Cognitive-Behavior Therapy

In Cognitive–Behavior Therapy, Dr. Jacqueline B. Persons demonstrates this frequently used system of psychotherapy. Dr. Persons uses a case conceptualization as a guide for choosing which standard cognitive–behavioral interventions to apply, and she adopts an active approach to helping clients solve problems. In this session, Dr. Persons works with a 29-year-old woman who recently developed social phobia. Together they work to overcome her fears through the use of exposure exercises and strategies for making social interactions more manageable.

This video features a client portrayed by an actor on the basis of actual case material.

Precipitating Events

The client, Lisa, went to see a physician at her HMO, complaining of dizziness and fainting spells about 1 month ago. Lisa made an appointment to see Dr. Persons on the basis of a referral from her HMO, commenting on a growing sense of avoiding the more "social" events at work.

About 5 weeks ago, Lisa attended the annual San Francisco Bay Area awards banquet of the Public Relations Society of America. Lisa's boss, Andrea, is the president of the local chapter of the Society and was scheduled to serve as the "mistress of ceremonies" at the banquet. Andrea was to give a few opening remarks, introduce the speakers, announce the award winners, and make the closing remarks.

As Lisa entered the awards banquet, Andrea's administrative assistant ran up to her in the lobby of the hotel, completely flustered and obviously upset. Andrea had been in a minor car accident on the way to the banquet. Andrea had called from the hospital emergency room to tell Lisa that she would have to "fill in for her and just wing it as the mistress of ceremonies" for the evening. When Lisa heard this, she thought she "was going to be sick." "Not the part about Andrea's accident," she told Dr. Persons, "but that I would have to be on stage as the mistress of ceremonies and make it all happen without being prepared." Lisa reported having the thoughts, "I know I have to do this, but I just can't. Nobody has briefed me; I don't know what to do. I'm wearing the wrong clothes. Oh my God, what am I going to do?" She told Dr. Person's that she had the impulse to run out the door and escape the situation.

Lisa believed her job would be on the line if she didn't "pull this off," so she went to the ladies room, washed her face with cool water, retouched her makeup, and went back out to the banquet room. As Lisa told Dr. Persons, "I felt the room closing in as I walked toward the podium; I felt like I couldn't breathe, and I couldn't hear anything around me, but I kept thinking "stay cool." Lisa told Dr. Persons that she was "using every ounce of strength I had to walk up the steps of the stage and take the microphone in front of all of those people." The next thing Lisa remembers is "laying on a cot in some back room and having a group of people hovering over me, asking me if I was OK." Lisa had fainted on stage.

Lisa had always been good at her job, and she prides herself on how rapidly she has ascended in her firm. About 6 months ago, she received a monetary award and public praise before the board of directors for the most successful presentation of a new product. Andrea also nominated Lisa's campaign for the next award of the local chapter of the Public Relations Society of America. Lisa had worked for weeks on the release of this product: She obtained all of the background material on competing products; she had completely researched the market; she knew the target audience for the product; and she worked with the marketing staff to prepare a "sophisticated, subtle, and highly effective" promotional strategy. As Lisa put it, "I knew this product and its potential inside and out." And this was not the first time Lisa had orchestrated and executed the public relations for a highly visible and successful project. Lisa knew she was "damn good at my job!"

Preceding Sessions

Initial Session: Dr. Persons spent the initial session learning about Lisa's presenting problem and working with her to develop a way of understanding the problem and its treatment that made sense to both of them. Lisa was able to clearly state that she knew she had a psychological problem, not a medical problem. Dr. Persons told Lisa that her problem seemed to be a social phobia with panic components. She taught Lisa about the key role that exposure to anxiety-provoking situations would play in helping her overcome her fears of failure and humiliation and her anxiety in speaking situations.

Dr. Persons explained that therapy would be problem-solving oriented and that Lisa's problems were quite treatable if she was willing to work hard. As a homework assignment, Dr. Persons gave Lisa the book Dying of Embarrassment and asked her to read the first chapter or two before the next session.

Session 2: Dr. Persons began the session by asking Lisa about how her week went, how her homework went, and what her agenda for the session was. Lisa reported she had completed her homework assignment and stated in general terms that she found the book helpful. She had no concrete agenda for the session; Dr. Persons explained the concept of an agenda for sessions, suggesting that the format would allow Lisa to take an active role in the treatment. Dr. Persons raised an agenda item of her own, which was to collect a full personal history. Lisa agreed to that, and most of the session was spent on learning about Lisa's upbringing and family.

At the end of the session, Dr. Persons taught Lisa a bit about how cognitions contribute to her problem, and they developed some tentative ideas about core cognitions contributing to Lisa's public speaking anxiety ("I can't handle demanding interpersonal situations, especially speaking situations," and "I'll mishandle the situation and be humiliated and rejected"). Dr. Persons also explained the importance of relaxation training and gave Lisa a relaxation tape, asking her to listen to it several times during the coming week and to read some more of the book.

Session 3: Dr. Persons began the session by asking Lisa about how her week went, how her homework went, and what her agenda for the session was. Lisa reported that she had listened to the tape and done some more reading; she had no agenda for the session. Dr. Persons suggested that the session be spent developing a hierarchy of feared speaking situations, and Lisa agreed to that. As a homework assignment, she agreed to tackle one of the lower items on the hierarchy, rated as "20" on her scale of 100, which was to chat informally with colleagues before each regular business meeting during the week, speaking for at least 2 minutes each time.

Session 4: to be viewed.

This psychotherapy approach emphasizes the use of a case conceptualization to guide the therapist's use of standard cognitive–behavioral interventions. A case formulation includes a description of the patient's overt problems as well as hypotheses about some of the core beliefs (schema) that drive and maintain both the overt problems and the patient's mode of responding to and coping with the overt problems.

Other central features of Dr. Person's approach include the following:

Set a primary therapeutic goal of alleviating, solving, or eliminating overt clinical problems and symptoms. As part of the emphasis on solving overt problems, therapists work with patients to measure these problems, whenever possible, in concrete, objective terms so that the outcome of the therapy can be monitored and assessed.
Adopt an active, problem-solving approach to clinical problems.
Focus on the here-and-now rather than the past. An effective therapist obtains a good family and social history. This information is important for several reasons, particularly in developing a useful case conceptualization. The therapist may even spend some time working on past events, but this is generally done in the context of helping the patient solve here-and-now difficulties.
Build a collaborative patient–therapist relationship. The therapist does not solve the patient's problems; the therapist works with the patient to develop solutions that are helpful to the patient.
Maintain an empirical attitude, both with regard to the choice of the therapy modality itself (what does the outcome literature say about which treatment approach is most effective for the problems presented by this patient?) and with regard to the conceptualization and interventions used to treat each particular patient.
Rely on cognitive and learning theories that view clinical problems as understandable within a framework of reciprocally connected behaviors, cognition, and affects that are activated by environmental events, including, of course, interpersonal events.
Assign homework. The key role of homework in cognitive–behavioral therapy draws directly on the view of therapy as a learning experience in which the patient learns new perceptions and skills.

Jacqueline B. Persons, PhD , received her BA degree in anthropology from the University of Chicago in 1972 and her PhD in clinical psychology from the University of Pennsylvania in 1979. Dr. Persons is a clinician, researcher, teacher, and writer. She has a private practice in Oakland, California. She is associate clinical professor, in the Department of Psychiatry, University of California, San Francisco, where she provides clinical and research training to psychologists and psychiatric residents, and conducts research on cognitive processes underlying depression and anxiety and on case conceptualization in cognitive–behavioral therapy. She is the author of Cognitive Therapy in Practice: A Case Formulation Approach, published by Norton in 1989 and translated into Japanese in 1993.

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Markway, B. G., Carmin, C. N., Pollard, C. A., & Flynn, T. (1992). Dying of embarrassment: Help for social anxiety and phobia. Oakland, CA: New Harbinger.
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APA Videos

Cognitive–Behavior Therapy for Depression Video Series
Jacqueline B. Persons, Joan Davidson, and Michael A. Tompkins
Cognitive–Behavioral Therapy for Clients With Anxiety and Panic
Bunmi O. Olatunji
Cognitive–Behavioral Therapy for Clients With Multiple Problems
Gayle Y. Iwamasa
Cognitive–Behavioral Therapy for Specific Phobias
Michael A. Tompkins
Cognitive–Behavioral Therapy With Donald Meichenbaum
Donald Meichenbaum
Cognitive Therapy
Judith S. Beck
Cognitive Therapy for Borderline Personality Disorder
Mary Anne Layden
Cognitive Therapy for Panic Disorder
David M. Clark
Mindfulness-Based Cognitive Therapy for Depression
Zindel V. Segal
Rational Emotive Behavior Therapy Over Time
Ann Vernon
Schema Therapy
Jeffrey E. Young
Shyness and Social Phobia
Anne Marie Albano

APA Books

Cognitive–Behavioral Group Therapy for Specific Problems and Populations
Edited by John R. White and Arthur S. Freeman
Culturally Responsive Cognitive–Behavioral Therapy: Assessment, Practice, and Supervision
Edited by Pamela A. Hays and Gayle Y. Iwamasa
Essential Components of Cognitive–Behavior Therapy for Depression
Jacqueline B. Persons, Joan Davidson, and Michael A. Tompkins
Personality-Guided Cognitive–Behavioral Therapy
Paul R. Rasmussen
Shy Children, Phobic Adults: Nature and Treatment of Social Phobia, Second Edition
Deborah C. Beidel and Samuel M. Turner
Understanding and Treating Anxiety Disorders: An Integrative Approach to Healing the Wounded Self
Barry E. Wolfe
Virtual Reality Therapy for Anxiety Disorders: Advances in Evaluation and Treatment
Brenda K. Wiederhold and Mark D. Wiederhold

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Cognitive–Behavior Therapy

Precipitating Events

Preceding Sessions

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