When we work with individuals with schizophrenia who have been hospitalized for many years, we need to find out what their needs are. We are often able to draw on their delusions. For example, six inpatients had delusions that they were God or Jesus. To our surprise, several of the individuals responded to the question, “What is good about being God?” with the response, “You can help people.”
I posited that if cognitive therapy were truly effective, then it should work on the most severely mentally ill. The three steps we followed were:
Dr. Aaron Beck recently did a roleplay with a therapist who was attending one of our on-site workshops. The therapist played a patient from his own practice, John. John is in his mid-twenties and has a longstanding anxiety disorder.
Reflections on recent developments in the application and formulation of cognitive therapy from Dr. Aaron T. Beck at the Greek Congress.
by 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.
by 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
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:
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.
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
Within the span of a few decades Dr. Aaron T. Beck, widely regarded as the “Father of Cognitive Behavioral Therapy”, has changed the way we think about mental health treatment. In 2007 the city of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), and Dr. Aaron Beck joined in a collaboration unlike any other to bring Cognitive Behavioral Therapy out of academia and into Philadelphia’s behavioral health system.
This unique partnership is one of many strategies employed by DBHIDS to ensure that all Philadelphians have access to the most effective treatments. To capture this fascinating story Dr. Beck, and DBHIDS’ Commissioner Dr. Arthur C. Evans have joined to create this short video about their work.
