Treatments Exam 2 PDF

EXAM 2 SYSTEMS-BASED APPROACHES, 1ST & 2ND WAVE CBT GROUP THERAPY HISTORY & CONTEXT 1905: Joseph Hersey Pratt creates first organized therapeutic group - recently-discharged patients with tuberculosis 1936: Paul Schilder & Louis Wender use group format - incarcerated individuals &...

EXAM 2 SYSTEMS-BASED APPROACHES, 1ST & 2ND WAVE CBT GROUP THERAPY HISTORY & CONTEXT 1905: Joseph Hersey Pratt creates first organized therapeutic group - recently-discharged patients with tuberculosis 1936: Paul Schilder & Louis Wender use group format - incarcerated individuals & people recently discharged from psychiatric hospitals World War II: utilized for those with emotional disturbances from the conflicts Increasingly utilized today (⬆ need, ⬆ cost) THERE ARE DIFFERENT TYPES OF GROUP THERAPY One key difference: support vs. (psycho)therapy SUPPORT GROUP ○ Main goal: Cope with a common struggle ○ Open (no commitment or pre-screening) ○ Peer-led, or leader as facilitator (may not be a professional) ○ No capacity limit ○ Extra-group contact encouraged THERAPY GROUP ○ Main goal: Change (often interpersonal) ○ Closed (commitment, prescreening) ○ Group leader is a professional, therapist, trained in this modality ○ Usually 6-10 members ○ Extra-group contact discouraged SIMILARITIES ○ Receipt of empathy, support, & understanding; building of hope; learning; expectation of confidentiality GOALS OF THERAPY GROUPS PROCESS GOALS ○ Facilitate patients’ growth, comfort, & function within the group Giving and receiving feedback in group can help everyone increase their awareness of maladaptive patterns of behavior, change points of view, and encourage more constructive and effective reactions. OUTCOME GOALS ○ Outside the group Behavior corrections Increased interpersonal skills Use preventative measures & new coping skills Increase functioning GROUP THERAPEUTIC FACTORS (YALOM) Universality ○ Not alone in their struggles Altruism ○ Group members experience the positive effects of helping others, which can boost self-esteem and foster a sense of purpose. Instillation of hope ○ Seeing others improve or recover in the group instills hope that change and healing are possible. Imparting information ○ Share information Corrective recapitulation of primary family experience ○ Group therapy offers a safe environment where members can explore and address unresolved family dynamics and behaviors. Development of socialization techniques ○ The group setting provides opportunities to develop, practice, and refine social skills in a supportive environment. Imitation of behavior ○ Members can learn by observing and modeling the behaviors of others in the group, including the therapist. Cohesiveness ○ Strong sense of belonging and acceptance within the group, which fosters trust and encourages openness. Existential factors ○ Members confront basic life issues, such as mortality and responsibility, helping them find meaning and acceptance. Catharsis ○ Group members can express emotions in a safe environment, which can lead to emotional relief and insight. Interpersonal learning Self-understanding A NOTE FROM YOUR READING As noted, group therapy can take a lot of different forms What does your reading (Day, 2014) suggest is the key, unifying theory behind all these different forms? In other words, what are clients getting? What makes group therapy powerful, regardless of the specific form it takes? SELECTING PATIENTS Use the therapeutic alliance ✅ ✅ ❌ Consider a formal assessment (e.g., NEO-FFI) extraversion, conscientiousness, neuroticism  Consider the patient’s primary concerns & challenges Typical exclusions: acute distress, active suicidality, those who cannot take part due to logistical, cognitive, or interpersonal factors Include patients at different stages of treatment Include patients with identical or similar conditions & concerns STAGES OF GROUP DEVELOPMENT Forming ○ Little argument ○ Unclear purpose ○ Guidance and direction →Storming ○ Conflict ○ Increased clarity and purpose ○ Power struggles coaching →Norming ○ Agreement and consensus ○ Clear roles and responsibility ○ Facilitation →Performing ○ Clear visions and purpose ○ Focus on goal achievement ○ Delegation →Adjourning ○ Task completion ○ Good feelings about achievements ○ Recognition GROUP THERAPY: SPECIAL CONSIDERATIONS & CHALLENGES Confidentiality Training Conflict Members who ramble Members who are disengaged ○ Can negatively impact others Patients’ individual limits ○ Know when to push and when to back off Simultaneous individual therapy or pharmacotherapy GROUPS: EMPIRICAL SUPPORT Effective for a range of psychiatric & behavioral disorders (Rosendahl et al.., 2021)  ○ As effective as individual therapy for most conditions (Rosendahl et al.., 2021) ○ More effective for some clients (e.g., those of marginalized identities: support & solidarity!) ○ Trauma & depression in refugee adults & children (Rafieifar et al., 2022) ○ LGBTQ+ patients coping with stress & bias (Craig et al., 2021) Works through Yalom’s therapeutic factors (Malhotra & Baker, 2023) It is cost-efficient It effectively provides unique & powerful training experiences FAMILY SYSTEMS THERAPY HISTORY, CONTEXT, & ASSUMPTIONS Psychiatrist Murray Bowen (1950s) ○ Convergence of other lines of work (anthropology, history, social work) Yes, we are individuals, but we are born into families; individual ←→ family ○ We are best understood through assessing interactions between & among family members ○ The “problem” is a symptom of how the family system functions ○ An individual’s problematic behavior grows out of the interactional unit of the family as well as the larger community and societal systems Problematic behavior may: ○ Serve a function or purpose for the family ○ Be unintentionally maintained by family processes ○ Come from a family’s inability to operate productively ○ Be a symptom of dysfunction handed down across generations Family therapy is short-term, solution-focused, and action-oriented, family therapy tends to deal with present interactions. ○ The main focus of family therapy is on here-and-now interactions in the family system. FAMILY THERAPY IN ACTION Family Counseling Role-Play - Relational Problems with Couple and Daughter FEMINIST THERAPY WHAT DO YOU THINK WHEN YOU HEAR “FEMINIST”? Most women believe perceptions about feminists are largely negative Many perceptions of feminists (especially among non-feminists) ARE negative (e.g., supports female superiority, dislikes men, discriminates based on gender, has negative personal characteristics) or unfounded (e.g., lesbian or “butch”) The label matters ○ Women who label themselves “feminist” are perceived by others as more competent but less warm than those who express gender-equal beliefs but don’t label themselves “feminist” FEMINISM Belief in and advocacy for the political, economic, and social equality of all sexes Holds the view that most societies prioritize the male point of view & male wellbeing & that women & other sexes are treated unjustly as a result FEMINIST THERAPY: HISTORY & CONTEXT Developed in the 1960s, alongside the second wave feminist movement ○ Initial goals were to serve as a safe space for corrective action against the sexist treatment approaches of the era (e.g., psychoanalysis; Rawlings & Carter, 1977; Rosewater & Walker, 1985) 1980s: Focus largely shifted to specific problems like body image, abusive relationships, eating disorders, incest, sexual abuse Current: Liberatory, technically integrative approach that uses the analysis of gender, social location, & power as strategies for comprehending human difficulties THEMES In-depth interrogation of most standpoints outside the dominant patriarchal mainstream ○ Patriarchy is a universal hierarchy social system which attributes traditional male as culturally valued and elevated. Associated with female are denigrated Human beings are responsive to the problems of their lives, capable of solving those problems, and desirous of change; the therapeutic relationship is egalitarian ○ Depathologize problems come to therapy with ○ Avoid diagnostic labels ○ Strength based approach ○ Relationship with client and therapist -close, first name basis, explicit decisions to see them in warmer setting, little bit more self disclosure Traditionally silenced voices & perspectives may be the greatest sources of wisdom ○ Focus on expertise of the oppressed Actively aims for having a political impact (because “the personal is political”) Viewing problems in a sociopolitical and cultural context rather than on an individual level Recognizing that clients are experts on their own lives Striving to create a therapeutic relationship that is egalitarian through the process of self-disclosure and informed consent FEMINIST THERAPY FOR MEN QUESTION: How or why can feminist therapy be useful with male clients? ○ Being socialized in a patriarchal society poses problems for men, too!  Toxic masculinity is harmful for everyone, including men Deaths of despair are on the rise, particularly among non-Hispanic White men Deaths of depairs- drug overdose, suicide, due to hopelessness, feeling useless or out of place in society Feminist therapy empowers men to explore & assert their full selves (i.e., vulnerability, sadness, worry, nurturing, self-care, asking for help) Encourages men to question where they got messages about strength, aggression, power, achievement, control, & sex & to examine whether these messages serve them well MULTICULTURAL THERAPY SOME IMPORTANT NOTES With a few exceptions, multicultural therapy is not a single approach to counseling Attention to culture is critical in any & all psychotherapeutic interventions If aspects of your identity match the dominant culture, those aspects may be nearly invisible to you (& it may be easier to ignore the role of culture & identity in your clients!) No group is a monolith Conceptually, multicultural therapy is a systems-based approach HISTORY & CONTEXT Interdisciplinary origins ○ Psychology PLUS anthropology, ethnopsychology, folk healing Recognition in the 1940s – 1960s that culture has a huge impact on mental health Formalization of attention to multiculturalism (e.g., APA Division 35 Society for the Psychology of Women in 1973, APA’s Office of Ethnic Minority Affairs in 1979, APA Division 44 Society for the Psychology of Sexual Orientation and Gender Diversity in 1985) KEY IDEAS Multicultural therapies are therapies that infuse cultural competence into clinical practice ○ A set of congruent behaviors, attitudes, & policies that reflect an understanding of how cultural & socio political influences shape individuals’ worldviews & related health behaviors Cross’s Cultural Competence Framework  ○ Cultural Destructiveness: Attitudes, policies, and practices that are openly hostile to or destructive toward other cultures. ○ Cultural Incapacity: Organizations lack the capacity or intent to support diverse cultures. ○ Cultural Blindness: Ignore or deny the influence of culture and assume that approaches that work for the dominant culture are equally effective for all. ○ Cultural Pre-Competence: Recognize the importance of cultural competence and have begun to make efforts to improve. ○ Cultural Competence: Actively accept, respect, and incorporate cultural differences into their practices. KEY IDEAS MINORITY IDENTITY DEVELOPMENT STAGES Conformity ○ May have a preference for the values, beliefs, and customs of the dominant culture, often downplaying or distancing themselves from their own cultural group. Dissonance ○ Ambivalence between their own cultural identity and the values of the dominant culture Resistance immersion  ○ Reject the values of the dominant culture and immerse themselves fully in their own cultural identity Introspection ○ Start to critically examine both their own cultural identity and their stance toward the dominant culture. Synergistic ○ Individuals achieve a secure, self-defined identity that integrates aspects of their minority culture with elements of the dominant culture. WHITE AMERICAN IDENTITY DEVELOPMENT STAGES Contact ○ Unaware of racial differences or the significance of race in society Disintegration ○ Begin to encounter information or experiences that challenge their previous beliefs about race Reintegration ○ To cope with the discomfort, individuals may revert to a belief in the superiority of the dominant (White) group, justifying privilege and systemic racism Pseudo Independence ○ Recognize the existence of systemic racism and the privileges that come with Whiteness, but they may still view these issues intellectually rather than fully engaging in personal change. Autonomy ○ Achieve a self-aware, positive White identity that acknowledges privilege and actively works toward racial justice. LGBTQ+ MINORITY IDENTITY DEVELOPMENT STAGES Confusion Comparison Tolerance Acceptance Pride Synthesis A key dimension of culture is the collectivistic (“we”) vs. individualistic (“me”) distinction Collectivism ○ Fosters interdependence and group success ○ Promote adherence to norms and respect for authority and group consensus ○ Stable hierarchical roles ○ Shared property and ownership Pakistan, Colombia, Indonesia, Venezuela  Individualism ○ Foster independence and achievement ○ Promote self expression and personal choice ○ Associated with egalitarian relationships ○ Private property and ownership USA, UK, Australia, Canada, Netherlands STRENGTHS-BASED & EMPOWERMENT APPROACHES Multicultural psychotherapists often focus on empowering clients Multicultural psychotherapists often actively engage in work to rectify social injustices Integration of community & indigenous resources for treatment SPECIFIC APPROACHES Treatment designed to address oppression (e.g., re-evaluation counseling; Roby, 1998) Cultural adaptations of (mainstream) interventions (e.g., CBT; Muñoz & Mendelson, 2005) Holistic approaches that center spirituality Ethnopsychopharmacology HOW TO WORK WITH CLIENTS? RESPECT model ○ R=Respect (show) ○ E=explanatory model (ask) ○ S=social context (ask) ○ P=power (share) ○ E=empathy (show) ○ C=concerns (ask) ○ T=trust (build, don’t assume) PSYCHOLOGY IS SLOWLY DIVERSIFYING Workforce and population demographics changing THE VALUE OF A DIVERSE PSYCHOLOGY WORKFORCE More expertise Better organizational/institutional decisions & better research  Marginalized clients are more likely to seek out treatment & stay in treatment with providers who share key parts of their identities ○ Impact of medical apartheid & other key historical & current events BEHAVIOR THERAPY BEHAVIOR THERAPY: BASIC CONCEPTS Focus is on changing behavior Change how they respond to environment Rooted in empiricism ○ Focus on getting a baseline assessment of how frequently and context problem behaviors occur ○ Data driven approach Behaviors are assumed to have a function Emphasis is on maintaining behaviors (not initial triggers) Supported by research Active Transparent HISTORY & CONTEXT: ROOTS Roots stem from experimental research on learning processes (early to mid-1900s) ○ Ivan Pavlov & classical conditioning Learning to associate an unconditioned stimulus that already brings about a particular response (i.e., a reflex) with a new (conditioned) stimulus, so that the new stimulus brings about the same response. Dogs could be conditioned to salivate at the sound of a bell if that sound was repeatedly presented at the same time that they were given food. ○ Rise of behaviorism in America ○ Thorndike & Skinner & operant conditioning Explain how animals learn behavior through reinforcement and punishment which he coined the term operant conditioning. A reinforcer is anything that increases the chance of a particular behavior and a punisher is anything that decreases the chance of a particular behavior. Rat to press bar and get shocked or get food Also influenced by Boulder Conference on Graduate Education in Clinical Psychology HISTORY & CONTEXT: BEGINNINGS Joseph Wolpe (physician in South Africa) developed systematic desensitization (1950s)  Hans Eysenck (United Kingdom) began systematically studying behavioral treatments & training students in these approaches, founded journals & professional organizations (1950s & 1960s) Nathan Azrin (United States, student of B.F. Skinner) developed therapies based on operant conditioning (1950s & 1960s) – applied behavior analysis, token economy, & more HISTORY & CONTEXT: CURRENT STATUS Albert Ellis & Aaron Beck introduced cognitive techniques (1950s & 1960s) Albert Bandura & social learning (1960s) ○ Bobo doll study ○ If you show kids an adult model playing aggressive with a doll, the kids will model that violence “Third-wave,” acceptance-based behavioral approaches (MBCT, DBT, ACT; 2000s & beyond) CLASSICAL CONDITIONING One stimulus comes to signal/predict the occurrence of a second stimulus ○ Initially a neutral stimulus (like a bell) becomes associated with an involuntary response (like salivation) after being repeatedly paired with a stimulus that naturally triggers that response (like food).  What would happen to the CR if… ○ The boy kept going to school without experiencing bullying? ○ The person kept going to that part of town & not using drugs? ○ Dr. Wenze started going to Rios? EXTINCTION! ○ But spontaneous recovery can also occur! OPERANT CONDITIONING The frequency, form, or strength of a behavior is influenced by its consequences ○ Learning through consequences-Behaviors are strengthened if followed by reinforcement (positive or negative) and weakened if followed by punishment. Extinction occurs when a behavior is no longer followed by a positive consequence Discrimination learning occurs when a response is reinforced or punished in one situation but not another Generalization occurs when a learned behavior is displayed in situations other than where it was acquired OTHER TYPES OF LEARNING THAT ARE HARNESSED IN BEHAVIOR THERAPY VICARIOUS LEARNING ○ AKA observational learning ○ Learning about environmental contingencies by watching others’ behaviors INSTRUCTIONAL LEARNING ○ Learning about contingencies & consequences from hearing or reading about them BEHAVIOR THERAPY: FORMAT & STRUCTURE Usually individual but may be conducted in groups or families Usually delivered by therapists but sometimes by others Session length & location may vary Usually time-limited; occasionally can be just one session Sessions may involve activities not often thought of as “therapy”; care must be taken to explain to the client why this is BEHAVIOR THERAPY: TECHNIQUES Therapist ○ Active and directive and to function as consultants and problem solvers ○ Conduct follow up assessments Always begins with assessment; often multi-method ○ Often includes functional analysis ○ Behavioral interviews ○ Behavioral observation (naturalistic or analog); beware of reactivity! ○ Monitoring forms & diaries ○ Self-report scales ○ Psychophysiological assessment Treatment planning ○ Set goals that are realistic, achievable, & specific, w/ a set timeframe ○ Decide on techniques based on functional analysis or diagnostic profile Functional analysis Depression is a function of reduced activity? Use behavioral activation! Depression is a result of social skills deficits? Use social skills training! Diagnostic profile Client is presenting with a simple phobia? Use exposure therapy! Exposure therapy ○ Types Real life: being exposed to fear in real life Imagined: vividly imagining a fear  Virtual reality Interoceptive: bring sensations into play in an effort to disconfirm the idea that physical sensations will lead to harmful events ○ Works via extinction ○ Works best when It is predictable & controllable Practice is frequent Sessions are longer Therapist models the behavior The client doesn’t escape the situation until distress subsides! EXPOSURE & RESPONSE PREVENTION (OCD) Applied behavior analysis (based on operant conditioning) ○ REINFORCEMENT-BASED PROCEDURES Differential reinforcement Token economy A behavior modification system where individuals earn tokens for desired behaviors, which can later be exchanged for rewards. Contingency management Change environment so behaviors not enforced Positive reinforcement involves the addition of something of value to the individual (such as praise, attention, money, or food) as a consequence of certain behavior Negative reinforcement involves the escape from or the avoidance of aversive (unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to avoid the unpleasant condition. ○ PUNISHMENT-BASED STRATEGIES Aversive conditioning Antabuse (alcohol) Relaxation training ○ Breathing retraining (diaphragmatic breathing) ○ Guided mental imagery ○ Progressive relaxation Stimulus-control procedures ○ Aim to correct problems related to stimulus control, especially problems in which a behavior is under the control of an inappropriate stimulus ○ Regain stimulus control by: --Use bed only for sleep (& maybe sex?) --Leave the bed(room) when you can’t sleep  --Avoid napping --Get up at the same time every morning Social skills training ○ Uses modeling, corrective feedback, behavioral rehearsal to help clients improve communication & social functioning Problem-solving training ○ Define the problem→ Identify possible solutions→ Evaluate the solutions→ Choose the best solution(s) → Implementation BEHAVIOR THERAPY: EVIDENCE FOR EFFICACY 75% of the 80 treatments that the APA’s Society of Clinical Psychology currently identifies as having strong or modest empirical support are behavioral or cognitive behavioral ○ Strong: Well-controlled, manualized studies by at least 2 different labs showing the treatment outperformed placebo, is superior to another form of treatment, or is equivalent to other established treatments ○ Modest: Fewer studies required, & no need for different labs Behavior therapy as an idiographic approach ○ Which treatment? ○ Delivered by whom? ○ For which patient? ○ With which problem? ○ Under which circumstances? WHICH BEHAVIORAL STRATEGIES FOR WHICH DISORDERS? Panic disorder: Combo of psychoeducation, cognitive re-evaluation, & exposure to feared situations & sensations OCD: Exposure & response prevention Depression: Behavioral activation (as well as more cognitively-based strategies) Substance use disorders: Contingency management Schizophrenia: Social skills training, token economy, problem-solving training BEHAVIOR THERAPY: FUTURE DIRECTIONS Improving effectiveness Understanding the mechanisms behind treatment Enhancing dissemination The role of cognitive enhancers like D-cycloserine Adapting behavior therapy for diverse populations COGNITIVE THERAPY COGNITIVE THERAPY: BASIC CONCEPTS Cognitive schemas: people’s core perceptions of themselves & others, goals, expectations, memories, fantasies, previous learning  Core beliefs & cognitive vulnerabilities Collaborative empiricism ○ Guide if ways of thinking serving you well Socratic dialogue ○ Common questioning when someone summarizes what you said and offer another question not a yes no or informational but get you thinking more critically ○ An open discussion between therapist and client with no pre-defined outcome other than exploration. Cognitive distortions ○ Irrational thought patterns Goal: Correct errors & biases in information processing & modify the core beliefs that promote faulty conclusions HISTORY: PRECURSORS Phenomenological approach: the individual’s view of self & the personal world are central to behavior Depth psychology (e.g., Freud) ○ Levels of conscious of what we are aware of ○ Unconscious is info processing we can get to Cognitive psychology & cognitive theories of emotion ○ Stimulus → appraisal → emotion → response HISTORY: BEGINNINGS Aaron Beck (1960s): Clinical observations led him to reject Freud’s teachings & his analytic training ○ CT emphasizes education and prevention but uses specific methods tailored to particular issues. The specificity of CT allows therapists to link assessment, conceptualization, and treatment strategies. Albert Ellis (1960s): People can consciously adopt reason & a client’s underlying assumptions are key targets of intervention HISTORY: CURRENT STATUS Tremendous body of research supporting CBT’s efficacy ○ Primarily depression & anxiety ○ Also panic disorder, social phobia, substance abuse, eating disorders, marital problems, OCD, PTSD, schizophrenia Growing research on interactions between genetic, neurochemical, & cognitive factors Suicide & hopelessness Psychotherapy integration (keeps some pieces of CT and discards others) Assessment scales Training COGNITIVE THERAPY: KEY CONCEPTS Cognitive vulnerability & cognitive schemas Types of schemas ○ Person schemas Organize knowledge about other people’s traits, behaviors, and personalities. Appearance Behavior Personality Preference ○ Social schema Guide expectations for social behaviors and norms in various settings. Be respectful Pay for movie ticket Don’t eat garlic ○ Self schema Relate to one’s beliefs about oneself, shaping self-perception and identity. Future doctor Hates broccoli Smart ○ Event schemas Provide expectations for the sequence of actions in specific contexts. Professionalism Portfolio Business suit Sociotropy-autonomy & relationship to depression ○ Interpersonal, occupation, change in environment Idiographic learning experiences & the importance of history-taking Multi-causal model of psychological distress Cognitive distortions-systematic errors in reasoning that lead you down to psychological distress ○ Catastrophizing Assume the worst will happen and you won’t be able to handle it ○ Selective abstraction Draw conclusions on basis of just one of many elements of a situation ○ Minimisation  Downplay importance of a positive thought or emotion or event ○ Fortune telling Assuming you know exactly how something will play out ○ Personalization Attributing personal responsibility for events which are not under a person's control ○ Arbitrary inference Draw conclusions when there is little or no evidence ○ Dichotomous thinking Categorize experiences into one of two extremes ○ Magnification Blowing out of proportion ○ Overgeneralization Make sweeping conclusions based on single event Systematic bias in psychological disorders Cognitive profile of specific diagnoses PSYCHOTHERAPY: THEORY Goals: Remove systematic biases in thinking & modify core beliefs that predispose to distress Aim is to see one’s world more realistically Cognition ←→ behavior ←→ emotion Cognitive change occurs at several levels  The therapist: ○ Actively collaborates with the client ○ Functions as a guide ○ Is warm and flexible ○ Elicits feedback from the client ○ Encourages Socratic dialogue Two major principles ○ Depression is a medical illness, rather than the patient’s fault or personal defect; moreover, it is a treatable condition. ○ Mood and life situation are related. PSYCHOTHERAPY: TECHNIQUES Real-time recording (& disputing) of automatic thoughts ○ A=activating event ○ B= belief/thought ○ C=consequence feelings/behavior ○ D=dispute with evidence Generating behavioral experiments ○ “I can’t carry on a conversation.” ○ “It’s hopeless; I’m going to fail this exam.” De-catastrophizing Reattribution ○ He didn't say hi to me Maybe he didn’t recognize or see me Redefining ○ Way to mobilize a client who thinks a problem is beyond their personal control At this party beyond my control to impact if people talk to me but really if you act different they will change their response  Decentering ○ Anxious clients who have social anxiety challenges Use of imagery to “rewrite the script” ○ Change imagery to empower yourself Homework ○ Self monitoring Hypothesis testing Exposure therapy Behavioral rehearsal & role-playing ○ Practice something during session Diversion techniques ○ Finding something else a client likes to do ○ Rumination ○ Do a different activity Activity scheduling ○ Main part of behavioral activation ○ Pick from a list of different activities of what are pleasurable to them and rate them on how pleasure and easy they are to achieve and if they give a sense of mastery Graded task assignment PSYCHOTHERAPY: EVIDENCE FOR EFFICACY Works best where problems are clearly-defined & cognitive distortions are apparent ○ I avoid others from fear of being judged Ideal for patients with adequate reality testing, good concentration & memory Not recommended as stand-alone treatment for bipolar depression or psychotic states Strong support, based on many RCTs & meta-analyses ○ **Depression & anxiety disorders; marital distress, anger, childhood somatic disorders, chronic pain; schizophrenia & bulimia nervosa ○ Outperforms medication for preventing relapse (depression & anxiety) General support for cross-cultural efficacy, but more studies are needed in LMICs Adapts particularly well to technology-delivered & technology-assisted formats