Leahy, R. L. (2017). Cognitive Therapy Techniques: A Practitioners Guide. Second Edition.

New York: Guilford press, xvii +517 pp., $45.75.

Robert Leahy, Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell

Medical Center, is Director of the American Institute for Cognitive Therapy in Manhattan. He is

Associate Editor of the International Journal of Cognitive Therapy and is a past President of the

Association for Behavioral and Cognitive Therapies, The International Association for Cognitive

Psychotherapy and the Academy of Cognitive Therapy. He has contributed greatly to the field of

Cognitive Behavior Therapy (CBT) with his books, seminars and articles.

Leahy organizes this Second Edition around categories of interventions or techniques. He

organizes the book into his introduction, 10 chapters focusing on techniques and four chapters

highlighting specific applications. He begins with traditional techniques for identifying and

evaluating thoughts and assumptions. Leahy writes in the first person with an easy to read style.

It is always a pleasure to read his work and listen to his lectures.

Leahy examines decision-making style, dealing with worry and rumination, establishing

perspective and identifying and altering schemas. He provides instruction on emotional

regulation techniques, strategies to alter cognitive distortions as well as dealing with self-

criticism and need for approval. One chapter is dedicated to anger management. He ends the

book with concluding comments, references and an index.

One strength of the book is the presentation of over 120 clinical and teaching forms, examining

such things as cost-benefit analysis, examining the quality of evidence, a perfectionism

inventory, examining confirmation bias, strategies to reduce thoughts to absurdity, risk versus
risk choices, “the boredom technique”, self-monitoring of worries, a form dealing with

understanding why individuals did not learn from past predictions, depolarizing comparisons,

challenging personal schemas, a daily emotional log, and a dimensions and interventions

inventory for emotional schemas, to name but a very brief view of the comprehensive forms

included. This new Edition focuses on improvements within CBT over the last many years

including metacognitive modeling, behavioral activation, acceptance and commitment therapy

and dialectical behavior therapy. It also includes compassion focus therapy and other approaches.

Leahy begins by focusing on the role of eliciting thoughts, as many models within CBT stress

relationship between stress, anxiety and depression and particular kinds of interpretive thoughts

which can lead to maladaptive coping. He contrasts Ellis’s Rational Emotive Behavior Therapy

with its demands and “awfulizations” with Beck’s model, which also deals with thoughts but

classifies them into automatic thoughts, classified by their distortions such as mind reading,

personalizing, fortune-telling, dichotomous or all or none thinking, and, deeper more difficult to

change core beliefs, which tend to be involved in negative self-evaluation. In both cases, one

uniting technique is that of disputation plus gathering the evidence to either prove or disprove the

idea being examined.

This Practitioner’s Guide is technique focused and throughout each chapter, Leahy presents a

series of techniques along with their description, strategies to utilize the technique, dialogue to

exemplify the technique, homework which might be utilized, a discussion of possible pitfalls and

cross reference to other techniques. Strategies to distinguish between events, thoughts and

feelings and strategies to explain how thoughts create feelings are presented and immediately

followed by strategies to help individuals discriminate between thoughts and facts. A helpful
checklist identifying 17 cognitive distortions is included along with many other chapter specific

worksheets, highlighting the key points presented. Leahy carefully provides a series of chapters,

each with many techniques for evaluating and testing thoughts, identifying assumptions and rules

and testing their rationality. He discusses dealing with confirmation bias, limiting attention to

alternative explanations, being insensitive to the typical prevalence of ideation and linking

unrelated events which leads some people to develop ideational relationships that do not exist.

After a very thorough and detailed examination of the many ways individuals might have a

distorted view of their world, the tone of the chapters shifts into techniques to deal with these

various cognitive distortions. Mindful detachment as a technique is presented together with

examining “thought-action” fusion. Leahy explains that many people tend to acquaint the mere

presence of a thought with the actual occurrence of the event thought about. Superstition also

plays a role, in that, individuals might believe that if they have a thought, it increases the

likelihood that the event will actually occur. Techniques are presented to assist individuals

determine if their thoughts are relevant. Acceptance procedures such as “welcoming the visitor”

or changing the perception of intrusive thoughts from being dangerous or problematic into those

of the “thought clown”, a procedures meant to create diffusion between thoughts and the related

affect. To that end, mindfulness techniques are also included.

In Leahy’s examination of worry and rumination, he begins by helping individuals identify their

worries and to determine whether they treat worry as a dire prediction of events without

hypothesis testing. Individuals are taught to ask if their rumination or prediction is testable and

then helped to examine such predictions for their “batting average”. One technique presented is

to have people actively image better outcomes which is followed by assisting people not reject

interventions because they might not be “perfect”. Assigning worry time, allowing people to be
flooded with uncertainty and many other techniques are detailed. As in many chapters, direct

intervention techniques are presented followed by those that are more based on mindfulness and

acceptance.

The stable, long-established sets of beliefs individuals hold about themselves and others, termed

schemas, can have a profound impact on depression, anxiety, anger and even memory. Memory

and memory recall tends to be selective, attending to those things congruent with our schemas.

Schemas are frequently difficult to alter. Leahy provides many possible techniques to deal with

this challenging process, starting with helping people understand they have schemas, then

assisting them in labeling and identifying them. The “vertical descent” procedure is discussed

and exemplified, whereby identification of automatic (more superficial thoughts) can help “bore

down” into more central ideational schemas or core beliefs in order to unearth their presence.

Schema compensation avoidance strategies are coupled with developing motivation to modify

such schemas. Leahy describes techniques of activating early memories, writing letters to the

possible source of negative self-beliefs, examining and challenging underlying schemas and

developing more positive and counterpointed schemas. As is the rule, exemplifying dialogue

between therapist and patient is illuminating and helpful. Mindfulness procedures of acceptance

and transcendence are also introduced.

Leahy correctly notes that there has been increased emphasis on the importance of emotion in

CBT. He provides many techniques meant to develop better emotional regulation. As with many

issues, one key initial step is always the identification of the problematic thought or, in this case

accessing and identifying the affect. Expressive writing techniques, techniques to identify

triggers that elicit strong emotions or, conversely, inhibit emotions are detailed together with a

comprehensive model of emotional schemas. Techniques to challenge guilt about emotions are
followed by acceptance procedures. Imagery re-scripting is described and is juxtaposed with the

technique entitled “doing what you don’t want to do”. This section is interesting reading, in that,

the reader can familiarize themselves with potent motivational questioning outlined by Leahy,

which is often similar to motivational interviewing.

In his discussion focusing upon examining and challenging cognitive distortions, Leahy notes

that on occasion, automatic negative thoughts may be true. Under these circumstances there are a

number of problem-solving strategies that can be brought to bear, coupled with examining the

underlying assumptions or conditional beliefs that may be potent in producing unwanted

depressive or anxious feeling. To this end, Leahy examines mind reading, fortune-telling,

catastrophizing, the tendency to assign global negative attributions to self and others, the

tendency to trivializing or discount successes as well as its opposite, to overfocus on negatives

and seldom notice positives. He also reviews generalizing from a single negative instance and

then developing a global pattern of negative ideation. All or nothing thinking, “shoulds”,

overestimating self-blame for negative events and its opposite – over-focusing on other people as

the source of negative feelings by always blaming them which often serves as an exercise in not

accepting personal responsibility are all discussed. Leahy covers unfair comparisons and

utilization of unrealistic standards together with the idea that we could and therefore must have

done better, even if we have done our best.

Many individuals ruminate by always asking “what if” questions. Other individuals often

overestimate the validity of feeling, such that, if they are depressed, then “everything” must be

bad. Some individuals reject any evidence or arguments that would belie their negative ideation

and, by extension, develop a judgment-based focus which polarizes everything into good versus

bad or superior versus inferior with little acceptance of human foibles. In each of these above
distortions, Leahy provides somewhere between 15 and 20 techniques to manage these

frequently encountered cognitive errors. In looking for unifying patterns throughout his

techniques, identifying the degree of belief in the distorted thought gauging its impact on

emotions tends to lead his list of techniques. This is followed by an exact and clear identification

of the distortion. Information gathering, conducting cost-benefit analyses, trying to gather

evidence that both supports and perhaps disproves the belief are typically recommended. The

quality of evidence is often scrutinized together with identifying what additional cognitive

distortions may be being utilized collaterally. Establishing testable hypotheses and developing

procedures to “see beneath” the initial belief which might uncover deeper, more relevant

schemas are suggested.

Helping people define the worst, best, and most likely outcome can be a useful procedure. Leahy

often suggests utilizing imagery to enhance behavioral rehearsal. He provides techniques to alter

the valence of negative thoughts, such as perceiving them being delivered by a telemarketer!

He suggests guiding people to ask if there might be a “silver lining” to the catastrophe they are

sure will occur. He encourages developing some prioritization system to assist people with all or

none thinking do not make their only emotional choice be between is catastrophe or bliss. He

suggests using perspective taking and asking individuals if others would have the same negative

appraisals that are being presented and adhered to by the patient. He provides procedures to

assist individuals understand that behavior is not fixed and is instead, transactional as well as

interpersonal, such that at different times and with different people, behavior varies.

Needless to say, with all the many distortions noted above and with 15 to 20 procedures and

techniques discussed for each one, Leahy provides a few hundred therapeutic strategies which
can be tried to help deal with the many ways people go about making their own lives more

challenging.

Leahy devotes extra focus on modifying the need for approval, challenging self-criticism and

managing anger. He explains that a key element in depression and anxiety is often an excessive

need for approval and self-validation, noting that such individuals typically have a combination

of distorted thoughts which can include mind reading, personalizing, catastrophizing, fortune-

telling, overgeneralizing, labeling, as well as others.

In his later chapters, Leahy fulfills the wish of many budding therapists to be “the fly on the

wall” as he takes us through dialogue between a skilled therapist and patient dealing with

anxiety, depression or anger. He provides dialogue of an initial session and then later sessions. In

these therapeutic exchanges, Leahy uses brackets to label the technique being utilized so that

readers have an understanding of how to weave these strategies into therapeutic dialogue. Leahy

takes us through collecting evidence, evaluating behavioral experiments, exposure procedures,

evaluation of self-fulfilling prophecy, all coupled with identifying and then enhancing coping

style.

Leahy has done cognitively oriented therapists a service by providing us with the Second Edition

of his Cognitive Therapy Techniques. It is, as the subtitle states, a practitioner’s guide which can

be an invaluable tool for those learning and beginning to utilize CBT techniques as well as an

excellent reference for those who been practicing and have experience.

I have often quipped that if graduate training programs in clinical psychology, social work and

residency programs in psychiatry simply had their students read all of Leahy’s books, they would

be well prepared! By ready his many books, it becomes clear that Leahy sees CBT as more than
a simple compilation of techniques. Familiarity with his presentations and other books precludes

criticizing this book is simply being “a bag of tricks”.

Typically, my reviews are somewhat more extensive however, as this is a book presenting

techniques, I fear that if I more extensively commented on the techniques presented, it might

reduce people’s motivation to purchase the book and hear it from Leahy himself. This book

would be an excellent addition to any graduate program or re4sidency training individuals in

CBT. It is an excellent adjunctive book to use in clinical supervision and a good review book for

seasoned practitioners to make sure that they are using the full spectrum of armamentarium

available. It is well worth its $46.75 price.

Howard A. Paul, Ph.D. A.B.P.P.

JCFBT Book Review Editor

Howardpaulphd.com

happhd@optonline.net