Pakistan Journal of Clinical Psychology, 2012, 11, 1,43-57 PJCP

©Institute of Clinical Psychology, University of Karachi

SCHEMA FOCUSED CBT INTERVENTION OF DEPENDENT

PERSONALITY DISORDER: A CASE STUDY
Uzma Masroor and Seema Gul
International Islamic University, Islamabad

ABSTRACT

Objective: The present case study explored the temperament and

charecterological nature of dependent personality disorder, and Cognitive
Behavior therapy with emphasis of childhood schemas as psychological
intervention strategy in this endeavor.
Research Design: Case study
Place and Duration of Study: Islamabad, Pakistan.
Sample and Method: Ms A.,26 years old female, a university student who
suffered from an enduring pattern of traits that comprised the characteristics
formally identified as “dependent personality disorder”. She also exhibited
anxiety states while encountering some challenging situation in general. Ms A
was provided with structured preplanned psychotherapy sessions of Cognitive
Behavior Therapy with special emphasis on identifying and restructuring of
schema constructs. Pre and post evaluation for rating the underlying schemas
and anxiety manifested was taken by using “young’s schema Questionnaire by
Young 1” and “Beck Anxiety Inventory by Beck and Steer2”.
Results: The results revealed momentous improvement in both variables.
Conclusion: It was concluded that Cognitive Behavior Therapy can be used as
an effective intervention strategy when focused on schema constructs of
individual suffering from dependent personality disorder.

Key words: Schema focused CBT; dependent Personality Disorder

1
Young, J. E. (1998). The Young Schema Questionnaire: Short form. Retrieved from
http://home. sprynet.com/sprynet/schema/ysqs1.htm
2
Beck, A. T., & Steer, R. A. (1990). Manual for the Beck Anxiety Inventory. San
Antonio, TX: Psychological Corporation
44 Masroor and Gul

INTRODUCTION

The treatment of a personality disorders remains controversial yet

challenging task among professionals as underlying rationale and overlapping
nature of such features becomes an additional task for clinician3.
Psychopharmacological treatment has been effective partially as no specific
medication can be administered to the patients per se, however maladaptive
personality traits like aggression, suspiciousness and mood instability, can be
attempted to manage through medication4. Psycho dynamic therapy was thought
to be only effective approach around five decades back as it showed effective
results in some controlled trial studies5 and a meta analysis6 as well. While a
comparative study of a short term psychodynamic and cognitive therapy yielded
equal results for cluster C personality disorders7, and relatively severe personality
disorders this combined treatment may prove effective8. Stone9 suggested to use
a collaborative approach of supportive therapy, psychoanalytical intervention and
cognitive behavior therapy for effective results.

3
Sperry, L. (1995). Handbook of the diagnosis and treatment of DSM-TR Personality
disorder (2nd ed.).New York:Brunner-Routeldge.
4
Reich, J. (2005). Drug treatment of personality disorder traits. In J. Reich (Ed.),
Personality disorder:current research and treatments, 127-146. New York:
Routeldge
5
Perry, J. (2004). Review: Psychodynamic therapy and cognitive behavioral therapy are
effective in treatments of personality disorder. Evidence–Based Mental Health,
7, 16-17.
6
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders: A meta
–analysis. American Journal of Psychiatry, 160, 1223-1232.
7
Svartberg, M., Stiles, T., & Seltzer, H. (2004). Randomized ,controlled trial of the
effectiveness of short –term dynamic psychotherapy and cognitive therapy of
cluster C personality disorders. American Journal of Psychiatry, 161, 810-818.
8
Gabbard, G. (2005). Psychodynamic psychiatry in clinical practice (4th ed.).Washington,
D. C. American Psychiatric Press
9
Stone, M. (1993). Abnormalities of Personality: within and beyond the realm of
treatment. New York :Norton.
 Schema Focused CBT Intervention 45

Cognitive Behavior Therapy (CBT) seems to be as effective as

medication 10 and has developed effective treatment methods focusing on self
defeating thought patterns but certain issues serve as obstacle when character
disorders are addressed with traditional methods, thus it fails to resolve
charecterologsical issues in true fashion11. The reason is that CBT assumes
essential motivation on the part of recipient while ignores deep down hidden
schema which are resistant to change with conscious effort ,hence these
inflexible patterns hinder challenging the thoughts and adopting healthier
behavior. Even large number of sessions may sometimes prove fruitless because
of underlying rigidity. Specifically individuals with personality disorder are over
or under modulated in terms of temperament and are irresponsible, uncooperative
and self focused in terms of character, as suggested by Cloninger et al.12.

Schema is charecterological component of personality. The temperament

can be defined as set innate, biological and constitutional influences on
personality (Biological aspect) and Cloninger13 contends that temperament has
four biological dimensions, i.e harm avoidance, novelty, co-operativenss and
persistence, while aggression and impulsivity are observed as additional
dimensions by Costello14. While dealing with personality disorder in
psychotherapy, both dimensions need to be considered for effective results.

10
Fawcett, J. (2002). Schemas or traits and states : Top down or bottom up? Psychiatric
Annuals, 32 (10), 567.
11
Beck, A., Freeman,, A., Davis, D., Pretzer, J., Fleming, B., Ottaviani, R., Beck, J. S.,
Simon, K., Padesky, C., Meyer, J., & Trexler, L., & Associates. (2004).
Cognitive therapy of personality disorders (2nd ed.). New York:Guilford.
12
Cloninger, R., Svrakic, D., & Prybeck, T. (1993). A psychobiological model of
temperament and character. Archives of General Psychiatry, 44, 573-588.
13
Cloninger, C. R. (2004). Feeling good: The science of well-being. New York:Oxford.
14
Costello, C. (Ed.). (1996). Personality characteristics of the personal disordered. New
York: Wiley
46 Masroor and Gul

The concept of schemas can be traced back to the early writings of

Beck15 and from the perspective of psychology /psychotherapy; a schema can be
referred as some extensive organizing code for making sense of one’s life
experience. Adler16 used the term “schema of apperception” and for him it is
central to person’s life style and the psychopathology refers to a person’s
“neurotic schema”. Millon17 established that personality disorders can be
conceptualized in a broader perspective by including both temperament and
character and personality is combination of character and temperament. Schema
refers to a set of core beliefs that he has learned from his childhood experiences,
and has been utilizing them to maintain a view of self, world and future. It also is
believed to be central to CBT and psychoanalytic therapy, as these both have
their own traditional conceptual framework18.

Dependent Personality Disorder (DPD) is characterized by “pervasive

and excessive need to be taken care of, that leads to submissive and clinging
behavior and fears of separation ,beginning by early adulthood” ,as described by
DSM IV –TR19. According to Psychodynamic perspective, problematic
dependency can be conceptualized in terms of the dependency conflicts, as
conflicts between urge to dominate and a desire to be cared for. Ego defenses
which are frequently used to manage the affect concerning these conflicts are
denial or projection, these defenses help identifying the approach in which

15
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New
York: Hoeber. Republished as Depression: Causes and treatment. Philadelphia:
University of Pennsylvania Press).
16
Adler, A. (1956). The individual psychology of Alfred Adler. H. Ansbecher & R.
Ansbacher (Eds.). New York:Harper & Row.
17
Millon, T. (1996). Disorders of Personality: DSM-IV and beyond (2nd ed.). New York:
Wiley
18
Stein, D., & Young , J. (1993).Schema approach to personality disorder. In D. Stein &
J. Young (Eds), Cognitive science and clinical disorders, 272-288. San Diego :
Academic Press.
19
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed, TR.). Washington, D C.
 Schema Focused CBT Intervention 47

underlying dependency needs are manifested20. In the DSM-IV-TR20, it is

mentioned is that separation anxiety disorder often leads to DPD and in this
case, the individual may seek help for some symptoms of anxiety or depressive
disorder 21.

Individuals with DPD do not actively participate in therapy process

usually ,yet another pattern of dependency 22 as responsibility of taking care of
their lives are assumed to be domain of others around them23.They view the
world as others will protect them and will care for them 24.

Young 25 developed schema therapy as a systematic approach to treat

patients with chronic characterological problems expanding traditional CBT by
utilizing techniques from several other therapies for treating such cases. Schema
focused CBT mainly places it’s emphasize on exploring childhood and
adolescence experiences to reach to the dysfunctional and maladaptive attitudes
and schemas. He also asserted that some of these schemas were the result of
“toxic childhood experiences” a core of personality disorders.

A revised, comprehensive definition of an Early Maladaptive Schema was given

by Young 26 is as follows
“• An extensive, persistent theme or pattern

20
Coen, S. J. (1992). The misuse of persons: analyzing pathological dependency.
Hillsdale, NJ: Analytic Press
21
Comer, R. J. (2010). Abnormal Psychology (7th Ed). NY: Worth Publishers.
22
Gabbard, G. (2005). Psychodynamic psychiatry in clinical practice (4thed.).Washington,
D C. American Psychiatric Press.
23
Allnut, S., & Links, P. S. (1996). Diagnosing specific personality disorders and the
optimal criteria. In P. S. Links (Ed.), Clinical assessment and management of
the severe personality disorders (pp.21-47). Washington DC: American
Psychiatric press.
24
Sperry. L., & Masak, H. (1996). Personality disorders. In L. Sperry & J. Carlson (Eds),
Psychopathology and psychotherapy: From DSM- IV diagnosis to treatment (2nd
ed.,pp.279-336), Washington DC: Accelerated Development /Taylor & Francis.
25
Young, J. E. (1999). Cognitive therapy for personality disorders: A schema-focused
approach. Sarasota, FL: Professional Resource Press.
48 Masroor and Gul

• comprised of memories, emotions, cognitions, and bodily sensations

• regarding oneself and one’s relationships with others
• developed during childhood or adolescence
• elaborated throughout one’s lifetime and
• dysfunctional to a significant degree”

Failure to achieve desired results through merely CBT in case of DPD

refers to the core set of beliefs that one cannot perform as well as others, so no
attempt is made out of fears of failure26.As we proceed a little deeper, we can
easily identify some schema functioning as determining factor. Their functional
dependency/incompetence schema are supported by their beliefs like “I am
helpless when am left alone” and “I must not do anything that offends my
supporters and helpers”11. Family may also be included in therapy as suggested
by Sperry 3.

CASE STUDY

History and presenting complaints:

Ms A, 26 years old female, belonging to a middle class family, student of

a university was referred by psychiatrist for her unprovoked anxiety symptoms
on encountering minor challenging situations like taking an exam, arranging for
workshop and preparing for a presentation, though it never led to a panic attack.
She reported situational / generalized and intense feelings of uneasiness and
tension invariably. She is older among three children and was completing her
master’s degree in economics from a local university, living with mother and two
siblings as father divorced her mother five years back. She approached author
after being referred from a consultant psychiatrist for comprehensive
investigation into her problem as well as behavioral intervention for her
persistence in excessive worry and concerns over minor day routine issues,
however some relaxant was prescribed. She was accompanied by a friend who
would stay with her for most part of the day; while mother also facilitated
required information during psychological assessment. She attained
developmental milestones well in time and the mother reported that no noticeable
physical disease was present since childhood. It was also added that there had
been unstable pattern of temperament while accomplishing her work, dealing
26
Young, J., Klosko, J., & Weishaar, M. (2003). Schema Therapy: A practitioner’s guide
.New York: Guilfords.
 Schema Focused CBT Intervention 49

with relationships and expressing thoughts. During initial clinical interview

session she appeared to be apprehensive, reluctant and less co-operative. She
informed her excessive concerns and worries about her everyday matters, also
feelings of inadequacy and shakiness once situation demands her competency
and independent effort, she is relatively calm and relaxed while have some
support and reassurance. Consequently, Ms A developed withdrawal tendencies,
irritability, and fear of facing people and challenging situations. Further relevant
information has been compiled in next section.

Assessment Phase

As assessment refers to a detailed review of history of the problem, in this case

both it was done from formal and informal perspectives.

Informal Assessment from CBT perspective: There is a brief review given on

her current problem
Childhood experiences Deprived of father’s affection, siblings not
interactive, mother over protected and
authoritative, strict and disturbed home
environment, broken family
Precipitating factors Few friends, Failed her fifth grade,
difficulties in learning ,financial crises
Mediating Factors Lack of social interaction and opportunities
to act independently
Current problem Anxious on self initialed tasks, decision
making or taking responsibility
Thoughts that run through “ I simply can’t do that (the task she is
mind assigned to)”
“I am incapable and weak, can’t take care of
my needs”
“They should understand I am not strong
enough to go ahead with this responsibility”
Resulting Behavior Clinging with someone, avoiding situations
where she is supposed to act independently,
becoming overwhelmed by fear
Physiology of problem Heart palpitation, uneasiness, cold flashes
and throat dryness
Emotions Anxiety and fear/apprehension
50 Masroor and Gul

It can be concluded from the above mentioned information that her early
environmental factors at home foster her feelings of inadequacy and self doubt
specifically maternal attitude (over protective and authoritative) and paternal
absence. There appears to be strong deprivation and helplessness acquired from
cold and detached interpersonal interaction styles practiced at home during her
early years of life. These factors lead to her strong beliefs about her inability to
do anything autonomously and she compensated the deficit by relying on other
persons (mother and friend), seeking their assurance and ensuring readily
available support. The acquisition of such negative thought pattern and coping
styles lead her towards being anxious and apprehensive for everything in general.
The problem interfered with her daily functioning to the extent of looking for
consultation.

She also fulfilled DSM –IV 20 criteria of dependent personality with

some features of generalized anxiety, excluding any major diagnosis on Axis I.

Formal Assessment
Formal assessment was done through the following measures

Young Schema Questionnaire, short form ((YSQ-S; Young)1.

The Young Schema Questionnaire (YSQ) was first developed by Young

and Brown in 1990, and revised in 1994 (YSQ: 2nd edition; Young & Brown)27.
A short 75-item version, 6 item likert rating YSQ-S1 measures 16 schemas.
Preliminary studies of validation have proved good convergent and discriminant
validity28. Evidence also suggests that the short and long forms of the YSQ
produce correspondent results29.

27
Young, J. E., & Brown, G. (1994). Young Schema Questionnaire. In J. E. Young (Ed.),
Cognitive therapy for personality disorders: A schema-focused approach (2nd
ed.). Sarasota, FL: Professional Resource Press.
28
Schmidt, N. B., Joiner, T. E., Young, J. E., & Telch, M. J. (1995). The Schema
Questionnaire: Investigation of psychometric properties and the hierarchical
structure of a measure of maladaptive schemas. Cognitive Therapy and
Research, 19, 295–321.
29
Waller, G., Meyer, C., & Ohanian, V. (2001). Psychometric properties of the long and
short versions of the Young Schema Questionnaire: Core beliefs among bulimic
and comparison women. Cognitive Therapy and Research, 19, 137–147.
 Schema Focused CBT Intervention 51

Following are the schemas measured by instruments.

1-ed Emotional Deprivation

2-ab Abandonment
3-ma Mistrust/Abuse
4-si Social Isolation
5-ds Defectiveness/Shame
6-su Social Undesirability (no longer a separate schema)
7-fa Failure
8-di Dependence/Incompetence
9-vh Vulnerability to Harm & Illness
10-em Enmeshment
11-sb Subjugation
12-ss Self Sacrifice
13-ei Emotional Inhibition
14-us Unrelenting Standards
15-et Entitlement
16-is Insufficient Self-Control/Self-Discipline

Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory (BAI), by Beck and Steer 2 is a 21-question

multiple-choice self reported inventory measures severity of anxiety.

The BAI is psychometrically sound instrument with Internal consistency

(Cronbach’s alpha) ranging from .92 to .94 for adults and test-retest (one week
interval) reliability is .75. The concurrent validity with the Hamilton Anxiety
Rating Scale, Revised is .51 and .54 for the mean 7 day anxiety rating of the
Weekly Record of Anxiety and Depression. The BAI also possesses acceptable
reliability and convergent and discriminant validity for both 14-18 year and
inpatients and outpatients. The responses have three categories: Not at All = 0;
mildly = 1; moderately = 2, and; Severely = 3. The values for each item are
summed that yields an overall or total score for all 21 symptoms ranging between
0 and 63 points.
52 Masroor and Gul

The scoring categories are as follows

 0-7: minimal level of anxiety

 8-15: mild anxiety
 16-25: moderate anxiety
 26-63: severe anxiety

RESULTS

Table 1. Measurement of Schemas and anxiety on respective measures

Measure Variable Maximum Obtained Interpretation

Score score
Dependence 90 79 Highest
YSQ-S2
Incompetence 102 81 Higher

Subjugation 60 45 High
BAI
Anxiety 63 23 Moderately high

Treatment strategies

It took 28 (twice a week) sessions to get the goals of therapy achieved.

After completion of comprehensive evaluation, planning and conduction of
therapeutic intervention sessions involved the following steps:

Engagement and Facilitation

In opening session Ms A was encouraged to openly speak about her

concerns as she perceived them to be influencing her performance and
interpersonal life. The matter of her uneasiness was pursued with
empathy and facilitation that resulted in her co-operation; however,
insight into her dependency was quite minimal. She ensured her
compliance in forthcoming sessions, though did not seem much
motivated at the moment. For next two sessions, her aberrant dependency
and declined self reliance in addition to her coping mechanisms that
contribute to escalation of them were brought into her awareness by
 Schema Focused CBT Intervention 53

picking live examples from her routine. She partially agreed to them;
however chances of working on them remained relatively better than
before. After achieving reasonable collaborative intent from her side
following goals were set as an agenda for therapeutic process.

 To reduce / replace her schema by providing insight and empathy.

 To enable her to plan and carry out tasks of her immediate involvement or
personal management, by taking minimal help from others.
 To teach her to manage/handle disturbing thoughts that aggravates anxious
and apprehensive behavior while handling some challenging situation.

Pattern analysis

The overall pattern of her schema was also conducted after her general
evaluation, as given below

a-Schema construct analysis

Schema dependence/incompetence
Automatic Thoughts representing her “I can’t do anything on my
Thoughts underlying schema own, I need others’ help”
Emotions Fear, sadness
Underlying Consequences anticipated If I disagree ,she
assumptions about automatic thoughts (friend/mother)might leave
or abundant me
Coping style Surrender submissive acceptance of
used to deal inadequacy
with schema Avoidance No initiation and taking new
challenges
Subjugation emotional and physical
submission due to fear of
being abundant
Perpetuation Cog. Distortions “I can never do that”,etc.
of schema
54 Masroor and Gul

Pattern breaking Strategies

In order to implement preferred therapeutic techniques, the obtained

information about her schema structure was considered as focus of intervention.
As it has already been established through research findings that schemas are
enduring and deeply rooted components of core beliefs, hence a few exercises
from Cognitive Behavior Therapy were borrowed to change maladaptive
schemas (incompetence /dependency) to create healthy adaptive modes.

a- Altering Automatic negative thoughts: She was told to write down her
automatic thoughts and identify emotions related to those thoughts, also
challenge them logically and further rate her emotions later. As automatic
thoughts and attached emotion represent underlying schema, hence bringing
them into one’s awareness by listing them down, and altering /substituting
them with positive thoughts (and emotion) .Her self defeating and
discouraging thoughts accompanied with emotions of sadness and fear were
replaced with neutral thoughts (with emotion of excitement and happiness).
The technique was repeated consistently in every session rigorously for 6-8
sessions.

b- Breaking Vicious circles of inadequacy: Prepare a list of behaviors that are

acting like vicious cycles like avoiding the situations and people who might
threaten her efficiency. She gradually was encouraged to participate and play
her required role by facing the reality compared to her presumed fears. It is
significant to mention that breaking of her schema construct by challenging
targeted negative thoughts facilitated this part of intervention. Her checklist
for such incidents (where she needed to enter to break vicious circle)
promoted the preparation of collaborative setting of experiments, so that she
could check and reverse her negatively active thought pattern.

Termination and follow-ups

The measures were re-administered after 28 sessions when she and her
mother reported positive change that was also observable to author as well in
terms of increased insight, less anxiety and facing situations of her immediate
concerns effectively. The results and differences on measures are as follows.
 Schema Focused CBT Intervention 55

Table 2: Difference obtained on measures after treatment

Measure Variable Pre treatment Post treatment

YSQ-S2 Dependence 79 45

Incompetence 81 60

Subjugation 45 30

BAI Anxiety 23 18

She was terminated mutually after the completion of 28 sessions on reporting

minimal anxiety and responsibility acknowledgement on her part, when she rated
her progress at significant level, was also confirmed by significant others. Her
two follow-ups with the duration of three months and no relapse of symptoms
was reported or observed.

DISCUSSION

Treatment of Personality disorders remained debatable due to diversity

and overlap among diagnostic criteria, as every case demands specific and
precise approach individually (for diagnosis and treatment). Several
psychotherapeutic techniques were introduced to deal with them and many of
them partially played their role effectively. Cognitive Behavior therapy has been
suggested by researchers as a valuable modality in this domain.

The present case demonstrates the key features of dependent personality

disorder and additionally the psychological management of the core symptoms
i.e intense need for dependency, feelings of inadequacy and incompetency, and
coping strategies of avoidance, and fear of incapability. Young25 proposed
schema therapy to help patients with chronic characterological problems that
could not be adequately treated by traditional cognitive-behavior therapy; he
named them as “treatment failures.” In present case the rigidity was encountered,
during initial workout as is already considered as a hallmark of personality
disorders.

In CBT schemas are identified through interview information11 as the

procedure was followed in a structured way hence revealed maximum of the
information. The method of deliberate avoidance of direct confrontations and
56 Masroor and Gul

interpretations of their dependency needs was considered seriously as are

difficult to accept for them 30. Assessment focused on childhood schema was
conducted considering the view of their stability over the course of time as
suggested by Kagan31. The detailed procedure revealed schema of
incompetence/dependency, that later was targeted in therapeutic sessions through
CBT techniques. Basic Cognitive-behavioral practitioners and researchers have
demonstrated excellent progress in developing effective psychological treatments
for Axis I disorders as well. These treatment procedures have traditionally been
short term (roughly 20 -24 sessions) and have focused on reducing problematic
symptoms, building multiple skills, and solving general problems in the patient’s
current life. However, although many patients are helped by these treatments,
many others are not. Treatment outcome studies using CBT usually report high
success rates32. Often patients with underlying or co-morbid personality disorders
and characterological issues are unable to respond fully to traditional cognitive-
behavioral treatments11 as it assumes that patients are already motivated to
change problematic cognitions and behaviors however, however, for
characterological patients, this may not be true. It is justified to mention that,
their imprecise thoughts and self-defeating behaviors are extremely rigid and
usually resistant to modification merely through cognitive-behavioral techniques.
Even after months of therapy, there is often no unrelenting improvement that was
rationale of the present case study.

Patients with the Dependence/Incompetence schema feel unable to

handle their everyday responsibilities without extensive help from others. For
example, they feel unable to manage money, solve practical problems, use good
judgment, undertake new tasks, or make good decisions, as has been observed
constantly in present case. The schema often presents as pervasive passivity or
helplessness. The same was addressed in therapy process in present study and
presented with noticeable results.

30
Othmer, E., & Othmer, S. (2002)The clinical interview using DSM – IV, Volume
1:Fundamentals. (2nd Ed). Washington DC; American Psychiatric Press.
31
Kagan, J. (1978). Infant antecedents of cognitive-functioning - longitudinal-study.
Child development, 49, 1005 -1023.
32
Barlow, D. H., Gorman, J. M., Shear, M.K. & Woods, S.W. (2000). "Cognitive-
behavioral therapy, imipramine, or their combination for panic disorder: A
randomized controlled trial". JAMA, 283 (19), 2529–2536.
 Schema Focused CBT Intervention 57

The replacement of negative thoughts running through mind (that could

be regarding self doubt, inefficacy etc. are in fact by product of underlying
schema, was considered crucial in the under discussion case. As schema is
manifested in automatic negative thoughts which are self statements and beliefs a
person develops over the course of time through life experiences, and are
restructured during therapy and it achieves good results33.

Conclusion

Challenging negative though appraisals and breaking vicious cycles of

marinating the problem are effective strategies of psychological treatment of
personality disorder ,also when schema are main focus. Though this is proven in
this single case that CBT, is an effective method of addressing underlying
maladaptive patterns of a Dependent personality disorder, however further
investigation into this is yet required. It is recommended to plan controlled trials
for couple of patients to reveal more effective results that could authentically be
applied in clinical settings. Additionally different clusters of personality disorders
should be emphasized in categorization of allocated effective techniques for
clinicians.

33
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005)
Cognitive therapy for post-traumatic stress disorder: development and
evaluation. Behavior Research and Therapy, 43, 413-431.