“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
“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
By Judith S. Beck, PhD,
President, Beck Institute for Cognitive Behavior Therapy
Guilford Publications asked me to reflect on my reasons for writing Cognitive Behavior Therapy: Basics and Beyond and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work, both of which Guilford first published in 1995 and 2005, respectively. Below is what I sent:
I remember the moment I conceived of writing CBT: Basics and Beyond. It was in the early 1990’s and I was presenting a workshop with my father, Dr. Aaron Beck, in California. Most of the workshop participants were familiar with his work but asked very basic questions. Again and again, I found myself surprised by what they didn’t know (e.g., how to conceptualize patients according to the cognitive model, structure a session, set an agenda, use Socratic questioning, handle homework challenges, ask for feedback). I realized they needed a basic book that could teach them these skills in a step-by-step format, with transcripts illustrating key therapeutic interventions. I had lots of automatic thoughts when writing the book (“People will think this is too simplistic,”), for which I used CBT techniques on myself to keep going. The book is now the basic text used by most graduate schools in all the mental health disciplines, in the United States and abroad.
I also remember when I conceived of writing Cognitive Therapy for Challenging Problems: What to do When the Basics Don’t Work and it traces back to the first book. When I was writing CBT: Basics and Beyond, I had to continually separate material that was basic from material that was advanced–which made me realize that people would probably need a sequel to the basic text. I presented dozens and dozens of workshops on Cognitive Therapy for Challenging Patients and Cognitive Therapy for Personality Disorders in the years that followed. At each workshop, I asked participants to specify problems they had with some of their patients. (“What does the patient do or not do in session or between sessions that’s a problem? What does the patient say or not say that’s a problem?”) I soon had a very long list of problems. The challenge for me was in organizing the material I collected, and I had lots of false starts. It took me five years to determine how the book should best be structured. Once I figured this out, it took just another two years to complete the book.
I started off my career, not in psychology, but in education. Early on, I learned how to break down and explain complicated ideas and tasks for my young elementary school students who had learning disabilities. Through my books and workshops and other training activities, I believe I’ve been able to do the same for therapists who are learning and practicing CBT.
Today, July 18, 2016, is Dr. Aaron Beck’s 95th birthday. At last week’s workshop, participants celebrated by signing ‘Happy Birthday” and hearing stories from Dr. Beck.
We recommend beginning this video at 2:40
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.
by Judith S. Beck, Ph.D.
Originally published in Cognitive Therapy Today, the Beck Institute Newsletter in 2004.
I have recently been supervising a number of novice therapists and experienced therapists new to cognitive therapy.
At the beginning of (and throughout) supervision, I stress conceptualization, the cognitive model, and structure.
Also from the beginning I stress the importance of using the conceptualization to plan treatment within individual sessions. I ask therapists to keep two questions in mind during a session:
These two questions have helped my supervisees deliver more effective treatment. One supervisee, Carol, had been a therapist for 22 years. For the most part, before our supervision began, she delivered supportive psychotherapy mixed with some psychodynamic and some problem-solving techniques. Her sessions were quite unstructured. She and patients discussed whatever was on the patient’s mind at the moment. Sometimes the topic involved a current difficulty; sometimes it was related to distressing childhood experiences. Patients tended to drift from one topic to another without closure and Carol followed their lead. When Carol occasionally made suggestion to help solve a problem, she rarely checked on the implementation of her advice at the next session and the problem was dropped unless the patient herself brought it up again.
Carol had been treating Cynthia, a 35-year-old divorced woman, for almost a year. Cynthia’s managed care company, noting that Cynthia had made no progress in that time, contacted us to supervise Carol. Carol was a willing supervisee. She truly wanted the best for her patients and realized that Cynthia was stuck in therapy. Cynthia was severely depressed and alcohol dependent. She had recently gone on disability from her job as a manager in a department store. I could hear from the initial audiotape that Carol sent me of her session with Cynthia that the two had developed a good therapeutic alliance. Therefore, my first goal (along with cognitively conceptualizing the patient) was to get Carol to actively do problem solving with Cynthia, teaching her the cognitive and behavioral skills she needed in the context of solving those problems. I role-played with Carol how to set agendas with Cynthia that contained current problems.
Three difficulties arose. First, when Carol asked Cynthia what problems she wanted to discuss, Cynthia started to describe the problem instead of just naming it. Because Carol did not interrupt and guide her to just name the problem at the beginning of the session, Cynthia did not bring up other crucial problems until the end of the session, if at all. Second, Cynthia put items on the agenda that were not problems she needed help with or was willing to work on. Often these agenda topics were about the way her ex-husband had treated her in the past or complaints about her children. Third, Carol did not add to the agenda herself. Cynthia, hoping to avoid discussions of her alcohol dependence, did not put her drinking on the agenda and neither did Carol.
To solve the first problem, I suggested that Carol model for Cynthia how to name a problem: “Can you tell me what problems you want my help in solving today? Can you just name the problem, for example, problem with drinking, problem with feeling lonely, problem with money?” When Cynthia again launched into a description of the problem, I role-played with Carol how to interrupt her, “Sorry to interrupt, but can you just tell me the name of the problem? Should we call this, “Problem with your son?”
After I recognized the existence of the second and third problems, I helped Carol conceptualize how it was that she thought Cynthia would get better. Through questioning, she was able to recognize that Cynthia most urgently needed to learn skills to deal with her urges to drink, to manage her negative emotions (the precursor to drinking), to solve problems around being alone in the house (which was the only time she drank), and to structure her day and feel productive. I also helped her evaluate Cynthia’s other difficulties and we agreed that Cynthia’s chronic problems with her grown children and with her finances, and the problem of returning to work, were of lesser immediate importance, unless these difficulties led her to feel so upset that they triggered urges to drink. Carol related this new treatment plan to Cynthia and elicited Cynthia’s agreement to give these four areas priority in treatment.
It was difficult for Carol initially to interrupt Cynthia and steer the discussion. I ascertained that Carol did not have any negative thoughts about imposing more structure; she simply did not recognize when she got off course. At first I gave Carol a written list of questions to review with Cynthia. When Carol had difficulty allotting sufficient time to go through the list, I gave her a list of questions for Cynthia to read aloud and answer. Data from these questions were crucial to help Cynthia plan the session. They included questions about frequency and circumstances of drinking, frequency and strength of urges, automatic thoughts related to urges and drinking, and use of coping behaviors. They also included questions about how Carol was spending her days and what had most upset her during the week, as well as problems Carol predicted might arise before their next session. I helped Carol figure out with Cynthia, given their limited amount of time together, what was most important to work on, i.e., what would help the patient feel better by the end of the session and what would help the patient have a better week.
Before we began supervision, Carol’s formula was: To get better, patients need to unburden themselves and receive support and encouragement from their therapist. Carol was beginning to learn a new formula: To get better, patients need to work on solving specific problems with their supportive and encouraging therapist, with a focus on what they can do (and how they can think differently) to have a better week. Setting a good agenda was the first step. Following the agenda and teaching skills in the context of solving problems was the second step. In a future column, I will address this step and further challenges in supervision with Carol.
Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.
At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?
Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.
Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.
Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.” Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”
Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking. For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers. For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.
Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).
Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.” The problem with perfectionism is that it’s impossible to be perfect. When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.
Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.
Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.
By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D.
We’ve stopped using the word “homework” in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we’ve switched. “Homework” is now called the “Action Plan.”
We like the label “Action Plan.” It conveys a sense of proactivity, of taking control.
Action plans aren’t optional. They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients:
That’s why we make sure that whatever is important for the client to remember about the session, including their Action Plan, is recorded, written down or entered as text or audio into an electronic device.
How likely are you to do this assignment(s) this week?
And that’s why we continue talking about potential obstacles that could get in the way when clients say they are 90% or less likely to complete the Action Plan.
Here is an example of a client who did not do his action plan, and this is how we worked on it.
A 28-year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome. During our session, he identified “getting into shape” as important to him and set up a specific action plan that included going to the gym he belonged to, two times during the week, for approximately 30 minutes. Upon returning the following week and checking in on how it went, he stated he did not go. When asked what got in his way, he stated he did not know. He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind. Using imagery, he was able to identify his interfering thoughts. Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.
The Action Plan isn’t optional. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. See, for example Conklin & Strunk (2015); Kazantzis, Deane, Ronan & L’Abate (2005). It’s up to therapists to help clients carefully design meaningful assignments with a good likelihood of success and to motivate clients to follow through. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.
Conklin, L. R., & Strunk, D. R. (January 01, 2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?. Behaviour Research and Therapy, 72, 56-62.
Kazantzis, N., & L’Abate, L. (2006). Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer.
Judith S. Beck, PhD
Worry, as defined by Clark and Beck (2012) is “a persistent, repetitive, and uncontrollable chain of thinking that mainly focuses on the uncertainty of some future negative or threatening outcome in which the person rehearses various problem-solving solutions but fails to reduce the heightened sense of uncertainty about the possible threat.”
This certainly describes the thinking of Stacy, a client I recently treated who suffered from Generalized Anxiety Disorder. She is a 44 year old woman, the mother of three children. And she worries constantly. “What if my boss doesn’t like my work?” “What if my kids get rejected at school?” “What if my husband falls in love with someone else?” “What if this cough I have is really throat cancer?” “What if the bus I’m on crashes?”
Some amount of worry is normal and can be productive when individuals think through a potential problem and come up with a way to prevent it, cope with it if it does arise, or lessen its impact. But Stacy’s worry is pervasive and unproductive. Why does she keep worrying when it’s clearly dysfunctional? Why does she have so little control over it? A number of factors account for why she worries so incessantly (while another client of mine, an adolescent, fails to worry in situations in which at least a little anxiety is warranted and would be productive).
Stacy’s safety behaviors include the following:
Other contributing factors include the following:
Rather than evaluating Stacy’s automatic thoughts (because successfully evaluating one worry-related automatic thought will often be replaced by another worry-related automatic thought), we focused on modifying her dysfunctional beliefs about worry itself (it helps me stay safe), reducing her safety behaviors (seeking reassurance) and attempts to control her worry (thought suppression), using functional problem solving when indicated, identifying when she was thinking catastrophically and mindfully refocusing her attention, facing her worst fear, and accepting and building her tolerance for uncertainty. Although she described having been “a worrier” her whole life, she was able to overcome her excessive worry. She gained a sense of competence and much improved peace of mind.
Clark, D., & Beck, A. (2012). The Anxiety and Worry Workbook: The Cognitive Behavioral Solution. New York: Guilford Press.
In many cases, it’s difficult for clients to know whether they’re making progress because therapists do not necessarily state the goals and desired outcomes of therapy sessions. Clients may need to rely on their own global impressions. When clients are treated by cognitive behavior therapy (CBT) clinicians, though, they know how well therapy is working, because CBT therapists monitor progress each week by:
In fact, research shows that when both therapists and clients receive feedback on progress, clients tend to have better outcomes (Lambert, et al., 2002).
For example, CBT clinicians ask clients to fill out symptom checklists before each session, such as those for depression and anxiety. If applicable, clients may track and report the occurrence of panic attacks, angry outbursts, or incidents of self-harm behavior. They may also track the frequency and amount of alcohol, drugs, nicotine, or food they ingested in the previous week—or the number of minutes they engaged in compulsive rituals. The type of monitoring and assessment varies from client to client, based on the goals they’ve decided they want to work toward. CBT therapists discuss these assessments with clients. When clients do not make expected progress, they conceptualize the difficulty and modify treatment accordingly.
How long can it take before clients’ symptoms decrease? Sometimes clients notice improvements almost immediately, especially when they have three kinds of experiences:
These three kinds of experience increase hope and clients are able not only to arrest their downward negative spiral but also to reverse direction. They then find themselves on an upward positive spiral.
So how can clients tell if therapy is working? They can ask themselves:
If the answers are yes, then therapy is working.
Lambert, M., Whipple, J., Vermeersch, D., Smart, D., Hawkins, E., Nielsen, S., & Goates, M. (n.d.). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology & Psychotherapy Clin. Psychol. Psychother., 91-103.
Judith S. Beck, PhD, President
Beck Institute for Cognitive Behavior Therapy
When a client poses a challenge in Cognitive Behavior Therapy (CBT), it is important to conceptualize why the problem has arisen. Is it a practical problem? Is it related to the client’s dysfunctional beliefs? Is it related to the therapist’s dysfunctional beliefs? In this article, I’ll describe two difficulties that were practical in nature. Future articles will focus on client and therapist cognitions.
Amy, a thirtyish woman, is a single mom with significant legal, financial, and parenting problems. When her therapist attempted to have her describe her financial problem (which Amy had indicated was the most important agenda item), Amy almost immediately burst into tears and sobbed uncontrollably. She was unable to identify her upsetting automatic thoughts, much less focus on what to do about her large credit card bills and the hounding phone calls from bill collectors. The therapist conceptualized that he should first try solving the practical problem of Amy’s high degree of emotionality, and suggested a change of topic. “Amy, I’m sorry this is so upsetting to you.” [pause] “Would it be okay if we talked about something else for a few minutes?” When Amy nods, her therapist asks a question which he thinks could brighten her mood. “Did Crystal [her 5 year old daughter] draw any pictures for you lately? Or bring home any art projects from school?”
Jeremy, an electrician in his mid-fifties, has a tendency to jump from topic to topic in therapy. In a recent session, he began describing a problem with his neighbor-then continually switched his focus. “You know, it’s the same kind of thing my brother has been doing to me for years. Just last week, he accused me of not spending enough time with Mom. And she’s a whole other problem. She’s been calling me and calling me. It’s driving me crazy. I don’t know how I’m going to keep my job. My boss said if I keep talking on my cell phone during work, he’s going to fire me. He’s such an unreasonable bastard to begin with. He’s always making these threats. But if I lose my job…” It was essential for the therapist to help Jeremy refocus. “Jeremy, can I interrupt for a moment? I want to make sure we talk about what’s most important to you first. Is it your neighbor, your brother, your mom, your boss? Or is it losing your job?”
In the first example, getting Amy to talk about a more uplifting subject settled her down enough to allow her to do some problem-solving about her finances. And in the second example, every time his therapist interrupted him and structured the discussion, Jeremy was able to focus on one problem. Practical solutions such as these, however, may be essential but not sufficient for clients whose cognitions are associated with unhelpful behaviors in session. On the other hand, the problems may look like practical ones, but these strategies may be irrelevant if underlying beliefs are involved. Stay tuned…
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