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.
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.
At this week’s CBT for Substance Use Disorders workshop, we had the pleasure of welcoming Katherin Torres back to Beck Institute.
She and her colleagues from Pathways in San Diego recently attended the CBT for Schizophrenia workshop in April, and now she returned solo to learn more about using CBT with her substance abusing clients.
A pre-licensed MFT intern at Pathways in San Diego, Katherin is a first episode of psychosis specialist, working in the Kickstart program which provides confidential assessment and early assistance for young people between the ages of 10 and 25 who are at risk for mental illness in San Diego County.
First episode of psychosis clients often have comorbidity, and this workshop taught Katherin new ways to treat substance use disorders, address issues with open communication, and provide support to her high-risk clients.
Katherin has a long time affection for CBT, “It’s my therapeutic style: collaborative.”
At the workshop, she enjoyed watching the videos of the instructor, Dr. Cory Newman, in therapy sessions and completing roleplays with fellow participants to put new skills into practice.
This workshop will help her to structure her sessions, remember to set goals, and better understand her clients with substance use disorders. She is most excited to bring what she has learned back to the staff in the Kickstart program.
This week’s workshop, CBT for Children and Adolescents, included Kanan Kanakia, who traveled from Mumbai, India to attend the workshop. She has experience as a psychotherapist, special educator, counselor, and hypnotherapist which allows her to choose the best treatment path for her clients.
After learning about CBT, she wanted to get the actual feel of how to apply CBT and researched Beck Institute workshops, deciding “which better institute than here.”
“This workshop was exactly what I was looking for with the know-how and the application in real life and real circumstances.”
When asked about Dr. Torrey Creed, the workshop instructor, Kanan replied, “Oh, she’s amazing!” She presented real case examples of the topics she was instructing, which made the complex topics easy to grasp.
Kanan also had the opportunity to role play a tough client with Dr. Aaron Beck via Skype.
By Deborah Beck Busis, LCSW
Director, Beck Diet Programs
A recent article published in the New York Times, “After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight,” details how most of the contestants on the television show, “The Biggest Loser,” regained much, if not all of the weight they had lost while on the show. The article also describes how the contestants’ metabolisms slowed down as they lost weight and did not return to their original level once they regained their weight. The level of the hormone leptin, which influences hunger, also did not return to the original level, and in fact, reached only about half of what it had been before they started to diet.
The article certainly is discouraging. It also emphasized that the dieters, who lost weight through extreme calorie restriction and high levels of exercise, had to eat substantially fewer calories (up to 500 calories less) than other people who hadn’t dieted, to maintain their weight loss. We don’t believe the situation is hopeless, however. There is a significant amount of research that shows that while there is a change in metabolism as people lose weight, the amount varies. These studies generally show that the metabolic penalty is between 20-200 calories and that this penalty decreases modestly in the year following weight loss. On the other hand, a meta-analysis that was published in 2012 found no change in the metabolic rates of dieters.
In our program, most people have been able to lose weight and keep it off—when they’re willing to have periodic booster sessions to keep their cognitive and behavioral skills sharp. There are several key components of our weight loss program that are drastically different from what the contestants on the “The Biggest Loser” do. First and foremost, our clients do not lose as much weight and they do not lose it quickly; usually, the rate is half a pound to two pounds per week.
Along with slower weight loss, our clients also follow diet and exercise plans that fit in with their lives. In terms of exercise, none of our clients devote the nine hours per week that the “Biggest Loser” participants were advised to do once they returned home. Although the article didn’t describe the specific diets participants followed while they were being filmed, it is likely that the diets were quite restrictive, both in terms of number of calories and the types of permitted foods. This, too, is quite contrary to our program. From the start, we work with our clients to incorporate all their favorite foods into their diets in reasonable ways. We work hard to ensure that our clients only make changes in their eating that they can sustain in the long term.
When helping our clients make changes in eating and exercise, the two words that we constantly use are reasonable and maintainable. We have found that when dieters lose weight eating or exercising in a way they can’t maintain, they invariably gain the weight back when they revert to old behaviors. Most of our clients don’t lose as much as they’d like because to do so would require unmaintainable eating and/or exercise plans. But they do get to a place where they feel strong and in control of their eating; their health is better; they have gained most of the advantages of being at a lower weight; they experience far fewer cravings; and they feel confident that they can keep doing what they’re doing. They not only know what to do but also can competently solve problems and address dysfunctional thoughts and beliefs that interfere with maintaining the needed changes in behavior.
As far as we can tell, “The Biggest Loser” is the antithesis of our program. Although we haven’t had our clients track their metabolisms before and after weight loss, we assume that taking a much more measured approach is part of what enables our clients to lose weight and keep it off. While doing it this way is less compelling in the moment, because the pounds fail to drop off at lightning speed, it seems to pay off in the long term, as dieters lose weight by putting behaviors into place, supported by changes in cognition, that they can ultimately maintain.
Are you a professional who works with dieters?
Norman Cotterell, Ph.D.
Beck Institute for Cognitive Behavior Therapy
Beck and Gellatly (2016) propose that catastrophic thinking is a central feature in psychopathology. Such thinking magnifies both the immediate and eventual consequences of any perceived threat. A variety of disorders can be conceptualized as such: Clients magnify external threats (accidents, attacks, arson) but most notably misinterpret and magnify perceived internal threats. Sensations, thoughts, and emotions are seen as signs of immediate physical or psychological catastrophe.
- Panic — immediate catastrophic consequences of an unexpected physical sensation: “If my heart races, I’m dying.” “If I feel lightheaded, I’m about to faint.”
- Social Phobia — catastrophic misinterpretations of the social consequences of anxiety: “If people see me sweat, I’ll be judged, shunned, rejected or shamed.”
- Agoraphobia — catastrophic beliefs about the consequences of anxiety: “If I panic, I’ll be trapped.”
- Specific phobias — catastrophic beliefs about a feared object or situation: “If I get on an airplane, I won’t be able to handle the anxiety.”
- Health anxiety — catastrophic consequences of an unexpected physical sensation, or image: “If my chest hurts, I have heart, lung, or infectious disease. If the doctor sends me for tests, it means I’m seriously ill.”
- Obsessive compulsive disorder — Catastrophic misinterpretation of an intrusive thought: “If I think something unacceptable, it means I myself am unacceptable. Thinking it is as bad as doing it.”
- Posttraumatic Stress Disorder — Catastrophic beliefs about the reoccurrence of danger: “If it happened before, it’s likely to happen to me again.” “Flashbacks mean danger.”
- Pain — Catastrophic beliefs about pain and its consequences: “If I’m in pain, it is unsafe to move, and I must stop my activities.”
- Traumatic Brain injury — Catastrophic misinterpretations of post concussive symptoms: “If I have a headache, my brain injury is getting worse.”
Beck and Gellatly regard such thinking as an essential ingredient in the development and maintenance of these anxiety disorders. They identify 6 essential ingredients of a cycle that fuels them: Catastrophic Beliefs (“I’m having a heart attack, I’m dying,”) triggered by a Precipitating Event (heart palpitations) results in both Anxiety Symptoms (shortness of breath, dizziness, feeling out of control) and an Interpretive Bias (“If my chest hurts, I’m having a heart attack”). These, in turn trigger an Attentional Fixation (“There’s no other way to look at this!”) and an Attentional Bias (“I really need to pay close attention to my chest.”) And these attentional factors serve to refuel the anxiety, the interpretative bias, the catastrophic beliefs and each other.
Beck and Gellatly propose taking catastrophizing into account would be useful in the diagnosis, prediction, prevention, and treatment of psychopathology. Future research and exploration will answer such questions as: Which catastrophic beliefs differentiate which conditions? Who is susceptible to developing such beliefs? How do we educate people to promote resiliency against such beliefs? What interventions will best enable clients to counter these beliefs?
Although they point to catastrophic beliefs as the key essential factor, other factors may serve as points of interventions. Decatastrophizing enables clients to test the validity of catastrophic beliefs through exposure to the sensations. Therapists use panic inductions, for example, to alter the misinterpretation of symptoms. Other techniques, such as cognitive reappraisal, may ameliorate attentional fixation by providing more plausible ways to account for symptoms. Various in-office procedures may modify attentional bias by directing focus to breathing, to objects in the office, or to sounds inside and outside the building. This model may serve as a way to conceptualize the problem and identify where interventions work.
Beck, A.T. & Gellatly, R. Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders. Cognitive Therapy and Research, 2016, pp. 1-12.
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.
As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.
Eidelman P., Talbot, L., Ivers H., Belanger, L., Morin, C. M., & Harvery A. G. (January 2016) Change in Dysfunctional Beliefs About Sleep in Behavior Therapy, Cognitive Therapy, and Cognitive-Behavioral Therapy for Insomnia. Behavior Therapy, 47(1), 102-115.
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