CBT intervention

Running Head: CBT INTERVENTION FOR ANXIETY MANAGEMENT

CBT Intervention For Anxiety Management

[Name of the writer]
[Name of the institution]

CBT intervention

CBT Intervention For Anxiety Management

Introduction
The purpose of this paper is to raise counsellors' awareness
of a common menopausal problem among women. Vasomotor problems or
hot flushes affect a high proportion of women in mid-life (54% in
Hunter's (1990a) study; 68% of Greene's (1984) sample; and 75%
according to Kronenberg (1990). They are most likely to occur in
the perimenopause (the year or so preceding and succeeding the
final menstrual period), but some women experience hot flushes on
a chronic basis. Kronenberg's review (1990), for example,
indicates that hot flushes may occur for more than 15 years. At
least 15-20% of women experience considerable distress during
flushing. Of all the problems associated with the menopause,
flushing is most likely to prompt consultation with the GP. Women
are thereafter most likely to be offered medical treatment (in
the form of hormone replacement therapy (HRT)) rather than
psychological or counselling interventions.
There are many reasons for this, including the biomedical
conceptualization of the menopause as a 'deficiency disease' and
the limited awareness about the sources of women's distress
during this experience. After reviewing some of the psychological
issues that have emerged in previous studies and acknowledging
the few psychological interventions that have been evaluated, the

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paper reports a further qualitative study of women's experiences

and goes on to suggest aspects of the flush experience for which
counselling may be helpful.
Flushes may occur many times daily although individuals show
a wide variety of patterns. During a hot flush, there is a strong
transient sensation of heat, sometimes radiating from a focal
point, and usually lasting between 1 and 5 minutes. The rise in
body temperature may be accompanied by reddening of face and
neck, marked perspiration, palpitations and sensations of
faintness or anxiety. Flushes are regarded as associated with
hormonal change particularly decline in oestrogen levels,
although the details of the role of circulating oestrogen in
triggering specific flush episodes remain unclear.
(HRT) has become the conventional medical treatment for hot
flushes. The therapy increases levels of oestrogen and also
provides progestin (to prompt a monthly bleed and reduce the risk
of endometrial cancer). However, only about 10% of menopausal
women in the UK continue with this medication for more than a few
months. The take-up may be low for several reasons. HRT is not
usually prescribed where there is a personal or family history of
breast or endometrial cancer. Hormonal treatment may be tried but
discontinued if side-effects are encountered. Common side-effects
include nausea, breast pain, menstrual bleeding and weight gain.
Some women decline HRT from fearing that prolonged use may

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predispose them to future health problems. Others reject the view

of menopause as a 'deficiency disease' and find long-term
medication for a normal life stage unacceptable.
For those women distressed by hot flushes but unable or
unwilling to take HRT, there is currently very little alternative
advice, support or other non-medical intervention. The lack of
nonmedical alternatives also presents difficulties to women who
find that taking HRT does not fully control their flushes.
In order to establish a potential role for psychological
interventions, common sources of distress during hot flushes need
to be identified. Unpredictable physical sensations of high body
temperature and excessive perspiration are the aspects of the
experience most commonly reported by women. Less investigated is
the cognitive and emotional 'interior' of the flush experience.
Hunter and Liao (1995) found that 36.4% of their sample were
distressed by social embarrassment and 18.2% by a perceived loss
of control. Their sample also described a variety of social and
environmental factors as influencing flush discomfort, with hot,
confined or otherwise stressful situations exacerbating distress,
for at least a third of the sample. Physical exertion, smoking
and consumption of hot drinks or alcohol were identified as
triggers of flushes by about 10%. During flushing, women not
surprisingly may become preoccupied with achieving a more normal
body temperature, and behavioural responses such as removing

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clothing, seeking fresh air, relaxing and taking a break from the
current task have been noted as quite common. Less is known about
whether and why women might adopt cognitive and emotional
strategies of managing the stressful experience.
It is also unclear why some women but not others experience
considerable distress during hot flushes. Whilst it is possible
that there is variation in objective severity of physical
sensations, women's reports of distress are only weakly related
to more objective measures such as duration and frequency of
flush episodes. It is possible that symptom awareness itself may
reflect wider personality and stress factors. In Hunter and
Liao's study, women who found their flushes more problematic
tended to be more depressed, more anxious and lower in selfesteem. Further enquiry is needed regarding whether distress
links more directly with the content of negative thoughts and
feelings stimulated during flushing. If so, counselling might
achieve wider acceptance as an adjunct or alternative to hormonal
therapy.
There are few published reports of effective psychological
approaches to assist women in coping with flushes. Where
psychological techniques have been tried, the aim has generally
been to reduce the frequency of flushes rather than subjective
distress of flush episodes. Stevenson and Delprato (1983)
evaluated a 10-session multiple component intervention for four

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participants to improve skills of relaxation, marital and daily

life stress management, use of cooling imagery and thoughts and
adoption of simple behavioural strategies for lowering body
temperature. All participants noted reductions in flush
frequency.
Some interventions have evaluated behavioural techniques
more specifically. Germaine and Freedman (1984) investigated the
impact of progressive relaxation, although their rationale was
not made explicit. They noted some positive effects on both
objective and subjective incidence of hot flushes in a laboratory
situation (possibly from increasing subjects' tolerance for the
heat stress used by the researchers to elicit flushes). Freedman
and Woodward (1992) similarly found relaxation and deep breathing
techniques helpful in reducing flush frequency. Both studies were
conducted in a laboratory rather than clinical setting and
neither addressed the impact of these techniques on cognitive or
emotional processes during flushing.
There has recently been a more substantial trial of
cognitive behavioural therapy with 52 women seeking treatment for
hot flushes from their GP. Hunter and Liao (1995) reported
successful outcomes of four-session CBT for women who expressed
preference for this approach over HRT (or had no preference). As
in previous studies, relaxation skills were developed. Diary
records of precipitants and exacerbators of flush episodes were

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kept, to enhance awareness of situational and cognitive factors.

Participants noted that flushes reduced in frequency and also
that remaining flush episodes were less problematic. Unlike the
HRT comparison group, anxiety levels were reduced in the group
receiving the psychological intervention. These findings support
further enquiry into women's construing of flush episodes,
particularly examining whether more and less distressed women
encounter substantially different cognitive and emotional issues.
If this is the case, a clearer role for counselling interventions
may emerge.
The few interventions to date have adopted a behavioural or
cognitive behavioural framework. Whether alternative counselling
perspectives could be helpful to women coping with menopausal hot
flushes is almost unexplored. There is a strong tradition, at
least within a psychodynamic framework, of viewing menopausal
women as locked in grief for their lost reproductive and
mothering. Some critics have criticized this view as limited and
overly patronising. Arguably women need to be listened to
carefully so that their concerns are not pre-judged. This study
has attempted to listen to women's experiences, examining through
qualitative methods the variety of self-reported thoughts and
feelings that accompany hot flushes, in order to identify more
closely the sources of distress experienced. The study in
particular addresses a question that has been largely unanswered

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by previous studies, namely whether women reporting high levels

of distress during flushes differ substantially in their
cognitive and emotional concerns from women who experience little
distress. From the qualitative accounts of flush experiences, a
clearer role for counselling emerges.
To date, various of psychological treatments have been
identified as being efficacious in the treatment of major
depressive disorder (MDD), all of which are predicated upon the
therapist's possessing a foundation of basic psychotherapeutic
skills. These skills have been defined as the ability to form an
effective working alliance with the patient, assess psychological
issues as separate from presenting symptoms, closely monitor
one's own feelings in the treatment, promote a safe therapeutic
milieu, and employ specific interventions .
Psychotherapy for depression is usually taught within the
context of discrete treatment modalities, each of which offers a
formulation and set of interventions for combatting the disorder.
Practising clinicians, however, are more likely to use an
eclectic mix of strategies from different models. This carries
the risk of diluting the strategies of any single model. The
recommendations outlined in this document are based on evidence
from studies in which there is careful attention to the correct
application of a specific model. In particular, the most
consistent data relate to cognitive-behavioural therapy (CBT) and

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interpersonal therapy (IPT), but these are models in which only a

few practitioners have received specialized training. These
guidelines may not be applicable to an informal and personalized
combination of strategies. IPT has demonstrated that better
results are found when the techniques are applied in an expert
manner, and it would not be surprising to expect the same from
CBT. One clear implication is that training in these
psychotherapy models is urgently required in the field.

Limitations of Methodology
Psychotherapy for depression can be provided in individual,
group, or couples formats and according to a range of models
outlining the core psychological disturbances that underlie and
maintain mood disorder. It has been suggested that treatments
should be based on best-practice standards identified in the
scientific literature and should embody ethical principles that
are endorsed by professional licensing bodies . To this we would
add the principle of meeting evidence-based criteria for
efficacy. Clinical treatment of depression with a form of
psychotherapy that does not conform to these criteria would be
difficult to justify. Evaluations of the evidence base for
particular forms of psychotherapy for depression are not,
however, entirely straightforward. While positive data from
randomized controlled trials (RCTs) will continue to be central

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to the empirical validation of psychotherapies for depression,

some treatments have not been evaluated in this manner. Others,
when evaluated, may have been compared with insufficient control
conditions, such as waiting lists or sham therapy, that provide
little information about efficacy relative to the meaningful
baseline rates of placebo response or natural remission. Lastly,
it is likely that the modal approach to the psychotherapy of
depression taken in practice does not fully resemble those
treatments for which reliable empirical data exist. This may make
it more difficult for psychiatrists to be persuaded by outcomesoriented research into harmonizing their practice patterns with
the findings from these studies.

When is psychotherapy indicated for treatment?

Various factors will go into the decision to recommend a
specific psychotherapy. Some patients and clinicians have strong
socially based beliefs favouring nonpharmacologic interventions,
or they have concerns about potential medication side effects.
Others have equally strong negative ideas about psychotherapy. In
light of this, the decision to employ psychotherapy in any given
case will continue to be influenced by the psychiatrist's
clinical judgment, the patient's preference, and, in cases where
the psychiatrist is not providing such treatment, the
availability of resources in the community. The data summarized

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in this document offer reassurance that such preferences can be

accommodated with empirically validated treatments for each
choice.

What are the general principles of cognitive therapy and

behaviour therapy?
Cognitive therapy (CT) pursues symptomatic relief from
depression through a systematic effort to change depressed
patients' automatic and maladaptive ways of thinking. At the
heart of this approach is the assumption that distorted beliefs
about the self, the world, and the future maintain depressive
affect. Patients first work at becoming aware of these thinking
styles and then learn how to respond to them in ways that are
more adaptive. These skills, when accompanied by affective
arousal and practised in the context of extra therapy
assignments, are an important engine of symptom change .
The typical course of treatment runs from 12 to 16 sessions,
and the sequence of treatment involves 3 phases. In the early
phase, the emphasis is on establishing a therapeutic relationship
with the patient, educating the patient about the cognitive model
and influences on emotion, setting goals, and eliciting and
evaluating automatic thoughts. The middle phase

involves a

gradual shift toward the identification of dysfunctional beliefs

and compensatory strategies the patient may be employing, helping

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the patient to identify core beliefs, and practising skills at

responding to and modifying depressogenic views. Tasks in the
late phases of CT revolve around preparing the patient for
termination, predicting high-risk situations relevant to relapse,
and consolidating learning through self-therapy tasks.
Behaviour therapy (BT) for depression is premised on the
observation that patients with a mood disorder are exposed to
fewer positive reinforcers in their environments . Behavioural
interventions are especially effective for symptoms of social
withdrawal and anhedonia and are often used in tandem with
cognitive strategies (for example, CBT). An important goal of
behavioural treatment is to increase patients' activity levels
and engage patients in tasks to increase their feelings of
mastery and pleasure.
In the early stages, patients are asked simply to monitor
their activities and to rate the degree of difficulty and
satisfaction associated with completing or attempting each task.
As treatment progresses, patients are asked to perform, as
homework assignments, a greater number of pleasurable activities
or events. Training in social skills and assertiveness might also
enhance the patient's interpersonal repertoire and reduce the
number of aversive, submissive interactions with others. Toward
the end of treatment, the focus shifts to self-control training
and problem solving, so that the learning achieved in therapy can

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be generalized and sustained in the patient's social

environment . BT is now usually incorporated with CT as CBT.
CBT for depression is still a relatively new form of brief
psychotherapy, and so the resources available to patients seeking
treatment may be limited. Identifying a qualified cognitivebehavioural therapist can be facilitated through The Academy for
Cognitive Therapy. There are also several user-friendly CBT
patient manuals that can be recommended to patients or referred
to by psychiatrists who use elements of CBT in their therapeutic
approach. These include Mind over Mood

and The Feeling Good

Handbook .

How effective is CBT?

To date, the efficacy of CT or CBT has been evaluated in
over 80 controlled trials , with most studies favouring CBT over
various control conditions. The most meaningful support comes
from RCTs in which CT was found to be as effective as welladministered pharmacotherapy for the treatment of depression .
Additionally, 4 metaanalytic reviews found CT to be at par with,
or slightly better than, antidepressant medication in alleviating
depression .
The results of the National Institute of Mental Health
(NIMH) Treatment of Depression Collaborative Research Project
have received much attention, largely because this study of 250

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patients exemplified a high level of attention to methodological

detail and was state of the art at the time. It also included a
stringent control condition of patients receiving placebo plus
CM. Rates of improvement were equivalent among patients receiving
IPT, CBT, or imipramine over a 16-week course of treatment.
The efficacy of BT has also been evaluated in several
controlled studies, and in 2 instances it has been compared with
amitriptyline. In the first trial, BT was as effective as
amitriptyline, and both were superior to dynamic psychotherapy
and relaxation training . In the second trial, clinical
improvement (in social functioning and symptomatology) with
social-skills training (BT) was similar to that achieved with
amitriptyline and superior to supportive psychotherapy plus
placebo , although these differences were not maintained at
follow-up .
To examine specificity of treatment, BT was compared with 2
different versions of CT: one emphasized change in automatic
thinking alone, and the other represented a more extensive form
of CT . Results indicated that the 3 treatments did not differ in
their effectiveness. All 3 conditions showed rates of improvement
in the 60% to 70% range, and changes in depression scores were of
the magnitude found in other outcome trials of CT and BT. This
pattern of findings was maintained across treatments over a 6month follow-up.

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A controversial issue is whether CBT is less effective for

patients with more severe depressive illness. In the NIMH
collaborative study, a post hoc analysis found that in patients
with more severe symptoms (Hamilton Depression Rating Scale
[HDRS] score of 20 or greater), the imipramine plus CM and IPT
conditions did better than placebo plus CM, but CBT did not .
There were no significant differences among treatments in the
less severely ill patients. Subsequently, a reanalysis found that
imipramine plus CM was superior to both IPT and CBT in patients
with more severe depression, both psychotherapy conditions did
better than placebo plus CM, and IPT was superior to CBT . Other
studies also suggest that patients with more severe depression
have lower response rates to CBT .

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References
FREEDMAN, R.F. & WOODWARD, S. (1992) Behavioural treatment
of menopausal hot flushes: evaluation by ambulatory
monitoring.American Journal of Obstetrics and Gynecology, 167,
436-439.
GERMAINE, L.M. & FREEDMAN, R.R. (1984) Behavioural treatment
of menopausal hot flashes: evaluation by objective methods.
Journal of Consulting and Clinical Psychology, 52, 1072-1079.
GREENE, J.G. (1984) The social and psychological origins of
the climacteric syndrome. Aldershot: Gower.
HUNTER, M.S. & LIAO, K.L. (1995) A psychological analysis of
menopausal hot flushes. British Journal of Clinical Psychology,
34, 589-599.
KRONENBERG, F. (1990) Hot flashes: epidemiology and
physiology.Annals of the New York Academy of Sciences, 592, 5286.
STEVENSON, D. & DELPRATO, D. (1983) Multiple component selfcontrol programme for menopausal hot flushes. Journalof Behaviour
Therapy and Experimental Psychiatry, 14,137-140.