190 J. Prasko, T. Diveky, A. Grambal, D. Kamaradova, P. Mozny, Z. Sigmundova, M. Slepecky, J. VyskocilovaPsychodynamic therapists view transference as a powerfultool in understanding the patient and eventually effectingchange. They believe that cognitive behavioraltherapists eschew transference as an intervention thatwould distract the patient from outside relationships andrisk therapeutic rupture 6 . Although the interpretation oftransference is not a central tool of cognitive therapy,automatic thoughts and feelings related to interactionswith the therapist are very much within the scope of explorationand may provide valuable opportunities for testingand modifying dysfunctional automatic thoughts 2,7 .A good therapeutic relationship is an important issue forthe effective treatment in cognitive behavioral therapy.Cognitive behavioral therapists generally aim to establishan open collaborative relationship at the start of therapyand then to work directly towards them without payingtoo much attention to interpersonal issues. Clinical competence,conviction, and consistency seem to predict amore successful psychotherapeutic outcome 8–10 . However,when working with difficult patients (e.g. patients withpersonality disorder, hypochondriasis etc.) psychotherapyis rarely strightforward. The dysfunctional schemas, beliefsand assumptions that bias the patient’s perceptions ofothers are likely to bias their perception of the therapist.The dysfunctional interpersonal behaviour strategies,manifest in the patient-therapist relationship. If theyare not addressed effectively, interpersonal difficultiesarising in the patient-therapist relationship can disruptthe therapy. However, these difficulties also provide thetherapist with an opportunity to directly observe anintervention rather than having to rely on the patient’sreport of interpersonal problems occuring outside thesessions 11 . Therefore transference and countertransferencefeelings/reactions are a valuable source of informationabout a patient’s (and therapist’s) inner world.TRANSFERENCE FROM THE COGNITIVEBEHAVIORAL POINT OF VIEWAlthough the word “transference” is not part of thejargon of cognitive behavioral therapy, examination ofthe cognitions related to the therapist apropos past significantrelationships is an integral part of assessmentand treatment within CBT 12,13 . The patient’s emotionalreaction to the dynamics of therapy and therapist areimportant especially in working with difficult patients.Always alert but not provoking, the therapist should beready to explore these reactions for more informationabout the patient’s system of thoughts and beliefs. If notexplored, possible distorted interpretations persist andmay interfere with the collaboration. If exposed, they oftenprovide rich material for understanding the meaningsand beliefs behind the patient’s idiosyncratic or repetitiousreactions. Some forms of therapy depend on theuse of transference. Simply stated, transference occurswhen the patient superimposes prior experiences on thetherapist 14 . The patient may perceive something about thetherapists personality, style, demeanor, or appearancethat may remind him or her of a significant person in thepatient’s past, such as a parent; hence, the patient may beginto respond to the therapist as the patient would to thatparent. Effective transference is facilitated by the therapistpersistently withholding self-disclosure, presenting as avirtually unbiased blank slate (tabula rasa) wherein thepatient is free to superimpose (transfer) his or her feelingsfor a significant person in his or her own life (a parent,spouse, sibling, peer, etc.) onto the neutral therapist 15 .This is not the aim of CBT. Self-disclosure, warm andempathetic atmosphere, collaborative relation and stresson the self-efficacy of the client may pollute this transferencepotential 14 .There are many telltale signs of transference. Theseare the same signs that suggest the presence of automaticthoughts during the session. E.g. there may be a suddenchange in the patient’s nonverbal behavior: sudden changein expression, abruptly switching to a new topic, stammer,block, pauses in the middle of a train of statements,slumping posture, clenching fists, kicking, tapping footand so on. One of the most revealing signs is a shift inthe patient’s gaze, especially if he/she has had a thoughtbut prefers not to reveal it 16 . When asked, the patient maysay, ”It is not important.” The therapist should press thepatient nonetheless, gently, as it might be important.The therapist should pay attention to any negative orpositive reactions to him/her that arise but should notdeliberately provoke or ignore them. He/she should bevigilant for signs of disappointment, anger, and frustrationexperienced by the patient in the therapeutic relationship.Similarly the therapist should be alert to excessiveidealization, praise or attempts to divert the attention oftherapy onto the therapist. These reactions open windowsinto the patient’s past and actual relations outsidethe therapy. The therapist would be unable to view themeanings or beliefs beyond these windows if the arousalof their own affective responses is viewed as a distractionto be controlled, avoided, or suppressed. Hoffartet al. 17 examined whether therapists’ emotional reactionsto their patients mediate the effect of personality disordersand interpersonal problem behaviours on the outcomeof treatment with a focus on an Axis I disorderand, whether the therapists’ reactions mediate the effectof personality disorders on the course of interpersonalproblems. Therapists completed a checklist of emotionalreactions to individual patients after the end of residentialcognitive or guided mastery therapy for 46 inpatients withpanic disorder with agoraphobia. The severity of DSM-III-R personality disorder was related to the therapists’insecurity feelings but not to interest or anger. A higherlevel of therapist insecurity feelings was related to lessreduction in self-reported agoraphobic avoidance duringtreatment, whereas the therapists’ emotions were unrelatedto symptomatic course after treatment. Therapists’insecurity feelings appeared partly to mediate the relationshipbetween patient severity of personality disorderand persistence of patients’ interpersonal dominance andnurturance problems.
192 J. Prasko, T. Diveky, A. Grambal, D. Kamaradova, P. Mozny, Z. Sigmundova, M. Slepecky, J. VyskocilovaTable 1. (Continued)Typeof transferenceExamples of typical thoughtsSuspicious Therapist does me wrong onpurpose, abuses me for hisown needs or for the needs ofsomebody else, he is againstme, has hidden motives, doesnot play fair.CompetitiveContemptuousJealousPossessiveCan’t let him overtop me, I ambetter in many things than heis. I will show him, don’t lethim humiliate me.He cannot make it! He is weak,stupid, he is a fool, etc. Howcould he help me? I am thedominant one in our relationshipHe prefers the others, he doesnot care for me.He is here for me, he has to bethere for my disposal anytime.EmotionalreactionsAnger, fear,feelings ofthreatTension,changes offeelings ofeuphoriaanger, envy,frustration,according tothe subjective“score“Contempt,impatience,angerAger, griefFeelings of euphoriachangewith anger accordingto thebehavior ofthe therapist.BehaviorHe withdraws, does not speakabout himself or only superficially,can be aggressive indirectly,does not do homework, drops outor stops attending the therapy.Secretly or openly competes, fierydiscuss everywhere, where expects“competition”, rationalizesnon compliance in homeworksHe despises the therapist, hecheapens what the therapist does,refuses to do the homework,drops out the lessons or stopsattending the therapyWithdrawal or regrets, sometimesoutbursts of anger, measuring thetime of sessions (others and himself),monitoring of manifestationof favor (himself and others).He domineers, calls very often,does not visit the therapist at thetime they agreed on and is angrywhen the therapist is not ondisposal. He blames or is verballyaggressive.Useful therapeutic reactionGive the feedback, discuss the situation openly,help to examine, where the sensibility comes fromand to go through the relationships, where it alsooccurs. Mapping the sensible attitudes, their advantagesand disadvantages, effects on the behavior.Experimenting with the confidence.Give the feedback for the specific situations, investigatethe competitive thoughts and deeper attitudes,their sources situations, where they occur, ,to whichbehavior they lead to, ,advantages and disadvantagesincluding their effects on the therapy..Give the feedback about the particular behavior,investigate thoughts and attitudes, find their origin,find how they work in different situations, thebehavior they lead to, advantages and disadvantagesfor the life and relationships, what they mean forthe therapy.Ask for the thoughts related to the sorrow (harmingthe therapeutic relationship), then help withopening the thoughts, emotions and behaviorconcerning the anger. Go through the reasons inthe past (place in the family as a sibling) and howthey affect the behavior, emotions and relationshipsin various life situations, advantages/ disadvantagesfor the relationships and life and for the therapy.Investigate thoughts and attitudes, find their originin the past (the need of possession instead of thefear of being left by someone), thoughts, emotionsand behavior in various relationships including thetherapeutic one, advantages and disadvantages.COGNITIVE ASPECTS OF TRANSFERENCETechniques of explicit formulation are included incognitive behavioral therapy. Having a clinical formulationthat is shared with a patient can help maintain thetherapeutic alliance during difficult reenactments 1,20 . InCBT, especially in schema focus therapy, therapists useoperationalized core schemas and beliefs as the focus oftherapy, targeting transference and maladaptive interpersonalpatterns. Developing a CBT case conceptualizationof patients is recommended for treating each patient inCBT 4 ; cognitive behavior therapists examine the thoughts,feelings, and behaviors related to a wide range of situations(including reactions to the therapist) and relevantchildhood experiences to understand the underlying corebeliefs and conditional assumptions of each patient 12 .Transference interpretation has remained a coreingredient in psychodynamic tradition, despite limitedempirical evidence for its effectiveness. In the field ofpsychoanalysis, the technical use of transference interpretationsversus other interpretations has been intensivelydebated over a period of 100 years. Despite this fact, theresearch base remains very limited and inconclusive. Onlyone of eight naturalistic studies has reported a positivecorrelation between transference interpretations and outcome21 . There is no study on the efficacy of using transferencediscussions in CBT. The goal of transferenceinterpretation is sustained improvement in the patient’srelationships outside therapy. It seems to be especiallyimportant for patients with long-standing, more severeinterpersonal problems. Although the central tool of CBTis not interpretation of transference, automatic thoughtsand feelings related to interactions with the therapistare very much within the scope of exploration and mayprovide valuable opportunities for testing and modifyingdysfunctional automatic thoughts 2,7 . One of the more commonmistakes in CBT, is moving too quickly away fromthe emotions being expressed about the therapist or thetherapy, and failing to sufficiently attend to this rich opportunityfor further understanding the patient 16 .Tact and timing in the exploration of transference reactionsare paramount. At the “macro” level of case analysis,formulation represents conceptualization at the level ofwhole treatment. Case formulation was initially developedin relation to psychodynamic approaches 22 and shownto be a replicable procedure. Recent work has includedexplicit formulation techniques in cognitive therapy 4 .Transference is also influenced by the actual behavior
Transference and countertransference in cognitive behavioral therapy193of the therapist. Explicit discussion of the patient’s ongoingrelationship with the therapist is compelling when itis accurate. Focus on the transference makes it possiblefor the patient (and therapist) to become directly awareof the distinction between reality and fantasy in the therapeuticencounter. However, in brief therapy, transferenceinterpretations may be too anxiety-provoking.COUNTER-TRANSFERENCECounter-transference occurs when the therapist reactsin complementary fashion to the patient’s transference.Attention to emotional reactions of both patientand therapist is a fundamental component of cognitivebehavioral therapy, especially during the process of therapywith difficult patients. Despite the manualization oftreatment and emphasis on techniques and pharmacotherapy,countertransference exists. No therapist is freeof countertransference. To guide patients effectively indiscovering their thoughts and expressing their feelings,the therapist needs to have a foundation of skills for recognizing,labeling, understanding, and expressing his/her own emotions 16 . To understand our own limitations,our own resistance to change, is necessary to discovermore about the patient and ourselves; as we learn how thepatient’s behavior affects our own countertransference,we are also learn about how the patient affects others 23 .Rather than having no feelings, or being an expert at repression,the cognitive therapist is attuned to personalemotions that might affect the therapy environment. Justas the therapist would encourage a client to do, cognitivebehavioral therapists use awareness to their own physicalsensations and subtle mood shifts as cues, suggestingthe presence of automatic thoughts. Any changes in thetherapist’s typical behavior might signal an emotional reactionand associated automatic thoughts, such as talkingin a commanding (or hesitating) tone of voice, increasedfrequency of thoughts about a client outside sessions, orperhaps avoidance of returning a client’s phone call ortardiness in starting or ending a session.TYPES OF COUNTER-TRANSFERENCEBetan et al. 24 studied a national random sample of 181psychiatrists and clinical psychologists in North America.Each completed a battery of instruments on a randomlyselected patient in their care, including measures of axisII symptoms and the Countertransference Questionnaire,an instrument designed to assess clinicians’ cognitive, affective,and behavioral responses in interacting with a particularpatient. Factor analysis of the CountertransferenceQuestionnaire yielded eight clinically and conceptuallycoherent factors that were independent of clinicians’ theoreticalorientation: 1) overwhelmed/disorganized, 2) helpless/inadequate,3) positive, 4) special/overinvolved, 5)sexualized, 6) disengaged, 7) parental/protective, and 8)criticized/mistreated. The eight factors were associatedin predictable ways with axis II pathology. An aggregatedportrait of countertransference responses with narcissisticpersonality disorder patients provided a clinically rich,empirically based description that strongly resembledtheoretical and clinical accounts.Countertransference patternswere systematically related to patients’ personalitypathology across therapeutic approaches, suggesting thatclinicians, regardless of therapeutic orientation, can makediagnostic and therapeutic use of their own responses tothe patient 24 .In some cases, the focus on the patient’s problemsmay allow the therapist to compartmentalize and avoidhis/her own personal problems or allow the therapist todisplace his/her conflicts with others onto the patient 23 .Some people are attracted to being therapists becauseit allows them a sense of competence, superiority, andapparent efficacy. This illusion of competence may allowthe therapist to unconsiously pursue other goals, such asthe need to have power or control, or the need to compartmentalize,intellectualize, and isolate oneself fromone’s own problems.Table 2. Examples of the counter-transference and possible strategies for a change.Type ofcountertransferenceModeratepositiveAdmiringOverprotectiveExamples of typicalthoughtsI like him, he is nice,good cooperation withhim, he will do well.That person is special(especially beautiful,original, intelligent, etc.)He cannot make decisionson his own, Leedshelp, advice, it will be myfault, if something wronghappens to him.EmotionalreactionsBehaviorNice tune Cooperation, support, empathy NoneAdmiration,fascinationFear, insecurityTherapist does not make appropriateexaminations, does not conduct thetherapy. Possible non-compliance ofthe patient is deprecated, does notrequire patient’s homework, tends totalk about the exceptional propertiesof the patientHe gives advice, protects, ensures,takes control over the patient, doesnot allow patient’s independentdecision making, doubts patient’sabilitiesStrategies of changeClarify own attitudes, their background, the effecton the behavior, advantages + disadvantages for thetherapy. Supervision needed. “Normalization of thetherapy”: conduct the same way like the others. In casethat the behavior is impossible to change and make astandard therapy, necessary to open that problem withthe patient or the patient should change the therapistClarify own attitudes, their background, the effecton the behavior, advantages + disadvantages for thetherapy. Supervision needed. Stop the directive leadingof the therapy, let the patient plan things, stop ensuring.Otherwise the patient should change the therapist.
Transference and countertransference in cognitive behavioral therapy195• Demanding standards: Anankastistic or perfectionistictherapists often view patients as irresponsible, selfindulgent,and lazy. They believe that the expressionof emotions, or even uncertainty, is devastating. Theyhave difficulty expressing warmth and empathy towardpatients and place a great deal of emphasis on “logic“and “rationality“. The patient may feel that the therapyis simply an opportunity for the therapist to show thathe or she is smarter than the patient. Perfectionistictherapists may attempt to compensate his/her underlyingfeelings of incompetence and worthlessness bydemanding perfect performance from self and patient.A typical sequence of automatic thought can be: “Mypatient is not getting better I’m not doing my job I’ll be exposed as a fraud I’m a failure I can’t acceptany failure in myself.“ In some cases the therapistwith demanding standards can compensate for his/herperfectionism by demanding more and more from thepatient.• Abandonment: the therapist with an abandonmentschema will be worried that if he/she confronts the patient,then the patient will leave the therapy. Prematuretermination of the therapy is interpreted as a personalrejection of the therapist. Therapists concerned aboutabandonment issues can behave in many differentforms that reflect countertransference: for exampleon the one hand, excessive caretaking of the patient,or on the other, avoidance of entering into a meaningfultherapeutic relationship. Excessive caretakingtakes the form of trying to protect the patient fromany difficulties and taking on the patient’s problemsas the therapist’s own to solve. Therapists who avoidattachment on the other hand, often focus more onsuperficial techniques than on more meaningful personalissues. This type of therapist avoids difficulttopics with patients and refrains from using anxietyprovokinginterventions, such as exposure techniques.They often personalize the patient’s lateness, failureto show up for a session, or lack of interest in therapy.Patient’s resistance can be seen as a personal rejection.• Special, superior person: the narcissistic therapist viewstherapy as an opportunity to show of his/her specialtalents. Therapy with the resistant patient may beginwith grandiose hopes, expressed by the therapist thatthe patient has finally found the “right therapist“. Thetherapist’s investment in his/her own image as being aspecial, superior therapist may result in his/her sidingwith the patient to vilify all the other therapists whohave “failed“ the patient. This therapist feels entitledto having the cooperation and adulation of the patient.This may result in the therapist encouraging boundaryviolations by the patient or, in some case, the therapisthimself/herself may initiate these boundary violations.As the therapeutic relationship unfolds – if the patientdoes not make rapid progress – the narcissistictherapist may grow bored with, angry at, or punitivetowards the patient. He may label the patient “He’s aborderline, histrionic, paranoid, hypochondriacal...“Rather than empathize with the patient’s understanablefrustration with lack of progress, the therapistmay turn on the patient, blaming the patient for alack of desire to improve. To modify the narcissisticperspective, one needs to ask one question: “Whatwould your life be like if you had to walk in the shoesof this patient?“• Need for approval: The “pleasing“ therapist may behighly skilled in showing empathy for the patient. He/she wishes to make the patient feel good regardlessof what is going on, is averse to any expression ofanger or disappointment by the patient. The warmthand empathy of such a therapist are much appreciatedby many patients but he/she has difficulty recognizingthat borderline patients are very angry. Thistype of therapist will avoid raising questions about thepatient’s substance abuse, anger, resistance, and selfdefeat.These topics are viewed as too disturbing forthe patient, and therefore as not appropriate. Patientsmay act out by missing sessions, showing up late, ornot doing homework, but the high-need-for-approvaltherapist, who does not want to cause a “conflict“communicates the idea that acting-out behavior is acceptable.One therapist found it difficult to make thedecision to hospitalize a suicidal patient because ofhis/her concern that the patient would get angry withhim/her. The therapist may find that the patient’s angeris difficult to tolerate. He/she can personalize thepatient’s behavior and viewed the patient’s disapprovalas a sign of his/her own failing. His/her assumptionwas, “If the patient is angry at me, it means that Ifailed.“SELF-CORRECTION OF COUNTER-TRANSFERENCEBy anticipating and paying attention to such countertransferentialresponses, CBT affords the therapist the opportunityto recognize and manage such responses, whichreduces the therapist’s risk of retaliatory acting out 7 .Throughout the process of providing therapy, in additionto tending to the patient’s expressions, the therapisthas to make an effort to monitor his/her reactions to thecontent of the sessions. Therapist must take special careto recognize his/her strong emotional reactions to patient,both positive and negative; this is an opportunity to askhim/herself how much of what the patient is processingmatches the therapist s prior experiences or preexistingopinions.The therapist monitoring his/her (positive and negative)feelings, must be aware of these reactions:• Dreading or happily anticipating session with the patient;• Having exceptionally strong hateful or loving feelingstowards a patient;• Wanting to end sessions early or extend sessions;• Strongly wishing for or dreading termination.The first step in managing counter-transference is thetherapist recognizing that his/her feelings toward a patientare unusually strong, either positive or negative. It is use-
196 J. Prasko, T. Diveky, A. Grambal, D. Kamaradova, P. Mozny, Z. Sigmundova, M. Slepecky, J. Vyskocilovaful to take some time, perhaps outside the therapeutic environment,to patiently ask some introspective questions:• What are my emotional reactions to this patient?• Are they somewhat exaggerated?• What is making me like or dislike this patient?• What issues do I want or not want to discuss with thispatient?• What is making me feel uncomfortable?• What were some signs of the patient’s pathology that Ihad missed? What was it about me that made me missthem?A second step may involve seeking out consultationwith a supervisor to help delve deeper into addressingand potentially resolving the source of strong countertransferencefeelings.E.g. the therapist may find himself/herself frustrated,angry, anxious, or threatened by the patient’s demand forvalidation. With the work with own thoughts he/she canrecognize for instance 23 : “This patient doesn’t really wantto get better. All she wants to do is whine. She’s keepingme from getting my job done. I’m going to look like I’mincompetent because she won’t do what she should do.This patient is just irrational. She shouldn’t be irrational.“It is immensely stress reducing and helpful to the patient’stherapy when the therapist can identify and challengethese negative countertransference thoughts. Challengesto these thoughts include the following: “It’s irrationalto think people should be rational all the time.“ “All ofus need validation some of the time.“ Reflecting, caring,showing curiosity and respect, and being a good listenerare interventions.“In order to examine the countertransference, the therapistshould examine the kinds of life problems that he/shetypically has. Is he/she someone who is concerned aboutrejection or abandonment? Then he/she should examinehow these issues arise in his/her contact with patients.Is he/she someone who always has to be “right“? Thenhe must examine how he/she may be trying to defeat patientsin debates, and thereby invalidate them. Is he/shesomeone who is afraid of failing, because he/she thinksthat success or failure indicates how worthwile he/she is?Then he/she must examine how he/she may be afraid ofdealing with difficult patients or afraid of taking chancesin therapy.The way the therapist views or deals with therapyrelatedthoughts and emotions may need some cognitiverestructuring to reduce intensity of negative affect or tomaintain adequate focus on therapy goals and objectives 16 .It may be useful to contront any fears about therapist emotionsbeing “mistakes“ or indications of failure in therapyand instead focus on ways of understanding the emotionalantecedents. Therapist reactions can stem from a numberof sources, including cultural of value-related beliefs, thetherapist’s view of his/her professional role, and uniquelearning history, as well as from the interactions with thepatient’s problematic behaviors 26 . The therapist can alsouse a self-directed inquiry of thoughts about a session,a situation or working with a particular patient or problemand log these thoughts into a dysfunctional thoughtrecord.Especially in preparing to work professionally with patientssuffering from personality disorders, hypochondriaor somatoform disorders, the therapist needs to be especiallycareful to be nonjudgmental. Once the therapist hasmade the diagnosis, it is much better to avoid labels andthink in terms of beliefs, core and conditional schemas,predictable reactions, behaviors and so forth. By trying toput him-/herself in the patient’s shoes, perhaps imaginghim-/herself with the same set of sensitivities, sense ofhelplessness, and vulnerability – the therapist can betterunderstand the patient. At the same time, the therapisthas to be on guard not to become so involved with thepatient’s problems that objectivity is lost.COUNTER-TRANSFERENCE AND SUPERVISIONHaving a formulation shared with the patient canhelp maintain the therapeutic alliance during difficultre-enactments; or, in supervision, help understand potentialre-enactments 27 . Ongoing discussion of the therapywith colleagues and with supervisor is valuable (even forexperienced therapists) and is built into those therapiesthat have been empirically validated 28 . Such discussionsenhance the therapist’ s ability to clarify the patient’stransference and contain counter-transference anger andresentment 29 .Table 3. Therapist’s Dysfunctional Thoughtr Record 16 .Situation Emotion Automatic thoughts Rational responsePatient arrives late; persistswith dramatic storytelling;breake into sobswhen I redirecte to agendasetting.FrustratedDisappointedUncertainEmbarrassedThis patient will neverget is!We are making no progressusing cognitive behavioraltherapy!I don’t know what to donext. I must be ineffectivewith the approach.Contempt on my part will not help, so I could avoid such eternalizedjudgments and be more sympathetic. She is showingmore skill in labeling affect, and identifying thoughts. Also,I’m focusing on the importance of making a list when herobvious priority is interpersonal support. I need to respecther values, help her learn to define problems, and not give up.Just because I feel uncertain does not mean I am ineffective,or have commited any shameful action. My discomfortcomes from believing all patients must change quickly, andif they don’t it’s my fault. Does it make sense that an effectivetherapist “never” feels uncertain? I can brainstorm someoptions to try next.
Transference and countertransference in cognitive behavioral therapy197Supervision should support the therapist, give anotherperspective to problem-solve difficult clinical dilemmas,bolster theoretical understanding to comprehend the patient’scurrent issues, and assist the therapist in maintaininga benevolent, caring, and curious attitude to thepatient’s vicissitudes. Effective supervision related to thetherapy should provide a safe place for the therapist todisclose feelings and attitudes 28 .Appreciation for the concept of transference mightinform the cognitive behavior therapist’s understanding ofa patient’s dysfunctional automatic thoughts and feelings.CONCLUSIONThe literature shows and it is our experience that bothtransference and counter-transference issues should beexamined carefully and openly in CBT and must be anintegral component of the complete management of eachpatient undergoing CBT. Analysis of transference aims toimprove interpersonal functioning. Transference elaborationsin CBT seem to be especially important for patientswith long-standing problematic interpersonal relationships.Specifically, those patients who need to improvethe benefit the most.Countertransference can be one of the most usefultools in helping patients by providing a window into the“real-world effects” that the patient has outside the therapy.This can be helpful in diagnosing his/her problemand helping the patient understand how his/her behaviormay affect others.AKNOWLEDGEMENTSThis paper was supported by the research grant IGA MZČR NS 9752– 3/2008.REFERENCES1. Goin MK. A current perspective on the psychotherapies.Psychiatric Services 2005; 56:255–257.2. Beck JS. Cognitive Therapy: Basics and Beyond. New York,Guilford 1995.3. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy ofDepression. New York, Guilford 1979.4. Persons J. Cognitive Therapy in Practice: A Case Formulation.New York, WW Norton 1989.5. Gluhoski V: Misconceptions of cognitive therapy. 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