ebook THE GUILFORD PRESS COGNITIVE THERAPY TECHNIQUES Also from Robert L. Leahy Contemporary Cognitive Therapy: Theory, Research, and Practice Edited by Robert L. Leahy Emotion Regulation in Psychotherapy: A Practitioner’s Guide Robert L. Leahy, Dennis Tirch, and Lisa A. Napolitano Emotional Schema Therapy Robert L. Leahy Overcoming Resistance in Cognitive Therapy Robert L. Leahy Psychological Treatment of Bipolar Disorder Edited by Sheri L. Johnson and Robert L. Leahy Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges into Opportunities for Change Edited by Robert L. Leahy Treatment Plans and Interventions for Bulimia and Binge-Eating Disorder Rene D. Zweig and Robert L. Leahy Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition Robert L. Leahy, Stephen J. F. Holland, and Lata K. McGinn Cognitive Therapy Techniques A Practitioner’s Guide S E C O N D E D I T I O N ROBERT L. LEAHY THE GUILFORD PRESS New York London Copyright © 2017 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved Except as noted, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote. This license is limited to you, the individual purchaser, for personal use or use with individual clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. The author has checked with sources believed to be reliable in his efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data Names: Leahy, Robert L., author. Title: Cognitive therapy techniques : a practitioner’s guide / Robert L. Leahy. Description: Second edition. | New York : The Guilford Press, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016047847 | ISBN 9781462528226 (paperback) Subjects: LCSH: Cognitive therapy. | BISAC: MEDICAL / Psychiatry / General. | SOCIAL SCIENCE / Social Work. | PSYCHOLOGY / Clinical Psychology. Classification: LCC RC489.C63 L382 2017 | DDC 616.89/1425—dc23 LC record available at https://lccn.loc.gov/2016047847 About the Author Robert L. Leahy, PhD, is Director of the American Institute for Cognitive Therapy in New York and Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell Medical Col- lege. His research focuses on individual differences in emotion regulation. Dr. Leahy is Associate Editor of the International Journal of Cognitive Therapy and is past president of the Association for Behavioral and Cognitive Therapies, the International Association for Cognitive Psychotherapy, and the Academy of Cognitive Therapy. He is the 2014 recipient of the Aaron T. Beck Award from the Academy of Cognitive Therapy. Dr. Leahy has published numerous books, including Overcoming Resistance in Cognitive Therapy and the coauthored volumes Treatment Plans and Interventions for Bulimia and Binge-Eating Disorder; Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition; and Emotion Regulation in Psychotherapy. v Preface The first edition of Cognitive Therapy Techniques provided clinicians with a wide range of cognitive- behavioral techniques that could be used to expand the arsenal of interventions that one could use in clinical practice. When I originally considered what I wanted to cover in that book, I thought of what I would want to know if I were learning cognitive-behavioral therapy (CBT), or what I would want to know if I hadn’t been at this for so many years. Many of us can find ourselves getting “stuck” with—or accustomed to—a few simple techniques. For example, one might just find oneself using techniques such as identifying the automatic thought, examining the costs and benefits of that thought, looking at the evidence, and coming up with another more adaptive thought. That’s fine—up to a point. Or one might think, “I will use some behavioral activation techniques”—and those might work, too. Or mindfulness—that can help. What I have learned, though, is that patients present with a wide range of problems, a wide range of beliefs about change, reasons not to change, and impediments to improvement. So, I guess I turned my own frustration as a clinician into writing a book, one that might be helpful if you want to move beyond your habitual techniques to see if there are some other things you can do. I have been fortunate to have wonderful and creative colleagues at the American Institute for Cognitive Therapy in New York City (www.CognitiveTherapyNYC.com). Rather than churn- ing out “mini-me’s” of me, I have encouraged our staff members to be the best that they can be at being themselves—whether it’s cognitive therapy, behavioral therapy, acceptance and commitment therapy, dialectical behavior therapy, mindfulness, or whatever it is that they do. This experience 5 9 9 has been immensely enriching for me because I learn so much from them. So, the current volume 3 9 6 reflects a lot of integration of CBT techniques from a wide range of approaches. And, of course, I 9 8 14 have learned from the many patients who have trusted me with their care, who have taught me s| alle about how things make sense when you are depressed and anxious, and who have sometimes come Rs up with their own ideas of change. I don’t think I am alone as a therapist in having experienced a bl| e patient saying something that he or she thinks is helpful, and thinking, “Gee, maybe I should try s- asi that in my life.” o I have organized this book around certain categories of interventions or techniques, beginning with many of the traditional techniques for identifying and evaluating thoughts and assumptions. Chapters 2–5—“Eliciting Thoughts,” “Evaluating and Testing Thoughts,” “Evaluating Assumptions vii viii Preface and Rules,” and “Examining Information-Processing and Logical Errors”—provide a number of techniques that target the cognitive content of often biased and unhelpful thinking. Chapter 6, “Modifying Decision Making,” examines the typical assumptions and biases—or heuristics—that affect difficulty or problems in making decisions. Decision making has been an interest of mine for years, and so this chapter brings into focus issues such as sunk-cost effects, risk aversion, basing decisions on limited information, overfocus on immediate consequences, and other factors. Many depressed and anxious people have great difficulty in making decisions and often get stuck with situations that they have trouble changing. Chapter 7, “Responding to and Evaluating Intrusive Thoughts,” owes a great debt to the metacognitive model advanced by Adrian Wells, which is one of the truly innovative models of the past decade. Again, intrusive thoughts often lead to an overvalu- ation of the content of that thought, the tendency to take a thought personally, beliefs that thoughts that are unpleasant or unwanted have to be eliminated, or that these thoughts are out of control. I hope this chapter provides the clinician with some techniques that will innovate change. For those familiar with my writing, it will come as no surprise that I’ve included a chapter on “Modifying Worry and Rumination” (Chapter 8), which provides a great number of techniques that can be combined with the many techniques on coping with intrusive thoughts. This material will be relevant to helping people with worry, rumination, and intrusive thoughts in posttraumatic stress disorder and in other disorders. In Chapter 9, “Putting Things in Perspective,” I provide numer- ous techniques that can be helpful in supporting patients in reducing their tendency to overreact to events and to assist in accepting the inevitable difficulties in life. Chapter 10, “Identifying and Modifying Schemas,” illustrates a wide range of techniques that one can use to address long-stand- ing schematic issues, often associated with personality disorders or “personality styles.” Clinicians working with patients who experience recurrent problems in relationships, with self-identity, and at work, and who often benefit from longer-term CBT, may find these techniques helpful. Chapter 11, “Emotion Regulation Techniques,” also reflects some of the work by many other clinicians, my colleagues, and me on helping patients utilize coping skills to live with turbulent emotions. Indeed, it may be that some patients will need emotion regulation work before they can even use the other techniques in this book. The last section of the book includes a brief chapter (Chapter 12) with examples of how to address each of the cognitive distortions mentioned earlier. Then I provide three short chapters that address techniques for common problems, such as “need for approval” (Chapter 13), “self-criticism” (Chapter 14), and “anger” (Chapter 15). We could cover many other problems, but I hope these examples will serve as a guide to how clinicians can actually use a wide range of techniques for other common and not-so-common problems. My hope is that clinicians will be able to integrate additional techniques and strategies to overcome impasses that inevitably occur, and provide patients with new skills to use in handling the difficulties that they face. No technique is a panacea, and no model is perfect. Given the world of limitations in which we live, having additional coping skills can make the difference between getting stuck and making the change that really matters. It’s part of the flexibility that we should all embrace.