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Cognitive-Behavior Therapy for Severe Mental Illness: An Illustrated Guide
Reviewed by Kimberly J. Tseng, M.D.; John Q. Young, M.D., M.P.P.
Am J Psychiatry 2010;167:108-108. doi:10.1176/appi.ajp.2009.09050634
View Author and Article Information

The authors report no financial relationships with commercial interests.

Book review accepted for publication May 2009.

Accepted April , 2009.

Copyright © American Psychiatric Association

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Clinicians who work with patients with severe mental illness are well aware of the multiple challenges inherent in caring for these individuals, including problems with poor treatment adherence, persistent symptoms resistant to medication, multiple relapses, and suicidality.

Over time, cognitive-behavioral therapy (CBT) has been adapted to help clinicians address such issues that arise when working with patients with severe mental illness.

In Cognitive-Behavior Therapy for Severe Mental Illness, the authors provide a written and video-illustrated how-to guide on using CBT with patients with schizophrenia, bipolar disorder, and severe depression.

The text is well written, practical, and concise, and the material is presented in an easy-to-follow format that clinicians can readily appreciate. Each chapter begins with objectives and concludes with a summary section that highlights key points for the clinician and concepts and skills for patients to learn. When available, evidence-based interventions and reference lists are provided at the end of the chapter. Within each chapter, the authors indicate when to watch the video vignettes in order to enhance important concepts; provide short case vignettes with written dialogue to illustrate CBT methods; incorporate figures and tables to highlight key ideas; suggest learning exercises to help the therapist take on the perspective of the patient; and direct the clinician to CBT aids included in the appendix. The appendix serves as a ready-to-use resource for clinicians and patients, with helpful worksheets, handouts, recommended readings and web sites, and a DVD guide. When issues arise that are beyond the scope of the book, such as substance abuse in patients with bipolar disorder, the authors refer the reader to resources for additional reading. This is an exceptionally well designed, practical resource.

The clinical content is superb as well. The first four chapters describe the overall approach. The authors introduce the concept of the cognitive-behavioral biological sociocultural model for severe mental disorders as the guiding framework for formulation and treatment planning. They highlight behavioral issues, personal circumstances, and sociocultural issues that may interfere with the therapeutic relationship. Specific guidelines for engaging a patient with psychosis, bipolar disorder, and severe depression are provided, along with information to gather during the assessment to determine the patient's readiness for CBT. The authors describe normalization and education as potent interventions to reduce the shame and self-blame that can hinder engagement in treatment. In addition, the clinician is guided on how to gather information such as formative influences, biological factors, strengths and assets, and cognitive and behavioral patterns in order to develop a meaningful, targeted CBT treatment plan.

The next section of the book addresses specific clinical problems. Chapter 5 ("Delusions") focuses on how to approach delusional beliefs in schizophrenia, such as normalization, assessment of impairment associated with delusions, using methods of examining delusions by mini-formulations, simplified thought record, checking out beliefs with someone the patient trusts, or exploring underlying inaccurate schemas of self. Chapter 6 ("Hallucinations") covers primarily auditory hallucinations, such as exploring explanations for the hallucinations, the utility of a voice diary, and three main categories of coping strategies: distraction, focusing, and schematic/metacognitive.

Chapter 7 ("Depression") focuses on three main clusters of symptoms in severe or treatment-resistant depression: hopelessness and suicidality, low energy and anhedonia, and low self-esteem. The authors describe CBT methods for building hope, reducing suicide risk, and generating an antisuicide plan. To target the symptoms of low energy and lack of interest, the authors emphasize behavioral activation through activity scheduling and graded task assignments. In Chapter 8 ("Mania"), the authors point out that the primary goal with mania is to reduce the risk of mania through lifestyle management, symptom recognition, preparation for future recurrence, symptom control, and learning from each manic episode.

The next set of chapters presents various strategies to address social and cognitive difficulties common in severe chronic illness. Chapter 12 ("Promoting Adherence") presents techniques to explore barriers to adherence, including denial of illness, rejection of treatment, and obstacles to treatment.

The final chapter focuses on relapse prevention in severe mental illness. The authors recommend helping patients identify triggers for relapse and to work collaboratively on developing relapse prevention plans. Moreover, the authors also describe situations where family involvement may be helpful in the therapeutic process, such as in symptom recognition, serving as a sounding board for checking out possible delusional perceptions, medication adherence, and redefining goals and expectations.

Lastly, the authors encourage the clinician to assist patients with finding meaning in life through the course of long-term treatment.

The book presents in a clear and practical fashion CBT strategies for addressing the most severe and persistent symptoms. Impressively, it does so while emphasizing a collaborative approach and helping the clinician appreciate the patient perspective.

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