Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide

Abstract

Treating Anxiety Disorders Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide Adrian Wells. New York: John Wiley & Sons (www.wiley.com). 1997, 314pp. Since the publication of Anxiety Disorders and Phobias: A Cognitive Perspective (1985) by Beck, Emery, and Greenberg, there have been significant advances in the treatment of the entire range of anxiety disorders. In this important book, Adrian Wells has attempted to present the reader with both a conceptual and practical guide to the treatment of the major anxiety disorders, bringing together much of the interesting and challenging work by David Clark, Paul Salkovskis, himself, and others. He has succeeded in providing us with an important book that significantly advances the field. The book can be divided into three sections: a review of the basic principles and techniques of cognitive therapy, separate chapters on each of the anxiety disorders (including hypochondriasis), and a last chapter on future directions. The cognitive conceptualization throughout this book is that anxiety disorders are often maintained by the patient's misinterpretation of symptoms (panic, hypochondriasis), thoughts (obsessive-compulsive disorder, generalized anxiety), and feelings (obsessive-compulsive disorder). Because of the emphasis on the patient's mislabeling of symptoms ("I'm having a heart attack"), maladaptive assumptions ("I have to get rid of my anxiety, completely"), conditional statements ("If I have a thought, then I'll act on it") and schemas ("I have no control"), each anxiety disorder can only be completely understood by developing a cognitive conceptualization. It is the emphasis on a deep, detailed and penetrating cognitive conceptualization that makes this book an outstanding contribution to the literature. At the center of the cognitive conceptualization is the identification of the patient's theory of his problem and how he has been trying to cope with his problem through safety behaviors such as avoidance, escape, magical rituals, reassuranceseeking and distraction. Behaviorists have emphasized "behavioral exposure" as the sine qua non of treatment?and Wells does use exposure techniques. The key element here is what "behavioral exposure" really teaches the patient?what does it confirm or disconfirm? For example, if someone has a fear of flying and she flies 10 times, what does this "exposure" disconfirm if she is practicing safety-prayers or seeking reassurance? Although Wells does not make this point directly, we should be mindful that the concept of exposure comes from the animal literature on extinction. Because of its "black-box" behaviorist legacy, behavior therapists have assumed that the "situation" that the individual is exposed to will sufficiently lead to the extinction of the anxiety. But, what Wells is really asking is the central cognitive (and theoretical) question: "What is the situation for the patient?" This has been a traditional controversy in much earlier debates between strict behaviorists like Skinner and "pure cognitivists" like Koffka and Kohler?that is, what is a "stimulus"? Wells is really making the point that the "situation" to which the patient is exposed can only be defined by the patient's cognitive construction. If we examine what the patient thinks about the situation, Wells indicates that we find that the anxious patient often believes that his covert avoidance, safetybehaviors and distraction have protected him from the full impact of the "stimulus"? that is, there has not been complete exposure. This raises the central issue in all exposure?that is, it must allow for disconfirmation of a specific thought or hypothesis. Consequently, Wells indicates that the therapist must fully assess any "protective" safety behaviors, assess the patient's theory about how this behavior protects him or allows him to be responsible, and what specific predictions the patient is making prior to exposure (e. …