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Emotion-Abstraction Patterns and Cognitive Interventions in a Single Case of Standard Cognitive-Behavioral Therapy

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Cognitive-behavioral therapy (CBT) assumes that therapeutic change de-pends mainly on change of cognitive content, while, from a theoretical viewpoint, other processes are excluded. This study aims to explore standard CBT interventions using a model of therapeutic change that includes both emotional and cognitive processes, i.e., the therapeutic cycle model (TCM; Mergenthaler, 1985; 1996), which describes the pro-cesses of therapeutic change in terms of cycles involving both emotional arousal and ab-stract thinking activation. We classified standard CBT interventions in three main are-as: assessing, disputing, and reframing biased beliefs. In 10 individual cognitive therapy sessions with a 30-year-old patient affected by a panic disorder with agoraphobia (PDA), this study aimed to explore whether cognitive interventions are not only related to abstract thinking but also to the emotional activation phases of TCM. Three inde-pendent judges assessed the presence of cognitive therapeutic interventions using the Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS; Trijsburg et al., 2002). A software program measured the TCM cognitive and emotional variables. The measures revealed significant correlations between cognitive therapeutic interventions and phases of abstract thinking activation during the therapeutic process. The results clarified the role of cognitive interventions in the therapeutic process as a useful instru-ment aimed to increase reality testing.
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Research in Psychotherapy: Psychopathology, Process an d Outcome
2014, Vol. 17, No. 2, 6572
© 2014 Italian Area Group of the Society for Psychotherap y Research
ISSN 2239-8031 DOI: 10.7411/RP.2014.020
Emotion-Abstraction Patterns and Cognitive
Interventions in a Single Case of
Standard Cognitive-Behavioral Therapy
Sandra Sassaroli1, Romina Brambilla1, Eva Cislaghi1, Roberta Colombo1,Francesco Centorame2,
Ettore Favaretto3, Francesca Fiore1, Guido Veronese4, & Giovanni M. Ruggiero 2
Abstract. Cognitive-behavioral therapy (CBT) assumes that therapeutic change de-
pends mainly on change of cognitive content, while, from a theoretical viewpoint, other
processes are excluded. This study aims to explore standard CBT interventions using a
model of therapeutic change that includes both emotional and cognitive processes, i.e.,
the therapeutic cycle model (TCM; Mergenthaler, 1985; 1996), which describes the pro-
cesses of therapeutic change in terms of cycles involving both emotional arousal and ab-
stract thinking activation. We classified standard CBT interventions in three main are-
as: assessing, disputing, and reframing biased beliefs. In 10 individual cognitive therapy
sessions with a 30-year-old patient affected by a panic disorder with agoraphobia
(PDA), this study aimed to explore whether cognitive interventions are not only related
to abstract thinking but also to the emotional activation phases of TCM. Three inde-
pendent judges assessed the presence of cognitive therapeutic interventions using the
Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS; Trijsburg et al.,
2002). A software program measured the TCM cognitive and emotional variables. The
measures revealed significant correlations between cognitive therapeutic interventions
and phases of abstract thinking activation during the therapeutic process. The results
clarified the role of cognitive interventions in the therapeutic process as a useful instru-
ment aimed to increase reality testing.
Keywords: therapeutic cycles, therapeutic moments, single case study, cognitive-
behavioral therapy
Standard cognitive-behavioral therapy (CBT) is
based on the assumption that there are three key
steps in a clinical psychotherapeutic intervention:
1) assessment of dysfunctional cognitive beliefs: a
therapeutic intervention aimed at encouraging pa-
tients to explicitly cognitively define their negative
emotional states in terms of biased beliefs; 2) dis-
puting: an intervention aimed at leading patients to
discuss and critique their dysfunctional beliefs; and
3) reframing: an intervention aimed at helping pa-
tients to develop alternative beliefs (Davidson &
Davidson, 2007; Dobson, 2013; Emmelkamp, 1993;
Lee & Turkel, 2013; Renaud, Dobson, & Drapeau,
2013). Empirical research supports this theory by
having shown both the efficacy of CBT protocols in
treating mood, anxiety, and eating disorders and
the psychopathological role played by cognitive be-
liefs and processes in emotional disorders (Burns et
al., 2013; Haaga, Dyck, & Ernst, 1991; Sethi, 2013;
Spielmans et al.,, 2013). However, proponents of
CBT are in danger of taking for granted that in
CBT the therapeutic process only depends on spe-
cific cognitive interventions that improve rational,
reality-checking thinking (Leahy, 2012). Actually,
little is known about the possible role of processes
not exclusively focused on cognition within the
CBT therapeutic process (Grant, Townend, Mul-
hern, & Short, 2010). Further research exploring
1 Psicoterapia Cognitiva e Ricerca, Post-graduate cognitive
psychotherapy school, Foro Buonaparte 57, 20121 Milano.
2 Studi Cognitivi, Post-graduate cognitive psychotherapy
school, Foro Buonaparte 57, 20121 Milano.
3 Azienda Sanitaria di Bolzano, Bolzano, Italy.
4 Department of Educational Science, University of Milano-
Bicocca, Milan, Italy.
Correspondence concerning this paper should be ad-
dressed to Sandra Sassaroli, Studi Cognitivi, Post-graduate
cognitive psychotherapy school, Foro Buonaparte 57,
20121 Milano; tel.: +39 02 6570350; fax: +39 02 36554665.
E-mail: grupporicerca@studicognitivi.net
Marogna and Caccamo 44
components not focused on cognitive processes in
CBT and their role in the CBT therapeutic process
is required in order to advance understanding of the
agents involved in therapeutic change and how they
interact with each other.
In order to implement a preliminary exploration
of this complex problem, this study aims to explore
the role of standard CBT interventions using a
model of therapeutic change that is able to describe
the interplay between mental states that involve the
activation of both abstract thinking and emotional
arousal. A process model that could satisfy these re-
quirements is the therapeutic cycle model (TCM;
Mergenthaler, 1985; 1996; 2008), which is both a
general model of therapeutic change and an opera-
tional method for conducting standardized explora-
tion of the processes of change occurring either
over the course of psychotherapy or at an individual
session. The TCM identifies key moments in the
psychotherapeutic process that may be measured in
terms of level of emotional activation and/or ab-
stract cognitive reflection (Benelli et al., 2012; Mer-
genthaler, 1996). According to the theory under-
pinning this model, a clinically significant moment
is characterized by the simultaneous presence of
high emotional activation and intense abstract
thinking. In other words, key therapeutic change
takes place when the patient processes his or her
psychological problems in both cognitive and emo-
tional terms, respectively called abstraction (AB)
and emotional tone (ET) (Mergenthaler, 1985;
1996; 2008). The possible combinations of these
two factors yield four emotionabstraction patterns
(EAP), as follows: relaxing (low ET and low AB), in
which patients talk about material that is not mani-
festly connected to their central symptoms or is-
sues; reflecting (low ET and high AB), in which pa-
tients speak using a high degree of abstraction and
without intervening emotions; experiencing (high
ET and low AB), in which patients find themselves
in a state of emotional arousal; and connecting
(high ET and high AB), in which patients find emo-
tional access to problematic states and explore them
from both an emotional and rational viewpoint.
The sequence of these four EAPs is called a “ther-
apeutic cycle,” and its prevalence in therapy has
been found to be positively associated with positive
clinical outcomes in treatments of different orienta-
tions (Mergenthaler, 1996; 2008). The ideal se-
quence of a good therapeutic cycle includes relax-
ing, experiencing, connecting, reflecting, and relax-
ing again. In this sequence, a problematic situation
is narratively recounted, critically examined, and
emotionally appraised in a way that allows the con-
nection of everything, leading to both emotional
and cognitive insights (Mergenthaler, 1985; 1996;
2008). These cycles represent a particular kind of
emotional and cognitive sequence, during which it
is reasonable to suppose that much of the prepara-
tory work carried out at other times during the
therapy come to fruition (Ribeiro, Ribeiro, Gon-
calves, Horvath, & Stiles, 2012).
Previous research has shown that TCM is useful
to investigate therapistpatient processes in psy-
chodynamic-oriented therapy (Fontao & Mer-
genthaler, 2008; Lepper & Mergenthaler, 2008; Lo
Verde, Sarracino, & Vigorelli, 2012; Mergenthaler,
McCarthy, Mergenthaler, Schneider, & Grenyer,
2011). In addition, Nicolò, Mergenthaler, Pontalti,
Semerari, and Catania (2000) and Molinaro (2013)
applied TCM to CBT. As is widely known, CBT
founding fatherse.g., Beck (1964) and Clark
(1986)assumed in their clinical and psychopatho-
logical models that emotional disorders depend on
rational biases of mental activity and that standard
CBT interventions work by applying a rational
thinking examination of these cognitive biases
(Beck, 1964; Clark, 1986), while in a second phase,
rational reframing influences emotional change
(Beck, 2011). This hypothesis implies that standard
CBT interventions may be correlated with a given
phase of the TCM model. We hypothesized that
cognitive assessment interventions would be signif-
icantly correlated to the relaxing TCM phases in
which patients recount problematic episodes. As-
suming that in the TCM model the reflecting phase
approximates rational CBT reframing (Beck, 1964;
Clark, 1986) while the connecting phase represents
the second emotional/cognitive reframing that
makes change stable (Beck, 2011), we hypothesized
that cognitive disputing interventions are signifi-
cantly correlated with the reflecting TCM phase in
which the patient critically examines his or her
problems mainly using intellectual reality testing.
We also hypothesized that cognitive reframing is
correlated with the connecting TCM phase in
which the patient is able to use both cognitive and
emotional processing. We had no specific hypothe-
ses about the experiencing TCM phase, although it
is plausible to hypothesize that the emotional in-
volvement aroused by cognitive disputing could al-
so relate this intervention to the expiring phase of
TCM.
Method
Sample and Treatment
For this study, we examined the transcripts of the
first 10 sessions of a standard course of CBT of G. R.,
a 30-year-old Italian male affected from adolescence
by a panic disorder with agoraphobia (PDA), as de-
fined by the DSM-IV (American Psychiatric Associa-
tion, 2000). Clark’s standard CBT protocol for PDA
has been shown to be highly effective with 7080%
of patients remaining panic-free at the 12-month fol-
low-up (Clark et al., 1994; Clark et al., 1999). There-
fore, PDA requires a strict implementation of a CBT
45 Analysis of the process
protocol and allowed us to use TCM to explore a
highly standardized form of CBT.
Clark’s standard CBT protocol for PDA includes
12 sessions. However, the good compliance and re-
sponse of the client allowed the psychotherapist to
implement the protocol in 10 sessions. Given that
the psychotherapist applied the protocol from the
beginning of the therapy, the first 10 sessions were
totally focused on standard CBT treatment of PDA.
The psychotherapist carried out the diagnosis us-
ing the Italian version of the Structured Clinical In-
terview for DSM-IV Axis I Disorders (SCID-I;
Mazzi Morosini, De Girolamo, Bussetti, & Guaral-
di, 2000; First, Spitzer, Gibbon, & Williams, 1997).
A psychotherapist trained in cognitive therapy con-
ducted the diagnostic interviews and applied
Clark’s CBT protocol for PDA (Clark, 1986). The
therapist was 45 years old and had 15 years of clini-
cal experience in CBT.
The diagnostic process revealed that G. R. had
suffered two full panic episodes when he was 18
years old, at the beginning of his university studies.
In the following years, he developed many avoidant
behaviors in relation to traveling alone. In particu-
lar, he avoided using the car and subway alone in
order to prevent a panic episode. Consequently, the
current and exact diagnosis was agoraphobia with a
history of past episodes of panic.
The therapy started in October 2008 and lasted
about one-and-a-half years. The first 10 once-a-week
sessions were focused on the implementation of the
abovementioned Clark’s standard CBT protocol for
PDA (Clark, 1986). The client asked to attempt the
therapy without using antidepressants. Given the
condition of the client, the therapist (who is also a
psychiatrist) agreed, although he reserved the right to
suggest antidepressants in the absence of any clinical
change. The client had no previous treatment.
Clark’s standard CBT protocol for PDA included
the assessment, disputation, and reframing of the
underlying cognition as well as active encourage-
ment toward behavior exposure to use transport
unaccompanied (Clark et al., 1994; Clark et al.,
1999). After the implementation of Clark’s stand-
ard CBT protocol for PDA in the first 18 sessions,
the therapy continued in a looser way, in which the
therapist and the client treated more existential and
general issues such as future projects, affective life
satisfaction, and personal achievements. Given the
extensive use of standard CBT techniques during
the first phase of the therapy and the shared goal of
the client and the therapist to implement standard
CBT, we considered the first 10 sessions as a good
case study for research on CBT interventions.
The therapist evaluated the symptoms again in
January 2009 using SCID-1. Although still appar-
ent, the agoraphobia was subclinical given that the
criteria were insufficient for a full diagnosis. Specif-
ically, the avoidant behaviors criterion was absent.
Figure 1. Graphic Representation of Sequences of EAPs
in Session 1.
X = WB sequence; Y = standardized ET and AB
activation values.
Instruments and Measures
We used cycle model software (CM) to apply the
TCM to the transcripts of the psychotherapy sessions
(Mergenthaler, 1998; 2003). In February 2010, during
a two-day stay at Ulm University, Germany, the first
author was trained by the TCM research team and re-
ceived the Italian version software used in previous
studies (Lo Verde, Sarracino, & Vigorelli, 2012; Mer-
genthaler & Gelo, 2007; Nicolò, Mergenthaler,
Pontalti, Semerari, & Catania, 2000; Molinaro, 2013).
We calculated TCM values for all of the transcrip-
tions, which means that we explored the therapist
client dyad as a whole rather than focusing on either
the client or on the therapist, given that we aimed to
explore CBT interventions that intrinsically entail
both the therapist’s activating initiatives and the cli-
ent’s responses. In order to prepare the data for com-
puter-assisted analysis via the CM, we divided session
transcripts into units of analysis consisting of word
blocks (WB) of at least 150 words. We defined the
units of analysis solely on the basis of length without
taking into account the content of the segments of text.
The CM uses word lists (Mergenthaler, 1998;
2003) that are organized in terms of the thematic
categories of ET and AB. The CM analyzes the texts
by measuring the frequency of occurrence of each
of the words listed in its dictionaries for each WB.
The software then generates a graphic representa-
tion of the psychotherapy sessions from which re-
searchers may identify the mentioned EAPs and
therapeutic cycles (Fig. 1). EAPs were a combina-
tion of z-scores of ET and AB. We set the following
thresholds: (a) relaxing: z(ET) ≤ 0, z(AB) 0; (b)
reflecting: (ET) ≤ 0, z(AB) > 0; (c) experiencing:
z(ET) > 0, z(AB) ≤ 0; and (d) connecting: z(ET) >
0, z(AB) > 0 (Gelo & Mergenthaler, 2012).
In addition, the software provides quantitative
measures of the levels of ET and AB to be used in
further statistical analysis. In turn, these levels can
be analyzed in terms of average scores that can be
correlated with the type of CBT intervention.
We used the Comprehensive Psychotherapeutic
Interventions Rating Scale (CPIRS; Trijsburg et al.,
2002) to provide a standardized evaluation of the
Marogna and Caccamo 46
cognitive interventions that took place during the
sessions. The CPIRS is an evaluation scale used to
measure the prevalence of interventions in psycho-
therapy using a presence/absence dichotomous
scale (Trijsburg et al., 2002). The scale includes de-
scriptors of 76 types of psychotherapeutic interven-
tion. The scale allows the assessment of interven-
tions used in different forms of therapy, including
CBT. We only used the 13 items in the cognitive
therapy section of the CPIRS. Furthermore, we col-
lapsed the 13 cognitive interventions identified by
the CPIRS into three main categories: assessment,
disputing, and reframing. Thus our assessment cat-
egory comprised the following CPIRS items, all fo-
cused on the detection and exploration of cognitive
contents: recognizing cognitive themes (item 31);
recognizing the relationship between thoughts and
feelings (item 32); recording and reporting cogni-
tions (item 33); exploring personal meanings of
thoughts (item 34); recognizing cognitive errors
and biases (item 35); and identifying underlying
cognitive assumptions (item 36). Our disputing cat-
egory comprised the following CPIRS items, all fo-
cused on the work of critical analysis of the cogni-
tive contents: distancing from beliefs (item 37); ex-
amining available evidence (item 38); prospective
testing of beliefs (item 39); and realistic conse-
quences (item 41). Our reframing category com-
prised the following CPIRS items, all focused on the
work of elaboration and implementation of new
and more functional cognitive contents: searching
for alternative explanations (item 40); adap-
tive/functional value of beliefs (item 42); and prac-
ticing rational responses (item 43).
The inter-rater reliability (calculated between
three independent judges and via joint probability
of agreement) for each intervention was 0.88 (as-
sessment), 0.76 (disputing), and 0.83 (reframing).
Procedures
First, the three abovementioned independent judges
classified the interventions that took place during the
sessions into the three categories derived from the
CPIRS of cognitive intervention outlined above: as-
sessment, disputing, and reframing. Each of the three
judges implemented this nominal coding of the ses-
sions separately. We also analyzed the 10 sessions us-
ing CM software to evaluate whether each of the WBs
was a therapeutic (part of a therapeutic cycle) or non-
therapeutic (not part of a therapeutic cycle) moment
and to identify the EAPs present in the transcripts.
Data Analyses
We analyzed the data using logistic regression and chi-
square analysis. We implemented logistic regression to
assess whether the association between the quantita-
tive values of the therapistclient dyad EAPs (inde-
pendent variable) and the absence/presence of each of
the three CBT interventions (dependent variable) was
significant.
We implemented chi-square analysis to assess
whether there were significant differences in the
occurrence of therapeutic interventions between
the therapeutic and non-therapeutic WBs of the
session transcripts.
Given that TCM is able to analyze the cognitive-
emotional modalities of both patient-only and pa-
tienttherapist activity, we chose to implement two
sets of analyses: one on patient-only activity and the
other on the joint activity of patient and therapist.
Results
Patient-Only Activity
The CM program classified 246 WBs as falling out-
side the therapeutic cycles (for brevity, non-
therapeutic WBs) and 76 WBs as forming part of
the therapeutic cycles (for brevity, therapeutic
WBs). Cognitive assessments occurred significantly
more frequently within therapeutic WBs than with-
in non-therapeutic WBs (Fig. 2). In fact, 53.9% of
the therapeutic WBs contained cognitive assess-
ments versus 26.4% of the non-therapeutic WBs (χ²
= 19.920; p <.001).
Figure 2. Occurrence of Cognitive Assessment In-
terventions During Patient-Only Non-Therapeutic
WBs and Therapeutic WBs.
In contrast, interventions involving the disputing of
existing beliefs and the reframing of alternatives were
equally distributed across therapeutic and non-
therapeutic segments and in any case were relatively
infrequent. Specifically, disputing was present in 7.9%
of therapeutic WBs and in 8.5% of non-therapeutic
WBs, while reframing was present in 2.6% of thera-
peutic WBs and in 5.7% of non-therapeutic WBs. Nei-
ther of these differences was statistically significant (χ²
= .970; p > .05; χ² = .117; p > .05).
In addition, logistic regression revealed that the
patient’s cognitive assessment activity predicted
higher prevalence of phases of reflecting of the
26,4
53,9
47 Analysis of the process
EAPs [OD = 1.123; CI = 95% p < .001].
PatientTherapist Joint Activity
The CM program classified 173 WBs as falling out-
side of the therapeutic cycles and 149 WBs as falling
within the therapeutic cycles. Cognitive assess-
ments featured in 34.7% of non-therapeutic WBs
and 38.3% of therapeutic WBs; challenges to exist-
ing beliefs took place in 34.7% of non-therapeutic
WBs and 38.3% of therapeutic WBs. None of these
differences were statistically significant (χ² = 2.585;
p > .05; χ² = 1.913; p > .05).
In contrast, there was a significant difference re-
garding the occurrence of the reframing of cogni-
tive alternative interventions. In fact, these inter-
ventions featured slightly more frequently in thera-
peutic WBs than in non-therapeutic WBs (Fig. 3).
Specifically, 21.5% of the therapeutic WBs con-
tained instances of reframing as opposed to 13.9%
of non-therapeutic WBs; this difference was mod-
erately significant (χ² = 3.222; p < .05).
Figure 3. Occurrence of Reframing of Alternative
Interventions During Joint Patient-Therapist Non-
Therapeutic WBs and Therapeutic WBs.
Logistic regression revealed that joint patient
therapist disputing interventions significantly pre-
dicted phases of experiencing of EAPs [OD =1.345;
CI = 95%; p < .05], as did reframing interventions
[OD = 1.811; CI = 95%; p < .05].
Summary of Results
In patient-only activity, cognitive assessment inter-
ventions were significantly more present in thera-
peutic WBs and were significantly associated with
the prevalence of reflecting phases of EAPs. In joint
patienttherapist activity, cognitive reframing in-
terventions were significantly more present in ther-
apeutic WBs and were significantly correlated with
phases of experiencing of EAPs. There was another
significant correlation between cognitive disputing
interventions and phases of experiencing of EAPs in
joint patienttherapist activity.
Discussion
The CBT psychopathological model assumes that
emotional disorders are related to cognitive biases
that can be uttered in a reflective and self-defining
language (Beck, 1964, 2011; Clark, 1986). The aim
of this paper was to test the hypothesis that CBT
disputing interventions can significantly predict the
reflecting TCM phase in which the patient critically
examines his or her problems mainly using intellec-
tual reality testing, while cognitive reframing pre-
dicts the connecting TCM phase in which the pa-
tient is able to use both cognitive and emotional
processing.
Our findings regarding cognitive assessment in-
tervention could be interpreted as a confirmation
that the process of the elicitation of irrational be-
liefs, at least on the part of the patient only, is relat-
ed to a high abstract and low emotional lexicon and
reflective EAPs, and, consequently, it is plausible to
implement activating mental functions related to
abstract cognition. These results are also confirmed
by another research study that used both CPIRS
and TCM and found similar results. In fact, Moli-
naro (2013) found that “cognitive interventions
that are primarily related to the analysis of the pa-
tient's thoughts and their relationship with the af-
fective experience, are positively associated with
high levels of Abstraction, Emotional Tone, and
positive Emotional Tone in the patient’s response”
(p. 99).
It is interesting to stress that this cognitive activa-
tion is solely observable in patient-only activity. We
interpreted this result by proposing that patient
therapist joint activity entails interpersonal aspects
that are emotionally laden and, consequently, not re-
lated to cognitive and abstract interventions.
The most clinically significant differences be-
tween joint patienttherapist activity and patient-
only activity were that in the joint activity the re-
framing of cognitive alternatives was associated
with therapeutic WBs, while in patient-only activity
cognitive assessments were associated with thera-
peutic WBs. Disputing was balanced between ther-
apeutic WBs and non-therapeutic WBs. This seems
to suggest that cognitive assessment is an activity
that is therapeutic when observed in the patient
alone, probably corresponding to an activity of self-
awareness and reflection, while the therapeutic
component of reframing is typically a joint activity
of the therapist and patient together.
Cognitive disputing and reframing are related to
the experiencing phases of EAPs and to patient
therapist joint activation. This suggests that these
interventions are more related to an emotional and
interpersonal activation (Gelo & Mergenthaler,
2012; Voutilanen, 2012) and that cognitive disput-
ing and reframing would imply not only abstract
reflection, but also emotional arousal. In fact, ab-
13,9
21,5
Marogna and Caccamo 48
stract reflection alone is plausibly a fallacious strat-
egy to solve problems and difficulties, given that in
figuring out strategies to overcome negative events
people need to use not only verbal and abstract
thought but must also use visual imagery
(Schonpflug, 1989). Patients affected by emotional
disorders, including PDA, tend to perceive emo-
tional activation as difficult to manage because it
stimulates negative emotions and somatic anxiety.
Thus, people affected by an intolerance toward
negative emotions, such as anxiety disorder subjects
and PAD individuals, tend to use abstract thinking
to suppress the emotional features of panic and
anxiety (Borkovec, 1994). In other words, cognitive
elaboration without emotional activation would not
allow the patient to access the emotional experienc-
es needed for successful habituation and extinction.
A negative reinforcement spiral ensues with the ex-
perience of worry because worry replaces the aver-
sive and fearful images with less disturbing, less so-
matically activating verbal linguistic activity. Thus,
while abstract thinking alone may be similar to a
sort of cognitive avoidance strategy, a good thera-
peutic change adds emotional and interpersonal en-
gagement to reflective cognition. Also, this result
parallels the similar work of Molinaro (2013), who
found that cognitive interventions are associated
with the integrated connecting pattern of TCM.
In conclusion, the paper suggests that in standard
CBT, pure cognitive interventions are not the only
present and working therapeutic mechanisms. The
therapeutic process is a complex event involving
cognitive, emotional, experiential, and interperson-
al elements. In this sense, we may conclude that
pure cognitive interventions are not the sole thera-
peutic moments but represent outcomes from the
ongoing therapeutic process: a sort of reaping of the
benefits (Lepper & Mergenthaler, 2007; 2008). At
such moments, patients enhance insight abilities
that enable them to cope with problematic situa-
tions, in both emotional and cognitive terms (Paris,
2010; Schauenburg, Schussler, & Leibing, 1991).
Limitations
In order to simplify the analyses in this study, we
chose to use the TCM, only selecting WBs of 150
words, regardless of content. This is a clear limita-
tion of the study. In the future, it would be prefera-
ble to replicate the study by extending the therapeu-
tic phases identified by the TCM model beyond a
single block.
We only focused on the first 10 psychotherapy
sessions that the therapist implemented according
to Clark’s standard CBT protocol for PDA (Clark
et al., 1994; Clark et al., 1999). In the future, it
would be intriguing to explore the subsequent and
less symptom-focused phases of the treatment.
Clearly, a limitation of this research is the fact
that it only examined the cognitive psychotherapy
sessions of a single case. Single case studies have
their strengths and limitations: they can help us un-
derstand complex inter-relationships, show the pro-
cesses involved in causal relationships, and facilitate
rich conceptual/theoretical development (Hodkin-
son & Hodkinson, 2001a). On the other hand, their
abundant data are not suited for readily under-
standable analysis and their results are not general-
izable, at least not in the conventional sense (Hod-
kinson & Hodkinson, 2001b). However, they can
be transposed beyond the original sites of study and
can corroborate provisional hypotheses and truths
(Hodkinson & Hodkinson, 2001a).
On the basis of the preliminary data obtained in
this study, follow-up research could usefully be
conducted by examining samples of CBT therapies
to analyze the cognitive interventions present be-
fore the onset of a therapeutic cycleas defined by
the CMto identify the types of cognitive inter-
ventions that may promote the occurrence of, and
facilitate access to, therapeutic cycles.
Of course, the strength of the findings about the
non-cognitive components of CBT is questionable.
The TCM cannot exhaustively account for the
complexity occurring in the therapeutic process un-
der examination. For example, TCM considers
emotion only at the lexical level, while it overlooks
prosodic and nonverbal emotive realizations.
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