COMMON LANGUAGE FOR
COMMON LANGUAGE FOR
The first 80
The first 80
Isaac Marks, Editor
Lucio Sibilia & Stefania Borgo, Co-Editors
First edition, 2010
Copyright (C) 2010 Centro per la Ricerca in Psicoterapia (CRP).
Piazza O. Marucchi n.5 - 00162 Rome (Italy)
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Invariant Sections are: "Sponsoring organisations", "Acknowledgements", "Task Force
members", "Authors of accepted entries", and "Introduction". A copy of the licence is
included in the section entitled "GNU Free Documentation License" at:
Printed by: Books on Demand GmbH, 22848 Norderstedt, Germany
Sponsoring organisations ..............................................................................6
Task Force members......................................................................................8
Authors of accepted entries............................................................................9
Acceptance, promoting of.............................................................................19
Assertiveness (assertive, assertion) training................................................27
Attention training ..........................................................................................29
Becoming the other....................................................................................... 31
Behavioral activation..................................................................................... 34
Community reinforcement approach ............................................................ 41
Computer-aided vicarious exposure ............................................................46
Coping cat treatment.....................................................................................48
Countertransference, use of.........................................................................51
Danger ideation reduction therapy ............................................................... 53
Decisional balance........................................................................................ 55
Dialectical behaviour therapy ....................................................................... 57
Empathy dots, use of....................................................................................63
Evoked response arousal plus sensitization.................................................65
Exposure, interoceptive (to internal cues).....................................................69
Exposure, live (in-vivo, live desensitization).................................................71
Expressive writing therapy............................................................................75
Family focused grief therapy......................................................................... 77
Family work for schizophrenia......................................................................80
Habit reversal................................................................................................ 89
Harm reduction ............................................................................................92
Imagery rehearsal therapy of nightmares.....................................................94
Imagery rescripting therapy..........................................................................96
Imago relationship therapy............................................................................99
Inflated responsibility, reducing..................................................................102
Internet-based therapy................................................................................ 107
Interpersonal psychotherapy ......................................................................109
Interpreting defenses against unpleasant feelings.....................................112
Life-review (reminiscence) therapy.............................................................114
Linking current, past and transference relationships .................................116
Mentalizing, promotion of............................................................................ 118
Metacognitive therapy ................................................................................ 121
Metaphor, use of.........................................................................................123
Method of levels ......................................................................................... 125
Motivational enhancement therapy ............................................................134
Motivational interviewing ............................................................................ 136
Problem-solving therapy ............................................................................141
Prolonged exposure counterconditioning...................................................143
Prolonged-grief therapy.............................................................................. 145
Promoting resilience in young children.......................................................148
Puppet play preparing children for surgery.................................................151
Reciprocal role procedures, describing & changing...................................154
Repertory grid technique.............................................................................159
Ritual (response) prevention....................................................................... 161
Schema focussed emotive behavior therapy .............................................163
Self as context............................................................................................166
Self-control skills training ...........................................................................168
Sibling fighting-reduction training................................................................ 173
Skills-directed therapy ................................................................................175
Solution-focused questioning / brief therapy...............................................179
Speech restructuring................................................................................... 181
Stimulus control of worry.............................................................................183
Task concentration training ........................................................................ 185
Time-boundary setting and interpreting......................................................188
Token economy.......................................................................................... 193
Transference interpretation......................................................................... 195
Triple P – positive parenting program.........................................................199
Validation of feelings................................................................................... 205
Values exploration and construction...........................................................207
Well-being therapy .....................................................................................209
Association for Behavioral and Cognitive Therapies
European Association for Behavioural and Cognitive Therapies
American Psychoanalytic Association
Asian Psychological Association
Australian Psychological Society
British Association for Counselling & Psychotherapy
Centro per la Ricerca in Psicoterapia
Royal College of Psychiatrists
Sociedad Mexicana de Psicología
Society for Psychotherapy Research
Society for the Exploration of Psychotherapy Integration
World Psychiatric Association
This volume has been made possible thanks to the collaborative
work of the clp Task Force members and of the 95 authors of the
80 entries listed below.
Task Force members
Isaac Marks, Institute of Psychiatry, King's College London, UK
Lucio Sibilia, Dept. of Clinical Sciences, Università di Roma Sapienza,
Stefania Borgo, Dept. of Education, Università di Roma Sapienza, Italy
Deputy Co-ordinating Editor
Miguel A Fullana, Dept. of Psychiatry, Autonomous University of Barcelo-
na, Bellaterra, Catalunya, Spain
Lorena Fernández de la Cruz, Dept. of Psychiatry, Autonomous Universi-
ty of Barcelona, Bellaterra, Catalunya, Spain
Association of Behavior and Cognitive Therapy (ABCT)
Marvin Goldfried, Dept. of Psychology Stony Brook University, Stony
Brook, NY, USA
Michelle G Newman, Dept. of Psychology, Pennsylvania State University,
George Stricker, Argosy University, Washington DC, USA
Australian Psychology Society (APS)
Kate Moore, Faculty of Education, Health and Science, Charles Darwin
University, Darwin, Australia
European Association of Behaviour and Cognitive Therapy (EABCT)
Pim Cuijpers, Dept. of Clinical Psychology, VU University Amsterdam,
Mehmet Sungur, Psychiatry Dept. of Marmara University Hospital, Istan-
Jeremy Holmes, Dept. of Clinical Psychology, Washington Singer Buil-
ding, University of Exeter, UK
Dynamic website creator and manager
Marco Benard, Dept. of Clinical Psychology, VU University Amsterdam,
Dimitra Kakaraki, Centro per la Ricerca in Psicoterapia, Roma, Italy
Miquel Tortella, Dept.of Psychology, University of Balearic Islands, Pal-
ma, Majorca, Spain
Authors of accepted entries
ALLEN, Jon G
Mentalizing, promotion of
ALPERS, Georg W
Exposure, live (in-vivo, live desensitization)
Puppet play preparing children for surgery
BARLOW, David H
Exposure, interoceptive (to internal cues)
Promoting resilience (social/emotional competence) in young children
BASDEN, Shawnee L
Exposure, interoceptive (to internal cues)
BATEMAN, Anthony W
Mentalizing, promotion of
BLACKLEDGE, John T
Acceptance, promoting of
Self as context
Values exploration and construction
Task concentration training
Life-review (reminiscence) therapy
Assertiveness (Assertive, Assertion) training
BORKOVEC, Thomas D
Stimulus control of worry
Method of levels
CHASSON, Gregory S
Puppet play preparing children for surgery
D’ZURILLA, Thomas J
DISKIN, Katherine M
Motivational enhancement therapy
DOBSON, Keith S
Validation of feelings
Stimulus control of worry
Mentalizing, promotion of
GREENBERG, Leslie S
HODGINS, David C
Motivational enhancement therapy
Interpreting defenses against unpleasant feelings
Countertransference, use of
Linking current, past and transference relationships (triangle of person)
Metaphor, use of
Time-boundary setting and interpreting
HOPKO, Derek R
Danger ideation reduction therapy
KENDALL, Philip C
Coping cat treatment
KERKHOF, Ad JFM
Community reinforcement approach
Coping cat treatment
KISSANE, David William
Family focused grief therapy
Puppet play preparing children for surgery
Computer-aided vicarious exposure
Family work for schizophrenia
LEJUEZ, Carl W
Imago relationship therapy
LOGAN, Diane E
Empathy dots, use of
Method of levels
Assertiveness (Assertive, Assertion) Training
Ritual (response) prevention
NEZU, Arthur M
NEZU, Christine M
NOVACO, Raymond W
Promoting resilience (social/emotional competence) in young children
PARKES, Colin Murray
Prolonged exposure counterconditioning
PENNEBAKER, James W
Expressive writing therapy
Ritual (response) prevention
Solution-focused questioning / brief therapy
RADOMSKY, Adam S
Inflated responsibility, reducing
RAO, Nasa Sanjay Kumar
Solution-focused questioning / brief therapy
RENWICK, Stanley J
Empathy dots, use of
Self-control skills training
ROOZEN, Hendrik G
Community reinforcement approach
Self-control skills training
RUBEN, Douglas H
Evoked response arousal plus sensitization
Sibling fighting-reduction training
Reciprocal role procedures; describing & changing
SAFRAN, Jeremy D
SANDERS, Matthew R
Triple P – Positive Parenting Program
Assertiveness (Assertive, Assertion) Training
Imagery rehearsal therapy of nightmares
SMUCKER, Mervin R
Imagery rescripting therapy
Becoming the other
Dialectical behavior therapy
TAYLOR, C Barr
Puppet play preparing children for surgery
Attention training (AT)
WHITE, Kamila S
Exposure, interoceptive (to internal cues)
Repertory grid technique
WINZELBERG, Andrew J
Schema focussed emotive behavior therapy
Common Language for Psychotherapy (clp) project hopes to de-
velop a general lexicon of psychotherapy procedures. Having no
common language can confuse clinicians and patients, hamper com-
munication, and impede research. It is frequently hard to know exac-
tly what therapists do just from the names of their procedures and
their orientation. There may be no clear con nection between what
therapists do and the reasons given for doing it. Different terms are
sometimes used to describe the same or very similar proce dures
(e.g. "brainstorming" at p.141 and "free association" at p.85) and the
same term for different procedures (e.g. "experiment" at p.67).
The lack of a common language also impedes research. Though
there is ample evidence that certain problems improve with particular
psychotherapy `packages’, those packages may have a variety of
names for varying combinations of procedures. This obscures which
procedure/s within the packages produce the improvement. The Ba-
bel of babble about what therapists do prompted the European and
the North American Associations of Behavioural and Cognitive The-
rapy to set up a Task Force to work towards a common language for
psychotherapy (clp) procedures that is internationally accepted.
Many more psychotherapy associations representing diverse ap-
proaches have added their sponsorship. The emergence of shared
plain terms can reduce confusion and speed the evolution of psycho-
therapy into a science. Progress towards a common language to de-
scribe psychotherapy procedures is seen in the expanding website:
www.commonlan guagepsychotherapy.org .
In this CLP website therapists portray how they use particular pro-
cedures in everyday language shorn of theory, and clarify what they
do with brief real case illustrations. Therapists submit website entries
describing a procedure in response to personal or clp-website invita-
tions. Their entry/ies describe operationally what they do with clients,
regardless of any background theory. Each entry submitted is edited
interactively between the Task Force and the Author to ensure it fol-
lows the common clp template. Each entry gives an empirical fly-on-
the-wall view of what the therapist does to apply a procedure, inclu-
ding a practical case illustration, and avoids theory as far as possi-
This reference volume is the fruit of the work of the clp Task Force
and the authors of the entries. It shows the first 80 entries for proce -
dures to appear on the clp web-site. They represent many therapy
approaches. Their 95 authors are from Australia, Canada, France,
Germany, Greece, Israel, Italy, Japan, Netherlands, Sweden, Swi-
tzerland and the UK and USA. More authors of entries are in train.
Their contributions and those of further therapists will be included in
a later expanded volume.
All therapists are invited to join this ongoing attempt to describe
most psychotherapy procedures in a way which anyone can under-
London, August 2010
ACCEPTANCE, PROMOTING OF
John T BLACKLEDGE, Morehead State University, Kentucky 40351, USA;
ph +1 606-783-2982; & Association for Contextual Behavioral Science Board
Definition: Training a willingness to experience thoughts, feelings, and
bodily sensations without trying to avoid or change them.
Elements: Discuss costs in the client’s life of non-acceptance e.g. from
harmful avoidance such as procrastination or drinking. Encourage contact
with the present both within (e.g. ask someone reluctant to feel anxiety du-
ring pursuit of a valued relationship to allow each sensation felt when frighte-
ned to remain as it is and regard thoughts about those feelings as just
thoughts or words) and without (be mindful of and accept external cues en-
countered while pursuing a value that elicits anxiety). Clients are encour-
aged to practice acceptance when distressing experiences impede engage-
ment in valued action.
Related procedures: Exposure, mindfulness.
Application: In individual or group ACT (acceptance and commitment thera-
1st use? Hayes (1994) in ACT. Is also promoted in other therapies and in
meditation and religious practices.
1. Hayes SC (1994). Content, context, and the types of psychological accep-
tance. In SC Hayes, NS Jacobson, VM Follette, MJ Dougher (Eds.), Accep-
tance and change: Content and context in psychotherapy (pp. 13-32). Reno,
NV: Context Press.
2. Hayes SC, Wilson KW, Gifford EV, Follette VM, Strosahl K (1996). Expe-
riential avoidance and behavioral disorders: A functional dimensional ap-
proach to diagnosis and treatment. Journal of Consulting and Clinical Psy-
chology, 64, 1152-1168.
3. Hayes SC, Strosahl KD, Wilson KG (1999). Acceptance and commitment
therapy: An experiential approach to behavior change. New York: Guilford.
4. Luoma JB, Hayes SC, Walser RD (2007). Learning ACT: An Acceptance
and commitment therapy skills-training manual for therapists. Oakland, CA:
Case illustration 1: (Blackledge unpublished)
Jill: “I can’t think about this anymore - it just makes me too anxious”.
Therapist: “I know this is important to you, so let’s see if we can just ease
into this experience one piece at a time. Physically, where in your body do
you feel this anxiety?” Jill: “My shoulders are tense… my stomach feels nau-
seous”. “Let’s focus just on that shoulder tension. Imagine you have a red
felt-tip pen and are coloring in the exact area where that shoulder ten sion is
and its borders... Now, notice what quality that tension has. Is it a dull pain, a
sharp pain, a tightness?... Is there anything about that muscle tension... -
that you can’t have? If so, can you let go of that resistance and instead let
that muscle tension be there, on its own terms?” Jill assents to fully allow the
tension to be there.
Therapist moves onto other aspects of her experience of anxiety, one
at a time.
Case illustration 2: (Blackledge unpublished)
Bill: “I’m so ashamed of what I’ve done, I don’t know if I can face her”.
Therapist:“Your relationship with Joy is very important to you - and you and I
know that to maintain it you’ll need to face her, and you’ll probably feel asha-
med when you do so. With that goal in mind, are you willing to stay with your
sense of shame in here, right now?” Bill (after long pause): “Yeah, I’ll try...”.
Therapist (empathically):“Tell me about that shame you’re feeling now. What
thoughts come with it?... Where does that feeling sit in your body - what sen-
sations go with it?... When a piece of that experience - a thought, a feeling,
a sensation - shows up that you’re unwilling to have, let me know, and we’ll
work through it.”
Raymond W NOVACO & Stanley J RENWICK, Department of Psychology
& Social Behavior, University of California, Irvine, CA 92697-7085; ph +1-
Definition: A structured treatment to foster self-regulation of anger and ag-
Elements: Clients are taught to become alert to triggers and signs of their
anger. Anger management tries to reduce anger frequency, intensity, dura-
tion, and mode of expression in three key areas:
1. Cognitive restructuring of clients’ attentional focus, thinking styles, fixed
ways of perceiving aversive events, and rumination.
2. Reducing general tension, arousal to provocation, and impulsive reac-
tions by training controlled breathing, deep muscle relaxation, and use of
3. Training behavioural coping (e.g. diplomacy, strategic withdrawal, and
respectful assertiveness) to handle provoking situations constructively and
promote problem solving.
Cognitive, arousal reduction and behavioural skills are fostered through the-
rapist-guided progressive exposure to simulated anger-provocations in ima-
gined and role play scenarios. People with angry dispositions, particularly in
forensic settings, often require preliminary raising of readiness for anger ma-
nagement by fostering recognition of the costs of recurrent anger, by lear-
ning and practising self-monitoring and relaxation skills, and by making it
safe to talk about anger.
Related Procedures: Cognitive restructuring, exposure, mindfulness, moti-
vational interviewing, problem-solving, relaxation training, role play, schema-
focused therapy, social skills training, stress immunization (inoculation).
Application: Individually and in groups, for adolescents and adults, in com-
munity and institutional settings. Depth and length of sessions vary with cli-
1st use: Novaco (1975).
1. Cavell TA, Malcolm KT (2007). Anger, aggression, and interventions for
interpersonal violence. Mahwah, NJ: Erlbaum.
2. Novaco RW (1975). Anger control: The development and evaluation of an
experimental treatment. Lexington, MA: DC Heath.
3. Novaco RW, Chemtob CM (2002). Anger and combat-related posttrauma-
tic stress disorder. Journal of Traumatic Stress, 15, 123-132.
4. Renwick S, Black L, Ramm M, Novaco RW (1997). Anger treatment with
forensic hospital patients. Legal and Criminological Psychology, 2, 103-116.
Case illustration: (Novaco & Renwick, unpublished)
Sandy, a soldier aged 26, was admitted to hospital after attempting
suicide by overdose. He was angry, irritable, slept poorly, and drank excessi-
ve alcohol. Outbursts caused social isolation and frightened his family. An-
ger had been lifelong, and alternated with depression. He blamed recurrent
“road rages” on `bad driving by miscreants’, whom he pursued and confron-
ted. Those “road rage” episodes had begun three years earlier, after two dri-
ving accidents in a combat zone where he’d been the commanding officer
but not the driver. The accidents left him disabled with pain and discomfort.
He was judged unfit for service. Social withdrawal led to self styled "para -
noid" rumination with high arousal and sensitivity. There was no post trau-
matic stress disorder. He’d been physically abused as a child.
Sandy had anger management in individual one-hour sessions twice-
weekly over six months. Keeping an anger diary helped him detect thinking,
feeling, and action aspects of his anger reactions. He was helped to spot
and replace antagonistic thinking with more constructive thoughts. For ex-
ample, he believed that his trouble in getting medical care and military-unit
support was because they felt embarrassed by and wanted to discharge
him. On uncovering this belief, the therapist encouraged Sandy to question
its validity and see realistic alternatives, such as errors in administration and
care pathways -- i.e., a flawed system rather than a conspiracy. His "para-
noid" world view was challenged supportively and changed from seeing
"conspiracy" to seeing “fallibility” or “incompetence”. In parallel, the therapist
helped Sandy to detect anger at its onset (e.g. when provoked by an official
letter or pain from his injuries). Early detection of anger signs prevented an -
ger intensifying and escalating into conflict with others. Slow breathing, cal-
ming self-instructions, and shifting attention to something benign served to
reduce angry feelings on the spot. Arousal-reduction skills were enhanced
by training in muscle relaxation and using tranquil imagery. Recurrent critical
problems were reviewed to help him adopt alternative constructive ways to
deal with them. In a stress-inoculation procedure the therapist reviewed with
Sandy past anger-evoking situations and re-exposed him to them, progres-
sing gradually from low-anger to high-anger ones. Sandy did the re-exposu-
res in imagined and role-play scenarios, such as difficult contacts with admi-
nistrators about his continuing medical-care needs. The therapist showed
and rehearsed with Sandy how to elicit the help he needed and to set aside
his hostile manner that alienated people.
During anger management work, Sandy’s anger outbursts became
less frequent and intense. This, in turn, helped him to sleep better, drink less
alcohol, and improve his family life. Despite continuing pain and disability, he
became more positive and self-confident.
Peter FISHER, Department of Clinical Psychology, University of Liverpool,
Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK; ph +44 151 794
Definition: Learning to relax rapidly as soon as signs of anxiety are recogni-
Elements: The therapist teaches the client to watch for early signs of anxie-
ty (worrying thoughts, somatic symptoms e.g. palpitations, abdominal di-
scomfort, muscle tension) as cues to immediately start progressive muscle
relaxation. This involves repeatedly tensing-then releasing a succession of
muscle groups across the whole body, starting with hands & fingers, fo-
rearms, biceps, shoulders, etc. For 15-30 minutes the client tenses each mu-
scle group for 5 seconds, then relaxes it for 10-15 seconds, and is asked to
practise this as daily homework. Later, the client practises the same tensing-
releasing with larger muscle groups such as the whole arm. This is followed
by release-only sessions and homework in which the client focuses on rela -
xing to release the tension from each muscle group from the head down to
the feet. Next, in cue-controlled relaxation, clients link release-only relaxation
to breathing. As they breathe in they are told to think ‘in’ and as they breathe
out to think ‘relax’ and release tension at the same time, and to practise this
daily and achieve a relaxed state in 2-3 minutes. Eventually, in rapid relaxa-
tion, the therapist asks the client to take a few deep breaths, think `relax’ be-
fore exhaling slowly, and aim to become relaxed in less than 30 seconds.
Application training follows. Clients are taught to achieve a relaxed
state during daily activities e.g. walking, shopping, and to apply and practise
rapid relaxation during exposure to feared situations until these are no lon -
ger frightening. They are encouraged to scan their bodies for signs of anxie-
ty and do rapid relaxation whenever they feel anxiety/muscle tension, and to
continue practising rapid relaxation after therapy has ended.
Related procedures: Progressive muscle relaxation, systematic desensiti-
sation, imaginal exposure, live (in vivo) exposure, breathing retraining, mo-
Application: With individuals, sometimes in groups, for panic, phobia and
general anxiety, and medical conditions worsened by anxiety/muscle ten-
1st use? Jacobson (1938) developed progressive relaxation and advocated
its use in real-life stressful situations.
1. Jacobson E (1938). Progressive Relaxation. Chicago, IL: University of
2. Ost L-G (1987). Applied relaxation: Description of a coping technique and
review of controlled studies. Behaviour Research and Therapy, 25, 397-
Maggie, a teacher age 45, had since her late teens worried about
many things, especially about being under-prepared for her classes. She be-
came anxious on leaving for work and for a few minutes just before starting
a class, and couldn’t give pupils her full attention. She had butterflies in her
stomach and palpitations and couldn’t relax.
Maggie had 12 sessions of applied relaxation. She rated anxiety and
mood weekly, initially rating moderate-to-severe anxiety and mild depres-
sion. She was taught to recognise early signs of anxiety and to relax rapidly
on noticing these. On a self monitoring form she noted early signs of anxiety
in everyday situations. She began progressive muscle relaxation by tensing-
then-releasing many small muscle groups e.g. toes, feet, calves, and later
her whole leg. Next she practised release-only relaxation by breathing slowly
and normally with calm, regular breaths and noticing her growing relaxation.
She was then asked to relax each small muscle group in turn, interspersed
with instructions to keep her breathing calm and controlled. She was given
an audiotape of this session to listen to during release-only relaxation ho-
mework. Differential relaxation followed starting with cue-controlled relaxa-
tion to relax while using only those muscles needed for a particular activity
e.g. `look out of the window while relaxing every muscle except those ne-
eded to turn your head’, ‘cross your legs using only the muscles necessary
and keep all your other muscles relaxed’.
Differential relaxation training in everyday situations began by walking
round the therapist’s office while relaxing facial muscles. Maggie then practi-
sed relaxing every muscle except those required during tasks such as rea-
ding or eating. Next she shortened cue-controlled relaxation to achieve rapid
relaxation. The therapist modelled this for Maggie and guided her through ta-
king one deep breath and then slowly exhaling while visualising the word `re-
lax’. She practised this in session and as homework in many situations e.g.
walking her dog, playing board games with her children, shopping, then at
school. To overcome self-consciousness that teachers or pupils would notice
her doing relaxation, to check that she was relaxing appropriately the thera -
pist asked Maggie to demonstrate rapid relaxation to him in session and
then accompanied her to a real supermarket and modelled rapid-relaxa tion
there to show it was inconspicuous. Maggie also looked at a video of her
practising rapid relaxation in the therapist’s office to see that her class was
unlikely to notice her doing rapid relaxation. By 3-month follow-up she had
no panics, worried far less about school and teaching, was not depressed,
and managed occasional anxiety just before classes and at other times by
applying rapid relaxation.
ASSERTIVENESS (ASSERTIVE, ASSERTION) TRAINING
Isaac MARKS, 43 Dulwich Common, London SE217EU, UK; ph+44 208
2994130; Lucio SIBILIA, Dipartimento di Scienze Cliniche, Università Sa-
pienza di Roma & Centro per la Ricerca in Psicoterapia, Roma, Italy; ph +39
06 86320838; Stefania BORGO, Università Sapienza di Roma & Centro per
la Ricerca in Psicoterapia, Roma, Italy; ph +39 06 86320838.
Definition: A form of social skills training to carry out culturally / context-ap-
propriate assertive behaviors that the client lacks e.g. initiating, continuing
and/or stopping social contact; responding to requests, demands and/or an-
noying behaviors; expressing feelings; exercising own rights while respec-
ting other people’s rights.
Elements: Targets the behavioral, cognitive, and emotive components of
assertion e.g. what to say, how to say it, tone, body language. Involves role
play, modeling, feedback of videotaped practice, homework of increasingly
difficult social tasks, praise of progress (reinforcement, reward, contingency
- Problem-solving by helping clients to: define their problem social behaviour
and break it down into manageable bits to be learned one by one; find alter -
native (adaptive) forms of social interaction; self-observe to achieve per-
- Exposure to feared social situations and behavioural experiments to chal-
lenge the negative thoughts, self-talk and imagery evoked by those situa-
- Rehearsal of new social behaviour in the treatment session and in ho-
mework in imagination and in real life (involves exposure and behavioural
experiments if behaviour/situations are feared), followed by reward.
- Cognitive restructuring to change socially maladaptive thoughts to more
Related procedures: Social skills training to remedy social skills deficits
(not excesses as in anger management) and of rational emotive therapy in
its education in personal rights.
1st use? Salter A (1949) Conditioned Reflex Therapy, Capricorn Books, NY
used `Assertiveness Training’ to describe how to increase clients' social
skills and reduce social anxiety.
Marks IM (1986). Behavioural Psychotherapy. Maudsley Pocketbook of Cli-
nical Management. John Wright, Bristol.
Case illustration: (Marks et al 1986)
Pat had long feared and avoided eating with people, and always been
shy and reserved with a limited social life. With her therapist she set mediu-
m-term targets of eating a meal with three other friends and also at her boy-
friend's home with his family (goal setting). She described a detailed imagi-
ned scene of having a meal with her boyfriend (imaginal [fantasy] exposure)
and the therapist prompted Pat’s flow of talk when she flagged (guided fan-
tasy/imagery). She then actually had a meal with herboy friend (live [real, in
vivo] exposure); Pat also role played asserting herself appropriately. In `play-
lets’ her therapist pretended to be a shop assistant and Pat acted the part of
a customer returning defective goods. This was videotaped and played back
to her (feedback). She was taught what to say as a disgruntled customer
(assertion), and they played the same parts again and switched roles with
Pat as the salesperson (reverse role play). They also acted asking the way
in the street from a stranger and refusing to carry out an unreasonable re-
quest from a colleague. The therapist first modelled what to do and then
asked Pat to do the same thing (rehearsal). Pat then lunched with an ac-
quaintance (live [real, in vivo] exposure). Pat now joined five other socially
phobic patients for a day-long group session (social skills training). The the-
rapist outlined the program. They played contact party games to encourage
mixing, like having one of their number break out of a circle... etc... made by
the others, and without using hands transfer an orange held under the neck
to another patient. These warm-up exercises led into role play of increasing-
ly difficult social situations (exposure). Toward evening the group split into
subgroups to shop for ingredients for a meal to cook together (social skills
training, confidence building). They chatted to one another and then ate to-
gether. After initial unease they enjoyed themselves and planned to meet
one another after the group's conclusion. Pat had further sessions with the
therapist alone. By six-month follow-up she was dining regularly with her fi-
ance and his family and in selected restaurants with him and occasionally
with a larger group of friends.
ATTENTION TRAINING (AT)
Adrian WELLS, University of Manchester, Division of Clinical Psychology,
Rawnsley Building, MRI, Manchester, M13 9WL, UK; ph +44 161 276 5399
Definition: AT involves attending to several kinds of sounds coming at the
same time from different places for about 11 minutes at a time without trying
to improve symptoms or perform particular tasks.
Elements: The therapist tells patients their disorder is maintained by pat-
terns of thinking that dwell on symptoms, traumas and social problems, so
Attention Training (AT) can help them control and react flexibly to those pat-
terns. If during AT practice unpleasant feelings/thoughts/ memories or bodily
sensations arise, patients should simply see these as noise and continue at-
tending to them without trying to get distracted from or analyse those or
make themselves feel better. Instead AT helps them suspend any response
of worry, rumination or attention to threat. Before starting AT, patients are
asked to rate self-focus on a scale from -3 (entirely externally focused) to +3
(entirely self-focused) and try to reduce self-focus by 2 points by the end of
the AT-practice session.
In attention training the therapist presents 5-7 sounds simultaneously and
asks the patient to:
1. for 5 minutes, attend selectively to each of those sounds in turn, first iden-
tifying it and then attending intensively to it e.g. “focus intensely on each
(specified in turn) of 6 sounds which you can hear in the near distance on
your right hand side”;
2. for the next 5 minutes, switch attention rapidly from one sound to a diffe-
rent sound at another location e.g. “switch your attention quickly from each
of those 6 sounds to another of those sounds”;
3. for the next minute, divide attention by simultaneously focusing on as
many different sounds and locations as possible e.g. “For 1 minute focus at
the same time on as many as possible of the 6 sounds that you can hear to-
gether (pause). Now, expand your attention and count how many sounds
you can hear at the same time”.
At the end of the session the therapist says “As homework until your
next session, once or twice a day when you’re not feeling anxious, practise
5’ of selective AT, then 5’ of rapidly-switching AT, then 1’ of divided AT.
Keep a diary of the number of times you practise AT’.
Related procedures: Meditation, task-focusing in sport psychology, test-an-
xiety, and pain management, task concentration training.
Application: AT is used to attain flexible control over runaway worry, rumi-
nation and focusing on threat that might worsen depression and anxiety. AT
may be used alone or during some applications of metacognitive therapy.
1st use? Wells A (1990).
1. Wells A (1990). Panic disorder in association with relaxation induced an-
xiety: An attention training approach to treatment. Behavior Therapy, 21,
2. Wells A, White J, Carter K (1997). Attention training: Effects on anxiety
and beliefs in panic and social phobia. Clinical Psychology and Psychothera-
py, 4, 226-232.
3. Papageorgiou C, Wells A (1998). Effects of attention training in hypochon-
driasis: An experimental case series. Psychological Medicine, 28, 193-200.
4. Papageorgiou C, Wells A (2000). Treatment of recurrent major depression
with attention training. Cognitive and Behavioral Practice, 7, 407- 418.
Case illustration: (Wells, unpublished)
Mary had been depressed for nine months - her second depressive
episode. She had negative thoughts e.g. “I’m a failure, a depressive, defecti-
ve; I’ll never recover; Why do people seem happier than me?”. The therapist
said those thoughts could be made easier to interrupt by practising attention
training (AT) in each therapy session and as homework. This could help her
gain flexible non-repetitive thinking. At the start of each session Mary did 11
minutes of AT (5’ selective, then 5’ rapidly-switching, then 1’ di vided AT) fol-
lowed by metacognitive therapy. The therapist asked Mary to listen to a
combination of sounds such as a ticking clock, a radio tuned between sta-
tions, a metronome, tapping with a pencil, and other sounds coming from ou-
tside. He also asked Mary to do AT practice at home twice a day listening to
several sounds at the same time which varied in loudness and location, in-
cluding an AT recording he gave her of sounds such as church bells, running
water, birdsong, traffic, and a clock.
After 8 sessions of attention training and other aspects of metacogni-
tive therapy Mary became less depressed and remained improved to 6-mon-
BECOMING THE OTHER
Maryhelen SNYDER, 9672 Farmside Place Vienna, VA 22182, USA, ph +1
703 759 3168
Definition: Teaching clients to dialogue empathically with another person,
speaking `in that person’s shoes’ expressing that person’s view and expe-
Elements: The therapist asks: `If you’d like to learn to listen deeply, could
you describe an emotionally important memory (up to 3 minutes)?’. The cli-
ent tells this. The therapist may say: `If it’s OK, I’d like to speak now as thou-
gh I’m you,... trying to enter your world and feel what you feel. I won't inter-
pret or analyze but may use words you didn't when I try to speak as you. I'm
not actually you, so please interrupt if what I say doesn't fit exactly for you’.
The therapist guides the client to:
- `Listen carefully in order to experience another person’s feelings, values,
intentions, and growing edges’.
- `While listening, set aside analysis, judgment, your perspective; instead,
welcome the other’s experience into your consciousness’.
- `As you practice “becoming”, allow yourself to deepen what the other per-
son has said... to be moved’.
- `If you’re interrupted (even by a facial expression that something doesn’t
fit), you can say, “I didn’t get that quite right , did I? Can you help me?” (or
“Let me try again”).’
- `When you stop, you can ask “Does that feel right? Is there anything you’d
like to correct , or add ?” ’
Clients & couples practice `becoming’ the other person within and
between sessions, starting with minor, and later major, conflict areas. At fol-
low-up couples who’re `blocking’ can have booster sessions.
Related procedures: Active listening, expressed empathy, internalized-o-
ther interviewing, two-chair dialogue.
Application: In individual, couple, and family therapy, and in training and
1st use? Of `Becoming’, Snyder (1995).
1. Scuka R (2005). Relationship enhancement therapy: Healing through
deep empathy and intimate dialogue. New York: Routledge.
2. Snyder M (1995). “Becoming”: A method for expanding systemic thinking
and deepening empathic accuracy. Family Process, 34, 241-253.
3. Snyder M (2009). Becoming each other: A single case example of relatio-
nal consciousness in couple therapy. Clinical Social Work Journal, 37, 190-
Case Illustration 1: (Snyder unpublished)
Ron and Janet attended their 4th weekly session where each spoke to
the other from their own experience, listened attentively as though inside the
other’s skin, and accepting corrections with grace and without argument. Ja-
net told Ron her differing view about their argument the previous night, wi-
thout being mean or critical. Ron’s face reddened with rigid neck tendons,
protruding veins, and clenched jaw.
Trying to empathize with clenched teeth without feeling attuned to the
speaker doesn’t usually work, so the therapist asked Ron if he’d like the the-
rapist to answer empathically and then allow him to express his feelings.
Ron replied “I might speak as you showed us in our last session” (see Ele -
ments above. Clients can learn empathic skill after just once speaking “in the
shoes” of another person. Ron spoke as Janet while looking at her: "Last
night when we talked I wanted so much to have you understand why I don't
feel heard by you, but I couldn't explain it right. It was one more time when I
didn't feel I was getting what I felt across to you," and relaxed as he did this.
Janet cried and said through tears, “You understood me better than I under-
stood myself.” Ron added, “Until now I could never get why you felt as you
did.” They listened while “becoming the other” to dialogue with rather than
against each other.
Case Illustration 2: (Snyder 2009)
After couple therapy with several therapists, before starting with Mel
Snyder Jean and Adam decided to divorce once their daughter finished high
school the next year. Jean saw Mel practising `becoming’ as a visiting pre-
senter, practised `becoming’ as an intern, and invited Adam to learn `beco-
ming’ with Mel to help them understand each other. By their 8th 2-hour cou-
ple session with Mel they had practised “becoming each other” at home, and
Jean: (turning to Adam) `You say you’re a “creature of habits” which someti-
mes seem more important to you than I am so I’d like to understand more
what you mean.
Mel: `Is it OK if I become you, Jean, and ask Adam about that somewhat dif-
ferently?’ (Jean assents. Mel moves a chair beside Jean to also face Adam).
`I long for more closeness with you. ...Your habits - watching TV, reading the
newspaper, being alone when you get home - seem to take you away from
me. I miss you. Might being a “creature of habit” be about fear? I want more
of you. I get lonely. (Adam’s body relaxes; Jean appears moved).
Mel: (to Jean) Does that feel right? Is there anything you want to change or
Jean: Yeh, that’s right. I feel vulnerable. I want to add something. (To Adam)
Saturday morning we usually each do our own thing, but last Saturday I bro-
ke the mold and it felt scary. Instead of going to Starbuck’s - a habit of mine
Adam: (smiling) Ding.
Jean: (laughing)... `I thought “I’ll see if Adam will come with me to our se -
cond house to work on the garden.” Your saying “yes” meant a lot be cause
gardening is my thing. You came and seemed to enjoy it.’
Adam: `Can I be you?’ (Jean nods). `I want us to be closer. I get lonely when
you withdraw into the comfort of TV or newspapers. I wonder if you’re afraid.
Saturday, when I risked asking you to come with me and you did and we had
a good time, made me happy.
Jean: (nodding assent through this) Yip
Adam: Mel’s modeling getting to your pain about this was very helpful.
Jean: Yeh, I could feel the shift… .
6 months after ending therapy Jean and Adam still often `became
each other’ when they felt disconnected.
Carl W LEJUEZ, Center for Addictions, Personality, and Emotion Research
(CAPER), University of Maryland-College Park, ph +1 301. 405.5932 / fax
314.9566; Derek R HOPKO, University of Tennessee-Knoxville, ph +1
Definition: A structured way of training patients to gradually increase plea-
sant, personally rewarding behaviors in order to improve thoughts, mood,
and overall quality of life.
Elements: Behavioral activation typically takes 8-15 sessions. In early ses-
sions the therapist explains how depressive behavior weakens efforts to en-
gage in rewarding activities and worsens already-depressed mood, and that
increasing pleasant activities that fit within their values and life goals can im-
prove mood. The therapist encourages the patient to record current activities
every day and then to select weekly behavioral goals concerning relation-
ships, education, employment, hobbies, exercise, and spirituality. Collabora-
tively they construct a hierarchy of 15 activities ranging from “easiest to do”
to “hardest to do”. The therapist and patient together then work out weekly
goals for how often and how long the patient will engage in each valued
pleasant activity. Every day the patient rates progress up this activity hierar-
chy on a Behavioral Checkout Form, and in each weekly session reviews
this with the therapist on a Master Activity Log, sets goals for the next week
depending on success or difficulty with goals in the last week, and works out
weekly rewards for meeting weekly goals. In some forms of behavioural acti-
vation, therapists particularly encourage hitherto-avoided pleasant activities,
do social skills training to help the patient engage in social activities, and
teach mental rehearsal of such activities. The therapist may also teach the
patient how to cope with depressive thoughts by distraction and/or mindfuln -
ess to accept negative thoughts or feelings without judgement when distract-
ion is ineffective.
Related procedures: Goal setting, contingency management, exposure
therapy, successive approximation, homework, diary keeping.
Application: Done individually or in groups for people with depression when
it is the sole concern as well as when depression is comorbid with anxiety,
substance use or personality disorders and/or obesity, HIV or cancer.
1st use? Lewinsohn (1973).
1. Lewinsohn PM, Graf M (1973). Pleasant activities and depression. Jour-
nal of Consulting and Clinical Psychology, 41, 261-268.
2. Lejuez CW, Hopko DR, LePage J, Hopko SD, McNeil DW (2001). Brief
behavioral activation treatment for depression. Cognitive & Behavioral Prac-
tice, 8, 164-175.
3. Martell CR, Addis ME, Jacobson NS (2001). Depression in context: Stra-
tegies for guided action. New York: WW Norton.
4. Hopko DR, Lejuez CW, Ruggiero KJ, Eifert GH (2003). Contemporary be-
havioral activation treatment for depression: Procedures principles, and pro-
cess. Clinical Psychology Review, 23, 699-717.
Case illustration: (Lejuez & Hopko, unpublished)
Phyllis age 30 had had recurrent depression since age 13. After high
school she became an administrative assistant for 12 years. In early ses-
sions she was asked to record her daily activities. This showed that though
she went to work regularly and busied herself with fairly unenjoyable activi-
ties like completing errands for others and housework, she did few things
she valued like being with friends and family and exercising. After Phyllis
and her therapist assessed her short- and long-term life goals and discussed
the treatment rationale, she constructed an activity hierarchy from fairly easy
tasks such as organizing her home and phoning friends to harder goals such
as regular exercise, dating, spending more time with friends and family, and
taking steps to find a more fulfilling job. At each session the therapist re-
viewed Phyllis’s Behavioral Checkout Form, praised her for goals she’d
achieved in the past week including phoning her sister one night, cooking for
a sit-down family dinner on 3 nights, and taking a 20-minute walk after din-
ner on 2 of the nights, and encouraged her to pick a reward for herself in the
next week - she chose buying a book recommended by a friend she was
spending more time with. Once she `mastered’ particular goals at her ideal
frequency and duration for 3 weeks in a row she stopped monitoring them.
She and her therapist discussed whichever chosen goals she hadn’t met in
the past week, problem-solving these to address obstacles and modifying
goals as needed and setting those for the next week. For example, her goal
of starting yoga classes by going to a studio and finding out membership de-
tails felt overwhelming, so she limited the next week’s goal to making a list of
nearby studios and phoning for a consultation time, with later goals to go to
the studio and enrol in a class, and attend each week.
Over her 12 one-hour sessions, Phyllis increased her rewarding acti-
vities until she achieved her ideal goal for each of her less- and moderately-
difficult activities like those above and waking up 30 minutes earlier each
morning to spend time with her family and to feel less rushed at the start of
her day, and met most of her difficult goals including weekly attendance at a
yoga class, reconnecting with a friend she had stopped speaking to because
of an argument, and starting a search for a new, more rewarding job. By ter -
mination and 3-month follow up, without having explicitly discussed her neg -
ative thoughts or social and assertiveness skills, her depressive thoughts
and mood had improved and she had become more independent and as-
John T BLACKLEDGE, Morehead State University, Kentucky 40351, USA;
ph +1 606-783-2982; & Association for Contextual Behavioral Science Board
Definition: Reducing distress from thoughts by training people to focus on
their process of thinking rather than its content or meaning.
Elements: Cognitive defusion diverts attention away from the content or
meaning of words and sentences toward the process of forming words and
stringing them into sentences by concentrating on their sound, pattern, rhy-
thm, frequency, and individual letters or words. Defusion temporarily disrupts
the usual meaning of thoughts or spoken/written words even though their
form or content may stay the same.
Related procedures: Self as context, mindfulness, meditation, metacogniti-
ve awareness, semantic satiation.
Application: In individual or group ACT (acceptance and commitment thera-
py) and other therapies and religious practices.
1st use? As an ACT term, by Hayes & Strosahl (2004) who initially called it
`deliteralization’, and in other therapies and religious practices.
1. Blackledge JT (2007). Disrupting verbal processes: Cognitive defusion in
acceptance and commitment therapy and other mindfulness-based psycho -
therapies. The Psychological Record, 57, 555-576.
2. Hayes SC, Strosahl KD (2004). A practical guide to acceptance and com-
mitment therapy. New York: Springer.
3. Hayes SC, Strosahl KD, Wilson KG (1999). Acceptance and commitment
therapy: An experiential approach to behavior change. New York: Guilford.
4. Wilson KG & Murrell AR (2004). Values work in acceptance and commit-
ment therapy: Setting a course for behavioral treatment (pp. 120-151). In S
Hayes, V Follette, M Linehan (Eds.), Mindfulness and acceptance: Expan-
ding the cognitive-behavioral tradition. New York: Guilford.
Case Illustration 1: (Blackledge, unpublished)
Jim struggled with his feeling that he was a “bad father” for often ha-
ving been unsupportive of his children, especially as he now felt they matte-
red very much to him. To help Jim experience the thought “I’m a bad father”
as `just a thought rather than a thought defining him, a repetitive defusion
exercise was conducted. Therapist: “I’d like to try something a little odd just
to show you how thoughts like `bad father’ work. Let’s start it with words that
are less compelling. Say the word ‘milk’ once, and notice what shows up.”
[Client says ‘milk’ and says he imagines a clear glass of white, cold milk.]
“Now, let’s say the word ‘milk’ out loud, over and over, fairly quickly, for at
least a minute”. [Therapist and client repeat “milk-milk-milk milk-milk...] “At
the end of that exercise, what did you feel as you kept saying ‘milk’?” Jim:
“Nothing... just this weird sound and a weird physical sensation in my throat”.
Therapist: “What if this is all words are? What if they’re just arbitrary sounds,
just noises you make? And when you look at them in a different way, they’re
exposed for that?” Jim: “It certainly seems that way with ‘milk’!” Jim then
agreed to and completed the same exercise with the words “bad father”. At
first saying this was extremely distressing, but after he and the therapist had
together repeated “bad father” on and on for over a minute, Jim said: “The
words just kind of fell apart. They ‘lost their power’ over me. The thought just
pulls me in less now.”
Case Illustration 2: (Blackledge, unpublished)
Jill believed she was a “bad person” because of how she’d someti -
mes treated people. The thought was problematic, in part because it often
kept her from engaging with others in a deep and meaningful way. With her
consent, the therapist tried a defusion exercise to ‘mess up rules of the lan-
guage game’ and help her view this thought differently. Together, Jill and the
therapist spoke the words “I am a bad person” out loud very slowly, spen-
ding 4-5 seconds on each syllable: “IIIIIIIII…ammmmmmmmm…
..aaaaaaaaaaaaaaa… baaaaaaaadddd… … … …perrrrrrrrrrrrrrrrrrrr… … …
Jill then said the words seemed strange, `fishy, less substantial, just
sounds’. The therapist suggested `carry those sounds with you’ the next time
she had an opportunity to get closer to her partner.
Isaac MARKS, 43 Dulwich Common, London SE217EU, UK; ph+44 208
2994130; Lucio SIBILIA, Dipartimento di Scienze Cliniche, Università Sa-
pienza di Roma & Centro per la Ricerca in Psicoterapia, Roma, Italy; ph +39
06 86320838; Stefania BORGO, Università Sapienza di Roma & Centro per
la Ricerca in Psicoterapia, Roma, Italy; ph +39 06 86320838.
Definition: Methods that encourage clients to identify dysfunctional sets of
thoughts and beliefs relating to their problem, and to challenge the validity of
those in order to produce and use more adaptive alternatives.
Elements: Helps clients to identify and challenge maladaptive thoughts (e.g.
absolute / all-or-none / dichotomous / black-and white / catastrophising /
over-generalising thinking) and beliefs concerning the problem through inter-
views and daily thought diaries. May include:
- Socratic questioning to weigh evidence for/against each thought and belief
- Downward arrow (what if?) technique and probabilistic reasoning to chal-
lenge maladaptive thoughts and beliefs
- Behavioural experiments to challenge maladaptive beliefs
- Distancing/giving perspective to generate alternative adaptive thoughts and
Related procedures: Rational emotional therapy, self-instructional training,
Application: Usually taught individually rather than in groups.
1st use? Concept first used by Alexander JM (1928).
1. Alexander JM (1928). Thought control in everyday life. Funk & Wagnalls,
2. Beck AT (1967). Depression: Causes and treatment. University of Penn-
sylvania Press, Philadelphia.
3. Ellis A (1969). A cognitive approach to behaviour therapy. Internat. J.Psy-
chother, 8, 896-900.
4. Lovell K (1999). Exposure and cognitive restructuring alone and combined
for PTSD. PhD dissertation, University of London.
Case illustration: (Lovell 1999)
A man of 26 with PTSD for 2 years after being assaulted, injured and
scarred was asked to keep daily diaries of thoughts to record negative
thoughts and beliefs. They related to fear of being re-assaulted. When
asked, he rated his belief in the probability of being re-assaulted as 80%
(monitoring). This belief was challenged by probabilistic reasoning - he was
asked to calculate how often he'd been out with friends in the years before
the assault and to estimate the probability of a future assault. The self-rated
difference between his initially perceived (80%) and the probable (now rated
as 10%) risk led him to identify his thinking error of over-estimation of dan-
ger. He reframed his belief as the alternative `My chances of being attacked
are no more than other people’s’, and rated his reframed belief in it as 90%.
Soon after this he began to go out with friends and then alone.
He also identified shaming thoughts and beliefs (diary keeping) e.g.
`I’m a coward as I cried after the attack; men don’t cry’. He rated their validity
as 85%. When challenged to provide evidence for and against such
thoughts, he recalled that his father had been upset after the assault and
had cried when visiting him in hospital, but his father was not a coward. He
also recalled that he and his friends had wept at a funeral, which was appro-
priate and not a sign of cowardice. He then reframed his thought to: `Crying
is appropriate in stressful situations’.
He recorded a negative overgeneralising thought: `People with scars
are thought to be criminals, so others seeing my scar will think I’m a
criminal’. He rated this thought as 85% valid. He was asked to list the hair
colour, height etc of criminals and to compare these features with his own.
Mismatch of the two lists led him to rerate his belief that others would consi-
der him a criminal as 40%. For homework he listened to the audiotape of the
session and was required to think of people he knew with scars and how
much he believed them to be criminals, and to spot his thinking error. At the
next session, he said he realised he knew many scarred people but did not
think them as criminals. He generated an alternative response: `Acting su-
spiciously and having a past criminal record suggest criminality, not a scar’.
He rated his belief in this reframed thought as 100%. He labelled his thinking
error as mind-reading (false attribution). The PTSD had reduced markedly
after 10 sessions and even more so 1 year later.
COMMUNITY REINFORCEMENT APPROACH (CRA)
Hendrik G ROOZEN, GGZ Bouman Mental Health Care, Thorbechelaan 63,
Spijkenisse, Netherlands & Ad JFM KERKHOF, Department of Clinical Psy-
chology, Vrije Universiteit, Van der Boechorststraat 1, 1081 BT Amsterdam
Definition: In the community reinforcement approach (CRA) the therapist
helps the patient to identify and engage in rewarding social and other activi-
ties in the community that compete with rewards from substance use, and
persuades the patient to recruit a `significant other’ to aid adoption of a heal-
Elements: The therapist trains patients’ skills by role-playing with them how
to refuse drugs and alcohol, communicate positively and appropriately as-
sertively, and how to behave in job interviews, and encourages them to find
and engage in pleasant hobbies and other non-substance related pursuits,
and to enlist a trusted relative or friend for help in carrying out the CRA.
Application: Both individually and/or in groups and in different settings such
as in- or outpatient settings, often supported by a relative or friend and com-
bined with medication.
Related procedures: Behavioral activation, contingency management, rein-
forcement, token economy, Morita therapy, motivational interviewing, nido-
therapy, stimulus control, successive approximation; role play, social skills
training; homework, diary keeping, problem-solving.
1st Use? Hunt GM, Azrin NH (1973).
1. Budney AJ, Higgins ST (1998). National Institute on Drug Abuse therapy
manuals for drug addiction: Manual 2. A community reinforcement approach:
treating cocaine addiction. (NIH Publication No. 98-4309). Rockville, MD:
U.S. Department of Health and Human Services.
2. Hunt GM, Azrin NH (1973). Community reinforcement approach to alco-
holism. Behaviour Research & Therapy, 11, 91-104.
3. Meyers RJ, Smith JE (1995). Clinical guide to alcohol treatment: Commu-
nity Reinforcement Approach. New York, NY, USA: Guilford Press.
4. Roozen HG, van den Brink W, Kerkhof AJFM (1997). Toepassing van nal-
trexon/clonidine bij een biopsychosociale behandeling (CRA) van opiaataf-
hankelijken. In Buisman WR, Casselman J, Noorlander EA, Schippers GM,
de Zwart WM (Eds.). Handboek Verslaving (B4250, 1-24). Houten: Bohn
Stafleu Van Loghum (in Dutch).
Case illustration: (adapted from Roozen et al 1997)
Mary, aged 29, sought outpatient help to withdraw and then abstain
from heroin especially and from cocaine and from methadone maintenance.
A boyfriend had introduced her to drugs 9 years earlier. They broke up after
a couple of years, after which she lived on her own. Recently she had stayed
with her parents. She had been heroin-dependent for 8 years and on substi-
tute methadone 40mg daily for 5 years. She had had no meaningful job for
some years and currently only had substance-using friends.
When the outpatient community reinforcement approach (CRA) be-
gan, Mary and her mother agreed with the therapist that mother would help
Mary throughout treatment. Both attended weekly outpatient sessions over 6
months. Over 30 days Mary reduced cocaine and heroin use from daily to in-
frequently and took prescribed methadone more regularly; her methadone
dose was increased slightly and stabilized. She then had opioid detoxifica-
tion over 72 hours to stabilise abstinence from heroin and methadone.
She had naltrexone (opioid-antagonist) induction followed by naltre-
xone 25mgs daily throughout the CRA to prevent relapse. After detoxification
Mary felt depressed and spent most of her time in bed at her parents’ home
for three weeks, during which she reported one cocaine relapse. She com-
pleted happiness scales to evolve treatment goals with her therapist and mo-
ther. Mary targeted and was encouraged to do potentially rewarding activi-
ties such as: shop, visit family with mother, meet a non-drug-using old
school friend, start fitness exercises and classes including stationary cycling
(spinning) at a gym, and find a job. Mother helped Mary take her naltrexone
and do homework assignments. Outpatient staff took urine specimens and
did urinalysis. Mary, her mother and the therapist discussed and completed
functional analysis forms showing that relief from depression was transient
after substance use and alternative longer-term relaxation came from heal -
thy pro-social behaviors, and Mary kept a `goals of counselling’ diary.
Completing the forms aided Mary’s growing stimulus control by gra-
dually avoiding drug-related situations and spending more time in pleasant
activities, as above, incompatible with drug use. In rehearsals with moth er
and therapist in outpatients andat home visits Mary improved communication
with mother. Mary also rehearsed job- interviews with her therapist. After 1-
month abstinence verified by urinalyses, Mary found a nearby factory job
and her mood improved rapidly. After 10 months of abstinence she disconti-
nued naltrexone and the CRA, feeling confident she would stay ab stinent.
Mary kept her job, went on vacation with new friends, and engaged in fre-
quent sports and other fitness activities such as spinning and jogging. She
made new friends, and planned to start adult education classes to get a bet-
ter job later.
At 6 months follow-up she reported sustained abstinence.
Paul GILBERT, Mental Health Research Unit, Kingsway Hosp, DerbyDE22
3LZ, UK; ph +44 1332 623579
Definition: Teaching people how to feel compassionate to themselves and
others during therapy and at other times.
Elements: Compassion involves empathy - being able to understand one’s
own and other people’s feelings - and being caring, accepting and kindly to-
lerant of distress in self and others. Compassion-focused therapy teaches
clients that, because of how our brains have evolved, anxiety, anger and de-
pression are natural experiences which are ‘not our fault’. Clients are helped
to explore how early experiences (e.g. neglect, abuse or other threatening
experiences) may relate to ongoing fears (e.g. of rejection, abuse), safety
strategies (e.g. social avoidance or submissive behaviour), and unintended
consequences such as social rejection or other mental health problems.
When people feel threatened and self-critical with strong bodily feelings, they
can learn to slow their breathing and refocus attention on imagining a com-
passionate place, becoming a compassionate person, and/or imagining so-
meone compassionate talking to them. For example, someone who thinks
s/he is useless and a failure can be taught to think kinder thoughts (e.g. ‘I’ve
actually achieved... in my life’, ‘friends often seek my support’, ‘these
thoughts come only when I’m depressed and so aren’t real’). Clients are hel-
ped to practise exercises to detect self-criticism and then refocus compas-
sionately by creating and practising feelings and thoughts that are kind, sup-
portive and encouraging, and noticing mindfully how this helps them. Some
people take to this within a few sessions, and others within 10 or more ses-
sions to work through resistance to positive feelings.
Related Procedures: Acceptance, anger management, cognitive restructu-
ring, imagery practice, meditation, mindfulness, validation of feelings, well-
Application: During individual and group therapy for any clients, especially
if they feel much shame and self-criticism.
1st Use? Gilbert & Procter (2006), compassionate imagery in Buddhist prac-
tice for 2500 years.
1. Gilbert P (2009). The Compassionate Mind. London: Constable-Robinson.
Oaklands CA.: New Harbinger.
2. Gilbert P (2009). An Introduction to compassion focused therapy. Advan-
ces in Psychiatric Treatment, 15, 199-208.
3. Gilbert P, Procter S (2006). Compassionate mind training for people with
high shame and self-criticism: A pilot study of a group therapy approach. Cli-
nical Psychology and Psychotherapy, 13, 353-379.
4. Laithwaite H, Gumley A, O’Hanlon M, Collins P, Doyle P, Abraham L, Por-
ter S (2009). Recovery after psychosis (RAP): A compassion focused pro-
gramme for individuals residing in high security settings. Behav & Cogn Psy-
chotherapy. 37, 511-526.
For many years Jane had had occasional depression with suicidal at-
tempts. As a child she had tried to appease her critical mother to win affec-
tion. Jane had shame memories about being bullied at school and mother’s
criticism. Conflicts and setbacks triggered self-criticism -“I’ve messed up
again, people don’t like me, I should deal with this better”. The therapist ex-
plained.“We have three types of feeling -anxiety and anger when threatened,
enjoyment and wanting to do things, and, third, contentment, peaceful well-
being and feeling soothed. Soothing feelings help us manage other fee lings,
and come when we feel people are being kind and helpful. Criticism from
others or ourselves makes us anxious, whereas kindness and helpfulness
soothes us”. Jane remained reluctant to develop kind compassionate-self
practice because she thought compassion is “going soft, letting one’s guard
down, being self-indulgent; I don’t deserve it, I should be tougher, not com-
The therapist said “Such reluctance is common. Let’s go one step at
a time. We don’t want to take your guard down. You’re free to keep that if
you want, to ignore compassion if you think you don’t deserve it at the end
of therapy, but you might find it useful to explore how to feel compassion
and how it works for you”. This encouraged Jane to start practising and de-
sensitising to her fear of feeling affiliative by exercises such as: To develop
your compassionate self, sit comfortably and focus on your breathing. Now
imagine you’re a deeply compassionate person. Think of your personal qua -
lities and create a kind expression”. After doing this repeatedly (like method-
acting practice) Jane could go into compassionate-self mode to practise
compassion to her anxiety and anger. She would imagine herself as a com -
passionate person, think of what was making her anxious, and become com-
passionate to her anxious self, and what she’d like to say or do to her an -
xious self to be helpful to it. She was taught the links between thinking, fee-
ling and behaviour, and to monitor self-criticism and become mindful of it by
slowing her breathing: “Bring self-critical thoughts to mind and notice what
happens to your body and feelings (pause for 30 seconds). Now let those
thoughts fade, breathe more slowly, and imagine someone talking to youin a
kind, understanding way”. Helping Jane notice how criticism and kindness
feel different was important. The therapist also asked Jane to engage in one
compassionate behaviour towards herself each day and notice how she
feels with this behaviour. She completed compassion- focused therapy in 25
COMPUTER-AIDED VICARIOUS EXPOSURE (CAVE)
Ken KIRKBY, Psychiatry Department, University of Tasmania, 28 Campbell
St, Hobart 7001, Australia; ph +613 6226 4885, +61 419 120041
Definition: A computer game to teach users exposure therapy as they direct
a supposedly phobic screen figure to approach and remain in avoided feared
situations shown on the screen until that figure’s fear score drops.
Elements: By pointing and clicking with CAVE’s computer mouse, users
steer a ‘phobic’ screen figure through avoided discomforting scenes (e.g.
spider phobic nearing a spider, agoraphobic leaving home, claustrophobic
entering a lift, OCD washer touching garden soil) as that figure’s supposed
anxiety thermometer score rises with each approach and then falls as the fi-
gure remains in the situation. The game gives and displays to users points
for moving the figure towards exposure scenes, the aim being to score 2000
points. All mouse human-computer interactions are recorded for process
Related procedures: Vicarious/symbolic/live/in vivo modelling of exposure,
vicarious/etc mastery (high initial fear falls as exposure continues), coping,
Application: Used individually to date in research trials.
1st Use? First CAVE software: Kirkby et al (1992).
1. Clark A, Kirkby KC, Daniels BA, Marks IM (1998). A pilot study of CAVE
for obsessive-compulsive disorder. Australian and New Zealand Journal of
Psychiatry, 32, 268-275.
2. Gilroy LJ, Kirkby KC, Daniels BA, Menzies RG, Montgomery IM (2003).
Long term follow-up of CAVE vs live graded exposure in the treatment of spi-
der phobia. Behavior Therapy, 34, 65-76.
3. Kirkby KC, Daniels BA, Watson PJ (1992). An interactive computerised
teaching program for self exposure therapy of avoidant behaviour in phobic
disorders. 4th World Congress on Behaviour Therapy, 4 July 1992, Gold
Coast, Queensland, Australia; Abstracts, Australian Academic Press,
Queensland, pp 73.
Case illustration: (Kirkby, unpublished)
Jill aged 45 had been phobic of spiders since childhood. After outpa-
tient assessment she had three 45-minute sessions of CAVE at 2-week in-
tervals. At Session 1 she met a researcher who remained to answer queries.
She sat at the computer to complete CAVE’s 5-minute explanatory introduc-
tion on the screen which showed navigation techniques for its animation sce-
nes. The researcher left the room. Over 45 minutes by trial and error Jill lear-
ned the effects of directing CAVE’s screen figure to do various things, eg ap-
proaching a spider in a room (= exposure), leaving that room (= avoidance),
staying in another room (= neutral). Jill saw the anxiety thermometer on the
screen display the screen figure’s anxiety which was high on first exposure
to the screen spider and then gradually fell with accumulating exposure. The
aim of the game was to score 2000 points gained, for example, by moving
the screen figure to repeatedly or persistently touch a perspex container with
a large live spider inside. She learned by doing how to achieve the target
score by exposing the screen figure to the phobic scenes and observing how
this reduced anxiety over time.
After 3 CAVE sessions Jill looked closely at a container with a large
spider in it, and held this partial improvement to follow-up some years later.
COPING CAT TREATMENT
Philip C KENDALL & Muniya KHANNA, Child & Adolescent Anxiety Disor-
ders Clinic, Department of Psychology, Temple University, 1701 N. 13th
Street, Philadelphia, PA 19129, USA; ph +1 215 746 5704 / fax 3311
Definition: The therapist helps anxious children to recognize signs of anxie-
ty, to relax, and to modify anxious self-talk and thinking, followed by self-mo-
nitored exposure tasks in and out-of session to help them better manage
their thoughts, feelings and behavior when anxious.
Elements: The therapist and youth together create a personalized FEAR
plan (e.g. Case Illustration below) to use in anxiety-evoking situations. Its
steps include answers to: Feeling frightened?; Expecting bad things to hap-
pen?; Actions and Attitudes that can help?; Results and Rewards. The child
memorizes these coping steps by their acronym FEAR and then practises
them during planned exposure tasks to feared situations in session and as
homework. Exposure tasks are graded from imagined slightly-frightening si-
tuations to moderate and then very frightening real ones. Though done in a
supportive environment, the tasks should challenge and evoke anxiety. With
this graded exposure children habituate to and apply coping strategies in an-
xiety-evoking situations and develop a sense of mastery rather than anxious
Application: In 16 individual or group sessions over 16 weeks for children
aged 7-13, helped by a workbook whose exercises parallel therapy sessions
to aid involvement and skill acquisition. Also done in 6 computer-guided and
6 therapist-guided sessions over 12 weeks using Camp Cope-A-Lot: The
Coping Cat CD Rom.
Related procedures: Graded exposure, role play, cognitive restructuring,
1st Use? Kendall PC (1994) to convert taunts that frightened children are
"scaredy cats" into a coping version.
1. Kendall PC (1994). Treating anxiety disorders in children: Results of a
randomized clinical trial. Journal of Consulting and Clinical Psychology; 62,
2. Kendall PC, Hedtke K (2006). Cognitive-behavioral therapy for anxious
children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing.
3. Kendall PC, Khanna MS (2008). Camp Cope-A-Lot: The Coping Cat CD
Rom-available too as Coach’s Manual CD (2008) and Go-to-Gadget work-
book CD (2008). Ardmore, PA: Workbook Publishing Inc.
4. Kendall PC, Hudson JH, Choudhury MS, Webb A, Pimentel SS (2005).
Cognitive- behavior treatment for childhood anxiety disorders. In ED Hibbs &
PS Jensen (Eds.), Psychosocial Treatments for Child and Adolescent Disor-
ders: Empirically Based Strategies for Private Practice, 2nd Edition. Americ-
an Psychological Association.
Case illustration: (Kendall et al 2005)
Sample FEAR plan from session 9 for Bill aged 10 who feared giving
a class presentation and getting lost when going to new places.
Feeling frightened? “Well, I have butterflies in my stomach and my
palms are sweaty.”
Expecting bad things to happen? “I’ll mess up”; “The other kids may
make fun of me”; “I’m going to look stupid and they’ll laugh at me.”
Actions and Attitudes that can help : “I can practice beforehand to
make sure I know what I’m going to say”; “I didn’t mess up the last time I
gave a report and the teacher said I did a good job”; “Even if I mess up, it’s
not a big deal anyway because everybody messes up sometime”; “I can lau-
Results and Reward: “I was nervous in the beginning but I felt okay
by the end”; Nobody laughed”; “I think I did a pretty good job and I tried real-
ly hard”; “My reward is to go to the movies with Mom and Dad this weekend”.
Typical use of the FEAR plan: In session 7 Bill and the therapist pre-
pared for an exposure task (walk around a shopping mall for 10 minutes alo-
ne while the therapist waits outside) to challenge Bill’s fears that he’ll get lost
in new places.
Therapist: Are you feeling nervous now?
Bill: I don’t know. Not really.
Therapist: How would you know when you were starting to get nervous?
Bill: My heart would start beating faster.
Therapist: (recalling Bill’s common complaint) What about your breathing?
Bill: I might start breathing faster.
Therapist: And what would you be thinking to yourself?
Bill: I might get lost or I don’t know where I am.
Therapist: And what are some things you could do if you start getting ner-
Bill: I could take deep breaths and say everything is going to be OK, there
are tons of adults here.
Therapist: That’s good, but what if you were unsure where you were or got
Bill: I could ask somebody.
Therapist: Yes, you could ask somebody. Might it be a good idea to ask one
of the guards or policemen? How are you feeling? Are you ready to give it a
The therapist and Bill agreed on several side-trips that Bill would do
alone between then and the next session within the mall, varying in distance,
duration, and familiarity. Bill wrote his exposure experience (including his
FEAR Plan) into his workbook. During one trip, Bill had to ask a guard for di-
rections in order to feel comfortable doing this in future, if needed.
COUNTERTRANSFERENCE, USE OF
Jeremy HOLMES, Department of Clinical Psychology, Washington Singer
Building, University of Exeter EX4 4QG
Definition: The therapist’s use of his/her persistent or brief emotional re-
sponses to the patient (countertransference) - as clues to the patient’s past
and present emotions.
Elements: a) The therapist senses and identifies his/her own feeling to-
wards the patient, b) verbalises this internally (e.g. ‘I’m feeling sad’), c) offers
this to the patient as a possible emotional resonance (‘I wonder if you’re fee-
ling sad right now’) usually without referring explicitly to the therapist’s own
feelings, and d) suggests this feeling may reflect recurrent themes in the pa -
tient’s life (‘perhaps you usually avoid feeling the pain of sadness’).
Related procedures: Transference interpretation.
Application: Psychoanalytic and psychodynamic therapy with individuals,
groups and couples.
1st Use? Freud S (1910).
1. Bateman A & Holmes J. (1995). Introduction to Psychoanalysis pp109-
2. Freud S (1910). Future prospects of psychoanalysis Standard Edition 11
(Eleven) pp. 145. London: Hogarth Press.
3. Gabbard G (1995). Countertransference: the emerging common ground
Int J.Psychoanalysis, 76, 475-85.
4. Gabbard G. (2005). In (Eds). G Gabbard, J Beck & J Holmes Oxford Text-
book of Psychotherapy pp. 8 Oxford: OUP.
Case Illustrations (Holmes, unpublished)
1. Using countertransference as a clue to a patient’s repressed rage Ale-
xandra’s husband had chronic depression and killed himself while she, mo-
ther of a 3-year-old son, was pregnant with her second child. She sought
help to come to terms with the suicide and find stability to raise her children
as a widow. During early sessions she poured out sadness and grief at what
had happened, guilt about a row with her husband on the day of his death,
and expressions of her lost love for him. The therapist was initially very mo-
ved by this but, as sessions continued, despite understanding the suicide
risk in depression, felt outraged at what the husband had done to his wife
and family, and intuited that anger was conspicuously absent in Alexandra’s
narrative. Sensing that she had repressed these feelings, partly to present a
positive image of her husband to her children, the therapist tentatively sug-
gested in Session 4 that in addition to her feeling of loss and sadness she
might be enraged at her husband for abandoning her. She dismissed this ini-
tially out of hand, but at the next session said she had woken in the night
feeling overwhelming fury at her husband for what he had done. Expressing
this seemed to reduce her guilt and enable her to realise that at moments
when she felt unable to talk to her son about his father it was because her
anger prevented her from seeing the positive side of his dad which her son
2. Using countertransference as a clue to the patient’s early and current re-
Peter, an unmarried loner, was an information technology specialist
seeking help for chronic low self-esteem and feeling inadequate. He had re-
cently been cautioned at work and told that, despite technical competence,
unless he ‘examined his attitude’, dismissal was likely. He often felt that his
excellent suggestions for reorganising his department were ignored, and af-
ter months of resentment had a ‘blazing row’ with his boss about this. An
only child, he described a loveless upbringing which emphasised order and
achievement rather than fun. The therapist repeatedly suggested that Pe-
ter’s anger with his boss might relate to similar anger towards his parents,
but Peter ignored this or dismissed it as absurd – “I come from a totally nor -
mal family”. At session 12, the therapist used his countertransference sense
of a lack of progress in therapy to point out how Peter tended to pass over
his comments and suggested that perhaps Peter felt he had never been
really heard or taken seriously by his parents, who knew in advance ‘what
was best’ for him, and that similar feelings might explain his interpersonal
difficulties at work. At this Peter dissolved into tears, for the first time in the -
rapy, complaining bitterly that his true feelings seemed of no consequence to
anyone. Later he saw that ‘not being heard’ worked both ways and that his
few girlfriends had left him when he had tried to impose his ideas of how
things should be rather than responding to their wishes.
DANGER IDEATION REDUCTION THERAPY (DIRT)
Mairwen JONES, University of Sydney, POBox 170 East St, Lidcombe,
NSW 1825, Australia
Definition: Cognitive-restructuring and attention focussing aiming to decrea-
se danger-related expectancies concerning contamination and disease in
Elements: DIRT tries to change unrealistic thoughts about illness to realistic
ones by: cognitive restructuring with probability-of-illness estimation before
and after giving detailed corrective information concerning the immune sy-
stem, disease rates, and usual risks people take without becoming ill, shows
filmed interviews with cleaners etc who touch dirt and brief reports about sci-
entific contamination experiments; daily attention exercises without thoughts
intruding by normal breathing (neither slow nor rapid) while focusing on a se-
ries of numbers while breathing in and focusing on the word ‘relax’ while
breathing out - no instructions are given about fear of or exposure to conta-
Related procedures: Attention focussing (training), cognitive restructuring,
diary-keeping, homework, probability estimation, rational emotive therapy.
Application: Taught individually or in groups to obsessive-compulsive wa-
1st Use? Jones MK, Menzies RG (1997). Danger Ideation Reduction Thera-
py (DIRT): preliminary findings with three obsessive-compulsive washers.
Behaviour Research and Therapy, 35, 955-960.
Hoekstra R (1989). Treatment of OCD with rational-emotive therapy. Paper
(describing probability-of-catastrophe-estimation task) to 1st World Congress
of Cognitive Therapy, Oxford: 28 June-2 July, 1989.
Over 6 years, for fear of contamination Mary aged 34 had avoided us-
ing public transport or toilets, shaking anyone’s hand, touching garbage or
raw meat, and contact with pets and pet owners. She showered 6 times a
day and washed her hands with antiseptic for 5 mins after touching anything
`contaminated’ and before handling food. Her therapist said incorrect beliefs
about contamination caused the problem and asked her to keep a diary (ho-
mework) of thoughts and beliefs about dirt and illness.
Mary felt 99% certain that touching her garbage bin would cause vo-
miting and diarrhoea. With her therapist she analysed the steps for this to
occur (bacteria on the bin, transfer to her hand, entering her body, immune
failure) and estimated the probability for each step. Multiplied together these
yielded an illness probability of .014% compared to her initial estimate of
99%. She was asked to apply such probability estimation to one new situa-
tion a week. Mary was shown a 10-min film of a healthy cleaner who often
touched pets’ hair while cleaning homes, used gloves only to prevent hand
irritation from bleach, and on finishing washed only briefly with any soap
Discussion noted that pet- and pet -shop owners, vets and cleaners
were not unduly ill (giving corrective information). The therapist gave Mary a
1-page microbiology report that undue washing can cause skin cracks allo -
wing in infection, and a 2-page report of an experimenter who with one hand
touched a cat, scoop for a cat litter tray, and garbage bin, after which no pa-
thogens grew from that hand or the other, control, hand. Mary was helped to
challenge excessive risk estimates for tasks, and asked her to read and
copy the summary daily for 15 min to make her thoughts realistic ( cognitive
From early on Mary was asked to practise attention focussing (trai-
ning) for two 10-minute sessions daily with eyes closed: during her 1st brea -
th in she had to focus on the number `1’ and during her 1st breath out to say
`relax’, during her 2nd breath in to focus on `2’ and during her 2nd breath out
to say `relax’, and so on until on her 10th breath in she focussed on `10’ and
during her 10th breath out said `relax’. She repeated this 10-breath cycle
over and over for 10 minutes and was asked to, between sessions, practise
these 10-min focusing-homework sessions twice a day in gradually noisier
environments with her eyes open.
After 12 one-hour individual DIRT sessions weekly and at 6-month
follow-up Mary’s contamination fears and washing reduced markedly. Wi-
thout fear she took the bus to shops, used public toilets and touched garba-
ge bins, and stroked pets which friends brought to her home.
Katherine M DISKIN, Mental Health Services, CFB Esquimalt, Victoria, Briti-
sh Columbia, Canada; ph +1 250 363 4411 & David C HODGINS, Departm-
ent of Psychology, University of Calgary, Calgary, Alberta, Canada; ph +1
403 220 3371
Definition: A decisional-balance exercise is an elaborated form of “pros-an-
d-cons” review that is often used in deciding whether to change behaviour. It
provides an opportunity to examine both the negative and positive aspects of
a behaviour, acknowledge ambivalence, and allow clients to feel understood
rather than judged.
Elements: Decisional balance can be done in written form or in conversation
at any point in therapy which seems appropriate. The clinician shapes the
process through questions, summaries and selective emphasis. Like a pros-
and-cons discussion, the therapist usually starts by exploring “good things”
and then “not-so-good things” about the status quo, and finally asks clients
to consider what might be “good and also not-so- good” if they ever decided
to change their behaviour. The client and the therapist can thus weigh both
the positive aspects and the potential difficulties of behaviour change, and
how drawbacks could be addressed.
Related Procedures: Motivational interviewing, motivational enhancement
therapy, pros-and-cons review.
Application: When indicated during any session of motivational interviewing
or motivational enhancement therapy or when addressing potential beha-
viour change, e.g. when discussing reducing addiction or other harmful be-
haviours, leaving an abusive relationship, starting an exercise program, re-
turning to school.
1st Use? Janis & Mann (1977), elaborated by Miller & Rollnick (1991).
1. Janis IL, Mann L (1977). Decision-making: A psychological analysis of
conflict, choice, and commitment. New York: Free Press.
2. Miller WR, Rollnick S (1991, 1st ed. & 2002, 2nd ed.). Motivational inter-
viewing: Preparing people to change addictive behaviour. New York: Guil-
Case illustration: (Diskin unpublished)
During therapy session 3 Gina and her therapist agreed that exercise
could probably help her low mood yet Gina hadn’t managed to start. The
therapist then shaped a decisional-balance discussion which lasted 11 minu-
(1. Staying unchanged - not exercising: A. Good things)
T. So tell me what’s good about not exercising?
G. I just don’t have the energy; it’s hard to get started… I don’t have the time
either - I drag myself around on weekends to do my chores
T. You sound pretty tired and overwhelmed already. What else?
G. Well, I’m out of shape, fat, a mess…I hate having to start
(B. Not-so-good things)
T. I see it’s really hard to get going …on the other hand, … tell me what you
dislike about not exercising?
G. It’s funny, but when I was working out I had more energy, and felt stron -
ger, less tired
T. Anything else?
G. I’m gaining tons of weight, hate looking like this. I used to be really fit
when I was running.
(2. Changing - starting to exercise: A. Not-so-good things)
T. Imagine you did decide to start. What would be hard, get in the way?
G. I’m in terrible shape. I’d hate feeling so weak.… but already feel that way.
T. What else would be hard?
G. I don’t like to run on my own. I’d have to phone someone and feel such a
T. So it would be hard to call old running friends because they’d look down
G. Yeah, …except Jen called a few times to ask if I want to run. She was in-
jured and wants to start.
T. You mentioned time as a problem.
G. Yeah, but I used to run before work, it wasn’t that bad once I started…
(B. Good things)
T. So if you did start and kept it up, what would that be like?
G. Well, I’d stop feeling a slob. …could lose weight, wear some of the clo-
thes I had to put away.
T. Anything else?
G. I’d have more energy – I used to be able to run in the morning, work all
day and go out at night. Now I’m barely making it to work… I like feeling
T. It felt good physically. Do you remember what your mood was like when
you were exercising?
G. Yeah, I felt a lot better and spent less time alone watching TV. I did more
non- running things, volunteer work.
After completing this exercise the therapist and Gina reviewed it,
Gina gradually began exercising, and her mood improved during her remai-
ning 7 sessions over 2 months.
DIALECTICAL BEHAVIOUR THERAPY (DBT)
Maggie STANTON, Psychology Services, 59 Romsey Rd, Winchester, Han-
ts, SO22 5DE, UK; ph +44 1962 825600
Definition: DBT for borderline personality disorder with suicidal and other
impulsive and high-risk behaviours includes skills training, exposure, cogniti-
ve modification and contingency management balanced with acceptance by
validation and mindfulness.
Elements: In a pre-treatment phase of 4-6 weekly individual sessions, a the-
rapist identifies client goals, orients the client to DBT, shapes commitment to
its goals, and develops a target hierarchy of the order in which to address
problem behaviours. If the client completes pre-treatment and agrees to
DBT, the client enters Stage 1 which encompasses five functions:
1. Enhance capabilities: Clients learn skills, usually in a group, in four modu-
les: mindfulness; distress tolerance; emotion regulation; and interpersonal
2. Improve motivation: In individual sessions, the therapist analyses cues for
problem behaviours and reduces obstacles to more skilful behaviour by ex-
posure, cognitive modification and contingency management.
3. Generalization: Clients can usually phone outside office hours for skills
4. Structure the environment to reward progress e.g. by offering an opportu-
nity to extend treatment. With adolescent clients a therapist may meet their
parents to advise contingency management of the target behaviours.
5. Enhance therapist skills and motivation by supervising the therapist team
in a weekly meeting.
Related procedures: Cognitive restructuring, contingency management,
diary-keeping, exposure, mindfulness, problem-solving, role-play, social
Application: After 4-6 weeks of pre-treatment individual sessions a team of
≥4 therapists gives weekly individual and group sessions plus phone coa-
ching usually over a year. DBT was developed for suicidal people with bor-
derline personality disorder. Adaptations are appearing for other disorders.
1st use? Linehan M (1987).
1. Linehan MM (1987). Dialectical behavior therapy: A cognitive behavioral
approach to parasuicide. Journal of Personality Disorders, 1, 328-333.
2. Linehan MM (1993). Skills Training Manual for treating Borderline Perso-
nality Disorder. Guilford Press, New York & London.
3. Linehan MM (2006). Two-year randomized controlled trial and follow-up of
dialectical behavior therapy vs therapy by experts for suicidal behaviours
and borderline personality disorder. Archives of General Psychiatry; 63, 757-
Case illustration: (Stanton M, unpublished)
Julia, 32, had for 15 years repeatedly overdosed, cut her arms, misu-
sed alcohol, and been hospitalised. DBT began after a serious over-dose.
During 6 individual pre- treatment sessions, Julia identified goals of having a
boyfriend and a job. With her therapist, Julia developed a hierarchy of target
behaviors, which were: life threatening (overdosing, suicide planning/actions,
cutting herself, self-harming urges), therapy interfering (missing therapy ses-
sions), and quality-of-life interfering (not applying for jobs, drinking >8 units
of alcohol/week or >4 units/day).
Julia attended an open weekly 2.5-hour skills-training group with 6-8
other clients and 2 therapists. She recorded on a diary card self-harming be-
haviour, suicide ideas, alcohol intake, and DBT skills used. In week 1, she
recorded trying mindfulness on 3 days, self-harming 5 times, and daily self-
harming and suicidal urges. In weekly 1-hour individual sessions Julia chain-
analysed her top target behaviour (‘cut my arm on Tuesday evening’) for
links among thoughts, feelings and actions in order to develop more con-
structive behaviour for each link. The therapist, by cognitive restructuring,
contingency management, skills coaching and exposure, encouraged Julia
to role-play each new behavior in session. For example, Julia had argued
with a friend, felt disliked by her, became angry, and drank a bottle of wine to
blot this out. When that did not work, she cut her arm. The therapist valida-
ted that distress is natural after arguing with a friend, and role-played with
Julia skills to talk to her friend without arguing while being mindful of her
judgments. She calmed herself by deep, slow breathing and practised thin -
king kindly about her friend’s perspective. This reduced her anger and self-
Over the first 2 months Julia noticed that self-harming and drinking al-
cohol reduced distress. She became aware of her feelings, their triggers,
and reasons for them. She could decide when to act on them or do some-
Julia’s frequent brief phone calls to her therapist for skills coaching di -
minished as her skills came automatically. She attended therapy regularly by
arranging her own mobile-phone prompts. She chain-analysed target beha-
viours and devised helpful solutions. For example, on feeling strong self-har-
ming urges and examining links in the chain Julia realised she felt sad be-
cause a friend was moving away and imagined this was her own fault. Julia
recognised it was natural to feel sad, mindfully noticed her thoughts without
involvement in them, challenged thoughts of being responsible by noting her
friend was moving to be near her ill mother, and resolved to keep in email
contact with her friend.
Julia began volunteer work in a plant nursery and was offered paid
work. After a year of weekly outpatient individual and group sessions and te-
lephone coaching, she began monthly 1-hour advanced-group meetings with
one therapist and 4-5 DBT `graduates’ for mutual support in maintaining
skills. She could come as long as she kept using her skills and has attended
6 such meetings so far.
Jacques MONTANGERO, 76, ch. de la Miche – F-74930 Esery, France; ph
+33 450 31 86 83
Definition: Attributing to the content of a dream a meaning related to the
dreamer’s concerns, aspirations, behaviour, or life episodes.
Elements: Dream interpretation starts with elements of the dream report
and leads to new ideas associated with these that the client considers rele-
Psychoanalytic dream interpretation concerns clients’ free associa-
tions to dream content, which the analyst relates to psychoanalytic meta-
phors e.g. oblong objects may represent a penis, and to topics such as
transference, sexuality, and early child-parent relationships. In Hill’s dream
interpretation the client is asked to describe the dream in detail and to re-ex-
perience associated feelings. Next the client is asked `What could your
dream mean?, and after this interpretation is asked how s/he would like to
change the dream and corresponding aspects of waking life.
Montangero’s cognitive-behavioural dream interpretation has three
1. `Please describe your dream again with everything you saw, or felt was
present but didn’t see, concerning its setting, action, characters and fee-
lings’. 2. `Now say what memory comes to mind about elements of your
dream, not necessarily as they were in the dream, e.g. about a blue car you
saw’. 3. Next, can you reformulate your dream in more general terms, de-
scribing it sentence by sentence with your meaning of each element (e.g. in-
stead of `my neighbour’ - `an uninteresting housewife’) or its encompassing
category (e.g. instead of `going down stairs’ - `changing level’) or its function
(e.g. instead of `the door’ - `something giving access). I may make sugge-
stions, but only you can decide what is relevant’. A doctor reformulated his
dream of `Two “gangs” competing in a flower market by spraying flowers to
refresh them’ as `Two groups competing in their task to cure’. Reformulation
helps clients interpret how their dream applies to their experience - the doc -
tor said it applied to two groups of doctors each claiming superiority for their
competing type of treatment. Such interpretations suggest helpful topics to
discuss e.g. feelings or ways of relating not mentioned before (e.g. guilt, or
avoidance of intimacy with a partner).
Interpretations may also raise awareness of distorted thinking, e.g. a
depressed young man dreamt about people who were either omnipotent (de-
vils, his rich influential landlady) or hopeless (someone homeless, priso-
ners). Discussion of this made him aware that he judged people unrealisti -
cally in all-or-nothing terms (either complete winners or total losers). Dream
interpretations may also raise awareness of a ‘schema’ - a belief underlying
distorted thoughts, e.g. commenting on her dream of feeling terribly embar-
rassed when her boss came late to care for a client, a young woman said
she could never do that: `I must do everything for other people, and immedi-
ately, otherwise they won’t love me’. Finally, dream interpretation allows the
therapist to underline a client’s resources e.g. a woman dreamed she was
driving and was stopped by a barrier that she managed to lift up, but further
on her car stuck in the mud and she had to get out and walk to go on. She
interpreted her dream pessimistically: “It shows my life is full of difficulties”.
The therapist pointed out that her dream also showed she knew she could
go on in spite of obstacles.
Related procedures: Psychodynamic interpretation of slips of the tongue,
cognitive restructuring, free association, reframing.
Application: Psychoanalytic and psychodynamic therapy, occasionally in
cognitive-behaviour therapy - usually individual.
1st use? Freud S (1900).
1. Freud S (1900). The interpretation of dreams. 1965 New York: Basic
2. Hill CE, Rochlen AB (2002). The Hill cognitive experiential model of dream
interpretation. Journal of Cognitive Psychotherapy, 16, 75-89.
3. Montangero J (2007). Comprendre ses rêves pour mieux se connaître
(Understanding one’s dream in order to improve self-knowledge). Paris: Odi-
Case illustration in cognitive-behaviour therapy: (Montangero 2007)
Charles came for help with his gambling dependency. In session 6 he
reported dreaming of seeing a chamois (wild mountain goat) rubbing its
horns against a tree trunk, but they were deer antlers, not chamois horns.
Asked to fully describe what he saw, felt and thought during the dream, he
said the rubbing helped the chamois get rid of the antlers. Asked what me-
mories came to mind about a chamois and then a deer, Charles said he re-
membered seeing chamois during his experience of great freedom when hi-
king in the mountains before he married. He also remembered a friend tel-
ling stories of hunting deer, and of deer rubbing their antlers until they lose
them even though the rubbing is painful.
Charles reformulated the dream report in more general terms as: “A
symbol of freedom (the chamois) tries to get rid of (rubs), a feature of victims
(deer are victims of hunters).” He immediately added his interpretation: “This
applies well to me now, to my effort to get rid of my gambling dependency.”
His interpretation steered therapy toward reinforcing Charles’s desire for
freedom. Charles was asked to list every aspect that freedom could take for
him, then every way in which gambling restricted his freedom, and was en-
couraged to feel free to make changes in his life. He got another, more inte-
resting, job, and resumed hiking accompanied by his wife. This gave him a
new sense of control over his life that he was keen to keep by not gambling
again. The dream interpretation also led him to address painful aspects of
not gambling and of being in therapy, which Charles had denied until then.
EMPATHY DOTS, USE OF
David RICHARDS, School of Psychology, University of Exeter, Room 118,
Washington Singer Building, Perry Road, Exeter, EX4 4QG, UK; ph +44
1392 724615 & Karina LOVELL, School of Nursing, Midwifery & Social
Work, University of Manchester, University Place, Oxford Road, Manchester,
UK, M13 9PL, UK; ph +44 161 306 7853
Definition: Empathy dots are marks which a high-volume mental health wor-
ker puts into the margin of a pre-printed or hand written psychotherapy inter-
view schedule that is about to be followed during an appointment - see ing
the dots reminds the worker to say something warmly empathic and/or un -
derstanding at intervals within the interview.
Elements: Just before seeing a patient the mental health worker puts simple
dots at intervals down the right-hand margin of their assessment-,
treatment-, and follow-up interview schedules. Each dot is a reminder that
regular empathic statements convey understanding and improve patient sati-
sfaction in therapy. For example, “that must be very difficult for you”, “I can
see your anxiety is causing you distress”. As therapists navigate through the
questions in their interview schedule they see the empathy dots at intervals.
These remind workers that as well as covering the required specific factors
in the interview, they must also express empathy. Such reminders are
extremely useful when therapists treat large numbers of patients with typical
individual caseloads of 45- 60 patients.
Related procedures: Expressing verbal empathy, reward.
Application: When using therapy-interview schedules in high-volume clini-
1st use? Richards & Whyte (2008).
1. Richards DA, Whyte M (2008). Reach Out: National Programme Educator
Materials to Support the Delivery of Training for Practitioners Delivering Low
intensity Interventions. London, Rethink.
Case illustration: (Lovell, unpublished)
(This - unlike in other clp-website entries – details a therapist’s proce-
dure with many patients, not just one). `I run a guided-self help clinic 1 day a
week in a deprived area. On an average day I complete about 4 30-minute
assessments and 17 15-minute follow-up appointments, which means I see
about 21 patients a day. I give low-intensity help to people with common
mental health problems which are often severe and enduring and complic -
ated by a risk of suicide and a wealth of social problems, so I must also li -
aise with many other agencies. I’m kept very busy. Though I enjoy the work I
sometimes feel frustrated. Gathering information in patient-centred inter-
views to obtain a shared understanding, agree goals and offer the right guid-
ance/support means I must think carefully about every question I ask so that
I maximise the value of my limited time with each patient. Working under
such pressure can make one risk forgetting to engage patients by warm em-
pathy, particularly when one is seeing the 20th patient of the day and still
has 10 phone calls to make to other agencies.
`I know I can’t always feel warm empathy but can try to express it by
my facial, body and verbal language. Just before I see each patient I spend
a few seconds reminding myself that `this person is trying to cope, … is ho-
nest, … is responsive’. To ensure that I show warm empathy I put and look
for prominent ‘empathy dots’ in the right-hand margin of my interview sche-
dule (I usually increase the number of dots as the day goes on!). The dots
remind me to check that I’ve expressed empathy, warmth and under standing
to enhance engagement and partnering with the patient.’ For example, “Life
seems to be pretty tough for you at the moment”, “I can see how your fee -
lings of depression are stopping you doing what you want to do right now”.
EVOKED RESPONSE AROUSAL PLUS SENSITIZATION
Douglas H RUBEN, Best Impressions International, 4211 Okemos Road,
Suite 22, Okemos, Michigan 48864, USA; ph +1 517-347-0944
Definition: A way to eliminate chronically ritualistic, violent child tantrums
that are self-injurious or dangerous to others. Staff ask an admired peer/s to
watch the tantrums from unpredictable times after their start. When the tan-
trum ends, staff ask the child who had the tantrum to say sorry to the obser -
Elements: Staff pre-select at least 3 children whom the aggressive child ad-
mires - looks for, is aware of their presence, imitates their gestures, postu -
res, speech or other behaviours, and is never violent in their presence.
When the child has a tantrum, staff remove surrounding objects as if s/he
has a major fit and wait for it to pass while placing an admired peer at a safe
distance away but still within clear sight. After the outburst ends, staff ask
the violent child to look at and say sorry to the admired peer. The violent
child may well refuse and looks uncomfortable on seeing the admired peer,
and even more so if more admired peers are added as observers at later ti-
mes. The violent child then tends to postpone and interrupt the tantrum ri -
tual, which then attenuates and stops.
Related procedures: Differential reinforcement of incompatible or low-rate
behaviours, avoidance conditioning, sensory extinction, shame aversion, co-
Application: For children individually (not in groups) who can stand around
others and mingle, and are age 6 or older; in schools, residential and group-
transition homes, psychiatric institutions, and correctional youth centers.
1st Use? As a concept, Asmus et al (1999).
1. Asmus JM, Wacker DP, Harding J, Berg WK, Derby KM, Kocis E (1999).
Evaluation of antecedent stimulus parameters for the treatment of escape-
maintained aberrant behavior. Journal of Applied Behavior Analysis, 32,
2. Ruben DH (1999). Why traditional behavior modification fails with urban
children. In NR Macciomei & DH Ruben (Eds.) Behavior Management in the
Public Schools: An Urban Approach, p19-27. Wesport, CT: Praeger Press.
3. Ruben DH (2003). Aggressive tantrum elimination using evoked response
arousal plus sensitization in preschool developmentally disabled. Behavioral
Systems Monograph, 2, 1-6.
Case illustration: (Ruben, unpublished)
Becky, a girl of 9 with autism, attended a special education classroom
for developmentally disabled children. With no or minimal warning, she ex-
ploded several times a day in a cascade of behaviors harming herself and
others. She beat her chest, hit her face, fell on the floor, might knock down
nearby furniture, and struck peers who were in her way. Staff pre-selected 3
peers she admired, around whom she never showed tantrums. During Bec-
ky's first tantrum of the day, staff asked a pre-selected peer to stand several
feet away and watch the tantrum from where Becky could see her. When the
aggressive burst ended, the teacher asked Becky to say 'I'm sorry' to the ob-
serving peer. Becky refused, got upset and ran to another part of the room.
At a different interval after the start of Becky's next tantrum that day, the
same peer watched her again until the tantrum ended. When it ended, the
teacher again asked Becky to say sorry to the observing peer. Becky refu-
sed. A second admired peer was recruited as a tantrum-observer and the
teacher asked Becky to apologize to both peers after her outburst ended.
Again Becky refused. By the 3rd or 4th consecutive day of tantrums with the
admired peers coming in unpredictably to watch Becky, Becky did something
different. Before she started her first tantrum of the day, Becky began to look
around the room 2-3 times to see if admired peers were present. If they were
not, she started her tantrum and after 30-60 seconds stopped abruptly and
again looked around for admired peers. If they remained absent she resu-
med her tantrum for up to a minute, and again looked round. By days 5 or 6,
Becky delayed starting her tantrums until later in the day. They become brie-
fer and less self-injurious, and she stopped mild outbursts within 30 se -
conds. Within 2 weeks her ritual violent tantrums stopped entirely, and she
only made occasional angry or obscene verbal remarks in a low voice over
the next 3 months.
Hal ARKOWITZ, Department of Psychology, Arizona University, Tucson,
Arizona 85721 USA; ph +15203254837
Definition: An activity a client carries out during or between therapy ses-
sions in order to test an idea about thoughts/feelings or to discover or beco-
me aware of new therapeutic information.
Elements: In discussion with the therapist, the client designs new activities
(experiments) to try during or between sessions. The activities may test hy-
potheses in any area. They usually concern: in anxiety, over-estimations of
danger; in depression, overly negative views of the self, world, and future.
Interpersonal experiments concern how the client or others might react to
his/her new behavior. Awareness experiments may include discovering how
s/he responds to a new situation about which s/he has no preconceptions.
Related procedures: Assignments; homework, cognitive restructuring, ex-
posure, programmed practice, empty-chair technique, two-chair technique,
guided discovery/fantasy/imagery, psychodrama, rehearsal, role-play, sha-
ping, successive approximation.
Application: Usually in individual therapy, sometimes with couples or
1st use? `Experiment’ first denoted exercises to increase awareness and
growth (Perls et al., 1951), and later denoted hypothesis-testing (Beck et al.
1. Arkowitz H (2003). An integrative approach to psychotherapy based on
common processes of change. In F Kaslow (Ed.) Comprehensive Handbook
of Psychotherapy, Vol. 4, Integrative and Eclectic Therapies, J Lebow (Ed.),
(pp.317-337). New York: John Wiley and Sons.
2. Beck AT, Rush JA, Shaw BR, Emery G (1979). Cognitive therapy for de-
pression. New York: Guilford Publications.
3. Perls FS, Hefferline RF, Goodman P (1951). Gestalt therapy: Excitement
and growth in the human personality. New York: The Julian Press.
4. Greenberg, L.S., Rice, L.N., & Elliott, R. (1993). Facilitating emotional
change: The moment-by moment process. New York: Guilford.
1. Hypothesis-testing experiment (Arkowitz 2003)
A young woman with panic and agoraphobia tested her idea that if
she tried to get to a shopping mall she would panic so she wouldn’t even get
out of the car. She was to report her feelings while anticipating all stages to-
wards entering a mall as far as she could get (imaginal exposure). Her hu-
sband drove her to the mall (live exposure) and remained in the car in the
parking lot while she stood just inside the mall entrance for 10 minutes and
found that anticipating entering the mall made her more anxious than actual-
ly being in the mall (homework; cognitive restructuring; live exposure; pro-
grammed practice; shaping; successive approximation). After standing at the
entrance for a few minutes she became far less anxious than she had antici-
pated, which encouraged her to do more. In subsequent days, she was able
to enter the mall and spend time shopping there. Had she been too anxious
to actually go to the mall, she would have examined her feelings when thin-
king of trying to do so.
2. Proposed hypothesis-testing experiment (Arkowitz 2003)
A young man with a flying phobia sought psychotherapy saying he
wanted to join his wife on some of her trips. In the therapist’s office he did
imaginal exposure but resisted doing live exposure, even as minimal as a
proposed experiment to drive to the airport with the therapist and see what
he felt while sitting in the car watching planes take off (homework; cognitive
restructuring; exposure; programmed practice; shaping, successive approxi-
mation). He thought this would not make him particularly anxious, and finally
admitted his unhappiness in the marriage and reluctance to spend more time
with his wife than he had to. After discussing this. he and his wife sought
3. Awareness experiment (Arkowitz 2003)
A woman sought help for depression and guilt 2 months after she had
inadvertently caused a car accident in which a driver (Steve) died. His family
blamed her for his death even though she was not at fault; they banned her
from attending Steve’s funeral, making it harder for her to mourn his death.
In therapy session 6 she seemed to speak to him directly and agreed to a
two-chair experiment in which she spoke as herself and as Steve at various
times (empty-chair technique; guided discovery / fantasy / imagery; psycho-
drama; rehearsal; role-play). This experiment took part of each of the next 5
sessions. The therapist suggested that she switch roles as needed and say
how she felt (e.g. “Tell `Steve’ how that makes you feel”). At first, she was
apologetic and guilt-ridden, and `Steve’ was angry, aggressive, and critical
of her. Then she said she was sorry for what happened but it wasn’t her fault
and she wanted him to stop harassing her. Her exchange became more
heated with her often asking “What do you want from me?” `Steve’ surprised
her by saying he wanted her to have a `ritual’ for him, and she began to cry.
In the next week she went to his grave in the evening, bringing a candle whi-
ch she lit and placed on the headstone while she read a poem she had writ-
ten for the occasion. These events seemed central to her eventual recovery.
EXPOSURE, INTEROCEPTIVE (TO INTERNAL CUES)
Kamila S WHITE, Shawnee L BASDEN, David H BARLOW, Center For
Anxiety & Related Disorders, Boston University; 648 Beacon Street, Boston,
MA, 02215, USA
Definition: Interoceptive exposure involves repeated engagement in tasks
which reproduce the full experience of distressing emotions such as
panic/anxiety and associated somatic sensations. It is commonly combined
with situational exposure, cognitive restructuring, and psychoeducation in
the treatment of panic/agoraphobic and other anxiety disorders.
Elements: Patients repeatedly induce emotion-evoking internal cues and
sensations until those no longer feel threatening. For panic/anxiety such ex-
ercises can include spinning in a chair, breathing through a straw, vigorously
exercising, and tensing muscles throughout the body.
Related Procedures: Vicarious/live/in vivo exposure, carbon-dioxide (CO2)
challenge tasks, mindfulness training.
1st Use? Wolpe J (1958).
1. Barlow DH, Craske MG (2000). Mastery of your anxiety and panic (MAP-
3): Client workbook for anxiety and panic (3rd ed.) San Antonio, TX. Gray-
2. Ito LM, Noshirvani H, Basoglu M, Marks IM (1996). Does exposure to in-
ternal cues enhance exposure to external cues in agoraphobia with panic: A
pilot controlled study of self-exposure. Psychotherapy & Psychosomatics,
3. White KS, Barlow DH (2002). Panic disorder and agoraphobia. In Barlow
DH Anxiety and its disorders:The nature and treatment of anxiety and panic
(2nd ed) New York: Guilford Press.
4. Wolpe J (1958). Psychotherapy by reciprocal inhibition. Stanford, CA:
Stanford University Press.
Ellie first panicked at age 14 on a school trip. She suddenly felt palpi-
tations, shortness of breath, a sense of choking, and dizziness; these lasted
10 minutes. She feared she might choke to death or embarrass herself by
fainting, so she avoided caffeine, spicy foods, social activities, and sports.
She sought treatment 4 months after her first panic. The therapist explained
that panic disorder is maintained by avoidance of not only public places such
as theaters and social events but also of other things which bring on panic-
like sensations, e.g. caffeine, exercise (palpitations), hot showers (hot
flushes), spicy foods (stomach discomfort), scary movies, skipping meals,
wearing a scarf (sense of choking), sexual arousal. After completing tests to
identify her feared sensations e.g. spinning in a chair for 60 seconds,
breathing through a straw for 2 minutes, Ellie was asked to do interoceptive
exposure exercises by engaging repeatedly in hitherto avoided activities like
those above until she felt no fear. During the exercises she was instructed to
focus fully on experiencing the sensations induced, to become a passive
observer doing nothing to reduce frightening feelings, to just patiently try to
get used to them by the end of the session. For homework she was asked to
do similar exercises daily 3 consecutive times. For each exercise she was
told to wait for ensuing unpleasant sensations to subside, and then to repeat
the procedure again. She completed interoceptive exercises of spinning in a
chair for 1 minute, running in place for 1 minute, shaking her head from side
to side for 30 seconds. As these became easier they were made more
challenging, often by pairing them with exposure to more frightening external
situations e.g. having caffeinated drinks at a mall, wearing a scarf to a social
event. After 14 sessions Ellie no longer avoided frightening sensations and
was instead seeking them out.
EXPOSURE, LIVE (IN-VIVO, LIVE DESENSITIZATION)
Georg W. ALPERS, Universitaet Wuerzburg, Biologische Psychologie, Klini-
sche Psychologie und Psychotherapie, Marcusstrasse 9-11, 97070 Wuerz-
burg, Germany; ph +49 931-312840/2
Definition: Systematic repeated exposure to real live situations that cause
distress until the resultant discomfort subsides.
Elements: Patients are asked to work out whichever cues usually evoke un-
due fear from the least to the most frightening. They are then persuaded to
gradually expose themselves to those real situations repeatedly, usually for
up to an hour or more at a time, to experience ensuing feelings and thoughts
to the full without escape, to continue exposure until the discomfort starts to
subside, and to do exposure homework preferably daily or as often as possi-
ble. If patients so wish, they can start with intense exposure to very frighte-
ning situations. Exposure may be with or without a therapist and/or guided
by appropriate self-help books or computer systems.
Related procedures: Exposure, habituation, extinction, confrontation, con-
tact desensitization, systematic desensitization (done with relaxation), gra-
ded modelling, guided mastery (participation), programmed practice, cue-
controlled relaxation, applied relaxation, imaginal (fantasy) desensitization,
flooding (intense exposure – implosion if imagined), interoceptive exposure,
arugamama in Morita therapy, behavioral experiment, paradoxical intention,
narrative exposure, prolonged exposure counterconditioning, virtual reality
exposure, CAVE (computer-aided vicarious exposure), rehearsal relief, co-
gnitive restructuring, homework.
1st Use? Garfield et al. (1967).
1. Alpers GW, Wilhelm FH, Roth WT (2005). Psychophysiological assess-
ment during exposure in driving phobic patients. Journal of Abnormal Psy-
chology, 114, 126-139.
2. Garfield ZH, Darwin PL, Singer BA, McBrearty JF (1967). Effect of "in
vivo" training on experimental desensitization of a phobia. Psychological Re-
ports, 20, 515- 519.
3. Malleson N (1959). Panic and phobia: a possible method of treatment.
Lancet, 31, 225-227.
4. Watson JP, Gaind R, Marks IM (1971). Prolonged exposure: a rapid treat-
ment for phobias. British Medical Journal, 1, 13-15.
Jen age 35 consulted a therapist for her severely handicapping and
inexplicable fear of spiders. She had never really liked spiders and her fear
had intensified over the years. Whenever she saw a spider she panicked
helplessly, couldn’t move, her heart raced, her palms sweated, and she felt
embarrassed at depending on other people then. She avoided walking
across a lawn or going into her basement or garage lest she encountered
spiders there. Having unsuccessfully tried to prevent spiders entering her
home she was about to move elsewhere. Jen was told her symptoms were
typical of a phobia and that she could endure them for long enough to get
used to whatever was frightening her. Even the mere thought of looking at a
spider evoked extreme fear and disgust so she learned to open a book with
pictures of spiders at the therapist's office. She took the book home and
brought herself to touch the pictures with her fingers. Next she looked at a
spider in an empty glass jar for at least 30 min. without her usual attempt to
remove it or turn away from it. Jen was encouraged to do exposure without
her usual subtle avoidances that stopped her experiencing the fear fully and
getting used to it.
Thus she looked at the spider and her own reactions in detail, and
was fascinated at not being overwhelmed by fear. Her distress decreased
during each exposure session and across repeated such sessions. She be-
came more confident exposing herself to spiders at home. After 12 50-minu-
te weekly sessions and several hours of practice at home she touched a lar-
ge spider and let it crawl across her palm. Jen then cleaned out her garage,
kept a spider in a jar in her kitchen and went to bed without checking for spi-
ders. Improvement continued at follow up 8 weeks later.
Lynne ANGUS & Helen MACAULAY, 108C Behavioural Sciences Bldg,
Psychology, York University, Toronto, Canada; ph + 416 736 2100 33615
Definition: Actively listening to, emotionally resonating with, and understan-
ding, another’s experience followed by accurately communicating this under-
standing to the other.
Elements: Expressed empathy starts with the therapist sensing his/her own
inner experience of a client’s disclosure during therapy e.g. “as she told me
of her husband’s tirade at the restaurant, I felt deep sadness, almost de-
spair, about her marriage”. The therapist then tries to highlight and put into
words the most poignant and implicit aspects of a client’s experience on a
moment-to-moment basis, for further exploration and new meaning construc-
tion. A highly-attuned therapist focuses clients’ attention on experience just
outside their awareness and thus offers meaning that disentangles, clarifies,
and allows clients to explore further: “so as you sat in the restaurant,
inundated by this torrent of criticism and complaint, it seemed as if you were
drowning in despair, that this would simply never ever be different?”. The
therapist phrases empathic communications tentatively, leaving the door
open for clients to co-construct new meanings and say if the therapist’s em-
pathic response fits their own experience of an event. Empathic explorations
can be reflections, or open-ended or direct questions, to help the client ex-
pand on and differentiate their current experience. A therapist’s attentive,
concerned facial expression, forward lean, direct eye contact, and sensitive
enquiring and tentative tone can all help convey empathic understanding to
the client. Finally, clients show perception of the therapist’s empathic re-
sponse “yeah, that’s it, I wasn’t angry, I felt sad and hopeless, that our mar-
riage is really over”.
Related procedures: Countertransference, use of; empathy dots, use of;
meaning making; metaphor, use of; validation of feelings.
Application: Widely used in individual- and group-therapy across theoretical
orientations to promote a working alliance and help clients understand their
assumptions and process and regulate emotion.
1st use? Rogers CR (1957).
1. Barrett-Lennard GT (1986). The Relationship Inventory now: Issues and
advances in theory, method, and use. In LS Greenberg & WM Pinsof (Eds.),
The psychotherapeutic process: A research handbook (pp 439-475). New
York: Guilford Press.
2. Bohart AC, Greenberg LS (1997). Empathy and psychotherapy: An intro-
ductory overview. In AC Bohart & LS Greenberg (Eds.), Empathy reconsi-
dered: New directions in psychotherapy (pp 3-32). Washington, DC: Ameri-
can Psychological Association.
3. Macaulay HL, Toukmanian SG, Gordon KM (2007). Attunement as the
core of therapist expressed empathy. Canadian J.of Counselling, 41, 244-
4. Rogers CR (1957). The necessary and sufficient conditions of therapeutic
personality change. J.of Consulting Psychology, 21, 95-103.
Case illustration: (Angus & Macaulay, unpublished)
Margaret sought therapy in her mid-thirties for profound loneliness
and depression after the unexpected break-up of a romantic relationship a
year earlier. In session 3 Margaret reflected: `I can (get along alone) for a
while but then think “why am I doing this”? I have no problem being with my -
self when I know there’s somebody out there, but when I’m by myself and
really feel that there’s nobody out there that after a while it starts to get to
me.’ Therapist: ‘Let me see if I understand - I’m not sure if I misheard. You
don’t have a problem being alone if you know someone’s out there’.
Margaret’s answer ‘Yeah, if you know’ signalled that her therapist had gra-
sped an important aspect of her experience of loneliness which he elabora-
ted by saying: “So then it’s alright to be alone.’
Margaret’s and the therapist’s sharing of a clear understanding of her
loneliness set the stage for her discovery of what was most painful about
being on her own now. Margaret: ‘Yeah, because you always know you’ve
got someone there to talk to or want to visit or’ (T: ‘Yeah’) ‘it’s when you feel
there’s nobody out there and you’re alone then there’s a difference between
being alone and feeling lonely’ (T: `Sure’) `you know that’s when you start
feeling lonely - you think, oh geez.’ Resonating to the core of Margaret’s di-
sclosure, her therapist responded empathically: ` So is it that your deepest
fear is of being really all totally alone’ (M:` Hm-mm’) ‘meaning “there’s not
even someone I can think of” (M: `Right’) “out there whom I could contact”
and then it’s this terrible loneliness?` This empathic response helped Mar-
garet to acknowledge `Yeah, that’s exactly how it felt without anyone and
how I felt last year, like I’d been totally abandoned’ (T: `Yes’) `and that my
life was going down the gutter and no one was reaching out to help and I
was amazed’ that set the stage for a sustained and productive focus on her
relational needs in ensuing therapy sessions.
EXPRESSIVE WRITING THERAPY
James W PENNEBAKER, Department of Psychology, University of Texas
at Austin, Austin, TX 78712 USA; ph + 1 512 2322781
Definition: A method whereby people write about emotional upheavals.
Elements: People are encouraged to write repeatedly about emotional ex-
periences, typically for 20 minutes per day on 4 consecutive days, though
length and number of writing sessions is flexible. The writing exercises aim
to help the writers explore their thoughts and feelings about one or more up-
heavals in order to identify, label, understand, and come to terms with their
experiences. The writers receive no feedback from others - the goal is to
stand back and to reassess upsetting experiences in writing for themselves
Application: Done individually on its own or together with other psychothe-
Related procedures: Disclosure methods in client-centered and other the-
rapy, religious confession, narrative exposure, prolonged exposure, goal set-
1st Use? Pennebaker & Beall (1986).
1. Pennebaker JW, Beall SK (1986). Confronting a traumatic event: Toward
an understanding of inhibition and disease. Journal of Abnormal Psychology,
2. Lepore SJ, Smyth, J.M. (Eds.) (2002). The writing cure: How expressive
writing promotes health and emotional well-being. Washington, DC: Ameri-
can Psychological Association.
3. Pennebaker JW (1997). Opening up: The healing power of expressing
emotions. New York: Guilford Press.
4. Frattaroli J (2006). Experimental disclosure and its moderators: A meta-a-
nalysis. Psychological Bulletin, 132, 823-865.
Case illustration: (Pennebaker 1997)
Hal, an engineer aged 52, participated in a writing project involving
over 40 laid-off workers after his company ended his 24 years of employ -
ment there. He was hostile, and had insomnia and difficulty talking with oth -
ers about his experience. In the 4 months since being laid off Hal had had 4
job interviews without success. At an outplacement company contracted by
the former employer to help laid-off employees find new jobs, Hal was asked
to write about his experience daily for 5 consecutive days, 30 minutes each
day. All 40 laid-off employees wrote by themselves in office cubicles. Daily
writings were turned in anonymously to project workers and no one ever re -
ceived feedback about them. By 1-month follow-up, Hal said the writing had
markedly improved how he thought about the job loss, including fewer ru-
minative thoughts and less anger and helplessness about it. He was now
talking with his wife about the layoff and sleeping better. After his writing
sessions Hal had successful job interviews and was about to start a new job
at a pay level above that in his previous job.
FAMILY FOCUSED GRIEF THERAPY
David William KISSANE, Weill Medical College of Cornell University and
Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY
10021, USA; ph +1 646 888 0019
Definition: Facilitation of a family’s expression of thoughts and feelings
about loss and coping with a relative’s illness and death to promote shared
grief and optimal family functioning, often commenced during palliative care
(with the ill relative attending) and continued into bereavement after the pa-
Elements: High-risk families may be screened with the Family Relationships
Index regarding communication, cohesion and conflict resolution. To prevent
maladaptive outcomes, a family therapist leads family sessions through i)
assessment and agreement about the focus of work, ii) active therapy, and
iii) consolidation and termination. Treatment takes 6-12 sessions, each la-
sting 90 minutes, and extending over 6-18 months, with later consolidation
sessions spaced more widely. Length of treatment depends on degree of fa-
The therapist uses circular questioning [‘Let me ask each of you to
describe who gets on best with whom?’] and confirmatory summaries to: di-
scern patterns of communication, teamwork and conflict, role delineation,
traditions, and transgenerational styles of relating; affirm strengths of family
life; encourage constructive ways of relating that support mutual care and
respect. The dying family- member’s wishes can be harnessed to overcome
prior misunderstandings and heal old grievances. The therapist attends to
the family-as-a-whole, avoids alliances with individuals, and helps the family
to focus on its communication, cohesion and conflict resolution. End-of-ses-
sion summaries help relatives to integrate their understanding of the themes
and processes discussed [“Today, we’ve learned that your parents and
grandparents avoided discussing feelings, as you’ve done too thus far.
You’ve talked about the benefits of striving to share your feelings.”].
The therapist sensitively encourages [“How serious is this illness?
What threat to life does it bring”] family members to safely discuss in the
session the hitherto- avoided subject of death and dying. Bigger disruptions
of communication and teamwork are addressed by highlighting entrenched
patterns of relating often transmitted from prior generations, but once reco-
gnized, capable of being worked on differently. For example, relational styles
involving much criticism may be tempered by introducing frequent affirmation
[“You’ve been tough on each other, yet I notice tremendous teamwork poin-
ting to genuine care you give each other.”]. Spacing therapy over 12-18
months of bereavement [up to 12 sessions] consolidates change and family
focus on improving relationships. High-conflict families need containment
[e.g. therapist stops in-session arguments, showing members how these es-
calate and damage] and support to interrupt disruptions, respect alliances
that serve members best, and recognition of the benefit of distance between
relatives who differ temperamentally and don’t get on. For very dysfunctional
families, modest goals for change may be set.
Related procedures: Anger management, anxiety management, cognitive
restructuring and meaning making, communication analysis and training, ge-
nogram analysis of transgenerational patterns of relating and coping with
loss, guided mourning, life review (reminiscence) therapy, prolonged-grief
therapy, problem solving, relational enhancement, ritual endorsement, social
skills training, use of narrative.
Application: Preventive and active treatment, done in the home,
hospice/hospital, or outpatient clinic, for: high-risk families whose relative of
any age is having palliative care for advanced progressive illness e.g. can-
cer; renal/pulmonary/cardiac failure; motor neurone disease/other neurode-
generation; families carrying hereditary cancer.
1st use? Kissane et al (1998).
1. Kissane DW, Bloch S, McKenzie M, McDowall C, Nitzan R (1998). Family
grief therapy: a preliminary account of a new model to promote healthy famil-
y functioning during palliative care and bereavement. Psycho-Oncology, 7,
2. Kissane DW, Bloch S (2002). Family Focused Grief Therapy: A Model of
Family- Centred Care during Palliative Care and Bereavement. Open Uni-
versity Press, Buckingham and Philadelphia. [Translated into Japanese
(2003) and Danish (2004)].
3. Kissane DW, McKenzie M, Bloch S, Moskowitz C, McKenzie DP, O’Neill I
(2006). Family focused grief therapy: a randomized controlled trial in palliati -
ve care and bereavement. American J.Psychiatry, 163, 1208 - 1218.
1. Blended family carrying unfinished business (Kissane & Bloch 2002)
Divorce had ended a 20-year marriage of a couple with 3 daughters.
The mother’s terminal illness 18 years later allowed resolution of unfinished
business from the divorce, her bitterness having prevented consolation of
her eldest daughter’s distress as a teenager. Mother knew intuitively that so-
mething remained amiss, and screening for family functioning led her to invi-
te sorting of this out before she died. Both her current and husbands joined
the 4 women in 8 family meetings, each of 90 minutes, held in her home.
Each member’s perspective of the marital breakup was shared as the family
retold their story. Enhanced understanding developed with greater
acceptance and forgiveness. The mother’s role was affirmed with gratitude.
Reminiscence helped celebrate her life, while the family prepared for her
2. Family burdened by double cancer (Kissane & Bloch 2002)
A family grieved intensely when both mother and a daughter develo-
ped cancer. The mother’s family was close, while father had migrated and
lost all contact. When the 2 daughters grew up the elder moved interstate for
several years and was perceived as the black sheep, while the younger
achieved academically and bonded to mother but developed breast cancer
followed by mother getting lung cancer. These illnesses drew the family clo-
ser. In therapy for ten 90-minute sessions in the home over several months,
a greater sense of reconciliation developed with the older daughter. About
half-way through, the therapist invited the sons-in-law to join, thus strengthe-
ning the experience of support from family meetings. Ways were explored of
creating memories for the grandchildren. Eventually, a creative outcome be-
came evident despite the challenge of loss.
FAMILY WORK FOR SCHIZOPHRENIA
Julian LEFF, Institute of Psychiatry, Kings College London, de Crespigny
Park, London SE5 8AF; ph +44 207 794 9724
Definition: Family work tries to avert relapse in schizophrenia by helping re-
latives reduce high levels of negative emotion expressed to the patient such
as critical comments, hostility, and over-involvement with overemotional be-
haviour, overprotection e.g. a mother would not let her 20 year old daughter
cross the road alone when she developed schizophrenia, and lack of boun-
dary-setting e.g. a mother allowed her son to establish a home gymnasium
in her living room thus excluding her from using it.
1. Reducing expressed emotion: Criticism and hostility can stem from
ignorance about schizophrenia and are tackled initially by education about it,
e.g. stating that apathy and self-neglect are caused by the illness and not by
the patient being lazy or dirty.
Thereafter, critical remarks are reframed as representing a caring attitude of
the relative, so allowing the relative and patient to negotiate the behaviour
being criticised, e.g. reframing ‘He’s always wearing a dirty shirt’ as ‘You
really care about your son’s appearance’. Overinvolvement is lessened by
helping the relative and patient recognise that they maintain this in a mutual-
ly reinforcing relationship e.g. asking each partner what they would feel like if
the other was absent for more than a day. Relatives’ guilt is alleviated by
therapist statements in education sessions that relatives cannot cause schi-
zophrenia, and direct exploration of the guilt, e.g. a mother was asked why
she allowed her son to beat her - she said she’d tried to abort the pregnancy
with a knitting needle and believed this had caused his illness. Joining a
group of other relatives also helps. The therapist/s relieves relatives’ anxiety
by congratulating them on their excellent care of the patient, saying they’ve
earned a rest, and asking them to choose and carry out enjoyable activities
outside the home which involve brief trial separations, e.g. suggesting that
the parents go out together for an hour to have coffee, leaving the patient at
home. The therapists encourage the patient to feel competent by choosing
and carrying out a small task in the relative’s absence, e.g. making her bed.
2. Reducing contact with a high-expressed-emotion relative: The the-
rapist addresses this if the patient is unemployed and has no daily activity
outside home, leading to long contact (over 35 hours a week) with a high-ex-
pressed-emotion relative at home e.g. elderly parents who’ve retired or given
up their job to care for the patient, or a homemaking partner. The therapist
advises the patient to attend a day hospital, day centre or sheltered work-
shop, and the relative to spend more time away from home in social activi-
ties, voluntary work, or attending adult education classes. Schizophrenia im-
pairs patients’ ability to form and sustain social relationships, but the therapi-
st tries to help them increase social activities by social skills training, e.g. en-
couraging eye contact and smiling during conversations, and by recruiting
healthy siblings to help the patient make social contacts outside the home.
Related procedures: Behavioral activation, community reinforcement ap-
proach, nidotherapy, reframing, social skills training.
Application: One or two therapists run sessions with individual families or
any family member/s, groups of up to 10 relatives excluding patients, and
multi-family groups of up to 8 families including the patients. Antipsychotic
medication is usually continued in parallel.
1st Use? Leff et al (1982).
1. Vaughn C, Leff JP (1976). The influence of family and social factors on
the course of psychiatric illness: a comparison of schizophrenic and depres-
sed neurotic patients. British Journal of Psychiatry, 129, 125-137.
2. Leff J, Kuipers L, Berkowitz R, Eberlein-Fries R, Sturgeon D (1982). A
controlled trial of social intervention in the families of schizophrenic patients.
British Journal of Psychiatry, 141, 121-134.
3. Kuipers L, Leff J, Lam D (1992). Family Work for Schizophrenia: A Practi-
cal Guide. London: Gaskell. 2nd ed. 2002.
4. Leff J (2005). Advanced Family Work for Schizophrenia. London: Gaskell.
Case Illustration 1: (Leff, unpublished)
John age 19 developed schizophrenia and was admitted to hospital
for 9 weeks. Antipsychotic medication reduced his delusions and hallucina-
tions. He resumed living with mother and stepfather, but stayed in bed all
morning and grew his hair long. His infuriated stepfather, a retired army offi-
cer, tried pulling John out of bed by his hair. Mother, an executive in a large
company, gave up her job to look after John. Stepfather accused her of be-
ing too soft with John and she complained he was too hard.
As is usual, 2 therapists worked with the family in their home. They
began with 2 sessions of education about schizophrenia, emphasizing that
John’s staying in bed was part of the illness, after which stepfather stopped
criticizing him. Mother said that from John’s birth she’d recognised his diffe-
rence from his older brother, who now lives on his own. She felt John nee -
ded more care and protection; the therapists praised her sensitivity but said
it was now actually counterproductive as it hindered John from developing
friendships with his peers. One-hour sessions with mother, stepfather and
John together were held every 2 weeks initially, later monthly, over a year.
The therapists tried to reduce conflict between the parents, enabling them to
manage John’s problems together. Both parents attended a relatives-only
group of up to 8 relatives meeting bi-weekly for 1.5 hours. The other group
members pressed mother to return to work. She finally agreed, having de-
veloped enough confidence in stepfather’s change of heart to allow him to
care for John by day. He relinquished his aggressive means of getting John
out of bed and, after discussion with the therapists, introduced inducements,
including activities he and John could do together, e.g. constructing a barbe-
cue in the garden. Apart from the first 2 education sessions with the parents
only, the 3 family members had 15 sessions over the year, and the parents
attended a relative’s group together or separately 13 times in all.
Case Illustration 2: Reducing contact with a high expressed-emotion relati-
ve (Leff, unpublished)
Brian age 35 has suffered from schizophrenia for ten years. He lives
with his mother and two younger stepbrothers, Mike and Joe, whose father
died a few years ago. Brian’s father separated from mother when Brian was
aged 8 and lost contact with the family. Brian has paranoid delusions and
tends to sit on the stairs to the upper floor holding a knife. Mother overpro -
tects him and does not establish boundaries to his behaviour, e.g. she pre-
pares special meals for him when he won’t eat with the family. He rarely
goes out and his stepbrothers never ask friends home because of embar-
rassment about Brian. One therapist conducted 2 education sessions atten-
ded by mother, Mike and Joe. In session 1 including all 4 family members,
Mike angrily announced that in the past he’d wished Brian would die. The
therapist asked Mike about his relationship with Brian before he became ill.
Mike gave an account of Brian teaching him to fish and how much he’d loo-
ked up to Brian. The therapist explained that protecting Brian against contact
with the outside world maintained the usual stigma of schizophrenia. At fami-
ly meeting 4 Mike said he’d told his friends about Brian’s illness and they’d
been sympathetic. They now visit the home and stay with Brian when Mike
wants to go out, and Brian stopped sitting on the stairs holding a knife. Fur-
thermore Mike now takes Brian out fishing and though Mike says little, there
is a sense of companionship. By these means contact between Brian and
mother has lessened considerably. The 4 family members had 6 sessions
over 4 months. No relatives group was available locally.
David WINTER, School of Psychology, University of Hertfordshire, College
Lane, Hatfield, Herts, AL10 9AB, UK; ph +44 1707 285070
Definition: Fixed-role therapy encourages the client to enact a new role
(written by the therapist) for about two weeks in order to try out alternative
views of the self and the world.
Elements: The therapist asks the client to write a short self-description, as if
written by someone who knows him/her well. Based on this the therapist, be-
fore the next session, writes a fixed-role sketch of someone with a new
name whom the client might enact in and between sessions. This sketches
someone not ideal or the opposite of the client, but adds features which dif-
fer from the client’s main existing ones and offer testable predictions, e.g.
that appropriate expression of feelings will not lead to rejection. It includes
an attempt to understand other people’s viewpoints.
The therapist shows the client the fixed-role sketch, asks if the cha-
racter portrayed is plausible and not too threatening, and may redraft the
sketch until the client finds it acceptable. The therapist then asks the client to
‘become’ the new character for two weeks while his/her current self is ‘on va-
cation’, during which time the client sees the therapist up to 5 times a week
for brief sessions to rehearse the new role in first superficial and then pro-
gressively more intimate interpersonal situations. The fixed-role exercise al-
lows clients to experiment with new behaviour in and between sessions
while protected by ‘make-believe’.
Application: In individual, group and couple therapy.
Related procedures: Experiment, personal-construct psychotherapy, psy-
chodrama,rehearsal, repertory grid technique, role play.
1st Use? Kelly (1955).
1. Bonarius JCJ (1970). Fixed role therapy: A double paradox. British Jour-
nal of Medical Psychology, 43, 213-219.
2. Epting FR, Nazario A Jr (1987). Designing a fixed role therapy: issues,
techniques, and modifications. In RA Neimeyer & GJ Neimeyer (eds.), Per-
sonal Construct Therapy Casebook (pp. 277-289). New York: Springer.
3. Kelly GA (1955, pp. 360-451) The Psychology of Personal Constructs.
New York: Norton (republished by Routledge, 1991).
4. Winter DA (1987). Personal construct psychotherapy as a radical alterna-
tive to social skills training. In RA Neimeyer & GJ Neimeyer (eds.), Personal
Construct Therapy Casebook (pp. 107-123). New York: Springer.
Case Illustration: (Winter, 1987)
Tom was referred for continuing to feel inadequate despite extensive
past treatment. In the second pre-therapy assessment session, a repertory
grid (see clp entry) and other personal-construct methods such as Tschudi’s
ABC technique, identified Tom’s dilemma of wanting to be assertive yet
viewing assertive extroverts as demanding and aggressive. The therapist di-
scussed its origin in childhood experiences and used fixed-role therapy in
sessions 6-7 to help Tom see himself differently. The therapist asked Tom
for a written self-description, as written by someone who knew him, which in
‘I’ve known Tom 20 years since our schooldays together. He was a
swot who pestered me for help with maths. We fished together, and in later
years went to concerts and drinks with friends. He envied my settling in a
good job while he after 5 years at university never settled down. Tom wasn’t
good company with my friends, longed for a girlfriend, joined clubs to meet
women, and seemed unhappy with his girl friend. After breaking up he’d re-
turn to my social scene for a week then disappear for weeks. He was usually
quiet, depressed and reticent. He stopped self-employment, preferring stea-
dy work with a company yet was anxious - it wasn’t what he wanted, just like
his tagging onto my friends. He moved away but remained unhappy there.
When we have a drink he looks miserable, worries whether he’ll marry and
have children, and says little.`
The therapist now sketched a fixed-role character `Roy’ which igno-
red searching for a girl friend and reframed as strengths what Tom saw as
impediments e.g. Tom’s serious intensity became Roy’s ‘passion and con-
viction which earns respect. He strives to work hard and have fun as best he
can’. Tom’s tennis skills anticipating other players’ moves were generalised
into Roy’s ‘ability to see the world through other people’s eyes. He mixes
with many kinds of people who usually reciprocate his curiosity, and deve-
lops rewarding relationships.’ Tom’s worries were reframed as `Roy naturally
has disagreements and disappointments but learns from those and looks
forward without brooding on misfortunes. He’s committed to causes yet tole-
rant of other people’s right to differ.’
On seeing the therapist’s fixed-role sketch of `Roy’ Tom thought it fit-
ted his own recent new social behaviour. He said he also wanted to show
more interest in people without seeming ‘nosey’; to help that, Tom carried
the sketch in his pocket and referred to it before entering new social situa-
tions. By session 8, the final one, Tom no longer saw assertive extraversion
as undesirable, and felt more comfortable socially.
Leon HOFFMAN, 167 East 67th Street New York, NY 10065, USA; ph
+1212 249 1163
Definition: A therapist encourages the patient to say whatever comes to
mind - thoughts, feelings, sensations, memories, wishes, fantasies.
Elements: The therapist suggests that the patient should try to express
openly all that comes to mind even if the associations seem unimportant, ir -
relevant, embarrassing or shameful. Both observe how and when the patient
hesitates, indicating resistance to reporting that association freely. When
such resistance appears the therapist suggests (interprets) that there is di-
scomfort in being open. This line of inquiry may reveal issues in that pa-
tient’s current or past interactions, worries, fears, defenses, wishes and
fantasies which are unique; even though “the casts in a person’s life may
change, the situations may differ, but the plots endure.” These plots in the
patient’s life are repeated in feelings and fantasies about the analyst (trans-
ference) which can be difficult to speak about frankly. In free associations
the patient may allude to interactions reminiscent of those with the analyst.
The analyst may interpret the patient’s reluctance to speak directly about the
analyst (analysis of the transference).
A free-association-equivalent in young children is the expression of
central wishes and worries in play and activities. The analyst can observe
how play interruptions may resemble adults’ resistance to talking about cer-
Related procedures: Interpretation against painful emotions, analysis of
conflicts and defenses, compromise formation (understanding that many ac-
tivities are a compromise between forbidden wishes and defenses masking
those), method of levels, close process monitoring (detecting shifts of mate-
rial in sessions and querying if those reflect avoidance of certain thoughts
and feelings), reducing affect phobia.
Application: In intensive dynamic psychotherapy and psychoanalysis.
1st use? Freud S (1893).
1. Freud S (1893). Frau Emmy von N-Case histories from Studies on Hyste-
ria. In: The Complete Psychological Works of Sigmund Freud, Volume II
(1893-1895): Studies on Hysteria, Standard Edition 2, 48-105. London: Ho-
2. Busch F (1997). Understanding the patient's use of the method of free as-
sociation: an ego psychological approach. J. Amer. Psychoanal. Assn., 45,
3. Kris AO (1992). Interpretation and the method of free association. Psy-
choanal. Inq., 12, 208-224.
4. Loewenstein RM (1963). Some considerations on free association. J.
Amer. Psychoanal. Assn., 11, 451-473
Case illustration: (Busch,1997)
Al sought treatment after he’d had several unsatisfying affairs when
he’d felt discontented with his wife and realized this told him about himself.
He began a session early in his four-time-a-week analysis by mentioning di-
sturbedly that it was really quiet at home since his wife and children had
gone to visit her parents in another city for two weeks. Al talked extensively
about having worked feverishly all evening on references for his new 500-
page book. He’d felt frustrated by the enormous task he’d tried to accom-pli -
sh in one fell swoop using a new computer program but glitches had led to
his making minimal progress. However, he’d felt really good about having
left his work all over the living room without his wife having a fit about it. He
moved onto a camping trip he planned with his brother but wasn’t crazy
about being alone the first few days before his brother joined him. Therapist:
`You seem bothered but yet happy by your wife's being away and the house
so quiet’. Al spoke again about feeling left alone, this time in future, saying
this was important and probably related to his difficulty in feeling close to his
wife. He recounted irritably that she’d phoned the previous evening to ensu-
re he had the instructions straight for taking care of the dog, and went on a
diatribe about her treating him like a child. Therapist: `You’ve become aware
of difficulties in being close to your wife but since this might be frightening
you spoke instead of a rift between the two of you, which you think she cau-
sed’. Al then said his wife had cried a lot at her father's funeral, as had his si -
ster when his mother died. Therapist: `Maybe you have difficulty knowing
how you feel about your wife, especially about loss because you see this as
something women feel and this feels dangerous to you’. Al replied he’d for-
gotten to say that the night before his wife left they’d had a wonderful eve-
ning together –he’d never felt so close to a woman before.
Colin Murray PARKES, 21 South Road, Chorleywood, Herts, WD3 5AS,
UK; ph +44 1923 282746
Definition: Guided Mourning is used to improve problems resulting from the
avoidance, denial or forgetting of grief. It involves reducing fear and facilita-
ting the expression of thoughts and feelings about the loss and the lost per-
son, along with acknowledgement of the continuing relationship with memo-
ries of that person.
Elements: Those who have difficulty in looking back and facing their loss
are most often male, and may have recurrent nightmares, avoidance of
thoughts of loss, symptoms like those of the deceased person, and unexpec-
ted break-through of delayed grief. They need time, reassurance and
encouragement to accept the pain that results from looking back, and assi-
stance in expressing grief, anger and other feelings. The therapist does not
discuss future-oriented activities.
The therapist first forms a trusting relationship with the bereaved per -
son, acknowledges their bravery in controlling their feelings, and shows un-
derstanding of its cost - a hand on the shoulder or a smile of sympathy may
convey support more than words might. Bereaved people often deny anxiety
while complaining of physical symptoms it produces; the therapist explains
this with reassurance and instruction in self-relaxation to reduce those symp -
Once bereaved people feel secure enough during therapy they can
start acknowledging the full reality of their loss and its implications. The the-
rapist aids this by inviting them to bring photos or other objects linked with
the lost person and talking about those, writing a ‘diary’ reminiscing about
that person, and pretending that he or she is sitting in an empty chair nearby
and conversing with them. The bereaved are helped to recognise the conti-
nuing value of their relationship with the person they’ve lost and the extent to
which s/he ‘lives on’ in memory.
Related Procedures: Anxiety management, cognitive restructuring, expo-
sure therapy, Gestalt therapy.
Application: Guided mourning helps the few bereaved people who avoid
looking back, and is usually done individually. Prolonged grief therapy (see
clp entry) helps another minority of bereaved people who show difficulty in
looking forward and have abnormally prolonged grief.
1st Use? Ramsay (1979).
1. Mawson D, Marks IM, Ramm L, Stern LS (1981). Guided mourning for
morbid grief: A controlled study. British Journal of Psychiatry, 138, 185-93.
2. Parkes CM, Prigerson HG (4th edition 2009). Bereavement: studies of
grief in adult life. Routledge, London & NY.
3. Ramsay RW (1979). Bereavement: a behavioural treatment for pathologi-
cal grief. In: Sjoden PO, Bayes S, Dorkens WS (Eds.), Trends in Behaviour
Therapy. Academic Press, NY.
Case Illustration: (Parkes, unpublished)
Arthur M was an intelligent and assertive businessman who avoided
close emotional involvements and was inclined to dominate others. After his
wife died from an abdominal cancer he put away anything that might remind
him of her and filled his life with work and other activities. For weeks he co-
ped well but then disturbing nightmares began and he developed abdominal
pains similar to those from which his wife had suffered. These had continued
for two years when he agreed reluctantly to referral for psychiatric help.
The therapist reassured Arthur that seeing a psychiatrist did not
mean he was weak or inferior. During the first two weekly interviews, behind
his brave exterior Arthur seemed very anxious and needing emotional sup-
port. The therapist tried to give this by saying he recognised the heroism
with which Arthur battled his way through life and understood that this strate-
gy was not easy to maintain. At the end of the 2nd interview the therapist felt
that sufficient trust and empathy had developed to invite Arthur to bring a
possession of his dead wife to the next interview (a ‘linking object’). Arthur
arrived at session 3 with a large paper parcel that he placed gently on the
floor before him. The therapist moved his chair close to Arthur and, placing a
hand on his shoulder, invited him to unwrap the parcel. As his wife’s hand-
bag came into view Arthur burst into tears, which continued throughout the
session. His tears were accompanied by a lightening of tension and Arthur
went through the contents of the handbag and smiled through his grief at the
nostalgic memories they evoked. This was a turning point in therapy. In 3
subsequent interviews he expressed other distressing feelings, including an-
ger and self-reproach. As Arthur reviewed the wreckage of their plans he di-
scovered that his wife could remain a continuing influence; he had indeed
been ‘burying my treasure’. He was sleeping well and the abdominal pains
Gregory S CHASSON & Sabine WILHELM, Department of Psychiatry,
Massachusetts General Hospital, Harvard Medical School, Simches Resear-
ch Building, 185 Cambridge Street, Floor 2, Boston, MA 02114, USA; ph +1
Definition: Therapy to reduce distressing or impairing behaviors e.g. hair
pulling, skin picking, nail biting, motor and vocal tics, by clients increasing
self-awareness, using alternative responses that compete with the targeted
undesired behavior, and practising general relaxation.
Train awareness of when the target behaviors are imminent or occur-
ring and of the cues that trigger and maintain them. Work out a hierarchy of
triggers and behaviors from the least to the most distressing. Patients then
watch the therapist model their target undesired behaviors, lift a finger each
time they see these, and, between sessions, record on a monitoring form the
frequencies of those behaviors over 30-minute intervals.
Train a competing response: Use alternative socially-appropriate be-
havior to compete with the target one until the urge to carry out the latter has
subsided for about 60 seconds. Example: counter a habit of pulling out eye-
brow hair by keeping one’s hands in one’s pockets for 60 seconds throu-
ghout any urge to pull; counter a tic of twisting one’s torso to the right by
slightly twisting one’s torso to the left whenever the urge arises. Intermediate
alternative behaviors can be introduced, in steps, to reduce target behaviors
that are complex or sequential e.g. to eliminate a tic of saluting at the fore -
head, as an intermediate step first practise brushing back one’s hair whene-
ver an urge to salute comes on.
Train relaxation: Practise slow deep breathing and progressive mu-
scle relaxation in session to lower general tension which can resemble or
exacerbate urges preceding the target behaviors.
Further elements: Educate patients about their targeted behaviors
e.g. tics, and their treatment. Raise treatment motivation e.g. design self- -
rewards for completion of treatment exercises. Review how the habit causes
distress or inconvenience. Train generalization e.g. rehearse during ses-
sions the competing responses to be performed whenever tics occur outside
sessions. Do homework practice of self-awareness and competing respon-
ses. Recruit a relative as a supportive cotherapist. Teach relapse prevention
e.g. monitor for new target behaviors starting and previously-treated beha-
viors worsening, and design appropriate competing responses. Continue ge-
neral relaxation exercises.
Related procedures: Behavior rehearsal, breathing exercises, competing
responses, contingency management, functional analysis, homework, moni-
toring, relapse prevention, relaxation, ritual prevention, shaping.
Application: To improve nail biting, hair pulling, skin picking, and tics inclu -
ding those of Tourette’s Syndrome, habit reversal can be guided individually
and by suitable self- help books and interactive internet sites.
1st use? Azrin & Nunn (1973).
1. Azrin NH, Nunn RG (1973). Habit reversal: A method of eliminating ner -
vous habits and tics. Behaviour Research and Therapy, 11, 619-628.
2. Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, We-
gner R, Nudel J, Pittenger C, Leckman JF, Coric V (2007). Systematic re-
view: Pharmacological and behavioral treatment for trichotillomania. Biologi-
cal Psychiatry, 62, 839-846.
3. Wilhelm S, Deckersbach T, Coffey BJ, Bohne A, Peterson AL, Baer L
(2003). Habit reversal versus supportive psychotherapy for Tourette’s disor-
der: A randomized controlled trial. American Journal of Psychiatry, 160,
4. Woods D, Piacentini J, Chang S, Deckersbach T, Ginsburg G, Peterson
A, Scahill L, Walkup J, Wilhelm S (2008). Managing Tourette Syndrome: A
Behavioral Intervention for Children and Adults: Therapist Guide (Treatment-
s that Work). New York: Oxford University Press.
Case illustration: (Chasson and Wilhelm)
Jane, a 25-year-old massage therapist with Tourette’s syndrome,
sought help for multiple tics ranging from complex neck and mouth move-
ments to simple throat clearing. Habit reversal therapy took 11 sessions.
Each lasted 60 minutes except the first two which took 90 minutes, when
she was educated about Tourette’s and ranked a hierarchy of seven of her
tics from the most to the least distressing ones.
Jane first targeted her distressing tic of jerking her neck to the left. On
a tic-monitoring form she tallied that tic’s frequency in 30-minute intervals at
home and found it became more severe in her husband’s presence – it an-
noyed him greatly. Monitoring helped Jane identify, just before each tic, a
premonitory tingling urge where her left collar bone meets her neck. In ses-
sion, she practised a competing response of tensing her neck muscles and
turning her head to the right whenever she felt that urge. Her husband was
invited to attend session 2. He learned about his impact on Jane’s tics and
how to help by praising her when she used her competing response and by
indicating her tics with a subtle finger signal instead of showing anger. This
helped reduce the frequency of her neck tic.
Jane then monitored her distressing tic of humming. She found it was
preceded by a humming feeling in her throat getting louder. She practised, in
and between sessions as soon as she noticed the throat feeling or actual
humming, a competing response of keeping her lips tightly closed and brea-
thing through her nose for 60 seconds until the urge passed. In sessions the
therapist also trained Jane in progressive muscle relaxation with slow deep
breathing. Treatment required much effort, so whenever Jane felt less moti -
vated she reminded herself of all the inconveniences her tics had caused
e.g. having to hide her tics at work, and feeling embarrassed with strangers.
In sessions 10 and 11 she rehearsed her new skills to prevent relapse by: 1.
monitoring current tics with the tic-monitoring form; 2. with help from her hu-
sband, practising the slow deep breathing she’d learned to reduce overall
tension; 3. devising and practising competing responses which could counter
future tics. After treatment ended Jane had follow-up sessions monthly for 3
months to troubleshoot her difficulty in developing a competing response for
a flexing tic that had developed. The therapist helped her devise a compe-
ting response of straightening her arm whenever she felt a premonitory urge
to flex it.
Diane E LOGAN & G Alan MARLATT, Addictive Behaviors Research Cen-
ter, University of Washington, Box 351629, Seattle, WA 98195, USA; ph +1
Definition: Harm reduction aims to reduce the adverse effects of addictive
and other problem behaviors by accepting clients’ goals, including but not li-
mited to abstinence, and by addressing those behaviors and the situations in
which they occur.
Elements: The therapist and client together establish and work to meet spe-
cific goals. Some clients choose abstinence, and identify high-risk situations,
alternatives to the problem behavior, and/or acceptance of urges. Others
choose to not stop entirely but rather to reduce problem behavior by identify-
ing acceptable limits and how to stay within those(drink only on weekends,
no more than one drink per hour, alternate alcoholic with non-alcoholic
drinks). In clients who are not ready or able to immediately change their be-
havior, the therapist may recommend how to increase safety (clean needles
for IV drug users, condoms for sexual activity, find a designated driver).
Related procedures: Alternative behaviour, working out of, motivational in-
terviewing, relapse prevention.
Application: Harm reduction is used mainly in individual and group settings
for addictive behaviors and high-risk sexual behaviors, but can be tailored to
almost any problem behaviour. Implementation takes 1-10 sessions, depen-
ding on client goals and progress.
1st use? Engelsman (1989).
1. Engelsman EM (1989). Dutch policy on the management of drug-related
problems. British Journal of Addictions, 84, 211-218.
2. Marlatt GA [Ed] (1998). Harm reduction: Pragmatic Strategies for Mana-
ging High- risk Behaviors. New York, NY, US: Guilford Press.
3. Marlatt GA, Witkiewitz K (2002). Harm reduction approaches to alcohol
use: Health promotion, prevention, and treatment. Addictive Behaviors, 27,
Case illustration: (Logan, unpublished)
Claire, a student, was referred for an alcohol evaluation and feedback
session after a heavy-drinking bout on her university campus when she blac -
ked out and couldn’t remember that she had caused a public scene with
campus police being summoned. She said she expected an abstinence lec-
ture and wasn’t really interested in following such advice. The clinician in-
stead explored Claire’s good as well as not-so-good experiences while drin-
king. As the only way to avoid all trouble from alcohol was to not drink at all
and Claire was under the legal drinking age, there was no way to remove
potential legal consequences. These risks were explained, and Claire
acknowledged understanding these.
She said she usually drank moderately without bad results, but at ti-
mes would “go nuts” and drink heavily and black out, which impaired her re-
lationships and academic work. She thought abstinence was unreasonable
for her as her typical drinking, a couple of beers, was no problem. She and
her therapist instead focussed on how to reduce harm from heavy drinking,
and in exploring situations when this happened, which turned out to be drin-
king-games at parties. They discussed harm- reducing skills such as refe-
reeing versus participating in drinking games, spacing her drinks, setting a li-
mit mentally or in writing before going out, and alternating alcohol drinks with
non-alcoholic drinks of water or other beverages. She agreed these tools
could reduce harmful consequences and she was likely to use them.
When her single 50-minute harm-reduction session ended, Claire ex-
pressed appreciation that this was not another “confrontational abstinence
session” during which she had expected to say whatever the therapist wan-
ted to hear to “get this over with”, but instead found it surprisingly useful and
planned to actually implement harm- reduction tools when drinking. The the-
rapist reiterated that though only abstinence would avoid all problems from
drinking, ultimately Claire herself had to decide what to do and how to mini-
mise potential harm. At four-week follow-up Claire said she’d been drinking
IMAGERY REHEARSAL THERAPY OF NIGHTMARES
Lucio SIBILIA, Dipartimento di Scienze Cliniche, Università Sapienza di
Roma & Center for Research in Psychotherapy, Roma, Italy; ph +39 06
Definition: Teaching clients to change their nightmares into new non-distur-
bing dreams by composing such new dreams while awake and writing them
down and practising them in imagination just before sleeping in order to
have those new dreams while asleep.
Elements: a. Record or write down a description of a nightmare (this can be
bypassed). b. Change that description in any way preferred, or describe a to-
tally-new desirable dream. c. For a few minutes before going to sleep, read
this description or listen to a recording of it, and imagine experiencing that
intended new dream to facilitate having it while asleep.
Related procedures: Alternative practice, cognitive rehearsal, covert re-
hearsal, dream control, guided fantasy, homework, imagery rescripting and
reprocessing, rational-emotive imagery, rehearsal relief.
Application: Relief of nightmares with or without PTSD.
1st use? Krakow et al (1993).
1. Bradshaw SJ (1991). Successful cognitive manipulation of a stereotypic
nightmare in a 40 year old male with Down's syndrome. Behav Psychother,
2. Krakow B, Kellner R, Neidhardt J, Pathak D, Lambert L (1993). Imagery
rehearsal treatment for chronic nightmares: A thirty month follow-up. J.Be-
hav Ther & Exper. Psychiat, 24, 325–330.
3. Germain A, Krakow B, Faucher B et al. (2004).