Exposure and Cognitive Restructuring

After the first in-session exposure, treatment enters a middle phase in which sessions (typically five to six in the recommended 16-session treatment program) revolve around the routine of in-session exposures and review and assignment of in vivo exposures for homework. Exposures are guided by the client’s Fear and Avoidance Hierarchy. For clients to benefit from this treatment, they must begin to engage in anxiety-provoking activities in their daily lives. It is essential that the therapist encourage this by carefully assigning and reviewing homework for in vivo exposure. At the beginning of each session, the therapist reviews the client’s completed Be Your Own Cognitive Therapist Worksheet and comments on aspects that show progress or use of cognitive restructuring skills. At a minimum, clients should engage in at least one in vivo exposure every week. As treatment progresses, this rate should increase if possible.

Introduction

This introductory chapter provides an overview of Antichrist (2009). Written and directed by Lars von Trier, Antichrist tells a story of parental loss, mourning, and despair that result from the tragic death of a child. The two main characters in the film are not specifically named; their distinction in the credits is only by their gender; ‘She’, a researcher into witchcraft and gynocide (Charlotte Gainsbourg), and ‘He’, a cognitive therapist (Willem Dafoe). The film is divided into four chapters — ‘Grief’, ‘Pain (Chaos Reigns)’, ‘Despair (Gynocide)’, and ‘The Three Beggars’ — book-ended by a prologue and an epilogue. Challenging his audience emotionally and psychologically, von Trier's oeuvre has focused predominantly on female characters suffering incredible social duress. In Antichrist, one encounters perhaps von Trier's bleakest vision and his darkest, angriest film to date, where accusations of misogyny were again a source of controversy, born of the black depression into which he had admittedly sunk. The chapter then presents a brief biography of von Trier, which gives a clear picture of von Trier's artistic motivations and offers an insight as to how the director capitalised on numerous factors to bring Antichrist to the screen.

The Rightful Demise of the Sh*t Sandwich: Providing Effective Feedback

Background: As a trainee cognitive therapist in the early 1990s, I was taught the Sh*t Sandwich by my supervisor. I continued to use this technique for many years without seeing the need to extend my repertoire of feedback strategies. Aims: This article describes a number of other feedback techniques, raising awareness of the processes underpinning feedback, and facilitating reflection on feedback methods. Method: This review examines feedback and the methods of feedback used to improve clinical competence. Results: Evidence informs us that the use of good feedback has a significant effect on learners’ outcomes (Milne, 2009). However, despite recognition of its importance, many supervisors fail to give adequate feedback and utilize methods that are sub-optimal. One such problematic method is the notorious “Sh*t Sandwich” (SS), which attempts to hide criticism within a cushion of two positive statements. This paper looks at various models of giving negative and positive feedback, suggesting that our repertoire of feedback methods may require expanding. Conclusion: The review suggests that feedback is a complex process and methods that place an emphasis on the learner as an active participant in the learning process (i.e. interactive approaches) should be encouraged. The paper suggests that negative feedback should generally be avoided in favour of constructive support, accompanied by specific, descriptive, balanced feedback, with new learning being consolidated by role play. Generally, feedback should be given about the task rather than the person, but when it is personalized it should relate to effort rather than ability.

Enhancing Creativity in Cognitive Therapy

This article explores the nature of creativity in psychotherapy and offers several methods and frameworks with which to enhance creativity as a cognitive therapist. It reviews the methodologically permissive parameters of Beck’s model, while providing a framework for enfolding methods from other models so as to retain the cognitive character of these interventions when used within the cognitive therapy session. It also extrapolates from Edward deBono’s model of how to improve the quality of thinking to suggest specific interventions as well as general principles that can be used or adapted in cognitive therapy treatment. Numerous case examples are given and further resources for nurturing and generating creativity are provided.