by Aaron T. Beck, MD
Part 3 of 3
I think that it is going to take a number of years for us to really get our Recovery Oriented Cognitive Therapy approach fully implanted. The reason is that the approach is novel, and compared to the standard approach for the severely mentally ill, it is revolutionary. For example, one important principle is that if that you treat these individuals as though they are normal, they are going to react normally. They are going to show normal affect, normal behavior, and normal thinking. Our idea is that not only can we bring out the normal personality, but we can maintain the normal personality throughout the individual’s stay in an inpatient facility and then back out into the community.
One of the problems is that this model runs counter to everything that has been taught before this. For example, when I took psychiatry in medical school, I was taught that there were two types of psychiatric patients. There was dementia praecox, which had to do with people who had delusions and hallucinations, who would gradually just get worse and worse until they were completely insane. Then, there were psychopathic personalities who were individuals with very distorted personalities. In either case, the question was, were these individuals treatable?
And so I was imbued with this story that severely mentally ill people, since they seemed so removed and so strange, were really untreatable. Working with Paul Grant and the others on our schizophrenia team, we were able to discover that if we changed our philosophy to the ideas of Recovery and went on the assumption that underneath the abnormal symptoms, there was a normal personality, that we could maintain the personality.
But the problem was, how do you maintain the person? Well, that becomes the problem. So the plan became to train all the individuals that have contact with the patients–actually we call them “individuals.” This includes the art therapists, the occupational therapists, the social workers, the line staff, nurses and psychiatrists. We needed all of them to come aboard, using this new approach. To do this, they needed a change in attitude, because many of them had the same erroneous belief that I had had—namely that the people who were insane by definition, were not capable of being sane at any time. And we would have to create an atmosphere in which all of the personnel would work toward establishing a cognitive milieu.
Now, to accomplish that would be difficult, because there are numerous problems that the staff has to deal with, that get in the way of this full recovery. For example, the most common problems are the negative symptoms. Some of the severely ill individuals also act out in various ways or become aggressive toward the staff. So numerous problems have come up, and the staff has had to learn how to deal with them. But once they do, the individual can move along and get back into their lives. Also, there is certainly turn-over at the various facilities, as staff comes in and out.
So, I expect that at the end of 5 years, we’re going to have a model program here at the Philadelphia Department of Behavioral Health and Intellectual Disability Services(DBHIDS), and people will come from all over the world to learn about the program. Right now, we have national and international clinicians who are trying to learn our method and export it to their own home towns, and eventually we’ll have a training program that will involve not only people at DBHIDS but people from around the world.
The hallmark of cognitive therapy is understanding clients’
reactions—emotional and behavioral—in terms of
how they interpret situations.
– Judith S. Beck
By Judith S. Beck, PhD,
President, Beck Institute for Cognitive Behavior Therapy
Guilford Publications asked me to reflect on my reasons for writing Cognitive Behavior Therapy: Basics and Beyond and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work, both of which Guilford first published in 1995 and 2005, respectively. Below is what I sent:
I remember the moment I conceived of writing CBT: Basics and Beyond. It was in the early 1990’s and I was presenting a workshop with my father, Dr. Aaron Beck, in California. Most of the workshop participants were familiar with his work but asked very basic questions. Again and again, I found myself surprised by what they didn’t know (e.g., how to conceptualize patients according to the cognitive model, structure a session, set an agenda, use Socratic questioning, handle homework challenges, ask for feedback). I realized they needed a basic book that could teach them these skills in a step-by-step format, with transcripts illustrating key therapeutic interventions. I had lots of automatic thoughts when writing the book (“People will think this is too simplistic,”), for which I used CBT techniques on myself to keep going. The book is now the basic text used by most graduate schools in all the mental health disciplines, in the United States and abroad.
I also remember when I conceived of writing Cognitive Therapy for Challenging Problems: What to do When the Basics Don’t Work and it traces back to the first book. When I was writing CBT: Basics and Beyond, I had to continually separate material that was basic from material that was advanced–which made me realize that people would probably need a sequel to the basic text. I presented dozens and dozens of workshops on Cognitive Therapy for Challenging Patients and Cognitive Therapy for Personality Disorders in the years that followed. At each workshop, I asked participants to specify problems they had with some of their patients. (“What does the patient do or not do in session or between sessions that’s a problem? What does the patient say or not say that’s a problem?”) I soon had a very long list of problems. The challenge for me was in organizing the material I collected, and I had lots of false starts. It took me five years to determine how the book should best be structured. Once I figured this out, it took just another two years to complete the book.
I started off my career, not in psychology, but in education. Early on, I learned how to break down and explain complicated ideas and tasks for my young elementary school students who had learning disabilities. Through my books and workshops and other training activities, I believe I’ve been able to do the same for therapists who are learning and practicing CBT.
How does cognitive theory integrate more recent clinical and experimental findings?
We define Cognitive Therapy in terms of the application of the Cognitive Model, rather than in terms of the specific techniques. Although the original version of the therapy emphasized techniques such as cognitive restructuring, it later emphasized behavioral methods that were shown to produce adaptive changes in information processing (for example, activity scheduling, role playing, and behavioral experiments).
The basic cognitive model assigns a major role to cognitive schemas in information processing. The content of the schema (beliefs, expectancies, images) shapes the content of the information processing. There is a continuum from adaptive to dysfunctional beliefs. When the beliefs are exaggerated or biased, they lead to inappropriate or exaggerated affect and behavior.
While the basic cognitive model emphasizes the importance of cognitive bias in creating psychological problems, a body of clinical observations and basic research findings has pointed to the role of deployment of attentional resources in adaptive and maladaptive behavior (Beck & Haigh, 2014). Thus, the combination of attentional focus and cognitive bias plays a major role in psychopathology.
Attentional fixation, an extreme form of attentional focus, is instrumental in the development of conditions as diverse as panic disorder, suicidal impulses, and the craving behaviors in addictions. When attention is fixated on a particular sensation and belief as in panic disorder, the individual is incapable of reasoning or accessing contradictory information regarding the benign nature of the symptoms.
When attentional focus is enhanced as in psychopathology or in intense states of arousal such as anger it is deployed on each component of the information processing sequence:
The combination of attentional hyper focus and bias is particularly evident in the development of the somatic conditions such as chronic fatigue syndrome, chronic pain, and hypochondrias.
The expanded cognitive model can be utilized to understand each of the psychological disorders with their unique cognitive formulation (Beck & Haigh, 2014). The formulation may be drawn on to conceptualize a specific case.
As indicated, the expanded model is comprehensive enough to provide a blueprint for the treatment. The treatment is geared to the characteristics of the disorder. The emphasis on discrete refocusing techniques such as mindfulness constitutes a central part of mindfulness based cognitive therapy and other mindfulness strategies. Refocusing approaches were initially used in cognitive therapy of panic disorders but are subsequently used in a variety of psychological problems such as chronic pain, hypochondriasis, hallucinations, and anxiety.
Learn to use the cognitive model in our CBT for Depression – Core 1 Workshop
Beck, A.T., & Haigh, E.A.P. (2014) Advances in Cognitive Theory and Therapy: The Generic Cognitive Model. Annual Review of Clinical Psychology, 10, 1, 1-24.
What do you think is important for a young CBT therapist or researcher to know about the history of CBT?
Aaron Beck has always started with clinical material first, working with clients and generating hypotheses about his observations. He tests his hypotheses, refines his theories, and bases treatment on these theories, continually testing and improving the validity of his theories and the efficacy of treatment. He continues to do so to this day, in his work with individuals with schizophrenia. Researchers should follow his lead, always treating clients to inform their work. And they should learn to treat clients outside of their specialty area, for example, clients with different ages, cultures, genders, diagnoses, and so on, so they can maintain a broad perspective.
What is in your opinion most exciting about CBT today?
There are many different directions the field is going in today, but I’ll just choose one, something that we’re heavily involved in at the Beck Institute: developing online training programs for therapists. So many mental health professionals throughout the world can’t afford existing training programs or can’t travel to attend workshops or conferences. With today’s technology, we can train many more mental health and health professionals in evidence-based treatments. So many more people, with a range of problems, can be helped.
Any predictions for the future? Will there be a place for CBT in the future?
Yes—and the treatment for certain disorders may look somewhat different from how it looks today, based on advances in research and technology. And I hope more people will adopt a different view of CBT. Many professionals believe that CBT is defined by its use of cognitive and behavioral strategies. But that’s too narrow a definition. CBT should be seen as a system of psychotherapy that is based on the cognitive model, not based on its use of certain techniques. In fact, with clients with personality disorders, we often adapt techniques from a range of psychotherapeutic modalities, used in the context of the cognitive model, such as strategies more commonly associated with Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Gestalt Therapy, Psychodynamic Psychotherapy, Interpersonal Psychotherapy, Positive Psychology, and a number of others. CBT will continue to be a major force in mental health treatment as long as research studies show equal or better outcomes for both treatment and relapse prevention.
Written by Paulo Knapp, PhD
A systematic review of the literature of all published papers in the year of 2014 describing randomized controlled trials (RCTs) that compared cognitive-behavioral interventions with a wait-list control group, or another form of psychosocial intervention or other medical treatment was conducted. Only RCTs that clearly specified a CBT theoretical orientation were included. Samples included all populations, undergoing any type of psychiatric or medical condition; subjects with no formal diagnosis (e.g., students in a school-based prevention program), and psychotherapy professionals in training condition were also included. As the objective of the review was to take an instant picture of the current clinical applications of CBT interventions in the whole spectrum of psychiatric and other medical disorders, variables such as fidelity of therapists to the proposed intervention, heterogeneity of the experimental samples, appropriateness of the control groups, and any other confounding variables were not analyzed.
The data extracted from 394 identified RCTs published in the year of 2014 revealed that around 58,000 individuals underwent CBT-based interventions conducted in 34 countries for the treatment of 22 different medical and psychiatric diagnoses. As could be expected, the most prevalent investigated diagnosis was depressive disorders in 20% of trials, while other medical conditions, as chronic pain and fatigue, and collateral symptoms of cancer treatments, e.g., insomnia, were treated with cognitive-behavioral interventions in 75 studies, 19% of total. Among other diagnosis, mixed anxiety-depression symptoms were addressed in 63 studies, and substance use disorders in 37 studies.
One hundred forty seven trials were conducted in the USA, and 15 in Canada, summing up 162 (41% of total) studies in North America. European countries showed a similar contribution with 167 (43% of total) studies, mostly from United Kingdom (43), The Netherlands (35), Germany (25), and Sweden (21), representing three quarters of the European trials. Outside North America and Europe, Australia published a fair amount of studies (35), and CBT-oriented trials were also reported with samples far apart in the globe as China (9) and Brazil (4), as well as in different countries like Israel, Pakistan, Iran, Congo, Indonesia, Turkey, Korea, India, and Greece, among others. However, almost all (95% of total) trials were conducted in high-income economy countries.
In accordance to our current times, 65 (16.5%) studies reported web-based cognitive-behavioral interventions, from Internet sites to phone apps. Four studies conducted in school settings aiming psychopathology prevention were published, as well as two trials comparing different formats and settings for professional training in CBT.
This systematic review shows that there has been a steady dissemination and adoption of the cognitive-behavioral therapies in practitioner’s clinical work in a wide array of psychiatric and medical conditions. The high number of randomized clinical trials conducted in a single year, with worldwide study samples, reporting an increasingly widespread use for different clinical conditions, demonstrates a definite consolidation of cognitive behavioral therapies in the contemporary therapeutic scene.
At this week’s CBT for Substance Use Disorders workshop, we had the pleasure of welcoming Katherin Torres back to Beck Institute.
She 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.
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 hypnotherapist 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.”
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.
By Deborah Beck Busis, LCSW
Director, Beck Diet Programs
A recent article published in the New York Times, “After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight,” details how most of the contestants on the television show, “The Biggest Loser,” regained much, if not all of the weight they had lost while on the show. The article also describes how the contestants’ metabolisms slowed down as they lost weight and did not return to their original level once they regained their weight. The level of the hormone leptin, which influences hunger, also did not return to the original level, and in fact, reached only about half of what it had been before they started to diet.
The article certainly is discouraging. It also emphasized that the dieters, who lost weight through extreme calorie restriction and high levels of exercise, had to eat substantially fewer calories (up to 500 calories less) than other people who hadn’t dieted, to maintain their weight loss. We don’t believe the situation is hopeless, however. There is a significant amount of research that shows that while there is a change in metabolism as people lose weight, the amount varies. These studies generally show that the metabolic penalty is between 20-200 calories and that this penalty decreases modestly in the year following weight loss. On the other hand, a meta-analysis that was published in 2012 found no change in the metabolic rates of dieters.
In our program, most people have been able to lose weight and keep it off—when they’re willing to have periodic booster sessions to keep their cognitive and behavioral skills sharp. There are several key components of our weight loss program that are drastically different from what the contestants on the “The Biggest Loser” do. First and foremost, our clients do not lose as much weight and they do not lose it quickly; usually, the rate is half a pound to two pounds per week.
Along with slower weight loss, our clients also follow diet and exercise plans that fit in with their lives. In terms of exercise, none of our clients devote the nine hours per week that the “Biggest Loser” participants were advised to do once they returned home. Although the article didn’t describe the specific diets participants followed while they were being filmed, it is likely that the diets were quite restrictive, both in terms of number of calories and the types of permitted foods. This, too, is quite contrary to our program. From the start, we work with our clients to incorporate all their favorite foods into their diets in reasonable ways. We work hard to ensure that our clients only make changes in their eating that they can sustain in the long term.
When helping our clients make changes in eating and exercise, the two words that we constantly use are reasonable and maintainable. We have found that when dieters lose weight eating or exercising in a way they can’t maintain, they invariably gain the weight back when they revert to old behaviors. Most of our clients don’t lose as much as they’d like because to do so would require unmaintainable eating and/or exercise plans. But they do get to a place where they feel strong and in control of their eating; their health is better; they have gained most of the advantages of being at a lower weight; they experience far fewer cravings; and they feel confident that they can keep doing what they’re doing. They not only know what to do but also can competently solve problems and address dysfunctional thoughts and beliefs that interfere with maintaining the needed changes in behavior.
As far as we can tell, “The Biggest Loser” is the antithesis of our program. Although we haven’t had our clients track their metabolisms before and after weight loss, we assume that taking a much more measured approach is part of what enables our clients to lose weight and keep it off. While doing it this way is less compelling in the moment, because the pounds fail to drop off at lightning speed, it seems to pay off in the long term, as dieters lose weight by putting behaviors into place, supported by changes in cognition, that they can ultimately maintain.
Are you a professional who works with dieters?
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