Making Cognitive Behavioral Therapy Work Clinical Process

for New Practitioners, 3rd Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/making-cognitive-behavioral-therapy-work-clinical-pr
ocess-for-new-practitioners-3rd-edition/

Click Download Now

Copyright © 2018 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

Except as indicated, no part of this book may be reproduced, translated,

stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

These materials are intended for use only by qualified mental health professionals.

The publisher grants to individual purchasers of this book nonassignable permission

to reproduce the blank assessment report template. This license is limited to you, the
individual purchaser, for personal use or use with clients. This license does not grant
the right to reproduce these materials for resale, redistribution, electronic display, or
any other purposes (including but not limited to books, pamphlets, articles, video- or
audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides
for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged).
Permission to reproduce these materials for these and any other purposes must be
obtained in writing from the Permissions Department of Guilford Publications.

The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that
are accepted at the time of publication. However, in view of the possibility of human
error or changes in behavioral, mental health, or medical sciences, neither the authors,
nor the editor and publisher, nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omis-
sions or the results obtained from the use of such information. Readers are encouraged
to confirm the information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data

Names: Ledley, Deborah Roth, author. | Marx, Brian P. | Heimberg, Richard G.

Title: Making cognitive-behavioral therapy work : clinical process for new
practitioners / Deborah Roth Ledley, Brian P. Marx, Richard G. Heimberg.
Description: Third edition. | New York : The Guilford Press, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2018006155 | ISBN 9781462535637 (hardback)
Subjects: LCSH: Cognitive therapy. | BISAC: MEDICAL / Psychiatry / General. |
SOCIAL SCIENCE / Social Work. | PSYCHOLOGY / Clinical Psychology.
Classification: LCC RC489.C63 L44 2018 | DDC 616.89/1425—dc23
LC record available at https://lccn.loc.gov/2018006155
 To Jenna, who shares my love of the written word
To Matthew, our inquisitive and empathic Junior Doctor
And to Gary, who supports me in everything I do
and whom I love to the moon and back
                       —D. R. L.

For Colin and Denise, both of whom teach me

something valuable every single day
                     —B. P. M.

To Chris, who always makes me proud

To Connor and Riley, who always make me smile
And, most of all, to Linda, who lights up my life
                     —R. G. H.
 About the Authors

Deborah Roth Ledley, PhD, is a psychologist in private practice in sub-

urban Philadelphia. She spent several years on the faculty of the Uni-
versity of Pennsylvania’s Center for the Treatment and Study of Anxi-
ety. Dr. Ledley’s research has focused on the nature and treatment of
anxiety. She has published over 50 scientific papers and book chapters
as well as several books, including Improving Outcomes and Preventing
Relapse in Cognitive-Behavioral Therapy, Becoming a Calm Mom, and
The Worry Workbook for Kids. She lectures widely on the treatment of
childhood anxiety.

Brian P. Marx, PhD, is a staff psychologist at the National Center for

Posttraumatic Stress Disorder (PTSD), Veterans Affairs Boston Health-
care System, and Professor of Psychiatry at Boston University School of
Medicine. Dr. Marx has published numerous articles and book chap-
ters on behavior therapy and assessment. His research interests include
the assessment and treatment of PTSD, identifying risk factors for post-
traumatic difficulties, and the association between PTSD and suicidal
behaviors.

Richard G. Heimberg, PhD, is the Thaddeus L. Bolton Professor of Psy-

chology and Director of the Adult Anxiety Clinic of Temple at Temple
University. He is past president of the Association for Behavioral and
Cognitive Therapies (ABCT) and the Society for a Science of Clinical
Psychology (SSCP) and former editor of the journal Behavior Therapy.
Well known for his efforts to develop and evaluate cognitive-behavioral

vii
viii About the Authors

treatments for social anxiety and other anxiety disorders, Dr. Heimberg
has published several books and 450 articles and chapters. As an educa-
tor and mentor of clinical psychology doctoral students, he has received
awards from ABCT, SSCP, the Society of Clinical Psychology, and the
American Psychological Association of Graduate Students.
 Preface

Back in 1999, when I (D. R. L.) was a postdoctoral fellow at Temple

University, Brian Marx (who was then an assistant professor), Richard
Heimberg (who was then my mentor), and I cooked up the idea of writ-
ing a book for beginning clinicians. Even at the fine training programs
with which we had been involved, we were struck by a gap in train-
ing. Although students knew a lot of facts about cognitive-behavioral
therapy and the disorders they were treating, they sometimes seemed lost
in the room with clients. And, as a new clinician myself, I often felt the
same way! There were so many “What should I do?” questions: What
should I do when a client asks me personal questions? What should I do
when a client gets angry during a session? What should I do with my
feelings of disappointment when clients discontinue therapy when I do
not think they are ready to do so? There were no books that addressed
these important questions. My own struggles, and the struggles of our
collective trainees, inspired us to write Making Cognitive-Behavioral
Therapy Work.
So much has changed since the first edition of our book was pub-
lished in 2005! I am no longer an inexperienced clinician, and over the
past decade or more, we have treated and supervised the treatment of
countless clients. This collective experience has led us to substantially
revise Making Cognitive-Behavioral Therapy Work for this third edi-
tion. In this new edition, we have included a chapter on working with
special populations. In that chapter (Chapter 9), we discuss the impor-
tance of providing culturally responsive cognitive-behavioral therapy

ix
x Preface

and offer guidance on how to work with children and families. We have
included new cases, including one that readers can follow from assess-
ment through the termination of therapy. This case is more complex in
nature than the one we had included in the previous two editions of the
book, inspired by our day-to-day work with clients who do not neces-
sarily fit neatly into a single diagnostic category. We have paid special
attention to new challenges that clinicians face in the increasingly digital
world. When we started thinking about this book, we were all worrying
about computer failure as 1999 became the year 2000, but we had not
yet encountered social media, texting, telehealth, or sending recordings
of therapy sessions over the Internet. As new technologies emerge, we
need to stay mindful of the ethical issues surrounding them, since the
legalities have lagged far behind. We have tried to articulate how to deal
with common issues that clinicians face in this new edition of the book.
We hope this book will help to alleviate the anxiety of beginning
clinicians and will also address the daily challenges faced by more expe-
rienced clinicians. We welcome your feedback about this new edition.
 Acknowledgments

We would like to thank all the wonderful people at The Guilford Press
for their hard work on the third edition of Making Cognitive-Behavioral
Therapy Work: Clinical Process for New Practitioners, in particular
Senior Editor Jim Nageotte and Senior Assistant Editor Jane Keislar.
Deborah Roth Ledley would like to thank Marty Antony, Richard
Heimberg, Edna Foa, and Marty Franklin for being influential clinical
teachers during her training and early career. And thank you to Tamar
Chansky, Lynne Siqueland, Muniya Khanna, Larina Kase, and Chiara
Baxt, who are the best colleagues and the best consultation group a cli-
nician could ask for.
Brian P. Marx would like to thank his colleagues, collaborators,
and supervisees at the National Center for Posttraumatic Stress Disorder
and the VA Boston Healthcare System for their wisdom and inspiration.
He would also like to give a special thanks to Meaghan Brown, Aaron
Harwell, Ali Klein, and Sara Pedersen, who assisted in compiling refer-
ences for this edition.
Richard G. Heimberg would like to thank the many doctoral stu-
dents and supervisees who have worked with him over the years in the
clinical psychology program at Temple University and who have taught
us so much about the things that clinicians in training need and want
to know.
Of course, thank you to our clients over the years, who keep our
work interesting and challenging.

xi
 Contents

Prologue: Common Challenges for New Clinicians 1

1. The Process of Cognitive-Behavioral Therapy 5

2. Initial Interactions with Clients 26

3. The Process of Assessment 45

4. Conceptualizing the Case and Planning Treatment 75

5. The Bridge from Assessment to Treatment 93

6. The First Few Sessions of CBT: Goals and Challenges 121

7. The Course of CBT: Goals and Challenges 145

8. Terminating Therapy: Goals and Challenges 182

xiii
xiv Contents

9. Doing CBT with Special Populations 199

10. The Process of Supervision: Goals and Challenges 232

11. Revisiting the Common Challenges 252

Appendix A. Recommended Readings in CBT 259

Appendix B. Further Reading on Special Topics in CBT 262

Appendix C. Treatment Manuals and Client Workbooks 264

Appendix D. Useful Information 266

for Cognitive-Behavioral Therapists

References 269

Index 279

Purchasers of this book can download and

print a blank assessment report template at
www.guilford.com/ledley-materials
for personal use or use with clients
(see copyright page for details).
 Prologue
Common Challenges for New Clinicians

Every professional must do things for a first time: architects must design
their first building, teachers must teach their first class, surgeons must
perform their first surgery. Similarly, beginning cognitive-behavioral
therapists must see their first clients. Learning new skills as well as devel-
oping one’s own professional identity can be fun and exciting, but also
overwhelming.
At the outset of this third edition of Making Cognitive-Behavioral
Therapy Work, we identify challenges commonly experienced by devel-
oping clinicians when starting out. Our goal throughout this book is to
provide suggestions for addressing these challenges should they arise.

1. Feeling incompetent and/or being perceived as incompetent. As

we just mentioned, everyone is a novice at the beginning of his or her
career. Even later in our careers, we might treat a client with a diagno-
sis we have never worked with before, or we might implement a ther-
apy technique that we only recently learned. Feelings of incompetence
can lead to worries about not being able to help our clients, or maybe
even making them worse. We might also worry about coming across as
incompetent to clients and their families, and these worries can distract
us and actually lead to less competent treatment. In Chapters 1, 6, and 9,
we discuss how to address our own worries about competence and how
to maintain focus during treatment.

1
2 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK

Beginning clinicians often worry about coming across as incom-

petent to their supervisors as well. In Chapter 10, we discuss how to
manage anxiety around supervision—and how supervision is in place to
actually help trainees build competence and confidence.

2. Being seen as not able to relate. Beginning clinicians may worry

that they will be seen by their clients as not able to relate to what they are
experiencing. Can someone who is not married relate to a client who is
dealing with infidelity in his or her marriage? Can someone who doesn’t
have children coach parents about discipline? Can a seemingly happy,
healthy therapist understand what it feels like to be terribly depressed?
In Chapters 6 and 9, we untangle what this kind of question from a
client actually means within the therapeutic relationship and how to
respond to it so that clients feel understood.

3. Figuring out how all the pieces of information clients present

to us fit together. It can be overwhelming to be in the room with a new
client. In the first few hours that we spend with them, new clients share
a great deal of information about their current problems and their per-
sonal histories. How do we fit all the pieces together to best understand
and treat each client we meet? In Chapters 1 and 4, we discuss the impor-
tance of developing a case conceptualization to help us understand the
client, his or her problems, and how to resolve them. We return to this
concept throughout the book because the case conceptualization is never
static—as we work with clients, our understanding of their difficulties
and how we should treat them continuously evolves.

4. Coming across as rigid and inflexible when performing assess-

ments and using treatment protocols. Many of the assessment tools and
treatments used by cognitive-behavioral therapists are guided by manu-
als. Adherence to manuals is particularly important during training and
in the context of clinical trials. Although having a manualized assess-
ment or treatment protocol can be reassuring to a novice clinician, it can
also cause anxiety. What if I sound like I am reciting facts rather than
empathically listening? What if using a protocol/manual makes me look
inexperienced? What if my client brings something up that is not covered
by the manual? We address these concerns and discuss the art and sci-
ence of using structured assessments (Chapter 3) and therapies (Chapters
1, 4, 6, 7, and 9).

5. Feeling overwhelmed by the complexity of clients’ lives. Begin-

ning clinicians may feel overwhelmed by the complexities of clients’
 Prologue 3

lives. This is particularly the case in settings such as the Department

of Veterans Affairs (VA) health care system, inner-city school districts,
and community mental health clinics. Although we are often trained
to treat single disorders, using an easy-to-follow manual, all of this
structure can fly out the window when a client presents not only with
multiple disorders but also with multiple “problems of living.” What
happens to the therapy then? Should it stay focused? Should a therapist
get involved in the numerous problems the client is facing? Or is there a
different way of viewing these clients’ concerns to which new clinicians
must adjust? The answers to these questions are addressed in Chapters
4, 7, and 9.

6. Managing unrealistic expectations about the outcome of ther-

apy. Many of us start our training with an idealized view of the degree
to which clients will improve over the course of therapy. The data on
cognitive-behavioral therapy feeds into this view: our treatments are so
effective that we are swayed into believing that if we stick to a treatment
protocol, and form a strong therapeutic relationship, every client should
do well. We forget about the percentage of clients who do not improve as
much as they (or we) would have hoped. In Chapters 7 and 8, we discuss
how to think about cases that aren’t going well, and how to deal with the
disappointment of a client who simply does not get better.

7. Working with clients who are difficult to treat. Beginning thera-

pists often embark on their careers not only believing that they can help
everyone (see Challenge 6), but believing that everyone wants help. In
reality, some clients are resistant to making the changes that would be
necessary to lead a healthier, more productive life. Others might desire
change but bring various factors to the table that get in the way. In Chap-
ters 6–9, we focus on how to recognize these roadblocks (which can be
quite subtle!) and how to move past them so that therapy will progress.
We also discuss how to terminate therapy with clients who are not ready
to do the work involved in getting well.

8. Managing the emotions that can arise in our interactions with

clients. Being a clinician is an emotional job. Novice clinicians often
experience anxiety about their clinical skills and their interactions with
clients. Although seasoned clinicians might experience less anxiety than
their novice counterparts, anyone working with clients should expect to
feel a range of emotions in any given week. We might feel anger toward
clients who are making bad choices, sadness about the lives our clients
are leading, and joy when a client experiences a success after many
4 MAKING COGNITIVE-BEHAVIORAL THERAPY WORK

setbacks. How do we manage our own emotions within therapy ses-

sions? We discuss this issue in Chapter 1, as well as in Chapters 6–9 and
10.

9. Leaving our work emotions at work. Following from the previ-

ous challenge, it is important to point out that the emotions we experi-
ence during therapy sessions can last once our workday is over. A few
unproductive sessions, or a few sessions with clients who are severely
depressed or angry, can leave you in a rough mood. For most clinicians,
we must still face our “real” lives when we leave the office. Knowing
how to move past these moods and move on with our day is an impor-
tant part of our self-care as clinicians. We cover this issue in Chapters
6–9.

10. Working with clients who pose a threat to themselves or others.

Although we feel responsible for every client with whom we work, there
is no greater sense of responsibility than assessing risk and putting safety
plans in place for a client who is threatening to harm him- or herself
or others. Fears of the client actually carrying out his or her plans get
entwined with fear of protecting ourselves—by legal and ethical stan-
dards, did we make all the “right” decisions? In Chapter 7, we cover
these complex issues and we return to them in Chapter 10 within the
context of the supervisory relationship.

11. Knowing how to handle new technologies. Being a clinician

has become more complex since the advent of e-mail, texting, and social
media. In a typical week, a clinician might receive a text from a client,
answer a Facebook friend request from another, and grapple with how
to write about a clinical issue on a blog without divulging a client’s iden-
tity. New technologies present exciting opportunities for clinicians, but
also ethical challenges. In Chapter 6, we discuss the most up-to-date
guidelines on these challenges.