Did you learn CBT through the tradition of “See one, do one, teach one?” Were your instructors and supervisors clinicians who had never learned the principles of adult learning? Did they instead teach or supervise you in the way they themselves had been taught or supervised?
Dissemination and training of quality CBT therapists has become a recent focus for CBT programs throughout the world. There is a renewed focus in the field of CBT and on the skills needed to effectively teach and supervise. In fact, CBT supervision skills have independently been recognized as a competency in recent years.
Perhaps surprisingly, little research exists on CBT training. What constitutes sufficient training? What does “competence” in CBT actually mean? How should therapist “drift” be monitored and assessed? Sudak et al (2015) summarizes the current research in training and supervision.
Training is defined as the effective transfer of knowledge about and practice of the key skills of CBT. It represents both knowing that and knowing how. Most skills are taught both in training and supervision. Therapists or students first learn the rationale for a skill; they watch experts, and model what they have learned in practice with roleplayed “clients” of varying degrees of difficulty (with corrective and confirming feedback). Once trainees have the necessary skills, they can then be supervised with actual clients in a setting of “real world complexity.”
CBT supervision is most effective and efficient when the supervisor uses processes that parallel CBT therapy. The supervisory alliance is critical to effective work in supervision. The relationship needs to be safe enough for the supervisee to tell the truth and to be able to hear and incorporate constructive feedback. Supervisors should do a needs assessment with supervisees and then collaboratively set goals which form the “road-map” for supervision. Good supervision uses a session structure similar to that employed with clients in psychotherapy (Liese and Beck, 1997). By so doing, the model is reinforced and the supervisee can have an experience akin to self-practice.
Several other important parallels exist between effective supervision and therapy. These include using Socratic questions to stimulate learning and reflection, action plans between sessions and eliciting and giving feedback. Tapes of client sessions must be used to assess progress, rated by both the supervisee and supervisor with a validated instrument to determine fidelity and integrity, such as the Cognitive Therapy Rating Scale and client symptom rating scales provide data to determine if care is adequate and safe.
Supervision also requires conceptualization – both of the client and the supervisee. We are more effective supervisors if we develop a tailored educational plan based on the educational needs of the trainee and his or her capacities as therapist. The cultural competence and the cultural background of supervisees and clients should also be considered as a part of the conceptualization.
Supervisees should be encouraged to use thought records regarding their reactions to clients and expectations of themselves as therapists. This practice helps them to learn more effectively and inculcates the self-reflection that encourages expertise. Bennett-Levy (2003) has published extensively regarding this core process in CBT training. Active engagement and thoughtful implementation of several learning methods, as described by Milne and Dunkerley (2010), heightens curiosity and interest in supervisees.
Making our supervision and training more effective is also more engaging and fun for the teacher, so everyone benefits from this effort to improve our work.
Sudak, D.M., Codd, R.T., Ludgate, J., Reiser, R.J., Milne, D., Sokol, L., Fox, M. Teaching and Supervising Cognitive Behavioral Therapy. (2015) Hoboken: John Wiley and Sons.
Bennett-Levy, J. Lee., N., Travers, K., Pohlman, S., & Hammernick, (2003). Cognitive therapy from the inside: Enhancing therapist’s skills through practicing what we preach. Behavioural and Cognitive Psychotherapy, 31, 145–163.
Liese, B.S., & Beck, J. S. (1997). Cognitive therapy supervision. In E. Watkins (Ed.), Handbook of psychotherapy supervision. New York, NY: Wiley
Milne, D.L., & Dunkerley, C. (2010). Towards evidence-based clinical supervision: The development and evaluation of four CBT guidelines. Cognitive Behaviour Therapist, 3, 43–57.
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.
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?
Norman Cotterell, Ph.D.
Beck Institute for Cognitive Behavior Therapy
Beck and Gellatly (2016) propose that catastrophic thinking is a central feature in psychopathology. Such thinking magnifies both the immediate and eventual consequences of any perceived threat. A variety of disorders can be conceptualized as such: Clients magnify external threats (accidents, attacks, arson) but most notably misinterpret and magnify perceived internal threats. Sensations, thoughts, and emotions are seen as signs of immediate physical or psychological catastrophe.
- Panic — immediate catastrophic consequences of an unexpected physical sensation: “If my heart races, I’m dying.” “If I feel lightheaded, I’m about to faint.”
- Social Phobia — catastrophic misinterpretations of the social consequences of anxiety: “If people see me sweat, I’ll be judged, shunned, rejected or shamed.”
- Agoraphobia — catastrophic beliefs about the consequences of anxiety: “If I panic, I’ll be trapped.”
- Specific phobias — catastrophic beliefs about a feared object or situation: “If I get on an airplane, I won’t be able to handle the anxiety.”
- Health anxiety — catastrophic consequences of an unexpected physical sensation, or image: “If my chest hurts, I have heart, lung, or infectious disease. If the doctor sends me for tests, it means I’m seriously ill.”
- Obsessive compulsive disorder — Catastrophic misinterpretation of an intrusive thought: “If I think something unacceptable, it means I myself am unacceptable. Thinking it is as bad as doing it.”
- Posttraumatic Stress Disorder — Catastrophic beliefs about the reoccurrence of danger: “If it happened before, it’s likely to happen to me again.” “Flashbacks mean danger.”
- Pain — Catastrophic beliefs about pain and its consequences: “If I’m in pain, it is unsafe to move, and I must stop my activities.”
- Traumatic Brain injury — Catastrophic misinterpretations of post concussive symptoms: “If I have a headache, my brain injury is getting worse.”
Beck and Gellatly regard such thinking as an essential ingredient in the development and maintenance of these anxiety disorders. They identify 6 essential ingredients of a cycle that fuels them: Catastrophic Beliefs (“I’m having a heart attack, I’m dying,”) triggered by a Precipitating Event (heart palpitations) results in both Anxiety Symptoms (shortness of breath, dizziness, feeling out of control) and an Interpretive Bias (“If my chest hurts, I’m having a heart attack”). These, in turn trigger an Attentional Fixation (“There’s no other way to look at this!”) and an Attentional Bias (“I really need to pay close attention to my chest.”) And these attentional factors serve to refuel the anxiety, the interpretative bias, the catastrophic beliefs and each other.
Beck and Gellatly propose taking catastrophizing into account would be useful in the diagnosis, prediction, prevention, and treatment of psychopathology. Future research and exploration will answer such questions as: Which catastrophic beliefs differentiate which conditions? Who is susceptible to developing such beliefs? How do we educate people to promote resiliency against such beliefs? What interventions will best enable clients to counter these beliefs?
Although they point to catastrophic beliefs as the key essential factor, other factors may serve as points of interventions. Decatastrophizing enables clients to test the validity of catastrophic beliefs through exposure to the sensations. Therapists use panic inductions, for example, to alter the misinterpretation of symptoms. Other techniques, such as cognitive reappraisal, may ameliorate attentional fixation by providing more plausible ways to account for symptoms. Various in-office procedures may modify attentional bias by directing focus to breathing, to objects in the office, or to sounds inside and outside the building. This model may serve as a way to conceptualize the problem and identify where interventions work.
Beck, A.T. & Gellatly, R. Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders. Cognitive Therapy and Research, 2016, pp. 1-12.
Aaron T. Beck and Keith Bredemeier – Department of Psychiatry, University of Pennsylvania
We propose that depression can be viewed as an adaptation to conserve energy after the perceived loss of an investment in a vital resource such as a relationship, group identity, or personal asset. Tendencies to process information negatively and experience strong biological reactions to stress (resulting from genes, trauma, or both) can lead to depressogenic beliefs about the self, world, and future. These tendencies are mediated by alterations in brain areas/networks involved in cognition and emotion regulation. Depressogenic beliefs predispose individuals to make cognitive appraisals that amplify perceptions of loss, typically in response to stressors that impact available resources. Clinical features of severe depression (e.g., anhedonia, anergia) result from these appraisals and biological reactions that they trigger (e.g., autonomic, immune, neurochemical). These symptoms were presumably adaptive in our evolutionary history, but are maladaptive in contemporary times. Thus, severe depression can be considered an anachronistic manifestation of an evolutionarily based “program.”
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