Lina Butkute-Van de Voort traveled from Ghana to Philadelphia for the Core 1: CBT for Depression and Suicidality workshop. She has been living in Ghana for 6 months working as a school psychologist for special needs students ages 3-18. The best part of the workshop for her was being able to meet both Drs. Beck, “A dream of mine for over 10 years”. She brought with her a translated copy of Dr. Judith Beck’s book, Basics and Beyond, in her native Lithuanian.
By Torrey Creed, PhD Adjunct Faculty, Beck Institute
While a description of CBT for Autism Spectrum Disorders (ASD) would require a large volume (at least), let’s highlight several important areas to consider when working with people with an autism spectrum disorder (ASD). First, a word about what we do not do in CBT for ASD: we do not treat the ASD itself. CBT will not move someone to being neurotypical, nor should it. Instead, we focus on secondary issues that are related to the experience of life on the autism spectrum: depression, bullying, stress, anger, aggression, anxiety, social skills deficits, and limited social support.
People with ASD have unique cognitive and behavioral styles, which vary with the severity of their ASD symptoms. Therefore, as with any client, we creatively adapt and adjust CBT to meet the strengths and needs of the individual. People on the ASD spectrum are generally very concrete thinkers, so we need to modify standard CBT to be more experiential and concrete than usual. Individuals who are cognitively on the higher end of functioning may benefit from a mix of both cognitive and behavioral strategies, but when their functioning is more impaired, the therapist de-emphasizes cognitive techniques. The ideas described below may be a better fit for a higher-functioning client, but most can be made more concrete for someone whose cognitive style makes abstract thought even more challenging.
As with all CBT clients, we start with a cognitive conceptualization, identifying key cognitions and behaviors to target in treatment. Engagement and the therapeutic relationship are key with any client, but building these with clients with ASD may be even more essential, and also challenging. Therefore, from the beginning of treatment, we help clients explore their goals, passions, and values, then identify specific steps that CBT can help them make in service of that long term goal. Framing treatment about things the individual truly values can increase both engagement and the relationship. Aspects of the ASD or the sequelae from secondary issues (e.g. information from the case conceptualization) are framed as challenges to reaching the goals, and CBT then becomes a way to address those challenges in order to move toward the tailored goals.
A component of treatment often focuses on the “rules of the game” in social situations, which may be intuitive to others but are generally very hard for a person with ASD to penetrate. CBT helps them learn to better read social interactions and read others’ reactions and behavior more accurately so they can more easily monitor and adjust their own behavior and responses. We help people work toward self-acceptance and compensatory strategies to mitigate the impact of things that cannot be changed (like specific cognitive deficits). We also help them learn to recognize and modify unhelpful patterns of information processing which contribute to stress, anxiety, and depression. Our major focus, as in any CBT, remains on teaching cognitive and behavioral skills and strategies that will help the person move closer to his or her goals, as well as preventative strategies to decrease or prevent symptoms of comorbid mental health concerns, such as anxiety disorders and depression.
Common beliefs of people with ASD include “I must stay in control because there may be danger;” “If I try to fit in, I’ll fail;” “If I stay away from people, I won’t get hurt;” “I can’t understand what is going on in [my] world;” or “Everyone takes advantage of me.” They also have negative beliefs about themselves, “I’m flawed;” “I’m weird,” “I’m out of control;” “I’m incompetent;” or “I’m vulnerable.” These beliefs may pose serious challenges to reaching a person’s individualized goals, and often these beliefs can become self-fulfilling prophecies. Helping people to shift to more accurate and more helpful cognitions is a powerful tool in helping them realize their goals and potential.
When the client is a child with ASD, that child is usually the identified client; however, working with families is also essential. Families may struggle with ASD-related issues, including a child’s obsessive interests, angry outbursts, poor self-care, repetitive rituals, and odd behavior. Parents may also experience frustration (with the child, or with others’ reactions to the child), and siblings may have strong reactions to their own experiences of being in a family with a child with ASD. Helping family members to identify ways in which their patterns of thinking, feeling, or behaving may be more or less helpful (or accurate) can help shift the dynamic of the family in a positive direction.
There is much more to learn about CBT with individuals with ASD. The work can be challenging but is also highly creative-and rewarding, as we see them and their families reaching their own meaningful goals.
Topics covered include how to:
- Develop an individualized cognitive case conceptualization for youths with OCD or other anxiety disorders or Autism Spectrum Disorder
- Create a tailored treatment plan from early treatment through relapse prevention
- Deliver specific, empirically based CBT interventions for individuals and for families, and
- Determine whether those interventions have been effective.
Training focuses on therapy with clients between the ages of 7 and 18 with Autism Spectrum Disorder, OCD or other anxiety disorders.
This workshop features a special question and answer and role-play session with Dr. Aaron Beck. Participants are encouraged to prepare or have in mind cases for discussion or role-play.
|When:||June 1-3, 2015|
|Where:||Beck Institute, Suburban Philadelphia|
|Time:||8:45am – 4pm|
|Faculty:||Torrey Creed, PhD|
|Enrollment:||Limited to 42 participants|
Correction Notice: An Erratum for this article was reported in Vol 82(6) of Journal of Consulting and Clinical Psychology (see record rid]2014-49169-001/rid]). In the article, the effect size of the Schnurr et al. (2003) study was incorrectly calculated because the standard error value was used instead of the standard deviation for the effect size formula. In addition, the Schnurr et al. (2007) study was omitted because it was not identified by the electronic search using keywords, but should have been identified by the authors’ manual search. The corrected and added effect sizes changed the results and are included.
Objective: Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches.
Method: The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life.
Results: The pre-post within-group and controlled effect sizes were moderately strong (Hedges’s g = 0.54 and Hedges’s g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments.
Conclusion: CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life.
Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 3, 375-391.
Background: Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive?behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults.
Methods: A total of 172 patients with PDA (DSM?IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18–60 years) and older (?60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions.
Results: Attrition rates were 2/31 (6%) for the over?60s and 31/141 (22%) for the under?60s group (?² = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate?to?large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age?related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P?values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (? = ?0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late?onset type and short DOI were linked to superior improvement of agoraphobic avoidance.
Conclusions: CBT appears feasible for 60+ PDA?patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.
Hendriks, G.-J., Kampman, M., Keijsers, G. P. J., Hoogduin, C. A. L., & Voshaar, R. C. O. (2014). Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: A comparison with younger patients. Depression and Anxiety, 31, 8, 669-677.
Phillip Smith, from Kansas City, MO, works at Truman Medical Center as well as in a private practice. He works as a designated therapist for an ACT team, where he facilitates Cognitive Enhancement Therapy (CET) and is currently working on an expansion grant for the center. He uses CBT by re-conceptualizing the symptoms of his patients. His goal in treatment is “to instill hope in patients who have been beaten down by their disorders”.
He enjoyed how Dr. Aaron Brinen “rolls with it” and was blown away by Dr. Aaron Beck during the question and answer session. He also appreciated learning from his co-worker who accompanied him to the workshop and he loved the opportunity to explore Philadelphia restaurants!
Method: Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60).
Results: Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups.
Conclusions: Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.
Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., . . . Morin, C. M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 82, 4, 670-683. doi:10.1037/a0036606.supp
Introduction: The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders.
Methods: To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search.
Results: 474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive–compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education.
Limitations: Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria. Conclusions: Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.
Gonçalves, R., Rodrigues, H., Novaes, F., Arbol, J., Volchan, E., Coutinho, E. S. F., . . . Ventura, P. (2015). Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders. Journal of Affective Disorders, 172, 231-240.
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