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Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges into Opportunities for Change edited by Robert L. Leahy (Guilford Press) Explores the nature of roadblocks within psychotherapy in general, and cognitive-behavioral therapy in particular. Highlights the importance of case conceptualization in illuminating why roadblocks arise and provides a framework for individualized intervention. For psychotherapists.

'The current volume represents the work of some of the leading cognitive-behavioral therapists in the field. As I put together this collection of contributors, I realized that, indeed, many more outstanding contributors could have been included. This realization made me even more hopeful, be-cause I understood that therapeutic impasses and resistance are the stuff of the real world of the clinician—a world that is experienced daily in clinical practice.

The volume is divided into five parts. Part I (Needleman, Chapter 1; Freeman & McCloskey, Chapter 2; and Tompkins, Chapter 3) includes fundamental examples of roadblocks and the use of case conceptualization. The more complicated the patient, the more important case conceptualiza­tion is. My experience may be idiosyncratic, but I seem to be finding my pa­tients to be more complicated than I thought they were when I first began doing therapy. I believe the reason is that, with experience and inevitable frustration and failure, we come to recognize the complexity in individuals that we did not initially see. The newer therapist will find some comfort and irony in recognizing that those of us who have been out here doing this for some time are more aware of how difficult this is—how much there is to learn. Each year I am more impressed with how much I still need to learn and how much that gap dwarfs whatever knowledge I have accumulated. So, if case conceptualization is something used with the more complicated cases, we may find that almost all cases are complicated.

In Part II, Wells, Leahy, and Holland each review some of the potential roadblocks in treatment that are consequences of metacognitive beliefs about anxiety, metaemotional beliefs that impede emotional processing, and experiential and defensive processes that result in avoidance of emo­tion. Wells, in Chapter 4, has developed a sophisticated model of metacognition that not only has direct relevance for conceptualizing each anxiety disorder but also has treatment implications as well. In Chapter 5, I at-tempt to develop a model of emotional schemas that can assist the therapist and patient in understanding how roadblocks can arise on the most funda­mental level of accessing and experiencing emotions. In Chapter 6, Holland indicates the importance of emotional avoidance as a factor that often escapes cognitive-behavioral therapists. In his analysis of this process, Hol­land indicates how the skilled therapist can identify this defensive process and utilize it to engage the patient in examining the meaning and fear of negative feelings, thereby accessing underlying assumptions and interper­sonal schemas.

Part III covers specific populations—patients with psychosis (Haddock & Siddle, Chapter 7), bipolar disorder (Newman, Chapter 8), posttraumat­ic stress disorder (Smucker, Grunert, & Weis, Chapter 9), or binge-eating disorder (Schaffer, Chapter 10). Obviously, every diagnostic group or cul­tural group could be considered here, but we had to limit ourselves in our coverage. In these chapters, the authors examine how specific roadblocks arise for these patient populations and how these roadblocks can be ad-dressed. Part IV addresses couples and families among whom the individual issues are complicated by the systemic issues in families and the underlying agendas within couples. The authors of these chapters, Epstein and Baucom (Chapter 11) and Dattilio (Chapter 12), provide sophisticated analyses of how specific areas can be addressed. Finally, in Part V, various psychotherapy processes are examined. The dialectical behavior therapy approach is presented by Foertsch, Manning, and Dimeff in Chapter 13 as a general model for addressing therapy-interfering behaviors. The chapter on medication compliance by Marcinko (Chapter 16) integrates standard cognitive therapy with motivational interviewing and dialectical behavior therapy. Stevens, Muran, and Safran, in Chapter 14, explicate the interper­sonal nature of therapy in evaluating the use of therapeutic ruptures to enhancing progress. In Chapter 15, Tafrate and Kassinove offer specific—and very valuable—ideas of how to address angry patients. This final part should be especially helpful in providing the reader with an integrative ap­proach to dealing with roadblocks.

In sum, I hope that the reader will find these contributions valuable in the following ways:

1. Recognizing roadblocks when they exist.

2. Developing case conceptualization as a strategy in understanding and dealing with these problems.

3. Viewing emotional schemas and emotional processing as important components in activating meaningful emotional experience.

4. Understanding how specific pathology can be an inevitable part of noncompliance with therapy.

5. Expanding therapy to include larger systems in the individual patient's life.

6. Using the transference relationship (and the therapist's own experi­ence) as therapeutic opportunities.

Therapists who are reading this book understand the following experi­ence to be valid in their own lives: A patient does not comply with treatment in various ways and blames the therapist for the failure of the treatment. The therapist may vacillate among anger, guilt, shame, and anxi­ety. The impasse is viewed as another frustration in the professional life of the therapist. What to do? First, recognizing that all of us have had similar experiences is to recognize that this "comes with the territory." You are not alone. Perhaps, I might add, you are in good company. Second, the impasse may now be an opportunity. Just as pain may tell us the location of the injury, resistance and roadblocks tell us more about the patient's personal ex­perience and the therapeutic relationship we are establishing with him or her. The avenue to change may be through the impasse.

Roadblocks in Cognitive-Behavioral Therapy provides a rich and multifaceted exploration of the many obstacles that can arise in the treatment process. It does a marvelous job of explaining why and how roadblocks occur in therapy with diverse individuals, as well as couples and families, and provides a coherent set of principles for turning obstacles into what Leahy calls windows of opportunity. Filled with clinical wisdom and specific strategies, this volume should be of use to both beginning and experienced clinicians. It could well become a mainstay of professional training programs at all levels."--Steven D. Hollon, Department of Psychology, Vanderbilt University

"Leahy, one of cognitive therapy's most prolific and creative writers, has brought together leading therapists in the field to address the important issue of impasses and disruptions in therapeutic progress. With coverage of such areas as case conceptualization, the relationship of cognition to emotion, and the therapeutic relationship, the volume provides a wealth of insights and practical solutions to clinical difficulties. I highly recommend this book and I am sure that, like me, others readers will learn much from it."--Paul Gilbert, FBPsS, Mental Health Research Unit, Kingsway Hospital , Derby , UK

"This book will suffer a lot of abuse from being pulled from your office shelf again and again to be pored over for ideas and inspiration. Leahy has pulled together some of the greatest CBT minds to share their thoughts, feelings, and strategies for working with some of our most difficult-to-treat disorders and populations. Whether a neophyte or a veteran therapist, the reader will find new ways to understand obstacles and overcome resistance in its many guises."--Peter J. Bieling, PhD, St. Joseph's Hospital, Hamilton, Ontario, Canada; Department of Psychiatry and Behavioral Neurosciences, McMaster University

Contents: Part I. Case Conceptualization: 1. Case Conceptualization in Preventing and Responding to Therapeutic Difficulties by Lawrence D. Needleman; 2. Impediments to Effective Psychotherapy by Arthur Freeman and Roya Djalali McCloskey; 3. Effective Homework by Michael A. Tompkins;
Part II. Metacognition and Emotion: 4. Anxiety Disorders, Metacognition, and Change by Adrian Wells; 5. Emotional Schemas and Resistance by Robert L. Leahy; 6. Avoidance of Emotion as an Obstacle to Progress by Stephen J. Holland;
Part III. Specific Populations: 7. Psychosis by Gillian Haddock and Ronald Siddle; 8. Bipolar Disorder by Cory F. Newman; 9. Posttraumatic Stress Disorder: A New Algorithm Treatment Model by Mervin R. Smucker, Brad K. Grunert, and Jo M. Weis; 10. Binge-Eating and Other Eating Disorders by Nicole A. Schaffer;
Part IV. Couples and Families: 11. Couple Therapy by Norman B. Epstein and Donald H. Baucom; 12. Family Therapy by Frank M. Dattilio;
Part V. Psychotherapy Processes: 13. Difficult-to-Treat Patients: The Approach from Dialectical Behavior Therapy by Christine Foertsch, Sharon Y. Manning, and Linda Dimeff; 14. Obstacles or Opportunities?: A Relational Approach to Negotiating Alliance Ruptures by Christopher L. Stevens, J. Christopher Muran, and Jeremy D. Safran: 15. Angry Patients: Strategies for Beginning Treatment by Raymond Chip Tafrate and Howard Kassinove; 16. Medication Compliance with Difficult Patients by Lynn Marcinko; 17. Conclusions by Robert L. Leahy; Index



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