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The role of maintenance conceptualization diagrams in CBT
Over the last 30 years cognitive behaviour therapy has proved itself as a treatment for a wide range of conditions. Its effectiveness is in no small part due to the ease with which it can be operationalized and manualized. Successful treatment protocols have almost invariably incorporated a model of how disorders are maintained through cognitive-behavioural cycles, with guidance on how these cycles can be broken. These formulations lend themselves to representation in visual form. The first and probably most influential of these is Clark's panic cycle (Clark, 1986). This was initially a simple spiral: anxiety leads to autonomic nervous system activation, which is misinterpreted catastrophically as a sign of impending death, serious physical danger or madness. These cognitions in turn generate more anxiety and the spiral escalates. The concept of safety seeking behaviours was later added to the model (Salkovskis, 1991). Safety behaviours are voluntary behaviours undertaken to prevent the feared catastrophe occurring. They are directly and logically connected to the physical symptom and its feared consequence e.g. sensations of breathlessness are interpreted as the onset of suffocation and lead to safety behaviours such as overbreathing, loosening clothes around the neck, and opening windows. Similar diagrammatic conceptualizations have been developed for other anxiety disorders such as obsessive compulsive disorder (Salkovskis, 1985), health anxiety (Warwick and Salkovskis, 1989), and social phobia (Clark and Wells, 1995; Wells, 1997) and a more complex model proposed for post traumatic stress disorder (Ehlers and Clark, 2000). Sometimes a more generic anxiety model is used (Salkovskis, 1996, p. 53; Butler, Fennell and Hackmann, 2008). This usually has the core cognitive process in anxiety (perceived threat) in the centre, and a series of cycles representing the maintenance factors around the edge. These include selective attention, worry, rumination, avoidance, reassurance seeking, and safety seeking behaviours. These vicious circles look like the petals of a flower and so the rather incongruous but memorable nickname of the "vicious flower" has been given to this model. Maintenance diagrams have also been drawn for other disorders (see for instance Westbrook, Kennerley and Kirk, 2007).
These diagrams form an important component of treatment and are very much in keeping with the ethos of making...