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.
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.
On my desk sits a stack of pictures that includes: “Evil Pink Monster,” “Bob, the angry wolf,” and “Enfado,” a small bird that breathes out long flames of anger. These pictures, all externalized images of emotion, play a crucial role in my clinical work with children. CBT is a problem-specific type of therapy, and as such, treatment goals reflect the identified problems, including those embodied in the monsters and birds on my desk. Kids think differently from adults, so it may not be surprising that CBT looks and works a little differently with children and adolescents.
Sara (not her real name) is the artist who created “Evil Pink Monster.” When she came into my office the other day, she wanted to make sure we included a recent “Pink Monster” episode in our agenda. Sara described an incident where she had acted verbally aggressive towards her sibling—an ongoing issue. When our work first began, Sara had explained to me that she was “just not a nice kid. I’m not one of those good kids, I’m just not.” As we delved deeper, it became clear that Sara had a great deal of difficulty regulating her emotions, and she often over-reacted to situations.
“The person is not the problem, the problem is the problem,” wrote narrative therapist Michael White. When a child thinks that she’s a problem kid because she always acts out in school or causes conflict at home, it’s harder to help her make changes. In that narrative, the problem is her. CBT involves reappraisal of the situation and a willingness to look at the problem through different perspectives. When the child feels as if she is the literal problem, it becomes harder for her to objectively view the situation and her reactions. In CBT with kids, this is where the process of externalizing the problem becomes very helpful. It’s amazing how much easier it is to tackle a situation when a kid doesn’t feel like she is the sole reason for the problem.
Here’s how it works: Sara, age 9, had struggled with her anger for quite some time. She entered into CBT with a clear sense that she was “messed up” and that she was at fault for causing stress in the family. Every adult in her life had asked her why she did the things she did, and tried to talk with her rationally about making different choices. The reality was that 9-year-old Sara didn’t have a good sense of why she acted the way she did, and she truly felt terrible about it. Sara and I worked on identifying the automatic thoughts she had when she was angry. These thoughts included: “It’s so unfair,” “This always happens—I always get blamed,” and “I hate them!”
As we wrote down Sara’s automatic thoughts and looked at her feelings (anger, frustration, sadness), we began to imagine what those thoughts and feelings would look like if they were an actual creature. Sara, an excellent artist, began to draw out some designs. (If Sara had been reluctant to actually draw the image, we would have narrowed down the type of creature [monster, wolf, etc.] and googled clipart versions to get ideas).
Sara and I kept talking about what we imagined her anger looked like while she drew, and she was able to verbalize the experience of her emotions and to voice her automatic thoughts. “Something mean, that makes everything seem like it’s worse than it is. He, like, gets in my head and tries to make me feel so bad and so mad. He’s an evil little monster.” Seeing a finger puppet on my desk, Sara picked it up and said, “This is it. It’s him.” Once we had a clear description and name for the monster (in this case, “Evil Pink Monster”) we had a new language for discussing the identified problem of her treatment—her difficulty controlling anger and regulating her emotions.
Sara had willingly come to therapy because she was unhappy with how little control she felt she had over her emotional responses, and because she felt guilty about how she acted. By externalizing her anger into a concrete image, she was able to view the problem more objectively. In this way it wasn’t all her fault; she wasn’t a bad kid; she just had an Evil Pink Monster inside that made things seem worse than they actually were.*
And now we needed to figure out how to battle the monster.
Traditional CBT techniques used to manage anger and regulate emotions now became more easily implemented into the therapy. As Sara and I began the process of identifying behavioral and cognitive patterns, we simply shifted the language to reflect situations where the Evil Pink Monster was likely to be triggered. In lieu of discussing behavioral patterns and automatic thoughts in traditional language, we discussed them through the lens of the Evil Pink Monster. As we rated the intensity of the anger response, we created our own 1-10 rating of how strong the Evil Pink Monster was at that moment (1 was Fuzzy Bunny strong and 10 was Godzilla Drinking Espresso strong). And as we began to incorporate imagery into self-calming strategies, we often imagined the Evil Pink Monster on the beach drinking from a coconut or relaxing in a swimsuit under a palm tree. The images in themselves were relaxing, but they were also funny, and the use of humor in coping strategies can often go a long way.
The process of externalization in CBT is frequently discussed in the OCD literature, but there is broader use for this technique. Just as anger can be externalized into an evil pink monster, so can sadness be understood as Eeyore from Winnie the Pooh or, as one child described it “the blue monster that follows me around.” A beautiful but anxious fourteen-year-old girl describe her social anxiety as a clown wearing plaid pants and braces. Her general anxiety was “the nasty storm cloud that always follows me around.” Externalization doesn’t take away the patient’s responsibility to address their problems, but it does provide a tool to take away some of the self-blame, allowing for greater objectivity and greater change.
Externalization is one of many techniques pediatric CBT clinicians employ to make the process relatable, meaningful, and developmentally relevant. Kids aren’t little adults, and their therapy looks a little different (and is often a lot more fun).
*To be clear, as a 9-year-old with no cognitive impairments, Sara could easily understand that we were using the monster as a symbolic representation of her anger. This technique would not be effective for children unable to differentiate between abstract and concrete ideas.
Learn more about CBT for Children and Adolescents at our upcoming workshop.
If you plan to treat patients suffering from substance misuse disorders, I have good news and bad news. First, the bad news. When people habitually misuse a psychoactive chemical – whether it is alcohol, marijuana, benzodiazepines, stimulants, opioids, hallucinogens, or any other – they typically receive significant, immediate positive reinforcement (e.g., a sense of “high”) as well as powerful, immediate negative reinforcement (e.g., relief from negative emotions and/or withdrawal symptoms). Even when people are motivated to change, these experiences are formidable opponents to healthier, more stable, more meaningful sources of gratification, such as the pride one feels in having the ability to say “no” to urges, the satisfaction of having spent a productive day, and the trust of caring others, including therapists. Thus, effective treatment is at once an uphill climb.
Now, here is the good news. In order for people to overcome a substance misuse disorder, they need psychological tools, and cognitive therapy provides this very well. In a nutshell, this includes skills in self-awareness (e.g., of the onset of cravings and urges), self-instruction, planning, problem-solving, well-practiced behavioral strategies to reduce risk and to increase enjoyable sober activities, and methods of responding effectively to dysfunctional beliefs (about drugs, oneself, and one’s “relationship” to drugs). A chief text for the cognitive therapy of substance abuse (Beck, Wright, Newman, & Liese, 1993) describes seven main areas of potential psychological vulnerability, each of which represents a factor that contributes to the patient’s risk of alcohol and other substance misuse, and each of which suggests a potential area for therapeutic intervention. These include:
- High-risk situations, both external (e.g., people, places, and things) and internal (e.g., problematic mood states).
- Dysfunctional beliefs about drugs, oneself, and about one’s “relationship” with drugs.
- Automatic thoughts that increase arousal and the intention to drink and/or use.
- Physiological cravings and urges to use alcohol and other drugs.
- “Permission-giving beliefs” that patients hold to “justify” their drug use.
- Rituals and general behavioral strategies linked to the using of substances.
- Adverse psychological reactions to a lapse or relapse that lead to a vicious cycle.
An overarching benefit that cognitive therapy brings to the treatment of substance use disorders is its emphasis on long-term maintenance. As misusers of alcohol and other drugs are often subject to relapse episodes, therapists need to teach patients a new set of attitudes and skills on which to rely for the long run. These attitudes and skills not only improve patients’ sense of self-efficacy, they also lead to a reduction in life stressors that might otherwise increase the risk of relapse. A short (non-exhaustive) list of some of the attitudes and skills that patients learn in cognitive therapy includes:
- Learning how to delay and distract in response to cravings, by engaging in constructive activities, writing (e.g., journaling), communicating with supportive others, going to meetings, and other positive means by which to ride out the wave of craving until it subsides.
- Identifying dysfunctional ways of thinking (e.g., “permission-giving beliefs”) and getting into the habit of thinking and writing effective responses. For example, a patient learns to spot the thought, “I haven’t used in 90 days, so I deserve a little ‘holiday’ from my sobriety,” and to replace it with a thought such as, “What I really deserve is to keep my sobriety streak alive, to support my recovery one day at a time, including today, and to stop trying to fool myself with drug-seeking thoughts.”
- Developing and practicing a repertoire of appropriately assertive comments with which to politely turn down offers of a drink (or other substance) from someone (e.g., “Thanks, but I’ll just have a ginger ale, doctor’s orders!”).
- Learning how to solve problems directly and effectively, rather than trying to drown out a problem by getting impaired, which only serves to worsen the problem.
- Becoming conversant in the “pros and cons” of using alcohol and other drugs, versus the pros and cons of being sober, and being able to address distortions in thinking along the way.
- Practicing the behaviors and attitudes of self-respect, including counteracting beliefs that otherwise undermine oneself and lead to helplessness and hopelessness (e.g., “I’m a bad person anyway, so I might as well mess up my life by using.”).
- Utilizing healthy social support, such as 12-step fellowship (12SF) meetings, friends and family who support sobriety, and staying away from those who would undermine therapeutic goals.
- Making lifestyle changes that support sobriety and self-efficacy, including having a healthy daily routine, refraining from cursing and raging, engaging in meaningful hobbies, and doing things that promote spirituality and serenity (e.g., yoga).
To provide accurate empathy to patients, and to ascertain the optimal combination of validation for the status quo versus action toward change, it is important for therapists to assess the patient’s “stage of change.” Some patients are quite committed to giving up their addictive behaviors, and thus are at a high level of readiness for change. Others are more ambivalent, and may waver in their willingness to take part in treatment. Similarly, patients who are uncertain about giving up drinking and drugging may present for treatment with the goal of “cutting back” on alcohol and other drugs. Such patients may disagree that they will need to eliminate their use of psychoactive chemicals, and may decide to leave therapy if the therapist insists that the goal must be abstinence. Of course, there are some patients who are remanded for treatment who otherwise would not seek treatment on their own. They may deny that they have a problem with alcohol and other drugs, and not truly engage in the therapy process at all. The therapist’s understanding of the patient’s stage of change will be vital in helping them know just how directive to be, without going too far for a particular patient to tolerate at a given time in treatment. This sort of sensitivity may allow therapists to get the maximum out of treatment with patients who are most motivated, while retaining less motivated patients in treatment until such time as they begin to feel more a sense of ambition in dealing with their problem.
Cognitive therapy can be used in conjunction with supplemental treatments. For example, cognitive therapy can be woven into a comprehensive program in which patients (for example) take suboxone, and also attend 12SF meetings. Similar to advancements in the treatment of bipolar disorder and schizophrenia, where promise has been shown in combining cognitive therapy with pharmacotherapy, the study of best practices for alcohol and substance use disorders will probably involve more instances of coordinated care. For example, the strength of medication-based treatments that diminish the patients’ subjective desire for their drug(s) of choice can be paired with the strengths of cognitive therapy in modifying faulty beliefs and maximizing skill-building.
Empirical evidence indicates that cognitive therapy has the potential to be an efficacious treatment for alcohol and other substance use disorders, especially with adult patients who present with comorbid mood disorders, and with adolescents. However, improvements in the treatment approach still can be made, most notably via alliance-enhancement strategies that may improve retention in treatment, and more routine incorporation of the “stages of change” model.
Anton, R. F., Moak, D. H., Latham, P. K., Waid, R., Malcolm, R. J., Dias, J. K., & Roberts, J. S. (2001). Posttreatment results of combining naltrexone with cognitive- behavioral therapy for the treatment of alcoholism. Journal of Clinical Psychopharmacology, 21(1), 72-77.
Baker, A., Boggs, T. G., & Lewin, T. J. (2001). Randomized controlled trial of brief cognitive-behavioral interventions among regular users of amphetamine. Addiction, 96(9), 1279-1287.
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.
Deas, D., & Thomas, S. E. (2001). An overview of controlled studies of adolescent substance abuse treatment. American Journal on Addictions, 10(2), 178-189.
Maude-Griffin, P. M., Hohenstein, J. M., Humfleet, G. L., Reilly, P. M., Tusel, D .J., & Hall, S. M. (1998). Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: Main and matching effects. Journal of Consulting and Clinical Psychology, 66(5), 832-837.
Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.
Nishith, P., Mueser, K. T., Srsic, C. S., & Beck, A. T. (1997). Differential response to cognitive therapy in parolees with primary and secondary substance use disorders. The Journal of Nervous and Mental Disease, 185(12), 763-766.
Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-Step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, 65, 230-240.
Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 303-313). New York: Oxford University Press.
Waldron, H.B., & Kaminer, Y. (2004). On the learning curve: The emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction, 99, 93-105.
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.
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.
Beck Institute for Cognitive Behavior Therapy is a leading international source for training, therapy, and resources in CBT.
Soldiers Suicide Prevention (Beck Institute) is a Combined Federal Campaign (CFC) Approved Charity: CFC # 11590
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