My Inspiration for Writing the Basic and Advanced Books in CBT

Judy Headshot 2016By 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.

A Unified Model of Depression: Integrating Clinical, Cognitive, Biological, and Evolutionary Perspectives

Aaron T. Beck and Keith Bredemeier  –  Department of Psychiatry, University of Pennsylvania


ATB Headshot


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.”

Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review


Background: Major depressive disorder (MDD) causes a massive disease burden worldwide. Cognitive behavioural therapy (CBT) is an important treatment approach for depression. Cost-utility analysis (CUA) is a method to support decisions on efficient allocation of resources in health policy. The objective of our study was to systematically review CUA of CBT in the treatment of patients suffering from MDD.research blog (6)

Methods: We conducted a systematic literature search in Medline, Embase, PsycINFO and National Health Service Economic Evaluation Database (NHS EED) to identify CUA of CBT for MDD. Cost data were inflated to the year 2011 and converted into USD using purchasing power parities (USD PPP) to ensure comparability of the data. Quality assessment of CUA was performed.

Results: Twenty-two studies were included in this systematic review. No study employed a time horizon of more than 5 years. In most studies, individual and group CBT as well as CBT for maintenance showed acceptable incremental cost-utility ratios (<50,000 USD PPP/quality-adjusted life year). The CUA results of CBT for children and adolescents and of computerized CBT were inconsistent.

Discussion: We found consistent evidence that individualized CBT is cost-effective from the perspective of a third-party payer for short-term treatment and for relapse prevention of MDD in the adult population.


Brettschneider C., Djadran H. Härter M., Löwe B.Riedel-Heller S., & König H.H. (January 2015). Cost-utility analyses of cognitive-behavioral therapy of depression: A systematic review.  Psychotherapy and Psychosomatics (84), 1, 6-21.

Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents A Randomized Clinical Trial


Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.


research blog (3)


To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.


Design, Setting, and Participants

A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.



The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.


Main Outcomes and Measures

The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.



Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.


Conclusions and Relevance

The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.


Brent, D. A., Brunwasser, S. M., Hollon, S. D., Weersing, V. R., Clarke, G. N., Dickerson, J. F., Beardslee, W. R., … Garber, J. (January 01, 2015). Effect of a cognitive-cehavioral prevention program on depression 6 years after implementation among at-risk adolescents: A randomized clinical trial. Jama Psychiatry, 72, 11, 1110-8.

CBT for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial


Numerous studies have demonstrated comorbidity between migraine and tension-type headache on the one hand, and depression on the other. Presence of depression is a negative prognostic indicator for behavioral treatment of headaches. Despite the recognised comorbidity, there is a limited research literature evaluating interventions designed for comorbid headaches and depression. research blog (2)Sixty six participants (49 female, 17 male) suffering from migraine and/or tension-type headache and major depressive disorder were randomly allocated to a Routine Primary Care control group or a Cognitive Behavior Therapy group that also received routine primary care. The treatment program involved 12 weekly 50-min sessions administered by clinical psychologists. Participants in the treatment group improved significantly more than participants in the control group from pre-to post-treatment on measures of headaches, depression, anxiety, and quality of life. Improvements achieved with treatment were maintained at four month follow-up. Comorbid anxiety disorders were not a predictor of response to treatment, and the only significant predictor was gender (men improved more than women). The new integrated treatment program appears promising and worthy of further investigation.


Martin, P. R., Aiello, R., Gilson, K., Meadows, G., Milgrom, J., & Reece, J. (January 01, 2015). Cognitive behavior therapy for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial. Behaviour Research and Therapy, 73, 8-18.

Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (prevent): A randomised controlled trial

New Study (1)Abstract:

Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months.

In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654.

Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial.

We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life.

Kuyken, Willem et al. (2015) Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet (386) 9988, p. 63 – 73.

CBT for Perinatal Distress

Amy Wenzel ProfileAmy Wenzel, Ph.D., ABPP

Beck Institute Faculty

Perinatal distress is defined as depression or anxiety experienced by women who are pregnant or who are in the first postpartum year (Wenzel, 2015). Those of you who have attended the Core 2 CBT for Anxiety Workshop at Beck Institute know that I do not include this issue as a part of the curriculum; nevertheless, questions pertaining to work with perinatal women are frequently asked once workshop participants know my background, and lively discussion usually ensues. Thus, we thought it would be of interest to address this topic in this e-newsletter.


On many occasions, I have encountered negative attitudes toward CBT in the community of mental health professionals (the vast majority of whom identify with other theoretical orientations) who treat perinatal women. Examples of these attitudes include:

  • Attention to the therapeutic relationship is paramount, and cognitive behavioral therapists place little, if any, significance on it.
  • Session structure is too rigid and cold for a perinatal woman in substantial distress, who needs to be provided with a “holding environment” (a Donald Winnicott construct) that provides nurturance, reassurance, and a sense of safety.
  • There is no way that a new mom who is frazzled and sleep-deprived can do homework in between sessions.


When I encounter these myths in conversations with colleagues, I treat them as assumptions that should be tested prospectively, rather than factual information that must be followed without critical evaluation in one’s clinical work. When I open up dialogue with these colleagues, they are pleased to learn about the central importance that cognitive behavioral therapists place on the therapeutic relationship and the high-quality research that has been published on the topic in the past decade. They are also surprised to learn that CBT with perinatal women (or with any clients, for that matter) should not be practiced in a mechanistic way, according to a checklist, but instead should proceed in a flexible, collaborative manner that is driven by the individualized case conceptualization and the client’s preferences. In contrast to the experience of some of my non-CBT colleagues, many perinatal women have expressed gratitude for CBT’s session structure and tangible exercises, remarking that it is precisely because they are frazzled and sleep-deprived that they respond well to CBT’s organized approach. Moreover, newer technology such as Mobile phone apps allow perinatal women much flexibility in completing homework; for example, many of my clients have completed the equivalent of a thought record or an activity log while nursing their infants to sleep.


Interestingly, unlike the literature on CBT for a host of adult mental health problems, there is mixed evidence for CBT’s efficacy with perinatal women (with postpartum depression being the perinatal mental health problem that has received the vast majority of the attention). Authors of meta-analyses on this subject generally conclude that there is strong evidence for the efficacy of interpersonal psychotherapy (IPT) and weak to moderate evidence for the efficacy of CBT for this population. However, in my recent comprehensive review of psychotherapy for perinatal mental health problems (Wenzel, 2016), I concluded that a true “Beckian” approach to CBT—one in which the case conceptualization lies at the heart of the treatment and informs intervention in a flexible, individualized, and collaborative manner—has not yet been evaluated with perinatal women. The majority of the “CBT” treatment packages evaluated to date are heavily focused on psychoeducation and specific techniques (e.g., relaxation) delivered at prescribed times throughout the course of treatment. Although these packages are thoughtfully designed and often theoretically driven, in many instances they did not fare better than usual care in outcome analyses. Thus, I recently published a manual that describes a case conceptualization-driven approach to CBT with perinatal women (Wenzel, 2015), and I look forward to empirical research that evaluates this approach to treating perinatal distress. I will also call your attention to an excellent article written by Arch, Dimidjian, and Chessick (2012) that refutes myths about the dangers of exposure therapy with pregnant women and provides guidelines for conducting exposures with this population in a safe but effective manner.


Arch, J. J., Dimidjian, S., & Chessick, C. (2012). Are exposure-based cognitive behavioral therapies safe during pregnancy? Archives of Women’s Mental Health, 15, 445–457.

Wenzel, A. (2015; with K. Kleiman). Cognitive behavioral therapy for perinatal distress. New York, NY: Routledge.

Wenzel, A. (2016). Psychotherapy for psychopathology during pregnancy and the postpartum period. In A. Wenzel (Ed.), Oxford handbook of perinatal psychology (pp. 341-365). New York, NY: Oxford University Press.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

New Study (1)Abstract

 Background: There are first indications that an Internet-based cognitive therapy (CT) combined with monitoring by text messages (Mobile CT), and minimal therapist support (e-mail and telephone), is an effective approach of prevention of relapse in depression. However, examining the acceptability and adherence to Mobile CT is necessary to understand and increase the efficiency and effectiveness of this approach.

Method:In this study we used a subset of a randomized controlled trial on the effectiveness of Mobile CT. A total of 129 remitted patients with at least two previous episodes of depression were available for analyses. All available information on demographic characteristics, the number of finished modules, therapist support uptake (telephone and e-mail), and acceptability perceived by the participants was gathered from automatically derived log data, therapists and participants.

Results: Of all 129 participants, 109 (84.5%) participants finished at least one of all eight modules of Mobile CT. Adherence, i.e. the proportion who completed the final module out of those who entered the first module, was 58.7% (64/109). None of the demographic variables studied were related to higher adherence. The total therapist support time per participant that finished at least one module of Mobile CT was 21 min (SD = 17.5). Overall participants rated Mobile CT as an acceptable treatment in terms of difficulty, time spent per module and usefulness. However, one therapist mentioned that some participants experienced difficulties with using multiple CT based challenging techniques.

Conclusion: Overall uptake of the intervention and adherence was high with a low time investment of therapists. This might be partially explained by the fact that the intervention was offered with therapist support by telephone (blended) reducing non-adherence and that this high-risk group for depressive relapse started the intervention during remission. Nevertheless, our results indicate Mobile CT as an acceptable and feasible approach to both participants and therapists.


Kok G., Bockting C., Burger H., Smit F. & Riper H. (2014). The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial. Internet Interventions p. 65-73. doi:10.1016/j.invent.2014.05.002

Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial

New Study (1)Abstract

Importance:  Generalized anxiety disorder (GAD) is common in older adults; however, access to treatment may be limited, particularly in rural areas.
Objective:To examine the effects of telephone-delivered cognitive behavioral therapy (CBT) compared with telephone-delivered nondirective supportive therapy (NST) in rural older adults with GAD.

Design, Setting, and Participants:Randomized clinical trial in the participants’ homes of 141 adults aged 60 years and older with a principal or coprincipal diagnosis of GAD who were recruited between January 27, 2011, and October 22, 2013.

Interventions: Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping.

Main Outcomes and Measures: Primary outcomes included interviewer-rated anxiety severity (Hamilton Anxiety Rating Scale) and self-reported worry severity (Penn State Worry Questionnaire-Abbreviated) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Mood-specific secondary outcomes included self-reported GAD symptoms (GAD Scale 7 Item) measured at baseline and 4 months’ follow-up and depressive symptoms (Beck Depression Inventory) measured at baseline, 2 months’ follow-up, and 4 months’ follow-up. Among the 141 participants, 70 were randomized to receive CBT and 71 to receive NST.

Results: At 4 months’ follow-up, there was a significantly greater decline in worry severity among participants in the telephone-delivered CBT group (difference in improvement, -4.07; 95% CI, -6.26 to -1.87; P?=?.004) but no significant differences in general anxiety symptoms (difference in improvement, -1.52; 95% CI, -4.07 to 1.03; P?=?.24). At 4 months’ follow-up, there was a significantly greater decline in GAD symptoms (difference in improvement, -2.36; 95% CI, -4.00 to -0.72; P?=?.005) and depressive symptoms (difference in improvement, -3.23; 95% CI, -5.97 to -0.50; P?=?.02) among participants in the telephone-delivered CBT group.

Conclusions and Relevance: In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.

Brenes G. A., Danhauer S.C., Lyles M.F., Hogan P.E. & Miller M.E. (2015) Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Aug 5. doi: 10.1001/jamapsychiatry.2015.1154.

The impact of executive function on response to cognitive behavioral therapy in late-life depression

New Study (1)Abstract:
Objective: Late-life depression (LLD) is a common and debilitating condition among older adults. Cognitive behavioral therapy (CBT) has strong empirical support for the treatment of depression in all ages, including in LLD. In teaching patients to identify, monitor, and challenge negative patterns in their thinking, CBT for LLD relies heavily on cognitive processes and, in particular, executive functioning, such as planning, sequencing, organizing, and selectively inhibiting information. It may be that the effectiveness of CBT lies in its ability to train these cognitive areas.
Methods: Participants with LLD completed a comprehensive neuropsychological battery before enrolling in CBT. The current study examined the relationship between neuropsychological function prior to treatment and response to CBT.
Results:When using three baseline measures of executive functioning that quantify set shifting, cognitive flexibility, and response inhibition to predict treatment response, only baseline Wisconsin Card Sort Task performance was associated with a significant drop in depression symptoms after CBT. Specifically, worse performance on the Wisconsin Card Sort Task was associated with better treatment response.
Conclusions: These results suggest that CBT, which teaches cognitive techniques for improving psychiatric symptoms, may be especially beneficial in LLD if relative weaknesses in specific areas of executive functioning are present.

Goodkind M.S., Gallagher-Thompson D., Thompson L.W, Kesler S.R., Anker L. Flournoy J., Berman M. P., Holland J.M., & O’Hara R.M. (2015) The impact of executive function on response to cognitive behavioral therapy in late-life depression. Int J Geriatr Psychiatry. 2015 Jul 30. doi: 10.1002/gps.4325.