The negative outcomes of past intuitive treatment reinforced one of the most common and fundamental beliefs of PTSD: “I am incompetent.” The woman perceived through past experiences in and out of therapy that something within her was so broken that she was beyond help, leading to a cycle of hopelessness, suicidality, and treatment avoidance.
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.
Norman Cotterell, Ph.D.
Beck Institute for Cognitive Behavior Therapy
Beck and Gellatly (2016) propose that catastrophic thinking is a central feature in psychopathology. Such thinking magnifies both the immediate and eventual consequences of any perceived threat. A variety of disorders can be conceptualized as such: Clients magnify external threats (accidents, attacks, arson) but most notably misinterpret and magnify perceived internal threats. Sensations, thoughts, and emotions are seen as signs of immediate physical or psychological catastrophe.
- Panic — immediate catastrophic consequences of an unexpected physical sensation: “If my heart races, I’m dying.” “If I feel lightheaded, I’m about to faint.”
- Social Phobia — catastrophic misinterpretations of the social consequences of anxiety: “If people see me sweat, I’ll be judged, shunned, rejected or shamed.”
- Agoraphobia — catastrophic beliefs about the consequences of anxiety: “If I panic, I’ll be trapped.”
- Specific phobias — catastrophic beliefs about a feared object or situation: “If I get on an airplane, I won’t be able to handle the anxiety.”
- Health anxiety — catastrophic consequences of an unexpected physical sensation, or image: “If my chest hurts, I have heart, lung, or infectious disease. If the doctor sends me for tests, it means I’m seriously ill.”
- Obsessive compulsive disorder — Catastrophic misinterpretation of an intrusive thought: “If I think something unacceptable, it means I myself am unacceptable. Thinking it is as bad as doing it.”
- Posttraumatic Stress Disorder — Catastrophic beliefs about the reoccurrence of danger: “If it happened before, it’s likely to happen to me again.” “Flashbacks mean danger.”
- Pain — Catastrophic beliefs about pain and its consequences: “If I’m in pain, it is unsafe to move, and I must stop my activities.”
- Traumatic Brain injury — Catastrophic misinterpretations of post concussive symptoms: “If I have a headache, my brain injury is getting worse.”
Beck and Gellatly regard such thinking as an essential ingredient in the development and maintenance of these anxiety disorders. They identify 6 essential ingredients of a cycle that fuels them: Catastrophic Beliefs (“I’m having a heart attack, I’m dying,”) triggered by a Precipitating Event (heart palpitations) results in both Anxiety Symptoms (shortness of breath, dizziness, feeling out of control) and an Interpretive Bias (“If my chest hurts, I’m having a heart attack”). These, in turn trigger an Attentional Fixation (“There’s no other way to look at this!”) and an Attentional Bias (“I really need to pay close attention to my chest.”) And these attentional factors serve to refuel the anxiety, the interpretative bias, the catastrophic beliefs and each other.
Beck and Gellatly propose taking catastrophizing into account would be useful in the diagnosis, prediction, prevention, and treatment of psychopathology. Future research and exploration will answer such questions as: Which catastrophic beliefs differentiate which conditions? Who is susceptible to developing such beliefs? How do we educate people to promote resiliency against such beliefs? What interventions will best enable clients to counter these beliefs?
Although they point to catastrophic beliefs as the key essential factor, other factors may serve as points of interventions. Decatastrophizing enables clients to test the validity of catastrophic beliefs through exposure to the sensations. Therapists use panic inductions, for example, to alter the misinterpretation of symptoms. Other techniques, such as cognitive reappraisal, may ameliorate attentional fixation by providing more plausible ways to account for symptoms. Various in-office procedures may modify attentional bias by directing focus to breathing, to objects in the office, or to sounds inside and outside the building. This model may serve as a way to conceptualize the problem and identify where interventions work.
Beck, A.T. & Gellatly, R. Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders. Cognitive Therapy and Research, 2016, pp. 1-12.
To test the feasibility and acceptability of implementing an evidence-based, peer-delivered mental health intervention for Somali women in Minnesota, and to assess the impact of the intervention on the mental health of those who received the training. In a feasibility study, 11 Somali female community health workers were trained to deliver an 8-session cognitive behavioral therapy intervention. Each of the trainers recruited 5 participants through community outreach, resulting in 55 participants in the intervention. Self-assessed measures of mood were collected from study participants throughout the intervention, and focus groups were conducted. The 55 Somali women who participated recorded significant improvements in mood, with self-reported decreases in anxiety and increases in happiness. Focus group data showed the intervention was well received, particularly because it was delivered by a fellow community member. Participants reported gaining skills in problem solving, stress reduction, and anger management. Participants also felt that the intervention helped to address some of the stigma around mental health in their community. Delivery of cognitive behavioral therapy by a community health workers offered an acceptable way to build positive mental health in the Somali community.
Pratt, R., Ahmed, N., Noor, S., Sharif, H., Raymond, N., & Williams C. (December 31, 2015) Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers Journal of Immigrant and Minority Health.
Judith S. Beck, Ph.D. and Robert Hindman, Ph.D.
At our recent Core 2 CBT for Anxiety Disorders workshop, we asked participants what is helpful in managing anxiety? What is not helpful?
Individuals with anxiety disorders unwittingly maintain their conditions by their behavioral strategies and their beliefs.
Avoidance is a hallmark of anxiety. Sometimes the avoidance is blatant, when, for example, an agoraphobic client does not leave the house. But sometimes it is quite subtle. For example, one of our panic patients tightly gripped the steering wheel while driving. A client with obsessive compulsive disorder tries not to think about an idea which is unacceptable to her. One of our most recent clients with social anxiety avoids making eye contact and tries to control his shaking hands.
Worrying is also unhelpful for people with anxiety disorders. Sometimes clients believe that it is important for them to worry in order to prevent danger; however, worrying actually leads to their continually overestimating danger over time. Our anxious clients have beliefs such as, “The world is dangerous.” “I have to be on guard. I need to anticipate any problems that could possibly arise; otherwise I’d be irresponsible.” “If I worry, I can figure out exactly what I should do.” Then, when the predicted catastrophe doesn’t happen, instead of recognizing that it was not likely to occur, they tell themselves, “It was good that I worried about it or else it might have happened.”
Anxious clients also demand certainty. A client we saw this week told me, “I have to know for sure that nothing bad will happen.” But many outcomes in life are unpredictable, or can’t be predicted with absolute certainty. Assuming that certainty is possible and demanding that they obtain certainty keeps anxiety going. One dysfunctional strategy clients use to demand certainty is constant reassurance seeking. For example, a client frequently seeks reassurance from her husband that he still loves her and will never leave. Demanding certainty is also associated with her attempts to over-control herself, her husband and children, and even her co-workers. For instance, she’s constantly texting her husband and children to make certain they’re ok, and will keep on frantically texting them until she hears back.
Another habit anxious clients have is paying too much attention to their anxious thoughts. People without anxiety disorders often do an automatic reality check and/or engage in problem solving when they notice anxious thoughts. Or they dismiss them as “just thoughts” and refocus their attention back to the task at hand. When an anxiety disorder is present, though, clients focus on their anxious thoughts, treat them as “facts;” their anxiety increases, and they often engage in an unhelpful action (such as the thought suppression, worry, or reassurance seeking mentioned above).
Perfectionism is also sometimes involved in maintaining anxiety disorders. Another recent client of ours believed, “I should be perfect because if I’m not, I’m vulnerable to bad things happening. I should figure out the perfect solution to any problem. If things aren’t perfect, everything will fall apart.” The problem with perfectionism is that it’s impossible to be perfect. When our client doesn’t meet her perfect expectations, she doesn’t think it’s because her standards are unrealistic, but instead, takes it as more evidence that she’s vulnerable to bad things happening, which keeps her anxiety elevated over time.
Finally, clients with anxiety disorders have difficulty tolerating, much less accepting the experience of anxiety because they are “anxious about being anxious”. One client we mentioned above believed that anxiety was bad and that if she didn’t try to control it, it would get worse and worse until she just couldn’t stand it and would “lose control.” You can think of anxiety as energy for a challenge, so when you believe experiencing anxiety is a challenge, you end up getting an additional level of anxiety whenever it shows up.
Fortunately, a large body of literature now supports the efficacy of Cognitive Behavior Therapy in effectively treating anxiety disorders. And treatment has become even more effective in recent years as therapists have added mindfulness to their repertoire of techniques, helping clients label and accept the experience of anxiety and learning, not how to try to rid themselves of it, but how to move anxiety to the background as they focus on whatever valued activity they are engaged in at the moment.
Traveling from Burlington, Vermont, Amy is a clinical social worker in a private practice where she treats anxiety and depression in college students and young professionals. The transition into college and navigating the independence and responsibility of adulthood can be daunting, and she uses CBT and mindfulness to improve the lives of her clients.
She attended our recent CBT for Anxiety: Core 2 workshop in Philadelphia and learned practical strategies for treating clients with anxiety. All the knowledge from this workshop hasn’t sunken in yet, so she is looking forward to “go home and study” the enormous amount of information Dr. Amy Wenzel presented during the workshop. Learning about the worry script and using exposures are the main take-aways for Amy. Her favorite part? Meeting with Dr. Judith Beck and having the opportunity to Skype with Dr. Aaron Beck were her favorite parts of the experience.
Clinical Psychologist at Beck Institute
Mindfulness-based interventions have been becoming more popular in psychotherapy. One such treatment, Mindfulness-Based Cognitive Therapy (MBCT), has specifically been developed to prevent relapse in clients who have experienced recurrent major depressive episodes (Segal, Williams, & Teasdale, 2001). We have incorporated mindfulness strategies into our work at the Beck Institute. Instead of thinking about mindfulness-based interventions as separate treatments, however, we think about mindfulness as a potential strategy to use in a larger CBT framework. I’ll review one common mindfulness technique we use with our non-suicidal depressed clients.
A body of research has demonstrated rumination to be an important factor in maintaining depression (e.g., Nolen-Hoeksema, 2000). We view rumination as a strategy clients use to cope with depression. For example, Mark, a client I recently treated, felt depressed, then ruminated to try to figure out why he felt depressed. His ruminative thoughts included, “Why do I feel so depressed? What’s wrong with me? I just can’t do anything right, like I got a bad review at work. My friends don’t try to call me either. . .” I worked with this client to help him identify his beliefs about the rumination process instead of solely evaluating the content of each thought.
First I help clients identify, and then evaluate, beliefs about rumination. I start this way (instead of going straight into mindfulness) because clients tend to continue to use strategies that they view as helpful. I want them to recognize that rumination is doing them more harm than good. One way to identify beliefs about rumination is to complete a cost-benefit analysis, eliciting from clients the advantages and disadvantages of rumination. Instead of using the term “rumination,” I asked them what they call the strategy (e.g., “asking myself why,” “listing all of my problems,” “trying to think my way out of depression”).
Typical advantages include “It helps me figure out my problems;” “I can come up with solutions.” “I’ll be able to know what to do next time I feel depressed.” Next we list the disadvantages, such as: “It makes me feel worse.” “Once I start, it’s hard to stop.” Then we evaluate each advantage. For instance, I asked Mark, “How often do you come up with a specific solution?” and “If ruminating helped you solve your problems, do you think they would be solved by now?” Next we evaluate whether the advantages or disadvantages are stronger. Clients have effectively assessed their positive beliefs about rumination when they conclude that the disadvantages outweigh the advantages. A list of the advantages and disadvantages shows clients the consequences of rumination and acts a motivator to stop the unhelpful strategy. (If the advantages are still stronger, you’ll need to either spend more time evaluating the advantages or add to the disadvantages.)
The next step is to teach clients how to use mindfulness as a strategy to disengage from rumination. I record the mindfulness exercises (usually using clients’ cell phones) to make it easier for them to practice. Before I start, I guide clients through a rumination induction by having them close their eyes and actively think about a topic involved in their typical ruminations. I get them to simulate the process of ruminating in session so they can experience being able to disengage from the rumination process. As I noted before, this strategy should not be used with actively suicidal clients because it can increase their depressed mood and sense of hopelessness.
Once clients have been ruminating for about 30 seconds, I ask for a rating of their depressed mood from 0-10, turn on the recording app on their phone (“voice memos” on iPhones or “voice recorder” on Androids), and begin guiding them through a mindfulness of the breath exercise that lasts for 5 minutes. At 5 minutes, I get another mood rating, end the exercise, and ask them about the experience (e.g., “What did you notice?” “Were you able to let go of ruminative thoughts and refocus on breathing?” “What happened to your mood over time?”) The vast majority of clients learn that it’s possible to disengage from rumination, and that by not actively ruminating, their mood gradually improves. I make sure to emphasize that mindfulness is not for the purpose of making them feel better or suppressing thoughts but is a strategy to help them relate to their thoughts in a different manner. Their action plan then consists of listening to the recording every day (preferably at the beginning of the day to serve as a reminder to use mindfulness throughout the day) and to use mindfulness by letting go of thoughts and refocusing on the breath with their eyes open whenever they notice themselves ruminating during the day.
Dr. Hindman will be teaching mindfulness exercises as part of the CBT for Depression – Core 1 workshop at Beck Institute in March and the CBT for Anxiety workshop in Chicago in April.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504-511.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-Based Cognitive Therapy for depression. New York: Guilford Press.
Anxiety disorders are common in adolescents (ages 12 to 18) and contribute to a range of impairments. There has been speculation that adolescents with anxiety are at risk for being treatment nonresponders. In this review, the authors examine the efficacy of cognitive-behavioral therapy (CBT) for adolescents with anxiety. Outcomes from mixed child and adolescent samples and from adolescent-only samples indicate that approximately two-thirds of youths respond favorably to CBT. CBT produces moderate to large effects and shows superiority over control/comparison conditions. The literature does not support differential outcomes by age: adolescents do not consistently manifest poorer outcomes relative to children. Although extinction paradigms find prolonged fear extinction in adolescent samples, basic research does not fully align with the processes and goals of real-life exposure. Furthermore, CBT is flexible and allows for tailored application in adolescents, and it may be delivered in alternative formats (i.e., brief, computer/Internet, school-based, and transdiagnostic CBT).
Kendall, C. P. & Peterman, S. J. (2015). CBT for adolescents with anxiety: Mature yet still developing. The American Journal of Psychiatry, 172(6). pp. 519-530. http://dx.doi.org/10.1176/appi.ajp.2015.14081061
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