Collaboration in cognitive behavioral therapy

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Collaboration in Cognitive-Behavioral Therapy Frank M. Dattilio1 and Michelle A. Hanna2 1 2

Harvard Medical School Moravian College

Collaborative empiricism, which involves a systemic process of therapist and patient working together to establish common goals in treatment, has been found to be one of the primary change agents in cognitive-behavioral therapy (CBT). This article focuses on the development of a therapeutic relationship and implementation of collaborative empiricism along with the elements that lead to success in treatment. This method is used to uncover patients’ automatic thoughts and underlying beliefs in treating an array of emotional and behavioral disorders. The role of the therapist is discussed in developing, promoting, and maintaining therapeutic collaboration and what is constituted by the empirical process. A case study illustrates the use of collaborative empiricism with a patient suffering from panic disorder. The article concludes with a series of clinical practices that will enhance collaborative empiricism and C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: collaboration in CBT, and thereby treatment outcomes.  In Session 68:146–158, 2012. Keywords: Collaborative empiricism; collaboration; cognitive-behavioral therapy; case study; panic disorder; panic sequence; therapeutic relationship

When Aaron T. Beck pioneered his cognitive approach to treating depression in the 1960s, the primary modality of psychotherapy was predominantly psychoanalytic. Although clientcentered therapy and behaviorism were coming into vogue, most psychotherapy systems lacked the patient-practitioner collaboration that debuted in Beck’s (1976) cognitive therapy. One of the hallmarks of the cognitive approach became the use of collaborative empiricism. Collaborative empiricism entails a cooperative effort between therapist and patient in devising a treatment plan and incorporates cohesiveness between the patient and the therapist as they explore together through discovery and experimentation those aspects of the patient that contribute to dysfunction. In addition to individual psychotherapy, this method has also been implemented with couple, family, and group therapy as well (Dattilio, 2010). A number of specific techniques employed within this process allow the therapist to help patients to process their cognitions, such as identifying automatic thoughts and underlying schemas, address regulation of their emotion, and monitor their behavior. This goal is accomplished by jointly generating activities and homework assignments to keep the engagement fluid between therapy sessions. In this article, we focus on the development of the therapeutic relationship and provide an example of how collaborative empiricism is implemented, along with highlighting the elements that lead to successful collaboration.

Collaborative Empiricism Working together in a collaborative manner benefits both the patient and the therapist in developing a solid therapeutic relationship whereby the therapist can understand the patient, and how the patient presents his or her specific thoughts, emotion, and behavior. Collaboration creates exploration and discovery of negative thoughts, which subsequently creates an increase in the patients’ motivation toward change (Beck, Rush, Shaw, & Emery, 1979). The empirical portion of collaborative empiricism is crucial to the contribution to cognitive change and guides case conceptualization. Selective aspects of patient content is taken and analyzed and subsequently reprocessed together by therapist and patient. Please address correspondence to: Frank M. Dattilio, Department of Psychiatry, Harvard Medical School, MMHC – Shattuck, 180 Morton St., Jamaica Plain, MA 02130. E-mail: [email protected]  C 2012 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(2), 146–158 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21831

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The cognitive model implies that people’s perceptions of situations influence how they react (Beck, 2005). If a patient’s automatic thoughts are negative and their core beliefs about themselves are also negative, this can cause many issues that therapists need to be aware of throughout the duration of therapy. A cognitive-behavioral conceptualization begins with relevant childhood data, which leads to core beliefs, conditional rules/assumptions, which leads to coping strategies. When put in a situation, an automatic thought occurs, the meaning of the thought comes from core beliefs, and then an emotion arises and a behavior is displayed (Beck, 2005). A patient’s core beliefs are very important to understand because they may always lead back to the how the person thinks and how the therapist can proceed in altering these negative thoughts by using collaborative empiricism. A specific interest is placed on the patients’ dysfunctional thoughts and beliefs about life experiences and future endeavors, which are woven into hypotheses that are systematically tested (Beck, Rush, Shaw, & Emery, 1979). For example, consider a patient who presents with the automatic thought, “Everything that I say and do is being judged negatively by others.” In this scenario, the patient has developed the belief system, “I can’t say anything without drawing a negative comment from others; therefore, I’m not viewed in a very credible light.” This belief system may have evolved from a number of unfortunate past experiences where the patient was justly or unjustly criticized and has now become subjected to his own distortions of “generalization” and “magnification” as a result of his poor self-image and frustrations with his situation in general. These distortions can become quite ingrained at times and appear very real to patients. To design an effective experiment to test this hypothesis, the therapist and patient might explore ways in which one conveys that he or she is being negatively judged by others (e.g., facial expressions, other nonverbal behaviors). The patient then participates in conversations with the therapist to test if such expressions or words of disdain are exchanged by others. If this is the case, the patient can subsequently relay this to the therapist. Repeating this experiment can modify the patients’ automatic thoughts and create a reasonable alternative to the negative or distorted thought, “I’m not viewed in a very credible light” (Segal & Shaw, 1996). In essence, the therapist and patient are collaboratively gathering evidence that may challenge such steadfast beliefs to help the patient consider alternative beliefs. Beck (2005) outlined key principles in cognitive therapy that help the therapist maintain a positive therapeutic relationship. Collaborative empiricism allows the therapist and patient to explore misconceptions together and to test the validity of the patients’ cognitions. For example, in the aforementioned case scenario, the therapist may encourage the patient to challenge that statement, “I can’t say anything without drawing a negative comment from others.” As a homework assignment, the therapist and patient may elect for the patient to actually keep written track of how many negative statements or questionable facial expressions others make toward him throughout the week and rate each one as either “positive,” “negative,” or “neutral.” Upon reviewing these data in the subsequent session, the therapist and patient can weigh the evidence to determine how much it supports the patient’s statement, “I can’t say anything without drawing negative comments from others.” In this respect, the validity of the patient’s statements is assessed and gives way to reevaluating whether they are accurate or based on distorted thinking and/or perceptions. What makes this intervention particularly effective is that it is done together by the patient and the therapist in a collaborative fashion. A therapist must actively encourage and promote collaboration because some patients will desire a therapist who only leads or guides them. Other principles involved in the collaboration are the therapist’s empathy and understanding, alleviating distress by the end of the session, and obtaining feedback from the patient before closure of the session (Beck, 2005). All of these elements enhance the therapeutic relationship and contribute to successful collaboration. Guided discovery is a term that explains Beck’s method in dealing with future unwanted thoughts. This involves learning through discovery and through the patients’ mistakes. In this method, Socratic questioning allows the patient to respond to the therapist’s questions and to help him or her remain on track with the relevant information pertaining to their problem. The four stages of guided discovery are as follows: asking informational questions (Socratic questions), listening for and identifying emotions, summarizing the session or having the client discuss the session, and asking a closing analytical question. Beck’s hypothesis testing includes this Socratic questioning as a specific method in CBT and has been discussed in detail elsewhere

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(Overholser, 1995). Collaborative empiricism is crucial because the client develops a repertoire of cognitive and behavioral techniques, as well as uses the therapist/client relationship to experiment and confront underlying beliefs, and events that pertain to the cause of distress in their future functioning (Scott & Freeman, 2010). To promote change, oftentimes collaborative empiricism entails Socratic questioning and homework assignments. These assignments create a collaborative bond in which therapists can help patients focus on their concerns, discover evidence for their beliefs, identify criteria for their evaluations, and examine the consequences of their actions (Segal & Shaw, 1996). When the Socratic method is used effectively, a patient reduces thoughts that they perceive as objective facts and begins to think critically. Homework assignments help the therapist to understand the patient’s thoughts when they are not in session and may serve to galvanize the treatment gains achieved during the session (Dattilio, 2002). These homework assignments can also involve experiments used to test the validity of patients’ thoughts, beliefs, or assumptions. Recognizing and understanding the belief system of the patient, behavioral strategies, and patterns in the therapeutic relationship can help the therapists understand and discover the patient’s expectations of therapy (Dattilio, Freeman, & Blue, 1998). The rapport between the therapist and the patient is something that the therapist should initiate and generate in the best interest of ultimately creating beneficial collaboration (Beck, et al., 1979). Therapists should convey warmth, express genuine empathy, and display a general acceptance of the patient. Also, the process of genuinely acknowledging the struggle that the patient is experiencing is often a powerful component of treatment. It serves as a measure of affirmation for the patient. All of these relational behaviors serve to facilitate a therapeutic relationship. The therapeutic connection occurs on both an intellectual and an emotional level. When this rapport develops, the patient perceives the therapist to be understanding of his or her feelings, to be sympathetic, empathetic, and accepted, and to have effective communication (Beck et al., 1979). Rapport can be established by simple courtesy, eye contact, the phrasing of questions, appearance, and mannerisms. There are many benefits to collaborative empiricism in CBT. It can help to balance the posture of the therapist with the nondirective support (Tee & Kazantzis, 2011). Collaborative empiricism minimizes assumptions that the therapist may make about the patient, allows for the therapist to better understand the beliefs of the patient, and strengthens the therapeutic relationship. Research studies have demonstrated collaborative therapy and the therapeutic relationship to be a key component of CBT’s effectiveness (e.g., Cross, 2007; Overholser & Silverman, 1998; Merali & Lynch, 1997). The process of collaborative empiricism allows for a broader range of information for the development of a case conceptualization. Testing it empirically allows for inaccurate information to be assessed and filtered out of the mix (Tee & Kazantzis, 2011). The research literature indirectly suggests that collaborative empiricism benefits those with serious disorders (Butler, Chapman, Foreman, & Beck, 2006). For example, if a patient has panic disorder, the therapist may use the technique of the downward arrow (Beck et al., 1979) or a variation of such (i.e., Dattilio & Kendall, 2007) to elicit the patient’s underlying fears about his or her symptoms. This can be implemented by asking questions that provoke a sense of anxiety in the patient. The therapist may ask the patient how they feel and what their thought process is when they become anxious. The therapist may also inquire as to what happens to the patient physically when they experience panic symptoms (Dattilio, 1990). The downward arrow method can provide him or her with links to the step-by-step process of identifying their automatic thoughts and connecting them to feelings. The patient may generate the assumption that “when people feel anxious, it means that there is something physically wrong with them.” This can serve as a hypothesis that can subsequently be tested using collaborative empiricism (Dattilio, 2001; Segal & Shaw, 1996). This process also helps therapists and patients reach some of the deeper conflicts that might underlie the symptom display. Although CBT is integrated and draws from various traditions, it also tries to remain true to its roots in a method that is practical, systematic, concrete, and empirical. Along with helping clients face squarely the inescapable reality of the pain in their lives, cognitive-behavior therapists attempt to address their specific symptoms and help them to develop tools they can use to live fully, even in the face of hard knowledge that life is always a gamble. Below is an example of

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how collaborative empiricism was used with a young patient suffering from panic attacks. The case outlines how the patient is helped to address his symptoms, but also, on a deeper level, deal with his sense of loss of control and basic human vulnerability:

Case Illustration “Jason” was a 36-year-old physician’s assistant working in the emergency department of a university hospital located in a large metropolitan region. Jason had worked in this position for 10 years at the time that he presented for treatment. He reported that, in that time, he had seen all types of emergency situations and quite a few deaths, which, for the most part, he had always taken in stride. That was until recently when he tended to a young male patient about his age that died on the table in the emergency department while they were attempting to resuscitate him. This young fellow had fallen unconscious while on a basketball court, playing a game of pickup with some friends. Several weeks after this incident Jason began to experience what he described as a “frightening feeling” while driving home from work. Initially, he shrugged the experience off as the result of being “wound up from work,” but after it occurred a second and third time, he grew increasingly concerned. Jason underwent a complete medical evaluation with his internist and consulted with a cardiologist on his own accord because of his concerns regarding his accelerated heart rate. He underwent an electrocardiogram, an echocardiogram, and a stress test. All of the test results were unremarkable and it was, therefore, suggested that he consult a clinical psychologist for psychological treatment. Jason’s internist referred him for an initial evaluation, at which time a complete clinical history was gathered, along with the administration of the Structured Clinical Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. The scale yielded a differential diagnosis of panic disorder on Axis I with no diagnosis on Axis II or III. Jason reported no unusual stressors precipitating the anxiety other than those associated with his work activities. Jason had no history of any emotional or behavioral problems, including illicit drug or alcohol use, relationship or financial stress. Jason did inform the psychologist, however, that he had always maintained a rather fastpaced life and that there were intense stressors with his job, particularly because of the fact that it was extremely hectic at times in the emergency department and he never knew what he was going to encounter on any given shift. “It’s quite crazy at times and takes a lot out of you, particularly when it’s time to disengage from work when your shift is over.” Jason was troubled by the fact that the young patient who had died in front of him was determined to have an undetected cardiomyopathy (enlarged heart), which contributed to fatal arrhythmia. It was shocking to Jason that someone so young and, otherwise, in such good physical shape could die spontaneously while playing an innocent game of basketball. This incident served to resonate the uncertainty that life often holds and seemed to upset a basic homeostasis within Jason. During the course of the assessment, Jason was administered the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), which yielded a score of 28 (severe), as well as the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), on which he produced a score of 11 (mild). Even during the initial assessment phase, the collaborative aspect of educating Jason to the need for evaluating his symptoms using empirical measures facilitates a basic understanding of the severity of his symptoms. The results of such an assessment will serve as “grist for the therapeutic mill” in setting future agendas in ameliorating his symptoms. In addition, Jason related that he had always struggled with the uncertainty of life and the fact that the death of his patient led him to conclude that he had little control over anything. “I went into emergency medicine to do what I could to help others to make a difference. But, sometimes I feel so powerless.” Jason struggled with this loss of control and uncertainty with his career, but struggled even more so with the loss of control over his personal life. He had been unfamiliar with the deep welling-up of unpleasant emotions that he experienced by the death of his young patient because he was used to being in control of himself and his surroundings.

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Jason was raised by a family that prided themselves on self-reliance and regarded emotional expressiveness (particularly the negative kind) as self-indulgent and undignified. He grew up feeling that “letting it all hang out” was an embarrassing lapse. Instead of consciously experiencing natural sadness, anger, and the helplessness caused by his patient’s death, Jason fought these feelings, channeling his mental and emotional energy into another set of essentially fictitious emotions, including an unrealistic sense of maintaining complete control of himself. It was hypothesized that this false sense of urgency and control led to the override of his anxiety, which manifested in eventual panic symptoms. What was particularly interesting is that Jason said that he would not allow himself to cry over the death of a stranger because “this was not the thing that we do. We have to remain tough and not allow such events to soften us.” When the psychologist explored with Jason the possibility of changing his view of emotional expression, he replied that “it felt disloyal to him, as though he was ridiculing his family and devaluing their values.” Not only did he assume that he had no right to grieve, but he didn’t even have the right to question that assumption. One of the goals in therapy, aside from reducing his panic attacks, involved teaching Jason how his learned rigid responses to emotions were limiting his ability to not only feel grief and rage but also think deeply about what such loss meant to him and what beliefs it evoked about life and death and the essential existential issues that all human beings face. When we reconcile ourselves to the realities of life and accept our weakness and inability to control much, then we have a shot at healing, happiness, and even wisdom. Jason related that he had been happily married to his wife, Jody, of 10 years and had no children. He did admit that he had been feeling some stress with regard to his career over the past 2 years before the incident in which his patient died. He also had thoughts of transferring to another branch of medicine because of the stress that was involved with emergency medicine. During the assessment period, Jason conveyed that he struggled with many of the traditional symptoms found among panic disordered patients. He met the diagnostic criteria for a panic disorder, which was directly related to the incident and his ongoing stress at work. But, more so, I suspected that he may be feeling trapped in his life by his rigid beliefs and his inability to accept fate. The following excerpt is of one of the first sessions with Jason and underscores one aspect of the therapeutic alliance characteristic of CBT in developing collaborative empiricism.

Dattilio : Jason, you stated to me during the initial intake session that your anxiety attacks appear to occur “out of the blue” with no precipitating event. What I would like to do is set an agenda for today’s session and obtain a clearer picture of exactly what occurs with you during an attack and the specific thoughts and beliefs that you experience during each episode. Jason : Well, it’s weird, almost like I am going into “V-tach” [ventricular tachycardia]. But, of course I know now that I’m not, or at least I don’t think that I am – I don’t know. I just don’t know what’s happening to me sometimes. Dattilio : Well, you have already been thoroughly evaluated by a cardiologist and you have been cleared of any heart problem. So, it appears to be more the actual spontaneity of these attacks that takes you by surprise, correct? Jason : Yes! They seem to overpower me but I know in my head that it’s nothing really serious and I feel so stupid sitting here telling you this. But when I experience the sensation, I just sort of become unglued. It’s as though my emotions take over like a runaway train. Dattilio : Well, I can understand how you might feel that way. Many people in your position experience similar reactions. It can be really scary at times. What we need to do is identify what symptoms typically trigger your panic sequence and what contributes to the “emotional override” that you describe. That will be one of our initial task assignments. Are there any one or two symptoms that you experience initially? Can you recall?

Collaborative CBT

Jason : Oh boy! Ah, let me see. I don’t know, it’s sort of a thing that takes me by surprise. It just comes on and I feel—overwhelmed. Dattilio : Okay, but let’s try to focus on what you experience first. For example, let’s back things up a bit and focus on your most recent panic attack. Can you close your eyes for a minute and think back a day or so? Jason : Well, that was 2 days ago. Dattilio : Where were you? What happened? Jason : I was driving home from my 7:30 to 3:30 shift and I had an attack in the car again. Dattilio : All right, now I would like you to just close your eyes for a moment and try to imagine yourself back in your car driving home from work just prior to the onset of the attack. Can you recall at what point you had the onset of the attack? Jason : Yes, okay. I remember now, I was in traffic on the spur route. It started with my heart, or at least that was one of the early symptoms that really alarmed me, but I am not so sure. Dattilio : Okay, so that was the target symptom, increased heart rate? Then what symptoms followed that? Can you recall? Jason : Well, I know somewhere close to that I started experiencing a shortness of breath. Dattilio : But you’re not really sure? Jason : No, I guess I just kind of blocked it out somehow like I always do because it’s so overwhelming to me. You know, this may sound odd, but I wish that I could almost experience a panic attack right now, just so you could see what I go through during these attacks. Dattilio : Well, there is an exercise that is designed to do just that, not perhaps to the exact extent that you might experience symptoms during a spontaneous attack, but close to it. Jason : Chee, I don’t know about this! Dattilio : Well, look, we don’t have to do that particular exercise, but I thought that I might mention it to you because it has been successful in helping some panic sufferers identify their symptoms and their adjoining thoughts and reactions. Jason : Well, I don’t know. I mean, it sounds like it may help, but I am not exactly keen on giving myself a panic attack right now. I’m not real fond of the feeling. Dattilio : Well, you see that’s the point. The idea here is that in reality you may just be doing that more than you are aware. Perhaps many of your attacks are brought on by the manner in which you catastrophically misinterpret bodily sensations, in this case, heart palpitations, lightheadedness and so on. Therefore, it is very important that we try to identify and pinpoint this sequence so that we can then devise a plan together for intervention. Jason : I’d like to give it some thought between now and the next session. Is that okay? Dattilio : That’s fine. What I would like you to consider as a homework assignment is to engage in some self-monitoring between now and then. Try to keep track through the use of this “panic log” (see Figure 1) each time you experience any symptoms of anxiety or panic, particularly noting the conditions of the onset of any symptoms and what bodily sensations you experience at the onset. Keep note of any thoughts or emotions and how you respond to them behaviorally. Even specific thoughts that you may have about the thoughts that go through your mind might provide us with important information. Jason : When you say “thoughts about thoughts,” what do you mean?

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Figure 1. Panic log.

Dattilio : Well, for example, one may say to him or herself, “I’d better not start thinking about how these symptoms could hurt me or I will get worse— these thoughts are dangerous.” As a result, you may develop thoughts about how to avoid thinking about the symptoms. Jason : Okay, that sounds like a homework assignment I can do without too much difficulty. I noticed that I do avoid certain thought statements that might escalate my symptoms. Dattilio : This will help us to gather some additional evidence to better conceptualize these attacks and provide both of us with a window into your thinking process. Next Session Jason : I didn’t have much luck gathering evidence this week. I had very little anxiety – I don’t understand why. It’s sort of strange to me—all of a sudden, nothing! Dattilio : Sometimes, due to the mere fact that you have initiated treatment, your symptoms of anxiety temporarily abate. This is sometimes referred to as the “honeymoon period.” Symptoms also tend to wax and wane at times for various reasons. This is not uncommon.

Collaborative CBT

Jason : Well, could we try that panic exercise that we discussed during the last session? I thought about it and would like to try it because I really want to tackle this thing. Dattilio : We could if you feel that you are up to it. It may certainly help us to obtain a better handle on the symptoms that you experience by gathering some important evidence regarding your functioning during these attacks. Jason : Well, okay. I’ll give it a try if you think it will help. Just so this doesn’t make me worse. I mean, I know that I can’t die from this or anything, but sometimes I just feel like I am going to. Do you know what I mean? Dattilio : Yes, I understand perfectly and no, you won’t die from it. We’ve already had you checked out thoroughly through Dr. Fox, your internist, as well as your cardiologist. Remember, he did the extensive cardiac workup on your heart and all of that blood work that you enjoyed so much. Jason : Yeah, I remember—and everything came back NORMAL. Dattilio : But I can certainly appreciate how frightening that must be for you since it seems to be tapping into a major issue of loss of control for you, along with a host of other emotions. This seems to be a major belief system for you—that any loss of control is a “bad” or “negative” thing. Jason : Yes, that’s it exactly. I can’t stand being out of control, okay? So, what do I have to do? Dattilio : I would like you to begin to breathe in a special manner by inhaling and exhaling only through your mouth, very quickly—almost as you would if you were out of breath - like this [therapist demonstrates method of breathing]. All right! Now you try it along with me—short staccato-type breaths in and out through your mouth, very quickly. Jason : [mimics the same procedure] Dattilio : Great! Now let’s try it for real, I am going to say “go” and I want you to begin breathing along with me in the manner that was just demonstrated. Once we start, I am going to discontinue after a bit, but I want you to continue on for about, oh, maybe 1 to 2 minutes or for as long as you can, nonstop. I have a glass of water here for you since your mouth may become dry. Okay? Are you ready? Jason : Yes, I guess! Dattilio : Let’s begin . . . [Therapist and Jason begin the exercise together. Throughout the exercise, the therapist supports Jason in his breathing by doing it with him simultaneously for short periods of time and also keeps track of the time. This is an important piece of the collaborative work because in a way, a therapist nonverbally conveys that he is taking a similar risk as Jason by engaging in over-breathing and disrupting the balance of his own CO2 and O2 levels as well.] Jason : [Only 45 seconds into the exercise, breathing very heavily] I can’t do this anymore! My heart is starting to race like crazy. Dattilio : Okay, what are you feeling right now Jason? Jason : Just my heart pounding. Dattilio : Anything else? Jason : Well, I don’t like not being able to breathe real well. I sort of enjoy breathing normally! Dattilio : What’s going through your mind as you say that to me and experience these sensations? Jason : I am thinking that I am going to have one of those freakin’ attacks, it never fails, I just don’t trust my body, I want to leave, run away. Note : [This is a very telling statement—”I just don’t trust my body”—that uncovers a vital belief that Jason maintains. This would almost suggest that Jason believes that his body or his own physiology will turn against him, thus contributing to his reaction of experiencing a loss of control.]

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Dattilio : Let’s try and go just a little further with the breathing to see if you experience any other symptoms. Jason : All right [stated reluctantly]. Dattilio : Jason, try to remember that this is a diagnostic exercise that is designed to help both of us learn to control your panic. It’s not meant to give you a hard time. Jason : I know, I just hate having these damn attacks! Dattilio : Does that insinuate that the emotion of anger or frustration may also be a part of the mix here as well? Jason : Probably, I don’t know—it’s sort of like a jumble of emotions. Dattilio : Okay, well that’s another target objective for us to focus on. Note : Jason resumes the breathing exercise. Jason : [As another 50 seconds passes] Oh no! I have to stop, I’m getting worse. [Begins to tear up] I know I shouldn’t have tried this because of what might happen. Dattilio : Okay, just try to calm down now by slowing down your breathing and tell me what’s shooting through your mind. Jason : I feel like I’m out of control. Dattilio : What are you experiencing, Jason? Jason : I am having lightheadedness and tingling in my hands, they feel numb. God, I can’t stand this! What’s wrong with me? I’m losing it! [Crying] Dattilio : All right, Jason, just begin to breathe slowly with me now. Look and me and let’s calm ourselves down. Close your eyes and just breathe slowly and continuously, inhaling slowly through the nose and exhaling slowly through the mouth so that we slow your breathing down to your normal resting state. Follow the direction of my voice as we work together to slow your breathing down and allow your symptoms to subside. [Several minutes pass as Jason does this.] Dattilio : How do you feel now? Jason : Better, but still a little dazed, like I’m in a fog. Dattilio : All right, well, that should pass in a little while. Let’s talk about the experience that you just had while it is fresh in your mind. Jason : I didn’t like it. It was almost as bad as what I experienced during my worst attack. Dattilio : Well, actually that’s kind of good, because it provides us with some insight into what you experience during an attack. So, let’s try to reconstruct what just went on with you and see whether or not there is some connection to what occurs each time you experience an attack. Jason : So, we’re just going to talk, no more hyper-breathing? Dattilio : Yes, no more over-breathing, at least for now! Now, when we first began the exercise, you stated that you felt your heart pounding. Jason : Correct! Dattilio : So, is it fair to say that this is usually the initial symptom? Jason : Yes. Dattilio : All right now, do you remember a few minutes ago when we began doing the exercise and your heart rate began to increase? Jason : Yes. Dattilio : What thoughts went racing through your mind at that point? Jason : “What’s going on? What’s happening?” Dattilio : Okay, and then do you remember what you felt, or did? Jason : Well, I began to really worry, believing that this is dangerous. Dattilio : Great, so we have the initial sequence of what occurred with you during the first few seconds of the attack. Let’s get this down on paper, along with your beliefs that “this is dangerous” (see Figure 2). Dattilio : So, what do you think so far? Does this look accurate to you?

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Figure 2. Jason’s panic sequence.

Jason : Yes, very accurate. The more that I think about it, that’s exactly what has been happening to me each time. Dattilio : Okay then, let’s continue. So, next, we have what? Jason : Ah, I am not really sure. Dattilio : Well, let’s go back and look at those Beck Anxiety Inventories that you completed and also what we have captured on paper during the panic induction. All right, we recorded here, “Increase and difficulty in breathing” and “Lightheadedness and sweating.” Does that look accurate to you? Jason : Yes, this seems right. Dattilio : Okay, now we need to attach a thought and emotion or behavior to each of these symptoms that you experienced during the attack. As the session progressed, Jason and I collaboratively constructed a schematic of his panic attacks and the process of escalation so that he could observe them on paper. This downward arrow-type method or what is referred to as the “SAEB” method (Dattilio, 1990) allows the patient to view the sequence logically and observe how their catastrophic misinterpretation and emotional responses contribute to the unnecessary escalation of his anxiety symptoms. In this collaborative way, Jason can challenge his beliefs about the dangerousness of his bodily sensations and the affect they have on him and modify the statements that he makes to

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himself in the second and third column, namely, automatic thoughts, emotion, and behavior to deescalate his panic symptoms. The end result is that he can decatastrophize the affect that the sensations have on him. In this respect, the combination of breathing retraining, progressive muscle relaxation, and thought restructuring help to offset the panic. This process is continued all the way through the last symptom Jason can recall experiencing, which is then restructured. As can be observed in Figure 2, the escalation process of the panic cycle is illustrated in this particular case, involving cognitions and affect, as well as behaviors. The connection is demonstrated via the vectors drawn. Arrows are also drawn downward from each sensation to indicate the sympathetic chain that occurs automatically in this process, aside from the escalation caused by thoughts, emotion, and behaviors. This technique has a number of therapeutic effects aside from allowing the panic sufferer to see the sequence of events graphically. It also allows the individual to break down each symptom so that both the patient and the therapist can intervene at various levels, particularly when attempting to restructure specific catastrophic misinterpretations. It may also be easier for the therapist and patient to collaboratively rewrite new cognitive interpretations and substitute alternative emotions and behaviors when everything is outlined on paper (Dattilio & Kendall, 2007). The downward arrow-type method can be used continually throughout treatment to aid patients in monitoring their cognitions, affect, and behavior in response to physiological and external scenarios. They can recall the process each time they reexperience bodily sensations that appear to be threatening. The method (mentioned previously) requires little coaching subsequent to the initial introduction. What is important is that in the collaborative process, Jason would also imagine our dialogue during the course of constructing this grid and the reassuring support given to him during sessions to practice this method on his own. Patients are usually encouraged to use this system outside of the therapy hour, particularly during panic-prone periods or high-stress events. It is important for patients to conceptualize how they are over-responding to bodily sensations, which may be a normal reaction to life’s stresses, and catastrophically misinterpreting these sensations as dangerous. In this particular case, Jason was pleased to have a model guide for helping him address his panic attacks. After several visits, he used these CBT methods of breathing retraining and decatastrophization to get his panic symptoms under control. During the course of the subsequent sessions, Jason was encouraged to practice over breathing and induce symptoms through hyperventilation. He was also encouraged to use the process of reframing the effects that the symptoms had on him by assigning new interpretive statements to each symptom and to use controlled breathing and relaxation techniques to manage his anxiety. However, a deeper issue still remained at hand, which was the antecedent of these attacks. Because medical etiology had clearly been ruled out, I explained to Jason that his panic symptoms were somewhat symbolic and may be representing his feelings of paralysis with regard to lack of control over his fate, and his particular discomfort with uncertainty in life. Helping Jason make a connection between his panic attacks and the uncertainty of life was a milestone, particularly because it enabled him to viscerally experience his own vulnerability. There was also the issue of whether or not he wished to continue to endure the hectic pace of working in a large metropolitan hospital emergency department. This was clearly something for him to contemplate for the future. This type of work in therapy prepared the way for having Jason examine his schemas about self-control and his anxiety, as well as his career aspirations, a major intellectual component of contemporary CBT. Schemas, which are considered the template-learned ways of filtering and structuring incoming experience, became a major focus of psychotherapy with Jason. His schema was that it was catastrophic not to always be in control and those spontaneous things that sometimes occur in life, such as the death of the young man in the emergency department, should not happen. We explored the roots of Jason’s beliefs, particularly as it related to his upbringing and practiced changing his behaviors out in the world. For example, learning to let go and embrace the notion that his concept of “control” was an illusion and that there are few things in life that one has control over, became a primary focus of our work together. Jason could never tolerate such ambiguity and uncertainty in life before; building tolerance for dyscontrol became important for

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him. “Learning to accept life as it comes” became somewhat of a mantra for Jason, particularly as he began to deeply examine his roots and the early upbringing by his over controlling parents. Of course, none of this happened over night and it took many months of approximately 25 sessions for Jason to learn to ask and then to think about questions he had ruthlessly put away, such as, “Why do I go on living when the young man before me in the emergency department died at such a young age?” The existential question of why do things happen and how do we go on living in the face of death became a struggle for him to work through and restructure his schemas. His ability to ask these questions and contemplate one’s own individual answers provided the grounding for a mature acceptance of life on life’s terms. Paradoxically, once comfortable with the reality of life’s inevitable risks, Jason found himself able to relinquish many of the anxiety and fears that had long been the bulwark against uncertainty. He also concluded that his religious beliefs reassured him that the young man who died in the emergency room was no longer suffering. With a small shock in thinking about his fate, Jason realized that the grief that he now openly expressed for his deceased patient was not so much for the ones who had died—they were beyond grief and misery—but for himself, not only for the loss of his patient, but also for the loss of his own armor—his implicit belief in his own invulnerability.

Summary and Clinical Practices In this particular example, Jason learned to not only regulate his panic symptoms to the point at which they eventually eliminated but also restructure his thinking to include and eventually accept the notion that life is messy and unpredictable. He discovered that the only thing that one can do about uncertainty is to accept fate on fate’s terms and not distort reality or try to force it into the pattern that we desire. Restructuring a lifelong philosophical orientation is not the kind of project that we can expect to complete in several hundred sessions, much less 25. CBT done within the frame of collaborative empiricism can offer the work that means much more to patients than interventions that simply train them to tolerate higher levels of stress. Exploring some of Jason’s deeper schemas and the existential dilemmas surrounding them, while giving him cognitive-behavioral tools to deal with life, not only encourages more mature thinking but also protects against despair. In the long run, learning to accept his own limitations and ultimate vulnerability made him stronger and freer. Collaborative empiricism plays an important role in helping patients achieve growth. As demonstrated in the case illustration, collaborative empiricism provided Jason with a guide for dealing with his panic symptoms that demonstrated effectiveness. Building a therapeutic relationship is crucial to understand the values and the culture of the patient. This relationship can be maintained by building an alliance, coordinating, planning goals, and recognizing milestones. The process of collaboration begins by creating a strong therapeutic alliance, which then leads to helping the patient with his or her automatic thought process. The therapist expresses empathy and understanding of their values and inner thoughts to gain the respect and trust. The therapist listens carefully, identifies emotions and distorted beliefs, and reviews each session at the end to receive feedback and monitor progress. Socratic questioning and homework assignments aid this approach. As patients begin to express their inner thoughts and cognitions (hypotheses), the therapist and the patient then explore them and devise a plan for action through a process of guided discovery.

Selected References & Recommended Readings Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: International Universities Press, Inc. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. Beck, A. T, Rush, A. J, Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press.

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Beck, A. T., Ward, C. H., Mendelson, M., Mock, M., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Beck, J. S. (2005). Cognitive therapy for challenging problems. New York, NY: Guildford Press. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitivebehavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. Cross, L. W. (2007). Islands of health: Implications of academic psychology for psychotherapy technique and integration. Journal of Psychotherapy Integration, 17(3), 251–273. doi:10.1037/1053-0479.17.3.251 Dattilio, F. M. (1990). Symptom induction and de-escalation in the treatment of panic attacks. Journal of Mental Health Counseling, 12(4), 515–519. Dattilio, F. M. (2001). Cognitive-behavioral treatment of panic complicated by medical illnesses. Psychotherapy, 38(2), 212–218. Dattilio, F. M. (2002). Homework assignments in couple and family therapy. Journal of Clinical Psychology, 58(5), 570–583. Dattilio, F. M. (2010). Cognitive-behavior therapy with couples and families: A comprehensive guide for clinicians. New York, NY: Guilford. Dattilio, F. M., Freeman, A., & Blue, J. (1998). The therapeutic relationship. In A. S. Bellack & M. Heresen (Eds.), Comprehensive clinical psychology (pp. 229–249). Oxford, UK: Elsevier Science. Dattilio, F. M., & Kendall, P. C. (2007). Panic disorder. In F. M. Dattilio & A. Freeman (Eds.), Cognitive Behavioral strategies in crisis intervention (pp. 68–92). New York, NY: Guilford. Merali, N., & Lynch, P. (1997). Collaboration in cognitive-behavioural counselling: A case example. Canadian Journal of Counselling, 31(4), 287–293. Overholser, J. C. (1995). Elements of the Socratic method: IV. Disavowal of knowledge. Psychotherapy: Theory, Research, Practice, Training, 32(2), 283–292. Overholser, J. C., & Silverman, E. J. (1998). Cognitive-behavioral treatment of depression, Part VIII. Developing and utilizing the therapeutic relationship. Journal of Contemporary Psychotherapy, 28(2), 199–214. doi:10.1023/A:1022967516338 Scott, J., & Freeman, A. (2010). Beck’s cognitive therapy. In N. Kazantizis, M. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp. 28–75). New York, NY: Guildford Press. Segal, Z. V., & Shaw, B. F. (1996). Cognitive therapy. American Psychiatric Press Review of Psychiatry, 15, 69–90. Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science and Practice, 18(1), 47–61.

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