Cognitive Therapy Treatment (COG)
This condition, formulated and supervised by Fred Friedberg, a clinical psychologist, incorporated a broad-based cognitive approach that focused on developing cognitive strategies to better tolerate and reduce stress and symptoms, and to lessen self-criticism. Cognitive changes were linked, in principle, to achieving a healthy balance between activity, rest, and leisure.
COG training was focused on treating maladaptive beliefs associated with illness-related depression, anxiety, and anger. It is a credible condition because it involves actively listening to participant’s complaints, as well as teaching coping and stress reduction skills. In comparison to CBT and ACT, the COG condition does not include structured schedules of increasing activity or exercise (Deale et al., 1997; Fulcher & White, 1997; Sharpe et al., 1996). Rather, this approach emphasizes pacing activities, which involves trying to remain as active as possible while avoiding over-exertion. Low effort activities that are not associated with symptom flare-ups are selectively increased while symptom-producing activities are decreased or managed more effectively. For instance, activity pacing was applied to completing job or household tasks in energy-conserving small steps that were less likely to produce symptom flare-ups. In a more narrowly focused early version of this protocol (Friedberg & Krupp,1994), a trend toward reduced depression scores and significant reductions in maladaptive illness beliefs were found. However, there were no changes in functional status. The 13-session COG protocol is summarized below.
Sessions 1–3. During the initial session, the therapist explained the purpose and goals of the intervention. Because of numerous encounters with physicians and others who have treated patients with CFS with condescension and even ridicule (McKenzie, Dechene, Friedberg, & Fontanetta,1995), rapport building was a critical aspect of the treatment regimen (Deale et al., 1997). As an initial intervention, the participant’s personal account of his/her illness, including CFS symptoms and their effects on vocational functioning, marital satisfaction, social relationships, and physical exercise was placed in the context of the four stage progressive model of chronic illness (Fennell, 1995). The model serves as a coping tool that allows the participant to view his/her reactions to the illness as understandable adjustments to an unpredictable, disabling condition. It also allowed the therapist to better target and individualize the coping techniques presented below.
Sessions 4–8. These sessions focused on stress reduction techniques for intrusive illness symptoms and limitations, as well as emotional distress. Initially, relaxation exercises were demonstrated and rehearsed in session. They were later prescribed for home use with audiocassette tapes. Cue-controlled relaxation was then introduced to create an association between the self-instructed relaxation and the feeling state of being relaxed. Specific relaxation benefits were addressed to the participant so that active use of relaxation as a coping skill (Ost, 1987) was clearly explained. In addition, cognitive coping statements were formulated and prescribed to counteract (1) catastrophic thinking about illness limitations and its vocational and social consequences; (2) symptom-exacerbating selfdemands for high achievement; and (3) intolerance of illness symptoms. To encourage practice of these coping skills, daily stress and fatigue records were reviewed to identify stress/symptom associations and then to prescribe relaxation and cognitive coping techniques to ameliorate these symptoms.
Sessions 9–13. As participants incorporated stress management and cognitive coping strategies into their daily routine, the imagery technique of pleasant mood induction was introduced as a method of alleviating depressed mood and uplifting mood in general. Pleasant mood induction involved visualizing enjoyable activities and events that could be performed by the participant, given the limitations of his or her illness. If the imagery exercises succeeded in elevating mood, they were incorporated into daily relaxation practice. The quality of social support was discussed in order to identify maladaptive beliefs that were detrimental to marital, family, and other significant relationships. Once identified, these maladaptive beliefs were used to generate cognitive coping statements that were intended to ameliorate relationship-damaging beliefs. These individually constructed coping statements were assigned as daily homework and were designed to counteract maladaptive thinking about relationships. Such sessions were devoted to the identification of specific cognitive difficulties and exposure to memory compensation and cognitive retraining techniques. For instance, to reduce debilitating feelings of cognitive overload, the participant was encouraged to (1) allow extra time to complete activities, (2) minimize distractions, and (3) watch for signs of increased mental fatigue and take necessary rest breaks. During the final session, the therapist and participant reviewed the course of therapy, including specific coping techniques that were learned and utilized. Improvements were also assessed in light of the four stage progressive model of CFS. Finally, a plan was developed to maintain the effective coping skills gained.