Cognitive-behavioral therapy is not an individual therapeutic technique, but a broad term that categorizes therapies that are related (Dobson & Dozois, 2010). Cognitive behavioral therapy includes treatments that endeavor to modify overt behavior through altering an individual’s thinking, understanding, one’s suppositions, and the individual’s strategies of responding to various situations in life (Dobson & Dozois, 2010).
The diverse forms of cognitive behavioral therapy incorporate dialectic behavior therapy, rational emotive behavior therapy, rational living therapy, cognitive therapy, problem solving behavior therapy, schema therapy and ultimately mindfulness and acceptance intervention (Baer, 2003). All these therapies arise from corresponding theories. According to Dobson and Dozois (2010), all cognitive behavioral theories share three basic presuppositions.
The first presupposition asserts that cognitive activity affects individual behavior. The second presupposition states that cognitive behavioral therapies can be modified and monitored, whereas the third presupposition alludes to a possibility of desired behavior change being shaped due to cognitive change. However, the different forms of psychotherapy have slightly differing assumptions on each of them.
Rational Emotive Behavioral Therapy
The rational emotive behavior therapy (REBT) is one of the forms of psychotherapy under the cognitive behavioral therapy. The therapy was developed by Albert Ellis in 1955 and was initially called the rational psychotherapy (Dryden, David, & Ellis, 2010). The name changed to rational emotive therapy (RET) in 1961 after the proponent was criticized for emphasizing rational and philosophical ideas while ignoring the emotional side of human beings.
Consequently, Ellis changed the name to rational emotive behavior therapy, which is still in use. Ellis’ theoretical perspective was greatly influenced by the stoic philosophers who held a view that “people are disturbed not by things but their view of things” (Dryden, David, & Ellis, 2010, p. 226). This view shaped his belief that philosophical factors gave more insight on psychological disturbances other than the traditional psychoanalytic and psychodynamic beliefs.
The modern version of the stoic saying that “people disturb themselves by the rigid and extreme beliefs they hold about things” shows the principal belief that REBT has on the origin of psychopathology (Dryden et al., 2010, p. 226). Ellis’ philosophical influence can also be traced from the works of Emmanuel Kant on the critique of pure reason. This brings out the influence and restrictions of cognition and ideation in humans. Ellis argues that REBT is founded upon logical and empirical scientific methods.
REBT is also strongly associated with the humanistic school of thought especially the idea of ethical humanism. It also includes ideas from existentialist school of thought in its arguments. The existentialists propose that humans are at the center of their universe, but are not the center of the universe itself. It also asserts that humans possess the power of choice, but not unlimited choice (Dryden et al., 2010). Therefore, Ellis makes two assumptions in his premises regarding REBT. First, he states that it helps people maximize their self control, individuality, self interest and maximize their freedoms. The second assumption is that REBT helps people live an involved, devoted and selectively loving lifestyle. Therefore, REBT strives to enhance the individual and social interests simultaneously (Dryden et al., 2010).
According to Dryden (2005), REBT rationality is a hypothesis relevant to a person’s beliefs. Rational beliefs are deemed the core of human’s psychological health. This theory presumes that rational beliefs are adaptable, logical, and they enhance one’s relationship with the self. Irrational beliefs, on the other hand, are the source of psychological disturbance. They are inflexible, illogical and deter relationships with others (Dryden, 2005).
This form of therapy condemns ideas such as religious fanaticism where individuals are controlled by rigid dogmatic views that appear to have serious implications on psychological development. It insists on the flexibility of an individual’s thought patterns. Ellis’ work is also influenced by semantic beliefs that focus on over generalizations in language and careless language use. He argues that error modification in human language and thinking has a profound influence on human emotions and actions (Dryden et al., 2010). Ellis borrows from a humanistic psychologist Alfred Adler who believes that a person’s behavior hinges on his ideas. This is particularly the role of inferior thoughts in creating psychological problems. Ego anxiety based on the concept of self rating precedes psychological disturbance (Dryden et al., 2010).
REBT views cognitive functions, cognition, emotion and behavior as highly interdependent factors. This leads to a famous statement that emotions are caused by cognition (Dryden et al., 2010). In the ABC of REBT, the letter A stands for activation that arouses a person’s beliefs, B for the beliefs and C for the emotional reaction system stemming from the beliefs. REBT views a person as having overlapping intrapsychic processes as the beliefs influence one’s behavior (Dryden et al., 2010). This leads to a hypothesis that humans are not infallible hence are encouraged therapeutically to accept that they can make mistakes. This helps in challenging self imposed demands for perfectionism. Humans are, therefore, encouraged to understand that they have endless opportunities to change how they think, feel and act.
REBT therapists are good psychological educators. They use the ABC model during therapy to help patients work on their problems. The therapists stress the alternative methods of dealing with the patients’ psychological problems. The therapists’ effectiveness depends on their competence in getting the clients’ informed consent throughout the therapeutic process. Therapists using the REBT approach often use an active-directive therapeutic style together with Socratic and Didactic teaching modes. Nevertheless, the styles are applied uniquely to each patient (Dryden, 2005).
The sessions essentially start with the clients identifying their problems and setting healthy goals. The therapists follow a procedure that involves the use of the ABC guideline, which is challenging irrational beliefs and working out practical goals with clients. Clients are helped to take a broad view of their learning in varying situations and develop them into the therapeutic process. Clients get help in recognizing, confronting and altering their rigid irrational beliefs that are the causes of their problems.
The strategy in REBT is making the clients their own therapists. The REBT therapists teach their clients the use of specific skills useful in confronting their irrational beliefs. The therapists give examples of the particular skill being taught and at times written instructions on how to practice the skill when alone (Dryden, 2005). Use of constructive feedback in such situations is encouraged as it leads to perfection of the skill. The therapists take a back seat after some time and let the clients lead the way to make them associate with the healing process.
Problem Solving Therapy
Another form of therapy under cognitive behavioral therapy is the problem solving therapy (PST). It is an approach to clinical intervention whose focus is the practical problem solving attitudes and the necessary skills. PST goals include decreasing psychopathology and improving behavioral and psychological functioning. Preventing relapses and controlling development of new clinical problems alongside improving people’s quality of life are also part of PST goals (D’ Zurilla & Nezu, 2010).
This form of therapy was developed by D’Zurilla and Goldfried in 1971. The therapy is a result of attempts to achieve cognitive mediation, assist people to have self control and maximize generalizations and finally to maintain behavior changes. At the same time, it is an attempt to shift from the psychodynamic school of thought. The use of PST is not only limited to children population but is also applicable to adolescent and adult population. The theory that guides PST is originate from two basic tenets, which are a social problem solving standard and relational problem solving archetype of stress and welfare (D’ Zurilla & Nezu, 2010).
Social problem solving model is a cognizant, logical and purposeful action aimed at improving a problematic circumstance as well as reducing and adjusting negative emotions produced by the problematic circumstances. It involves finding solutions to the problem in the natural setting in which they occur. It may also be considered as a learning method, a strategy to manage the situation and a self control strategy.
The social problem solving model is a learning strategy as it results in change in performance of the individual (D’ Zurilla & Nezu, 2010). It is a management strategy that enables one cope with a wide range of circumstances in a versatile situation. Finally, the whole process is self driven because it enables an individual develop self control. This approach is useful in solving a wide range of everyday interpersonal and intrapersonal life problems.
Relational problem solving model of stress and wellbeing is the other assumption in PST. It states that symptoms of psychopathology are recognized and successfully treated if viewed as self defeating and maladaptive behaviors characterized by negative social and psychological consequences (D’ Zurilla & Nezu, 2010). Such symptoms are depression, low self-esteem, impaired interpersonal relations, and anxiety.
Cognitive therapy is among the therapies under cognitive behavioral therapy and is a reaction to the psychoanalytic school of thought. It was developed by Aaron Beck in 1960. Beck is said to have developed this therapy as an answer to some fundamental questions on depression that psychoanalysis does not address. The therapy assumes that a depressed person demonstrates distorted information processing (DeRubeis et al., 2010).
The information distortion causes the person to have a consistently negative view of self, the world and his future. The cognitive processes and matter are reputed to trigger behavioral, emotional and motivational signs of depression. For a clear understanding of the nature of emotional disturbances, cognitive model of emotional disorder is used. It centers on the cognitive content of a person’s response to upsetting events or the individual’s stream of thought.
Unlike psychoanalytic school of thought that focuses on the unconscious, the cognitive therapy focuses on the conscious mental events. The three domains that patients apply to report their state is the cognitive triad. The triad is useful to the therapists and patients in identifying areas affected by emotional distress (DeRubeis et al., 2010). Cognitive therapy assumes that sadness, lack of interest in normal activities and suicidal thoughts are related to concerns in one or all of the domains in the triad. Same focus on thought content is also used to identify other disorders. Anxiety disorders can be identified by focusing on the thought content of the patient.
Cognitive therapy focal point is on different beliefs. Alongside these beliefs, CT focuses on the patients’ evaluation and attributions of the cause of their conditions. As the patients get to terms with the content of their cognitive reaction, they are guided to view them as hypotheses rather than facts (DeRubeis et al., 2010). They are to view the thoughts as mere possibilities and not as realities. This phenomenon is called distancing whereby when the patients dissociate themselves from the negative belief patterns, they can have a more objective observation of their situations.
Cognitive therapy differs from other forms of behavioral therapies because of the role assumed by the therapist and the patient (DeRubeis et al., 2010). In CT, the therapist and client assume an equal role in solving the problem. However, the patients are assumed to be experts in their own experience as they know the meanings they have attached to the various events and situations in their lives. According to DeRubeis et al., the cognitive therapists do not claim to have knowledge of the experience but depend on the patients’ recollection of ongoing mental thoughts and images (2010).
Another form of cognitive behavioral therapy is the schema therapy. It is commonly used to treat clients with personality disorders. This form of therapy is believed to evolve from Beck’s cognitive therapy. It is as a result of clinical experiences of Jeffrey Young in his attempt to view life issues from a broad perspective. Schema therapy integrates aspects from gestalt therapy, behavioral therapy, object relations, and some aspects of psychoanalysis. Schema therapy targets acute character disorders rather than the serious psychiatric cases (Martin & Young, 2010). The schema therapy is a cognitive-development model founded on the postulation that unconstructive cognitions originate from childhood and previous encounters.
The three main concepts associated with schema therapy are a person’s schemas, an individual’s modes and a person’s coping styles at a given time. The Young Schema Questionnaire (YSQ) and Schema Mode Inventory (SMI) are valid tests developed and used to measure schemas and modes respectively (Young, Klosko, & Weishaar, 2003). These tests guide clinical assessment disorders that are treated using the schema therapy. Schema therapy suggests an integrative methodical model of treatment for a wide scope of chronic and characterological issues (Martin & Young, 2010).
The schema therapy is a premeditated advancement by Jeffrey Young to respond to constant self-overcoming prototypes known as early maladaptive schemas (EMS). Young classifies eighteen early maladaptive schemas by means of clinical observation, as opposed to the Freudian unconscious concept that cannot be ascertained (Martin & Young, 2010). According to Martin and Young (2010), people with more complicated tribulations have a few untimely maladaptive schemas that render them susceptible to emotive problems.
An early maladaptive schema is a widely persistent theme or pattern regarding self concept and a person’s relationship with other people. This concept is formed in childhood and is made clear throughout a person’s lifetime (Young, Klosko, & Weishaar, 2003). The themes about the self are dysfunctional to a large extent. Schemas are established based on lasting patterns holding notions, memoirs, a person’s feelings, physical sensations, and intense emotions.
For instance, people with EMS for abandonment have memories of early abandonment. The resultant emotions are those of anxiety and such people live in constant fear that the people they cherish will abandon them (Young, Klosko, & Weishaar, 2003). , For that reason, early maladaptive schemas are most genuine degrees of cognition that host reminiscences and resilient sentiments when triggered.
Schema therapy is a therapeutic technique targeting maladaptive schemas, survival strategies and modes that are unique to each client. The origin of a person’s emotional problem according to the proponents of the schema therapy is their unmet core needs during their adolescence and childhood that lead to the development of maladaptive schemas (Martin & Young, 2010)
As observed earlier, schemas are internal experiences that affect overt behavior by developing coping styles. According to Martin and Young, there are five needs of a child in the early years of life (2010). The child has a need for secure attachment to others, which involves nurturing.
The second need is the need for autonomy and competence. The child should also enjoy the freedom to convey valid needs and emotions. Spontaneity and play are also realistic needs during a child’s development. On the other hand, coping styles are the survival mechanisms a child uses to deal with his schemas. Some clients may cultivate escaping inclinations as a survival mechanism to deal with their anxiety schemas (Clarkin & Levy, 2006; Martin & Young, 2010). Therefore, in this kind of therapy, the therapist focuses on changing the schemas.
However, it is difficult to alter schemas as they are kept in the amygdala, the emotive region of the brain. Therefore, reason cannot be effective in its alteration. Schemas are resistant to change and can only be managed through therapy (Clarkin & Levy, 2006). Schemas can be practical or impractical and are primary cognitive concepts in what we usually refer to as our personality type. Even when provided with proof that refutes the schema, individuals twist information to maintain its validity. According to Martin and Young (2010), some schemas satisfy the law of primacy in learning that the first things learnt in life are likely to have a lasting impression. These preverbal schemas are likely to be deep-rooted and unquestionable even as the later ones are inclined to be conditional.
Early maladaptive schemas are usually unreserved premises (deep-rooted attitudes and points of view) of individuals frequently associated with the person’s self-perception as well as his or her surroundings. People tend to hold on to the familiar concepts due to this notion alongside the fact that schemas develop early in life. People have a sense of safety recognizing themselves and their surroundings (Martin & Young, 2010; Clarkin & Levy, 2006). The Schema therapy representation of therapy intends to assist people end maladaptive survival techniques that maintain pessimistic thought designs, outlooks and manners. Consequently, people can meet their core needs.
Schemas are greatly used in a therapeutic relationship as a way for change. Therapists work directly in cooperation with the client in recognizing and altering schema-directed thoughts and emotions. Using imagery and clear discussions of early life situations, the patients understand the origin of the dysfunctional schemas and what maintains the schemas (Martin & Young, 2010). This process challenges and modifies negative thoughts and behaviors.
Dialectical Behavioral Therapy
The reason behind DBT is the difference in individuals’ reactions. While some people may have normal reactions, others have extra ordinary reactions that are intense in given emotional situations (Stanley & Brodsky, 2009). DBT theory, therefore, stipulates that certain groups of people’s excitement extents may rise faster than a normal person’s projected provocation. Certain people are also likely to attain high degrees of emotional inspiration and require lengthy periods to return to the normal excitement levels.Dialectical behavior therapy (DBT) is the work of Marsha Linehan in 1990 (Stanley & Brodsky, 2009).
The primary goal of the dialectical behavioral therapy is to treat suicidal and self harming patients exhibiting borderline personality disorders. This, however, does not limit dialectical behavioral therapy as it can be used for special adolescent population with eating disorders (Baer, Fischer, & Huss, 2006). DBT is an answer to therapeutic segment that psychodynamics does not tackle effectively. Dialectical behavioral therapy puts emphasis on the psychosocial mode of treatment.
Dialectic behavioral therapy has certain characteristics (Robinns, Ivanoff & Linehan, 2001). Dialectical behavioral therapy is support-oriented and enables people to recognize their strengths and improve on them. This makes people feel better concerning themselves and their lives. DBT also helps patients identify thoughts and assumptions that make their lives difficult and teaches different thought patterns that make life bearable (Robbins et al., 2001; Stanley & Brodsky, 2009).
Therefore, it is dialectical because it focuses on behavior and thoughts that result in emotional deregulation. These characteristics offer considerable help in the assessment of the patients. The therapist can then gauge the patients’ emotional state depending on the feedback they give. Thoughts that particularly make patients’ lives difficult and how long such thoughts last can be considered in order for the therapist to fit the patient into an effective treatment plan.
For clinical intervention, the following approach can be used. Treatment of disorders using dialectical behavioral therapy either takes an individual approach or is done in a group session (Linehan et al., 2006). Standard DBT deals with five tasks that include enhancing behavioral capabilities and increasing motivation for adaptable behavior through emergency management and by decreasing emotions and cognitions interfering with the treatment procedures (Baer, Fischer, & Huss, 2006). For the effectiveness of DBT, there should be an assurance of a positive outcome in the patient’s natural environment. The treatment environment should assume a structure that strengthens functional behaviors. Finally, the therapist abilities and impetus to treat patients effectively is enhanced for desired outcomes (Linehan et al., 2006).
Mindfulness and Acceptance Intervention
Mindfulness and acceptance intervention in cognitive behavior therapy is included in the list of cognitive behavioral therapies (Fruzzeti & Erikson, 2010). This is a growing discipline within the therapeutic context essentially linked to Jon Kabat Zinn as the founder (Fruzzeti & Erikson, 2010; Teasdale et al., 2000). It is based on the Buddhist practice of meditation. However, in the practice of psychology it is used independently without religion.
Mindfulness and acceptance in this case are often used together. Mindfulness is “bringing one’s complete attention to the present experience on a moment to moment basis. It is also the awareness that emerges through paying attention on purpose at the present moment and non-judgmentally to the unfolding experience moment by moment” (Fruzzeti & Erikson, 2010, p. 348). Mindfulness is simply being aware of one’s own internal and external processes in an objective standpoint. Acceptance, on the other hand, is the willingness and ability to be open to experience as it is presented without any alterations (Fruzzeti & Erikson, 2010; Teasdale et al., 2000).
Acceptance is appropriate in CBT when the most desired change is difficult and appears unattainable. Mindfulness and acceptance therapy act as buffers to the clients especially when they appear stuck in unchanging situations (Baer, 2003). The first instinct for the client is usually to want to adopt an observable change immediately, which is not usually the case in this form of therapy.
Mindfulness and acceptance skills are considered operant and are negatively reinforced to alleviate the clients’ suffering (Roemer & Orsillo, 2011). Therefore, this technique is partly based on learning theories, which are forms of control strategies for stimuli in the event that change is either impossible or undesirable to the clients (Fruzzetti & Erikson, 2010). Mindfulness skills are essential in replacing maladaptive behaviors.
Mindfulness and acceptance centered therapies are founded on the premise that distress is not innate in one’s experience, but is a result of a reaction to the experience (Abba, Chadwick, & Stevenson, 2008). Such a treatment is anchored on present events (Segal, Williams, & Teasdale, 2002). The reality involves actively being absorbed in an objective self observation without trying to suppress inner experiences. Mindfulness acceptance therapy has no foreseen endpoint. The distinct feature of this therapeutic technique in relation to others is the lack of focus on release of tension (Segal, Williams, & Teasdale, 2002). Mindfulness and acceptance therapy does not analyze internal experiences, but focuses on awareness of substitute ways of connecting with internal experiences.
Mindfulness and acceptance therapy is considered a core concept in other cognitive behavioral therapies. It originally came about as treatment for depression (Segal et al., 2002). In dialectical behavior therapy, mindfulness and acceptance skills are essential for a complete treatment program, which is a therapy that was first developed for the treatment of patients with borderline personality disorder (Robbins, et al., 2001; Verheul et al., 2003). Acceptance and commitment therapy (ACT) approach relies on full acceptance of present day experiences and mindful discarding of barriers to pursuing life goals (Roemer & Orsillo, 2011). Research statistics show that mindfulness and acceptance based approaches are reliable treatments for numerous mental health conditions comprising depression and generalized feelings of anxiety (Baer, 2003).
Rational Living Therapy
Rational living therapy is a type of cognitive behavioral remedy that Aldo R. Pucci advances. It is an all-inclusive temporary cognitive, behavioral psychotherapy that puts emphasis on long-standing outcomes. Rational living counselors are not concerned with assisting people to recover. RLT incorporates knowledge and research findings from areas such as linguistics, cognitive development, social psychology and perception, theories of learning, and brain functioning (Pucci, n.d., para.1).
It is a systematic approach to cognitive-behavioral therapy. The rational living therapists know where they are at all points in the therapeutic process. RLT focuses on the therapist and client. For therapists, focus is on competence while, for the clients, the focus is on their rational skills. RLT stresses Aldo Pucci’s conviction that a method of psychoanalysis and psychiatric help that puts prominence on directions is likened to a sales task. The helper sells the philosophy and techniques of rational self-counseling with the hope that the client will buy them. RLT employs powerful persuasive techniques that reduce conscious resistance to therapy (Pucci, n.d., para.2).
Rational living psychotherapy is an enthusiastic type of treatment. It is projected to make use of the patient’s wishes by employing coherent motivational interrogation methods. Rational living therapy also has an instructive nature useful for production of long-term results for the patient and considers the underlying assumptions. The therapy discourages unreasonable categorization (Pucci, n.d., para.2). Pucci argues that diagnostic procedures and manuals are labels for a set of actions (n.d.). The labels often create an impression that the client has a disorder. This impression can cause the client further problems and may result in hopelessness or living self-fulfilling prophecies even in the case of a misdiagnosis. Rational living therapists, therefore, discourage irrational labeling.
Rational living therapy disagrees with the concepts of self-esteem and self-confidence and diverges from cognitive behavioral therapies’ insistence on self-acceptance (Pucci, n.d., para.3). Instead of these concepts, RLT sometimes utilizes an optional component called the rational hypnotherapy. In hypnotherapy, the patient does not have to believe the therapist’s suggestions. When opinions and responses are obtained by means of hypnosis, the patient feels as though a heavy weight has been lifted off his shoulder. This, therefore, is the way hypnotherapy techniques help people to change their maladaptive thought patterns. A deep hypnotic state also necessitates few repetitions of information for clients for it to integrate into their thoughts (Pucci, n.d., para. 4).
As much as the mentioned therapies fall under the umbrella of cognitive behavioral therapies, they are all different in their unique ways. Each therapy under this category subscribes to its own school of thought and uses different techniques in doing assessments as well as treating different psychological disorders.
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