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Cognitive and Behavioral Practice 18 (2011) 350–361

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When Clients' Morbid Avoidance and Chronic Anger Impede Their Response to
Cognitive-Behavioral Therapy for Depression
Cory F. Newman, Center for Cognitive Therapy, University of Pennsylvania School of Medicine

In spite of the fact that cognitive-behavioral therapy (CBT) for major depressive disorder is an empirically supported treatment, some
clients do not respond optimally or readily. The literature has provided a number of hypotheses regarding the factors that may play a role
in these clients' difficulties in responding to CBT, with the current paper focusing on two of these: (a) morbid avoidance, and (b) chronic
anger. Clients who engage in extreme avoidance patterns (including experiential avoidance) often leave therapy prematurely, and even
when they attend sessions they typically struggle to face homework assignments and other central aspects of treatment. This problem is
compounded when the clients also maintain longstanding feelings of anger and bitterness secondary to beliefs about having been
wronged in life. They reason that they have the right to refuse any situation or experience that would add to their subjective sense of
burden, including the challenging work of CBT. The case of “Trixie” highlights how the CBT therapist has to strike a balance between
nurturing and validating the client so as to encourage her to remain in the depression treatment study in which she is enrolled, and
focusing on issues and promoting homework assignments that are most germane to her depression and its maintaining factors of
avoidance and anger. Implications for conducting CBT and research with depressed clients such as Trixie are discussed, including
methods to retain the clients in treatment, facilitating their learning of and memory for the therapy, and repairing strains in the
therapeutic relationship.

C OGNITIVE-BEHAVIORAL therapy (CBT) for depression is

well established as an empirically supported treat-
ment, and yet this seemingly straightforward assertion is
not so much a conclusion as a starting point in trying to
understand and manage the extraordinary challenges
and complexities inherent in achieving optimal clinical
outcomes for the widest range of clients. The phenom-
enon of major depression, though well-described and
specified as a nosological concept (American Psychiatric
Association, 2000), is actually a highly heterogeneous
disorder, comprising diverse client populations in terms
of age, gender, and ethnicity, and more often than not
coinciding with comorbid clinical problems that compli-
cate the clinical picture (Whisman, 2008). Further,
depression can manifest itself in differing levels of severity
and/or chronicity, factors that impact the course of the
illness and the scope of the treatment. Additionally,
therapist skills come into play as well, as greater
competence in the delivery of CBT leads to improved
outcome, regardless of whether or not the depressed
clients exhibit problematic comorbidity (DeRubeis, Hollon,
et al., 2005; James, Blackburn, Milne, & Reichfelt, 2001;
Kuyken & Tsivrikos, 2009). Client variables have been
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© 2011 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
found to account for a significant proportion of the
variance in outcome, and need to be understood in their
own right (Garfield, 1994).
The aim of this paper is to focus on two factors that
seem to be prevalent and prominent in depressed clients
who have difficulties in readily benefitting from standard
CBT—(a) morbid avoidance, and (b) chronic, severe
anger or bitterness—each factor, individually and/or in
combination, often being related to comorbid personality
disorders. Specifically, the ways in which CBT therapists
can best manage these problems will be explored. The
therapist's goal in this regard is to be flexible and adaptive
in incorporating the appropriate interventions for clients'
avoidance and/or anger, while staying as true as possible
to the core elements of CBT for depression. The basis for
the following discussion is derived partly from the
literature, but also from experiences gained in having
taken part as a protocol therapist in several major
outcome studies involving the delivery of CBT for severe
and/or medication-resistant depression.
The Cognitive-Behavioral Model of Depression
One of the central features of CBT for depression is its
emphasis on the psychological significance of clients'
negatively biased beliefs about themselves, others (and the
world in general), and their personal future (Beck, Rush,
Shaw, & Emery, 1979). Clinically depressed clients tend to
 When Avoidance and Anger Impede CBT for Depression
believe that they are incapable of helping themselves
through difficult times and circumstances (helplessness),
that others are more competent and judgmental (inade-
quacy), and that the future will provide no relief
(hopelessness). The client's depressotypic thinking is
perpetuated by cognitive processes that maintain it.
“Such biases in information processing often lead
depressed individuals to neglect their interpersonal
relationships and to give up prematurely in trying to
achieve important goals. The result is a deepening of their
pessimism, a worsening of their mood, and a vicious cycle
of further withdrawal” (Newman & Beck, 2009, p. 2857).
Another important aspect of CBT for depression is its
focus on the client's actions. Specifically, depressed clients
often demonstrate problems with fatigue, low motivation,
and withdrawal from activities that otherwise could give
them a sense of mastery and pleasure. Thus, their
inactivity leads to low positive reinforcement, few oppor-
tunities for experiencing joy, and stagnation or regression
in feeling a sense of self-efficacy. This low level of activity
interacts negatively with their cognitive biases to produce
even more self-reproach, helplessness, and hopelessness.
In the most severe cases, depressed clients believe that life
is too painful and unrewarding, and that it will only get
worse, thus leading them to consider suicide.
The major aims of CBT are to teach depressed clients
the skills of systematically identifying, evaluating, and
modifying their thinking styles (toward the goal of gaining
a more objective and manageable view of their problems
and their potential solutions), and increasing their
involvement in activities that are enjoyable, prosocial,
and that lead to a sense of accomplishment. This system of
therapy is comprised of a broad set of cognitive and
behavioral techniques used strategically in the context of
a comprehensive case conceptualization (see Kuyken,
Padesky, & Dudley, 2008), facilitated by an understand-
ing, accepting, empathic therapeutic relationship (see
Gilbert & Leahy, 2007). The approach is characterized by
being time-effective, structured, and collaborative, with
special emphasis on “empowering and educating [clients]
in psychological skills such as rational responding,
objective self-monitoring, formulating and testing per-
sonal hypotheses, behavioral self-management, problem-
solving, and [other skills]” (Newman & Beck, 2009,
p. 2858). Homework assignments are implemented to
reinforce these skills, leading to better maintenance of
therapeutic gains over the long term (Burns & Spangler,
2000; Persons, Burns, & Perloff, 1988; Rees, McEvoy, &
Nathan, 2005), a hallmark of CBT (DeRubeis, Hollon, et
al., 2005; Dobson et al., 2008; Gloaguen, Cottraux,
Cucherat, & Blackburn, 1998; Hollon et al., 2005). The
client's responses to the assignment and review of
homework also provide the cognitive-behavioral therapist
with valuable information for the case conceptualization,
351
the likes of which can help therapists better understand
and assist their clients who would otherwise struggle with
self-help tasks (Garland & Scott, 2005). The client's active
participation in the process of CBT, including homework,
is of central importance to outcome.
Review of Efficacy Research
There is ample empirical support for CBT for
depression across the lifespan. While an exhaustive
overview of the efficacy literature on CBT for depression
is well beyond the scope of this paper, it is instructive to
mention a few representative studies, such as Dobson's
(1989) meta-analysis of the early CBT outcome studies,
and the mega-analysis of four high-profile randomized
controlled trials in which pooled, raw data showed the
benefits of CBT (DeRubeis, Gelfand, Tang, & Simons,
1999). More recently, a comprehensive review of CBT
for depression reported 16 methodologically rigorous
meta-analyses showing large effect sizes of approximately
0.95 (standard deviation = 0.08) when compared to no-
treatment, wait-list, or placebo controls (Butler, Chapman,
Forman, & Beck, 2006). Notably, relapse rates for CBT of
depression have been found to be significantly less than
for pharmacotherapy, even in moderate to severe cases
(Butler et al., 2006; DeRubeis, Hollon, et al., 2005; Dobson
et al., 2008; Hollon et al., 2005). In a similar vein, there are
data suggesting that clients who experience multiple failed
trials of antidepressant medication have an improved
chance of treatment success via the implementation of
CBT (Leykin et al., 2007).
At the same time, there is evidence that CBT may not
work for all clients in all situations, as noted in an
important recent trial studying extreme nonresponders
receiving CBT or behavioral activation (BA: a treatment
that diligently targets depressed clients' avoidance and
passivity), in which clients receiving BA outperformed
those in CBT (Coffman, Martell, Dimidjian, Gallop, &
Hollon, 2007). Research on suboptimal response to CBT
has identified a number of predicting variables, including
chronicity of the depression (Hamilton & Dobson, 2002;
Moore & Garland, 2003), insufficient participatory beha-
viors by the clients, including rejecting of homework
(Detweiler-Bedell & Whisman, 2005; Schulte & Eifert,
2002), premature termination (Saatsi, Hardy, & Cahill,
2007), the client's negative attributions about the therapist
and the treatment at the outset of the first session (Moras,
2002, 2006), clients exhibiting significantly avoidant
behaviors (Hollon & Devine, 1995) and endorsing a set
of beliefs that support such avoidance (Kuyken et al.,
2001), and certain life circumstance factors, including
being older and alone (Fournier et al., 2009).
In her work on treatment-resistant depression, Moras
(2002, 2006) notes that results for psychotherapies such as
352 Newman
CBT are disappointing when remission from depression
(not simply an improvement) is the goal, especially in cases
when clients have had a history of poor response to
treatment. Reflecting on her study sample, Moras states
that 35% of the clients (n = 5) posed a notable challenge
even when expertly delivered, advanced schema-focused
versions of cognitive therapy were used. For emphasis,
Moras (2002) goes on to add that, “… the clients
manifested reflexively dismissive, hostile, avoidant …
reactions and attributions … evident at the outset of
therapy, as well as difficult to modify …” (p. 44).
Similarly, in spite of promising data on the efficacy of
CBT for clients with Axis-II psychopathology such as
avoidant personality disorder and obsessive-compulsive
personality disorder when the clients complete the course
of treatment (see Newman & Fingerhut, 2005; Sanderson,
Beck, & McGinn, 1994; Strauss et al. 2006; Svartberg,
Stiles, & Seltzer, 2004), premature termination is a
frequent problem. Regardless of the comorbid diagnosis,
depressed clients who are not retained for an adequate
trial of CBT generally do not fare as well as those who
complete an intended course of therapy (Kuyken et al.,
2001; Kuyken, Watkins, & Beck, 2005; Saatsi et al., 2007).
This phenomenon takes on extra significance in light of
recent data suggesting that depressed clients may be more
apt to terminate prematurely from CBT than comparative
treatment models such as supportive psychotherapy,
behavioral activation treatment, interpersonal psycho-
therapy, problem-solving therapy, and others (Cuijpers,
van Straten, & Andersson, 2008).
The identification of the problem of “dropout” cases
raises questions about what causes such early exits from
therapy, and what can be done to ameliorate this problem
so that the clients may benefit from the full CBT
treatment package. As an example, a study by Bados,
Balaguer, and Saldaña (2007) at the Behavioural Therapy
Unit at the University of Barcelona found that 89 out of
their sample of 203 clients (43.8%) dropped out of
therapy early. Of these 89 clients, 46.7% evinced low
motivation and/or dissatisfaction with the treatment and/
or the therapist, suggesting that the therapists need to pay
close attention to the state of the therapeutic relationship,
to actively address the client's concerns in this realm, and
to make extra efforts to engage such clients. Echoing this
theme, Saatsi et al. (2007)—in their study of the
predictors of outcome and completion status in CBT for
depression—note that treatment efficacy may depend
significantly on whether clients persist in therapy or not,
and that “the length of time clients remain in therapy may
vary according to their presenting level of interpersonal
problems” (p. 185). Saatsi et al. add that, “The picture
that emerges of the client who ends therapy prematurely
is someone … who tends to report somewhat weaker
alliances with their therapist, fails to make significant
improvements early in treatment, and remains severely
depressed at termination” (p. 194).
Another 40% of the clients who left therapy premature-
ly in the Bados et al. (2007) study cited external difficulties,
which suggests that therapists must be vigilant in helping
their clients apply problem-solving skills to those obstacles
of everyday life that may otherwise impede their taking part
in regular treatment. Such a high figure of clients who
drop out of treatment early serves as a reminder to the field
of CBT that evaluation of treatment efficacy must take
these difficult-to-retain clients into account (i.e., by
examining the entire intent-to-treat samples).
Along the same lines, some clients are more difficult
to engage in the process of doing therapy homework
than others, and these clients are therefore at a
disadvantage at outcome and follow-up (Burns &
Spangler, 2000; Detweiler-Bedell & Whisman, 2005;
Strunk, Chiu, DeRubeis, & Alvarez, 2007). Inasmuch as
CBT is a psychoeducational approach to treatment,
motivating clients to be more active participants in
building coping skills via between-sessions assignments
is a vitally important part of improving outcomes and
maintenance. On the other hand, Cuijpers et al. (2008)
posit that, “It may be possible that the drop-out rate is
higher in cognitive-behavior therapy because some
clients find it difficult to understand how cognitions
work and how they can be changed and because therapy
requires homework to be efficacious” (p. 919). From this
perspective, homework may be considered to be an
“aggressive” treatment element of CBT, in that it has
great value, but also may entail some added risk.
Therapists who wish to encourage their reluctant
clients—some of whom may already have misgivings
about the therapeutic relationship—to engage actively in
therapy homework may have to demonstrate especially
high levels of skill in creating a sense of benevolent
teamwork in order to keep the clients in treatment long
enough to reap its benefits. In sum, CBT for depression is
as powerful a treatment approach as we have in the field,
but we have a long way to go in order to help those
clients who do not optimally engage or respond.
Case Example: The Role of the Client's Avoidance
and Anger in Her Response to CBT1
The following case example serves as an illustration of
a client's slow, initial failure to respond to CBT, as well as
her related vulnerability to abandoning treatment at any
given time. The client was enrolled in a major multisite
study of the treatment of moderate to severe depression
that was conducted as a follow-up to an earlier, similar
trial (see DeRubeis, Hollon, et al., 2005; Hollon et al.,
1
Details about the cases have been modified to protect the identity
of the clients.
 When Avoidance and Anger Impede CBT for Depression
2005). The discussion below will focus specifically on two
hypothesized factors—the client's morbid avoidance of the
treatment procedures, as well as her chronic anger. Severe
avoidance can manifest itself in a number of ways that may
interfere with treatment. Clients may miss sessions and/or
habitually arrive late, thus losing valuable treatment time,
making it difficult to pursue a full agenda in any given
session, and sending a message of low engagement to the
therapists. These clients may believe they are neither
intellectually skilled enough nor emotionally resilient
enough to take part in what may seem to them to be a
rigorous process of treatment, including homework. They
may be afraid to get their hopes up, and therefore they
invest little energy, as if to follow the maladaptive credos
that “I can never be disappointed if I never expect
success,” and “If I don't try, I can't fail.” As noted,
avoidance of homework can be a serious problem, as
clients lose the opportunity to learn and practice
important self-help skills. Further, highly avoidant clients
may also fail to tune into their own experiences, including
emotions, thoughts, and memories (Newman, 1991,
1999), resulting in poor processing of therapeutic
information, and exacerbating any existing deficit they
may have with specific autobiographical recall, which has
been linked to mood disorders (Gibbs & Rude, 2004).
Chronic anger (e.g., bitterness) is another impediment
to the process of CBT, as clients experience deep
resentments about having been treated unfairly in life,
and thus are more apt to evince negative reactions to the
notion that they are the ones who will need to make
changes. This characteristic has been associated with
Axis-II disorders such as borderline personality disorder
(Giesen-Bloo et al., 2007) and narcissistic personality
disorder (Newman & Ratto, 2003). Therapists who treat
depressed clients with longstanding anger issues often
find that they have difficulty engaging such clients unless
they readily validate the clients' negative feelings and
beliefs. Although it is vitally important for therapists to
provide accurate empathy, there is a limit to which
therapists can serve as the clients' advocates without losing
their ability to bring professional objectivity to the
therapeutic discourse. Therapists in such cases have to
walk a narrow line as they try to “prove” themselves to
clients who otherwise expect to be invalidated, while also
being an agent of change. Even if a chronically angry
client does not necessarily meet the diagnostic criteria for
a serious personality disorder, he or she may still believe
that it is too late to right the wrongs that have occurred,
and that the best way to face a cruel world is to be
emotionally hardened, even in therapy.
In the vignette below, the therapist recognizes that the
client views herself as having been beaten down by a harsh
life, and that she believes that she has “suffered
enough”—thus, she reasons to herself that it would be
353
futile and wrong to take part in any aspects of treatment
that may tax her or lead to her being disappointed yet
again. In response, the therapist will need to be sensitive
to the client's views, lest she drop out of treatment
prematurely, an occurrence that is often associated with
poor outcome. At the same, time, he will need to find ways
to make the active parts of the treatment (including
homework) somewhat more palatable for the client so as
to maximize her collaboration in the process of CBT.
Although the clinical issues portrayed below are similar
enough to the actual events in treatment as to make
relevant observations pertinent to this thesis, the identi-
fying features of the client and the specific nature of the
key real-life situation in question have been altered
sufficiently to protect the client's anonymity.
Summary of the Case
The client (who shall be given the pseudonym
“Trixie”) was a 34-year-old, never-married Caucasian
female who worked as a dental hygienist. She received
CBT in a major randomized controlled trial for the
treatment of chronic depression. As the study sought to be
as applicable as possible to CBT in “real-life practice,”
clients could meet criteria for most comorbid personality
disorders and still be included in the protocol, with the
exception of schizotypal, borderline, and antisocial
personality disorders. Although Trixie did not qualify
for the full diagnosis of borderline personality disorder at
intake (thus she was not screened out of the treatment
study protocol), she demonstrated many of the cognitive
and emotional features consistent with this disorder,
including marked abandonment fears, significant issues
with anger, an ill-defined sense of self, and suicidal
ideation. Thus, any therapist in charge of Trixie's care
would have to balance the need to stay as close to the
study protocol as possible (CBT for major depression)
with the need for providing this client with interventions
that are consistent with cognitive-behavioral approaches
for the treatment of borderline personality disorder (e.g.,
Brown, Newman, Charleswoth, Crits-Christoph, & Beck,
2004; Giesen-Bloo et al., 2007; Linehan, 1993).
Trixie's progress in therapy was tracked at regular,
repeated intervals via the use of a number of measures,
such as the self-report Beck Depression Inventory (BDI;
Beck, Steer, & Garbin, 1988), the interview-based
Hamilton Depression Rating Scale (HDRS; Williams,
1988), the Longitudinal Interval Follow-up Evaluation
(LIFE; Keller et al., 1987, which assesses the client's
psychosocial and psychopathology status), and the Clin-
ical Global Impression Scale (CGI; Guy, 1976, which rates
the client's severity of illness and global improvement over
the course of treatment), among others. More subjective-
ly, the therapist kept close tabs on such factors as Trixie's
354 Newman
attentiveness and communicativeness in session, as well as
her level of activity in setting an agenda, discussing
relevant topics in depth, and practicing self-help techni-
ques via between-session homework assignments.
A look at Trixie's background is highly instructive, as
her personal history was notable for three important
interpersonal scenarios. First, she was adopted, which
later resulted in Trixie experiencing doubts about her
personal identity. Second, both of her adoptive parents
died before she reached adolescence, resulting in
significant grief, compounded by Trixie's feeling like an
unwanted outsider in the home of her aunt, uncle, and
cousins. Third, Trixie went through a number of
romantic relationships (in college and beyond) in which
she felt more invested than her partners, ultimately lost
the relationships, and came to believe that she was
unlovable and that all men would inevitably abandon her.
Trixie entered therapy with very negative beliefs about
relationships, an extremely strong sense of emotional
vulnerability, and an aversion to any implication that
she could or should “try harder,” or that there was hope
for her.
The therapist soon realized that Trixie was demon-
strating both pervasive avoidance and marked anger in
treatment. A flashpoint in therapy (for both of these
factors) occurred when the therapist tried to implement a
homework assignment to help Trixie counteract a
dysfunctional belief (“Nobody cares”) in the context of
her plan to avoid attending a community event in which
she was slated to receive an award for her substantial
volunteerism at a local animal shelter. When Trixie first
mentioned the civic honor that had been bestowed upon
her, the therapist was very enthusiastic, telling Trixie how
significant he thought this achievement was, and how
happy he was for her that she had received such
recognition for her work with animals. Trixie's resultant
shrug and grimace were immediate clues that her
thoughts and emotions were at odds with the therapist's
positive response. The dialogue below is a condensed
version of what transpired next.
Clinical Excerpt
THERAPIST: I'm very happy for you Trixie [pause], but
you don't look very happy for yourself. What are you
thinking and feeling right now?
TRIXIE: [Curt response. Arms folded tightly.] I don't want
to go. There is no point.
THERAPIST: Are you referring to the award cere-
mony?
TRIXIE: [Nods slightly. Looks grim.]
THERAPIST: Can we talk about this? I think this is an
important decision you're making, and I think it's
relevant to what we're trying to accomplish in therapy.
TRIXIE: There's nothing to talk about. There is no point
in going. Nobody cares.
THERAPIST: [Trying to look for evidence pertinent to Trixie's
belief that “nobody cares”]. Have you been asking certain
people to attend, but finding that they can't make it?
TRIXIE: [Sarcastic tone]. There is no point in asking
people to take time out of their busy lives just to go to
some insignificant ceremony. Nobody would care
enough to go, so I'm not going either.
THERAPIST: That seems so sad. [Pauses to reflect]. Your
award sounds significant to me. Maybe I'm guilty of
jumping to conclusions, but I have to believe that
somebody that you know would want to be there with you
on your special day. I have an idea, if you are up for
listening to it. Trixie?
TRIXIE: [An edge in her voice]. Whatever.
THERAPIST: How about a homework assignment? It
would be a behavioral experiment. You would ask a few
people of your choosing and see for yourself who would
want to go to your award ceremony, and if at least two
people say “yes,” then you would agree to go too. How's
that?
TRIXIE: [Sounding exasperated]. You know I never do
these homework assignments. Why do you still bother
giving them to me?
THERAPIST: I just want to help you the best I can, and I
know that homework can be a very useful part of therapy.
I realize that you are less than convinced about that, but I
would like to keep giving you homework assignments
that I think could be beneficial for you, so that if you
were ever to change your mind, the homework would be
there waiting for you to do it and benefit from it. Also,
I'm willing to take the risk that you might be somewhat
disgruntled by my giving you this behavioral experiment
assignment right now, because I figure that this situation
is somewhat time sensitive. When is the award cere-
mony?
TRIXIE: A week from Saturday.
THERAPIST: That's what I mean. If we postpone acting
on this situation, we might miss our chance to do
something significantly helpful for you. I guess assigning
 When Avoidance and Anger Impede CBT for Depression
you a behavioral experiment is my way of giving you an
encouraging message of Carpe Diem…seize the day! What
do you think? Who might you ask to attend?
TRIXIE: You know, I'm really not interested in getting
my hopes up, and then being let down yet again. It's just
too painful and I'm tired of it [weeps]. I've suffered
enough in my life.
THERAPIST: [Pauses to formulate a comment that would
combine empathy with encouragement to change]. That helps
me understand why you're so reluctant to do this. You
view it as a set-up for more rejection, hurt, and
abandonment. I see. At the same time, I hate to see
you abandon yourself. I think you deserve to treat
yourself better than that.
TRIXIE: [Continuing to be tearful]. I don't get what you
mean.
THERAPIST: Regardless of whether anybody you know
is there to witness your receiving your award, you have
earned the right to be there, and to be recognized by an
organization that appreciates what you have done to
help them in their cause to improve conditions for these
poor animals.
TRIXIE: I just don't want to be alone, again.
THERAPIST: I know you feel strongly about that. I don't
want you to be alone either, but I imagine that you would
be most alone at home at a time when you could be
celebrating and feeling proud. That thought makes me
sad. I hope we can talk about this some more before you
reach a firm conclusion. This situation seems so relevant
to everything we have been talking about in your life,
especially your expectation that you are going to be let
down, and your compensatory strategy of avoiding any
situation where you might feel disappointed, which just
winds up fulfilling your prophecy of being alone and sad,
with little sense that you have anything worthwhile to
look forward to. That just further reinforces your feelings
of bitterness.
TRIXIE: [Silent, with tense posture].
THERAPIST: [Waits for a response]. You seem quite upset.
I'm sorry. [Pauses]. I'm interested to hear what is on your
mind right now.
TRIXIE: [Sounding irritated]. You know, I don't think I can
stay in this therapy anymore. It's too much. I can't do it.
THERAPIST: I hear you, Trixie. I know I am asking a lot
of you. I don't want to add to your stress, really. [Pauses].
355
Can I tell you what's on my mind?
TRIXIE: [Shrugs].
THERAPIST: I am wrestling with a dilemma, because I
want to be helpful to you in two ways that seem opposite to
each other, and that puts me in a quandary [tries to sound
playfully self-deprecating]. On the one hand, I want to give
you my full emotional support. I know you have had many
painful losses in your life, and the last thing you need is
another experience that reminds you that nobody is there
for you in your life. With that in mind, I am tempted to
agree with you that you should play it safe, not attend the
award ceremony, not risk feeling alone and abandoned,
and not bother with the homework assignment.
TRIXIE: [Makes eye contact].
THERAPIST: On the other hand, I feel that I owe it to
you to offer you all the strongest parts of this treatment
that give you the best chance to having unexpectedly
positive experiences and an increased sense of confi-
dence and optimism. That's why I'm so gung-ho about
the homework assignment, to the point of being really
annoying. I really think that it would be just and right for
you to receive your award, and to have others there to
share in your shining moment. The homework assign-
ment is intended to help you find out for yourself that this
can happen. I want that for you. [Pauses]. But I also don't
want to stress you out with more homework when you're
feeling down and vulnerable. What am I to do? Help!
[tries to be appropriately playful].
TRIXIE: I wish I could feel differently. It just doesn't seem
like I have any other choice.
THERAPIST: [Perking up]. I'm glad to hear that you wish
you could feel differently! I think you might be able to
accomplish that goal, but it might require that you try a
different strategy in your thinking and in your actions.
That's where the behavioral experiment comes in, and I
would be happy to work with you on this project to give
you every possible chance of exceeding your expecta-
tions. Trixie, I am so eager to help you with this. I am
personally impressed by your award, and call me naïve
but I have to think that at least a couple other people in
your life would be impressed as well, if you would only tell
them.
TRIXIE: What if I try this homework assignment, and
nobody wants to come? What then?
THERAPIST: I hope the outcome is better than that, but
if it comes to that, I think that you still have every right to
be proud of your accomplishment, and that it would be a
356
triumph for you to go to receive your award, and to refuse
to abandon yourself.
Trixie and her therapist continued this “negotiation”
over the homework, with Trixie hinting by session's end
that she would “think about it.” To the therapist, this
represented a step in the right direction, and so he
decided not to press the matter any further at this time,
lest Trixie become irritated by the perceived pressure to
perform. Conceptually, Trixie's avoidance of her own
award ceremony, based on anticipatory beliefs about being
abandoned and feelings of sadness and resentment about
being alone was an all-too-typical response to situations
that might otherwise give Trixie evidence against her
negative beliefs, and that would offer her the support and
care she craved. The therapist also recognized that Trixie's
belief that “nobody cares” transcended the discrete
situation of the award ceremony—she believed that she
was generally uncared for in life. He could have addressed
this broader negative belief on the spot, but decided that it
was best to stay close to the specific situation of the award
ceremony at this time, especially as it afforded a prompt,
concrete test of Trixie's expectations, focusing on an event
of some immediate significance in the client's life. The
therapist made it a point in future sessions to address
Trixie's more generalized belief about being unloved in
her life. Focusing on this sort of sensitive issue was always
somewhat risky, as Trixie often hinted that she was
thinking of “pulling out of the study,” reporting that the
work of therapy (especially homework assignments) was
“causing too much pain.” The therapist frequently felt as
though he were walking a very fine line between giving
Trixie an adequate enough “dose” of CBT to alleviate her
chronic depression and associated personality disorder
features, and losing her altogether to early termination
owing to her perceived incapacity to handle the rigors of
the treatment.
With regard to the specific assignment above, Trixie
did in fact follow through, and wound up accepting her
civic award in the presence of two cousins, two neighbors,
four other volunteers from the animal shelter, and her
employer (the dentist)! The therapist responded to
Trixie's news with great enthusiasm and words of
congratulations for her having had the courage to enact
the assignment, thus creating such a positive outcome. In
response to the therapist's positive feedback, Trixie was
somewhat low-key, even saying that it was “no big deal.”
The therapist's thoughts were, “That's a maladaptive bias!
It was a very big deal when Trixie thought that nobody
cared and that she would not attend the award ceremony,
so of course it is also a big deal now that she could attend and
that others cared enough to attend too.” The therapist opted
not to share these thoughts, reasoning that it would risk a
power struggle over “Who was right?” about the assign-
Newman
ment. Instead, he simply continued to offer positive
feedback, and made plans to try additional assignments in
upcoming sessions so as to parlay this triumph into
additional therapeutic benefits for Trixie. Indeed, Trixie
now became more willing to do therapy homework
assignments (behavioral experiments much more so
than written assignments) even if she seemed less than
enthusiastic about them. Nevertheless, an important
change had taken place.
Clinical Outcome
Trixie completed the treatment protocol in its entirety,
including the follow-up phases of the study. Toward the
end of the “acute” phase (active, weekly sessions), Trixie's
scores on the self-report BDI, and interview based HDRS,
LIFE, and CGI dropped into the range indicating that she
was a “responder” to treatment. The therapist had some
concerns about how durable these positive changes might
be, but with the exception of only one follow-up data
point, all of Trixie's outcome measures demonstrated
maintenance of her gains in treatment. Upon reflection,
this was a very fortuitous result in light of how minimal
Trixie's response to treatment was in the early stages, how
avoidant she was of homework for so many weeks, and how
often she seemed irritated and on the verge of quitting the
treatment. The therapist learned a number of important
lessons from this experience with Trixie. First, a client's
initial lack of response to treatment does not necessarily
mean that he or she has dim prospects for change. In such
cases, hopefulness starts and continues with the therapist.
Second, by continuing to present homework assignments
to the client—albeit in a nondemanding and judiciously
timed manner—the client was able to use them in ways
that facilitated her learning and boosted her morale,
without being unduly burdened. Third, the therapist had
to be very aware of Trixie's ambivalence about being in
therapy lest he lose her, and he had to show a great deal of
empathy for her sense of vulnerability and loss while still
promoting the active, efficacious tasks of therapy. Fourth,
the therapist reconfirmed for himself that it was okay to
share his own reactions in the service of improving the
therapeutic relationship.
Clinical and Research Implications
In order to further improve outcomes regarding CBT
for depression, therapists will need to pay special
attention to the clients' problems with morbid avoidance
and chronic anger. This will entail focusing on: (a)
engagement and retention of clients at risk for missed
sessions and premature termination, (b) facilitating the
clients' long-term memory of the positive lessons of
therapy, whether through homework or other means,
and (c) skillfully managing the clients' long-term resent-
ments and short-term strains/ruptures in the therapeutic
 When Avoidance and Anger Impede CBT for Depression
relationship. It will be important to include measures
related to these factors, as will be described below.
Toward a Complete Course of CBT
Some depressed clients (such as Trixie) are ambivalent
about being in therapy, and may be only one subjectively
negative experience away from leaving treatment at any
given time. Therapists must not assume that the clients
necessarily “want to be in treatment; after all, they're
here.” The situation may be much more tenuous than
that, especially when the clients evince an avoidant coping
style, a history of failed treatments, as well as bitterness
about never having been helped to overcome their
depression. Building a positive alliance is an obvious
requisite, but it may require much more than simply
acting in a genuine, professional manner. It may
necessitate an ongoing readiness—indeed, perhaps a
proactive stance—to address the client's misgivings about
being in therapy at all (Newman, 2007).
It is important to deal directly with the clients'
avoidance behaviors and supporting beliefs in everyday
life as one of the overarching goals of treatment (Kuyken
et al., 2001; Newman, 1999; Newman & Fingerhut, 2005).
The clients' avoidance behaviors can be assessed in part via
the Daily Activity Schedule (DAS; J. S. Beck, 1995), a
homework assignment that requires clients to account for
how they spend their time each day. Sparse or vague
responses, indications of excessive sleep and/or time
spent alone and idle, and/or failure to do the DAS
altogether will quickly alert therapists to the need to help
clients become more active. In order to assess the clients'
avoidance beliefs, inventories such as the Personality
Beliefs Questionnaire (PBQ; Beck et al., 2001) and the
Young Schema Questionnaire (YSQ; Schmidt, Joiner,
Young, & Telch, 1995) can highlight the assumptions
clients maintain that support their maladaptive avoidance
behaviors. Data from these measures can be gathered at
repeated intervals, from pretreatment to follow-up, and
may serve as important indicators of meaningful, endur-
ing change. Although Trixie and her research cohort
were not required to complete these particular ques-
tionnaires as part of their periodic assessments, future
studies—especially those that do not exclude clients with
personality disorders from the treatment protocol—
would benefit from inclusion of such measures.
In general, it should be a red flag for therapists when
their depressed clients magnify the negative significance
of errors of commission (e.g., subjective risk of conspicu-
ous humiliation), while simultaneously minimizing the
negative significance of errors by omission (e.g., abandon-
ing goals, missing opportunities). These sorts of cogni-
tive errors should be discussed as an important agenda
item in treatment, and their relationship to the perpetua-
357
tion of depression should be made clear. If the depressed
clients feel helpless and powerless, therapists must
explicitly state that the goals of therapy include
improving self-confidence via gradual exposures to
challenging situations that stimulate personal growth,
such as attending work, school, social situations, therapy,
and so on. Therapists can empathically state that they
know this will provoke apprehension in the clients, but
that they will encourage their clients every step of the
way, will teach the clients to learn the skills of rational
responding in order to decatastrophize their concerns,
and will not be judgmental of the clients if they
experience difficulties. Therapists can also “touch base”
with short, supportive voice-mail messages to their clients
during the week, expressing hope and enthusiasm about
the upcoming session (see Newman & Fingerhut, 2005).
This may be especially important following sessions in
which the clients worked very hard, disclosed something
typically withheld, or otherwise felt “stressed out”
because they were confronting things they would
customarily avoid.
If depressed clients can succeed in modifying their
avoidant style and stay in therapy until their symptoms
remit (at which time they may transition into a
“continuation phase” of treatment, in which they taper
the frequency of sessions and take progressively more
responsibility for the maintenance of their therapeutic
gains—see Jarrett, Vittengl, & Clark, 2008), their chances
for long-term improvement will be greatly enhanced.
Toward this end, therapists must be persistent and
tenacious in engaging their clients, staying active in trying
to reestablish contact with clients who have taken an
unscheduled hiatus from treatment.
Enhancing the Client’s Learning: Counteracting Their
Experiential Avoidance in Therapy
Good CBT is not a spectator sport. Clients must be
active participants in the process. Neither should clients
“audit” their course of therapy. They need to take their
course of CBT “for a grade,” which means ideally that the
clients need to take notes, study, do homework, and
perhaps even be ready for a few “quizzes” (e.g., “What are
the main points you are taking from this session?”).
However, as noted, clients who exhibit longstanding
patterns of avoidant behaviors and beliefs are generally
disinclined to be so invested and engaged in the arduous
work of therapy, if they remain in treatment at all.
Somehow, therapists need to make the therapy process
simultaneously more compelling and less threatening for
highly avoidant clients, a difficult task indeed. A useful
way to approach this goal is to think in terms of making
therapy more memorable. This is in keeping with the
educational aspects of CBT.
358 Newman
As in the case of taking an academic course, it may be
useful to provide clients with a pre-therapy “orientation”
meeting, in which the goals and methods of the treatment
approach are spelled out in a spirit of hopefulness and
teamwork. At the same time, the clients may be invited to
express their doubts about treatment, in a spirit of
collaboration, and in order to assess some of their
potential misconceptions about the process before it
begins. This preliminary meeting may also be a good time
to present the clients with some questionnaires that can
be completed and turned in to the therapist on the spot.
Ideally, these questionnaires would assess the clients'
thoughts and behaviors pertinent to their acceptance of,
adaptation to, and utilization of the self-help skills and
tasks of CBT, such as the Ways of Responding question-
naire (WOR; Barber & DeRubeis, 1992) and the Basic
Behavior Questionnaire (Schulte & Eifert, 2002), among
others. Clients' responses on these inventories at different
points in the course of treatment can shed light on how
well they are grasping the tools of the treatment. If the
clients struggle with the paperwork, the therapist is there
to elicit the client's concerns and help manage the
problem, which may provide clues about difficulties that
may occur as the client moves forward.
In order to make the learning experiences of therapy
more active and memorable, therapists have to use a
wider range of methods, including switching from a
“content-oriented” approach to a “process-oriented”
approach when routine, conservative means continually
have hit a roadblock (J. S. Beck, 2005; Leahy, 2001, 2004;
Schulte & Eifert, 2002). This entails talking to the client
about what is happening in the immediacy of the
moment, with the therapists sometimes choosing to talk
benevolently about their own thoughts and feelings about
how they are trying to cope with the therapeutic impasse,
as Trixie's therapist did in discussing his sadness at the
image of Trixie being all alone at home when she could
be at a celebratory event. In order to facilitate memory for
the treatment procedures and coping skills, it is best if
clients take notes in session, write themselves a reminder
regarding homework (see Detweiler-Bedell & Whisman,
2005), utilize CBT workbooks between sessions (e.g.,
Bieling & Antony, 2003; Greenberger & Padesky, 1995),
and engage in behavioral experiments (Bennett-Levy et al.,
2004), among other learning tools. Clients should also be
encouraged to audio-record their own sessions (as they
might do for a university course lecture), and to make use
of personal mementos (e.g., photos, greeting cards,
certificates, personal letters) to facilitate story-telling
about their lives, and thus improve autobiographical recall.
In Trixie's case, the therapist recognized that he would
lose the client to early termination if he continued to press
for written assignments, but he was willing to take a chance
by strongly endorsing a behavioral experiment that had a
potentially high pay-off in giving Trixie a sense of self-
efficacy in the context of supportive others. Fortunately,
Trixie was willing to follow through with the assignment to
invite people to her award ceremony, with extremely
positive results. Although Trixie seemed nonchalant in
response to her apparent triumph, she remained in
treatment, began to incrementally increase her involve-
ment in homework assignments, and seemed more
connected to the therapist in the latter part of the course
of therapy. The fact that Trixie's outcome measures
continued to improve during the follow-up phases of the
study supports the hypothesis that she actively learned
something from therapy that she was able to utilize
successfully on her own later on, thus overcoming the
morbid avoidance that predominated in the early sessions.
Addressing and Reducing the Client’s Anger, and
Repairing Alliance Ruptures
It is instructive to examine the complex emotion of
anger in terms of the clients' related beliefs (Beck, 1999;
Eckhardt, Norlander, & Defenbacher, 2004; Jones &
Trower, 2004). Thus, assuming that the clients are
socialized and willing to complete periodic assessment
questionnaires, it would be advisable to make use of self-
report inventories such as the PBQ, the YSQ, and the
State-Trait Anger Expression Inventory-2 (STAXI-2;
Spielberger, 1999) over the course of treatment and
follow-up. The client's beliefs that seem to reinforce
cynicism, mistrust, and denigration of self and others can
become overt targets of intervention in treatment.
When the client's anger is directed at the therapy
process (and perhaps the therapists themselves), it is
important to take action to assess and repair the alliance
rupture, which may manifest itself in terms of client
withdrawal (i.e., angry avoidance) and/or confrontation
(Safran, Muran, Samstag, & Stevens, 2001; Samstag,
Muran, & Safran, 2004). In a study of the therapeutic
alliance in an open trial of cognitive therapy for avoidant
and obsessive-compulsive personality disorders, outcomes
were most favorable when there had been a rupture in the
therapeutic relationship that subsequently was managed
and resolved (Strauss et al., 2006). Thus, anger in the
therapeutic relationship per se does not have to signal a
failed treatment. Rather, it is the manner in which the
therapists and clients actively deal with their differences
that can turn the tide. This is where therapists earn their
stripes as professionals, as they steadfastly remain hopeful
and empathic in the face of clients who harbor and/or
express anger about the treatment (Newman, 2007). In
the case of Trixie, the therapist responded to the client's
threat to leave therapy by “using himself” via presenting
his “dilemma” of wanting to be caring and giving to the
client in two apparently opposing ways (i.e., show
 When Avoidance and Anger Impede CBT for Depression
empathy by expunging the homework in light of her
feelings of vulnerability, yet give her the maximum help
that the treatment can provide, including assigning
relevant behavioral experiments). This sort of interven-
tion borrows directly from dialectical behavior therapy
(Linehan, 1993) and other well-described cognitive-
behavioral approaches to the treatment of personality
disorders (Beck, Freeman, Davis, & Associates, 2004;
Young, Klosko, & Weishaar, 2003).
In order to keep tabs on the vicissitudes of the
therapeutic relationship, measures such as the California
Psychotherapy Alliance Scale (CALPAS; Marmar, Weiss, &
Gaston, 1989)—which was one of the dependent mea-
sures in the Strauss et al. study—can be used periodically
throughout treatment. Therapists and clients fill out the
CALPAS independently at the same points in treatment,
leading to an informative series of time-lapse snapshots of
their respective views about the quality of their collabo-
rative relationship.
At times, therapists confronted by angry clients are
hesitant to present their clients with the more rigorous
elements of CBT, lest they risk further damaging the
therapeutic relationship. However, there is evidence that
the therapeutic relationship can be improved as a result of
the client's having success with the methods of CBT
(DeRubeis, Brotman, & Gibbons, 2005; Feeley, DeRubeis,
& Gelfand, 1999), and that sessions in which clients report
making positive changes in behaviors and cognitions lead
directly to significant improvements in mood symptoms in
the next session (Tang, DeRubeis, Hollon, Amsterdam, &
Shelton, 2007). Thus, it seems worth the risk to keep the
bar raised high for clients, even when they evince
significant avoidance and/or anger, provided that the
therapists are ready, willing, and able to work on being
extra understanding and validating in order to repair the
alliance. Otherwise, there is a risk that CBT will be
watered down, with its chief strengths remaining under-
utilized, and the clients failing to make adequate progress.
Conclusion
Although there is a wealth of data supporting CBT for
depression as an empirically supported treatment, results
are still disappointing for a significant number of clients
whose symptoms do not respond optimally. Many factors
that interfere with clients' responsivity to CBT have been
hypothesized and studied, and this paper has commented
on two of those: morbid avoidance and chronic anger.
The case of Trixie illustrates some of the issues that
therapists must deal with in order to have more success
with clients who have an avoidant style and/or harbor
anger that complicate their depression. Therapists must
be prepared to deal positively and hopefully with alliance
rifts, to address the process of the therapeutic interactions
359
when encountering roadblocks, to stay focused on
imparting the skills of CBT even when clients are
doubtful, and to try to make the therapy seem more
compelling, active, and memorable. In order to study
these phenomena, it is advisable to utilize measures of
client beliefs, expressions of anger, and the quality of the
therapeutic relationship.
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Address correspondence to Cory F. Newman, Ph.D., Center for
Cognitive Therapy, 3535 Market Street, 2nd floor, Philadelphia, PA
19104-3309; e-mail: psydoc@mail.med.upenn.edu.
Received: September 8, 2009
Accepted: July 29, 2010
Available online 4 February 2011