Overcoming Obstacles in CBT


Craig Chigwedere, Yvonne Tone, Brian Fitzmaurice & Michael McDonough

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    To Petronella Chigwedere from all of us

    List of Figures

    • 2.1 Collaborative therapeutic alliance structure 13
    • 2.2 The case of Eva: five areas assessment 16
    • 2.3 Therapist reflection on relational issues with Eva 21
    • 3.1 Leo's panic-related faints: two models at play 45
    • 3.2 Jack's case conceptualisation 47
    • 4.1 Curve of energy levels for optimal learning 56
    • 4.2 CBT assessment – building the story out from the central complaint 58
    • 4.3 Legal triangulation – hazards for patients and therapists 61
    • 5.1 The therapeutic alliance, including the role of significant others 74
    • 5.2 Simple schematic representation of Dion's formulation 78
    • 5.3 Dion's distress equation 79
    • 5.4 Idiosyncratic formulation of Peter and Kim's interaction 85
    • 7.1 Conceptualising emotional shut-down 115
    • 8.1 The weight-scale analogy 144
    • 10.1 A problem-focused formulation 172
    • 12.1 Different settings and different parameters for CBT provision 218

    List of Tables

    • 2.1 Summarising common obstacles 29
    • 3.1 Examples of disorder-specific CBT models 42
    • 5.1 Early maladaptive schemas 76
    • 6.1 Normal versus abnormal perfectionism 97
    • 7.1 Differentiating exposure and normalising interventions 122
    • 7.2 Episode monitoring diary 125
    • 8.1 Common features of shame and guilt 133
    • 8.2 Dimensions of shame and guilt 134
    • 8.3 Shame and guilt experiences of self and others 135
    • 9.1 Types of intrusive and repetitive thinking 158
    • 11.1 Supervisory competence framework 193
    • 12.1 Identifying differences between CBT and CBA 211

    About the Authors

    Craig Chigwedere is a cognitive behavioural psychotherapist, clinical lecturer and director of the Foundation Course in CBT at St Patrick's University Hospital and Trinity College Dublin. He has many years of experience as a CBT clinician, trainer and supervisor. He trained in CBT at Maudsley Hospital and Institute of Psychiatry, London. His main area of clinical interest is in the field of medically unexplained disorders, where he has been involved in treatment of, and research into, non-epileptic seizures. He has taught and presented at workshops and conferences internationally, as well as being involved in the authoring of peer-reviewed publications in CBT. He is currently involved in research into the utility of self-practice and self-reflection in CBT training.

    Yvonne Tone is an experienced cognitive therapist at the Student Counselling Service, Trinity College Dublin. In addition to clinical work, she co-ordinates group therapy development and training. A registered psychiatric and general nurse, she gained valuable mental health experience as Senior Cognitive Behavioural Psychotherapist at St Patrick's University Hospital over many years. She completed her MSc in CBT at Trinity in 1999 and devised and facilitated two five-day foundation-level training courses in CBT for nurses in 2005/2006. She was an active committee member, developing the CBT Diploma/Master's course at Trinity College, where she is an honorary lecturer and supervisor. She is a member of BABCP and NABCT and is accredited as a trainer, supervisor and therapist.

    Dr Brian Fitzmaurice is the Postgraduate Course Director for the Postgraduate Diploma and MSc in Cognitive Psychotherapy at Trinity College Dublin and also Clinical Senior Lecturer in the School of Medicine. He is a Consultant Psychiatrist and Psychiatric Tutor in Wicklow Mental Health Services. He has special interests in the integration of CBT into community mental health services, early intervention services, medical education and the use of e-learning in healthcare. He has researched, received grants and published papers in these fields. He is a founding director of a campus company (http://www.etu.ie) that uses personalised e-learning to teach communication skills.

    Dr Michael McDonough is a full-time consultant psychiatrist and BABCP accredited CBT therapist at St Patrick's University Hospital. He is director of the hospital's anxiety disorders service and psychotherapy tutor on the Trinity College Dublin psychiatric training programme. He is honorary clinical lecturer at the Department of Psychiatry, TCD and supervises, examines and teaches on the department's postgraduate CBT courses. He trained in CBT at the Maudsley Hospital and Institute of Psychiatry, London. He has researched and published on a wide range of mental health topics including CBT, anxiety disorders, pharmacotherapy, medical education and addictions.


    We would like to thank many colleagues, family and friends from whom we have received support, advice and encouragement in the writing of this book. It is not possible to thank everyone by name; however, we would primarily wish to offer our thanks to:

    • our partners Jô, Sean, Alison and Alice and our families for the patience, tolerance, love and support during the writing process;
    • our colleagues for their support, stimulating discussions and assistance in the inception and development of this project, the layout of the manuscript, and review and reading of chapters, in particular Colette Kearns, Patricia Maher, Mary McGoldrick, Maria McMorrow, Melissa Hayde and Deirdre Flynn;
    • our patients, students and supervisees, from whom we have drawn the inspiration for the vignettes and many of the ideas for the obstacles and hypotheses presented in this book;
    • the editorial team at SAGE, in particular Suzanna Trefgarne, Alice Oven and Kate Wharton, and their reviewers, for their support and guidance.

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