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The Future of Community Mental Health for Persons with Severe Mental Illness

dr-aaron-beck-2015by Aaron T. Beck, MD

 

Part 3 of 3

Read part 1, A Biography of Cognitive Behavior Therapy

Read part 2, The Evolution of CBT in Community Mental Health

 

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.

A Biography of Cognitive Behavior Therapy

atb-2016-headshotby Aaron T. Beck

Part 1 of 3

 

I thought I would begin today with a little bit of the history, but as Emerson once said, “There is no such thing as history, only biography.”  So I am going to give you my biography and we will see how it wraps up into history.

Many years ago, I wanted to test out an intervention that I had developed called Cognitive Therapy, and so I set up a clinic that was called The Mood Clinic. The clinic served many purposes. It was simultaneously a research clinic, a training clinic, and a service clinic. We first dealt with depression, and I wanted to see if what we had developed as the intervention for depression was a valid one. In those days, as well as today, in order to prove the validity of any type of intervention, you would have to have a clinical trial with a control group and an intervention group. The control group received 12 weeks of Imipramine. The intervention group received 12 sessions of cognitive therapy. This randomized controlled trial showed that cognitive therapy treatment was more effective than Imipramine.  This was the first study that showed that a psychosocial intervention worked with depressed people, and that cognitive therapy worked at least as well as pharmacological therapy.

Indeed, when we continued to follow the patients during the follow up period, we found that patients who had received 12 weeks of Imipramine tended to not do well in the follow up period, but those using our psychosocial intervention continued to do well. The explanation was that the Cognitive Therapy intervention had actually taught people new skills. The pharmacotherapy people could no longer progress without receiving more drugs.

In subsequent clinical trials, people were kept on the drugs longer; however, the period for the psychotherapy was reduced! To make a long story not quite as long, we fine-tuned the treatment and wrote a book describing the treatment. Then we turned our attention to anxiety disorders. From then on, we continued with the same paradigm.  We would make clinical observations of patients with a different disorder, develop a cognitive formulation of the disorder, and adapt our interventions. We would then do a clinical trial to demonstrate that it was valid. And we would publish a book. And so we went on from depression to suicide, substance use, anxiety, and personality disorders. We found that our clinical trials were quite effective, and we wrote a number of books on a number of other disorders too. This took us about forty or fifty years. When you have a new therapy, you have to start when you are very young, or you are not going to live to see the ultimate applications!

 

Read part 2: The Evolution of CBT in Community Mental Health

The Hallmark of Cognitive Therapy

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The hallmark of cognitive therapy is understanding clients’

reactions—emotional and behavioral—in terms of

how they interpret situations.

– Judith S. Beck

 

Why do we structure the session in the first place?

“Every minute in a session is precious, and we want to maximize the time we have to help clients learn to deal with the issues that are most important to them.”

Dr. Judith Beck

 

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Cognitive Therapy: A New Focus

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Aaron T. Beck, MD

 

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:

Information Processing Sequence CT New Focus ATB

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

 

Reference:

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.

 

 

Judith Beck

Q&A with Dr. Judith Beck

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.

Judith Beck

Drs. Beck and Evans Discuss Evidence-Based Practices

Within the span of a few decades Dr. Aaron T. Beck, widely regarded as the “Father of Cognitive Behavioral Therapy”, has changed the way we think about mental health treatment. In 2007 the city of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), and Dr. Aaron Beck joined in a collaboration unlike any other to bring Cognitive Behavioral Therapy out of academia and into Philadelphia’s behavioral health system.

This unique partnership is one of many strategies employed by DBHIDS to ensure that all Philadelphians have access to the most effective treatments. To capture this fascinating story Dr. Beck, and DBHIDS’ Commissioner Dr. Arthur C. Evans have joined to create this short video about their work.

CBT: Review of Randomized Trials

Written by Paulo Knapp, PhD

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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.

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.