Cognitive Behavioral Therapy for Anxiety Disorders – Mastering Clinical Challenges Gillian Butler, Melanie Fennell & Ann Hackmann, Guilford Press, 2009, £24.00, hb, 224 pp. ISBN: 9781593858308

A look at National Institute for Health and Clinical Excellence (NICE) guidance for treatment of anxiety disorders reveals a revolution: first-line treatment for anxiety disorders is cognitive-behavioural therapy (CBT) and some other psychological interventions. Cognitive-behavioural therapy of severe anxiety disorders has reached a high degree of effectiveness through almost 25 years of treatment development and testing in randomised controlled trials. Improved access to Psychological Therapies (IAPT) is the only logical consequence of putting decades of research work into clinical practice and making it available for the wider population.

Gillian Butler, Melanie Fennell and Ann Hackmann, all of whom have played a leading part in this revolution, have summarised their insights in a great book.

This book is diagnosis driven, the CBT treatment models vary for each disorder, and it is essential to know the models to conduct therapy successfully. The authors though take a transdiagnostic approach to help deal with complex cases. The advanced CBT practitioner will find a wealth of practical ideas on how to progress when one gets stuck. Every step is backed up with easy-to-grasp diagrams and algorithms. Formulation of the case represents the ‘map’ for the ‘journey’ that the therapist takes with the patient through CBT to reach the ‘destination’, the goals of therapy. The authors suggest a generic way of using the formulation as an important step to deal with complexities. The ‘surgical blade of the mental health practitioner’, the appropriate concise questions targeting a particular symptom or leading guided discovery are outlined verbatim. We are being reminded that CBT, like mindfulness-based therapeutic approaches, promotes not only a more balanced and fair content of our thinking, but also a distanced, more objective relationship with our thinking process as a whole.

The book puts emphasis on overcoming common obstacles in CBT: the chapter about low self-esteem and the intolerability of uncertainty are highly useful for our understanding of factors indirectly related to anxiety. The chapter about emotional avoidance, a common and ill-understood phenomenon, is invaluable. In CBT the therapeutic relationship is generally not valued as highly as in other psychological therapies: here, the authors dedicate a whole chapter to exploring the opportunities and difficulties arising between therapist and patient.

I feel that there would have been an opportunity to dedicate a chapter to the intricate psychopathology and physiology of anxiety. I also would have liked to read more about the fascinating aspects of evolutionary psychology on anxiety disorders. Both can be useful to normalise anxiety experiences to patients and validate their symptoms.

This is a book for the experienced CBT practitioner. The authors should be congratulated for advancing the field with this structured and easy-to-read book.