Telephone-Delivered CBT for Pain Management among Older Military Veterans

This study investigated the effectiveness of telephone-delivered cognitive-behavioral therapy (T-CBT) in the management of chronic pain with older military veterans enrolled in VA primary-care clinics. We conducted a randomized clinical trial comparing T-CBT with telephone-delivered pain education (T-EDU). A total of 98 military veterans with chronic pain were enrolled in the study and randomized into one of two treatment conditions. Study participants were recruited from primary-care clinics at an urban VA medical center and affiliated VA community-based outpatient clinics (CBOCs). Pain management outcomes were measured at mid-treatment (10 weeks), post-treatment (20 weeks), 3-month follow-up (32 weeks), and 6-month follow-up (46 weeks). No significant differences were found between the two treatment groups on any of the outcome measures. Both treatment groups reported small but significant increases in level of physical and mental health, and reductions in pain and depressive symptoms. Improvements in all primary outcome measures were mediated by reductions in catastrophizing. Telephone-delivered CBT and EDU warrant further study as easily accessible interventions for rural-living older individuals with chronic pain.

Carmody, T. P., Duncan, C. L., Huggins, J., Solkowitz, S. N., Lee, S. K., Reyes, N., Mozgai, S., … Simon, J. A. (January 01, 2013). Telephone-delivered cognitive-behavioral therapy for pain management among older military veterans: A randomized trial. Psychological Services, 10(3), 265-275.

 

Dr. Aaron Beck’s Transition from Psychoanalysis to Cognitive Theory

During a recent Beck Institute Workshop, Dr. Aaron Beck describes how he transitioned from psychoanalysis to cognitive theory. Dr. Beck explains that his transition period spanned two years and began when he discovered a lack of empirical evidence supporting psychoanalytic theory of depression. He subsequently began to question the effectiveness of psychoanalysis in the treatment of depression. In 1963, Dr. Beck published “Thinking and Depression: Idiosyncratic Content and Cognitive Distortions” in the Archives of General Psychiatry, widely recognized as his first publication on Cognitive Therapy.

For CBT resources, visit our website.

Changes in Early Maladaptive Schemas After Residential Treatment for Substance Use

Early maladaptive schemas are cognitive and behavioral patterns that cause considerable distress and are theorized to underlie mental health problems. Research suggests that early maladaptive schemas may underlie substance abuse and that the intensity of early maladaptive schemas may decrease after brief periods of abstinence. The current study examined changes in early maladaptive schemas after a 4-week residential substance use treatment program. Preexisting records of a sample of male alcohol- and opioid-dependent treatment seeking adults (N = 97; mean age = 42.55) were reviewed for the current study. Pre-post analyses demonstrated that 8 of the early maladaptive schemas significantly decreased by the end of the 4-week treatment. Findings indicate that early maladaptive schemas can be modified during brief substance use treatment and may be an important component of substance use intervention programs. Implications of these findings for substance use treatment are discussed.

Shorey, R. C., Stuart, G. L., Anderson, S., & Strong, D. R. (September 01, 2013). Changes in Early Maladaptive Schemas After Residential Treatment for Substance Use. Journal of Clinical Psychology, 69(9), 912-922.

 

Selecting Techniques in CBT

How do you decide which techniques to use in a given therapy session? There are many factors to consider. It is helpful, before starting the session, to consider the following questions: What is the acute disorder(s) for which the client has sought treatment and what is the cognitive formulation for this disorder? What has research demonstrated to be effective in treating this disorder? What is your overall conceptualization of the patient? How strong is the therapeutic alliance? What are the client’s preferences and learning style? Which stage of treatment is the client in? How many sessions do you have left? How motivated is the client? What has worked well or not worked well with the client up to this point?

The next set of questions focuses on the here and now. What is a recent, specific example of the problem the patient wants to discuss? What is your conceptualization of this problem and has the patient confirmed it? Is it important to make an empathic statement and/or link the resolution of this problem to the clients’ values and goals? Will you work on one or several parts of the cognitive model: devising solutions for the problem? addressing the client’s automatic thoughts (and/or beliefs)? teaching emotional regulation skills? working on behavior change? decreasing the client’s physiological arousal? Making such decisions should be collaborative. If it’s not clear at which level(s) it would be most beneficial to work, ask the client. (“Do you think it would help more if we did _______ or ______?”)

When working at the automatic thought or belief level, you might draw from techniques from many psychotherapeutic modalities. To name a few, you might do Socratic questioning, propose an alternate viewpoint, do imaginal restructuring, devise a behavioral experiment, use self-disclosure, teach a distancing or mindfulness technique, help the client respond compassionately to his cognitions, and/or work toward acceptance (especially when the clients’ thoughts are accurate).

Throughout the session, you will likely create opportunities for both reflective and experiential learning. As noted in the video clip we’ve linked to below, it is also crucial, not only for symptomatic relief but also to prevent relapse, to modify clients’ basic beliefs.

Judith Beck, PhD
President, Beck Institute

Reference:

Beck, J.S. (2011). Cognitive Behavior Therapy: Basics and Beyond, 2nd edition, Guilford Press.

 

In this video clip from our 4th Annual Student Workshop, Dr. Aaron Beck discusses selecting techniques in CBT:

CBT for Medication-Resistant Psychosis: A Meta-analytic Review

OBJECTIVE:
Support for cognitive-behavioral therapy (CBT) for psychosis has accumulated, with several reviews and meta-analyses indicating its effectiveness for various intended outcomes in a broad variety of clinical settings. Most of these studies, however, have evaluated CBT provided to the subset of people with schizophrenia who continue to experience positive symptoms despite adequate treatment with antipsychotics. Despite several reviews and meta-analyses, a specific estimate of the effects of CBT for patients with medication-resistant positive symptoms, for whom CBT is frequently used in outpatient clinical settings, is lacking. This meta-analysis examined CBT’s effectiveness among outpatients with medication-resistant psychosis, both on completion of treatment and at follow-up.

METHODS:
Systematic searches (until May 2012) of the Cochrane Collaborative Register of Trials, MEDLINE, PsycINFO, and PubMed were conducted. Sixteen published articles describing 12 randomized controlled trials were used as source data for the meta-analysis. Effect sizes were estimated using the standardized mean difference corrected for bias, Hedges’ g, for positive and general symptoms.

RESULTS:
The trials included a total of 639 individuals, 552 of whom completed the posttreatment assessment (dropout rate of 14%). Overall beneficial effects of CBT were found at posttreatment for positive symptoms (Hedges’ g=.47) and for general symptoms (Hedges’ g=.52). These effects were maintained at follow-up for both positive and general symptoms (Hedges’ g=.41 and .40, respectively).

CONCLUSIONS:
For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT for psychosis can confer beneficial effects above and beyond the effects of medication.

Burns, A., Erickson, D., & Brenner, C. (2014). Cognitive-behavioral therapy for medication-resistant Psychosis: a meta-analytic review. Psychiatric Services. doi: 10.1176/appi.ps.201300213

CBT Treatment Goals for Schizophrenia

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck describes the shift in treatment aims for clients with Schizophrenia. He explains that previously “getting better” meant a decrease in symptoms of delusions and hallucinations. Today, Cognitive Behavior Therapy (CBT) aims to help clients function in their communities, whether or not they still experience symptoms. Dr. Beck goes on to say that when clients reintegrate into society, overall adaptive functioning typically improves.

For CBT resources, visit our website.

Physical Therapist-Delivered Cognitive Behavioral Therapy

The importance of the bio-psychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists’ learning and delivering of psychological interventions within the practice context. The aim of this study was to investigate physical therapists’ experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis. A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST). Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audio recorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis. Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice. Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.

Nielsen, M., Keefe, F. J., Bennell, K., & Jull, G. A. (January 01, 2014). Physical Therapist-Delivered Cognitive-Behavioral Therapy: A Qualitative Study of Physical Therapists’ Perceptions and Experiences. Physical Therapy, 94, 2, 197-209.

The Role of Play in CBT with Children

By Torrey Creed, PhD

Seasoned child therapists who pursue training in cognitive behavioral therapy (CBT) often ask the same question: “I usually spend time playing with my clients, but in CBT, do you ever actually just play with kids?” This question is not as simple as it may first appear, and the answer addresses two important principles behind the therapeutic work.

First, the answer to this question is yes… and no. Yes, a CBT therapist often uses play with child clients. Any child therapist whose repertoire is limited to holding a conversation with a child while both parties sit still, hands folded in their laps, will likely find limited success. CBT therapists and clients might be observed playing a game, going for a walk, painting, singing, playing basketball, and more. The part that makes the question less simple than it may appear is the word “just.” A CBT therapist certainly may play with a child, but “just” play? Perhaps not.

Principle 1: Children may benefit from CBT that is experiential. CBT (with clients of any age) focuses on the cognitive model, or the connection between thoughts, feelings, and behavior. When the client’s thoughts, feelings, or behavior are related to distress or impairment, intervention aims to make a shift in at least one of these three components. In other words, intervention may target a shift in thoughts, leading to different feelings and behavior. Alternatively, intervention may target a shift in behavior, leading to different thoughts and feelings. When we begin by examining thoughts, particularly through discussion about the thoughts, we are focused on the abstract. Asking a client to identify a thought, consider whether the thought is as accurate or helpful as it might be, and then shift to a new thought, relies in part on a client’s meta-cognitive abilities. In children, those skills for thinking about thinking are still developing. If instead CBT begins with behavior, the child may have a new experience that can lead to new ways of thinking and feeling. For example, imagine 8-year old Ben, who avoids challenges because he thinks that if he cannot do something perfectly, he will be unable to enjoy doing it at all. Ben’s CBT therapist may design a behavioral experiment where they play a new game while tracking Ben’s anticipated and actual enjoyment. If the behavioral experiment is successful, Ben may find that he actually enjoyed himself quite a bit even though he had to learn the game as they went along. Beginning with behavior (playing the game while learning it) leads to a new experience that Ben can use as concrete evidence against his original unhelpful belief.

Principle 2: Within legal and ethical limits, there is very little a CBT therapist will not do in session – as long as there is a rationale behind the action. Using the example above, the therapist was not playing the game “just” to play the game. Instead, the intervention was selected based on a case conceptualization to strategically target the belief that was causing Ben to avoid challenges. Using case conceptualization as a guide, a CBT therapist has great opportunities to be creative, playful, engaging, and flexible in designing interventions. When the therapist is able to identify why he or she is playing a game, collaborating on a song, or taking a walk, the activity has the potential to become a powerful intervention.

Using these two principles as a guide, a child CBT therapist may quite often use play with clients in session, but very rarely will they be “just” playing. They may be practicing new skills, gathering evidence, testing out negative predictions, and having fun at the same time.

 

Dr. Torrey Creed leads Beck Institute’s CBT for Children and Adolescents Workshop. For more information, or to register, visit www.beckinstitute.org/cbt-for-children-and-adolescents.