By Judith S. Beck, PhD
This Months Expert Cognitive Behavioral Therapy: Not Just for Depression Judith S. Beck, PhDTCRBH: As author of the most widely used textbook in cognitive therapy, you have said that the goal of cognitive behavior therapy (CBT) is for patients to “become their own therapists.” What do you mean by that?
Dr. Beck: In our program at the Beck Institute for Cognitive Behavior Therapy, we orient every session toward helping patients solve problems, evaluate and respond to their inaccurate thinking, and modify their behavior. But we don’t only help patients make these changes. We teach them what to do so they can make these changes themselves—during the time between sessions, and for the rest of their lives. We aim for therapy to be as short-term as possible, and to prevent relapse.
TCRBH: How do clinicians help patients become their own therapists?
Dr. Beck: At each session, we help patients specify the problems they’ve encountered during the week, or that they expect to encounter in the current week. Then we collect data to identify the ideas and behaviors that have interfered with patients being able to solve problems themselves. We get them actively engaged in deciding where to start working. Together we develop an “action plan,” or homework for patients to do during the week. They generally work on implementing solutions to problems and making changes in their thinking and actions. This process gets patients actively involved in their own treatment, and they begin to recognize that the way to get better is to make small changes in how they think and what they do every day. When treatment ends, they’re able to use the skills and tools they’ve learned in therapy in their day-to-day lives.
TCRBH: What are the most useful techniques or questions to ask in CBT?
Dr. Beck: That really depends on what we are treating. Good cognitive therapists use a different formulation for each psychiatric disorder, and we use this formulation in conceptualizing the individual patient. This individualized approach leads to a good therapeutic relationship, setting the right goals for the right patient, planning treatment, and selecting the best interventions. A crucial part of every therapy session is helping patients respond to inaccurate or unhelpful ideas. The basic question to ask when a patient is reporting a distressing situation, emotion, or dysfunctional behavior is: “What is going through your mind right now?” Once we identify the dysfunctional thinking, we encourage them to examine the validity and usefulness of their thoughts—which we hope will lead to more adaptive and accurate perspectives. We also help them design behavioral experiments to test the accuracy of their predictions.
TCRBH: CBT has expanded from depression to other psychiatric problems, such as eating disorders, substance abuse, and anxiety. How is treatment tailored to fit these other problems? For example, how is CBT used with depression vs panic attacks, and how successful is it?
Dr. Beck: Treatment for depression centers on the negative appraisals depressed patients make of themselves, their world, and their futures. They may view themselves as helpless, inadequate, defective, weak, inferior, unlovable, or bad. Depressed patients often believe that the world poses obstacles to their well-being and that others are likely to evaluate them negatively. They view their futures as hopeless; they believe that they will never be able to solve their problems, and that their lives will never improve; they anticipate only hardships and negative experiences, and predict failure and suffering. When treating depressed patients, we emphasize behavioral activation and problem solving. We help patients identify and respond to their dysfunctional thoughts, for example, those that might prevent them from carrying through with activities. We have them test their negative predictions. As a result, we see patients’ energy levels increase, they engage in more realistic and adaptive thinking, and they achieve a sense of mastery and pleasure, all of which contribute to improvements in mood. Research shows that CBT for even severe depression is about as effective as medication but has half the relapse rate.
TCRBH: That’s depression. How about panic disorder?
Dr. Beck: Cognitive therapy for panic disorder focuses on patients’ interpretations of the physical symptoms they experience in response to fear-evoking situations. These patients believe that the bodily sensations they experience during a panic attack are dangerous and uncontrollable. Treatment for panic disorder includes helping patients identify and respond to the distorted thinking that contributes to their anxiety; psycho-education; and exposure exercises that help patients grasp the idea that while the symptoms they experience are very uncomfortable, they are not dangerous, and in fact, are the body’s normal response to fear. Research indicates that cognitive therapy is an extremely effective treatment for panic disorder.
TCRBH: We’ve heard that CBT is being developed for suicidal patients. Can you tell me more?
Dr. Beck: Treatment for suicidality is based on the premises that suicidal patients (1) lack essential cognitive/behavioral coping skills, (2) fail to use previously learned coping skills, and (3) fail to utilize resources when facing a suicidal crisis. In the latter two cases, it’s often patients’ maladaptive thoughts and beliefs that prevent them from using their coping skills and resources. Cognitive therapy for suicidal patients is broken down into three phases. During the early phase, we aim to help patients acquire adaptive coping strategies, identify reasons for living, and gain a sense of hope. We help patients improve their abilities to problem-solve, boost their connections with their social support network, and increase adherence with adjunctive medical, pharmacological, addiction, and other pertinent interventions. During the next phase, we engage patients in treatment, conduct suicide risk assessments, develop safety plans, convey hope, and have patients provide narrative descriptions of the events leading up to and occurring during their last suicidal crises. We teach and help patients develop cognitive, behavioral, and affective coping skills to help them manage suicidal thoughts when faced with a crises. During the final phase, we focus on relapse prevention—we use guided imagery in which patients imagine their previous suicidal crises and describe, step by step, the ways in which they would cope with suicidal thoughts, feelings, behaviors, and relevant situations (Wenzel A et al, Cognitive therapy for suicidal patients: Scientific and clinical applications. Presented at: APA 2009; Washington, DC).
TCRBH: Another promising application of CBT appears to be helping people with schizophrenia. How does CBT improve life for individuals with this diagnosis?
Dr. Beck: Recent research has focused on the finding that people with severe schizophrenia have the same goals as people with other psychiatric disorders. They want to have good relationships; they want to be productive; they want to be independent. A recent study by my father, Aaron T. Beck, MD, Paul Grant, PhD, and colleagues focused on recovery-oriented, cognitive therapy treatment methods to help patients move, in small steps, toward these goals. And, in fact, patients were able to reach a whole new level of functioning, demonstrated by an increase of 10 points on an instrument called the Global Assessment Scale. They were more motivated to achieve their goals, and showed reductions in both negative symptoms and positive symptoms, such as hallucinations, delusions, and disorganization (Grant PM et al, Arch of Gen Psychiatry;Oct 2011:online ahead of print).
TCRBH: CBT has been used successfully with various medical illnesses, including chronic pain. How can we use CBT techniques for chronic pain patients?
Dr. Beck: A chronic pain patient might have inaccurate ideas, such as, “I won’t be able to get out of bed,” or, “Nothing will make me feel better,” or, “I’ll feel worse if I get some exercise.” We can help these patients by identifying and then testing their negative predictions about their abilities, and as a result they often become actively re-involved with life. This actually tends to reduce pain and improve mood.
TCRBH: We’ve noticed that cognitive therapy is now being used with couples, adolescents, and even children. Is CBT effective in treating these different kinds of patients?
Dr. Beck: Yes, when treating couples, we gather data and formulate working conceptualizations for both partners just as we would with individual patients. CBT with couples tends to focus on the expectations that each partner holds, the thinking styles behind their perceptions and beliefs, and the nature of their interactions. Inaccurate and unhelpful cognitions are viewed as the root of each partner’s subjective dissatisfaction with the relationship, and we address and help modify these cognitions during treatment (Dattilio FM. Cognitive Therapy for Relationship Distress. Academy of Cognitive Therapy. http://bit.ly/vOwF7y). Sessions with children are usually structured similarly to sessions with adults. We use cognitive restructuring (the identification and correction of distorted thoughts), and behavioral exposure techniques (for example, the safe exposure to a feared object), psychoeducation, and self-monitoring. Of course, your interactions have to be more playful and child-friendly to be successful. My father and his colleagues recently published Cognitive Therapy for Adolescents in School Settings, which provides a sound introduction to CBT for children and adolescents. It gives clinical tools and interventions for working with this population and helpful case examples (Friedberg RD and Kahn A. Cognitive Therapy with Children and Adolescents. Academy of Cognitive Therapy. http://bit.ly/whXLYa).
TCRBH: Thank you, Dr. Beck.
Some helpful information, including a question and answer section about CBT, can be found at www.beckinstitute.org. Referrals to certified cognitive therapists can be found at the Academy of Cognitive Therapy website at www.academyofct.org.