac tio n seem ed som ew hat positive, b u t no clear progress was m ade d u rin g the exchange in term s o f creating fu rth e r in te rac tio n in th e fu tu re, w hich was disap p o in tin g . Step 5. D escribe how you w an ted th e event to com e o u t fo r you: 1 w ould have liked for th e in te rac tio n to indicate m u tu a l in te r­ est a n d a ttra c tio n on b o th o u r p a rts a n d to have clearly d e m o n ­ stra te d th a t fu rth e r close in te rac tio n was likely. T ra n s c rip t 2 (several m o n th s in to therapy) Step 1. D escribe w h at h appened: 1 called so m eo n e w ho re sp o n d ed to a n e-m ail I h a d sent, a n d we talked for aw hile b u t d id n ’t en d u p going o u t th a t night. Step 2. D escribe y o u r in te rp re ta tio n s o f w hat h appened: I really w a n t to go o u t w ith som eone. I c ould set s o m e th in g up for later in the w eek. I’m a little nervous. I’m expecting trouble. I ’m n erv o u s an d could choose to be calm to help m e ask h er o u t. D o n ’t be tim id. Be aw are o f m y a ttitu d e so I d o n ’t self­ defeat. I’m calm an d pleasant. T his is going okay so far. She can’t go o u t to n ig h t, b u t we can m ake plans for a n o th e r tim e.

PERSONALITY DISORDER NOT OTHERWISE SPECIFIED

Step 3. Describe w hat you did du rin g the situation: I picked up the ph o n e to call this w om an after getting back from class. I hesitated w ith the phone in m y h and for a few sec­ onds because I had becom e a little nervous and scared at the th o u g h t o f m aking the call. I rem inded m yself not to act tim id and m ade the call. W hen she picked up, I said hello, asked how she was doing, and briefly talked about how I had just moved. We chatted about m ovies for a couple o f m inutes. I noticed th at I d id n ’t sound nervous, m y voice sounded calm and at ease, b u t I noticed th at we accidentally spoke at the same tim es a couple tim es I thin k because I was nervous o n the inside. I asked her if she’d like to go o u t that night. She said she had plans. Step 4. Describe how the event cam e o u t for you: I tried to get together w ith som eone that night, b ut it d id n ’t w ork out. Step 5. Describe how you w anted the event to com e out for you: I w anted to get together w ith som eone that night.

P rogress

Improvement was observed following several more months o f prac­ tice using the CSQ and a willingness by Sam to make attempts at expressing his attraction or acknowledging his anger. Specifically, Sam learned that by acknowledging and expressing these emotions that he had labeled as negative, he reduced his anxiety during situ­ ations, was able to achieve his goals rather than thwart them, and felt less guilt and distress over situations in which his DO was not achieved. After approximately 1 year o f treatment, Sam’s dysthymic symp­ toms were in remission, and many of his schizotypal and avoidant personality symptoms had improved. During the following 5 months, the CBASP treatment approach remained unchanged with the goal of ensuring maintenance of symptom reduction and increasing com ­ fort with his new social skills and moderated philosophical beliefs. After 17 months of treatment, Sam requested that therapy be termi­ nated. He felt that he had met his goals of reducing dysthymic symp­ toms and establishing a social network. Sam stated that he had learned the skills necessary to maintain his positive gains on his own.

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F urtherm ore, w ith respect to the CSQ, he stated th at he “did it a u to ­ m atically in his h e ad ” and no longer felt the need to com plete the form s in therapy. At term in atio n , Sam did n o t have diagnoses on Axes I, II, III o r IV and his Global Assessm ent o f F unctioning rating was 85.

OBSTACLES TO TREA TMEN T We have used CBASP to treat patients w ith PD NO S and have seen im provem ent in m any personality sym ptom s. Despite these im prove­ m ents, several difficulties often arose d u rin g the course o f trea tm e n t and are likely to be e ncountered in o th er settings w hen treating these patients w ith v arious p ersonality d isorder features. O ne o f the earliest difficulties therapists are likely to en co u n ter in using the CSQ is the intrinsic cognitions associated w ith personality disorders. Patients w ith personality disorders have dysfunctional beliefs th a t are e n ­ trenched in their cognitive organization and thus require significant tim e and effort to m odify. F u rth erm o re, m any personality-disordered patients do n o t regard their personality traits as dysfunctional unless they are asso­ ciated w ith o th er sym ptom s, such as depression o r suicidal sym ptom s (Beck & Freem an, 1990). A n other difficulty in treating PD NOS is choosing th o u g h ts a n d behav­ iors to prioritize w ith the CSQ. W hereas th o u g h ts related to helplessness, hopelessness, and assertiveness are consistently chosen as m atters o f in te r­ vention for the trea tm e n t o f patients w ith depressive disorders, it can often be unclear how to prioritize the th o u g h ts and behaviors o f PD NOS patients w ho present w ith sym ptom s o f several personality disorders. As the trea tm e n t o f these patients evolved in o u r clinic, it becam e evident that a clear conceptualization o f the p a tie n t’s personality sym ptom s was neces­ sary to target the th o u g h ts and behaviors th at m ost severely im paired the patient. After determ ining which th o u g h ts and behaviors to target, it is essential th at therapists m ake it a p rio rity because m any patients have diffi­ culty generating th o u g h ts and behaviors to include in the CSQ, o r they generate th o u g h ts and behaviors th at are unrelated to it. A th ird difficulty in using the CSQ relates to the m anagem ent o f in te r­ personal difficulties betw een the therapist and patient, potentially inherent in any therap eu tic relationship and particularly salient in personalitydisordered patients. For exam ple, w ith an individual w ith p aran o id fea­

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tures, it m ay be necessary to spend m ore tim e establishing a high level o f tru st before asking him o r h e r to share, in m in u te detail, the specific c o n ­ ten t o f th o u g h ts and actions. Similarly, it is necessary for the therapist to resist the tem p tatio n to generate the entire c ontent o f the CSQ for an in d i­ vidual w ith d ependent features. For an individual w ith schizotypal fea­ tures, it is im perative th at therapists be aware o f the im pact the patien t is having on them , including frustration, confusion, o r annoyance, and to use these feelings and th o u g h ts as targets o f intervention rath er than allowing th em to disengage the therapists. A fo u rth potential obstacle in treating patients w ith PD NOS using the CSQ is the generation o f alternative th o u g h ts and behaviors th at are bo th suitable to the p atient and socially acceptable. By definition, the diagnosis o f any personality disorder im plies th at an individual d em onstrates an e n during, pervasive, and inflexible p attern o f in n er experience and behav­ ior th at deviates from norm s. D ue to the pervasiveness a n d rigidity o f these sym ptom s, patients w ith personality disorders m ay be resistant to change and m ay feel sadness, confusion, o r discom fort over the loss o f beliefs and behaviors th at have been so familiar. C onsequently, the therapist m ust keep in m in d th at th ro u g h the course o f therapy, a patien t is likely to u ndergo a type o f role tran sitio n th at is accom panied by fear, sadness, and adju stm en t to the new pattern s o f behavior. For exam ple, in the case study presented previously, Sam, a patien t w ith a diagnosis o f PD NOS w ith schizotypal and avoidant features, was faced w ith challenging deeply ingrained philosophical beliefs on which he based m uch o f his behavior. Acknow ledging th at som e o f the behaviors were interfering w ith his strong desire for social intim acy led to grief over the loss o f his old beliefs and behaviors. T herefore, for patients w ith PD NOS, it is essential to m anage grief or discom fort at the loss o f certain pattern s o f behavior w hile e n co u r­ aging the developm ent o f new skills th at will help in achieving DOs.

T he use o f the CSQ trea tm e n t approach was successful w ith Sam. T he in fo rm atio n presented in this chapter is a case study, representing a m ere beginning to consistent successful trea tm e n t o f patients w ith PD NOS. T his specific exam ple, however, d em onstrates th at application o f the CBASP technique m ay be useful in altering the deeply ingrained, persist­ ent, m aladaptive thou g h ts a n d behaviors present in personality-disordered patients. F urtherm ore, patients w ith PD NOS often present m any in te r­

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p erso n al an o m alies th a t m ake efficiency a n d consistency o f tre a tm e n t difficult to m a in ta in , th ereb y decreasing tre a tm e n ts’ effectiveness. T he CBASP tec h n iq u e, how ever, m ay im p ro v e tre a tm e n t efficiency in this g ro u p by p ro v id in g a consisten t stru c tu re a n d a p redictable th era p e u tic agenda. A lthough fu tu re research is still needed to em p irically validate the efficacy o f the CBASP tec h n iq u e for p a tie n ts w ith PD N O S, the in itial fin d ­ ings in o u r clinic suggest th a t successful tre a tm e n t a n d m ain ten a n ce o f tre a tm e n t gains in these p a tie n ts is in d ee d possible.

PART

II

A nxiety Disorders

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Chapter

Social Anxiety D isorder and Avoidant Personality Disorder*

This chapter demonstrates how the Cognitive Behavioral Analysis Sys­ tem of Psychotherapy can be easily incorporated, and in fact dovetails nicely, with existing empirically validated treatm ents for social anxiety disorder (e.g., exposure). Moreover, the incremental efficacy of inte­ grating the present approach is depicted in the transcripts of actual therapy sessions with Fred, a 19-year-old with severe social anxiety and comorbid depressive symptoms. The Cognitive Behavioral Analysis System of Psychotherapy effectively targeted the specific behaviors and cognitions that contributed to Fred’s long-term avoidance of social in­ teractions, until his desired outcome of either endured or thwarted anxiety was regularly attained across a variety of interpersonal con­ texts. A discussion of com m on problems and difficulties in treating this pernicious, but treatable, condition is also provided.

As recently n o ted by Barlow, Raffa, a n d C o h en (2002), Social A nxiety D iso rd e r (SAD) m ay be th e m o st p re v alen t anxiety d iso rd e r (lifetim e prevalence o f 13%) a n d the th ird m o st prev alen t o f all m ental disorders. A ccording to th e D iagnostic and Statistical M a n u a l o f M ental D isordersFourth Edition (D S M -IV ; A m erican Psychiatric A ssociation, 1994), SAD has a typical o n se t in m idadolescence w ith a co n tin u o u s course a n d lifelong d u ra tio n if u n tre a te d . It is m o re c o m m o n in w o m en th a n in m en in c o m ­ m u n ity sam ples. SAD involves “a m ark ed a n d p e rsisten t fear o f o n e o r m o re social o r p e rfo rm a n ce situ atio n s in w hich th e p erso n is exposed to u n fa m il­ iar p eople o r to possible sc ru tin y by o th e rs” (A m erican Psychiatric A ssoci­ *The primary authors contributing to this chapter were Bradley A. White, Kelly C. Cukrowicz, and Ginnette C. Blackhart.

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a tio n , 1994, p. 416). Ind iv id u als w ith SAD also fear h u m ilia tio n o r e m b a r­ ra ssm e n t a n d usually experience anxiety an d , som etim es, p anic attacks u p o n exposure to feared social situ atio n s. A dults w ith SAD recognize th a t th e ir fear is u n re aso n a b le o r exaggerated. N evertheless, th ey typically avoid o r e n d u re feared situ atio n s w ith intense a n x io u s a n tic ip a tio n o r distress, w hich interferes significantly w ith th e ir n o rm a l fu n c tio n in g in social, aca­ dem ic, o r o c cu p a tio n a l realm s. In such individuals, this fear is n o t b e tte r a ttrib u te d to m edical c o n d itio n s, substance abuse, o r to o th e r m en ta l d iso r­ ders (A m erican Psychiatric A ssociation, 1994). F requently c o m o rb id d is­ o rd e rs in clu d e specific ph o b ias, a g o rap h o b ia, generalized anxiety disorder, substance abuse, m ajo r depression, dysthym ia, a n d obsessive-com pulsive d iso rd e r (Schneier, Jo h n so n , H o rn ig , L iebow itz, & W eissm an, 1992). SAD is specified as generalized if th e fears in clu d e m o st social situ atio n s. In such cases, A voidant P ersonality D iso rd e r (A PD ) is c onsidered as an a d d itio n al d iagnosis o n Axis II. A ccording to th e D S M - I V (A m erican Psy­ ch ia tric A ssociation, 1994, p. 664), A PD is ch aracterized by “a pervasive p a tte rn o f social in h ib itio n , feelings o f inadequacy, a n d hypersensitivity to negative evaluation, b e g in n in g by early a d u lth o o d and p re sen t in a variety o f contexts.” At least fo u r features m u st be present, in clu d in g avoidance o f activities th a t co u ld result in criticism , rejection, o r disapproval; fear-based re stra in t in in tim a te relationships; p re o cc u p atio n in social situ atio n s w ith criticism o r rejection; in h ib itio n in new social situ atio n s; a self-view as socially inep t, inferior, o r unappealing; a n d a reluctance to take risks o r engage in new activities d u e to fear o f e m b a rrassm en t. D ebate is on g o in g reg ard in g th e rela tio n sh ip betw een SAD (p a rticu la rly th e generalized type) a n d A PD a n d tre a tm e n t o u tco m e (e.g., B row n, H eim b erg , & Juster, 1995). H erein, we regard generalized SAD a n d A PD as essentially id entical w ith regard to tre a tm e n t im plications. T he interested read er is referred to o th e r sources fo r in fo rm a tio n o n th e etiology o f SAD (e.g., B arlow et al., 2002; Beck & F reem an, 1990; H o p e & H eim b erg , 1993; Schlenker & Leary, 1982).

E X I S T I N G T R E A T M E N T S F OR S A D A N D A P D T he m o st effective psychosocial tre a tm e n t fo r SAD is c o m b in e d exposure a n d cognitive b ehavioral th e ra p y (CBT; B arlow et al., 2002). B arlow a n d colleagues suggest th a t ex p o su re is th e crucial elem en t a n d th a t cognitive exercises en h an ce the effects o f exposure. We c o n c u r a n d describe how the C ognitive B ehavioral Analysis System o f P sychotherapy (CBASP; M cC ul­ lo u g h , 2000) is a useful a d ju n c t to exposure. E xposure involves rep eated

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c o n fro n ta tio n w ith th e feared situ atio n , in vivo w ith n a tu ra l stim uli, via im aginai exercises, o r th ro u g h role plays, u n til h a b itu a tio n o f th e anxious response occurs (B arlow et al., 2002), w hereas th e cognitive aspect o f tra d i­ tio n al CBT em phasizes the identification, evaluation, a n d m o d ific atio n o f logically d isto rte d , a n x ie ty -in d u c in g th o u g h ts. A g ro u p version o f CBT for SAD (C ognitive B ehavioral G ro u p T herapy, o r C B G T ), d escrib ed later, has also b een sh o w n to be effective (H o p e & H eim berg, 1993). A lth o u g h social skills tra in in g a n d relax atio n tec h n iq u es (e.g., p ro g res­ sive m uscle relaxation) have n o t b een show n to o n th e ir ow n successfully trea t SAD, th ey m ay be useful a d ju n c ts w hen exposure a n d CBT are c o m ­ b in ed . Less research has b een c o n d u cted o n psychosocial in te rv en tio n s for the tre a tm e n t o f APD, a lth o u g h g ro u p -a d m in iste re d behav io ral in te r­ v en tio n s involving ex p o su re o r social skills tra in in g have received som e s u p p o rt (C rits-C h risto p h & Barber, 2002). Several pharm aco lo g ical tre a tm e n ts also exist for SAD, w ith selective se ro to n in reu p tak e in h ib ito rs receiving the m o st scientific s u p p o rt and sh ow ing few er side effects th a n m o n o a m in e oxidase in h ib ito rs, tricyclic an tid e p re ssan ts, b en zo d iazap in es, o r b eta blockers (R oy-B yrne & Cowley, 2002). H ow ever, th ere is little research o n lo n g -te rm efficacy o f p h a rm a ­ cological in te rv en tio n s for SAD (R oy-B yrne & Cowley, 2002), an d th ere are n o c o n tro lled stu d ies o f p h a rm a c o th e ra p y specifically fo r A PD (K oenigsberg, W oo-M ing, & Siever, 2002). P h arm acological a n d psychosocial in te r­ v entions su ch as CBASP are n o t necessarily m u tu a lly exclusive a n d can even w o rk synergistically (Keller et al., 2000). H ow ever, q u e stio n s re m a in as to w h e th er a n tia n x ie ty m ed ic atio n s interfere w ith psychosocial in te r­ v en tio n s fo r SAD, a n d H o p e a n d H eim b e rg (1993) re co m m e n d th a t p a ­ tie n ts reduce o r at least stabilize intake o f a n tia n x ie ty m ed ic atio n s u n d e r a physician’s su p e rv isio n before u n d e rta k in g CBGT. We re c o m m e n d th at th era p ists stay abreast o f p a tie n ts’ m ed ic atio n s a n d air concerns w hile d eferrin g to p rescribers as arb iters o f change to m ed ic atio n regim ens.

C B A S P AS A SEPARATE OR S U P P L E M E N T A L TREATMENT A lthough o u r p ro p o sitio n s m u st aw ait em pirical valid atio n , th ere are a n u m b e r o f reasons to a n ticip ate in crem en tal efficacy an d use o f in teg ratin g the prin cip les a n d p ro ced u res o f CBASP w ith established psychosocial a n d pharm aco lo g ical tre a tm e n ts o f SAD a n d APD. First, CBASP has recently b een show n to be a highly efficacious fo rm o f cognitive behav io ral th era p y

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for tre a tm e n t-re sista n t c h ro n ic depression, p a rticu la rly w hen co m b in ed w ith p h a rm a c o th e ra p y (Keller et al., 2000). Second, th e h ig h c o m o rb id ity o f anxiety a n d dep ressio n suggests th a t these d iso rd ers m ay share c o m ­ m o n etiological m ech an ism s, a n d th ey seem to be sim ilarly responsive to p a rtic u la r in te rv en tio n s (CBT a n d b ehavioral a ctiv atio n /ex p o su re). T h ird , CBASP’s em phasis o n evaluating in te rp re ta tio n s based on personal goals (fu n ctio n ality vs. veridicality, p e r tra d itio n a l CBT) seem s p a rticu la rly likely to help p a tie n ts w ith SAD a n d A PD to reduce self-criticism and develop g reater se lf-d eterm in atio n (R yan & Deci, 2000). F o u rth , socially an x io u s ind iv id u als ten d to u n d e restim ate successes a n d th ereb y m iss valuable positive experiences. U sing CBASP to exam ine success situ atio n s in w hich D esired O u tc o m e s (D O s) are achieved can fu rth e r stim u late selfefficacy beliefs a n d m o tiv a tio n . Fifth, socially an x io u s in dividuals te n d to u n p ro d u c tiv ely focus o r shift a tte n tio n in a biased o r unsystem atic fashion, fu rth e r e xacerbating an x io u s arousal. M astery o f CBASP helps replace this h a b it w ith a m o re prod u ctiv e, system atic, p ro b lem -so lv in g ap p ro ach . Finally, CBASP em phasizes social p ro b lem s a n d in te rp erso n al re la tio n ­ ships, th e p rim a ry realm s affected in SAD and APD.

A P P L Y I N G C B A S P TO T H E T R E A T M E N T OF S A D A N D A P D T he fu n d a m e n ta l tec h n iq u es o f M cC ullough’s (2000) CBASP fo r c h ro n ic dep ressio n are applicable to p a tie n ts w ith SAD a n d APD, a n d th e general fo rm a t for th e C o p in g Survey Q u e stio n n aire (CSQ ) elicitatio n a n d re m e ­ d iatio n phases is th e sam e. H ow ever, c ertain m o d ificatio n s a n d ap p lic a ­ tio n s o f CBASP ap p ea r to en h an ce in te rv en tio n for SAD a n d APD. For the sake o f c h ap ter o rg a n iz atio n , we co n sid er b o th elicitation a n d re m e d ia tio n phases in th e sam e section for each step o f th e CSQ . H ow ever, it is im p e ra ­ tive to teach p a tie n ts to system atically co m p lete th e full elicitation phase o f each CSQ p rio r to b e g in n in g th e re m e d ia tio n phase, follow ing tra d itio n a l CBASP.

Preliminary Interventions T he e la b o ratio n a n d re m e d ia tio n o f CSQ s requires focused c o n ce n tra tio n , p a rticu la rly before the tec h n iq u e has b ecom e a u to m a tic. A nxious arousal interferes w ith c o n c e n tra tio n , a n d p a tie n ts w ith SAD a n d A PD m ay have difficulty focusing o n CSQ w o rk w hen th ey are experien cin g anxious arousal invoked by th e th e ra p is t’s presence, th e recall o f distressing s itu ­

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ations, o r generalized w orry. T herefore, we so m etim es find it helpful to teach p a tie n ts to practice sta n d a rd relax atio n exercises (e.g., b re ath in g , im agery, o r progressive m uscle relaxation) th a t th ey can em p lo y to regulate th e ir em o tio n al state an d achieve a m in d se t conducive to c o m p letin g CSQs.

Sit uat i ons T he first step o f the elicitatio n phase o f the CSQ req u ires the p a tie n t to describe a tem p o rally discrete, specific situ atio n . P erfo rm an ce evaluation and in te rp e rso n a l situ atio n s are usually th e m o st distressing to in dividuals w ith SAD a n d APD, a n d th u s th ey are a m o n g th e best cand id ates for use w ith th e CSQ in th e tre a tm e n t o f these d isorders. Such situ atio n s include, b u t are n o t lim ited to, public speaking o r p e rfo rm in g , in itiatin g a n d engag­ ing in conversations, d a tin g , in te rac tin g w ith a u th o rity figures, a tte n d in g p arties o r social events, using p u b lic re stro o m s, w ritin g o r eating in public, exercising o r playing sp o rts, in terview ing, sh o p p in g , b eing assertive o r expressing o p in io n s, a n d dealing w ith conflicts. Such situ a tio n s are also useful to co n sid er in p a tie n ts’ c o n stru c tio n o f fear h ierarch ies a n d e x p o ­ sure assignm ents, w hich are described later. P atients w ith SAD a n d A PD ten d to u n d e re stim a te a n d u n d e rre p o rt the freq u en cy o f positive social experiences a n d to d isc o u n t th e ir influence in success situ atio n s, in w hich anxiety was th w a rte d o r e n d u re d so th at D O s w ere a ttain ed . It is im p o rta n t to tra in socially a n x io u s p a tie n ts to be o n the lo o k o u t for, a n d to co m p lete CSQ s, for success situ atio n s as well as for s itu ­ a tio n s in w hich D O s w ere n o t a tta in e d . D o in g so helps p a tie n ts recognize th era p e u tic gains, overcom e the h a b it o f d isc o u n tin g th e positive, and identify in te rp re ta tio n s a n d b ehaviors th a t h elped th e m achieve th e ir D O s a n d m anage th e ir anxiety. D ue to extensive avoidance, p a tie n ts w ith generalized SAD a n d APD often have in freq u e n t o r restricted experience w ith n a tu ra l social s itu ­ ations. W ith such patien ts, CSQ s m ay initially focus alm o st exclusively on in-session role plays a n d in vivo exposure h o m ew o rk assignm ents, w hile p a tie n ts w ork to find ways to increase the frequency o f n a tu ra l social en co u n ters.

Si tuati onal Int erpret at i ons In the second step o f th e elicitation phase o f the CSQ , p a tie n ts identify sev­ eral in te rp re ta tio n s o f the situ atio n at the tim e it o ccu rred . W hen asking th e p a tie n t w h a t the event m e a n t to h im o r her, it can be helpful fo r the

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th era p ist to be aw are o f th e general in te rp re ta tio n p a tte rn s o f socially a n x ­ ious individuals. In d iv id u als w ith SAD a n d A PD are freq u en tly p erfectio n istic, pessim istic, hyperv ig ilan t fo r th re a t cues, hypersensitive to criticism a n d rejection, d e p e n d e n t, self-deprecating, a n d low in self-esteem , distress tolerance, a n d acceptance o f self a n d others. T hey m ay m ake global ju d g ­ m en ts o f self-w orth based o n p erfo rm a n ce . T hey are also p ro n e to m any o f th e cognitive d isto rtio n s th a t are labeled in tra d itio n a l CBT, in clu d in g fo rtu n e telling, m in d reading, a ll-o r-n o th in g th in k in g , p e rso n alizatio n , o v ergeneralization, m ag n ificatio n a n d m in im iz a tio n , a rb itra ry inference, c atastro p h ic a n d pro b ab ilistic th in k in g , and u n d e re stim a tio n o f social skills. M cC ullough (2000, Table 6.3, p. 122) a n d Beck and F reem an (1990) pro v id e excellent reviews o f a d d itio n al cognitive th em e s relevant to p a ­ tie n ts w ith SAD a n d A PD th a t can affect a tta in m e n t o f DO s. D u rin g the re m e d ia tio n phase, p a tie n ts evaluate a n d revise irrelevant a n d in accu rate in te rp re ta tio n s based p rim a rily on th e m ain c rite rio n — “D id this in te rp re ta tio n help o r h u r t th e a tta in m e n t o f m y desired o u t­ com e?” P atients m ay also evaluate in te rp re ta tio n s w ith regard to th e fol­ low ing q uestions: “W as this relevant?” a n d “ D id it reflect w h a t was actually h a p p e n in g in th is situ atio n ? ”

Ad di t i onal Step: Subjective Uni t s o f Di st res s Scale W h en using CSQ s in th e tre a tm e n t o f SAD, it can be useful to also elicit from p a tie n ts the subjective level o f anxiety co rre sp o n d in g w ith each in te r­ p re ta tio n as it occu rred . T his a d d itio n helps p a tie n ts see th e link betw een th o u g h ts a n d e m o tio n s, a n d it p rovides a sim ple way to q u a n tify an d m o n ­ ito r progress in red u cin g anxiety sy m p to m s. A c onvenient m easu re for this p u rp o se is th e Subjective U nits o f D istress Scale (SU D S) ratin g s (W olpe & Lazarus, 1966), used regularly in CBGT. Patients assign a n u m erical value to th e ir anxiety on a 100-point scale th a t has reference p o in ts at 25 ( m ild anxiety), 50 ( m oderate; beginning to have difficulty concentrating), 75 (high; thoughts o f escaping), a n d 100 p o in ts ( worst an x ie ty ever experienced or im aginable). As in CBGT, p a tie n ts can be tra in e d to give SUDS ratin g s at v ario u s intervals d u rin g in-session exposures as well, as discussed later.

Si tuati onal Behavi or In the next step o f th e elicitation phase, p a tie n ts are asked to describe th eir beh av io rs in th e situ atio n , in clu d in g b o th w hat th ey did a n d how they did it (e.g., to n e a n d vo lu m e o f voice, p o stu re , m an n e rism s, facial expressions).

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T he m o st c o m m o n p ro b lem atic beh av io rs associated w ith SAD a n d APD are p a rtial o r co m plete avoidance, escape, a n d safety behaviors; unassertive o r passive-aggressive actions; excessive reassurance seeking; social skill im p le m e n ta tio n deficits; a n d su b stan ce use. T hese b ehaviors m ay be very subtle, soph isticated , a n d a u to m a tic, o c cu rrin g o u tsid e the p a tie n ts’ aw are­ ness. T he th era p ist sh o u ld w atch for u ndisclosed details a n d have p a tie n ts reen act th e ir situ atio n al b e h av io r in session w henever necessary. C o m m o n exam ples o f g o a l-in terfe rin g b e h av io r include b eing m entally d istracted (in clu d in g w o rry in g over task -irre le v a n t m atters), p ro c ra stin atin g , busying on eself w ith w ork, o v e rp re p a rin g o r rehearsing, re ad in g o r w earing h e a d ­ p h o n e s, always a tte n d in g events w ith a frien d , o r h id in g signs o f anxiety (blushing, avoiding eye c o n ta ct) w ith m akeup, hair, cloth in g , o r sunglasses. In th e re m e d ia tio n phase, th e p a tie n t d e te rm in e s w h e th er b ehaviors m u st be replaced o r a d d ed to increase the o d d s o f a tta in in g the DO. Socially a n x io u s p a tie n ts often have at least a good co n cep tu al grasp of, if n o t practice w ith, helpful behaviors, a lth o u g h they m ay fear the po ten tial consequences o f try in g o u t these beh av io rs in a new situ atio n . At o th er tim es, how ever, th ere exists a tru e skill o r im p le m e n ta tio n deficit, p a r­ ticu larly in p a tie n ts w ith generalized SAD a n d APD, w hose social skill re p erto ire m ay be u n d e rd ev e lo p e d across social settings d u e to extensive avoidance. In e ith er instance, after verbal re m e d ia tio n o f behaviors o n th e CSQ , it can be very helpful to have the p a tie n t rehearse desirable b ehaviors via role play, w ith th e th e ra p ist m o d elin g a p p ro p ria te beh av io rs first if n e c ­ essary. T h era p ists sh o u ld illu m in a te d istin c tio n s b etw een passive ( o th e r’s needs over o n e ’s o w n ), assertive (b o th ow n a n d o th e r’s needs considered) a n d aggressive (ow n needs over o th e r’s) b e h av io r because socially an x io u s p a tie n ts often confuse passivity w ith b ein g nice a n d assertiveness w ith b eing aggressive o r m ean.

De si r ed Ou t c o m e s T he next a n d arguably m o st im p o rta n t step in CSASP involves clearly specifying th e D O in th e situ atio n . W h en asking socially an x io u s p eople how th ey w a n t the situ atio n to com e o u t, it is crucial th a t the p a tie n t id e n ­ tify a n d select only o n e D O a n d state it in objective, specific, observable term s. To e n su re th a t the latter re q u ire m e n ts are m et, th e th e ra p ist can ask, “H o w w o u ld an observer know th a t you had a tta in e d y o u r desired o u t­ come? W h at w o u ld he o r she see?” In tra d itio n a l CBASP, p a tie n ts are asked to specify a single D O at the tim e o f th e situ atio n . How ever, p a tie n ts w ith SAD a n d A PD som etim es

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generate D O s th a t redu ce anxiety in th e s h o rt term , via escape o r avoidance, b u t conflict w ith lo n g -te rm objectives, su ch as b e co m in g m o re co m fo rtab le in sim ilar situ atio n s over tim e o r learn in g to e n d u re som e d isc o m fo rt to p u rsu e p erso n al goals. Because o n ly o n e D O can be a tta in e d for any s itu ­ a tio n , SAD o r A PD p a tie n ts m u st learn to p rio ritize lo n g -te rm D O s over p o ten tially conflicting sh o rt-te rm goals, such as always m ak in g favorable im pressions, w in n in g social approval, p e rfo rm in g perfectly, o r im m ediately re d u cin g o r h id in g anxiety sy m p to m s. T he th era p ist can s u p p o rt the p a ­ tie n t in this end eav o r by m a in ta in in g a n o n c o n fro n ta tio n a l a p p ro a c h a n d e m p a th iz in g w ith the p a tie n t’s im m e d ia te goals, w hile e n co u ra g in g the p a tie n t to co n sid er his o r h e r lo n g -te rm goals to e n su re th a t these are b e ­ ing served by th e D O th e p a tie n t g enerated. As M cC ullough (2000) n o ted , p a tie n ts typically com e to recognize on th eir ow n th e u n a tta in a b ility o f u n ­ realistic o r co nflicting D O s after repeated practice w ith CSQ s. O n the o th e r h a n d , we find th a t it is beneficial to explain to p a tie n ts (a n d su b seq u en tly elicit from th em th ro u g h exam ples) the benefits o f to le ratin g th e s h o rt­ te rm d isc o m fo rt o f exposure to a n x iety-invoking situ atio n s fo r th e sake o f lo n g -te rm p erso n al goals, in clu d in g increased c o m fo rt in social situ atio n s.

A c tu a l O u tc o m e s In the last step o f the CSQ elicitation phase, p a tie n ts generate a single, observable A ctual O u tc o m e (AO ) for th e situ a tio n th a t is a n ch o re d in tim e a n d sta te d in objective behav io ral term s, ra th e r th a n am b ig u o u s o r e m o ­ tio n al term s (a lth o u g h it can be acknow ledged verbally o r w ith ad d itio n al SUDS ratings th a t feelings usually acco m p an y objective o u tco m e s). D ele­ terio u s consequences o f avo id an t o r unassertive b ehaviors sh o u ld be ex­ p lo red if th e p a tie n t is n o t fo rth co m in g , for instance, by asking “W h at else cam e o u t o f this situ atio n ? ” P atients are th en asked to co m p a re th e AO to th e D O to d e te rm in e w h e th er the D O was achieved.

A p p lic a tio n o f D O s to E x p o s u re a n d A n x ie ty -R e d u c tio n G o a ls A n o th e r p o ten tial m o d ific atio n to th e tra d itio n a l use o f CBASP in the tre a tm e n t o f SAD a n d A PD is th e a p p lic atio n o f CSQ s to plan fo r a n d m o n ito r exposure assignm ents. H a b itu a tio n a n d lo n g -te rm anxiety re d u c ­ tio n is m o st effective w hen the in d iv id u al rem ain s in the ex p o su re s itu ­ a tio n s lo n g e n o u g h to no tice a re d u c tio n in th e ir anxiety. E xposure assign­

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m en ts are typically based o n a fear h iera rch y list created by th e p a tie n t, sta rtin g w ith exposure to situ atio n s th a t are identified as causing only slight d isc o m fo rt a n d grad u ally progressing over tim e to w a rd situ atio n s at the to p o f th e hierarch y (i.e., those th a t cause tre m e n d o u s d isc o m fo rt). Regular SUDS ratings can help th e th era p ist a n d p a tie n t m o n ito r for suffi­ cient h a b itu a tio n in b o th sim u la ted a n d in vivo exposure situ atio n s. It m ay at tim es be desirable for th e p a tie n t to define D O s in term s o f re m a in in g in th e ex p o su re situ atio n u n til h e o r she reaches a targ e t SUDS level. H ow ever, it is very im p o rta n t th a t th e D O focus on b eh av io ral ele­ m en ts, such as staying in th e ex p o su re situ atio n , p e rh ap s fo r a p re d e ­ te rm in e d m in im u m a m o u n t o f tim e (e.g., 20 m in ), ra th e r th a n vaguely d efining the D O as th e a tta in m e n t o f a p a rtic u la r SUDS level o r feeling, such as “n o t being anxious.” C o n siste n t w ith the tra d itio n a l CBT m odel, we view em o tio n al change (in clu d in g anxiety re d u c tio n ) as th e p ro d u c t o f changes in in te rp re ta tio n s a n d behavior. O verfocusing a tte n tio n a n d effort o n the im m e d ia te co n tro l o r re d u c tio n o f a n x io u s feelings is n o t only m is­ directed, b u t also it can have th e paradoxical effect o f in creasing o n e ’s d is­ tress, to w hich m an y p a tie n ts w ith social anxiety can attest. Instead, we favor D O s th a t em phasize a proactive a p p ro a c h to w ard o n e ’s p erso n al goals despite anxiety, w hile allow ing on eself to experience in an accepting, n o n ju d g m e n ta l fashion w hatever feelings o n e is having at the tim e. T his view is c o n sisten t w ith m o d e rn m in d fu ln ess/accep tan ce-b ased ap p ro ach es to CBT fo r o th e r disorders, in clu d in g G eneralized A nxiety D isorder, w hich often coincides w ith SAD a n d A PD (e.g., L inehan, 1993a; R oem er & O rsillo, 2002). As p a tie n ts m ay confuse acceptance w ith giving up a tte m p ts to change, it can be h elpful to clarify d istin c tio n s b etw een d e m a n d in g /c a t­ astro p h ic, a cc ep tin g /to lera n t, a n d resigned/acquiescent stances. A lbert Ellis’ (2001) ra tio n al em otive a p p ro ac h o f rew o rd in g “sh o u ld ” a n d “m u s t” in te rp re ta tio n s (e.g., “ I sh o u ld /m u s t n o t feel a n x io u s”) as “like” a n d “p re ­ fer” sta te m en ts (e.g., “I w o u ld like/prefer to feel less a n x io u s”) is highly consisten t w ith a n d a p p ro p ria te for accep ta n ce -o rie n ted CSQ in te rp re ta ­ tio n re m e d ia tio n for p a tie n ts w ith SAD a n d APD.

C o m p a rin g A O s a n d D O s a n d R e m e d ia tio n M cC ullough’s (2000) CBASP re m e d ia tio n phase is largely u n m o d ifie d for th e tre a tm e n t o f SAD a n d APD. Patients are asked, “ D id you get w h a t you w an ted in this situ atio n ? ” A lthough the answ er to this q u e stio n m ay ap p ea r self-evident, having p a tie n ts explicitly acknow ledge it crucially illu m in ates

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th e m atc h o r discrep an cy b etw een AO a n d DO , as well as the p a tie n ts’ resp o n sib ility for a tta in m e n t o f th e ir p erso n al goals, m o tiv a tin g th em to w a rd change. D u rin g th e re m e d ia tio n phase, p a tie n ts are asked to exam ine each in te r­ p re ta tio n in term s o f relevancy to th e situ atio n , accuracy, a n d , especially, w h e th er a n d how it help ed o r im p e d e d the p a tie n t in o b tain in g the DO. T he sam e p ro c ed u re is repeated next w ith each situ atio n al behavior. If an u n a tta in a b le o r unrealistic D O is identified along the way, th e p a tie n t is asked to revise it a ccording to th e guidelines described earlier before p r o ­ ceeding. A lth o u g h it can be very te m p tin g to answ er re m e d ia tio n q u estio n s for th e p a tie n t o r argue w ith th e ir responses, d o in g so defeats th e collabo­ rative a n d a g en c y -p ro m o tin g benefits o f th e CBASP ap p ro ach . A fter labeling each in te rp re ta tio n a n d b ehavior as helpful o r h u rtfu l, p a tie n ts revise o r a d d in te rp re ta tio n s a n d b ehaviors to increase th e likeli­ h o o d o f atta in in g th e DO . If social skills deficits are identified, the p a tie n t can be g uided to w ard several p o ten tial alternative b ehaviors, asked how these m ig h t affect th e likelihood o f achieving th e D O , a n d en co u ra g ed to rehearse selected beh av io rs follow ing th e th e ra p is t’s lead. A fter the re m e d i­ a tio n phase is c om pleted, it can also be w orth w h ile to briefly discuss g e n ­ eral p a tte rn s (e .g .,“ H ow does this p a tte rn apply to sim ilar situ atio n s yo u ’ve experienced?”).

A p p lic a tio n o f C B A SP to C B G T In a d d itio n to its a p p lic atio n to in d iv id u a l tre a tm e n t, we fo u n d th a t CBASP is easily m odified fo r use in c o n ju n c tio n w ith C B G T fo r SAD, developed by H o p e a n d H eim b e rg (1993). T his em pirically su p p o rte d tre a tm e n t involves in-sessio n ex p o su re exercises, tra d itio n a l cognitive re stru c tu rin g exercises, a n d progressive in vivo ex p o su re assignm ents a d m in istere d in a g ro u p fo rm at. At the F lorida State U niversity Psychol­ ogy C linic, we have b eg u n to in te g rate CBASP w ith CBG T to e n h an c e p a tie n t m o tiv a tio n a n d acceptance. In a d d itio n to g ro u p sessions, m e m ­ bers typically a tte n d weekly in d iv id u al th e ra p y sessions, in w hich th ey learn the fu n d a m e n ta ls o f CBASP (illustrated later in o u r case exam ple). In g ro u p sessions, p a tie n ts are asked to iden tify th e ir D O s fo r in-sessio n role plays a n d in vivo h o m ew o rk situ a tio n s a n d to a rticu la te how m o d i­ fying d isto rte d co g n itio n s a n d beh av io rs will help th em to achieve th e ir D O s. We have observed anecdotally th at having o u r CBG T p a tie n ts c o n ­ sider the im p a c t o f th e ir in te rp re ta tio n s on D O a tta in m e n t en h an ces th eir

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acceptance, m in d fu ln ess, and se lf-d eterm in atio n in anxiety -in v o k in g situ atio n s.

— —=> C a s e E x a m p l e

^

To illustrate ho w CBASP can be in c o rp o ra te d in to CBT fo r SAD a n d APD, we p re sen t a case stu d y o f an a d u lt in th e ra p y for SAD a n d APD at th e F lorida State U niversity Psychology Clinic. Fred was a 19-year-old college stu d e n t b e g in n in g his so p h o m o re year w hen he cam e to th e clinic seeking tre a tm e n t for SAD. F red ’s social anxiety in h ib ited his life in a n u m b e r o f ways. A lthough he was able to p a rticip a te in m o st solitary a n d fam ily activities, he re p o rte d experiencing a g reat deal o f anxiety in all situ atio n s in w hich he w ould have to be a ro u n d o r in te ra c t w ith others. T his in clu d e d w alk­ ing o n cam p u s, b ein g in class, going to th e m all, going to th e grocery store, eating in re stau ra n ts, going to the m ovies, talk in g on the tele­ p h o n e , having to speak in class, going to parties, a n d having to talk to o th e rs (in d iv id u als o r g ro u p s). H e was b o th e re d by a u to n o m ic aro u sal sy m p to m s (e.g., sw eaty palm s, racing h e art) a n d c o n stan tly w o rried a b o u t w hat o th ers m ig h t be th in k in g o r saying a b o u t him , believing th a t th ey w ere negatively evaluating him . He w as un ab le to m ake eye c o n ta ct w ith o th e rs o r to initiate o r m ain tain conversations w ith o th e r people. Fred re p o rte d th a t h e had experienced som e social anxiety since th e age o f 12 b u t th a t it h a d b ecom e m u c h m o re severe since b e g in ­ n in g college. H e h a d n o friends o r acq u ain tan ces, a n d he h a d never been o n a date. H is fam ily was his only source o f social su p p o rt, and, a lth o u g h he was extrem ely close to th em , they lived several h o u rs away. Fred re p o rte d experiencing q u ite a b it o f loneliness as well as so m e depressive sy m p to m s, in clu d in g occasional suicidal th o u g h ts. Fred was diag n o sed w ith SAD, G eneralized Type, a n d APD. H e was also diagnosed w ith D epressive D iso rd e r N o t O therw ise Specified because his a fo re m en tio n ed depression sy m p to m s did n o t m eet c ri­ teria fo r M ajor D epressive D isorder. F r e d ’s T r e a t m e n t P l a n

T he tre a tm e n t plan for Fred consisted o f CBT for Social P h o b ia based on Leahy a n d H o llan d (2000), in clu d in g relaxation train in g , expo-

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su re to feared situ a tio n s, a n d c ognitive re s tru c tu rin g . CBASP te c h ­ n iq u e s w ere also in c o rp o ra te d in to tr e a tm e n t u sin g th e C SQ . D u rin g th e first tw o th e ra p y sessions, Fred w as ta u g h t p rogressive m u scle re la x atio n a n d d e e p -b re a th in g exercises as ways to m an a g e his feel­ ings o f a n x ie ty w h e n in social s itu a tio n s a n d to re d u ce a n x io u s a ro u sal w h e n n ece ssa ry b e fo re c o m p le tin g C SQ s. A fear h ie ra rc h y w as also d e v elo p ed a n d im p le m e n te d in e x p o su re u sin g SU D S r a t ­ ings. T h e ra tio n a le o f th e C SQ a n d h o w to use it in c o n ju n c tio n w ith th e e x p o su re a ssig n m e n ts w ere d iscu ssed w ith Fred. B ecause Fred in itially p re se n te d w ith c o m o rb id d e p re ssio n a n d su icid al id e a tio n , th e th e ra p is t chose to a d d ress th ese sy m p to m s u sin g tra d itio n a l CBASP a lo n e d u r in g th e first several w eeks o f th e r ­ apy, w ith o u t a d d itio n a l e x p o su re assig n m en ts. F red q u ick ly m a ste re d th e C SQ fram e w o rk , a n d his d epressive s y m p to m s d e cre ased s u b ­ sta n tia lly over th is tim e . N ext, in -se ssio n role plays a n d in vivo e x p o ­ su re a ssig n m e n ts w ere g ra d u a lly in te g ra te d in to th e tre a tm e n t b ased o n F re d ’s hierarchy. A fter a tte m p tin g a n e x p o su re a ssig n m e n t, Fred c o m p le te d a C SQ o n th e e x p o su re situ a tio n . T h e fo llo w in g is a v ig n ette (a b b re v ia te d to focus o n ju s t o n e in te r­ p re ta tio n a n d o n e b e h a v io r) o f Fred a n d his th e ra p is t d isc u ssin g a C SQ in session n e a r th e b e g in n in g o f th e ra p y o n a n e x p o su re a ssig n ­ m e n t F red c o m p le te d . T h e th e ra p is t b e g an w ith th e e lic itatio n phase. Therapist: Let’s look at the CSQ. Here the assignm ent was that you were to make eye contact with som eone and greet that person. Fred: Yeah. I went to the grocery store Friday night, and when I was going through the checkout line, I said hello to the grocery clerk and asked her how she was doing. Therapist: Okay, now on to Step 2. W hat were your interpretations or thoughts when you were in that situation? Fred: O ne o f my thoughts was “I’m not norm al because I am here alone.” Therapist: Okay. So one o f your interpretations in this situation was “I’m not norm al because I am here alone.” I see your SUDS rating for this thought was 90. This seems to be a good interpretation for us to focus on. Now let’s move on to Step 3. W hat were your behaviors in that situation? Fred: While I was in the grocery store, I kept my head dow n the entire tim e and looked at the floor or nothing at all, except w hen I looked at the clerk and m ade eye contact with her.

SOCIAL ANXIETY A ND AVOIDANT PERSONALITY DISORDERS

Therapist: W hat else did you do? Fred:

I ju st p re tty m u ch kept m y h ead

do w n a n d did n o t talk to

anyone, except for w hen I asked the clerk how she w as doing. So I said, “Hi,” a n d asked h e r h ow she was do in g b u t said it very softly. Therapist: D id th e clerk respond? Fred:

Yes, she said she w as d o in g fine.

But th en I co u ld n ’t th in k o f any­

th in g else to say, so I looked back do w n a n d d id n ’t say a n ything else. Therapist: So y o u r b ehaviors in this situ atio n w ere to keep y o u r h ead do w n a n d lo o k at th e floor a n d n o t to talk to anyone, except w hen you greeted th e clerk. Fred:

Yes.

Therapist: Let’s m ove o n to Step 4. W h at w as yo u r DO? Fred: To go to the grocery sto re an d get m y g roceries w ith o u t any stress. Therapist: A nd w hat was th e AO? Fred:

I got m y groceries, b u t m y SUDS was a b o u t 85 o r 9 0 .1 was able to m ake eye con tact w ith the grocery clerk an d ask h e r how she w as doing.

Therapist: D id you achieve yo u r DO, then? Fred:

S ort of. I was able to m ake eye co n tact w ith th e clerk a n d speak to her, b u t I w asn’t able to talk to anyone else o r even look at anyone else, a n d I still experienced a lot o f stress.

Therapist: It so u n d s like you m ay have actually h a d tw o D O s, th en . O ne w as to get y o u r groceries w ith o u t ex periencing any stress. But it also seem s like a n o th e r D O for you w as to be to m ake eye c o n ­ tact a n d greet a p e rso n w hile in the grocery store. D o you th in k th a t is true? Fred:

I guess so. I w as able to look at the clerk a n d ask h e r how she was doing. But I still experienced a lo t o f anxiety w hile in th e grocery store, a n d I c o u ld n ’t th in k o f an y th in g else to say to th e w om an at th e checkout counter.

F re d in itia lly d e s c rib e d m o r e t h a n o n e D O t h a t in c lu d e d b o t h s h o r t - t e r m a n d l o n g - te r m g o als: to g o to th e g ro c e ry s to re a n d to m a k e eye c o n ta c t w ith s o m e o n e a n d g r e e t t h a t p e r s o n (h is A O ) as w ell as to k e e p th e c o n v e r s a tio n g o in g a n d n o t e x p e r ie n c e a n y d is tre s s (g o a ls h e d id n o t a tta in ) . T h e t h e r a p is t th e r e f o r e a sk e d F re d w h e th e r g o in g to th e g ro c e r y s to re a n d n o t e x p e r ie n c in g a n y s tre s s w a s a re a l­ istic D O , a n d F re d a g re e d t h a t it w a s n o t. H e t h e n f o r m u la te d a

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c o m p ro m is e b e tw e e n h is g o a ls a n d re v ised h is D O to sta te “M a k e eye c o n ta c t w ith s o m e o n e , say ‘hello,’ a n d a sk th e p e rs o n h o w h e o r sh e is d o in g [th e re b y c o m p le tin g h is e x p o s u re a s s ig n m e n t], w h ile a tt e m p t ­ in g to a c c e p t a n d to le ra te feelin g s o f a n x ie ty .” T h e tr a n s c r ip t c o n tin ­ u e s fo llo w in g th is re v isio n . Therapist: So did you get this corrected DO? Fred: I suppose so. But I still w asn’t able to thin k o f anything else to say, and m y SUDS level was a bout 90 w hen I spoke to the g ro­ cery clerk, w hich bothered m e a lot. A fte r a c k n o w le d g in g t h a t h e a c tu a lly o n ly p a rtia lly a tta in e d his D O , F re d a n d h is th e ra p is t m o v e d o n to th e re m e d ia tio n p h a se : Therapist: Okay, then, let’s go back th ro u g h your interpretations to see which ones were helpful and hurtfu l to you in getting your DO o f m aking eye contact w ith som eone and greeting the person, while tolerating any anxiety. Your first interpretation was, “I am not norm al because I am here alone.” Do you think that tho u g h t was helpful or h u rtfu l to you in this situation? Fred: H urtful. Therapist: Why? Fred: Because I kept m y head dow n and d id n ’t speak to anyone because they w ould look at m e and th in k I was weird because I was alone and because I was talking to them . Therapist: Can you th in k o f any thoughts, then, th at you could replace the h u rtfu l tho u g h t w ith th at w ould be helpful to you in this situation? Fred: I am norm al. Therapist: G ood. H ow do you th in k th at w ould have helped you? Fred: Well, if I kept telling m yself that I was norm al an d was n o t w eird for being there alone, and th at it’s okay to feel anxious, I m ay have been m ore likely to have kept m y head up and m ade eye contact w ith som eone. I probably w ould have been m ore likely to say hello to som eone. Therapist: So telling yourself “I am norm al and I am n o t w eird for being here alone o r feeling anxious” w ould have m ade it easier for you to keep y our head up, m ake eye contact w ith others, and to talk to oth er people? Fred: Yes. Therapist: It seems, though, that in this situation you were able to do that. You m ade eye contact w ith the checkout clerk and greeted her.

SOCIAL ANXIETY A ND AVOIDANT PERSONALITY DISORDERS

Fred:

But I still felt a lo t o f anxiety, w hich really b o th ere d m e, a n d th at m ade it h a rd e r to look up.

Therapist: D o you th in k th a t y o u r rep lacem en t th o u g h t w ould have m ade y ou feel less anxious, th e n , o r h elp you accept the anxiety you felt? Fred: Probably. It w ould have been a lo t easier for me. Therapist: So y o u r in te rp re ta tio n “ I am n o t n o rm al because I am here alo n e” w as h u rtfu l to y ou because it m ade you keep y o u r head d ow n a n d n o t speak to anyone w hile y ou w ere in th e g rocery store, except w hen you spoke to th e clerk, a n d th e n you still experienced a lot o f anxiety, w hich m ad e you feel m o re u n c o m ­ fortable. If you replaced th a t in te rp re ta tio n , th en , w ith “ I am n o rm al and I am n o t w eird for b eing h ere alone, an d it’s okay to feel a n x io u s” you w o u ld have experienced less anxiety o r been m o re accepting o f it, a n d you w ould have been m o re likely to keep y o u r head up an d speak to others. Is th a t right? Fred:

Yes.

Therapist: T h en let’s m ove o n to Step 3. O n e o f y our behaviors in this s itu ­ a tio n was to keep yo u r head d o w n th e e n tire tim e, except w hen you m ade eye con tact w ith th e clerk. D o you th in k this w as h e lp ­ ful o r h u rtfu l to you in achieving y our DO? Fred:

H urtfu l. I pro b ab ly w ould have been m o re likely to m ake eye c o n ta ct w ith o th e r p eople a n d m aybe even say hi if I d id n ’t look d ow n th e en tire tim e.

Therapist: But you w ere able to m ake eye con tact a n d speak to th e clerk. H ow was it h u rtfu l, then? Fred:

W hile I was looking at th e g ro u n d , I ju st kept th in k in g a b o u t h ow I w asn’t n o rm al

a n d th a t I ju st w anted to leave.

Therapist: So keeping y o u r h ead d o w n actually m ad e you th in k m o re nega­ tively? Fred:

Yes. If I h a d m y h ead

up a n d looked at o th e r people, I m ig h t

have b een d istracted a n d n o t th o u g h t th o se things over a n d over again. Therapist: T h en , w h at b eh av io r w ould have been h elpful to you in th is situ ­ ation? Fred:

To keep m y h ead up.

I p robably w o u ld n ’t have th o u g h t nega­

tively as m u ch a n d w ould have b een m o re likely to m ake eye c o n ta ct w ith o th ers a n d to even speak to people in the grocery store. Therapist: So in this situ atio n , if you w ould have th o u g h t to yo u rself “ I am n o rm a l and I am n o t w eird for b eing h ere alone, and it’s okay to feel anxiety” instead of, “I am n o t n o rm a l because I am here

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Fred:

alone, and I shouldn’t feel anxiety,” and if you would have kept your head up instead of looking at the ground the entire time, you would have been more likely to get your entire DO, which was to make eye contact and greet someone while feeling less anxiety and better tolerating the anxiety you did feel, right? Yes.

D u rin g the elicitatio n phase, Fred identified several th o u g h ts a n d beh av io rs th a t n o t only coincided to increase his anxiety in this social situ a tio n b u t also m ade it less likely th a t he w ould a tta in his DO . Fred also discovered th a t p a rt o f his initial D O was unrealistic a n d u n a t­ tain ab le a n d p artially conflicted w ith his lo n g -te rm goals. T he th e ra ­ p ist th u s asked Fred to im m ed iately revise his D O before pro ceed in g w ith the CSQ . D u rin g the re m e d ia tio n phase, Fred was able to g e n er­ ate plausible alternative in te rp re ta tio n s a n d a ctio n s th a t he felt w ould increase the chance o f a tta in in g his revised DO.

O utcome

F red’s initial level o f social anxiety a n d avoidance w ere q u ite p ainful a n d debilitating. A fter several m o n th s o f in dividual a n d g ro u p th e r ­ apy, Fred experienced d ra m a tic im p ro v e m en t. He w as able to m aster th e CBASP m e th o d after six sessions a n d can co m p lete the CSQ b o th after situ atio n s a n d prospectively. Fred c o n tin u e s to experience a n x i­ ety in social situ atio n s; how ever, his anxiety level has decreased s u b ­ stantially. D u rin g a recent exchange w ith a stranger, h e re p o rte d an in itial SUDS o f 60 th a t decreased to 25 after 15 m in o f conversation. Fred was able to m ake eye c o n tact, m a in ta in his p a rt o f th e conversa­ tio n , laugh a n d sm ile, a n d ask this p erso n to jo in him for a m ovie in the c o m in g weeks. D u rin g the tim e Fred has been in therapy, he has a tta in e d e m p lo y m en t, established relatio n sh ip s w ith several co ­ w orkers, given speeches in fro n t o f large g ro u p s o f people, a n d played his g u ita r a n d su n g in fro n t o f sm all groups. Fred c o n tin u e s to fear som e social situ atio n s a n d experience anxiety w hile p a rticip a tin g in th em , b u t th e level o f anxiety a n d fear has decreased from a level th a t p reviously im p a ired his p e rfo rm a n ce to a m ild er one. Fred is able to generate situ atio n al in te rp re ta tio n s th a t are m o re likely to decrease his anxiety o r help him accept a n d e n d u re it (e.g., “I m ay be anxious, b u t I know I can do th is”). He has also acq u ired social skills th a t m ake

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it less o bvious th a t he is an x io u s in these situ atio n s (e.g., he m ain tain s eye c o n tact, sm iles, a n d show s red u ced e x tra n eo u s bo d ily m o v e­ m e n t). Fred has also im p ro v ed in his avoidance o f feared situ atio n s. To d ate he has c o m p leted his initial hierarch y o f feared situ atio n s a n d has established a second o n e consisting o f exposure situ atio n s he felt w ere com pletely unrealistic at intake (e.g., talking to a w om an a n d asking for a d ate). Fred has also im p ro v ed significantly in his ability to carry o u t previously difficult daily tasks. F red ’s depressive sy m p to m s a n d suicidal id ea tio n have fluctu ated d u rin g therapy, b u t overall th ey have decreased significantly th ro u g h o u t th e course o f tre a tm e n t.

O B S T A C L E S TO T R E A T M E N T A variety o f obstacles m ay o c cu r w hen im p le m e n tin g CBASP for SAD a n d APD. In a d d itio n to th e challenges in c o m p letin g th e CSQ (addressed in prev io u s c h ap ters), obstacles specific to socially an x io u s p a tie n ts often include th e c o m p le tio n o f exposure assignm ents, as well as general p a tie n t a n d th era p e u tic alliance factors discussed later. A first step in dealing w ith these challenges is to exam ine a n d resolve w ith th e p a tie n t any pro b lem s in the th era p eu tic alliance (does th e p a tie n t believe th a t the th e ra p ist a d e ­ quately m et him o r h e r at p o in t A before w orking to a ccom pany him o r her to B?). Second, it can be helpful to revisit regularly the ra tio n ale b e h in d the tre a tm e n t to m a in ta in th e p a tie n t’s m o tiv a tio n to co m plete exposure a n d CSQ assig n m en ts despite distress a n d anxiety, w hile lea rn in g to accept such sh o rt-te rm flu ctu atio n s in c o m fo rt level. A dditionally, e xploring the p a tie n t’s p erso n al experience w ith anxiety by c o n stru ctin g a fear h ierarchy also elucidates im p o rta n t issues to address th ro u g h role plays, cognitive re stru ctu rin g , a n d CBASP principles. O bstacles to co m p le tin g exposure assignm ents m ay m anifest in v a rious form s; how ever, in socially an x io u s p a tie n ts, they m o st often o rig in ate from th e a p p re h e n sio n a n d am bivalence SAD a n d A PD p a tie n ts feel a b o u t the challenges th ey m u st c o n fro n t to experience positive change. For instance, p a tie n ts m ay have low confidence in th e likelihood o f a positive o u tco m e o r in th e ir ability to e n d u re th e situ atio n . T h ey m ay have real o r perceived skills deficits th a t im pede th e ir p erfo rm a n ce , o r th ey m ay fear negative evaluation by others. T hey m ay have failed in a previous situ atio n sim ilar to this exposure assignm ent, o r th ey m ay believe th a t th ey c a n n o t

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be assertive enough to com plete the assignm ent. T hey m ay believe they cannot tolerate a high level o f anxiety and th at som ehow their anxiety will eventually d im inish w ith o u t having to endure exposure. A variety o f p rocedures m ay be effective in addressing and rolling w ith resistance to the com pletion o f exposure assignm ents; techniques o f m o ti­ vational interview ing (M iller & Rollnick, 2002) are helpful in this regard. A lthough avoidance behaviors m ay at tim es seem frustratingly irrational to the therapist, it is im p o rta n t to identify and address the function b ehind the p a tie n ts’ resistance and their beliefs th at lead them to fail in com pleting assignm ents. As described earlier, the therapist should help find and vali­ date the kernel o f tru th in these concerns, acknow ledging the pros and cons o f con tin u ed avoidance, while asking the patien t w hether the long­ term advantages o f con fro n tatio n outw eigh the sh o rt-term disadvantages, in light o f his o r her DOs. T he therapist can also have patients explain their u n d erstan d in g o f the rationale for com pleting exposure assignm ents. A nother strategy is to highlight previous successes for the p atient, in clu d ­ ing situations in w hich the patien t was initially resistant to b u t ultim ately succeeded in c o nfronting and h andling the exposure. T he th erap ist can ask the patien t to identify parallels betw een in terp retatio n s in the previous sit­ u atio n and the c u rre n t one. W hen a patien t is particularly sure th at he or she “ju st can’t do it,” it can help to role play the situation in session, w ith the therapist first m odeling the role o f the patient. O nce this role play is com plete, the therapist can congratulate the p a tie n t on his o r her courage and effort and ask the p a tie n t to identify several positive aspects o f his or her ow n perform ance (w ith o u t disqualifying the positive). T he p a tie n t’s fear hierarchy is also useful for m o n ito rin g and highlighting progress, while balancing the push for change w ith acceptance for the p a tie n t’s c u r­ rent level o f functioning and personal goals for therapy. Individual p atient factors can create obstacles in trea tm e n t for SAD and APD w ith CBASP. These m ay include suicidality, th erapy-interfering be­ havioral patterns, tru st issues, com orbidity, and acceptance issues. Each therapist delivering this treatm en t needs to assess these factors carefully to d eterm ine the im pact they m ight have on the trea tm e n t im plem entation. T he m ost im p o rta n t o f these factors is suicidality. T his should be assessed thoro u g h ly d u rin g every session for a p atient th at presents w ith suicidal ideation (see Joiner, W alker, R udd, & Jobes, 1999, for details o f suicide assessm ent). After d eterm ining the im pact these factors will have on th e r­ apy, the therapist should address them specifically w ith the p atient and arrive at an agreem ent as to how they will be dealt w ith.

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Problem s w ith th erapeutic alliance can interfere w ith CBASP for SAD and APD. Patients m u st be able to tru st th at the therapist is n o t only know ledgeable and able to help b u t also concerned ab o u t th em and their welfare. Beck and Freem an (1990) em phasize how the dysfunctional schem as o f individuals w ith APD frequently m anifest in the therapeutic relationship itself, reducing trust, com prom ising the therapeutic alliance, and retarding progress in treatm ent. As Beck and colleagues note, patients m ay n o t volunteer these cognitions even w hen they notice them . T he th e r­ apist m u st co m m unicate w arm th, concern, validation, em pathy, and respect tow ard patients, consider m indful self-disclosure (based on p a ­ tie n ts’ needs), and nondefensively acknow ledge and apologize for m is­ takes. A lthough the collaborative and acceptance-prom oting n atu re o f CBASP goes a long way to reduce alliance disturbances, we have fo u n d it to be extrem ely valuable to regularly elicit patien ts’ c u rre n t th o u g h ts about the therapeutic process. B orrow ing from Dialectic Behavioral T herapy techniques (L inehan, 1993a, 1993b), the therapist can elicit agreem ent from the p a tie n t early in therapy on the im p o rta n ce o f developing a tru s t­ ing relationship for therapy to w ork and a policy o f openly discussing any­ th in g the therapist does th at is both erso m e to the patient.

Previous studies indicate th at CBASP is an efficacious treatm en t for p a ­ tients w ith chronic d epression o r dysthym ia (Keller et a l, 2000). T his ch ap ­ ter focused on applying this trea tm e n t for patients w ith SAD o r APD by com bining CBASP w ith existing treatm en t m odalities. T his approach addresses a n u m b er o f goals for patients w ith SAD and APD. It includes com p o n en ts o f exposure, cognitive restructuring, a n d g oal-oriented evalu­ ation o f previous situations as well as future situations. T he m echanism o f change w ith this therapeutic approach appears to rest on patients’ m astery o f the process o f generating goal-oriented in terp retatio n s and behaviors. This approach seems likely to p ro m o te a sustained reduction in the sy m p ­ tom s o f SAD and APD, as well as a variety o f c om orbid disorders. A lthough the efficacy o f this treatm en t m odality awaits fu rth er investigation, o ur experience w ith this application o f CBASP to SAD and APD suggests that it is a sim ple and highly beneficial approach to intervention for these c o m ­ plex an d disabling disorders.

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Chapter

Generalized Anxiety Disorder and Panic Disorder*

Little modification of the Cognitive Behavioral Analysis System of Psychotherapy approach is actually needed to effectively target the maladaptive cognitions and behaviors thought to m aintain both Panic Disorder and Generalized Anxiety Disorder. This chapter sum ­ marizes existing empirically validated treatm ents for Panic Disorder and Generalized Anxiety Disorder, but demonstrates that emphasis the Cognitive Behavioral Analysis System of Psychotherapy places on specific situations offers a practical advantage as an in-session means to manage the often diffuse, unfocused anxiety symptoms associated with each of these conditions. Two case descriptions illus­ trate the successful im plementation of the system in the treatm ent of Panic Disorder and Generalized Anxiety Disorder in our outpatient clinic.

T his c h ap ter p rovides an overview o f th e a p p lic atio n o f M cC ullough's (2000) C ognitive Behavioral Analysis System o f P sychotherapy (CBASP) a n d its stru c tu re d c o m p o n e n t, th e C o p in g Survey Q u e stio n n a ire (C SQ ), to anxiety disorders. Specifically, we discuss th e value o f in te g ratin g CBASP in to em p irically validated tre a tm e n ts for Panic D iso rd e r (P D ) a n d G e n e r­ alized A nxiety D iso rd e r (G A D ). We offer specific re c o m m e n d a tio n s fo r its a p p lic atio n to trea tin g these d iso rd ers a n d discuss som e p o ten tial obstacles th e th e ra p ist m ay e n c o u n te r w hen a pplying CBASP a n d th e CSQ to the tre a tm e n ts for PD a n d GAD. *The primary authors contributing to this chapter were Ginette C. Blackhart and Sheila Stanley. 101

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O n e o f th e m o st im p o rta n t c o m p o n e n ts in th e tre a tm e n t o f anxiety d is­ o rd e rs is exposure, a behav io ral tec h n iq u e em p h asizin g th a t o n e ’s anxiety only dissipates if o n e is exposed to th e feared o bject o r situ atio n . A n o th e r im p o rta n t c o m p o n e n t o f tre a tm e n t for anxiety d iso rd ers is cognitive th e r ­ apy, p rim a rily because p ersons w ith anxiety diso rd ers often experience cognitive d isto rtio n s a n d w orries. T h erefo re, by in c o rp o ra tin g cognitive th era p y in to behav io ral tre a tm e n t for m an y anxiety d iso rd e rs— in clu d in g PD a n d G A D — the th e ra p ist n o t only exposes th e p a tie n t to th e feared o bject o r situ a tio n b u t also targets the p a tie n t’s w o rries a n d negative d is­ to rte d cognitions. W o rry a n d cognitive d isto rtio n s play a p a rticu la rly im p o rta n t role in b o th PD a n d GAD. T hose w ith PD (w ith o r w ith o u t A gorap h o b ia) often have c atastro p h ic c o gnitions, w hich are in accu rate in te rp re ta tio n s o f the physical sen satio n s they experience ju st b efore a n d d u rin g a p anic attack (Z u ck erm an , 1999). In a d d itio n , th ey m ay c o n stan tly w o rry a b o u t e x p eri­ encing fu tu re p anic attacks a n d the consequences o f th e p a n ic attacks (Barlow , Esler, & Vitali, 1998). T h o se w ith A g o rap h o b ia (w h e th er o r n o t th ey are d iagnosed w ith PD ) c o n stan tly experience anxiety a n d w o rry a b o u t experiencing a p anic a tta ck o r paniclike sy m p to m s w hile in a public place, such as a sh o p p in g m all, re sta u ra n t, a n d so on. Finally, those w ith GAD experience c o n sta n t w o rry th a t is m ostly negative in c o n te n t a n d difficult to c o n tro l (A m erican Psychiatric A ssociation, 1994).

T RE A TM EN T S FOR A N X I E T Y D I S O R D E R S : W H A T C B A S P H A S TO OF F ER C ognitive d isto rtio n s a n d w o rry are key features in these an x iety disorders, a n d m an y em pirical studies fo u n d th a t a c o m b in in a tio n o f cognitive th e r­ apy a n d behav io ral tre a tm e n ts for PD, A go rap h o b ia, a n d GAD is m ore effective th a n behav io ral tre a tm e n ts alone. D ue to th e cognitive c o m ­ p o n e n t p re sen t in these anxiety diso rd ers, a n d th a t th e m o st successful tre a tm e n ts fo r these anxiety d iso rd ers include behav io ral (i.e., exposure, relaxation) a n d cognitive c o m p o n e n ts (N a th an 8c G o rm a n , 1998), it seem s logical th a t th e CSQ , used by M cC ullough (2000) in th e tre a tm e n t o f d epression, w ould be ideal for use w ith existing em p irically validated tre a t­ m en ts for these d isorders. T he CSQ (as explained in C h a p te r 1 a n d o th e r ch ap ters in this vo lu m e) encourages the p a tie n t to recognize his o r h er ow n in te rp re ta tio n s (o r c o g n itio n s) a n d beh av io rs in specific situ atio n s. T hese

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in te rp re ta tio n s a n d beh av io rs are th e n evaluated a n d reanalyzed in term s o f the o u tco m e the p a tie n t desires in th a t specific situ atio n (the D esired O u tc o m e , o r D O ). If em p irically v alidated cognitive b ehavioral tre a tm e n ts for panic a n d GAD already exist (B arlow et al., 1998; B orkovec & C ostello, 1993; Butler, Fennell, R obson, & G elder, 1991), th e n w hy w ould the th e ra p ist w a n t to in c o rp o ra te CBASP in to th e tre a tm e n t o f these anxiety disorders? T he answ er is sim ple. CBASP is p a rticu la rly useful in the tre a tm e n t o f anxiety d iso rd ers because it focuses th e p a tie n t o n his o r h e r specific goals w ith in a situ a tio n a n d on the goals o f tre a tm e n t, a task th a t can be difficult for p a tie n ts w ith these anxiety d isorders. As a su p p le m e n t to th e em pirically validated tre a tm e n ts for PD a n d GAD, CBASP m ain ta in s th e p a tie n t’s a tte n tio n on the specific goals o f therapy, th ere b y in creasing the likelihood th at the p a tie n t will engage in exposure exercises a n d alter his o r h er co g n i­ tio n s a n d b ehaviors appropriately. In th e sections th a t follow, we show how CBASP m ay be specifically applied to th e tre a tm e n ts fo r PD (w ith o r w ith o u t A gorap h o b ia) a n d GAD. Each section p rovides a detailed d e sc rip tio n o f the sy m p to m s o f each d is­ o rd e r a n d th e ir established em p irically validated tre a tm e n ts, as well as any obstacles th a t m ay im p ed e CBASP’s im p le m e n tatio n . Case exam ples are p ro v id ed to b e tte r illustrate the use o f CBASP as applied in o u r clinic.

C B A S P A P P L I C A T I O N TO P A N I C D I S O R D E R T he D iagnostic an d Statistical M a n u a l o f M en ta l Disorders {D S M -IV ; A m erican Psychiatric A ssociation, 1994) characterizes PD by th e follow ing criteria: re c u rre n t, u n ex p ected p anic attacks a n d at least one o f th e attacks is follow ed by 1 m o n th o r m o re o f p e rsisten t c oncern a b o u t having a d d i­ tional attacks, w o rry a b o u t th e im p lica tio n s o f th e attack o r its conse­ quences, a significant change in b e h av io r related to the attacks, o r a c o m b i­ n a tio n o f these criteria. A p a n ic attack is d efined as a discrete p e rio d o f intense fear o r d isc o m fo rt, in w hich p anic sy m p to m s develop a b ru p tly a n d reach a p eak w ith in 10 m in . F o u r o f th e follow ing sy m p to m s m u st be p re s­ e n t for this diagnosis: 1. H e a rt p a lp itatio n s, p o u n d in g h e a rt, o r accelerated h e a rt rate 2. Sw eating, trem b lin g , o r shaking; sh o rtn e ss o f b re ath 3. Feelings o f choking; chest pain o r d isc o m fo rt 4. N ausea o r a b d o m in a l distress

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5. Feeling o f dizziness, unsteadiness, lightheadedness, o r faintness 6. D erealization (feelings o f unreality) o r depersonalization (selfdetachm ent) 7. Fear o f losing control o r going crazy; fear o f dying; num bness or tingling sensations 8. Chills o r h o t flashes (A m erican Psychiatric A ssociation, 1994). Panic C ontrol T reatm ent (PCT; Barlow & Craske, 1994; Craske & Barlow, 1992) presently constitutes the em pirically validated treatm en t o f choice for PD, involving the key com p o n en ts o f interoceptive exposure as well as cognitive restru ctu rin g (Barlow et al., 1998). Interoceptive exposure c o n ­ fronts the patien t w ith specific physical sensations o r sym ptom s directly associated w ith his o r her panic attacks. For instance, the therapist m ay have the p a tie n t hyperventilate to create shortness o f breath o r perhaps have the person jog in place to induce sw eating a nd h e art rate acceleration. C ognitive re stru ctu rin g is directed at m isconceptions ab o u t anxiety and panic (catastrophic cognitions) and d istorted cognitions focusing on over­ estim ations o f the th rea t and the danger associated w ith panic attacks (Barlow et al., 1998). T he application o f CBASP as an adju n ct to PCT m ay be especially h e lp ­ ful because it requires the patien t to focus specifically on cognitions and behaviors th at m ay be exacerbating sym ptom s o f panic by em phasizing the connection betw een physical sym ptom s, thoughts, behaviors, and panic attacks. PCT consists o f three m ain com ponents. T he first is a u n it o f e d u ­ cation ab o u t the causes and consequences o f panic attacks, w hich is designed to help the patien t view panic attacks as less threatening. T he sec­ o n d co m p o n e n t is exposure to bodily sym ptom s sim ilar to those present d u rin g a panic attack (interoceptive exposure). T he th ird c o m p o n e n t con­ sists o f restru ctu rin g cognitions th at tend to escalate panic attacks. No m odifications to the CSQ are necessary w hen in co rp o ra tin g CBASP into PCT, b u t CBASP should focus on situations specific to having a panic attack o r experiencing paniclike sym ptom s. E m phasis should be placed on those cognitions o r in te rp reta tio n s th a t are specific to the panic sym ptom s, the events or behaviors before the panic attack occurred, and the p a tie n t’s behaviors while experiencing panic. Finally, the D O should focus on som e aspect o f controlling panic, such as evading a panic attack, controlling som e o f the panic sym ptom s, reducing the intensity o f panic sym ptom s, and so on. It is often helpful for the therapist a nd p atient to com plete the first CSQs in session so th at the p atient understan d s the rationale and p u rp o se o f its

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use in therapy. A fter th at, how ever, it is im p o rta n t fo r the p a tie n t to c o m ­ plete m o st o f the CSQ s as ho m ew o rk . T his leaves m o re tim e fo r in-session d iscussion as well as exposure in te rv en tio n s. T he follow ing case exam ple was derived from o u r experience w ith a p a tie n t w ith p a n ic d iso rd e r a n d sh o u ld help to illustrate how CBASP can be in c o rp o ra te d in to PCT.

v— —= C a s e E x a m p l e 1: P a n i c D i s o r d e r

Kara is a 22-year-old u n d e rg ra d u a te college stu d e n t w ho presen ted w ith a co n cern a b o u t a h isto ry o f panic attacks. H er first p anic attack o c cu rre d w hen she was 16 years old, a n d she experienced tw o m ore w hen she was 19 years old. She stated th a t these attacks w ere m ore th a n likely p re cip ita te d by h e r use o f d ru g s a n d alcohol. Kara began experiencing m o re freq u e n t p a n ic attacks appro x im ately 8 m o n th s before seeking tre a tm e n t a n d again suspected th a t so m e o f th em m ig h t have b een d u e to d ru g a n d alcohol use. A lth o u g h Kara d isc o n ­ tin u e d using d ru g s a n d red u ced h e r c o n su m p tio n o f alcohol, she c o n tin u e d to experience freq u e n t panic attacks. W h en K ara presen ted for tre a tm e n t, she w as experien cin g tw o o r m o re p anic attacks a w eek. Each generally lasted from several m in ­ utes to h a lf an hour. D u rin g these episodes, h er h e a rt raced, she h a d difficulty b re ath in g , she h a d the feeling th a t h e r th ro a t was closing up, h e r sto m ac h felt tw isted in k n o ts, a n d she w o rried th a t she was going crazy o r was going to die. Kara often experienced p anic attacks w hile at w o rk o r w h e n w atching an intense m ovie. A lth o u g h she re p o rte d ly w o rried a b o u t having a p a n ic attack w hen driving, she did n o t avoid driving. She also d id n o t avoid w o rk o r o th e r social s itu ­ a tio n s in a n tic ip a to ry fear o f a p anic attack. K ara did, how ever, fear having p a n ic attacks w hen alone at h o m e, a n d , consequently, she often sp e n t the n ig h t at frien d s’ houses. Based o n th e in fo rm a tio n o b ta in e d d u rin g th e intake interview , Kara was diag n o sed w ith PD w ith o u t A goraphobia. A ccordingly, th e tre a tm e n t plan was to use PCT, C raske a n d B arlow ’s (1992) m an ualized tre a tm e n t fo r PD, described previously. In a d d itio n , Kara was ta u g h t b re a th in g exercises designed to help h e r m an ag e h e r level o f anxiety d u rin g a p a n ic attack. At th e o u tset, CBASP w as used in c o n ju n c tio n w ith PC T to help K ara recognize w hich physical sensa­ tio n s signaled to h e r th a t she was going to have a p a n ic attack, her

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re sp o n se s to th o se se n sa tio n s, a n d a n y th o u g h ts o r c o g n itio n s esca­ latin g o r e x ac e rb a tin g h e r p a n ic a ttack s. L ater in th era p y , th e CBASP m e th o d w as u se d p ro sp e ctiv ely to h elp K ara d e te rm in e w h ic h th o u g h ts a n d b e h a v io rs m ig h t h elp h e r avoid h a v in g a p a n ic attack. T h e fo llow ing is a s h o r t e x ce rp t o f K ara a n d h e r th e ra p is t w o rk in g th ro u g h a C SQ h o m e w o rk a ssig n m e n t in o n e o f th ese late r th e ra p y sessions. K ara h a d g o n e to th e m o v ies w ith so m e frie n d s a n d b e g an e x p e rie n c in g th e sy m p to m s o f a p a n ic a tta ck . Therapist: Did you experience any panic sym ptom s or panic attacks since our last session? Kara: Yes— I went to see a horror movie the other night with som e of my friends. Halfway through the movie, I began experiencing some panic sym ptoms. Therapist: W hat sym ptom s specifically? Kara: My heart started racing, and it was really difficult to breathe. I also started to get a headache. Therapist: Did you experience a full-blown panic attack at that m om ent? Kara: Came close, but I did som e o f the stuff we talked about before to try and avoid having a full panic attack. Therapist: The interpretations and behaviors we talked about? Kara: Yeah. Therapist: Let’s focus first on the thoughts, then. W hen you started experi­ encing these panic sym ptom s in the movie theater, what thoughts helped you avoid having an attack? Kara: I just kept telling myself, “I am not going to die” and “I can con­ trol this.” Therapist: T hat’s great! Do you think that having these thoughts helped you avoid having a panic attack? Kara: Yeah— they definitely helped m e calm down and helped me rem em ber that I was going to be okay and there are other things I can do to keep from having a panic attack. Therapist: W hat about your behaviors? Kara: Well, after I calmed down a little and rem em bered that I can control this, I started doing the breathing exercises we have been practicing in here. That helped a lot. My heart slowed down and it was easier to breathe. C learly, K ara w as able to use th e skills she h a d le a rn e d fro m p re v i­ o u s sessions to av ert a p a n ic a ttack . A lth o u g h e x p o su re is th e m o st im p o r ta n t c o m p o n e n t to PCT, re co g n izin g w h ich c o g n itio n s a n d b e h a v io rs m ay lead u p to a n d escalate a p a n ic a tta ck , as well as g e n e r­

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atin g c o g n itio n s and beh av io rs th a t enable the p a tie n t to avoid fu tu re p anic attacks, is also an im p o rta n t c o m p o n e n t. In K ara’s case, CBASP also help ed reveal w hich b ehaviors a n d events led to h e r p a n ic sy m p ­ tom s. T his in clu d ed c o n su m in g large q u a n titie s o f caffeine earlier in th e day, view ing a frig h te n in g m ovie o r television show , a n d extrem e stress. W h en K ara first began experien cin g sy m p to m s o f a panic attack, such as increased h e a rt rate, sh o rtn e ss o f b re ath a n d difficulty b re ath in g , she was n o t able to do a n y th in g to co n tro l these physical sensations. In a d d itio n , w hen experien cin g these sy m p to m s, h er th o u g h ts o r in te rp re ta tio n s w ere o ften, “I am going crazy,” “I am going to die,” a n d “T here is n o th in g I can do to c o n tro l this.” By o b tain in g a b e tte r u n d e rsta n d in g o f th e events, behaviors, a n d in te r­ p re ta tio n s leading to p anic attacks in th e co n tex t o f CBASP assign­ m en ts, Kara a n d h er th era p ist w ere able to devise plans th at m ig h t enable h e r to avoid p a n ic attacks. T h e CSQ was an integral c o m p o ­ n e n t o f this exercise, a n d th e th e ra p ist a n d Kara w orked to g eth e r to generate in te rp re ta tio n s a n d beh av io rs th a t w ould help h e r evade fu tu re p anic attacks. A fter 20 sessions, K ara’s p a n ic sy m p to m s re m itte d entirely, a n d h er feelings o f general anxiety significantly d im in ish e d as well. K ara was also able to generalize th e skills learn ed in th e ra p y to address h e r lack o f assertiveness in w ork a n d social situ atio n s by applying the CBASP m eth o d s. T hese tec h n iq u es pro v ed effective a n d K ara re p o rte d a sig­ nificant im p ro v e m en t in h e r sense o f assertiveness.

OB S T A C L E S TO T R E A T M E N T O n e po ten tial obstacle to using the CSQ w ith PC T is th a t the p a tie n t m ig h t n o t be able to identify specific th o u g h ts th a t are o c c u rrin g d u rin g a p anic attack o r ju st b efore th e attack. In such instances, it is helpful for the th e ra ­ pist to ask the p a tie n t to focus o n his o r h e r th o u g h ts d u rin g interoceptive exposure in session, w hen p a n ic sy m p to m s, a n d possibly a p a n ic attack, are b eing in d u ce d in session. T his helps the th e ra p ist a n d the p a tie n t d e te r­ m in e th e p a tie n t’s in te rp re ta tio n s b efore a n d d u rin g a p anic attack, on w hich th e ra p y can later focus to effectively c o n tro l p a n ic sy m p to m s a n d avoid fu tu re p anic attacks. A second obstacle is th a t the p a tie n t m ay n o t u n d e rsta n d how the rela­ tio n o f his o r h e r th o u g h ts a n d b ehaviors exacerbates sy m p to m s o f panic

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and ultim ately leads to a p anic attack. If th e p a tie n t is un ab le to m ake this co n n ec tio n , th e th e ra p ist has to w o rk closely w ith the p a tie n t to help h im o r h e r u n d e rsta n d ho w th e c ertain c o g n itio n s are c o n n ec te d w ith b e h av ­ iors in increasing panic. Fortunately, th e CBASP m e th o d can be q u ite u se ­ ful in this regard as well. A dditionally, after the th era p ist a n d p a tie n t have d e te rm in e d the co g n i­ tio n s a n d b ehaviors involved in escalating p anic a n d alternative th o u g h ts a n d beh av io rs to avoid p anic, the p a tie n t m ay experience difficulty execut­ ing th a t p lan w hen experiencing p a n ic sy m p to m s. In su ch cases, it is h e lp ­ ful to try CBASP in session. A gain, d u rin g in teroceptive exposure, re m in d th e p a tie n t o f th e plan (the in te rp re ta tio n s a n d beh av io rs he o r she is to im p le m e n t to try to avoid a panic attack) a n d have the p a tie n t execute this in session. A fter receiving s u p p o rt from the th e ra p is t— a n d seeing th a t the p a tie n t has som e c o n tro l— the p a tie n t m ay find it easier to im p le m e n t the a ltern ate in te rp re ta tio n s a n d b ehaviors o u tsid e o f session. It m ay also be helpful for the th e ra p ist to m ake the p a tie n t a n o te card o n w hich som e o f th e th o u g h ts a n d beh av io rs discussed in session are w ritte n fo r the p a tie n t’s reference w hen a pplying CBASP to p anic sy m p to m s experienced o u tsid e o f th e th e ra p y room . A lth o u g h Kara did n o t presen t w ith sy m p to m s o f A goraphobia, th e CSQ can be used in m u ch the sam e way for th e tre a tm e n t o f A goraphobia. Be­ cause the em p irically v alidated tre a tm e n t for A goraphobia includes e x p o ­ sure to feared a n d avoided situ atio n s, as well as cognitive re stru c tu rin g , the th e ra p ist can in c o rp o ra te th e CSQ in to this tre a tm e n t as well. Specifically, th e p a tie n t could co m p lete CSQ s th a t c o rre sp o n d w ith avoidance behaviors and exposure assig n m en ts m u c h in th e way CBASP was in c o rp o ra te d into tre a tm e n t for Social A nxiety D iso rd e r (see C h a p te r 6, this volum e). In su m , use o f CBASP in c o n ju n c tio n w ith P C T is especially useful for focusing th e p a tie n t o n specific c o g n itio n s a n d b ehaviors th a t exacerbate sy m p to m s o f panic. It also helps to em phasize th e c o n n ec tio n s betw een physical sy m p to m s, th o u g h ts, behaviors, a n d panic attacks.

C B A S P A P P L I C A T I O N TO G E N E R A L I Z E D ANXIETY DISORDER A ccording to the D S M -IV , the th ree m ain d iagnostic features o f GAD are excessive w o rry a n d anxiety a b o u t a n u m b e r o f events o r activities, o c c u r­ rin g m o re days th a n n o t for at least 6 m o n th s; ex trem e difficulty c o n tro l­

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ling the w orry; and p e rsisten t o verarousal th a t acco m p an ies th e w orry. O verarousal can be exhibited several ways, in clu d in g restlessness o r a keyed-up feeling, a feeling o f being o n edge, fatigue, difficulty c o n c e n tra t­ ing, b lan k m in d , irritability, m uscle ten sio n , o r sleep d istu rb an c e (A m e ri­ can Psychiatric A ssociation, 1994). T he tw o p rin cip le target c o m p o n e n ts in th e tre a tm e n t o f GAD are excessive, u n c o n tro llab le w o rry a n d p e rsisten t o verarousal (B row n, O ’Leary, & Barlow, 1993). Indeed, a lth o u g h th ere are few er tre a tm e n t o u tco m e stu d ies for GAD, it has b een show n th a t C o g n i­ tive B ehavioral T h era p y (CBT) is su p e rio r to behav io ral th e ra p y (B utler et al., 1991) a n d n o n d irectiv e th e ra p y (B orkovec & Costello, 1993). A ccordingly, th e m o st successful tre a tm e n ts presen tly available fo r th e tre a tm e n t o f GAD c o m b in e exposure, relaxation tra in in g , a n d cognitive therapy, w ith th e goal o f b rin g in g th e w o rry process u n d e r c o n tro l (Barlow et al., 1998). T his involves exp lo rin g irra tio n a l an x iety -p ro v o k in g th o u g h ts a n d m od ify in g these in te rp re ta tio n s by challenging th e irra ­ tio n a lity o f th e th o u g h ts. T his a p p ro ac h also involves exposure to w o rry co u p led w ith relax atio n (Ballenger, 1999). As one exam ple, Leahy a n d H o lla n d ’s (2000) tre a tm e n t fo r GAD p re ­ scribes a c o m b in a tio n o f relax atio n tra in in g , avoidance c o n fro n ta tio n th ro u g h ex p o su re tech n iq u es, w o rry m o n ito rin g , cognitive evaluation o f th e n a tu re o f w orry in g , in te rp erso n al in te rv en tio n s, stress re d u ctio n , a n d p ro b lem -so lv in g train in g . T his ap p ro ac h also calls for d istin g u ish in g b e ­ tw een p ro d u c tiv e w orry, w hich results in an im m e d ia te plan o f action, a n d u n p ro d u c tiv e w orry, w hich e ith e r does n o t p ro m p t actio n o r p e rta in s to so m e th in g o u tsid e o f o n e ’s co n tro l. Regardless o f type, all w o rry is p o st­ p o n e d u n til a specified w o rry tim e, d u rin g w hich p a tie n ts are req u ired to ru m in a te (w o rry exposure). As an a d ju n c t to this ap p ro ac h , CBASP enables th e th e ra p ist a n d p a tie n t to focus specifically o n excessive, negative, d isto rte d w orries a n d re stru c ­ tu re those w o rry cognitions. In a d d itio n , the th e ra p ist a n d p a tie n t are able to focus on any avoidance b ehaviors o r o th e r b ehaviors th a t m ay w ork to increase w o rry a n d anxiety. H ow ever, th e real b enefit o f in c o rp o ra tin g CBASP in to CBT for GAD m ay be th at the CSQ focuses the p a tie n t (an d th era p ist) o n a specific g o a l— th e DO . It is this focus th a t illustrates how w orries a n d d isto rte d c o gnitions, as well as behaviors, m ay be h u rtin g th e p a tie n t in his o r h er effort to achieve a D O (e.g., re d u c tio n o f w orry ). T he CSQ is also useful in GAD tre a tm e n t because p a tie n ts w ith GAD often c a n n o t focus on a specific w o rry for a long p e rio d o f tim e. T h ey te n d to ju m p from o n e w o rry to the o ther, w hich m ain ta in s th eir elevated anxiety

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levels. T h e p u rp o se o f th e CSQ is to focus th e p a tie n t o n th e th o u g h ts and b ehaviors th a t are m o st helpful in achieving th e D O ; th u s, the CSQ keeps th e p a tie n t a n d th e ra p ist focused on a specific w o rry a n d does n o t p e rm it th e p a tie n t to stray to o th e r w orries. CBASP teaches p a tie n ts to m a in ta in a pro b lem -so lv in g , g o al-o rien te d focus ra th e r th an u nsystem atically shifting th eir a tte n tio n from o n e w o rry to an o th e r, w hich is a typical avoidance m ech an ism . As w ith PCT, n o m o d ific atio n s to the CSQ are necessary w hen in c o r­ p o ra tin g CBASP a n d th e CSQ in to CBT for GAD. It can be easily in c o rp o ­ ra te d in to Leahy a n d H o lla n d ’s (2000) tre a tm e n t for GAD as an exposure tec h n iq u e, b o th in session a n d fo r in vivo exposure, a n d for challenging negative th o u g h ts associated w ith c h ro n ic w orry. H ow ever, w hen using th e CSQ , p a tie n ts sh o u ld focus specifically o n w o rry co g n itio n s a n d beh av ­ iors (such as a v o id an t b ehaviors) th a t exacerbate w o rry a n d anxiety. T he p a tie n t’s D O sh o u ld focus o n co n tro llin g w orry, focusing o n o n e to p ic (o r w orry) at a tim e, a n d re d u cin g anxiety. O nce th e p a tie n t m asters th e te c h ­ n iq u e a n d is freq u en tly achieving th e D O , th e CSQ p rovides a good source o f evidence for challenging re m a in in g w orries. T he follow ing case exam ple illustrates th e ben efit o f CBASP fo r GAD.

C a s e E x a m p l e 2: — -—=■ G e n e r a l i z e d A n x i e t y D i s o r d e r

ct—— .

M ichael is a 23-year-old college stu d e n t w h o p re sen te d w ith concerns a b o u t excessive a n d u n c o n tro llab le w orry. H e cam e to o u r clinic after having a severe anxiety attack, difficulty co n tro llin g w orry, and th o u g h ts o f suicide. At the b eg in n in g o f therapy, he in d icated a m o d ­ erate level o f depression (Beck D epression In v en to ry = 15), a high level o f anxiety (Beck A nxiety In v e n to ry = 27), a n d clinical elevations o n th e M in n e so ta M ultiphasic P ersonality In v e n to ry -2 scales for d epression, p sychasthenia (anxiety), a n d social isolation. At intake, M ichael in d icated th a t his excessive w o rry was m ostly c o n ce n tra ted o n academ ic a n d social failures. H e disclosed th a t the p rim a ry stressors th a t led to his anxiety a tta ck in clu d ed an u n a n tic i­ p a te d increase in his academ ic w orkload, feelings o f to tal isolation, a n d lack o f social su p p o rt. M ichael’s w o rry c o n su m ed m u ch o f his day a n d typically focused on sm all, u n re la te d m atters, such as his gait a n d his perceived lack o f table etiq u ette. M ichael’s anxiety m anifested

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in his self-proclaim ed feelings o f being keyed u p a n d o n edge, w hich was very a p p a re n t in his early sessions. M ichael was diag n o sed w ith GAD a n d O bsessive-C om pulsive P er­ so n ality D iso rd e r (e.g., p re o cc u p atio n w ith lists a n d details, p e r­ fectionism , overly co n scien tio u s a b o u t m orality, a n d reluctance to delegate w ork). T he tre a tm e n t p lan in clu d ed CBT for GAD as o u t­ lin ed in Leahy a n d H ollan d (2000) w ith the in te g ra tio n o f CBASP a n d the CSQ. T h e goal o f this tre a tm e n t plan was to identify a n d challenge any cognitive d isto rtio n s a n d th e a tte n d a n t b ehaviors m a in ta in in g M ichael’s w o rry a n d anxiety to help h im develop a m o re realistic, g o a l-o rien te d a p p ro ac h to his behavior. W h en M ichael cam e to o u r clinic he was engaging in extensive exercise th a t in clu d ed a e ro ­ bics a n d w eight lifting. H e rarely co n su m e d caffeine o r alcoholic bev­ erages. T he th erap ist, therefore, d ecided to direct p rim a ry a tte n tio n to the cognitive a n d behav io ral c o m p o n e n ts o f the tre a tm e n t plan a n d to im p le m e n t ad d itio n al relaxation tech n iq u es as necessary. T he CSQ was used to decrease M ichael’s a v o id an t social behaviors. M ichael sp e n t an in o rd in a te a m o u n t o f tim e w o rry in g a b o u t how o th ers perceived h im (e.g., “if I’m o u t alone p eople will th in k th a t I’m p a th e tic ”). H is incessant w o rry a b o u t o th e rs’ p erce p tio n s o f him often in terfered w ith his e n g ag em en t in p leasurable activities a n d his in itiatio n a n d m ain ten a n ce o f m ean in g fu l a n d in tim ate re la tio n ­ ships. T he CSQ a id e d M ichael in w o rk in g th ro u g h his negative th o u g h ts in session, a n d he was given exposure h o m ew o rk assign­ m en ts th at fu rth e r addressed specific w orries. For exam ple, alth o u g h M ichael enjoyed going to th e m ovie theater, he w ould n o t go alone a n d feared rejection if he asked so m eo n e to a ccom pany h im . A fter w o rk in g th ro u g h a CSQ focusing o n this w orry, M ichael was given an exposure h o m ew o rk a ssig n m en t th a t re q u ire d th a t he ask so m eo n e o u t to a m ovie, a n d go to th e m ovie, even if th e p e rso n he asked refused to a ccom pany him . T he CSQ is also useful in n o n in te rp e rs o n a l situ a tio n s (e.g., w o rry a b o u t academ ic failures). M ichael h a d re c u rre n t d re am s a b o u t failing a high school class, a n d his w orst possible o u tco m e was th a t he w ould be unsuccessful in his career. M ichael’s c o m p e n sa to ry strategy for re d u cin g his fear o f failure (i.e., taking o n to o m an y tasks) h a d th e o p p o site effect. R ather th a n re d u cin g anxiety a n d w o rry a b o u t fail­ ure, M ichael’s c o m p e n sa to ry strategy created m o re stress a n d tim e p ressure, in w hich anxiety an d w o rry were m u ch m o re likely to occur.

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M ichael w o rried daily a b o u t task c o m p le tio n , w hich often led to his use o f p ro c ra stin a tio n a n d d istra c tio n as c o ping m echanism s. T he follow ing is a CSQ taken from an early session in w h ich th e CSQ was useful in d elin eatin g how M ichael’s th o u g h ts a n d b ehaviors w ere w o rk in g against him . Elicitation Phase Situation: Michael had spent a stressful and frustrating night working on a project that was due the following morning. He started work­ ing on the project around 9 p . m . and completed it at 8 a . m . the following morning. Interpretations: God, I am such a slacker___I should have done this earlier___ This is all my fault___I could have prevented this___ I’m doing this much slower than everyone else___Is this what graduate school will be like? Behaviors: Pounded on desk___Paced because I couldn’t concentrate___ Took a break and watched television for a few hours. Desired Outcome: I wanted to work faster and complete the project by

1

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Actual Outcome: I was up all night working on the project. Clearly, M ich ael’s c o g n itio n s w ere n o t conducive to achieving his goal a n d d im in ish e d his ability to focus o n the task at h a n d . A fter d is­ cussing w h e th er M ichael’s in te rp re ta tio n s w ere helpful o r h u rtfu l w ith regards to achieving his DO , he p ro d u c ed the follow ing in te r­ p re ta tio n s a n d beh av io rs th a t w ould have increased th e likelihood o f his DO. Remediation Interpretations: This is not an impossible task___This is taking longer to complete than I expected, but I am making progress, and if

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I continue to w ork on it, I will finish it___In order to finish this on tim e, I need to stay in the m om ent and concentrate on this task. Behaviors: W ork in 1-h r tim e blocks and take sh o rter breaks. Do n o t tu rn on the television. Therapist: M ichael, how w ould it have helped you to com plete the project by 1:00 a . m . if you had th o u g h t, “T his is taking m uch longer to com plete than 1 planned, b u t I am m aking progress, and if I co n ­ tinue to w ork on it I will finish it?” Michael: It m ay n o t have helped m e finish it by 1 a . m ., b u t I d o n ’t thin k I w ould have been so frustrated if I had realized the am o u n t of progress I was m aking and had concentrated on finishing it instead o f everything else that was going on in m y head. And I probably w ouldn’t have watched television so long if I h a d n ’t been so upset, and I w ould have finished soon er th an 8 a . m . Therapist: It sounds like you’re saying that your DO m ay not have been realistic given the circum stances. Michael: So you’re saying that I p u t m ore pressure on m yself by saying that I had to finish by 1 : 0 0 a . m .? Therapist: Is that w hat happened? Michael: Yes, I th in k so. I know th at I d id n ’t plan this o u t very well. I knew about this assignm ent well in advance b u t kept p u ttin g it off. Therapist: Do you do that a lot, p u t things off until the last m inute? Michael: Yes. Therapist: W hy do you th in k th at is? Michael: Som etim es I just underestim ate the a m o u n t o f tim e it takes me to do things, and som etim es I p u t things off because thinking about them makes m e m ore anxious. Therapist: It’s good th at you realize th at p a rt o f your p rocrastination is related to your anxiety. Based on the CSQ th a t we’ve ju st w orked through, how do you thin k your p rocrastination affects your w orry an d anxiety? Michael: I d o n ’t know. It seem s th at w hen I p u t things off until the last m inute, even though I feel b etter w hen I’m no t thinking about it, in the long run it m akes m e m ore anxious and affects the thoughts I have about myself. Therapist: W hat do you m ean? Michael: Well, if I h ad n ’t put this assignm ent off, I w ouldn’t be thinking that I’m a slacker or that I am a failure.

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Therapist: Good. Do you think working through this situation will help you in similar situations in the future? Michael: Definitely. First I don’t think that I will put things off until the very last minute, but if I do, I know that it’s im portant to direct all my attention to the task at hand, and thinking about what should or could have happened is not productive in the m oment. T his tra n s c rip t p rovides a clear d e m o n s tra tio n o f th e use o f th e CSQ tec h n iq u e for red irectin g GAD p a tie n ts’ a tte n tio n away from negative th o u g h ts a n d to w a rd goal-d irected th o u g h ts a n d behaviors. It is clear th a t a lth o u g h M ichael’s initial th o u g h ts did n o t help him get his D O , th ro u g h re m e d ia tio n he was able to generate alternative th o u g h ts. H e was fu rth e r able to recognize th a t given the c irc u m ­ stances, his initial D O was n e ith e r realistic n o r attainable. As this exam ple illustrates, th e CSQ p rovides the th era p ist w ith a useful ex p o su re tool, w hile also allow ing fo r sim u lta n eo u s c h al­ lenge o f negative th o u g h ts a n d avo id an t behavior. Follow ing his 10th session o f CBASP, M ichael’s anxiety a n d ten sio n h a d significantly decreased (Beck A nxiety In v e n to ry = 6) a n d he no lo n g er avoided engaging in enjoyable activities because o f o th e rs’ percep tio n s. Indeed, M ichael expressed his su rp rise at n o t having a n y th in g to w o rry a b o u t d u rin g w o rry tim e.

O B S T A C L E S TO T R E A T M E N T In c o rp o ra tio n o f th e CSQ in to the CBT tre a tm e n t for GAD w as m ade eas­ ier by tw o o f the p a tie n t’s characteristics, intelligence a n d m otiv atio n . W hereas it typically takes p a tie n ts several sessions to get a firm grasp o f the c o n n ec tio n betw een th eir th o u g h ts, behaviors, a n d o u tco m es, M ichael alm o st im m ed iately m ad e the co n n ec tio n . W ith in th e first few sessions, he sta rte d to apply the concept o n his ow n a n d never n eed ed to be p ro m p te d o r re m in d ed to provide a CSQ for each session. A lth o u g h n o t all p a tie n ts m ake su ch speedy progress, steady th e ra p e u tic gains can be expected w ith m o tiv a te d patien ts, regardless o f intelligence level. A n obstacle to a pplying CBASP to th e tre a tm e n t o f GAD is th e distress a n d an x io u s arousal th a t so m e p a tie n ts feel. T his m ay leave th em un ab le o r unw illing to focus on the c o n te n t o f the w orry. T h u s, instead o f focusing o n w o rry specific to o n e c o n te n t area, they m ay focus o n w orries in m u lti­

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pie c o n te n t areas to reduce th e anxiety related to a specific w orry. T his can be p ro b lem atic because CBASP is goal o rien ted a n d requires th e p a tie n t a n d th e ra p ist to focus o n o n e c o n te n t area at a tim e (this is also a re q u ire ­ m e n t o f th e w o rry ex posure c o m p o n e n t o f CBT for GA D; see Brow n, O ’Leary, & Barlow, 1993). In a d d itio n , an x io u s arousal m ay keep the p a ­ tie n t from engaging in exposure exercises a n d discussion o f the CSQ s. It is therefo re helpful to teach relaxation tec h n iq u es a n d use these tech n iq u es in session (o r o u tsid e o f session) w hen th e p a tie n t experiences high levels o f an x io u s arousal th a t interfere w ith th e th e ra p e u tic process a n d in c o m ­ pletin g th e CSQ exercise.

In this chapter, we o u tlin e d the in c o rp o ra tio n o f M cC u llo u g h ’s (2000) CBASP, p a rticu la rly th e use o f th e CSQ , in to em p irically validated CBT for PD (w ith o r w ith o u t ag o rap h o b ia) a n d GAD. T h e CSQ pro v id es a goalo rien ted , pro b lem -so lv in g , focused a p p ro ac h critical to m ak in g th e ra p e u ­ tic gains w ith these disorders. For PD, this goal involves th e re d u c tio n in, or cessation of, p anic sy m p to m s a n d p anic attacks, w hereas fo r GAD the D O is a re d u c tio n in w o rriso m e th in k in g a n d overall anxiety levels. For b o th PD a n d GAD, th e CSQ can be used b o th c o n c u rre n tly a n d prospectively. A lthough this c h ap ter discussed in detail how CBASP can be applied to CBT for PD a n d GAD a n d offered case exam ples from o u r clinic to illus­ trate its successful im p le m e n ta tio n , it sh o u ld be kept in m in d th a t this m e th o d has n o t yet b een em p irically validated. CBASP, how ever, is an em p irically validated tre a tm e n t w ith d epression, and th u s its in c o rp o ra ­ tio n in to em p irically validated tre a tm e n ts fo r PD a n d GAD sh o u ld only en h an ce th e efficacy o f established in te rv en tio n s for these d isorders.

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III

Parents, Children, and Couples

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Chapter

Parents of Children Diagnosed W ith Behavior Disorders*

Parents of children with behavior disorders often focus on the need to change the child’s behavior without recognizing the role that their own thoughts and behaviors play in the perpetuation of family conflicts. This chapter summarizes existing empirically validated treatm ents for externalizing behavior disorders and argues for the incorporation of the Cognitive Behavioral Analysis System of Psychotherapy into these treatments. The unmodified use of the Cognitive Behavioral Analysis System with parents in a group therapy setting is dem onstrated to be an effective means for positively changing parents’ thoughts and behaviors, resulting in improvement not only in children’s behaviors but also in overall family functioning.

D ue to th e disru p tiv e n a tu re o f ex ternalizing behaviors, c o n d u c t diso rd ers are th e m ost freq u en tly cited p ro b lem in b o th clin ic-referred a n d general p o p u la tio n s (Q uay, 1986). E xternalizing beh av io r includes aggressive, a n ti­ social, a n d n o n c o m p lia n t acts th a t are su b su m e d by the c h ild h o o d sy n ­ d ro m es A tten tio n -D efic it/H y p e rac tiv ity D iso rd e r (A D H D ), O p p o sitio n al D efiant D iso rd e r (O D D ) a n d C o n d u c t D iso rd e r (C D ). A D H D is characterized by m u ltip le sy m p to m s o f in a tte n tio n , im p u lsiv ­ ity, o r b o th , th a t are develo p m en tally in co n g ru e n t. T hese sy m p to m s m u st be p re sen t in m u ltip le settings (e.g., school, social, a n d h o m e) fo r at least 6 m o n th s, resulting in significant im p a irm e n t. A lth o u g h this d iso rd e r does *The primary authors contributing to this chapter were Rebecca R. Gerhardstein, Rita Ketterman, and Scharies C. Petty.

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n o t assum e aggressive o r antisocial behavior, A D H D is freq u en tly com o rb id w ith C D (A m erican Psychiatric A ssociation, 1994). M u ltim o d a l tre a tm e n t o f A D H D is suggested, in clu d in g stim u la n t m ed ic atio n , P arent M a n a g em en t T raining (P M T ), a n d sch o o l-b ased in te rv en tio n s focused on classroom b e h av io r a n d academ ic p e rfo rm a n ce (T ripp & S u th erlan d , 1999). T he D iagnostic an d Statistical M a n u a l o f M en tal D isorders-F ourth E di­ tion (D S M -IV ; A m erican Psychiatric A ssociation, 1994) lists tw o cate­ gories o f disru p tiv e b e h av io r disorders: O D D a n d CD. T h e essential feature o f O D D is a re c u rre n t p a tte rn o f negativistic, defiant, d iso b e d ie n t, a n d h ostile b e h av io r to w ard a u th o rity figures characterized by th e freq u e n t o ccu rren ce o f losing o n e ’s tem p er, arg u in g w ith adults, active n o n c o m p li­ ance, a n d deliberate a n n o y an ce o f others. CD is ch aracterized by a p ersist­ e n t p a tte rn o f beh av io r in w hich the rig h ts o f o th e rs a n d ag e-a p p ro p ria te social n o rm s are violated. T h e critical d istin c tio n betw een these tw o d iso r­ ders is th a t O D D b ehaviors are less severe in n a tu re a n d typically do n o t in clu d e aggression to w ard p eople o r anim als, d e stru c tio n o f pro p erty , theft, o r deceit. P atients w ith earlier o n set o f C D are characterized by beh av io r th a t is m o re aggressive in n a tu re , w hereas adolescent o n set reflects m o re d e lin q u e n t behavior, su ch as vandalism a n d th eft (A m erican Psychiatric A ssociation, 1994). A ntisocial b e h av io r (ASB) is d efined by acts th a t reflect social rule v io la tio n s a n d actions against others. A w ide range o f ASB is highly correlated w ith child, p a ren t, a n d fam ily fu n c tio n in g th a t could be c onsidered c o n d u c t-d iso rd e re d b e h av io r (e.g., substance use a n d associ­ a tio n w ith d e lin q u e n t peers); how ever, CD is c onsidered b ey o n d ASB in its frequency, intensity, a n d chronicity, w hich results in im p a irm e n t o f the c h ild ’s ability to fu n c tio n (K azdin, 1997). T he m u ltip le factors a n d pathw ays th a t c o n trib u te to th e etiology o f these d isru p tiv e b e h av io r sy n d ro m e s m ake it difficult to d e te rm in e the exact re la tio n sh ip s b etw een th em (A m erican Psychiatric A ssociation, 1994; K azdin, 1997). C h ild -c e n te red factors (e.g., te m p e ra m e n t, n e u ro lo g i­ cal, cognitive a n d intellectual deficits), p a ren tal factors (e.g., b irth c o m p li­ cations, fam ily h isto ry o f psychopathology, p u n is h m e n t a n d p a re n tin g practices, su p erv isio n o f child, m arital disco rd ), a n d e n v iro n m en ta l factors (e.g., fam ily size, socio eco n o m ic disadvantage, school setting) in te ra c t w ith each o th e r to influence th e d ev elo p m en t o f externalizing b e h av io r on a c o n tin u u m from O D D to CD (K azdin 1998). T he D S M - I V (A m erican Psychiatric A ssociation, 1994) diagnosis o f C D su b su m es th e sy m p to m s o f O D D , reflecting th e b elief th a t o n e d iso rd e r m ay be a sufficient, b u t n o t a necessary, develo p m en tal link to the o ther. In a d d itio n , these risk factors

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m ay result in c o m o rb id anxiety diso rd ers a n d dep ressio n th a t m ay im pede tre a tm e n t efforts (K azdin, 1997,2000).

T R E A T M E N T S FOR E X T E R N A L I Z I N G BEHAVIORS T h ere are several em pirically based tre a tm e n ts fo r ex ternalizing behaviors: PM T, C ognitive P roblem -S olving Skills T rain in g (P S S T ),an d m u ltisystem ic th e ra p y (M ST). Each o f these tre a tm e n ts has repeatedly d e m o n stra te d efficacy in c o n tro lled trials w ith follow -up p e rio d s o f at least 1 year in ch il­ d re n w ith b e h av io r severe e n o u g h to w a rra n t referral to clinical settings (K azdin, 2000). In PM T, it is assu m ed th a t beh av io r p ro b lem s in the child w ill be red u ce d if p a ren ts change th e re in fo rc em e n t c ontingencies th a t m ain tain d ev ian t behavior. T he tec h n iq u es used in PM T are tau g h t to p a ren ts to alter th e ir in te rac tio n s w ith th e ir ch ild ren to red u ce coercive in te rac tio n s (K azdin, 2000). T rea tm e n t typically includes prin cip les o f b e h av io r m a n ­ ag em en t a n d specific skills tra in in g , su ch as a tte n d in g , rew arding, ig n o r­ ing, giving d irections, giving tim e o u t, a n d m a in ta in in g token e conom ies w hen a p p ro p ria te (B rosnan & C arr, 2000; T ripp & S u th erlan d , 1999). T he PM T p arad ig m indirectly a d o p ts a system s perspective (E strada & Pinsof, 1995), w hich is im p o rta n t because m an y fam ilial ch aracteristics, such as psychopathology, c rim in al behavior, substance abuse, h a rsh p u n is h ­ m e n t practices, p o o r su p e rv isio n , p o o r re la tio n sh ip s w ith in family, m a ri­ tal discord, larger fam ily size, low so cio eco n o m ic sta tu s (SES), a n d an o ld er sibling w ith ASB, are each c o rrelated w ith externalizing b ehaviors (K azdin, 1997). PSST is aim ed at co rre c tin g th e cognitive d isto rtio n s a n d deficiencies th a t have been associated w ith teach er ratings o f disru p tiv e behavior, peer evalu ations, a n d direct assessm ent o f overt b e h av io r in a variety o f settings. E xam ples o f such im p a ired cognitive processes include th e g e n era tio n o f alternative so lu tio n s to in te rp erso n al p ro b lem s, th e p la n n in g a n d im p le ­ m e n ta tio n o f steps necessary to achieve a goal, th e re co g n itio n o f c o n ­ sequences related to o n e ’s ow n actions, th e p e rce p tio n o f ho w o th ers feel, a n d th e in te rp re tio n o f o th e rs’ m o tiv a tio n s fo r th e ir actions. C h ild re n are ta u g h t to exam ine th e ir th o u g h t processes th a t guide th e ir beh av io r in in te rp erso n al situ atio n s. S elf-statem ents are ta u g h t to enable th em to d i­ rect a tte n tio n to situ atio n al cues th a t lead to effective solutions. F u rth e r­

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m o re, th e results o f th e child's b e h av io r are also exam in ed to identify and reinforce p rosocial b e h av io r (K azdin, 2000). M ST takes a holistic a p p ro ac h to th e tre a tm e n t o f ex ternalizing b e h av ­ ior th ro u g h the e x am in atio n o f family, peer, school, a n d n e ig h b o rh o o d system s in search o f th e variables th a t lead to the d e v elo p m en t, m a in te ­ nance, o r a m e lio ra tio n o f p ro b lem atic behavior. M ST exam ines the b i­ directio n al in te ra c tio n betw een the child a n d his o r h e r e n v iro n m e n t, w ith a specific focus on how the c h ild ’s b e h av io r affects others. T his tre a tm e n t has b een used p rim a rily w ith d e lin q u e n t adolescents. T he tre a tm e n t goals are b ro a d a n d m ay in clu d e h e lp in g p a ren ts to develop th e a d o lescen t’s prosocial b e h av io r a n d help in g th e m resolve m arital conflicts th a t u n d e r­ m in e p a re n tin g a n d reduce cohesion a m o n g fam ily m em b ers. T he te c h ­ niq u es used to accom plish this include PM T, co n tin g en cy m an a g em e n t, PSST, a n d m arital th era p y (K azdin, 2000). O f the em pirically valid ated tre a tm e n ts for externalizing behaviors, PM T has b een evaluated th e m o st frequently th ro u g h n u m e ro u s ra n d o m ­ ized, c o n tro lled o u tc o m e trials w ith c h ild ren ra n g in g in age fro m 2 to 17 years, across a c o n tin u u m o f severity o f c o n d u c t-d iso rd e re d b e h av ­ ior. B restan a n d E yberg’s (1998) review n a m e d PM T as th e o n ly wellestablished tre a tm e n t for CD. PM T led to su ch vast im p ro v e m en t in c h il­ d re n ’s b e h av io r th a t nonclinical, n o rm ativ e levels w ere o b ta in e d th ro u g h ratings by b o th p a ren ts a n d teachers, th ro u g h d irect o b se rv atio n o f b e h av io r at h o m e a n d school, a n d th ro u g h e x am in a tio n o f in stitu tio n a l records. O ften such gains w ere m a in ta in e d from 1 to 3 years, a n d in one stu d y th ey w ere m a in ta in e d from 10 to 14 years p o sttre a tm e n t. In a d d i­ tio n , in d ire ct tre a tm e n t effects w ere in im p ro v ed sibling b e h av io r in the h o m e a n d decreased d ep ressio n a n d o th e r psychopathology. T he th e o ­ retical fo u n d a tio n o f PM T is stro n g ly based in fam ily system s a n d in te r­ p erso n al d ynam ics, p rin cip les o f social lea rn in g theory, a n d b ehavioral analysis (K azdin, 2000). F or these reasons, PM T w as d e te rm in e d to be the tre a tm e n t o f choice for p a ren ts o f c hildren e x h ib itin g ex ternalizing b e h av io r at o u r clinic. H ow ever, th e lim ita tio n s o f PM T w ere also considered. As w ith any tre a tm e n t, th e p a tie n t m u st agree th a t th e in te rv e n tio n offered is valuable, applicable, a n d effective. P arental c o m m itm e n t to th e in te rv e n tio n facili­ tates c o n sisten t a tte n d an c e, c o n sisten t practice o f th e o b se rv atio n o f the c h ild ’s behavior, consisten t im p le m e n ta tio n , a n d consisten t su p erv isio n o f rew ard a n d p u n ish m e n t schedules to increase the likelihood o f positive outco m es. T his m ay n o t be easily accom plished because p a ren ts frequently

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see th e c h ild ’s b e h av io r as th e p ro b lem a n d p o in t o f in te rv en tio n , ra th e r th a n th e a fo re m en tio n ed risk factors, w hich include p a re n tin g practices. In a d d itio n , the a m o u n t o f social learn in g th e o ry a n d rein fo rc em e n t p r in ­ ciples th a t p a ren ts m u st m aster to sto p the coercive cycle a n d reduce the escalation o f conflict betw een fam ily m em b e rs, im prove th e fam ily envi­ ro n m e n t, a n d increase the c h ild ’s p rosocial b e h av io r m ay be d a u n tin g (K azdin, 2000). Lastly, a d irect p ro b lem -so lv in g skills c o m p o n e n t is n o t delin eated in PM T, despite the success o f PSST w ith p a ren ts o f children w ith externalizing b e h av io r problem s. T he in c o rp o ra tio n o f CBASP (M cC ullough, 2000) offers a p o ten tial so ­ lu tio n to these lim ita tio n s. CBASP p rovides a concrete, system atic m e th o d o f o b se rv atio n a n d analysis o f b o th p a ren tal a n d child beh av io r th a t leads to th e id en tificatio n o f th e a n te ce d e n ts a n d consequences o f behavior, as well as n a tu ra l reinforcers a n d p u n ish ers. T he ability to educate p a ren ts in th e use o f CBASP at h o m e increases th e ir consistency in observ atio n . Analysis o f b e h av io r in b o th p ro b lem atic a n d n o n p ro b le m a tic situ atio n s effectively teaches th e p rin cip les a n d im p o rta n c e o f social lea rn in g theory, w hile p ro v id in g rein fo rc em e n t w ith highly salient, personalized exam ples. P rob lem -so lv in g skills are also ta u g h t a n d increased th ro u g h use o f CBASP. In a d d itio n , its use p ro m o te s th e im p le m e n ta tio n a n d sup erv isio n o f beh av io r schedules. Lastly, CBASP is very p o rtab le. It is a skill th a t p a r­ ents can learn a n d apply in any situ atio n , at any tim e, th ereb y decreasing th e negative im p a c t o f p o o r th e ra p y a tte n d an c e a n d a ttritio n . Two m an u a liz ed P M T tre a tm e n ts by B lo o m q u ist (1996) a n d Barkley (1997) w ere c o m b in e d w ith CBASP to p ro d u c e th e tre a tm e n t used in o u r clinic w ith p a ren ts o f ch ild ren w ho engaged in ex ternalizing behaviors.

I N C O R P O R A T I O N OF C B A S P I N T O P MT B loom quist (1996) a n d Barkley (1997) offer tra in in g for p a ren ts o f ch il­ d re n w ith externalizing b e h av io r diso rd ers, su ch as A D H D , O D D , a n d CD. Barkley focuses p rim a rily o n teaching p a ren ts re in fo rc em e n t strategies to help im p ro v e th e ir c h ild ’s aversive b e h av io r (e.g., forgetting th e ir h o m e ­ w o rk at school, yelling o u t answ ers in class), w hereas B loom quist focuses p rim a rily on teaching p a ren ts m eth o d s for im p ro v in g th e ir c h ild ren ’s social skills (e.g., d e m o n s tra tin g tec h n iq u es for how to initiate a conversa­ tio n w ith an u n k n o w n child). In a d d itio n , B lo o m q u ist offers a section th at helps p a re n ts m anage th eir ow n stress a n d teaches th em ho w to m o n ito r

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their negative thoughts. The n o tio n o f teaching parents how to m o n ito r and perhaps even change their th o u g h ts is consistent w ith the n o tio n that parents need to learn how to m anage them selves before they can help their children to do so. In addition to these beneficial interventions, CBASP offers a relatively sim ple form at for integrating the cognitive an d behavioral teachings o f Barkley (1997) and B loom quist (1996). In the first step (situation), parents describe a specific situation in w hich their child is nonco m p lian t. In the second step (th o u g h ts), parents describe the th o u g h ts th at they are having d u rin g the situation. In the th ird step (behaviors), parents describe w hat they did in the situation (e.g., h ow they acted, h ow they appeared to others, w hat they said). In the fo u rth step (Actual O utcom e, o r AO), parents describe the outcom e o f the situation. In the fifth and final step (D esired O utcom e, o r D O ), parents describe how they w ould have liked the situ a ­ tion to tu rn o u t for them . Typically, the AOs and D O s do n o t m atch. After parents realize th at they d id n o t get w hat they w anted, the real intervention occurs in the rem ediation o f Steps 2 (th o u g h ts) and 3 (behaviors). D uring this process, the focus is on the identification o f helpful or h u rtfu l th o u g h ts and behaviors relative to th eir DO. Should a th o u g h t o r behavior be labeled as hu rtfu l, an alternative, helpful th o u g h t o r b ehavior is identified. In m ost cases, the helpful th o u g h ts o r behaviors com e directly from B loom quist’s and Barkley’s m anuals. B loom quist (1996) suggested that w hen a p a ren t thinks “My child is behaving like a b ra t” an alternative th o u g h t w ould be “My child behaves positively, too.” CBASP offers a fram ew ork to this process by focusing on how a th o u g h t was h u rtfu l and how changing a h u rtfu l th o u g h t to a helpful one aids in the achievem ent o f the p a ren ts’ DO. Focusing on w hat parents ideally w ant from interactions w ith their children m otivates th em to th in k ab o u t how th eir th o u g h ts are im pacting their behavior and, in tu rn , the outcom e o f these interactions. This m otivates parents to change their th o u g h ts and behaviors to have a positive im pact on the interactions w ith their children. Barkley (1997) offers m any exam ples o f how parents can help shape their ch ild ’s behavior, such as rew arding good behavior and ignoring bad behavior. In m any cases this is extrem ely difficult to do. For exam ple, w hen parents d eterm ine a p u n ish m en t for their child and the child throw s a ta n tru m , the parents m ay give in and relinquish the p u n ish m en t. Inadver­ tently, the parents have just negatively reinforced their child for throw ing a tem per ta n tru m (Barkley, 1997). Negative reinforcem ent is often difficult for parents to conceptualize; however, it can be directly illustrated using

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CBASP. In the analysis o f a specific situ atio n , th e th era p ist asks w h e th er the p a re n ts’ b e h av io r o f rem o v in g th e p u n ish m e n t h elped th e m achieve th e DO . T he re co g n itio n th a t specific p a ren tal b ehaviors are n o t w orking, th o u g h difficult to a d m it, is p e rh ap s an easier con cep t to grasp th an a b stract principles o f rein fo rcem en t. A fter the p a ren ts recognize th at rem o v in g the p u n ish m e n t prev en ted them from achieving th eir DO , they m ay be able to see th a t consisten t p u n ish m e n t a n d ig n o rin g the c h ild ’s ta n tru m w ould be m o re helpful in a tta in in g the DO. R einforcem ent, p u n ish m e n t, a n d social lea rn in g p rin cip les are th e basis o f th e in c o rp o ra tio n o f CBASP in to PM T, and these prin cip les are illus­ tra te d in specific situ atio n s th a t are m o re salient to p aren ts. Specifically, helpful th o u g h ts a n d b ehaviors th a t p a ren ts can ultim ately p e rfo rm to achieve goals are identified. CBASP is c o n sisten t w ith th e concepts a dvo­ cated by B loom quist (1996) a n d Barkley (1997), a n d it p rovides a vehicle by w hich in -d e p th illu stra tio n o f social lea rn in g prin cip les can o c cu r in a way th at is m ean in g fu l a n d n o n th re a te n in g to p aren ts. Because the u n d e r­ sta n d in g o f social lea rn in g p rin cip les is related to b e tte r tre a tm e n t o u t­ com es (K azdin, 1997), th e in c o rp o ra tio n o f CBASP in to P M T m ay increase tre a tm e n t effectiveness. T he in c o rp o ra tio n o f CBASP in to PM T also reduces p a re n ts’ ten d en cy to use session tim e to c o m p lain , w hich is n o n p ro d u c tiv e. T he specificity in Step 1 a n d the c h an g in g o f p a ren tal th o u g h ts a n d b ehaviors in Steps 2 and 3 m o tiv ate change by forcing p a ren ts to focus o n w hat th ey w ant a n d on m eth o d s th a t will help th e m to achieve th o se outco m es. Also, the system ­ atic fram ew o rk th a t CBASP affords is likely to increase consistency in p a ren tal behavior, w hich is freq u en tly cited as key to im p ro v ed p a re n tin g and increased desired b e h av io r in ch ild ren (B lo o m q u ist, 1996). A n a d d ed benefit o f CBASP is th a t it is th e cru x o f an em p irically vali­ d ated tec h n iq u e used in c h ro n ic dep ressio n (Keller et al., 2000). M any p a ren ts w h o have struggled to deal w ith difficult ch ild ren re p o rt d e p res­ sive sy m p to m s (B lo o m q u ist, 1996). CBASP was devised to help p a tie n ts c o u n te r negative th o u g h ts th a t exacerbate o r m ain tain depression. T he sam e tec h n iq u e can be used to help p a re n ts beco m e aw are o f negative eval­ u a tio n s th a t are m ad e a b o u t th e ir ch ild ren , th e ir p a re n tin g skills, th e ir c ir­ cum stances, a n d th e ir spouse o r them selves. It can also be used n o t only to illustrate th e re la tio n sh ip s in th e im m e d ia te situ a tio n b u t also to e m p h a ­ size the lo n g -te rm em o tio n al consequences o f h a rb o rin g su ch beliefs. M any benefits o f using CBASP w ith p a ren ts o f ch ild ren w ith A D H D , O D D , o r CD have been observed in session. As w ith m o st psychosocial

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trea tm e n ts, the o u tco m e o f PM T is affected by the d u ra tio n o f tre a t­ m e n t (K azdin, 1997). O ften, p a ren tal resistance to PM T results in reduced in-session p a rtic ip a tio n , tre a tm e n t d issatisfaction, a n d p a ren tal n o n c om pliance (E strada & P insof, 1995). T rea tm e n t n o n c o m p lian c e is likely increased by the presence o f p a ren tal characteristics th a t have been associ­ ated w ith the d e v elo p m en t a n d m ain ten a n ce o f ex ternalizing b e h av io r in ch ild ren , such as h arsh , lax, erratic, a n d in co n siste n t discip lin ary practices; alcoholism ; c rim in al b ehavior; m arital discord; in te rp erso n al conflict and inequality; a n d aggression. In a d d itio n , re la tio n sh ip s b etw een th e p a re n t a n d child m ay be less accepting, less w arm , less affectionate, a n d less e m o tio n ally su p p o rtiv e, w hich results in red u ced a tta c h m e n t a n d in te r­ actio n (K azdin, 1997). T he analysis o f th o u g h ts a n d b ehaviors m ay illu­ m in a te fam ily dynam ics th a t m ay affect tre a tm e n t effectiveness, a n d c o n ­ sid e ratio n sh o u ld be given to h a n d lin g these issues in in d iv id u al o r couples sessions. In a d d itio n , CBASP enables the th e ra p ist to c o n fro n t ineffectual p a ren tal a n d in te rp erso n al b e h av io r in an in d ire ct m an n e r, w hich decreases resistance. Im p o rta n tly , th e CBASP tec h n iq u e o f p ro b lem solving can be ta u g h t to ch ild ren as well as p a ren ts (see C h a p te r 9, this volum e). T he tec h n iq u e becom es, in effect, a c o m m o n o p e ra tin g system th a t allows p a ren ts a n d ch ild ren to discuss p ro b lem atic in te rp erso n al in te rac tio n s in a n o n ju d g m en tal, n o n c o n fro n ta tio n a l m an n er. A necdotal evidence show s th a t the ap p licatio n o f CBASP in this m a n n e r reduces escalation o f e m o tio n a n d reinforces lessons ta u g h t in session. Lastly, prospective use o f CBASP can be helpful in a n tic ip a tio n o f situ atio n s w here m isb eh av io r is likely to occur. P arents and ch ild ren can be ta u g h t to sta rt w ith th e ir D O and d e te r­ m in e th e th o u g h ts and b ehaviors th a t increase the likelihood o f o b tain in g satisfactory results.

BRI EF D E S C R I P T I O N OF G R O U P T H E R A P Y C o n d u c tin g PM T in g ro u p settings in n o t u n c o m m o n . T here are several benefits to the g ro u p th e ra p y a p p ro ac h . First, it helps w ith tre a tm e n t c o m ­ pliance to see o th e r p a ren ts regularly b rin g in g in h o m ew ork. It creates social pressure for any negligent p a ren ts to b rin g in th e ir h o m ew o rk as well. In a d d itio n , m an y p a ren ts find it useful to h ear o th e rs discussing th eir im p le m e n ta tio n o f the p rin cip les o f b o th CBASP a n d PM T. N o t only can th ey relate to the p ro b lem atic situ atio n s th a t o th e r p a re n ts b rin g up, b u t

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also th ey can learn from o th e r p a re n ts’ m istakes a n d successes. M oreover, w hen a p a re n t is stru g g lin g w ith th e steps o f CBASP, it is invaluable if th ere are o th e r p a ren ts available to offer suggestions a b o u t alternative th o u g h ts a n d behaviors th a t m ay have been helpful in th e situ atio n . For each case the a d u lt g ro u p follow ed a 12-week itin e ra ry stressing an in te g ra tio n o f B lo o m q u ist (1996), Barkley (1997), a n d M cC ullough’s (2000) techniques. A lth o u g h the follow ing cases a n d tre a tm e n t plan are exam ples o f the c o m b in a tio n o f CBASP a n d PM T in a g ro u p setting, it is possible th a t th ey can be applied to in d iv id u al cases as well. T he C oping Skills Q u e stio n n a ire (C SQ ) is th e p rim a ry to o l by w hich CBASP is im p le ­ m en te d in th is a p p ro ac h . It consists o f a single sheet o f p a p e r (assigned for h o m ew o rk every w eek), w hich lists th e five steps o f CBASP (i.e., situ atio n , th o u g h ts, behaviors, AO, a n d D O ). An o u tlin e o f the g ro u p fo rm at is show n in Table 8.1. To best illustrate th e in te g ratio n o f CBASP a n d PM T, tw o case exam ples are presen ted . B oth fam ilies a tte n d e d sim u lta n eo u s p a re n t a n d child g ro u p s offered at o u r clinic: o n e g ro u p was fo r p a ren ts only a n d one fo r ch ild ren only. (F or a co m p lete d e sc rip tio n o f th e child g roup, see

TABLE 8.1 Outline of Group Format

Week

Description of Activities

Week 1

Introduction and Chapter 3 from Bloomquist (1996) Discussion of stress management, the coercive cycle, and consistency Homework: Work on stress management techniques

Week 2

Review consistency and Chapter 4 from Bloomquist (1996) Introduction of McCullough’s Coping Skills Questionnaire (CSQ) Steps 1 through 5 Discussion of changing hurtful thoughts into helpful thoughts, including an integration of Bloomquist’s Chapter 4 and McCullough’s Step 2 of the CSQ (thoughts) The impact of Step 2 of the CSQ (thoughts) on Steps 4 and 5 (outcomes) is considered. Homework: Complete a CSQ

Week 3

Review consistency and review the CSQ Each parent’s CSQ homework is considered within the group. Should any parent have difficulty changing hurtful thoughts to helpful thoughts, the group is consulted. Homework: Complete a CSQ (Continued)

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TABLE 8.1 (Continued) Week

Description o f Activities

Week 4

Review consistency, the CSQ, and Steps 2 and 3 from Barkley (1997) Each parent’s CSQ is considered w ithin the group. Discussion o f Step 3 o f the CSQ (changing hurtful behaviors into helpful behaviors) follows with an em phasis on the techniques from Steps 2 and 3 from Barkley (paying attention and rew arding good behavior). The im pact o f Step 3 o f the CSQ (behaviors) on Steps 4 and 5 (outcom es) is considered. H om ework: C om plete a CSQ

Week 5

Review consistency and the CSQ Each parent’s CSQ hom ew ork is considered w ithin the group. Should any parent have difficulty changing hurtful behaviors into helpful behaviors, the group is consulted. H om ework: C om plete a CSQ

Week 6

Review consistency, the CSQ, and Step 5 from Barkley (1997) Each p aren t’s CSQ is considered w ithin the group. Discussion o f Step 3 o f the CSQ (changing hurtful behaviors into helpful behaviors) follows with an em phasis on the techniques from Step 5 o f Barkley (ignoring bad behavior). The im pact o f Step 3 o f the CSQ (behaviors) on Steps 4 and 5 (outcom es) is considered. H om ework: C om plete a CSQ

Week 7

Review consistency and the CSQ Each p aren t’s CSQ hom ew ork is considered w ithin the group. Should any parent have difficulty changing hurtful thoughts and behaviors into helpful thoughts and behaviors, the group is consulted. H om ework: C om plete a CSQ

Week 8

Review the CSQ and Step 4 from Barkley (1997) Each p aren t’s CSQ is considered w ithin the group. Discussion o f Steps 2 and 3 o f the CSQ (changing hurtful thoughts and behaviors into helpful thoughts and behaviors) follows. The im pact o f Steps 2 and 3 o f the CSQ on Steps 4 and 5 (outcom es) is considered. Barkley's Step 4 (token econom y) is reviewed as a m ethod for consistently rew arding good behavior and ignoring bad behavior w ithin the hom e. H om ework: C om plete a CSQ, consider token econom y (Continued)

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TABLE 8.1 (Continued) Week

Description o f Activities

Week 9

Review CSQ and token econom y Each parent’s CSQ is considered w ithin the group. Discussion o f Steps 2 and 3 o f the CSQ (changing hurtful thoughts and behaviors into helpful thoughts and behaviors) follows. The im pact o f Steps 2 and 3 o f the CSQ on Steps 4 and 5 (outcom es) is considered. Problem solving the im plem entation o f Barkley’s token econom y w ithin the household is reviewed. H om ework: Com plete a CSQ

Week 10

Review the CSQ and Step 8 from Barkley (1997) Each p a ren t’s CSQ is considered w ithin the group. Discussion o f Steps 2 and 3 o f the CSQ (changing hurtful thoughts and behaviors into helpful thoughts and behaviors) follows. The im pact o f Steps 2 and 3 o f the CSQ on Steps 4 and 5 (outcom es) is considered. Barkley’s Step 8 (behavioral report card) is reviewed as a m ethod for consistently rew arding good behavior and ignoring bad behavior w ithin the classroom environm ent. H om ework: Com plete a CSQ and consider the behavioral report card

Week 11

Review the CSQ and the behavioral report card Each p aren t’s CSQ is considered w ithin the group. Discussion o f Steps 2 and 3 o f the CSQ (changing hurtful thoughts and behaviors into helpful thoughts and behaviors) follows. The im pact o f Steps 2 and 3 o f the CSQ on Steps 4 and 5 (outcom es) is considered. Problem solving the im plem entation o f Barkley’s behavioral report card w ithin the classroom environm ent is reviewed. H om ework: C om plete a CSQ

Week 12

Review the CSQ and C hapter 6 from Bloom quist (1996) Each p aren t’s CSQ is considered w ithin the group. Discussion o f Steps 2 and 3 o f the CSQ (changing hurtful thoughts and behaviors into helpful thoughts and behaviors) follows. The im pact o f Steps 2 and 3 o f the CSQ on Steps 4 and 5 (outcom es) is considered. B loom quist’s strategies for positive familial interactions are reviewed. Parents are encouraged to continue using the CSQ on their own.

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C h a p te r 9, this v olum e.) P rio r to b o th fam ilies’ atte n d an c e at th e first g ro u p session, th ey co m p leted interview s to d e te rm in e th e p resen tin g p ro b lem a n d to d e te rm in e w h e th er th ey w ere c onsidered a p p ro p ria te a d d itio n s to th e groups.

•—--5

C a s e E x a m p l e 1 =—

Susan is a 39-year-old m o th e r o f th ree. H er d a u g h te r G retch en is 10 years old a n d the m id d le child in h e r family. G re tch e n ’s father lives w ith th e m at h o m e b u t was n o t a p a rt o f tre a tm e n t. Susan first b ro u g h t G retchen to th e clinic because she w a n ted help teaching G retchen p eer relatio n skills. Susan also w a n ted to reduce G re tch e n ’s freq u e n t e m o tio n al o u tb u rsts, w hich w ere b e g in n in g to interfere n o t only w ith G retch en ’s re la tio n sh ip s w ith h e r friends b u t also w ith h e r re la tio n sh ip s at h o m e. G retch en received a diagnosis o f O D D a n d was referred to th e child group. Susan was n o t diag n o sed , b u t it was clear from h e r interv iew th a t she was experiencing depressed m o o d a n d c h ro n ic stress related to th e p ro b lem s th a t she was having w ith G retchen. Susan was referred to th e c o rre sp o n d in g a d u lt g roup. T he follow ing is a tra n s c rip t o f an unsuccessful CSQ w ith Susan. Unsuccessful CSQ Step 1: Situation I asked Gretchen if she thought it was time for bed, and we ended up getting into an argum ent about her bedtime. She was trying everything she could to get me to agree to let her stay up. I was getting angry, and she was throwing a temper tantrum . Step 2: Thoughts She knows exactly what to say to me to get me angry. I m ust be a very bad m other because I don’t know how to get her to stop. Maybe I should just let her have it her way and enforce my rules next time. Step 3: Behaviors I yelled some more but got so tired of our argum ent that I gave in and let her stay up another 30 min.

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Step 4: AO Gretchen stopped yelling, but she didn’t go to bed on time. I didn’t enforce my rules. Step 5: DO I wanted Gretchen to stop yelling at me. I wanted her to go to bed on time like I had told her. I really wish I hadn’t yelled at Gretchen and that I could enforce my rules without yelling. W h en discussing Susan’s CSQ , th e g ro u p d ecided to focus on Susan’s D O o f enforcing rules w ith o u t yelling. It was d e te rm in e d th at n o n e o f Susan’s th o u g h ts w ere help in g h e r to calm ly enforce h er rules. E xam ples o f so m e alternative th o u g h ts w ere suggested, such as “If I give in to h e r this tim e, th e next tim e I w a n t G retch en to do so m e th in g she will be less likely to do it” and “R em ain calm . Yelling at G retch en is n o t going to m ake h e r any m o re likely to go to bed.” T he g ro u p d e te rm in e d th a t b o th o f these th o u g h ts w ould likely help Susan to enforce h e r rules w ith o u t yelling. In a d d itio n , th e gro u p d ecided th a t Susan’s beh av io r o f lettin g G retchen stay u p later was n o t h elping Susan enforce h er rules. Instead, it was suggested th at Susan escort G retchen to h e r b e d a n d tu rn off the lights; rem ove d is­ trac tio n s, such as television a n d v ideo gam es; speak in a calm n o n o n se n se voice telling ( n o t asking) G retch en th a t it is tim e for bed. Finally, Susan a n d th e g ro u p w ere asked w h e th er Susan w ould have b een m o re likely to get w h a t she w an ted if she had used th e a lte rn a ­ tive th o u g h ts a n d behaviors. T he g ro u p agreed th a t she p ro b ab ly w ould have g o tten w hat she w a n ted using helpful th o u g h ts a n d actions. T he follow ing are Susan’s responses o n a successful CSQ. Successful CSQ Step 1: Situation Gretchen and I were driving in the car, and she was really irri­ tating me. She was being loud and kicking the back of my seat really hard. I told her to stop, and she did not stop. I was getting more and more angry at her. Step 2: Thoughts I thought she was being a complete brat.

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Wait, remember what we have talked about in group? You can control your own thoughts and behaviors. You know what to do. Relax. Ignore her. She will stop. Step 3: Behaviors I stopped the car and turned the radio off and didn’t say another word to her. Step 4: AO This was the first time that I actually got what I wanted. I con­ trolled my reaction to my daughter. The really cool thing was that by controlling my reaction to Gretchen, I impacted her behavior, too (she stopped). Step 5: DO I really wanted Gretchen to stop kicking my seat, but I know that I couldn’t completely control that. What I wanted for myself was to control my reaction to her (not yell, not swerve on the road). T h ro u g h o u t th e course o f tre a tm e n t, Susan m ad e a g reat deal o f progress w ith h e r ab ility to evaluate h er th o u g h ts a n d behaviors. T his exam ple rep resen ts th e first tim e th a t she actually em ployed th e CSQ w hile she was in a situ atio n . A fter weeks o f co n sid erin g the h e lp fu l­ ness o f h e r th o u g h ts a n d a ctio n s p o st hoc, she finally to o k the m u c h needed step a n d applied th e CSQ tec h n iq u es d u rin g th e situ atio n . She excitedly b ro u g h t this CSQ b ack to th e g ro u p a n d was m et w ith m an y accolades. Because o f this rein fo rcem en t, she c o n tin u e d to use th e CSQ tec h n iq u e for th e re m a in d e r o f th e g ro u p sessions.

•— - - s

C a s e E x a m p l e 2 =—

C heryl is a 45-year-old m o th e r o f three. N a th an is 12 years old and the youngest child in his family. N a th a n ’s ste p fath er lives w ith th em at h o m e, b u t was n o t a p a rt o f th e g ro u p tre a tm e n t. C heryl first b ro u g h t h e r son N a th an to the clinic because o f p ro b lem s w ith anger co n tro l, class d isru p tio n , social p ro b lem s, a n d academ ic difficulties. She w an ted an evaluation a n d possibly th era p y for h e r son. N ath an received a diagnosis o f A D H D a n d O D D a n d was referred to th e child

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g r o u p . C h e r y l w a s n o t d ia g n o s e d , b u t it w a s c le a r fr o m h e r in te r v ie w t h a t sh e w a s e x p e r ie n c in g d e p re s s e d m o o d a n d c h r o n ic stre s s re la te d to th e p r o b le m s t h a t sh e w a s h a v in g w ith N a th a n . C h e r y l w a s re fe rr e d to th e c o r r e s p o n d i n g a d u lt g r o u p . In a d d it i o n , b o th m o th e r a n d s o n w e re re c e iv in g in d iv id u a l th e ra p y . C h e r y l’s re s p o n s e s o n a n u n s u c ­ c essfu l C S Q follow . U n su ccessful CSQ Step 1: S ituation N ath an was n o t listening to m e. I asked him repeatedly to clean u p his ro o m , a n d he w as w atching T V instead. 1 fo u n d m yself getting m o re a n d m ore an g ry at him . Step 2: T h o u g h ts He w as d riving m e absolutely crazy. If he do esn ’t m ake som e m o v em en t tow ard his ro o m really so o n , I am going to grab him a n d shake him u n til he listens to m e. M aybe if I sta n d rig h t next to him and yell in his ear, h e will do w hat I w ant h im to do. Step 3: Behaviors I yelled at him , saying, “If you d o n ’t clean up yo u r ro o m right now, y ou are going to get a w hooping.” I ran a n d got m y p ad d le a n d w aved it in fro n t o f his face. Step 4: AO N a th an cleaned his ro o m b u t only after I yelled a n d th rea te n e d him . I got really angry. I’ll bet m y b lo o d p ressure w en t up 30 points! Step 5: DO I w a n ted N a th an to listen to m e o n th e first try. I w an ted him to obey m e a n d n o t m ake m e angry. I w an ted to n o t let him have so m u c h c o n tro l over m y em o tio n s. I w anted N a th an to clean his room . W h e n re v ie w in g th e C S Q , th e g r o u p re a liz e d t h a t C h e ry l h a s v e ry little c o n tr o l o v e r a n y o f h e r D O s . T h e y a sk e d h e r to d e te r m in e w h e th e r th e r e w e re a n y re a lis tic D O s w ith w h ic h C h e r y l c o u ld b e sa tis fie d . S h e s e ttle d o n th e o u tc o m e o f n o t lo s in g h e r s e lf -c o n tro l

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(i.e., n o t yelling, n o t w aving th e p a d d le in fro n t o f N a th a n ’s face). It w as d e te rm in e d th a t n o n e o f C h e ry l’s th o u g h ts w ere h e lp in g h e r m a in ta in h e r c o m p o s u re . S om e a lte rn a tiv e th o u g h ts w ere g e n era te d , su c h as “ I n e e d to relax b efo re I sp eak w ith N a th a n ,” “ M aybe I sh o u ld p ra ctic e so m e o f m y stress m a n a g e m e n t te c h n iq u e s,” a n d “ M y t o u c h ­ in g N a th a n is n o t g o in g to h e lp m e re m a in calm ; h e will likely fight b a c k a n d I w ill really lose c o n tro l th e n .” T h ese th o u g h ts fo c u sed on th e c o n se q u en c es o f C h e ry l’s actio n s, w h ic h c o u ld h e lp h e r m a in ta in h e r c o m p o s u re w h e n d e alin g w ith N a th a n . In a d d itio n , th e g ro u p d e c id e d th a t yelling a n d w aving th e p a d d le in fro n t o f N a th a n ’s face w as n o t h e lp in g h e r m a in ta in se lf-co n tro l. In ste ad , th e g ro u p su g ­ gested th a t C h e ry l re m o v e h e rse lf fro m th e s itu a tio n a n d e m p lo y a stress m a n a g e m e n t te c h n iq u e . C h e ry l a n d th e rest o f th e g ro u p ag reed th a t she p ro b a b ly w o u ld have g o tte n w h a t she w a n te d if she h a d u sed m o re h e lp fu l th o u g h ts a n d b e h av io rs. Successful CSQ Step 1: Situation N athan misplaced a toy. I let him look around for it on his own, but he gave up saying, “Never m ind. I can’t find it.” I volun­ teered to help him look for his toy, b u t he yelled at me saying, “You don’t trust me. You m ust think I’m stupid.” Step 2: Thoughts This toy has to be somewhere; he just got it today. Nathan thinks that this is all my fault, and he’s m ad at me. Whoa! I’m doing that again! Cut it out. It’s not your fault. This is not w orth getting worked up over. Step 3: Behaviors I really thought about yelling back at him that I do love him and trust him , but I held my tongue. Instead, I simply said that I do trust him ; I stopped looking for the toy and went back to my work. Step 4: AO I got what I wanted! Step 5: DO To get through this situation w ithout yelling at Nathan. That would have only m ade me feel worse about it.

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C h e ry l’s success is sim ilar to th a t o f Susan. A fter several weeks o f co n sid erin g th e h u rtfu ln e ss o f h e r th o u g h ts a n d b ehaviors in m an y o f th e in te rac tio n s w ith h e r son, C heryl finally began to m ake changes in h er th o u g h t p attern s. T his was all it took. T he helpful th o u g h ts th a t she had practiced g e n era tin g in g ro u p on a w eekly basis began to p e n e tra te h er th o u g h ts in the situ a tio n as it was h a p p en in g . O nce she was able to th in k helpful th o u g h ts, she fo u n d th at helpful b ehaviors n atu rally flowed from th em . As a result, h e r AO m atc h ed h e r DO. Just as in Susan’s case, C heryl c o n tin u e d to use th e CSQ tec h n iq u e fo r the re m a in d e r o f the g ro u p sessions.

O B S T A C L E S TO T R E A T M E N T T h ro u g h o u t th e course o f th e 12 sessions, several obstacles w ere e n c o u n ­ tered th a t p o ten tially lim ited th e effectiveness o f the tre a tm e n t. P rim ary a m o n g the obstacles was a tten d an ce. O f th e seven p a ren ts w ho atte n d ed the a d u lt g ro u p each sem ester, only th ree to fo u r a tte n d ed o n a regular basis. T hese th ree to fo u r p a ren ts w ere th o se w ho achieved th e m axim al benefit from th e group. A n o th e r obstacle to tre a tm e n t was resistance. M any o f the p a ren ts ex­ pressed c oncern th at it was n o t th eir b e h av io r th at needed to change b u t th e ir ch ild ren ’s behavior. T hey d id n ’t u n d e rsta n d how focusing on th eir th o u g h ts a n d actions w ould help im prove th e ir c h ild ren ’s behavior. In dealing w ith this resistance, we discussed tw o issues. T he first was w h e th er o r n o t w hat th ey w ere d o in g was w o rk in g fo r th em . T he response to this was a re so u n d in g no. M any o f th e m trie d one p u n ish m e n t after a n o th e r w ith o u t en fo rcin g it consistently en o u g h for it to be effective. O th e rs w ere m asters o f consistency, b u t th e b e h av io r th a t th ey w ere consistently re in ­ forcing was th eir c h ild ’s bad behavior. For exam ple, o n e p a re n t w ould yell at h e r child every tim e he w o u ld do so m e th in g anno y in g . T his p a re n t was in ad v e rte n tly rein fo rcin g the c h ild ’s b a d b e h av io r w ith a tte n tio n , albeit negative a tte n tio n . Social lea rn in g p rin cip les w ere tied to these p ro b le m ­ atic beh av io rs to reiterate th a t b o th positive a n d negative a tte n tio n are rein fo rcin g to a child. As p a ren ts realized th a t past p a ren tal practices had n o t b een effective, th ey becam e m o re w illing to co n sid er alternative stra te ­ gies to b e h av io r m an ag em en t. In a d d itio n , the belief th at p a ren ts have direct co n tro l over th e ir ch il­ d re n ’s b e h av io r was challenged. T he d istin c tio n betw een in fluencing th eir

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c h ild ren ’s b e h av io r a n d c o n tro llin g it w as m ad e to identify a m o re logical p o in t o f in te rv en tio n : p a ren tal th o u g h ts a n d behaviors. Also, th e im p o r­ tan ce o f m o d elin g th e tec h n iq u e to th e ir ch ild ren w as stressed as a m ajo r factor in facilitation o f im p ro v ed behavior. T he im p o rta n c e o f consistency was stressed th ro u g h o u t. For exam ple, we focused o n the im p o rta n c e o f staying w ith o n e strategy. If p a re n ts consistently m o n ito re d th e ir ow n th o u g h ts a n d behaviors, they w ould n o t only be able to achieve p erso n al o u tco m e s th a t w ere desirable, b u t also th ey m ay in ad v erten tly influence th e ir c h ild ’s beh av io r in th e process. By b e co m in g m o re consisten t people, th ey becam e m o re consisten t p a ren ts, a n d th e ir ch ild ren n oticed. T he final obstacle in these g ro u p s is typical to any a p p lic atio n o f the CSQ. Initially, it is difficult to get th e client to focus o n realistic D O s. C o n ­ sider the unsuccessful CSQ s for b o th Susan a n d G retchen a n d C heryl a n d N ath an . In b o th cases, the m o th e rs’ D O s w ere related to th e ir children acting differently. O u r strategy was to go b ack th ro u g h th e CSQ a n d see w h e th er th ere was a n y th in g they could have said o r d o n e to get th e ir ch il­ d re n to behave differently. In m o st cases, th ere w ere som e actions th a t m ay have forced the ch ild ren in to o beying (e.g., span k in g , yelling, th rea te n in g ), b u t th e p a ren ts w ere n o t pleased w ith these actions as o p tio n s because th ey w ould n o t feel like good p a ren ts after th ey em ployed th em . T his process allow ed the g ro u p to un co v er alternative D O s, those th a t w ere m o re w ith in the realm o f th e p a re n ts’ co n tro l a n d th u s m o re realistic. As in o u r two unsuccessful CSQ exam ples, these m o re controllable, realistic ou tco m es usually h a d so m e th in g to do w ith the actio n s, feelings, o r th o u g h ts o f the p a ren t, n o t the child. It to o k several weeks to get the p a ren ts th in k in g o f the in te rac tio n s w ith th e ir ch ild ren in a self-focused way, b u t th e results w ere p ro m isin g . N o t only did we see p a ren ts w ho w ere atten tiv e to th in k ­ ing a n d acting in a consisten t m a n n e r w ith th e ir c h ild ren , b u t we saw the consistency generalize to o th e r areas o f th e p a re n ts’ lives. W e saw p a ren ts in te rac tin g b e tte r w ith th e ir spouses, w ith th e ir parents, a n d w ith th e ir col­ leagues. A nd, as often h a p p en s w hen p a tie n ts begin th in k in g a n d behaving in a consistent, helpful m an n e r, p a ren ts w ere able to shape o r influence the b e h av io r o f those a ro u n d th em , in clu d in g th e ir c hildren.

O u r case stu d ies illustrate the beneficial im p a c t o f CBASP w hen in c o rp o ­ ra te d in to existing m an u a liz ed PM T tre a tm e n ts for use w ith p a re n ts o f pread o lescen t boys a n d girls w ho exh ib it ex ternalizing b e h av io r problem s.

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A lth o u g h the evidence at this ju n c tio n is an ecd o tal in n a tu re , we believe th a t the in clu sio n o f CBASP is su p p o rte d theoretically. In the fu tu re, research p ittin g th e c o m b in a tio n o f CBASP a n d PM T against PM T alone w ould help distin g u ish w h e th er th e inclusion o f CBASP has any in c re m e n ­ tal v alidity in th e tre a tm e n t o f c h ild h o o d ex ternalizing b ehaviors in term s o f decreased p a ren tal resistance, increased tre a tm e n t c om pliance, b e tte r iden tificatio n o f p ro b lem atic behavior, a n d increased sh o rt- a n d lo n g -te rm tre a tm e n t effects.

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Chapter

C hildren W ith Social Skills Deficits*

Social skills deficits are com m on am ong children with a variety of behavioral problem s including A ttention-D eficit/H yperactivity Dis­ order, O ppositional Defiant Disorder, and C onduct Disorder. Chil­ dren with these disorders often engage in negative behaviors that are intended to gain attention but that actually result in a lack o f peer acceptance and, ultimately, peer rejection. This chapter dem onstrates how the Cognitive Behavioral Analysis System o f Psychotherapy can be modified for use with children, both in the individual therapeutic setting and in the group therapeutic setting. Two case examples p ro ­ vide support for the m odification o f the Cognitive Behavioral Analy­ sis System o f Psychotherapy, with particular em phasis on the analysis of the behavioral aspects o f the treatm ent. However, consideration to children’s own thoughts and feelings as well as the thoughts and feel­ ings o f others is also stressed in the m odification o f the technique.

In his b o o k a b o u t c h ild re n ’s social re la tio n s h ip s , A sh er (1990) d escrib es so m e o f th e m a n y fu n c tio n s o f frie n d s in c h ild h o o d . H e states th a t c h il­ d re n ’s frien d s “serve as so u rc es o f c o m p a n io n s h ip a n d re c re a tio n , sh a re advice a n d v alu ed p o ssessio n s, serve as tru s te d c o n fid a n ts a n d critics, a ct as loyal allies a n d p ro v id e sta b ility in tim e s o f stress o r tra n s itio n ” (p. 3). M a n y c h ild re n navigate th e ir social w o rld w ith o u t difficulty, m a k in g a n d k eep in g frie n d s h ip s th a t are m e a n in g fu l a n d fulfilling. H ow ever, so m e c h il­ d re n fin d frie n d m a k in g tric k y a n d o ften e stab lish p a tte rn s o f ineffective p e e r re la tio n sh ip s. P ro b le m a tic p e e r re la tio n s have b e e n a sso ciated w ith a ‘The primary authors contributing to this chapter were Karla K. Repper and Kimberly A. Driscoll. 139

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variety o f negative outcom es, including higher rates o f delinquency, p ro b ­ lem s in school, and later psychopathology. Research has d em o n strated that children w ith a variety o f behavioral problem s struggle significantly w ith peer relations, experience peer rejection, and, n o t surprisingly, display social skills deficits (M cM ahon & Wells, 1998). Schaefer, Jacobsen, an d G h ah ram an lo u (2000) define social skills as the ability to interact appropriately w ith peers in a given social context. Social skills include interactions that are acceptable, valued, and beneficial and include the abilities to co m m unicate effectively, to dem o n strate good sportsm anship, to resolve conflicts quickly, and to enter into conversations and groups w ith ease. Social skills likely con trib u te to social com petence. C hildren w ho display social skills deficits in prosocial situations often resort to m ore severe co n d u ct p ro b lem -rela te d behaviors to gain attention (Slaby & Crowley, 1977), which can result in a lack o f peer acceptance and, ultim ately, p eer rejection. T he Diagnostic and Statistical M anual-F ourth Edition (A m erican Psy­ chiatric A ssociation, 1994) includes three disorders u n d e r the category o f A ttention Deficit H yperactivity and D isruptive Behavior D isorders: A ttention-D eficit/H yperactivity D isorder (A D H D ), O ppositional D efiant D is­ o rd er (O D D ), an d C on d u ct D isorder (C D ). T he prevalence rates for these disorders are 3 % -5 % in school-age children for A D HD, 2% —16% for OD D , and 6% —16% for boys and 2 % -9 % for girls for CD (A m erican Psy­ chiatric A ssociation, 1994). Aggression, disruptiveness, and social skills deficits are essential features o f these disorders; thus, it is interesting to note the lack o f social skills train in g research w ith children diagnosed with A D HD, OD D , and CD. Recently, social skills train in g p rogram s have been developed in an effort to im prove school-age children’s social skills and to im prove parent coping m echanism s w hen dealing w ith their children’s behavior problem s. K aduson and Schaefer (2000) developed a 10-week social skills cu rricu lu m for parents and children th at incorporates negative consequences, m o d el­ ing, p ro m p tin g , ignoring, and rep rim an d in g into interesting lessons and hom ew ork assignm ents. T he specific skills focus on conversational skills building, g roup entry, assertiveness, social problem solving, cooperation, com plim enting, aw areness o f feelings, good sportsm anship, and sm iling. B loom quist (1996) developed a guidebook for providing skills train in g directly to parents, w hich addresses increasing parental involvem ent and positive reinforcem ent, changing p aren ts’ negative thoughts, enhancing positive family interaction skills, helping children to com ply w ith requests,

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im proving children’s social behavior skills, and enhancing social and gen­ eral problem -solving skills. T hus, in contrast to K aduson and Schaefer’s p rogram , children are n o t actively in co rp o rated into B loom quist’s train in g approach.

A CBASP T RE A T ME N T AP P R O A C H T he child therapy group at the Florida State U niversity Psychology Clinic was held for 12 weeks. T he skills outlined by K aduson and Schaeffer (2000) were com bined w ith the problem -solving approaches described by B loom ­ quist (1996) and M cC ullough (2000) (see Table 9.1 for a description o f the skills tau g h t). Two graduate stu d e n t therapists co-led the children’s group, w hich included five children. Two o th er graduate stu d e n t therapists co-led the parent group. See C hapter 8 for a description o f the p aren t therapy group, w hich was held sim ultaneously. TABLE 9.1 Skills Taught in Group Therapy Introducing yourself Beginning a conversation Asking a question Saying thank you Ignoring distractions Giving a compliment Asking permission Being honest Sharing Joining in Dealing with boredom Staying out of fights Problem solving Dealing with anger Dealing with another’s anger Avoiding trouble Acccpting consequences Dealing with group pressure Saying no Knowing your feelings

Expressing your feelings Relaxing Saying good-bye Dealing with group pressure Dealing with fear Apologizing Asking a favor Reacting to failure Dealing with losing Ending a conversation Deciding what caused a problem Expressing affection Accepting consequences Negotiating Smiling Having fun Dealing with fear Responding to teasing Accepting no Suggesting an activity

Note. From Skillstreaming the elementary school child: New strategies and perspectives for teaching prosocial skills (pp. iii-v) by Ellen McGinnis and Arnold P. Goldstein, 1997, Cham­ paign, IL: Research Press. Copyright 1997 by Ellen McGinnis and Arnold P. Goldstein. Reprinted with permission.

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T he c hildren w h o p a rticip a te d in th e g ro u p p re sen te d w ith b ehavioral p ro b lem s as re p o rte d by p a ren ts d u rin g an in itial interview . C h ild re n w ith severe b eh av io ral p ro b lem s consisten t w ith a diagnosis o f CD, th e m o st severe o f th e d isru p tiv e b e h av io r diso rd ers, w ere n o t in clu d e d in th e group. Instead, because o f th e n a tu re o f th e ir beh av io r p ro b lem s (e.g., cru elty to anim als, fire setting), ch ild ren w hose sy m p to m s w ere co n sisten t w ith a diagnosis o f CD w ere referred for indiv id u al therapy. T he children in the g ro u p p rim a rily h a d difficulties g etting along w ith th e ir peers a n d siblings, com plying w ith p a re n t a n d teach er requests, a n d acting in socially a p p ro ­ p riate ways. P arents re p o rte d th a t th e ir ch ild ren behaved in a n n o y in g ways, h a d few friends, a n d failed to take resp o n sib ility fo r th e ir actions.

F O R M A T OF T H E G R O U P : I N T E G R A T I O N OF S P E C I F I C S O C I A L SKILLS IN M O D I F I C A T I O N S OF C B A S P At the b e g in n in g o f each g ro u p session, we in tro d u c e d a new social skill, w hich was a d ap ted from b o th K aduson a n d Schaeffer’s (2000) play th era p y p ro g ra m a n d M cG innis a n d G o ld stein ’s (1997) re co m m e n d e d strategies fo r teach in g c hildren prosocial skills. A fter th e in tro d u c tio n , we co n d u cted a sh o rt discussion a b o u t each o f the c o m p o n e n ts necessary for m asterin g th e skill. F or exam ple, w hen we ta u g h t th e skill jo in in g a g roup, we d is­ cussed the fo u r c o m p o n e n ts o f jo in in g a g roup, w hich in clu d e d m ak in g a decision a b o u t jo in in g th e g roup, decid in g w hat to say, ch o o sin g a good tim e to jo in th e g roup, a n d jo in in g th e g ro u p in a friendly way. Follow ing in tro d u c tio n o f th e new skill, th e c o th e rap ists m od eled th e skill fo r the ch ild ren u sing situ atio n s th a t th ey identified as p ro b lem atic. Again, using th e skill jo in in g a g ro u p as an exam ple, o n e c o th e rap ist p re te n d e d to be playing basketball on the p lay g ro u n d w hile th e o th e r c o th e rap ist d e m o n ­ stra te d how to jo in the gam e using the skill. T h en , the ch ild ren w ere p ro ­ vided w ith a h y p o th etica l situ atio n , a n d v o lu n teers role played th e use o f th e skill in th e situ atio n . C o th era p ists n o t only p ro v id ed feedback to th e v o lu n teers a b o u t th e ir use o f th e skill b u t also solicited feedback from the o th e r c hildren. T his p ro v id ed an o p p o rtu n ity to teach a n d review th e skill w ith the e n tire group. Sim ilar to the w ay in w hich we in tro d u c ed , tau g h t, a n d m o d eled in d i­ vidual social skills, we also in stru c te d th e ch ild ren in the use o f a seven-step C o p in g Survey Q u e stio n n a ire (C SQ ) based o n a p p ro ac h es by M cC ullough

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(2000) a n d B lo o m q u ist (1996). D u rin g sessions th a t focused on th e CSQ, we review ed th e steps a n d asked g ro u p m e m b e rs to describe a p ro b lem atic situ a tio n a n d th e n answ er th e follow ing q u e stio n s, given th e ir p a rticu la r p ro b lem atic situ atio n (B lo o m q u ist, 1996): 1. W h at is the problem ? 2. W ho o r w h a t caused th e problem ? 3. W h at does each p erso n th in k o r feel? 4. W h at are so m e plans? 5. W h at is th e best plan? 6. D id th e p lan work? 7. W h at could you have d o n e differently to prev en t th e problem ? Step 1 — W hat is the p ro b lem ? — asks the ch ild ren to state the pro b lem sim ply a n d concisely a n d to lim it th e d etail to descriptive in fo rm a tio n only. To do this, th e ch ild ren w ere en co u rag ed to describe th e situ a tio n as th o u g h it h a p p e n e d o n a television p ro g ra m o r a m ovie th ey h a d seen. T he b enefit o f this step, as in th e a d u lt CSQ , is th a t th e p a tie n t is forced to isolate p ro b lem atic situ atio n s a n d to take an objective stance w hile d e ­ scrib in g it. In Step 2 — W ho o r w hat caused the p ro b lem ? — the c hildren m u st identify th e source o f conflict. O u r g ro u p was focused p rim a rily o n in te r­ p erso n al conflicts, a n d Step 2 encourages the ch ild ren to focus on the roles th ey a n d o th ers play in conflicts. Step 3 — W h at does each p e rso n th in k o r feel?— asks th e ch ild ren to co n sid er th e ir ow n th o u g h ts a n d feelings as well as th e th o u g h ts a n d feel­ ings o f o th ers in an effort to p ro m o te sensitivity to th e role o f cognitive fac­ to rs in achieving d esired o u tco m e s a n d to increase th e ir aw areness o f how feelings o f o th e rs can affect situ atio n s. For m o re advanced c h ild ren , this step is sufficiently challenging to e n su re su stain ed a tte n tio n to the task. Step 4 — W 'hat are som e plans?— asks the ch ild ren to b ra in s to rm w hat th ey co u ld have d o n e in th e situ atio n . A sking th e ch ild ren w h a t th ey a c tu ­ ally did in the situ a tio n a n d w ritin g th e ir b e h av io r d o w n as a plan provides an o p p o rtu n ity in th e next step to evaluate th e ir actu al a ctio n s d u rin g the situ atio n . T his step offers a n o n ju d g m e n ta l way to exam ine a ctio n s insofar as th e plan is trea te d th e sam e as th e p o ten tial plans offered by the children. G enerally, th ree o r fo u r plans provide am p le m aterial for evaluation in the next step. T his step provides the c hildren an o p p o rtu n ity to creatively

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problem solve w ith o u t em phasis on the right answer, and the therapist w rites dow n all plans presented by the children, regardless o f their viability o r usefulness. T he skills train in g co m p o n e n t o f the group helps the chil­ dren to build a repertoire o f social tools to plug in to this step o f the CSQ, and we have found it helpful to encourage the children to consider these skills w hen generating plans d u rin g the initial training o f the CSQ process. If the children present no a p p ro p riate b ehavioral plans, the therapist offers a b rie f suggestion, preferably a previously taught social skill, to include in the list o f plans. Step 5 — W hat is the best plan?— requires the children to choose the best plan from the list o f plans generated in Step 5. D oing this requires an evaluation o f each o f the possible plans. T he cotherapists begin the evalu­ ation o f each plan by asking the children w hat m ight happen if each plan were enacted and to label the plan as helpful o r hurtful based on the p re­ dicted outcom e. W hile w orking w ith the children to evaluate the plans, the cotherapists ask the group leading questions in an effort guide the children to consider ways in w hich they could have used the previously learned social skills to prevent the original problem o r to better the outcom e o f an already p roblem atic situation. Step 6 — D id the plan w ork?— asks the children to consider specifically w hat they actually did in the situation a n d w hether o r n o t it w orked o u t the way they w anted, as well as how their behavior was different from the best plan identified in the previous step. A lthough this step could be in co r­ po rated into Step 5, we feel it is im p o rta n t to pay specific a tten tio n to the actual behaviors o f the children in the situation and to isolate them for evaluation. P ositioning this step after Steps 4 and 5, w hich are usually fun and hopeful, reduces som e o f the p o tential stress, em barrassm ent, o r anger felt by the children while evaluating th eir ow n behavior (and having it evaluated by others). Over tim e, it has been o u r experience th at children hab itu ate to this step and becom e increasingly better able to objectively analyze their behavior in relation to the outcom e o f the situation. Finally, Step 7 — W hat could you have done differently to prevent the problem ?— asks the children to think about ways to prevent the problem altogether. Unlike the first six steps o f o u r m odified CSQ, w hich focus on handling a problem once it arises, this step focuses on m aking good deci­ sions before a problem arises. M any children w ho have social problem s struggle w ith im pulsivity, and this step is designed, in part, to address this issue. However, it should be n oted th a t there is little em pirical evidence to suggest th at psychosocial interventions are effective in reducing impulsivity.

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