Introduction to Cognitive Behaviour Psychotherapy - Essay Example

? Introduction to Cognitive Behaviour Psychotherapy Introduction Cognitive Behaviour Psychotherapy, as its suggests, blends the theoretical insights of both the behavioural and cognitive therapists. The origins of Cognitive Behaviour Psychotherapy can be traced back to Stoic, Taoist and Buddhist philosophies which link human emotions to thoughts and ideas (Beck et al, 1979). Modern CBT is psychologically based and historically can be linked to behavioural theories such as those developed by Pavlov (Classical conditioning, 1927) and Skinner (Operant conditioning, 1938). Behavioural therapy (BT) proved particularly effective in the treatment of anxiety disorders, particularly with specific phobias. However BT did not recognise the importance of the patient’s internal thoughts in relation the maintenance of the distress, and was proved to be ineffective in the treatment of depression. (Fennell, 1999). It was in the 1960’s that treatment for depression was revised and ‘cognitive therapy’ (CT) was devised. CT was developed by theorists such as Albert Ellis (1962) who established the Rational Emotive Theory and Aaron Beck (1963, 1969) who is the most famous fore-founder of cognitive therapy. Beck’s work specifically focused on how a person’s thinking style would have an influence on their emotions and this in turn would impact on how they behaved in any given situation. Cognitive Behavioural Therapy further developed through Beck’s cognitive techniques utilising earlier behavioural techniques, thus dealing with both cognitions and the psycho-somatic aspects of their illness. Within CBT a core principle is that thoughts influence a person’s emotions and behaviour. Beck, et al (1979) postulated that an individual’s thoughts or cognitions are based on attitudes and assumptions, which are known as schemas. These schemas are developed from previous experiences and can determine how an individual reacts to situations. If theses schemas are negative this can lead to maladaptive thinking and dysfunctional behaviour and this in turn may influence the individual’s mental health. Thus, the underlying assumption of CBT is that if one is able to change the manner in which one thinks about an event, then one is most likely to be able to feel differently about it, thus altering the way one reacts to it. This essay will provide an understanding of the historical principles of Cognitive Behaviour Therapy and its application to a case study of someone who suffers from generalized anxiety disorder. Definition and Meaning of CBT There are many varieties of cognitive behavioural therapies practiced today and it is quite difficult to define cognitive behavioural therapy in such a way so as to include all these types of cognitive therapies. However, Beck’s definition of CBT sounds to be concise and comprehensive. Beck defines cognitive therapy as “an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders” such as depression, anxiety, phobias, and pain problems (Beck 3). For him, all cognitive behavioural therapies are based on the underlying theoretical rationale that an individual’s behaviour is shaped by his cognitions-the way he thinks and conceives the world. Beck goes on to explain that a person’s cognitions are based on his/her attitudes or assumptions (referred to as schemas) which the individual formulates from his/her previous experiences. CBT in general has got several approaches which include cognitive-behavioural therapy, including Rational Emotive Behaviour Therapy, Rational Behaviour Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy. All these various therapies under CBT focus on the cognition levels of patients. It can be stated that CBT can help one to change how one thinks and what one does. As purported by authors Whitfield and Davidson, CBT does not focus on the causes of one’s distress or symptoms in the past, but it looks for ways to improve one’s state of mind in the present (Whitfield & Davidson 4). As Robertson has rightly pointed out, the basic assumptions shared by all variations of cognitive-behavioural therapy can be summarised as: “cognitive activity affects behaviour; cognitive activity may be monitored and altered; desired behaviour change may be affected through cognitive change (Robertson 30). It is also worthwhile to consider CBT as “a process of teaching, coaching, and reinforcing positive behaviours” which help people “to identify cognitive patterns or thoughts and emotions that are linked with behaviours” (Somers & Queree 7). Cognitive Behaviour Therapy: Origin, development and basic concepts The historical development of cognitive behavioural therapies can be traced back to Stoicism, the ancient Greek philosophy that emphasised rational acceptance and held that man can overcome his emotional difficulties by using reason. In the twentieth century the work of Ellis and his Rational-Emotive Psychotherapy have much in common with that of cognitive behavioural therapy. Like CBT, Ellis’s Rational-Emotive Psychotherapy “aims at making the patient aware of his irrational beliefs and the inappropriate emotional consequences of these beliefs” and the aim of the therapy is “to modify these underlying irrational beliefs” (Beck 9). It was Aaron Beck who propagated the cognitive behavioural psychotherapy. Beck could identify that the depression of various patients stemmed from conscious negative thoughts. Thus, “Beck proposed that specific cognitive content characterized each psychiatric disorder and that the goal of therapy was to identify and modify the patient’s distortions or biases in thinking and the patient’s idiosyncratic cognitive schemata” (Leahy 1). The attributional model of depression propounded by Abramson, Seligman and Teasdale in 1978 also held that people’s depressive pessimism and low self-esteem were associated with “attributing negative events to lasting personality traits of the self that led the depressive to generalize failure to other tasks and to future events” and as such both the models stressed on the ‘conscious thought processes of depressed individuals’ (Leahy 1). Thus, it can be seen that the cognitive behavioural therapies regarded that depression is very often associated with negative schemata of various sorts varying from thoughts of failure, loss to anxiety. However, one should always bear in mind that cognitive therapy does not follow the same principles or treatment models for all sorts of cognitive or psychiatric disorders. As a result one can find considerable differences in the therapy offered for various disorders. For instance, the cognitive therapy model and treatment of depression varies from that of the treatment of panic disorder, the cognitive therapy of paranoid delusional disorder and cognitive therapy of narcissistic personality disorder. Today cognitive behavioural therapy is not limited to anxiety disorders or depression alone. On the other hand, one can find the successful application of cognitive behavioural therapy in such cases as substance abuse, borderline personality, paranoid delusional disorder, marital conflict, and so on. Beck’s cognitive behavioural therapy model for depression In his cognitive behavioural therapy model for depression Beck describes that “the characteristic cognitions in depression are the negative cognitive triad, namely negatively biased views of oneself, of the world in general, and of the future” (Kennerley, Westbrook & Kirk 12). Beck argues that each one develops core beliefs and assumptions as one grows up. These beliefs can be either functional or dysfunctional. When one comes across an incident or series of events that violates one’s core beliefs and if one is unable to handle them using positive beliefs these are likely to give vent to dysfunctional assumptions. These dysfunctional assumptions thus become active and they evoke negative thoughts and create unpleasant emotional states of anxiety or depression. As pointed out by various researchers “interactions between negative thoughts, emotions, behaviour and physiological changes may then result in persisting dysfunctional patterns, and we get locked into various cycles or feedback loops that serve to maintain the problem” (Kennerley, Westbrook & Kirk 14). Therefore, it is imperative that the therapist identifies the dysfunctional patterns and negative cognitions that have caused depression in the patient. Thus, it can be argued that Beck’s cognitive behavioural therapy model for depression is based on identifying the negative cognitive triad (dysfunctional beliefs and assumptions) and converting them into positive functional beliefs. The Cognitive model of depression has attracted the attention of psychologists, scholars and therapists. In fact, Beck’s cognitive model “postulates three specific concepts to explain the psychological substrate of depression: (1) the cognitive triad, (2) schemas, and (3) cognitive errors (faulty information processing)” (Beck 10). Among these, the cognitive triad consists of three major cognitive patterns that accelerate depression in the patient. These include the patient’s negative view of himself, his ‘tendency to interpret his ongoing experiences in a negative way’ and his habit of cherishing ‘a negative view of the future’ (Beck 11). Very often, the patient regards himself as defective, inefficient, inadequate and good for nothing. The patient tends to show various signs and symptoms of his depressed state when he/she is moved by these negative cognitive patterns. In Beck’s cognitive therapy model the schema refers to stable cognitive patterns; for Beck, “a schema constitutes the basis for screening out, differentiating, and coding the stimuli that confront the individual” and “the kinds of schemas employed by the determine how an individual will structure different experiences” (Beck 13). As the individual’s negative assumptions and ideas increases his schema is badly affected and he tends to show more signs of depression. According to Beck the third factor that leads to depression is the patients’ cognitive errors or faulty information processing. The cognitive behavioural therapists hold that the clients would subject themselves to faulty information processing and the six varieties of cognitive distortion originally propagated by Beck include arbitrary inference, selective abstraction, overgeneralization, magnification and minimization, personalization, and absolutistic/ dichotomous thinking (Beck 14). It is essential to have a thorough understanding of the cognitive behavioural therapy model propounded by Aaron Beck. Beck’s cognitive model of psychopathology emphasises that thinking plays a pivotal role in managing and maintaining depression, anxiety, or anger. Beck argues that patients are more likely to be moved by their cognitive biases and as a result they tend to interpret life events in an exaggerated, personalized, and negative manner. Beck also argues that various levels of cognitive assessment are also possible. For him, it is the most immediate automatic thoughts that are “associated with problematic behaviour or disturbing emotions” and these automatic thoughts can be classified according to their specific biases or distortions as mind reading, personalizing, labelling, fortune telling, catastrophising, or dichotomous (all-or-nothing) thinking” (Leahy , 2003, 7). It can thus be observed that very often the automatic thoughts may not be true or reasonable. The personal schemas, the underlying assumptions or rules maintained by the patient, may make these automatic thoughts emotionally vulnerable and maladaptive. Very often, the patient’s maladaptive assumptions “are typically rigid, over inclusive, impossible to attain, and impute vulnerability to future depressive episodes or to anxiety states” and “their mind reading and personalizing will make them more likely to perceive rejection when it is not there” (Leahy , 2003, 7). Similarly, people who have high opinion about themselves but who fail to live up to these self-built standards are most vulnerable to depression. Therefore, in Beck’s model it is essential for the therapists to understand the automatic thoughts and to identify the underlying personal schemas that govern them. Similarly, the cognitive model of psychopathology holds that the thinking distortions or cognitive biases of individuals can be categorized into diagnostic categories and that specific conceptualizations can be arrived at for each of these categories. As Leahy postulates the CBT “recognizes commonalities in thinking distortions and biases across diagnostic categories” such as automatic thought distortions and that it “also recognizes that there are specific conceptualizations for each diagnostic grouping” (Leahy, 2003, 8). It is therefore imperative that the CB therapist resorts to a cognitive approach whereby the patient can identify similar patterns of thinking in his/her cognitive system rather than focussing on individual expressions of emotions. However, it is also essential to take the emotional schemas of the patient in to consideration as these are stirred by the unmet needs of the patient and can play a dominant role in modifying the thoughts and feelings of the patient towards the end of therapeutic sessions. It is true that many patients are quite unaware of the fact that their feelings and emotions are creations of their own thoughts. Many patients need to be convinced that they can bring about drastic changes to their emotions and feelings just be modifying their thoughts and interpretation of life events. One should always bear in mind that “the fundamental assumption guiding cognitive therapy is that the individual’s interpretation of an event determines how he or she feels and behaves” (Leahy, 2003, 8). The success or failure of CBT depends on the ability of the therapist to convince the patient that their thoughts have the power to modify their feelings, emotions and behaviour. As such, cognitive behavioural therapists lays more emphasis on current behaviours and thoughts of the patients rather than digging into their past. Therapeutic Skills in CBT CBT presupposes a collaborative relationship from the part of the therapist and the patient. It holds that “the practitioner is an expert on CBT whereas the individual is an expert on her own life and experiences” and therefore “during therapy, both of them work together to generate and try out new ways for the person to think and behave” (Somers & Queree 10). The therapist needs to identify the patient’s difficulties and the contributing cognitive distortions from a collaborative effort and the goal setting that follows should be a collaborative venture of both the parties. However, in CBT the therapist also needs to be active and directive. The therapist needs to steer “the direction of the therapy and, rather than necessarily allowing the client to decide the content of the sessions, will suggest the tasks that need to be tackled within the sessions and the strategies that should be used” (Whitfield & Davidson 4). However, maintaining trust between the client and therapist is essential and both need to work together to form a ‘therapeutic alliance’. The therapist’s ‘shared understanding of the problem’ should lead to ‘a written formulation that is referred repeatedly throughout therapy to direct, structure, and assess the impact of therapy (Whitfield & Davidson 5). It is based on this written formulation that the therapist needs to generate a number of specific goals which are agreed by the client as well. Similarly, conducting cognitive therapy of depression necessitates certain specific skills from the part of the therapist. The therapist should have a thorough understanding of the clinical syndrome of depression. He should be trained therapeutic interviewing skills necessary to define the patient’s mental status. Like all therapies, the therapist should establish a strong therapeutic relationship with the patient. He should be able to understand the patient’s exaggerated responses or misinterpretations as distorted reactions, should not be overtly deductive or excessively interpretative, should not be superficial and should never react negatively to depressed patients. On the other hand, the attempt of the therapist should be to initiate a collaborative enterprise with the client and to facilitate strong social support systems after the therapeutic sessions. Strategies and Techniques employed in CBT The CBT “therapeutic techniques are designed to identify, reality test, and correct distorted conceptualizations and the dysfunctional beliefs (schemas) underlying these cognitions” and the aim of the therapy is to enable the patients “to master problems and situations which he previously considered insuperable by re-evaluating and correcting his thinking” (Beck 4). The cognitive therapist needs to play a significant role in the therapeutic process. The ultimate aim of the therapist is to point out the errors in thinking committed by the patient and to assist him to think and act more realistically to overcome the symptoms through a number of cognitive and behavioural strategies. In cognitive behavioural therapy the therapist makes use of both cognitive and behavioural strategies. Cognitive techniques are widely employed by the therapists to identify, grasp and test the patient’s specific misconceptions and maladaptive assumptions. Thus, the therapist resorts to a cognitive approach where he/she employs a variety of specific learning experiences to convince the patient the following operations: “(1) to monitor his negative, automatic thoughts (cognitions); (2) to recognize the connections between cognition, affect, and behaviour; (3) to examine the evidence for and against his distorted automatic thought; (4) to substitute more reality-oriented interpretations for these biased cognitions; and (5) to learn to identify and alter the dysfunctional beliefs which predispose him to distort his experiences” (Beck 4). The rapport between the therapist and the patient is a significant factor in all these cognitive operations. However, one should always bear in mind that there exists sharp contrast between cognitive and behavioural therapies. While behaviour therapies lay emphasis on the external behaviour and behaviour traits of the patients cognitive therapists stresses on “the patient’s internal (mental) experiences, such as thoughts, feelings, wishes, daydreams, and attitudes” and evaluates ‘the patient’s automatic thoughts, inferences, conclusions, and assumptions’ (Beck 7). The focus of cognitive approach is to bring to light the dysfunctional ideas, beliefs, assumptions and negative views of the patient and for these cognitive strategies have been proved to be highly effective. On the other hand, from a behavioural point of view, it can be observed that “CBT helps people to learn new behaviours and new ways of coping with events, often involving the learning of particular skills” (Somers & Queree 9). For instance, CBT would guide one who suffers from social alienation to develop the necessary social skills. The cognitive and behavioural strategies employed in CBT differ considerably from that of psychoanalytic theory. One of the powerful components of cognitive behavioural therapy is that the patient shares and masters many of therapeutic techniques of the therapist himself. The patient very often needs to engage in self-questioning and it is the duty of the therapist to train the patient in this regard. The therapist can also make use of behavioural techniques “with more severely depressed patients not only to change behaviour, but also to elicit cognitions associated with specific behaviours” (Beck 5). As we have already discussed, unlike psychoanalytic therapy, the content of cognitive therapy focuses on the present condition of the patient rather than his/her childhood experiences. The childhood recollections of the patient are use only to confirm or clarify present observations. Thus, the patient’s cognition level, his feeling and emotions during and between the therapy sessions deserve primary attention in CBT. The therapist needs to set up schedules of activities, and make homework assignments to bring about a desirable positive outcome in the personal schema and cognitive system of the patient. It can also be noticed that the cognitive therapists draw on behavioural therapy by “utilizing exposure to feared stimuli, modelling and behavioural rehearsal, relaxation training, activity scheduling, graded task assignments, assertiveness training, communication and listening skills, and self-reinforcement” (Leahy 4). On the other hand, the cognitive techniques include identifying the negative thoughts, rating the emotion associated with the thought, categorizing the negative thought, judging the costs and benefits of the thought, weighing out the quality of evidences, arguing back at the negative thought, employing logical analysis, supplementing the lack of information, examining alternative causes and consequences, deciding whether there is a problem to be solved, and finally preparing the client to accept the realities (Leahy 8). Cognitive behavioural psychotherapy makes use of the positive theoretical formulations of both the cognitive therapists and the behavioural therapists. Cognitive therapy stresses on the cognition or thinking of individuals. Cognitive therapists hold that one’s personality is shaped by the way one thinks and that one’s thinking in turn exerts great influence on the way one feels and behaves. Cognitive therapists make use of collaborative process with the patient to bring out the patient’s maladaptive interpretations and conclusions that cause disorders in his personality. The ultimate aim of the therapy is to bring out a desirable therapeutic change in the patient. According to Cash and Weiner the therapist needs to undertake various behavioural experiments and verbal procedures “to examine alternative interpretations and to generate contradictory evidence that supports more adaptive beliefs and leads to therapeutic change” (Cash & Weiner 198). For this it is essential that the therapist rightly understands the cognitive distortions or errors in thinking usually committed by the patient in his/her day-to-day life. One can also notice that CBT has imbibed therapeutic insights of the behavioural school also. It has been identified by many researchers that the behavioural therapy is highly effective with regard to with anxiety disorders such as phobias and obsessive-compulsive disorders (OCD). It has also been observed by various researchers that behavioural therapy has its roots in scientific psychology, follows an empirical approach, proves to be highly effective in relieving anxiety problems and that it is “a far more economical treatment than psychotherapy, typically taking six to 12 sessions” (Kennerley, Westbrook & Kirk 3). However, the limitations of the behavioural approach have also been much discussed. One of the major drawbacks of the behavioural approach was that it failed to address “mental processes such as thoughts, beliefs, interpretations, imagery and so on” which have lasting impressions on the personality of any individual (Kennerley, Westbrook & Kirk 3). This led to the ‘cognitive revolution’ in the 1970s whereby both the behaviour and cognition of the individual are taken care of and this gradually led to the widespread acceptance of cognitive behavioural psychotherapy. Basic Principles of Cognitive Behavioural Therapy The basic principles of cognitive behavioural therapy are the following. It should be based on the cognitive-behavioural model of emotional disorders that stress the fact that thoughts influence feelings and behaviour; it should be brief, structured, directive, problem-oriented, and time-limited; there should be sound therapeutic relationship which is collaborative; it should be inductive and should bring about a desirable positive cognitive structure in the patient (Somers & Queree 13). The first and foremost principle of cognitive behavioural therapy is that the therapist should “uncover the patient’s underlying assumptions---that is, the patient’s rules or values---that predispose him to depression, anxiety or anger;” the therapist should always bear in mind that “each individual has his or her own idiosyncratic rules or assumptions” (Leahy 2). For this the therapist should rightly identify the cognitive distortions that the client subjects himself/herself into. These cognitive distortions can vary from mind reading, fortune telling, catastrophizing, labelling, discounting positives, negative filter, dichotomous thinking, shoulds, personalizing, blaming, unfair comparisons, regret orientation, emotional reasoning, inability to disconfirm, to judgement focus. It is worthwhile to discuss the basic principles that govern the Cognitive Behavioural Psychotherapy. The cognitive principle stands at the heart of CBT. The cognitive principle behind CBT holds that “people’s emotional reactions and behaviour are strongly influenced by cognitions” and thus patients are highly influenced by their thoughts, beliefs, and interpretations about themselves or the situations in which they find themselves (Kennerley, Westbrook & Kirk 4). It also argues that the interpretations and the meaning people provide to the events of their lives stem from one’s cognitions and as such changing the psychological states or disorders of patient presupposes a positive change in his/her cognitions too. On the other hand, CBT also holds that one’s behaviour can have a strong impact on one’s thought and emotion as what one does is most likely to change what one thinks and feels. To quote the researchers’ observations: “The CBT believes that behaviour can have a strong impact on thought and emotion, and, in particular, that changing what you do is often a powerful way of changing thoughts and emotions” (Kennerley, Westbrook & Kirk 5). This can be regarded as the Behavioural principle behind CBT. CBT is also characterized by “The ‘continuum’ principle” and “The ‘here and now’ principle.” The ‘continuum’ principle holds that “psychological problems are at one end of a continuum, not in a different dimension altogether” (Kennerley, Westbrook & Kirk 5) whereas the ‘here and now’ principle focuses on the present cognitions of the patient rather than his past life. Thus, the main focus of CBT is maintaining the current problem of the patient rather than digging out the root causes that led to its development in the past. Another major principle that govern CBT is the ‘interacting systems’ principle. This highlights the need to interact with the environment of the patient. The environment here is to be understood in its widest sense which should include not only the physical environment of the patient but also his ‘social, family, cultural and economic environment’ (Kennerley, Westbrook & Kirk 4). Case study: a patient with Generalized Anxiety Disorder The case study of a patient who suffers from Generalized Anxiety Disorder (GAD) has been selected to apply the various principles of CBT. For the purpose of the assignment and in accordance to BAPC’s Professional Conduct Procedure for confidentiality the clients name has been changed to the pseudonym George. George suffers from constant worry and anxiety over different activities and events in his daily life. He finds it difficult to concentrate and his mind goes blank at crucial periods. Similarly, he is restless, gets easily tired and finds it difficult to sleep peacefully. It is evident from the case study that George suffers from a number of cognitive distortions which have resulted in his depression. Therefore, the therapist needs to build up a strong therapeutic alliance with him and through effective dialogues he needs to grasp the cognitive triad, the personal cognitive schemas and the cognitive errors that he undertakes in his daily life. The patient needs to be told that most of his problems are associated with his thinking and that he needs to convert the negative views and assumptions into realistic ones. The patient needs to be offered worry awareness training. For this the therapist needs to convince the patient of the worry cognitive patterns that dominate his personal cognitive schemas. Similarly, he needs to be trained to cope up with uncertainties, stress, excessive worries and anxieties. Similarly, the therapist should enable him to challenge and test the existing cognitive system that worry is useful for him. In the same way, George is to be offered the basic skills in problem-solving training which is an effective alternative to worry. He should also put an end to engaging in cognitive avoidance of troubling thoughts. Instead, the patient should be trained to understand and gain control over his misperceived views of life stressors and help him to manage his stress through self-help approaches. The therapist can also make sure sufficient social support systems for the patient. Conclusions To conclude, it can be stated that CBT presupposes both cognitive and subsequent behavioural changes in the patients. The ultimate theoretical goal of CBT is to bring about positive changes in the personality of the individual by modifying his/her maladaptive beliefs and by correcting the patient’s cognitive distortions. Cognitive behavioural therapy has been practiced and evaluated within the academic discipline of behavioural and cognitive psychology. It has also been identified that CBT is an effective treatments available to reduce the frequency and severity of OCD symptoms. However, one of the limitations of CBT is that “the effectiveness of this therapy has been demonstrated only with unipolar, nonpsychotic, depressed patients” who prefer to use CBT rather than antidepressant medication (Beck 26). In the past few decades CBT has been proved to be extremely beneficial for many patients who were thoroughly ignorant that their problems or disorders were associated with their own cognitions. Works Cited Beck, Aaron T. Cognitive therapy of depression. Reprint ed: Guilford Press, 1979. Print. Cash, Adam & Weiner, Irving B. Posttraumatic stress disorder. Ed. Irving B. Weiner. Illustrated ed: John Wiley and Sons, 2006. Print. Kennerley, Helen., Westbrook, David & Kirk, Joan. An Introduction to Cognitive Behaviour Therapy: Skills and Applications. 2nd ed: SAGE Publications Ltd, 2011. Print. Leahy, Robert L. Cognitive therapy techniques: a practitioner's guide. Illustrated ed: Guilford Press, 2003. Print. Leahy, Robert L. “Chapter 1 Introduction: Fundamentals of Cognitive Therapy.” Practicing Cognitive Therapy: A Guide to Interventions. Ed. Robert L. Leahy. Jason Aronson Publishing. Web. 16 Nov. 11. < http://www.352express.com/wpm/files/40/arosnon02INTRO-2.pdf>. Robertson, Donald. The Philosophy of Cognitive Behavioural Therapy (CBT): Stoic Philosophy as Rational and Cognitive Psychotherapy. Karnac Books, 2010. Print. Somers, Julian & Queree, Matthew. Contributing Author Cognitive Behavioural Therapy (Core Information Document). British Columbia: Ministry of Health CARMHA, 2007. Web. 20 Nov. 11. < http://www.health.gov.bc.ca/library/publications/year/2007/MHA_CognitiveBehaviouralTherapy.pdf>. Whitfield, Graeme & Davidson, Alan. Cognitive Behavioural Therapy Explained. Reprint ed: Radcliffe Publishing, 2007. Print. Read More