______________________ Cognitive-Behavioral Therapy: Theory, Techniques, and Applications, 3rd Edition
GENERALIZED ANXIETY DISORDER Applying the cognitive model to generalized anxiety disorder posits that the disorder may be caused by a set of beliefs cen- tered on the concept that the world is a dangerous or threaten- ing place. The individual may believe they lack the vital coping tools to survive, manage, or excel in such a world. An example belief may be “Something bad is going to happen no matter what.” Emotional responses include anxiety and may also include irritability and apprehension. Behavioral responses may consist of rumination, constant worry, and hypervigilance. Physiological responses may include: • Poor sleep • Fatigue • Difficulty concentrating • Muscle tension • Restlessness POSTTRAUMATIC STRESS DISORDER According to the cognitive model, after exposure to trauma, the individual experiences a generalized sense of danger and believes the world to be unsafe and that they are vulner- able. Emotional responses include anxiety, fear, anger, and depression. Behavioral responses include hypervigilance and avoidance. Physiological responses may consist of chronic physiological stress and nightmares. OBSESSIVE COMPULSIVE DISORDER The cognitive model of obsessive-compulsive disorder is the strong sense of uncertainty associated with circumstances oth- ers consider safe. The individual experiences continual doubts about safety and underlying beliefs that the world is unsafe and that they may be harmed if things “aren’t done just so.” Obsessions are constant ruminations about feared subjects. The individual exhibits a strong sense of responsibility and accountability for their safety and tries to control as much uncertainty as possible to mitigate risk. Emotional responses include anxiety, fear, and panic. Behavioral responses are profound, including compulsions (e.g., hand washing, check- ing behaviors), avoidance, and hypervigilance. Physiological responses include stomach upset, increased heart rate, and physical impact of compulsions (e.g., raw skin from hand washing, exhaustion from checking, or vigilance). PERSONALITY DISORDERS In the cognitive model, personality disorders are conceptual- ized as chronic, inflexible, and maladaptive patterns of cogni- tions and behaviors. The cognitive components of personality disorders differ depending on the disorder. They can result from a complex combination of factors, including genetic predisposition, environmental factors, early experiences, maladaptive cognitions, and under- and overdeveloped coping
strategies (J. S. Beck & Beck, 2011). For example, an individual with dependent personality disorder may hold core beliefs such as “I am incapable; I need someone to help me if I am to be safe.” In antisocial personality disorder, a core belief may be “Others exist to be exploited” (J. S. Beck & Beck, 2011). The emotional, behavioral, and physiological responses depend on the specifics of the particular disorder. ANGER The cognitive model views anger as being triggered by violating an individual’s view of the world, expectations of others or self, and rigid rules for living. Such rigid perceptions may reflect feeling hurt or a fear of not being in control. Anger can result when such beliefs are challenged or threatened. In addition to anger, emotional responses may include frustration, annoy- ance, or rage. Behavioral responses include:
• Being “short-fused” • Verbal aggression • Physical violence • Sarcasm
• “Put-downs” • Substance use Physiological responses may include: • Muscle tension • Headaches • High blood pressure • Stomach upset • Sweating
Potential Challenges in Practicing Cognitive Therapy As in other therapies, challenges often arise during cognitive therapy. Even experienced providers will encounter challenges throughout therapy. When challenges arise, revisiting the case formulation or conceptualization is generally a good strategy to see if the challenge may be related. Clinicians are also encouraged to examine themselves and what they are bring- ing to the situation. One might be tempted to blame the lack of progress on perceived client resistance; however, there are likely many other possible explanations. The following section reviews some common challenges that may arise in applying cognitive therapy. Novice therapists may mistakenly attempt to target core beliefs too early in the therapy. The therapist may feel pressure to “get right to the cause of it all.” This can result in client resistance, early termination, and/or slow progress. Instead, the therapist should begin therapy by focusing on automatic thoughts, which are readily accessible during the session and offer frequent opportunities for practicing thought modification techniques.
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