The Effects of Therapist Competence in Assigning Homework in Cognitive Therapy With Cluster C Personality Disorders

newstudy-graphic-66x60.jpgThis study examined the effects of therapist competence in assigning homework on the outcome of CT (cognitive therapy) in patients with Cluster C personality disorders. 25 participants underwent 40 weekly, 50 minute, CT sessions that followed the Beck and Freeman treatment manual for personality disorders. The six treating therapists employed three primary techniques: guided imagery, homework assignments that led the patients to try new adaptive responses, and cognitive, behavioral, and emotion-focused techniques to develop new, more adaptive beliefs to replace the pathological beliefs.

The researchers used the Global Severity Index of the Symptom Checklist 90 Revised to measure symptom distress, the mean scores of the 127-item version of the Inventory of Interpersonal Problems to evaluate interpersonal problems, and the Millon Clinical Multi-axial Inventory to measure personality pathology, as prescribed by the personality disorder scales of avoidant, dependent-submissive, compulsive-conforming, and passive-aggressive. Additionally, they tracked initial symptom improvement after the fourth session using the Helping Alliance Questionnaire. The researchers measured therapist competence in assigning, monitoring, and reviewing homework with the homework assignment subscale of the Cognitive Therapy Scale. This rating is based on the extent to which the therapist reviewed previous homework and summarized progress and conclusions, provided rationale for the assignment and the intended goals, tailored the assignment to the patient’s specific needs, and asked for reactions and feedback from the patient. The researchers also measured therapist competence in agenda setting.

Higher ratings of therapist competence in assigning homework were related to statistically significant improved outcomes on all measures at mid and post-treatment. Therapist competence in agenda setting, however, did not predict treatment outcome at either time. This study is the first to examine the relationship between therapist competence in assigning homework and treatment outcome in patients with Cluster C personality disorders, and the first to find that higher ratings of therapist competence in assigning homework predict greater positive change in symptoms, interpersonal problems, and Cluster C personality pathology.

Note taking in Session

judith-beck_1024w.jpgRecently, there’s been an interesting discussion on the Academy of Cognitive Therapy listserv about the therapy notes patients take home with them to review. Here’s how I make sure a patient is able to remember important ideas we discussed in treatment, specifically the changes a patient makes in his thinking:

Generally, when I ascertain that the patient has modified his thinking during a session (e.g., following Socratic questioning, behavioral experiments, roleplaying, etc.), I’ll ask the patient for a summary. I might say:

• Can you summarize what we just talked about?
• What do you think it would be important for you to remember this week?
• What do you think the main message is?

If the patient comes up with a good summary, I positively reinforce him and ask whether he wants to write it down or if he would like me to do so. If his summary is not quite on point, I usually offer a revised version and ask the patient whether he thinks it might be helpful to remember it this latter way. If he agrees, he or I will write the summary down. At that point or later on in the session, I will ask the patient how likely it is that he will read these important therapy notes every day at home. If he’s not highly likely, I’ll ask him about what might get in the way.

I’ve found that most patients just don’t learn the skill of writing cogent summaries. They rarely write down complete ideas and they usually add in extraneous or less important material which dilutes what is really important; that’s why I’m nicely directive about what is written down. I want to be certain the patient has good notes to read this week and ten years from now, if a similar problem arises.

What Cognitive Therapy does to your brain…

Cognitive Therapy is well known for being effective for depression (it’s twice as effective as medication in preventing relapse) and it’s also been shown to work for many other disorders — but why? How does it work?

A major clue to how Cognitive Therapy affects the brain came out in this study two years ago — researchers were interested in seeing how Cognitive Behavior Therapy affected the brains of depressed people as compared to medication. They hypothesized that since both CBT and medication were effective for depression, both treatments would affect the same part of the brain. Using brain imaging technology, they scanned participants’ brains before and after the course of treatment.

And they were in for a surprise. Researchers found that antidepressants affected one part of the brain among depressed patients, and CBT treatment affected another part altogether. Antidepressants dampened activity in the limbic system — the emotional center of the brain. Conversely, CBT calmed activity in the cortex — the brain’s seat of reason.

In other words, antidepressants reduced emotions, whereas CBT helped patients process their emotions in a healthier manner.

Which explains why those on antidepressants have a much higher likelihood of relapse if they go off of their meds — negative emotions can flood back in. But with CBT, patients gain the skills to respond to their emotions more effectively — for long-term benefits.

Another CT Myth… Put on those Rose-Colored Glasses

Here’s another one of the most common misunderstandings about Cognitive Therapy: 

Myth: Cognitive Therapy simply teaches people to put on “rose-colored glasses” and see everything in a positive light, even if a situation really is negative.

Fact: Cognitive Therapy does not try to teach people to view things more positively. What Cognitive Therapy does is teach people to view things more realistically. When someone has a psychiatric disorder, he or she often sees situations in a distorted manner (for an explanation of distorted thoughts, see the comment from Judith S. Beck at the end of this blog post).

For instance, someone suffering from an anxiety disorder might think that something awful has happened to his or her loved ones every time the phone rings (even though, time and again, this is not the case). The person might have anxious thoughts whenever the phone rings, followed by distressing physical symptoms like clammy hands, light headedness or difficulty breathing.

A Cognitive Therapist would work with this person to help him/her evaluate whether or not he/she is viewing the situation of the phone ringing in a realistic light, to understand why he/she is afraid of the phone ringing, and to come up with alternative possibilities (“Maybe that’s just my husband calling to say he’s stuck in traffic.” “Maybe that’s just the doctor calling to confirm my appointment,” etc.), and then to monitor what really does happen when the phone rings in between therapy sessions.

Cognitive Therapy would help the individual to evaluate which possibilities are more realistic, to come up with responses to distorted thoughts when they arise when the phone rings, to improve the person’s physiological response, and also to address key underlying beliefs that person might have, such as “If something actually did happen to my husband, I’d be devastated. I wouldn’t survive.” An individual suffering from an anxiety disorder like this is not viewing the situation of the phone ringing in a realistic manner, and is unduly suffering because of it.

On the other hand, if an individual comes in for CT treatment to address a problem such as dissatisfaction with his or her job, he or she might be viewing the situation in a perfectly realistic manner (i.e. perhaps the situation really is not good/doesn’t pay enough/isn’t that interesting for the person, etc.). The Cognitive Therapist in this scenario would not try to teach the person to see the situation more “positively.” Instead, the Cognitive Therapist would accept that the person really does not like his/her situation, and would find out what the individual’s goals are, or help him/her develop goals, such as “To gain advancement within the same company” or “To find a better job somewhere else.” Then the Cognitive Therapist would work with the patient to address any “unhelpful thoughts” or underlying beliefs that are preventing that person from reaching for his/her goals, such as, “I’ll never get promoted. If I ask for more money, they’ll just think I’m greedy,” or “I’ll never find a better job – it’s no use looking.”

When people come in for therapy they’re usually having some distorted or dysfunctional thoughts (but that doesn’t mean that everything they think is overly negative or distorted). Cognitive Therapy works to address only those views that are actually distorted or dysfunctional, and that are causing distress and suffering to the individual. CT does not try to get people to think more positively, but to think more realistically. And Cognitive Therapy works with the person to enact change in his or her life (It’s not all just a matter of adjusting the thoughts in your head!).

In other words, CT does not tell people to put rose-colored glasses on. It’s more like helping people who already have on really dark sunglasses to take them off…

Judith S. Beck Writes In: Self Disclosure in Cognitive Therapy

I’ve recently been thinking about Self Disclosure in CT. In traditional psychoanalysis, analysts deliberately refrain from revealing anything about themselves. There is no such prohibition in Cognitive Therapy and I find that I do a lot of self-disclosure to patients whom I think will benefit from it. For patients with perfectionistic standards, I might reveal the standard I apply to myself and have taught my children: To try to do a reasonable job a reasonable amount of the time. For patients who believe they are inferior because they have not achieved as much as they or others expect them to, I often talk about my son who has severe learning disabilities and my view that he is neither inferior nor superior to others. For patients who struggle with self-esteem, I usually describe how I give myself credit throughout the day, whenever I complete a task (or part of a task), even if it’s minor and not particularly difficult. Following self-disclosure, I discuss with patients how they believe what I’ve said might apply to them. 

I don’t use self-disclosure with every patient but I do with most. Self-disclosure often gives them a different way of thinking about their problems. And it goes a long way in strengthening our relationship when patients recognize that I am a human being who is willing to share something of herself to help them.  

Judith S. Beck Writes In: More on CT for New Year’s Resolutions

judith-beck_1024w.jpgI enjoyed being interviewed for an NPR radio story on the Cognitive Therapy approach to New Year’s resolutions. When I’ve been interviewed for radio shows in the past, I’ve almost always talked to the interviewer by phone from my office. But this time the reporter, Joanne Silberner, asked me to go to the local NPR affiliate (WHYY) in Philadelphia, so I got to wear headphones and speak into a big microphone (and had the nicest conversation with the sound engineer).

Joanne interviewed me for almost an hour.  Most of what I talked about wasn’t included in the final piece though (Joanne oriented the story toward one specific New Year’s resolution — losing weight. See the post below). Here’s what didn’t make it onto the show:  I talked about how Cognitive Therapy basically helps people set resolutions (that we term “goals”) at the very first treatment session when we ask, “How would you like to be different as a result of therapy? How would you like your life to be different?”  I talked to Joanne about how we help people get to their goals by:

(1)     making sure that people’s goals are realistic
(2)     helping people break down big goals into small steps
(3)     collaboratively devising a plan to implement these steps
(4)     problem-solving difficulties that interfere with implementation
(5)     effectively responding to “sabotaging” thoughts that interfere with implementation

The interview was fun, despite the fact that I was incredibly congested, following a bad head cold. I’ve now done so many media interviews that I don’t get nervous at all any more. (I used to be worried about getting asked questions I didn’t know the answer to…)

Nurses Trained to use Cognitive Therapy with Children in Low-Income Communities

In a recent Philadelphia area pilot program, thirteen Advanced Practice Nurses (APNs) were trained by the Beck Institute to use Cognitive Therapy techniques to treat mental and behavioral health problems of children and adolescents between the ages of 7 and 18. The APNs were the children’s primary care providers in low-income populations, primary care providers are sometimes the only point of access for mental health care.

For this program, APNs were trained by Dr. Christine Reilly, a psychologist with expertise in Cognitive Therapy, and a nurse herself. The nurses participated in workshops, group supervision conference calls, and individual supervision sessions as needed, during the year-long program. The population served included children and adolescents from the Philadelphia region who presented with a range of problems, including depression, anxiety, behavioral problems, teen pregnancy, obesity, and substance abuse. The pilot program showed that nurses improved their understanding of the Cognitive Therapy model and CT techniques (developed by Aaron T. Beck, M.D. in the 1960s). Patients demonstrated improved outcomes, as assessed using the Beck Youth Inventories at the start and end of the program. Moreover, the nurses saw benefits of the CT training program in other aspects of their practice, including applying CT techniques to patients in other age groups, and improving the nurse/patient relationship.

This pilot program indicates that training nurses in Cognitive Therapy is a practical, feasible way to improve mental health care and patient outcomes among children and adolescents. The program was conducted by the National Nursing Centers Consortium, in partnership with the Beck Institute for Cognitive Therapy and Research, through a generous grant from the van Ameringen Foundation.

Research Results: Cognitive Therapy Reduces Suicide Attempts by 50%

In light of all the recent discussion about antidepressant drugs that increase the risk of attempted suicide, we thought we’d highlight the study that came out last year, which showed that Cognitive Therapy (developed by Aaron T. Beck, M.D. in the 1960s) can reduce attempted suicide by 50% among those who have recently attempted suicide. This study, funded by the NIH and the CDC, followed 120 patients, half of whom were randomly assigned to 10 Cognitive Therapy treatment sessions, and the other half of whom received usual community services. At the 18 month follow-up, those who had not received CT treatment were twice as likely to attempt suicide as those who had received CT treatment. Check out the NY Times coverage of this study (you have to be registered to view the article – registration is free).

CT Myths: Three of the Most Common Misunderstandings about Cognitive Therapy

Myth: Cognitive Therapy (CT) is all about changing your thinking, and does not involve behavioral change.

Fact: Actually, Cognitive Therapy (developed by Aaron T. Beck, M.D. in the 1960s) addresses your thinking, emotions, behaviors, and physiological symptoms (if applicable). Cognitive Therapy (CT) is called Cognitive Therapy because it is based on the premise that your underlying beliefs about yourself, others and the world influence the way you perceive situations, and prompt you to have certain thoughts, emotions, behavioral responses and physical symptoms. CT treatment actually starts by addressing present problems and helping patients to have a better week — patients often begin evaluating their own thoughts and doing some behavioral experimentation very early on.

Myth: Cognitive Therapy only deals with surface layer problems, and it doesn’t do much to change the root of people’s problems.

Fact: Cognitive Therapy treatment starts by addressing present problems as a way to help patients gradually change their underlying problems. Cognitive Therapists work to understand patients’ ‘core beliefs’ — how they view themselves, others and the world. These beliefs are often formed in childhood and are deep-seated. And these beliefs pop up in every day situations in the form of anxious or depressed thoughts that lead to negative feelings and behavioral reactions to situations. Cognitive Therapists work with patients to analyze what’s happening in a given situation, come up with alternative responses, experiment with implementing new ways of thinking and acting, and gradually begin to change their responses to situations. When patients see how their reactions, mood and other symptoms can improve once they begin viewing situations in a more realistic light, they gradually begin to chip away at their ‘deep-seated’ core beliefs. In other words, Cognitive Therapists recognize that the best way to help patients alter their deep-seated beliefs and their current distress is to take action now, in the present, so that patients can see the effects of changing their thinking and behavior, and start to develop more positive and realistic outlooks after seeing the results in action their own lives.

Myth: All Cognitive Therapists do the same kind of therapy. So if I already tried a Cognitive Therapist and it didn’t help, that means that the treatment itself doesn’t help.

Fact: Not all therapists who call themselves Cognitive Therapists, or Cognitive Behavior Therapists are really trained and qualified to practice Cognitive Therapy (CT). As CT becomes more and more well known, due to the many studies that have shown it to be effective, more and more therapists are including CT ‘techniques’ in their practices, and some may call themselves Cognitive Therapists even if they do not have much training in Cognitive Therapy. Just because someone uses some part of CT in their practice, does not mean that he or she is actually delivering overall CT treatment (which is an integrative form of therapy that requires mastery of many different therapeutic techniques, and understanding of individualized treatment approaches for different disorders). We recommend that patients who are interested in CT treatment search for an ACT-Certified Cognitive Therapist. The Academy of Cognitive Therapy is the only Cognitive Therapist certifying organization that reviews therapists’ knowledge and ability before granting certification.

What does Cognitive Therapy have to do with Nursing?

As Advanced Practice Nurses (APNs) interact with patients who have health problems, many of them find that their patients also suffer from mental health problems, including depression, anxiety, and other illnesses. So how can APNs best address the mental health needs of their patients? Two articles published this fall in Medscape’s Advanced Practice Nursing ejournal discuss how Cognitive Therapy (CT), also referred to as Cognitive Behavior Therapy (CBT), is an effective, time-limited, clinically tested treatment that is ideal for nursing settings. (To view these articles, you have to be registered with Medscape – registration is free.)

In Cognitive Behavioral Therapy in Advanced Practice Nursing: An Overview, Dr. Sharon Morgillo Freeman, a psychologist and certified Cognitive Therapist, discusses how CBT meets APNs’ need for effective, empirically based treatment — it’s a great overview for any APN interested in CBT, and includes a case example of a depressed patient treated with CBT. In Nurses Integrate Cognitive Therapy Treatment Into Primary Care: Description and Clinical Application of a Pilot Program, Dr. Judith Beck and Dr. Christine Reilly describe a pilot program that trained 12 APNs in CT, and monitored their success in implementing CT with low-income, underserved patients. This pilot program, conducted by the Beck Institute and the National Nursing Centers Consortium (NNCC), showed that APNs were able to integrate CT techniques in their primary care practices, with better patient results. We expect that in the future, we’ll see more and more integration of CT in nurse settings…