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July 8, 2015

Judith S. Beck, PhD, President

Beck Institute for Cognitive Behavior TherapyBeck0135

When a client poses a challenge in Cognitive Behavior Therapy (CBT), it is important to conceptualize why the problem has arisen. Is it a practical problem? Is it related to the client's dysfunctional beliefs? Is it related to the therapist's dysfunctional beliefs? In this article, I'll describe two difficulties that were practical in nature. Future articles will focus on client and therapist cognitions.
  Amy, a thirtyish woman, is a single mom with significant legal, financial, and parenting problems. When her therapist attempted to have her describe her financial problem (which Amy had indicated was the most important agenda item), Amy almost immediately burst into tears and sobbed uncontrollably. She was unable to identify her upsetting automatic thoughts, much less focus on what to do about her large credit card bills and the hounding phone calls from bill collectors. The therapist conceptualized that he should first try solving the practical problem of Amy's high degree of emotionality, and suggested a change of topic. "Amy, I'm sorry this is so upsetting to you." [pause] "Would it be okay if we talked about something else for a few minutes?" When Amy nods, her therapist asks a question which he thinks could brighten her mood. "Did Crystal [her 5 year old daughter] draw any pictures for you lately? Or bring home any art projects from school?" Jeremy, an electrician in his mid-fifties, has a tendency to jump from topic to topic in therapy. In a recent session, he began describing a problem with his neighbor-then continually switched his focus. "You know, it's the same kind of thing my brother has been doing to me for years. Just last week, he accused me of not spending enough time with Mom. And she's a whole other problem. She's been calling me and calling me. It's driving me crazy. I don't know how I'm going to keep my job. My boss said if I keep talking on my cell phone during work, he's going to fire me. He's such an unreasonable bastard to begin with. He's always making these threats. But if I lose my job..." It was essential for the therapist to help Jeremy refocus. "Jeremy, can I interrupt for a moment? I want to make sure we talk about what's most important to you first. Is it your neighbor, your brother, your mom, your boss? Or is it losing your job?" In the first example, getting Amy to talk about a more uplifting subject settled her down enough to allow her to do some problem-solving about her finances. And in the second example, every time his therapist interrupted him and structured the discussion, Jeremy was able to focus on one problem. Practical solutions such as these, however, may be essential but not sufficient for clients whose cognitions are associated with unhelpful behaviors in session. On the other hand, the problems may look like practical ones, but these strategies may be irrelevant if underlying beliefs are involved. Stay tuned...  Register for the Beck Institute E-Newsletter here and receive our bi-weekly newsletters directly to your inbox.