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by David F. Tolin
Guilford Press, 2016
Review by Kamuran Elbeyoğlu on Jul 11th 2017
Since its introduction in the 1960's by Aaron Beck in order to conceptualize depression in other ways than psychoanalysis, Cognitive-behavioral therapy (CBT) has been studied and demonstrated to be effective in treating a wide variety of disorders. David F. Tolin, who is the founder and director of the Anxiety Disorders Center/ Center for Cognitive Behavioral Therapy at the Institute of Living-Hartford Hospital, introduces an evidence-based practice, which means starting with the best research evidence for the presenting problem and then tailoring treatment based on clinical expertise and client characteristics. In his own words, CBT is "more than anything, an approach to case conceptualization that guides our understanding of why someone is suffering and how we can help him or her" (p. 8).
"Artless science is probably not going to be helpful in providing psychotherapy, nor will scienceless art" (p. 6). This sentence sets the whole idea of this book. Tolin believes that a good CBTer mixes science and art into his/her practice of therapy in order to combine evidence to fit a specific client. That's why, in Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions, Tolin covers a lot of ground such as discussing how we understand psychological problems, how we engage our clients and a wide range of techniques we can use to help our clients improve their lives by presenting a number of fictitious clinical cases that illustrate what he talks about.
Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions is divided into three main parts. Tolin opens by exploring the fundamentals of CBT and what is known about how psychological problems develop and are maintained. Subsequent chapters take the reader step by step through conceptualizing a case, engaging the client, and planning the therapy. The nuts and bolts of specific interventions are described in detail, including a wealth of concrete examples and sample dialogues. Throughout all chapters, Tolin presents case illustrations covering the entire process of treatment from intake to termination and offers readers a window to effective therapeutic decision making. To improve understanding, he discusses the science behind CBT in instructive sidebars, offers clinical pointers and at the end of each chapter, distills essential points to remember and provides a Personal Target Worksheet for the readers self-practice key skills.
Part I, "Why Do People Suffer?", is dedicated to using the principles of CBT to answer the fundamental question of why our clients are suffering in the first place. Why is this person depressed? Why does this client experiences panic attacks? Why does this client engage self-injury? Why is that client abusing drugs? And so on. This part consists in four chapters covering three main components of CBT, namely the behavioral system, which reflects what the person does; the cognitive system, which reflects what the person thinks and how the person processes information; and the emotional system, which reflects how the person feels. After talking about each system in detail, in the last chapter, Tolin discusses how these three systems interact with each other and how a therapist can put them all together to understand how they fit together and use this information to create a road map for his/her treatment.
Part II, "How Do We Help?", describes ways that CBT therapists work with clients with psychological problems. Here, Tolin uses a strategy that is called case formulation approachdeveloped by Persons (1989), in which information gathered during a thorough assessment is used to develop a formulation about the causes of the problem and the formulation directly informs the selection of interventions. He suggests that since our "hows" are heavily dependent on our "whys", a good CBT therapist should select interventions based on his/her working understanding why the problem persists. This part is divided into four sections, first of which, titled "How We Engage the Client", review the aims of the therapist and several important elements that should be incorporated into therapist's interactions with the clients in two chapters.
Following three sections are behavior-level interventions, cognitive-level interventions and emotion-level interventions, respectively. In the first section, Tolin gives a very detailed description of behavior-level interventions used in CBT in five chapters. First chapter of this section, chapter 8 titled "Adjusting the Triggers" takes on the idea that a therapist should consider interventions that affect the triggers to the core pathological process begin with. The following chapter then continues to discusses contingency management in therapy, namely deciding and consequently controlling whether the client has a behavioral excess or a behavioral deficit. The tenth chapter is about direct behavioral prescriptions, which is the core of much of the behavioral side of CBT. Chapter eleven titled "Exposure" is about the process of confronting previously avoided stimuli and offers concrete cues to the therapist for different kinds of disorders. And finally the last chapter of this section discusses how behavioral skill deficits can play a major role in the etiology and maintenance of psychopathology and offers again concrete tolls and step by step instructions for therapist to improve their clients' social skills and problem solving abilities.
The second section on cognitive level interventions is also divided into five chapters. Chapter thirteen is about figuring out what the client is thinking. In this chapter and the next, Tolin focuses on interventions that directly target semi-automatic cognitive processes. These thoughts are the client's interpretations that are produced automatically but that can, and with some effort, be identified and modified. So, this chapter provides techniques, such as Socratic questioning, role play and checklists to help the client identify his or her maladaptive thoughts and to instruct the client to self-monitor these thought in his or her natural environment between sessions. Then, in chapter fourteen, he goes on discussing the techniques for cognitive restructuring, the process of getting the client to rethink and revise maladaptive interpretations. Chapter eleven titled "Leave Them Thoughts Alone" he offers very useful advice to therapists to teach their clients the art of not challenging intrusive thoughts by combining strategies from mindfulness and acceptance theory, as well. The next chapter turns the attention into core beliefs and provides a strategy called pattern detection to find core beliefs. And finally in the last chapter of this section titled "Addressing Information-Processing Biases", he discusses the importance of attention deployment. The problem with intrusive thoughts he thinks is that people tend to deploy attention disproportionately toward stimuli that are congruent with their current beliefs or mood states, and he discusses several strategies to get it. In this chapter, he introduces
The third section on emotion-level interventions discusses how to affect emotional targets, but as Tolin rightly points out, affecting an emotion sometimes addressing how the person thinks and acts in response to that emotion. This section is divided into two chapters, each of which is devoted one of the main ways to affect emotional targets. The first of these is emotion modulation, in which the aim of the therapist is to change the person's emotional experience. In this chapter he introduces emotion modulation strategies such as breathing and relaxation training, which are designed to decrease the client's level of physiological arousal. Chapter nineteen is devoted to the distress tolerance, which is the other way of addressing maladaptive emotion.
Part III, "Putting It All Together", walks the reader through several case examples, from the beginning to the end of therapy, so that one can see how these conceptual and interventional elements are woven together in a single case.
Tolin, himself is one of the field's experienced, leading clinician-researchers, in this exceptional book, does not only give the science behind CBT principles and provide a very clear and concise account of how to do CBT, but also provides vivid and practical strategies to build a therapeutic environment designed to meet the patient's specific needs by merging CBT with the new science of emotion regulation, mindfulness and acceptance. In a witty, straight-talking style, he explains core concepts and presents evidence-based techniques for addressing the behavioral, cognitive and emotional elements of psychological problems. Vivid examples of diverse clients of all ages are followed throughout the book, illustrating how CBT principles in real-world practice in a range of clinical settings.
Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions is designed to expand the skills and knowledge base of both novice and more experienced clinicians, including clinical psychologists, social workers, counselors, psychiatrists and psychiatric nurses. It can also be an ideal text book for graduate-level CBT and psychotherapy courses. This book, written in an accessible and entertaining style provides a complete introduction to the art and science of CBT and aptly deserves to be called a practitioner resource.
© 2017 Kamuran Elbeyoğlu
Kamuran Elbeyoğlu (Prof. Dr.), Toros University, School of Business Administration and Social Sciences, Department of Psychology, Yenisehir, 33140 Mersin, Turkey.