Using Cognitive Behavioral Therapy to Treat Children with Asperger’s Syndrome

A recent report by Donoghue et al (2011) explored the use of Cognitive Behavioral Therapy (CBT) in children and young people diagnosed with Asperger’s Syndrome (AS).  Children with AS have impairments in social interactions, language and communication problems, theory of mind deficits, and they display difficulties in executive functioning.  Previous studies have shown that children with AS may also develop an affective disorder, such as depression, anxiety, or Obsessive Compulsive Disorder (OCD).  Recent reviews have concluded that CBT is effective in treating depression and OCD in young patients, but there has been little research exploring the efficacy of  CBT to treat these disorders in children with AS.

This article examines different methods of modifying CBT to meet the needs of children with AS.  The authors used the PRECISE framework of cognitive therapy developed by Stallard (2005), which focuses on the active role of patients in therapy and the importance of forming a helpful therapeutic relationship.  The investigators’ intent was to explore various aspects of CBT and how they can be adapted to treat patients with AS.  The study suggests that therapists should set specific expectations about the goals of each session, using literal language that the child can understand, visual materials to identify the patient’s feelings and technology such as pictures and text messages in order to communicate better with the child.  Therapists should also strive to make treatment  fun by using non-verbal materials to help engage the child. Therapists should also use role-playing in sessions to teach children that their initial cognitions and beliefs can be changed in certain situations.

This study suggests that using CBT to treat children with AS is promising; however, randomized controlled trials are needed to investigate the effectiveness of using the suggested changes in CBT.

Donoghue, K., Stallard, P., & Kucia, K. (2011). The clinical practice of cognitive behavioural therapy for children and young people with a diagnosis of Asperger’s Syndrome. Journal of Clinical Child Psychology and Psychiatry.

Using CBT and Smart Phones for the Self-Management of Chronic Pain

In this age of technology, internet interventions are becoming more common in the practice of Cognitive Behavioral Therapy (CBT).  Chronic Widespread Pain (CWP) causes patients to live in constant pain, as well as fear of that pain, which can lead to avoidant behavior and depression.  Kristjansdottir et al (2011) hope to develop an intervention program that will help patients with CWP to self-manage their pain.  Using CBT with a focus on mindfulness and the acceptance of pain, researchers developed a four week intervention that is administered to the patients via Web-enabled smart phones.  In the present study, the researchers look into the feasibility of the intervention.

Six women with CWP were recruited to participate in the intervention.  Each participant first met one-on-one with a therapist where she was asked about her condition, informed of the intervention, and lent a web-enabled phone.  For the next four weeks, the participants received an SMS text message three times a day (morning, evening, and a random time between 11:30 am and 2 pm) reminding the participants to fill out an online diary.  This diary included a set of questions asking about current thoughts and pain awareness.  Within 90 minutes, each participant received online feedback from a therapist, who was supervised by two other professionals of mindfulness meditation and CBT.

Each online diary included questions regarding the usefulness of the previous diary’s feedback.  The effects of the intervention were quantified by use of the Chronic Pain Acceptance Questionnaire (CPAQ) and the Pain Catastrophizing Scale (PSC), given to participants before and after the intervention.  Half-way through the intervention, and after completion, researchers met with participants to ask them about their experiences and opinions.

Kristjansdottir et al found that the participants were responsive to the intervention and saw it as supportive and useful.  Despite minimal technical difficulties, the program was found to be user-friendly and feasible.  Future randomized studies can adapt the program and explore its effects on CWP.

Kristjansdottir, O. B., Fors, E. A., Eide, E., Finset, A., van Dulmen, S., Wigers, S. H., & Eide, H. (2011).  Written online situational feedback via mobile phone to support self-management of chronic widespread pain: A usability study of web-based intervention.  BMC Musculosketital Disorders, 12(51).

Happy 90th Birthday to Dr. Beck


Today we honor you, for a life full of valuable discoveries and influential lessons. Thank you for all you’ve done.

From your staff, at the Beck Institute for Cognitive Behavior Therapy

The Importance of Meanings in Our Reactions

Aaron T. Beck, M.D., President Emeritus

People often make statements such as “You upset me,” “She makes me so angry,” or “The news is depressing.” They do not realize that the specific event is not directly responsible for their feelings. Rather, the meaning they attach to the experience accounts for feelings of sadness, anger, or anxiety. Our emotional response to an event is generally so rapid that it seems as though there is an inexorable bond between the stimulus situation and the feeling. For many years this notion was dominant in the field of psychiatry and psychology. Then it was discovered that there was a link between an event and the emotional response. The missing link was termed an “automatic thought.” This occurs rapidly and automatically in response to the event and incorporates the actual meaning of the event.

For example, a wife angrily reprimanded her husband “You upset me” after he forgot to run an errand. On reflection, she recognized her automatic thought was “He always lets me down.” The automatic thought and the meaning embodied in it were exaggerations, but they led to anger and recriminations. By identifying excessive, inappropriate, or exaggerated meanings, people can reduce the intensity of their reactions. The meanings we attach to our experiences may enrich our lives on the one hand, but on the other hand negative meanings can lead to excessive frustration, conflict, and misery.

Once we reflect on our automatic thoughts we often realize that the meanings are exaggerated, illogical, or without basis. We can question their validity, examine the evidence, consider alternative explanations, and arrive at more realistic meanings.

For more information see A. T. Beck, “Prisoners of hate: The cognitive basis of anger, hostility and violence.”

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Featured comment

Dear Dr. Beck,

I read with interest the brief note on “The Importance of Meaning in Our Reactions.” I certainly agree that there is an intermediate step between an event or situation and our reaction. However, I believe that what you state also misses a crucial aspect- i.e.that words or cognitions point to something “more,” that they are also labels or shorthand for a more intricate felt sense that can be directly contacted in the body. For example, when the wife tells her husband, “You upset me,” because he did not run an errand, these words are symbols for a felt meaning that is not yet in awareness. It is not that we attribute or misattribute meanings (automatic thoughts) but that anything explicit such as this statement is a “shorthand” for a much more complex implicit experiencing.

So we might for instance say, “So there is something about your husband not doing the errand that evoked a reaction. Maybe you can sense that…” which points toward a bodily felt sensing of the reaction. Another possibility would be to invite the wife to attend to the whole quality of the “upset” so that more specific information comes. etc.Then if she pauses and says, “Well, it is more like feeling disappointed…” and there is a slight easing or sigh. that is actually a bodily shift, a change-step. Then if we stay with that, we might invite her to sense into the felt quality of (or felt meaning of) disappointment, and more would come and so on.

Thus any specific or explicit content contains to a wealth of implicitly sensed or bodily felt information that can open up and unfold into deeper meanings and steps forward if we help clients directly refer to the bodily felt quality (felt sense) of the whole situation or issue. This feels more organic and respectful of the person who carries these meanings then to label it as “irrational” etc. That part of the person (partial self) that feels or believes this is based on its history, and experiencing, so I would recommend allowing that aspect to unfold just as it is. Eventually it will open its implicit meaningfulness into something more and different than when it started- and will carry forward the client’s living in new and expansive ways- including developing new cognitions and meanings that often come.

Thanks for listening and for offering this opportunity to express a Focusing-orientation to cognitive change.


Dr. Glenn Fleisch, PhD, MFT

Mill Valley, CA.

Response from Dr. Aaron T. Beck

Dear Glenn,

You are quite correct. The individual’s reaction is not simply a disembodied thought but a definite feeling state, oftentimes described as a “hurt” feeling. This is rapidly replaced by a retaliation in a motor form such as yelling, but also by another feeling state, generally described as “anger.” I go into this in great detail in “Prisoners of Hate,” and will come back to this in a later note when I describe the genesis of anger.

In any event, thank you for your comment.

Dr. Beck

University Professor Emeritus of Psychiatry
University of Pennsylvania
Perelman School of Medicine
Aaron T. Beck Psychopathology Research Center
Room 2032
3535 Market Street
Philadelphia, PA 19104-3309

CBT Interventions: The SPIRIT Training Course

Recently, due to important policy changes, there has been a significant increase in the demand for psychologists specializing in CBT in the United Kingdom.   As a result, specialists have been stressing the importance of various teaching approaches in CBT, such as workbooks or courses, to enable more professionals to practice CBT. In a recent study, the Structured Psychosocial InteRventions in Teams (SPIRIT) course, which is a university accredited program consisting of 38.5 hours of workshops and 5 hours of clinical supervision, was utilized to train professionals in CBT.

17 Mental Health Teams, consisting of 267 professionals from mental health fields in Glasgow were recruited to participate in this study.  These clinicians completed the SPIRIT course, in which they learned how to build relationships with their patients and modify the distorted thinking of their patients through various problem solving activities. Participants were given a subjective skill test, subjective knowledge test, and objective skill test three separate times: before the intervention, immediately following the intervention, and 3 months after the intervention.

The results demonstrated that the SPIRIT course was effective in teaching professionals CBT. The baseline scores on the subjective skill test, subjective knowledge test, and objective skill test all significantly increased after the SPIRIT training program.  In addition, the scores on each test after the intervention and the scores on each test 3 months after the intervention remained constant. This implies that the participants were still able to utilize the knowledge they had learned from the intervention 3 months after their training. Future research is still necessary to investigate whether patients are benefiting in therapy sessions from techniques learned in the SPIRIT course.

Williams, C., Martinez, R., Dafters, R., Ronald, L., & Garland, A. (2011). Training the wider workforce in cognitive behavioural self-help: The SPIRIT (structured psychosocial inteRventions in teams) training course. Behavioural and Cognitive Psychotherapy.

June 20 – 22, 2011, Cognitive Behavior Therapy Workshop Level ll: Personality Disorders and Challenging Problems

Last week Beck Institute held its second Cognitive Behavior Therapy Workshop Level II: Personality Disorders and Challenging Problems. Psychologists, psychiatrists, social workers, councilors, and other professionals traveled from all over the world, including Brazil, Romania, Singapore, Switzerland, Turkey, Uzbekistan, Zimbabwe and seven U.S. states, to receive training in Cognitive Behavior Therapy. Participants received professional training from Aaron T. Beck, M.D., Judith S. Beck, Ph.D., Leslie Sokol, Ph.D., and Norman Cotterell, Ph.D.  Lectures and role-plays emphasized the need for the therapeutic alliance in order to differentiate the therapist from everyone else.  The need to identify core beliefs and automatic thoughts as soon as possible was also stressed.  Dr. Sokol discussed patient collaboration and made it clear that a therapist should always be there for the client.  The use of mood checks was discussed and participants were told that a patient will start with negative emotions and it is critical to probe them for positives to counter the negatives.

CBT Worksheet Demonstration

Dr. Judith Beck (right) demonstrated how to use a variety of CBT worksheets for therapists to use, such as the Cognitive Conceptualization Diagram. Dr. Beck encouraged workshop participants to roleplay with one another to practice CBT techniques. One of the highlights of the workshop was watching Dr. Aaron Beck (above-left) conduct a live patient session.  Dr. Beck started the session with a mood check and followed with setting the agenda.   Following the patient interview, Dr. Beck led a case discussion with workshop participants. All participants are pictured (below) with both Drs. Beck.

Beck Institute Scholar Meets with Dr. Aaron Beck

Marcus Huibers, Ph.D., a former Beck Institute Scholar, visited us last week. He has conducted important research in the field of Cognitive Therapy and Depression in the Netherlands and followed up his visit with this message:

When I was first invited to become a Beck Institute Scholar in June 2006, I initially thought someone was pulling a prank on me. It was late at night when I received the email from Drs. Aaron T. Beck and Judith Beck, inviting me for the extramural training program in Philadelphia for the upcoming academic year, and it felt like I had just won the lottery. At that time, I was an assistant professor at Maastricht University, fortunate to have been awarded three large research grants in the previous years, but also struggling with the responsibilities that came along with it and the theoretical directions my work was about to take. The year before, I had met Dr. Steven Hollon for what turned out to be the start of a long and fruitful collaboration on depression research in the Netherlands, and he had nominated me for the Scholarship, which in itself was a great honor. The academic year that followed (2006-2007), I visited Philadelphia three times on overseas trips that were a tremendous learning experience, and great fun at the same time. I felt I already was a pretty good cognitive therapist, but coming to Philadelphia made me realize there was so much more I could learn on the art and wonders of state-of-the-art cognitive therapy. Not surprising, of course, since it was the founder of cognitive therapy that stood in front of the classroom to pass on his infinite knowledge.

I learned so much, talking (and even role playing) with Dr. Beck, but also from Judy Beck and Leslie Sokol, my all-time favorite CT supervisor. It also opened up the (international) world of CT research for me, with many new friends and colleagues I made during my many stays in Philly, the undisputed CT capital of the world. Since then, the depression research program we are doing in the Netherlands has expanded, with treatment studies on Internet CT, CT and interpersonal therapy (IPT), CT and behavioral activation, schema-focused therapy for chronic depression, mechanisms of change studies and experimental lab studies on cognitive theory in depression., This month, I am on a ‘mini-sabbatical’ visiting with Dr. Robert DeRubeis at the University of Pennsylvania, another one of my ‘heroes’ in the field of cognitive therapy. It has been so great to interact with Rob, his students and colleagues at the Department of Psychology, and meet Dr. Beck, Judy and many others at the Beck Institute again. Coming back here, I realize what a strong impact the Beck Institute Scholarship has had on my professional career as a researcher and therapist, and I am very grateful for that. My time at the Beck Institute has been most rewarding, and I can recommend the training program to anyone who is interested in CT. Here is where you learn from the best.

Marcus J.H. Huibers, PhD,
Professor of Empirically Directed Psychotherapy
Chair of the Department of Clinical Psychological Science
Maastricht University
The Netherlands