Cognitive-Behavioral Therapy

This book, volume 23 of American Psychiatric Publishing's Review of Psychiatry series, is a user-friendly overview of cognitive-behavioral therapy. The book is edited by Jesse H. Wright, M.D., Ph.D., who authors the chapter on computer-assisted cognitive-behavioral therapy. The remaining four chapters cover cognitive-behavioral therapy for schizophrenia, a cognitive-behavioral approach to treatment of bipolar I disorder, cognitive-behavioral therapy for patients with physical illnesses, and cognitive-behavioral therapy with children and adolescents. The book succinctly covers a broad scope of cognitive-behavioral therapy, including both clinically useful treatment strategies and evidence-based reviews of the literature.

In the first chapter, Jan Scott, David Kingdon, and Douglas Turkington outline the use of cognitive-behavioral therapy for schizophrenia. The authors provide an overview of treatment, including an algorithm for treating delusions, hallucinations, and negative symptoms with cognitive-behavioral strategies. Several patient examples are included in the chapter, illustrating many of the treatment strategies. For example, the authors describe cognitive-behavioral therapy for delusions, involving engagement, the building of trust, discussing a range of explanations for the delusional beliefs, and reality testing (eliciting examination of evidence, logical inquiry, and reasoning). The chapter reviews the randomized controlled studies among psychotic patients who have residual symptoms after treatment with medication. The studies reviewed compared cognitive-behavioral therapy with supportive counseling and with treatment as usual among patients with schizophrenia. The data from clinical trials are impressive and make a strong case for increased access to cognitive-behavioral programs for psychotic patients.

Cognitive-behavioral therapy as adjunctive treatment for patients with bipolar disorder is described in the second chapter. This approach is broadly defined in terms of psychoeducation, early warning systems, medication adherence, cognitive-behavioral strategies for controlling symptoms, and methods to decrease stressors. Several preliminary studies of cognitive-behavioral therapy for bipolar disorder are reviewed and suggest benefits in improved medication adherence, management of symptoms, and psychosocial functioning. The authors describe cognitive-behavioral treatment for patients with newly diagnosed bipolar disorder as well as patients who are experiencing sustained remission. The chapter includes a sample symptom summary worksheet, compliance contract, and "mood graphing" as examples of tools used in cognitive-behavioral therapy for bipolar disorder.

The third chapter, on computer-assisted cognitive-behavioral therapy, is a surprisingly enjoyable and informative overview of the use of computerized programs to supplement treatment as usual for a variety of psychiatric disorders. Wright anticipates and addresses clinicians' potential concerns and fears of technology's usurping human clinicians. He reassures readers that this approach is not geared toward displacing therapists but, rather, serves to increase access for patients receiving partial or no psychiatric treatment. He describes computerized cognitive-behavioral therapy programs, including a three-dimensional virtual exposure-based treatment for phobias and posttraumatic stress disorder, multimedia programs (including video, audio, mood graphs, checklists, self-ratings, and interactive exercises) for mood and anxiety disorders, hand-held computers to augment cognitive-behavioral therapy for anxiety disorders, and an interactive voice response system to deliver self-help for obsessive-compulsive disorder and depression. Randomized controlled trials are summarized in a table comparing computer-assisted cognitive-behavioral therapy for phobias, depression, panic disorder, and binge-eating disorder. The chapter offers a balanced view of the potential benefits of this technology as well as the numerous limitations and barriers to its implementation.

Cognitive-behavioral therapy has been incorporated into the treatment of patients with physical illness with the goals of exploring the patient's model of illness, identifying maladaptive aspects of the patient's model, and helping patients manage effectively. Tom Sensky effectively maps out several approaches to working with medically complex patients, using cognitive-behavioral therapy to address affective disturbance, motivation, coping strategies, and distress tolerance. His use of clinical vignettes as well as figures outlining conceptualizations of health anxiety and body image problems illustrate the utility of cognitive-behavioral therapy with this patient population. More than 30 randomized controlled trials and meta-analyses are summarized; demonstrating positive outcomes with cognitive-behavioral therapy with respect to treatment adherence, improved coping, decreased somatic symptoms, improvements in disease outcomes, and altered illness perception. The studies included a wide range of patients with general medical illnesses, including cardiac illness, chronic pain syndromes, obesity, and HIV infection. The data from these studies are encouraging, not only with regard to decreasing depression and anxiety, but also in terms of improvements in the course or outcome of physical illnesses.

The fifth chapter, on cognitive-behavioral therapy with children and adolescents, provides an overview of the use of cognitive-behavioral therapy for anxiety and depressive disorders among younger patients. The authors outline psychoeducation, somatic management skills, cognitive modification procedures, exposure techniques, modeling techniques, skills training, and parental involvement. They review the current literature, which is encouraging in terms of improved outcomes among patients receiving cognitive-behavioral therapy for anxiety and depressive disorders.

I highly recommend this book for clinicians who want to learn more about the broadening scope of cognitive-behavioral therapy. The chapters are well-written, succinct, and clinically useful. The book certainly attains its goal of "enriching the understanding of strengths and limitations of cognitive-behavioral therapy and providing new opportunities for helping patients."

Dr. Greene is affiliated with Harvard Medical School in Boston.