Book Review
Psychotherapy 
Roadblocks in Cognitive-Behavioral Therapy. Robert L Leahy, editor. New York: The Guilford Press; 2003. 364 p. US$40.00
Reviewer
rating*: Excellent
Review by: Irene Patelis-Siotis, MD, FRCPC
Hamilton, Ontario
This excellent book, which explores the issue of resistance in cognitive-behavioural therapy (CBT), should be read by anyone practising CBT. Most of the chapters are easy to read and address critical CBT issues. Several themes can be summarized as follows:
1. As the title indicates, the book focuses, first, on “roadblocks” to effective CBT. Many of these roadblocks are discussed in detail, with the discussion focusing particularly on personal roadblocks that can be attributed to the therapist, roadblocks inherent in the inter-personal process of therapy, and on how these interfere with the therapy course.
2. The book’s second theme is that cognitive therapists need to pay more attention to emotions when practising CBT. Although practising CBT techniques is an essential component of treatment, patients’ emotions are equally important and should not be neglected.
3. A third important theme is the risk that therapists will become too rigid when practising CBT. Here, interesting issues are discussed, such as the advantages and disadvantages of using manuals in the practice and study of CBT.
4. A final theme is that in most clinical situations it is important, if not essential, to work at a deeper cognitive level, focusing on schemas to better understand the complexity of our patients.
This book has 5 parts. Part 1 addresses case conceptualization and how essential it is to our deep understanding of the patient. Its chapters are well written and practical. I would particularly recommend them for learners of CBT. Along with the case conceptualization, the authors incorporate stages-of-change theory, which is critical to understanding why a patient may not be doing well in therapy. Part 2 has 3 chapters that are interesting to read, particularly for any psychiatrist treating patients with severe mental illness. One does not need to be a cognitive therapist to benefit from these chapters. Adrian Wells’ review of the metacognitive processes and overall processing of information helps us understand one of the many factors contributing to the chronicity of illness. Robert Leahy’s chapter on “Emotional Schemas and Resistance” is particularly interesting, as it gives us a model to understand some patients’ difficulties with tolerating emotional pain. As do many of the other chapters’ authors, Leahy illustrates his model with a clinical example. He also provides useful interventions to address this form of resistance. The last chapters of Part 2, by Stephen Holland, integrate Greenberg’s model of emotional processing with CBT to explain the frequently encountered problem of emotional avoidance. Part 3 covers specific populations, including patients with psychosis, bipolar disorder (BD), posttraumatic stress disorder (PTSD), and binge eating disorder. The chapter on PTSD offers an excellent algorithm treatment model to guide clinicians in choosing the treatment best suited to each patient. The chapter on BD is the weakest, in that it fails to address some common factors contributing to resistance in BD patients, such as perfectionism and the presence of comorbid disorders that frequently interfere with improvement. Part 4 addresses couple and family issues that so frequently contribute to resistance. The chapter on couple therapy is, unfortunately, not specific enough to CBT. Part 5 is one of the most interesting sections of this book: it discusses some of the psychotherapy processes that may contribute to resistance. Chapter 13 deals with the difficult-to-treat-patient from the perspective of Linehan’s dialectical behaviour therapy. This chapter is both practical and easy to read. I recommend it to anyone treating individuals with complex clinical presentations. In chapter 14, Christopher Stevens and colleagues focus on the therapeutic relationship. The authors educate us about “metacommunication,” a critical process that occurs in any therapeutic relationship. Indeed, understanding metacommunication provides tools to address alliance ruptures without compromising the cognitive therapy approach.
In summary, this is an excellent, affordable, and well-written book that skilfully addresses the issue of resistance in therapy, a difficult problem for most clinicians.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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