Philadelphia College of Osteopathic Medicine Commencement Address

By Judith Beck, PhD
President, Beck Institute for Cognitive Behavior Therapy
Clinical Professor, University of Pennsylvania

President Feldstein, Provost Veit, Vice President Cuzzolino, Chairman Kearney, faculty, administration, graduates, family, and friends: I am so grateful to receive an honorary degree from the Philadelphia College of Osteopathic Medicine.

Today is a day to celebrate. Graduates, you have triumphed. You have overcome challenges and roadblocks. You have studied hard, very hard, to reach this day. If this were the Olympics, I’d give you all gold medals. And here’s something I want you to remember. Life being life, you will encounter difficult challenges in the future.  But you can do hard things. Always remember that. Graduating from PCOM has demonstrated that’s true.

And here’s my wish for you. That you all, every single one of you, have a happy life.

That is, I hope you have many moments, days, months and years when you’re generally happy.

But it’s unrealistic to think you could possibly be continuously happy. If you have that expectation, I can assure you, you’ll be disappointed in life.

Because, as Buddha said, life is suffering. I’d like to add—while life is suffering, it also contains joy and everything in between. And the degree to which you enjoy life will have less to do with your external circumstances than with your interior life—how you view yourself and your circumstances.

In June, I returned to Philadelphia from a two-week trip to Bhutan. Bhutan is a tiny kingdom in Asia, with fewer than a million people, about the size of West Virginia. It is surrounded by Tibet, which is part of China, and by India. There are no traffic lights in the whole country. Bhutan is pretty much made up of ridiculously tall mountains (including the Himalayas) and lush green valleys with terraced farms. And it is called the happiest nation on earth.

In fact, the government measures the Gross National Happiness quotient each year.

Yet more than half of the people are farmers, growing not much more than they need for a subsistence level of living. Most people eat mainly rice for their three meals a day. There is only one major paved road, so transportation, even to neighboring villages, can be quite challenging. Yet the people there seem happier than we Americans are.

Why?

The Bhutanese just live their day-to-day lives. It helps that in addition to free universal education and healthcare, there’s very little corruption. It helps that their beneficent king is ecologically minded and encourages his people to maintain their traditional lifestyles. It helps that the country is infused with Buddhist philosophy and a religious conviction that it is important to be kind to every living creature. And it helps that the mountains discourage a great deal of moving around, so most people expect to live out their lives in close-knit villages. Except in a handful of towns, people tend to have very few material possessions.  There isn’t a great deal of difference within a village between the rich and the poor.

And, interestingly, the people of Bhutan don’t try to be happy. They don’t expect to be happy. They just live their lives, lives that are full of personal significance and meaning, and for the most part they are content.

One of the problems in our country is that many of us TRY TO BE HAPPY. We buy lots and lots of things. We spend an inordinate amount of time online instead of in face-to-face interactions with others. We may be somewhat detached from our neighbors and our community. Many of us don’t value a spiritual life that could add important meaning to our existence. We focus much too much on the acquisition of material goods. And we compare ourselves, often unfavorably, to people with greater fame and fortune, assuming they must be happier than we are.

But there’s another reason that people are probably less happy in the U.S. It has to do with their THINKING. As a cognitive behavior therapist, I know a lot about thinking. I’d like to tell you a little about cognitive behavior therapy, or CBT, as it’s called for short.

CBT is an evidence-based psychotherapy with nearly 2,000 outcome studies that demonstrate its efficacy with people who have mental health problems or medical conditions with a psychological component. To name just a few, CBT is helpful for individuals with depression, chronic pain, substance abuse, health anxiety, panic attacks, cancer, gastrointestinal disorders, eating disorders, somatoform disorders, tinnitus, hypertension—I could go on and on.

Most of you graduates will provide direct care to people with medical or psychiatric disorders. I hope you’ll learn CBT techniques so you can add to your expertise. I’m sure you will interact daily with people who are distressed, who are fearful of their physical symptoms, or who don’t follow through with your recommendations.

You should learn about CBT for many reasons, but I’ll mention just two. First, it can make it far more likely that your patients will take their medication, show up for their appointments, and adhere to their treatment regimens. Second, it can decrease their anxiety and increase their ability to cope with their conditions.

The theory of CBT is based on the cognitive model. Cognitive means thinking. In CBT, we understand that it is not situations, external or internal, that directly impact how we feel, what we do, and often our physiological response. It’s our THINKING that is more closely connected to these reactions.  People’s emotions and behavior always make sense once we know what they’re thinking.

About half of what we do in CBT is to help people solve problems. The other half is teaching people skills to change their thinking and behavior. And it’s important to know that CBT is conducted in the context of a respectful, empathic therapeutic relationship. I hope you’re able to forge this same kind of relationship with every patient at every appointment for your whole career.

When individuals are feeling stressed, some of their thoughts are undoubtedly distorted or unhelpful. For example, let’s say you’re treating a patient whom you just diagnosed with Type 2 diabetes. The patient might think, “This is terrible. I’ll have to change my whole life!” These thoughts, of course, lead to a great deal of distress, and the patient may not be able to focus on anything else you say.

One important concept we teach our patients is that just because we think something doesn’t necessarily mean it’s true. We all make mistakes in our thinking from time to time. We make many more mistakes, however, when we’re under stress.

We don’t necessarily know, though, how accurate a patient’s thoughts are. We never challenge their thinking. Instead, we teach them to evaluate their thinking, to find out the degree to which their ideas are true or not true, helpful or not helpful. We guide them to develop a new perspective, and then we make sure the most important points are written down, so they can read them every day.

Did you know that most people forget between 40-70% of what they hear during a medical appointment? 40-70%!

Our rule of thumb is: Anything we want a patient to remember needs to be recorded, especially more helpful ideas and new coping strategies.

Back to patients with a new diagnosis of Type 2 diabetes. They are unlikely to follow their treatment plan if they think: “I can’t possibly do what I’m supposed to.” Or “It’s not fair that I have to make all these lifestyle changes.” Or “I don’t have to make any changes. I’ll be okay.” Or “I’m sure the diagnosis is wrong.”

There are a number of CBT techniques we might use to increase the likelihood that patients will follow their treatment plan. In addition to responding to their dysfunctional thinking, we help them identify and solve problems. For example, how will they remember to take their medication? How will they make the time to prepare healthy food? We also ask, “What are the advantages of following the plan? We help them write a list to read every day. Then we ask about the disadvantages and help them respond to each one.

Solving problems, examining pros and cons, and evaluating thinking are just three of many techniques you might use to help your patients feel better and act in a more adaptive way.

If you’d like to learn more about CBT, and I hope you will, please visit our website, beckinstitute.org, where I’ve posted this address. I’ve also posted references for you, describing how health care professionals can incorporate CBT techniques in medical appointments.

For a sense of well-being and satisfaction, it’s important to live life according to your values. What’s really important to you? Friends and family? Community, social justice? Work, productivity, achievement? Spirituality, creativity, intellectual challenge? Good health? I’ll tell you about an important value you may have skimped on while you were getting your degree. Fun. I hope you’ll add that back into your life starting right now.

Also think about what may be too important to you: having everyone like you or listen to you, making piles of money, striving to look beautiful, being the best. Living in accordance with those values probably means less engagement in activities that could bring enduring meaning to your life.

Here’s a good exercise. Think about your values, what’s most important to you. Then draw a circle. Fill it in with the percentage of time you spend on various daily activities, such as work, household management, self-care, time with friends and family, and so on. Then ask yourself: How closely does my expenditure of time reflect what’s really important to me?

If you find you’re not devoting much time to the things that are most important, I hope you’ll sit down with a trusted family member or friend. You may need help figuring out how to make time for areas in your life that you’ve been neglecting. What should you do less of or do less well? What can you postpone doing or delegate to others? Monitor how you’re feeling during this discussion. You may very well have to evaluate and respond to negative thoughts. And you may need to do some problem-solving.

Happiness is not something to strive for. It’s a by-product, if you’re lucky, of living a valued life that’s balanced and full of meaning.

Having said that, I am very happy today and so honored. It is especially meaningful that I’m being honored by PCOM, where I have so many connections. I would be remiss if I didn’t mention at least three.  First, if a young man, dear to my heart, had not done his residency in orthopedic surgery at PCOM, I wouldn’t have a 1 ½-year-old granddaughter visiting me this week. Second, my father, Aaron Beck, also known as the father of cognitive therapy, received an honorary degree from PCOM ten years ago. I’m pretty sure we are the first father-daughter pair in PCOM’s history to receive this honor. Third, I have many close ties with friends and colleagues in PCOM’s excellent psychology department, including the chairman, Bob DiTomasso. I am honored to be associated with you and your remarkable students.

And finally, I want to congratulate the graduates once again. What a wonderful, wonderful landmark day this is.  You are fortunate to have been educated at PCOM. At campuses here in Philadelphia and in Georgia, this institution is devoted to attracting an excellent diverse faculty and student body.  It values the education of practitioners, administrators, scholars, and researchers, who are dedicated to serving the underserved in our society.  And how terrific that you’ve chosen a profession that will bring health and well-being to countless individuals — and I hope, a great deal of satisfaction to you. My fervent wish is that you continue to craft lives for yourself that are rich, productive, and meaningful, and in accordance with your most cherished values. Good luck!

CBT Interventions for Health Care Professionals

France, R., & Robson, M. (1997). Cognitive Behaviour Therapy in Primary Care: A Practical Guide. London: Jessica Kingsley.

Lee, D. (2006). Using CBT in General Practice: The 10-Minute Consultation. Bloxham: Scion.

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford.

Sudak, D. M. (2011). Combining CBT and medication: an evidence-based approach. John Wiley & Sons.

Wright, J. H., Sudak, D. M., Turkington, D., & Thase, M. E. (2010). High-yield cognitive-behavior therapy for brief sessions: An illustrated guide. American Psychiatric Association.

Basic CBT Text

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