February 2012  << Back  

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Cognitive-Behavioral Therapy with Adults. A Guide to Empirically-Informed Assessment and Intervention

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Stefan G. Hofmann and Mark A. Reinecke. New York, NY: Cambridge University Press; 2010; ISBN 978-0-521-72089-2; pp 188; $50 (paperback).

Because the efficacy and tolerability of treatments for mental disorders, especially the pharmacological ones, have been questioned lately, we have been searching for other treatment approaches. In view of this quest, psychological treatments have become more carefully studied. Cognitive-behavioral therapy (CBT) has come out as a clear winner among psychotherapies, with proven efficacy and treatment approaches for a wide range of mental disorders. CBT has been touted as more efficacious and cost effective than medications and other treatments. This led to significant changes in health care policies in some countries, such as the United Kingdom, where the government is spending a lot of money to provide psychological treatment methods, namely CBT, by adding 8,000 new therapists (p x). Nevertheless, CBT still is not widespread in many parts of the world, including the United States, and there are not many CBT therapists with at least rudimental training available. Many CBT manuals have been published, but because there is no single type of CBT (p ix), these books usually focus on 1 mental disorder or group of disorders or pathological conditions. Manuals reviewing in a simple short text all CBT types available for various mental disorders are not published frequently. Therefore, 2 well-known CBT therapists and theoreticians, Drs. Hoffmann and Reinecke, put together a team of CBT experts to summarize the present state of knowledge of CBT for a spectrum of mental disorders.

This slim guide consists of a Foreword, Introduction, and 12 chapters that cover CBT for depression; bipolar disorder; generalized anxiety disorder; social anxiety disorder; panic disorder and agoraphobia; obsessive-compulsive disorder (OCD); posttraumatic stress disorder; eating disorders; schizophrenia and psychotic disorders; body dysmorphic disorder; and mindfulness in CBT. The Introduction covers the basics of CBT, emphasizing that CBT is “not a single treatment protocol, and it is inappropriate to talk about the cognitive therapy or the cognitive model” (p xiii). According to the editors, it is important to realize that CBT techniques do not ask patients to think positively, but rather, more adaptively (p x). “Patients are not considered to be helpless and passive, but rather, experts about their own problems” (p xi). “Cognitive-behavioral therapy is a problem-solving process” (p xi) that “includes clarifying the status of the presenting problem, defining the desired goal, and finding the means to reach that goal” (p xi). These are important principles framing the rest of the book. The Introduction also points out the vast body of literature on efficacy of CBT in various disorders and conditions. The 11 chapters reviewing CBT for various disorders are standard summaries of those topics, heavily emphasizing the efficacy and all positive aspects of CBT. All chapters are well-written, but unfortunately a bit uneven.

It is clear that in mild depression, generalized anxiety disorder, panic disorder with agoraphobia, social anxiety disorder, simple phobia, and OCD one would chose CBT for that particular disorder as the initial treatment modality. It seems that in other disorders (eg, bipolar disorder, schizophrenia, eating disorders) CBT could be a part of comprehensive management. Exposure-based CBT seems to be useful in posttraumatic stress disorder.

At times, I found it incomprehensible why some chapters also review other psychosocial treatments in addition to CBT and do not mention pharmacotherapy (for example the chapter on generalized anxiety disorder in contrast to the chapter on bipolar disorder). At times, one may feel that the evidence is not completely there, such as in cases of bipolar disorder, eating disorders, or schizophrenia. This is particularly important to realize in schizophrenia because CBT for this disorder, according to this book, focuses mostly on the development, formation, and maintenance of positive symptoms, but does not address (at least in this volume) negative symptoms. Nevertheless, the book is full of interesting information and advice. It provides the basics, general approach, and at times, case-based guidance. The chapters include recommended reading and online resources. Novices to CBT will find this book to be useful, practical reading, but would not be able to start using CBT based on this text alone because they would need more specific advice and training. Therefore, the book is a useful hodgepodge, but its usefulness is limited.

My main concern with this otherwise interesting volume is that it is a book by psychologists for psychologists, although psychiatrists and others may find is useful. This is not a criticism—there are books for psychiatrists written by psychiatrists—but rather a statement of the sad state of affairs. At one point, the authors of the chapter on depression state that, “Cognitive-behavioral therapy has demonstrated efficacy in a number of randomized controlled trials (RTCs) and is listed among the empirically supported therapies for depression. Considering RTCs the gold standard of empirical support has been met with criticism. Some researchers contend that this research does not address the complexity of clinical care…. One common argument, for instance, is that the clinical reality is one of comorbidity, whereas patients with comorbid conditions often are excluded from clinical trials. Another frequent criticism levied against this research is that the patients in clinical trials are often less severe than are those commonly seen in practice” (p 12). All are true. However, that applies to all treatment modalities equally. What also applies to all treatment modalities equally is that in the modern era of managing mental disorders, 1 modality rarely should be used alone. In most cases, at least in my clinical practice, various treatment modalities (eg, pharmacotherapy and psychotherapies) are used in combination (either by 1 person or by a psychiatrist and a therapist). Therefore, I would be interested in seeing a good guiding text on combining CBT with medications and other modalities to be able to help our patients in the best, most comprehensive way.

My vision/opinion, however, should not stop anybody interested in CBT from buying this volume.