“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.
How does cognitive theory integrate more recent clinical and experimental findings?
We define Cognitive Therapy in terms of the application of the Cognitive Model, rather than in terms of the specific techniques. Although the original version of the therapy emphasized techniques such as cognitive restructuring, it later emphasized behavioral methods that were shown to produce adaptive changes in information processing (for example, activity scheduling, role playing, and behavioral experiments).
The basic cognitive model assigns a major role to cognitive schemas in information processing. The content of the schema (beliefs, expectancies, images) shapes the content of the information processing. There is a continuum from adaptive to dysfunctional beliefs. When the beliefs are exaggerated or biased, they lead to inappropriate or exaggerated affect and behavior.
While the basic cognitive model emphasizes the importance of cognitive bias in creating psychological problems, a body of clinical observations and basic research findings has pointed to the role of deployment of attentional resources in adaptive and maladaptive behavior (Beck & Haigh, 2014). Thus, the combination of attentional focus and cognitive bias plays a major role in psychopathology.
Attentional fixation, an extreme form of attentional focus, is instrumental in the development of conditions as diverse as panic disorder, suicidal impulses, and the craving behaviors in addictions. When attention is fixated on a particular sensation and belief as in panic disorder, the individual is incapable of reasoning or accessing contradictory information regarding the benign nature of the symptoms.
When attentional focus is enhanced as in psychopathology or in intense states of arousal such as anger it is deployed on each component of the information processing sequence:
The combination of attentional hyper focus and bias is particularly evident in the development of the somatic conditions such as chronic fatigue syndrome, chronic pain, and hypochondrias.
The expanded cognitive model can be utilized to understand each of the psychological disorders with their unique cognitive formulation (Beck & Haigh, 2014). The formulation may be drawn on to conceptualize a specific case.
As indicated, the expanded model is comprehensive enough to provide a blueprint for the treatment. The treatment is geared to the characteristics of the disorder. The emphasis on discrete refocusing techniques such as mindfulness constitutes a central part of mindfulness based cognitive therapy and other mindfulness strategies. Refocusing approaches were initially used in cognitive therapy of panic disorders but are subsequently used in a variety of psychological problems such as chronic pain, hypochondriasis, hallucinations, and anxiety.
Learn to use the cognitive model in our CBT for Depression – Core 1 Workshop
Beck, A.T., & Haigh, E.A.P. (2014) Advances in Cognitive Theory and Therapy: The Generic Cognitive Model. Annual Review of Clinical Psychology, 10, 1, 1-24.
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?
Marjan G. Holloway, Ph.D., Beck Institute Faculty
As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians. The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients. When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases. These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.
- All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
- Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
- Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
- Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )
We have all been there. I recall my excitement after having received a new client referral in the early years of my practice. This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors. I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training). Not surprisingly, I avoided taking the case. To address my sense of responsibility and guilt, I started to call other community clinicians and colleagues in private practice to find a good referral source. Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide. As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client. I realized that these beliefs – along with my negative emotions – were dictating my decision to avoid.
During an upcoming 2016 Beck Institute Workshop on CBT for PTSD, I plan to review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996). While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:
- The importance of having the client understand (i.e., “digest”) the traumatic event
- The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided
By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.
To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms. CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:
- Gaining continuing education in evidenced-based CBT for PTSD
- Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
- Seeking peer consultation and/or supervision, as needed
- Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
- Paying close attention to self-care and early signs of professional burnout
Working with traumatized clients is certainly not easy. However, we as CBT clinicians have the responsibility to intervene, rather than to avoid. Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based. Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.
Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.
Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.
Mobile Apps to Consider
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a widely used treatment model for trauma-exposed children and adolescents (Cohen, Mannarino, & Deblinger, 2006). The Healthy Coping Program (HCP) was a multi-site community based intervention carried out in a diverse Canadian city. A randomized, waitlist-control design was used to evaluate the effectiveness of TF-CBT with trauma-exposed school-aged children (Muller & DiPaolo, 2008). A total of 113 children referred for clinical services and their caregivers completed the Trauma Symptom Checklist for Children (Briere, 1996) and the Trauma Symptom Checklist for Young Children (Briere, 2005). Data were collected pre-waitlist, pre-assessment, pre-therapy, post-therapy, and six months after the completion of TF-CBT. The passage of time alone in the absence of clinical services was ineffective in reducing children’s posttraumatic symptoms. In contrast, children and caregivers reported significant reductions in children’s posttraumatic stress (PTS) following assessment and treatment. The reduction in PTS was maintained at six month follow-up. Findings of the current study support the use of the TF-CBT model in community-based settings in a diverse metropolis. Clinical implications are discussed.
Konanur S., Muller R. T., Cinamon J.S., Thornback K. & Zorzella K. P. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy in a ommunity-based program. Child Abuse Negl. 2015 Aug 25. pii: S0145-2134(15)00242-2. doi: 10.1016/j.chiabu.2015.07.013.
Anxiety disorders are common in adolescents (ages 12 to 18) and contribute to a range of impairments. There has been speculation that adolescents with anxiety are at risk for being treatment nonresponders. In this review, the authors examine the efficacy of cognitive-behavioral therapy (CBT) for adolescents with anxiety. Outcomes from mixed child and adolescent samples and from adolescent-only samples indicate that approximately two-thirds of youths respond favorably to CBT. CBT produces moderate to large effects and shows superiority over control/comparison conditions. The literature does not support differential outcomes by age: adolescents do not consistently manifest poorer outcomes relative to children. Although extinction paradigms find prolonged fear extinction in adolescent samples, basic research does not fully align with the processes and goals of real-life exposure. Furthermore, CBT is flexible and allows for tailored application in adolescents, and it may be delivered in alternative formats (i.e., brief, computer/Internet, school-based, and transdiagnostic CBT).
Kendall, C. P. & Peterman, S. J. (2015). CBT for adolescents with anxiety: Mature yet still developing. The American Journal of Psychiatry, 172(6). pp. 519-530. http://dx.doi.org/10.1176/appi.ajp.2015.14081061
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.
In general, as well as part of dissemination and implementation science, there is the need to focus on training of mental health professionals in cognitive-behavioral therapy (CBT). Unfortunately, the usual training methods (e.g., workshops, seminars) and the availability of treatment manuals have not produced full uptake or quality practice. Web-based therapist training programs can improve and expand access to CBT training. Advantages of a web-based training approach allows for increased flexibility, accessibility, cost-efficiency, scalability, potential for both didactive and interactive learning, consistency in quality, and importantly, the potential for remote supervision/consultation. We provide a rationale for the use of technology in clinician training in CBT, highlight several promising programs, and describe the technology and research considerations in web-based training using the example of computer-based training in CBT for childhood anxiety disorders. We also discuss directions for future research, as well as the challenges that remain.
Khanna, S. M. & Kendall, C. P. (2015) Bringing Technology to Training: Web-Based Therapist Training to Promote the Development of Competent Cognitive-Behavioral Therapists. Cognitive and Behavioral Practice 22(3) p. 291-301. doi:10.1016/j.cbpra.2015.02.002
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