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

This volume demonstrates the application of cognitive behavior analysis system (CBAS) psychotherapy to a number of clinical problems, including personality disorders, anxiety disorders, couples and family distress, anger management, and correctional psychiatry. It uses multiple vignettes and a relatively standardized format in each chapter. This anthology has some systemic problems, none fatal, that impede it from reaching maximal usefulness.

CBAS is probably best known through the work of Keller and associates (1), who conducted a widely cited study comparing nefazodone, CBAS, and their combination in the treatment of depression. One effect of this study was to illustrate the augmentation of antidepressant medication with psychotherapy, in this case CBAS. However, the specific nature of CBAS requires some explication. The authors write as though the principles, theory, and efficacy of CBAS are well known to the reader and can be taken for granted. Regrettably, this book devotes only one brief chapter to CBAS basics, so that any reader who is not familiar with the system must catch up very quickly. The method is spelled out in each clinical chapter, but it would have been better if the authors had initially taken their time, detailing their theoretical rationale, citing whatever outcome studies have been done with CBAS, and comparing CBAS with more standard forms of cognitive-behavioral therapy. If the reader is not adequately persuaded of the face validity of CBAS by the end of chapter 1, there is almost no subsequent discussion of these issues.

Another problem relates to the book's treatment of patient noncompliance. The vignettes include examples of patients who do not follow through with homework assignments. But the process notes here give the reader the impression that one or two logical discussions with a well-informed and enthusiastic therapist is all it takes to enable patients to resume their compliance with homework. Particularly in the discussions of patients with personality disorders, this just does not seem credible.

Yet much clinical wisdom and practical help can be found in this volume. The chapter on correctional settings is detailed and likely to help clinicians working in these settings. There are specific chapters on schizotypal, passive-aggressive, avoidant, and mixed (not otherwise specified) personality disorders, complicated nosologic entities often ignored in the literature. And the section on families, couples, and children includes useful strategies for the treatment of attention-deficit and oppositional problems.

Overall, this book is a good sampler of applications of CBAS. To use it well, clinicians need a good grounding in basic cognitive-behavioral therapy, and attention to outcome studies would improve the rigor and generalizability of these vignettes considerably. If the CBAS method is to catch on, it will need to address these issues of theoretical superstructure and empirical validation. Once these are attended to, clinicians may find the method, and this anthology of its uses, quite compelling.

Dr. Goisman is associate professor of psychiatry at Harvard Medical School and director of residency training and medical student education at the Massachusetts Mental Health Center in Boston.