Dr. Aaron Beck’s 95th Birthday

Today, July 18, 2016, is Dr. Aaron Beck’s 95th birthday. At last week’s workshop, participants celebrated by signing ‘Happy Birthday” and hearing stories from Dr. Beck.

 

 

Part 1

We recommend beginning this video at 2:40

Part 2

 

 

Workshop Participant Spotlight – Katherin Torres

At this week’s CBT for Substance Use Disorders workshop, we had the pleasure of welcoming Katherin Torres back to Beck Institute.

DSC_0046editShe and her colleagues from Pathways in San Diego recently attended the CBT for Schizophrenia workshop in April, and now she returned solo to learn more about using CBT with her substance abusing clients.

A pre-licensed MFT intern at Pathways in San Diego, Katherin is a first episode of psychosis specialist, working in the Kickstart program which provides confidential assessment and early assistance for young people between the ages of 10 and 25 who are at risk for mental illness in San Diego County.

First episode of psychosis clients often have comorbidity, and this workshop taught Katherin new ways to treat substance use disorders, address issues with open communication, and provide support to her high-risk clients.

Katherin has a long time affection for CBT, “It’s my therapeutic style: collaborative.”

At the workshop, she enjoyed watching the videos of  the instructor, Dr. Cory Newman, in therapy sessions and completing roleplays with fellow participants to put new skills into practice.

This workshop will help her to structure her sessions, remember to set goals, and better understand her clients with substance use disorders. She is most excited to bring  what she has learned back to the staff in the Kickstart program.

 

Workshop Participant Spotlight: Kanan Kanakia

This week’s workshop, CBT for Children and Adolescents, included Kanan Kanakia, who traveled from Mumbai, India to attend the workshop. She has experience as a psychotherapist, special educator, counselor, and hyKanakiapnotherapist which allows her to choose the best treatment path for her clients.

After learning about CBT, she wanted to get the actual feel of how to apply CBT and researched Beck Institute workshops, deciding “which better institute than here.”

“This workshop was exactly what I was looking for with the know-how and the application in real life and real circumstances.”DSC_0281

When asked about Dr. Torrey Creed, the workshop instructor, Kanan replied, “Oh, she’s amazing!” She presented real case examples of the topics she was instructing, which made the complex topics easy to grasp.

Kanan also had the opportunity to role play a tough client with Dr. Aaron Beck via Skype.

 

 

Why Anxiety Persists

Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.

 

At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?

Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.

Rob Web

Robert Hindman, PhD

Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.

Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.”  Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”

Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking.  For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers.  For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.

Judith S. Beck, PhD

Judith S. Beck, PhD

Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).

Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.”  The problem with perfectionism is that it’s impossible to be perfect.  When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.

Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.

Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.

 

Learn more about the upcoming CBT for Anxiety workshop in Chicago. 

 

A Buckley

Amy Buckley – Workshop Participant Spotlight

Traveling from Burlington, Vermont, Amy is a clinical social worker in a private practice where she treats anxiety and depression in college students and young professionals. A BuckleyThe transition into college and navigating the independence and responsibility of adulthood can be daunting, and she uses CBT and mindfulness to improve the lives of her clients.

She attended our recent CBT for Anxiety: Core 2 workshop in Philadelphia and learned practical strategies for treating clients with anxiety. All the knowledge from this workshop hasn’t sunken in yet, so she is looking forward to “go home and study” the enormous amount of information Dr. Amy Wenzel presented during the workshop. Learning about the worry script and using exposures are the main take-aways for Amy. Her favorite part? Meeting with Dr. Judith Beck and having the opportunity to Skype with Dr. Aaron Beck were her favorite parts of the experience.

CBT and Mindfulness for Depression

Rob Webby Robert Hindman, PhD

Clinical Psychologist at Beck Institute

 

Mindfulness-based interventions have been becoming more popular in psychotherapy. One such treatment, Mindfulness-Based Cognitive Therapy (MBCT), has specifically been developed to prevent relapse in clients who have experienced recurrent major depressive episodes (Segal, Williams, & Teasdale, 2001).  We have incorporated mindfulness strategies into our work at the Beck Institute. Instead of thinking about mindfulness-based interventions as separate treatments, however, we think about mindfulness as a potential strategy to use in a larger CBT framework.  I’ll review one common mindfulness technique we use with our non-suicidal depressed clients.

A body of research has demonstrated rumination to be an important factor in maintaining depression (e.g., Nolen-Hoeksema, 2000).  We view rumination as a strategy clients use to cope with depression.  For example, Mark, a client I recently treated, felt depressed, then ruminated to try to figure out why he felt depressed. His ruminative thoughts included, “Why do I feel so depressed? What’s wrong with me?  I just can’t do anything right, like I got a bad review at work.  My friends don’t try to call me either. . .”  I worked with this client to help him identify his beliefs about the rumination process instead of solely evaluating the content of each thought.

First I help clients identify, and then evaluate, beliefs about rumination. I start this way (instead of going straight into mindfulness) because clients tend to continue to use strategies that they view as helpful. I want them to recognize that rumination is doing them more harm than good.  One way to identify beliefs about rumination is to complete a cost-benefit analysis, eliciting from clients the advantages and disadvantages of rumination.  Instead of using the term “rumination,” I asked them what they call the strategy (e.g., “asking myself why,” “listing all of my problems,” “trying to think my way out of depression”).

Typical advantages include “It helps me figure out my problems;” “I can come up with solutions.” “I’ll be able to know what to do next time I feel depressed.”  Next we list the disadvantages, such as: “It makes me feel worse.” “Once I start, it’s hard to stop.”  Then we evaluate each advantage.  For instance, I asked Mark, “How often do you come up with a specific solution?” and “If ruminating helped you solve your problems, do you think they would be solved by now?”  Next we evaluate whether the advantages or disadvantages are stronger. Clients have effectively assessed their positive beliefs about rumination when they conclude that the disadvantages outweigh the advantages. A list of the advantages and disadvantages shows clients the consequences of rumination and acts a motivator to stop the unhelpful strategy.  (If the advantages are still stronger, you’ll need to either spend more time evaluating the advantages or add to the disadvantages.)

The next step is to teach clients how to use mindfulness as a strategy to disengage from rumination.  I record the mindfulness exercises (usually using clients’ cell phones) to make it easier for them to practice. Before I start, I guide clients through a rumination induction by having them close their eyes and actively think about a topic involved in their typical ruminations. I get them to simulate the process of ruminating in session so they can experience being able to disengage from the rumination process.  As I noted before, this strategy should not be used with actively suicidal clients because it can increase their depressed mood and sense of hopelessness.

Once clients have been ruminating for about 30 seconds, I ask for a rating of their depressed mood from 0-10, turn on the recording app on their phone (“voice memos” on iPhones or “voice recorder” on Androids), and begin guiding them through a mindfulness of the breath exercise that lasts for 5 minutes.  At 5 minutes, I get another mood rating, end the exercise, and ask them about the experience (e.g., “What did you notice?” “Were you able to let go of ruminative thoughts and refocus on breathing?” “What happened to your mood over time?”)  The vast majority of clients learn that it’s possible to disengage from rumination, and that by not actively ruminating, their mood gradually improves.  I make sure to emphasize that mindfulness is not for the purpose of making them feel better or suppressing thoughts but is a strategy to help them relate to their thoughts in a different manner.  Their action plan then consists of listening to the recording every day (preferably at the beginning of the day to serve as a reminder to use mindfulness throughout the day) and to use mindfulness by letting go of thoughts and refocusing on the breath with their eyes open whenever they notice themselves ruminating during the day.

 

Dr. Hindman will be teaching mindfulness exercises as part of the CBT for Depression – Core 1 workshop at Beck Institute in March and the CBT for Anxiety workshop in Chicago in April.

 

References

Nolen-Hoeksema, S. (2000).  The role of rumination in depressive disorders and mixed anxiety/depressive symptoms.  Journal of Abnormal Psychology, 109, 504-511.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001).  Mindfulness-Based Cognitive Therapy for depression.  New York: Guilford Press.

Reducing Clinician Stress When Treating Traumatized, Suicidal Clients

Marjan G. Holloway, Ph.D., Beck Institute Faculty

 

Portrait

Marjan G. Holloway, Ph.D.

As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians.  The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients.  When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases.  These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.

  1. All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
  2. Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
  3. Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
  4. Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )

We have all been there.  I recall my excitement after having received a new client referral in the early years of my practice.  This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors.  I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training).  Not surprisingly, I avoided taking the case.  To address my sense of responsibility and guilt, I started to call other community clinicians and colleagues in private practice to find a good referral source.  Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide.  As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client.  I realized that these beliefs – along with my negative emotions – were dictating my decision to avoid.

During an upcoming 2016 Beck Institute Workshop on CBT for PTSD, I plan to review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996).  While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:

  • The importance of having the client understand (i.e., “digest”) the traumatic event
  • The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided

By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.

To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms.  CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:

  • Gaining continuing education in evidenced-based CBT for PTSD
  • Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
  • Seeking peer consultation and/or supervision, as needed
  • Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
  • Paying close attention to self-care and early signs of professional burnout

Working with traumatized clients is certainly not easy.  However, we as CBT clinicians have the responsibility to intervene, rather than to avoid.  Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based.  Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.

 

Recommended Resources

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.

Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.

 

Mobile Apps to Consider

PE Coach

Breathe2Relax

Provider Resilience

Cathryn Prendergast – Workshop Participant Spotlight

Traveling all the way from Perth, Australia, Cathryn is a psychologist at the Hollywood Clinic, a private hospital, where she provides individual and group treatment to inpatients and outpatients for a variety of diagnoses including addiction, borderline-personality disorder, and eating disorders. Cathryn initially learned the foundation of CBT from her masters program at Curtin University and always wanted to travel to Beck Institute as, “the base of CBT globally.” DSC_0002

The most valuable part of the workshop for Cathryn was not a specific skill, but the entire experience. “At times, the workshop felt more like specialized supervision for my practice. I’m taking a lot home with me.” Cathryn also mentioned that, while the instructors are wildly experienced, they are still human and provide examples that apply to a variety of professions.

Unlike most workshop participants, Cathryn decided to stay in downtown Philadelphia to get the full experience, and used the convenient SEPTA bus to travel to the Crowne Plaza each day for the workshop. This allowed her to explore the Reading Terminal Market, and plan to visit Independence Hall and the Liberty Bell on Thursday.

“This workshop exceeded my expectations very much. I hope I can come back!”

Workshop Participant Spotlight – Pablo Alonso

As a therapist in Madrid, Pablo knew he wanted to improve his skills and, after reading many of both Drs. Beck’s books, he decided to come to Philadelphia for our Core 2: CBT for Anxiety course. “Part of being a great therapist is constantly working to improve your skills, and the best way is to go directly to the source.”

DSC_0138Pablo works in a clinic at the University of Madrid where he is a therapist, researcher, and supervisor of final-year students. He also works at the Deyre Medical Clinic, where he provides therapy to trauma patients. His clients are mainly adults and adolescents with depression, anxiety, and substance use disorders.

“When I grow up as a therapist I want to be just like Amy,” referring to Dr. Wenzel, who instructed the 3 day course on CBT for Anxiety. Roleplays were his favorite part of the workshop, because that’s when he got to see Dr. Wenzel “in action.”

On having the opportunity to meet Dr. Aaron Beck, “I have seen so many videos on YouTube, it was like I met him a long time ago.” 

His favorite lesson from the workshop was that “CBT is eclectic, it’s not a rigid therapy where you have to do A, B, then C. It’s fluid.”

No trip to Philadelphia is complete without a history tour and a cheese steak, which Pablo enjoyed and said,”I’m going to have to repeat that!”

participants at a recent workshop in San Antonio, Texas

  • Absolutely fantastic. [The speaker] was extremely knowledgeable on the subject and presented [the material] in an excellent manner. Best training ever! The training is invaluable to both experienced and inexperienced therapists. Keep up the good work.
  • This [workshop] was the most in-depth introduction to CBT I have ever had. Our instructor was outstanding; animated and gracious.
  • This was an excellent training that has given me a new perspective on the material.
  • We need so many more trainings like these for all [of us] providers!