The Future of Community Mental Health for Persons with Severe Mental Illness

dr-aaron-beck-2015by Aaron T. Beck, MD

 

Part 3 of 3

Read part 1, A Biography of Cognitive Behavior Therapy

Read part 2, The Evolution of CBT in Community Mental Health

 

I think that it is going to take a number of years for us to really get our Recovery Oriented Cognitive Therapy approach fully implanted. The reason is that the approach is novel, and compared to the standard approach for the severely mentally ill, it is revolutionary.  For example, one important principle is that if that you treat these individuals as though they are normal, they are going to react normally.  They are going to show normal affect, normal behavior, and normal thinking.  Our idea is that not only can we bring out the normal personality, but we can maintain the normal personality throughout the individual’s stay in an inpatient facility and then back out into the community.

One of the problems is that this model runs counter to everything that has been taught before this.  For example, when I took psychiatry in medical school, I was taught that there were two types of psychiatric patients.  There was dementia praecox, which had to do with people who had delusions and hallucinations, who would gradually just get worse and worse until they were completely insane.  Then, there were psychopathic personalities who were individuals with very distorted personalities.  In either case, the question was, were these individuals treatable?

And so I was imbued with this story that severely mentally ill people, since they seemed so removed and so strange, were really untreatable.  Working with Paul Grant and the others on our schizophrenia team, we were able to discover that if we changed our philosophy to the ideas of Recovery and went on the assumption that underneath the abnormal symptoms, there was a normal personality, that we could maintain the personality.

But the problem was, how do you maintain the person?  Well, that becomes the problem.  So the plan became to train all the individuals that have contact with the patients–actually we call them “individuals.” This includes the art therapists, the occupational therapists, the social workers, the line staff, nurses and psychiatrists. We needed all of them to come aboard, using this new approach.  To do this, they needed a change in attitude, because many of them had the same erroneous belief that I had had—namely that the people who were insane by definition, were not capable of being sane at any time.  And we would have to create an atmosphere in which all of the personnel would work toward establishing a cognitive milieu.

Now, to accomplish that would be difficult, because there are numerous problems that the staff has to deal with, that get in the way of this full recovery.  For example, the most common problems are the negative symptoms.  Some of the severely ill individuals also act out in various ways or become aggressive toward the staff.  So numerous problems have come up, and the staff has had to learn how to deal with them.  But once they do, the individual can move along and get back into their lives.  Also, there is certainly turn-over at the various facilities, as staff comes in and out.

So, I expect that at the end of 5 years, we’re going to have a model program here at the Philadelphia Department of Behavioral Health and Intellectual Disability Services(DBHIDS), and people will come from all over the world to learn about the program.  Right now, we have national and international clinicians who are trying to learn our method and export it to their own home towns, and eventually we’ll have a training program that will involve not only people at DBHIDS but people from around the world.

The Evolution of CBT in Community Mental Health

 

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Aaron T. Beck, MD

Part 2 of 3 (Read part 1, A Biography of Cognitive Behavior Therapy)

 

At some point, Cognitive Therapy morphed into what was then called Cognitive Behavioral Therapy, and continued to be quite popular.  It turned out to be widespread, and people came to us from all over the world for training.  However, I had a nagging feeling that we were mostly training therapists who would be seeing individuals in private practice. That meant that people with a higher social economic status tended to receive Cognitive Therapy, but there was a huge population of other individuals, being treated within the community, who did not receive Cognitive Therapy or any of the other evidence based treatments.  So the question become, how do we get to treat patients in a community setting?  I had no contacts within the community in Philadelphia.  And then by a stroke of fortune, I heard that there was a new director of the Philadelphia Department of Behavioral Health and Intellectual Disabilities Services (DBHIDS). Arthur Evans, Ph.D. was coming from Yale University.  I could see right off there would be a meeting of the minds.  I was looking for a community in which to disseminate Cognitive Therapy and he was looking for an evidence based treatment to disseminate in DBHIDS.  Thus, we started a partnership in 2007.

And so we continued on and it was quite successful.  Dr. Torrey Creed joined my team and headed up the work, developing implementation strategies to bring CBT to diverse real-world settings.  Again, there was a great deal of adaptation, but this time it was to find ways to fit CBT to the challenges of community mental health.  We published a paper in the Journal of Consulting and Clinical Psychology describing the first 7 years of our work, showing that we are able to bring high-quality CBT to the previously missed community populations, even in non-traditional treatment settings with complex patients.  In fact, the clinicians were able to deliver CBT with as much competency as therapists in the earlier clinical trials!

Then around 2011, Arthur Evans told me that there was a panel at the American Psychological Association on the Recovery movement, and he asked if I would give a lecture on Recovery.  Well, that puzzled me. I asked, “What is Recovery?  Well, Recovery has to do with setting up certain objectives for the individuals rather than simply focusing on relief of symptoms.  It was ascertaining from the individuals what their major goals in life were—e.g., to be independent, to have connections with other people, to be involved productively, to have a restoration of dignity and to have purpose.  I thought, wow – that all sounds ideal.  So I asked Arthur, “How do you go about doing this?  They are wonderful objectives, but how do you go from A to Z?  For example, a patient who is huddled in a corner and talking to himself all day, how do you get him out, to living independently, getting a job, making connections with other people?”  And he said, “Well, that’s going to be the topic of your speech!”

So I did a lot of head work.  I talked with Dr. Paul Grant, and we came up with a new way in which we are able to use the same principles of Cognitive Therapy that we use with depression and anxiety.  The same principles could be utilized within a Recovery framework, working with severely mentally ill individuals – but it differed in many respects from the standard Cognitive Therapy techniques. For example, there is less emphasis on dialogue and much more on forming a solid relationship with the individual – some call it engagement – and then setting goals with the individuals, and following this up with a number of experiential and behavioral experiences or assignments, which would advance the individual from being huddled in a corner, to becoming more engaged with the therapist and with the therapeutic community (which was very important), and then moving on to less restrictive levels of care, and then finally, finding their place in the community.

And so we started off at the Episcopal Hospital and then moved on to Girard Hospital, and from there, we went to various other settings. Eventually, we were able to go to facilities that were serving the severely mentally ill individuals.

Using Rogerian Counseling Skills

img_8141You (the therapist) need to use all the basic Rogerian counseling skills. In other words, you need to be a nice human being in the room with the client and treat every client the way you’d like to be treated. And of course, therapists need to work on their own negative reactions to clients.

  • – Judith S, Beck, PhD

A Biography of Cognitive Behavior Therapy

atb-2016-headshotby Aaron T. Beck

Part 1 of 3

 

I thought I would begin today with a little bit of the history, but as Emerson once said, “There is no such thing as history, only biography.”  So I am going to give you my biography and we will see how it wraps up into history.

Many years ago, I wanted to test out an intervention that I had developed called Cognitive Therapy, and so I set up a clinic that was called The Mood Clinic. The clinic served many purposes. It was simultaneously a research clinic, a training clinic, and a service clinic. We first dealt with depression, and I wanted to see if what we had developed as the intervention for depression was a valid one. In those days, as well as today, in order to prove the validity of any type of intervention, you would have to have a clinical trial with a control group and an intervention group. The control group received 12 weeks of Imipramine. The intervention group received 12 sessions of cognitive therapy. This randomized controlled trial showed that cognitive therapy treatment was more effective than Imipramine.  This was the first study that showed that a psychosocial intervention worked with depressed people, and that cognitive therapy worked at least as well as pharmacological therapy.

Indeed, when we continued to follow the patients during the follow up period, we found that patients who had received 12 weeks of Imipramine tended to not do well in the follow up period, but those using our psychosocial intervention continued to do well. The explanation was that the Cognitive Therapy intervention had actually taught people new skills. The pharmacotherapy people could no longer progress without receiving more drugs.

In subsequent clinical trials, people were kept on the drugs longer; however, the period for the psychotherapy was reduced! To make a long story not quite as long, we fine-tuned the treatment and wrote a book describing the treatment. Then we turned our attention to anxiety disorders. From then on, we continued with the same paradigm.  We would make clinical observations of patients with a different disorder, develop a cognitive formulation of the disorder, and adapt our interventions. We would then do a clinical trial to demonstrate that it was valid. And we would publish a book. And so we went on from depression to suicide, substance use, anxiety, and personality disorders. We found that our clinical trials were quite effective, and we wrote a number of books on a number of other disorders too. This took us about forty or fifty years. When you have a new therapy, you have to start when you are very young, or you are not going to live to see the ultimate applications!

 

Read part 2: The Evolution of CBT in Community Mental Health

The Hallmark of Cognitive Therapy

JSB Sept 2015 Headshot 2

The hallmark of cognitive therapy is understanding clients’

reactions—emotional and behavioral—in terms of

how they interpret situations.

– Judith S. Beck

 

Positive Reinforcement

“Clients should always be positively reinforced for expressing their doubts and concerns about therapy or the therapist. ”

Judith S. BeckBeck JSB Portait

Why do we structure the session in the first place?

“Every minute in a session is precious, and we want to maximize the time we have to help clients learn to deal with the issues that are most important to them.”

Dr. Judith Beck

 

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My Inspiration for Writing the Basic and Advanced Books in CBT

Judy Headshot 2016By Judith S. Beck, PhD,

President, Beck Institute for Cognitive Behavior Therapy

 

Guilford Publications asked me to reflect on my reasons for writing Cognitive Behavior Therapy: Basics and Beyond and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work, both of which Guilford first published in 1995 and 2005, respectively. Below is what I sent:

 

I remember the moment I conceived of writing CBT: Basics and Beyond. It was in the early 1990’s and I was presenting a workshop with my father, Dr. Aaron Beck, in California. Most of the workshop participants were familiar with his work but asked very basic questions. Again and again, I found myself surprised by what they didn’t know (e.g., how to conceptualize patients according to the cognitive model, structure a session, set an agenda, use Socratic questioning, handle homework challenges, ask for feedback). I realized they needed a basic book that could teach them these skills in a step-by-step format, with transcripts illustrating key therapeutic interventions. I had lots of automatic thoughts when writing the book (“People will think this is too simplistic,”), for which I used CBT techniques on myself to keep going. The book is now the basic text used by most graduate schools in all the mental health disciplines, in the United States and abroad.

 

I also remember when I conceived of writing Cognitive Therapy for Challenging Problems: What to do When the Basics Don’t Work and it traces back to the first book. When I was writing CBT: Basics and Beyond,  I had to continually separate material that was basic from material that was advanced–which made me realize that people would probably need a sequel to the basic text. I presented dozens and dozens of workshops on Cognitive Therapy for Challenging Patients and Cognitive Therapy for Personality Disorders in the years that followed. At each workshop, I asked participants to specify problems they had with some of their patients. (“What does the patient do or not do in session or between sessions that’s a problem? What does the patient say or not say that’s a problem?”) I soon had a very long list of problems. The challenge for me was in organizing the material I collected, and I had lots of false starts. It took me five years to determine how the book should best be structured. Once I figured this out, it took just another two years to complete the book.

 

I started off my career, not in psychology, but in education. Early on, I learned how to break down and explain complicated ideas and tasks for my young elementary school students who had learning disabilities. Through my books and workshops and other training activities, I believe I’ve been able to do the same for therapists who are learning and practicing CBT.

Cognitive Therapy: A New Focus

ATB Headshot 2016

Aaron T. Beck, MD

 

How does cognitive theory integrate more recent clinical and experimental findings?

 

We define Cognitive Therapy in terms of the application of the Cognitive Model, rather than in terms of the specific techniques. Although the original version of the therapy emphasized techniques such as cognitive restructuring, it later emphasized behavioral methods that were shown to produce adaptive changes in information processing (for example, activity scheduling, role playing, and behavioral experiments).

The basic cognitive model assigns a major role to cognitive schemas in information processing.  The content of the schema (beliefs, expectancies, images) shapes the content of the information processing. There is a continuum from adaptive to dysfunctional beliefs. When the beliefs are exaggerated or biased, they lead to inappropriate or exaggerated affect and behavior.

While the basic cognitive model emphasizes the importance of cognitive bias in creating psychological problems, a body of clinical observations and basic research findings has pointed to the role of deployment of attentional resources in adaptive and maladaptive behavior (Beck & Haigh, 2014).  Thus, the combination of attentional focus and cognitive bias plays a major role in psychopathology.

Attentional fixation, an extreme form of attentional focus, is instrumental in the development of conditions as diverse as panic disorder, suicidal impulses, and the craving behaviors in addictions. When attention is fixated on a particular sensation and belief as in panic disorder, the individual is incapable of reasoning or accessing contradictory information regarding the benign nature of the symptoms.

When attentional focus is enhanced as in psychopathology or in intense states of arousal such as anger it is deployed on each component of the information processing sequence:

Information Processing Sequence CT New Focus ATB

The combination of attentional hyper focus and bias is particularly evident in the development of the somatic conditions such as chronic fatigue syndrome, chronic pain, and hypochondrias.

The expanded cognitive model can be utilized to understand each of the psychological disorders with their unique cognitive formulation (Beck & Haigh, 2014). The formulation may be drawn on to conceptualize a specific case.

As indicated, the expanded model is comprehensive enough to provide a blueprint for the treatment. The treatment is geared to the characteristics of the disorder. The emphasis on discrete refocusing techniques such as mindfulness constitutes a central part of mindfulness based cognitive therapy and other mindfulness strategies. Refocusing approaches were initially used in cognitive therapy of panic disorders but are subsequently used in a variety of psychological problems such as chronic pain, hypochondriasis, hallucinations, and anxiety.

 

Learn to use the cognitive model in our CBT for Depression – Core 1 Workshop

 

Reference:

Beck, A.T., & Haigh, E.A.P. (2014) Advances in Cognitive Theory and Therapy: The Generic Cognitive Model. Annual Review of Clinical Psychology, 10, 1, 1-24.

 

 

Dr. Aaron Beck’s 95th Birthday

Today, July 18, 2016, is Dr. Aaron Beck’s 95th birthday. At last week’s workshop, participants celebrated by signing ‘Happy Birthday” and hearing stories from Dr. Beck.

 

 

Part 1

We recommend beginning this video at 2:40

Part 2