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.

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

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



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



Drs. Beck and Evans Discuss Evidence-Based Practices

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.

A Unified Model of Depression: Integrating Clinical, Cognitive, Biological, and Evolutionary Perspectives

Aaron T. Beck and Keith Bredemeier  –  Department of Psychiatry, University of Pennsylvania


ATB Headshot


We propose that depression can be viewed as an adaptation to conserve energy after the perceived loss of an investment in a vital resource such as a relationship, group identity, or personal asset. Tendencies to process information negatively and experience strong biological reactions to stress (resulting from genes, trauma, or both) can lead to depressogenic beliefs about the self, world, and future. These tendencies are mediated by alterations in brain areas/networks involved in cognition and emotion regulation. Depressogenic beliefs predispose individuals to make cognitive appraisals that amplify perceptions of loss, typically in response to stressors that impact available resources. Clinical features of severe depression (e.g., anhedonia, anergia) result from these appraisals and biological reactions that they trigger (e.g., autonomic, immune, neurochemical). These symptoms were presumably adaptive in our evolutionary history, but are maladaptive in contemporary times. Thus, severe depression can be considered an anachronistic manifestation of an evolutionarily based “program.”

From our Archives: Reflections on My Public Dialog with the Dalai Lama

Aaron T. Beck, M.D.

Göteborg  June 13, 2005


Judy Beck and I met with the Dalai Lama initially in his private drawing room in the hotel for an informal discussion a couple of hours prior to the actual public dialog.  Also attending were Paul Salkovskis, Astrid Beskow, and a number of his own representatives, including his long-time interpreter.  Initially, I presented His Holiness with a copy of Life magazine from 1959, which had a cover picture of him receiving bouquets from his American supporters after his escape from Tibet to the United States.  He seemed pleased to see this much younger picture of himself.  I also presented him with a hard copy of Prisoners of Hate.  He seemed taken by the title, which epitomized his own view that hatred imprisons the people who experience it.  He then remarked that there must be six billion prisoners in the world!


On a personal level, I found him charismatic, warm, engaging, and very attentive to what I had to say.  At the same time, he seemed to maintain an objective detachment not only with me but also with the members of the entourage.  He also impressed me with his wit and wisdom and his ability to capture the nuances of very complex issues.


The dialog was held at the Göteborg Convention Center with about 1400 attendees at the International Congress of Cognitive Psychotherapy (view full video here).  In keeping with his expressed wish, I started the dialog.  I began to recite the dozen or so main points of similarity between Tibetan Buddhism and cognitive therapy (listed below).  After I recited four or five similarities, he interrupted with the statement that they were as many items as he could absorb at one time.


My main challenge in the dialog was to inform him about the cognitive approach to human problems without in any way taking away from the broad philosophy and psychology of Buddhism.  My strategy was to find appropriate points in his discourse where I could introduce cognitive concepts that were relevant in some way to his train of thought.  I tried to represent the cognitive approach as a valid system or discipline in its own right that overlapped but also was complimentary to Buddhism.  I also had to be conscious of my choice of words.  Although His Holiness is quite fluent in speaking English, he is not familiar with more technical words, especially those for which there are no Tibetan equivalents.  For example, he used the term “negative thoughts,” which I repeated in preference to the more technical (and precise) cognitive terms, such as self-defeating thoughts or dysfunctional cognitions.


Among the points that I brought up, which he then expanded on from his own vantage point, were that both systems use the mind to understand and cure the mind.  Acceptance and compassion were key similarities.  Also, in both systems, we try to help people with their overattachment to material things and symbols (of success, etc., something we call “addiction”).  I gave a case example of a depressed scientist who was so attached to success (in this case, specifically winning a Nobel Prize) that he excluded everything else in his life, including his family.  I had used a typical cognitive strategy to give the patient perspective.  In the course of a single session, he changed his beliefs and got over his depression (at least temporarily).  The Dalai Lama’s response to this anecdote was, “You should get the Nobel Prize for Peace.”


Another point that I brought up was our distinction between pain and suffering.  I suggested that much of people’s suffering is based on the fact that they identify themselves with the pain.  People who are able to separate (“distance”) themselves from the pain and view it more objectively had significantly less distress (as pointed out by Tom Sensky’s group in London).  His Holiness seemed taken with this concept and then said in an amusing way that maybe he could use this notion to help himself with his chronic itch.  (This half-serious comment, of course, evoked a large amount of laughter from the audience.)  He later referred to cognitive therapy as similar to “analytical meditation.”


I asked His Holiness how he thought that his message could really take root in the world.  He then expanded on his ideas that education had to be the answer.  He also expressed his own philosophy, which he described as secular ethics.  Although people of different faiths could embrace the values that he expressed, such as total acceptance of all living things, he did not feel that religion was a necessary instrument for this.  He appeared to echo what is also the essence of the cognitive approach, namely self-responsibility rather than depending on some external force to inspire ethical standards.  Since I believe that CT also regards unethical and morally destructive behavior as a cognitive problem and thus would advocate a “cognitive morality,”  I later was able to get this point across but in different words.  When he asked me for my view of human nature, I responded that I agreed that people were intrinsically good but that the core of goodness was so overlaid with layer after layer of “negative thoughts” that one had to remove the layers for the goodness to emerge.  He expressed the belief that positive thinking (focusing on positive and good things) was the way to neutralize the negative in human nature.  My position was that the best way to reach this goal was to pinpoint the thinking errors and correct them.  After we concluded the dialog, Paul Salkovskis gave an outstanding summation of the topics that we had covered.


Since Astrid Beskow (the prodigious organizer of the event) discovered that by coincidence this was his birthday, there was a short birthday celebration during which he was then given a large bouquet.  He then gave Astrid, Paul, and myself a Buddhist prayer shawl.  I later learned from an intermediary that he enjoyed the dialog and that he would think about several points that I raised.


All in all, it was a thrilling experience for me and, from what I heard from several of the attendees, also for the audience.


From my readings and discussions with His Holiness and other Buddhists, I am struck with the notion that Buddhism is the philosophy and psychology closest to cognitive therapy and vice versa.  Below is a list of similarities that I suggested to the Dalai Lama in our private meeting.  Of course, there are many strategies we use such as testing beliefs in experiments and formulating the case that are not part of the Buddhist approach.



  1. Goals: Serenity, Peace of Mind, Relief of Suffering
  2. Values:
    1. Importance of Acceptance, Compassion, Knowledge, Understanding
    2. Altruism vs. Egoism
    3. Universalism vs. Groupism: “We are one with all humankind.”
    4. Science vs. Superstition
    5. Self-responsibility
  3.  Causes of Distress:
    1. Egocentric biases leading to excessive or inappropriate anger, envy, cravings, etc. (the “toxins”) and false beliefs (“delusions”).
    2. Underlying self-defeating beliefs that reinforce biases.
    3. Attaching negative meanings to events.
  4. Methods:
    1. Focus on the Immediate (here and now)
    2. Targeting the biased thinking through:
      1. Introspection
      2. Reflectiveness
      3. Perspective-taking
      4. Identification of “toxic” beliefs
      5. Distancing
      6. Constructive experiences
      7. Nurturing “positive beliefs”
    3. Use of Imagery
      1. Separating distress from pain
      2. Mindfulness training

Omar L.V.

Absolutely the best CBT training I have ever attended, which is not surprising since it is given by its founders. It was an honor to have the opportunity to discuss a real case with Dr. Aaron Beck. I think everyone doing cognitive therapy in the world should attend this training at least once.

Advice for Working with Clients Who are Focused on the Past

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck gives advice on how a clinician can keep a client presently focused in order to achieve the most effective results from therapy.