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A review of cognitive therapy in acute medical settings. Part I: Therapy model and assessment

  • Tomer T. Levin (a1), Craig A. White (a2) and David W. Kissane (a1)
  • DOI:
  • Published online: 22 November 2012

Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings?


Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.)


Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized.

Significance of results:

The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

Corresponding author
Address correspondence and reprint requests to: Tomer T. Levin, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave, 7th Floor New York, New York10022. E-mail:
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J.A. Astin , W. Beckner , K. Soeken , (2002). Psychological interventions for rheumatoid arthritis: A meta-analysis of randomized controlled trials. Arthritis and Rheumatism, 47, 291302.

W. Bardwell , L. Natarajan , J. Dimsdale , (2006). Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. Journal of Clinical Oncology, 24, 24202427.

A.T. Beck (1964). Thinking and depression: II. Theory and therapy. Archives of General Psychiatry, 10, 561571.

J.M. Bostwick & S. Rackley (2007). Completed suicide in medical/surgical patients: Who is at risk? Current Psychiatry Reports, 9, 242246.

J.A. Bourgeois , J.A. Wegelin , M.E. Servis , (2005). Psychiatric diagnoses of 901 inpatients seen by consultation–liaison psychiatrists at an academic medical center in a managed care environment. Psychosomatics, 46, 4757.

K. BrintzenhofeSzoc , T.T. Levin , Y. Li , (2009). Mixed anxiety–depression in a large cancer cohort: Prevalence by cancer type. Psychosomatics, 50, 383391.

H.E. Bronheim , G. Fulop , E.J. Kunkel , (1998). The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine. Psychosomatics, 39, 30.

L.F. Brown & K. Kroenke (2009). Cancer-related fatigue and its association with depression and anxiety: A systematic review. Psychosomatics, 50, 440447.

A.C. Butler , J.E. Chapman , Forman, (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 1731.

D. Clarke & D. Kissane (2002). Demoralization: Its phenomenology and importance. Australian and New Zealand Journal of Psychiatry, 36, 733742.

E.C. Devine (2003). Meta-analysis of the effect of psychoeducational interventions on pain in adults with cancer. Oncology Nursing Forum, 30, 7589.

M.R. DiMatteo , A. Taranta , H.S. Friedman , (1980). Predicting patient satisfaction from physicians' nonverbal communication skills. Medical Care, 18, 376387.

B. Druss & H. Pincus (2000). Suicidal ideation and suicide attempts in general medical illnesses. Archives of Internal Medicine, 160, 15221526.

G.L. Engel (1997). From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics, 38, 521528.

S. Folkman , R.S. Lazarus , C. Dunkel-Schetter , (1986). Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology, 50, 9921003.

G. Fulop & J.J. Strain (1986). Psychiatric emergencies in the general hospital. General Hospital Psychiatry, 8, 425431.

S.S. Himelhoch , D.R. Medoff & G. Oyeniyi (2007). Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: A systematic review and meta-analysis. AIDS Patient Care and STDs, 21, 732739.

S.D. Hollon , R.B. Jarrett , A.A. Nierenberg , (2005). Psychotherapy and medication in the treatment of adult and geriatric depression: Which monotherapy or combined treatment? The Journal of Clinical Psychiatry, 66, 455468.

M. Hotopf , W. Lee & A. Price (2011). Assisted suicide: Why psychiatrists should engage in the debate. British Journal of Psychiatry, 198, 8384.

F. Huyse , F. Stiefel & P. de Jonge (2006). Identifiers, or “red flags,” of complexity and need for integrated care. The Medical Clinics of North America, 90, 703712.

D.W. Kissane , B. Grabsch , A. Love , (2004). Psychiatric disorder in women with early stage and advanced breast cancer: a comparative analysis. Australian and New Zealand Journal of Psychiatry, 38, 320326.

R.S. Lazarus (2000). Toward better research on stress and coping. American Psychologist, 55, 665673.

M. Lederberg & T.T. Levin (2009). Consultation psychiatry. In Psychiatric Ethics, 4th ed., S. Bloch & S. Green (eds.), pp. 495570. Oxford: Oxford University Press.

A.F.G. Leentjens , J. Rundell , A. Diefenbacher , (2011). Psychosomatic medicine and consultation–liaison psychiatry: scope of practice, processes, and competencies for psychiatrists or psychosomatic medicine specialists. A consensus statement of the European Association of Consultation–Liaison Psychiatry and the Academy of Psychosomatic Medicine. Psychosomatics, 52, 1925.

T.T. Levin (2003). Mood vs. affect. Psychiatric News, 38, 48.

T.T. Levin & D.W. Kissane (2006). Psychooncology – the state of its development in 2006. European Journal of Psychiatry, 20, 183197.

T.T. Levin , J.H. Riskind & Y. Li (2007). Looming threat processing style in a cancer cohort. General Hospital Psychiatry, 29, 3238.

W.G. Lichtenthal , M. Nilsson , B. Zhang , (2008). Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches? Psychooncology, 18, 5061.

H.T. Mermelstein & J.J. Wallack (2008). Confidentiality in the age of HIPAA: A challenge for psychosomatic medicine. Psychosomatics, 49, 97103.

S. Moorey , S. Greer , J. Bliss , (1998). A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer. Psycho-oncology, 7, 218228.

A.M. Nezu , C.M. Nezu , S.H. Felgoise , (2003). Project Genesis: Assessing the efficacy of problem-solving therapy for distressed adult cancer patients. Journal of Consulting and Clinical Psychology, 71, 10361048.

R.L. Osborn , A.C. Demoncada & M. Feuerstein (2006). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analyses. The International Journal of Psychiatry in Medicine, 36, 1334.

J.C. Overholser (1995). Elements of the Socratic method: IV. Disavowal of knowledge. Psychotherapy: Theory, Research and Practice, 32, 283292.

P.L. Paddison , J.P. Strain & J.J. Strain (1989). Psychiatric consults on medical and surgical wards: a six year study. International Journal of Psychiatry in Medicine, 19, 347361.

C. Pitceathly , P. Maguire , I. Fletcher , (2009). Can a brief psychological intervention prevent anxiety or depressive disorders in cancer patients? A randomised controlled trial. Annals of Oncology, 20, 928934.

J.G. Rabkin , S.M. Albert , M.L. Del Bene , (2005). Prevalence of depressive disorders and change over time in late-stage ALS. Neurology, 65, 6267.

R. Spitzer , K. Kroenke & J. Williams (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. Journal of the American Medical Association, 282, 17371744.

R.L. Spitzer , K. Kroenke , J.B. Williams , (2006). A brief measure for assessing generalized anxiety disorder: the GAD–7. Archives of Internal Medicine, 166, 10921097.

F. Stiefel , F. Huyse , W. Sllner , (2006). Operationalizing integrated care on a clinical level: the INTERMED project. The Medical Clinics of North America, 90, 713758.

J.J. Strain , G.C. Smith , J.S. Hammer , (1998). Adjustment disorder: a multisite study of its utilization and interventions in the consultation–liaison psychiatry setting. General Hospital Psychiatry, 20, 139149.

K.L. Syrjala , S.L. Langer , J.R. Abrams , (2004). Recovery and long-term function after hematopoietic cell transplantation for leukemia or lymphoma. Journal of the American Medical Association, 291, 23352343.

K. Tatrow & G.H. Montgomery (2006). Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: a meta-analysis. Journal of Behavioral Medicine, 29, 1727.

M.E. Thase , J.B. Greenhouse , E. Frank , (1997). Treatment of major depression with psychotherapy or psychotherapy–pharmacotherapy combinations. Archives of General Psychiatry, 54, 1009.

A.B. Thomson & L.A. Page (2007). Psychotherapies for hypochondriasis. Cochrane Database of Systematic Reviews, 4, CD006520.

J.R. Vittengl , L.A. Clark , T.W. Dunn , (2007). Reducing relapse and recurrence in unipolar depression: A comparative meta-analysis of cognitive-behavioral therapy's effects. Journal of Consulting and Clinical Psychology, 75, 475488.

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