Features

Changing distorted thinking

David Kaplan July 12, 2011

Judith S. Beck, president of the famous Beck Institute for Cognitive Therapy and Research, was a keynote speaker at the 2011 American Counseling Association Annual Conference in New Orleans this past March. ACA Chief Professional Officer David Kaplan recently followed up with Beck to discuss current aspects of cognitive behavior therapy.

David Kaplan: Thank you for being a keynote speaker at the ACA Conference in New Orleans. What was it like to be on stage looking at 4,000 professional counselors?

Judith Beck: It was wonderful because it was one of the first opportunities I’ve had to address so many counselors at once. We’ve always had counselors who have come to the Beck Institute for our training programs, but they’ve been part of a larger group. I think many counselors have a much harder job than I do, so it was wonderful to speak to those in the trenches who are making a difference every single day.

DK: During your keynote, you used two labels for your approach: cognitive therapy and cognitive behavior therapy. Are these terms interchangeable?

JB: They used to be different. Originally, cognitive therapy referred to the specific kind of psychotherapy that my father, Aaron Beck, developed in the early 1960s, and cognitive behavior therapy was more of an umbrella term that originally referred to integrating cognitions into behavior therapy. But now they’re becoming more and more interchangeable. ACA members might be interested in the fact that we are changing our name from the Beck Institute for Cognitive Therapy to the Beck Institute for Cognitive Behavior Therapy because people now seem more familiar with the term CBT.

DK: During your keynote, you emphasized that cognitive therapy focuses on more than just cognitions. Why do you think the prevailing wisdom says that cognitive therapy is only about cognitions?

JB: I think it’s just a misunderstanding about what cognitive therapy is. It’s true that an important part of treatment is helping people change their distorted or dysfunctional thinking. But the whole reason we want them to do that is to bring about a lasting impact on their mood and behavior. We don’t want to change cognition just for cognition’s sake. It’s all in the service of helping people feel better and move toward their goals. And I’d like to add that cognitive therapy requires the same good, basic counseling skills to develop a strong therapeutic alliance as any other kind of psychotherapy.

DK: It was really interesting to hear you talk about all the additional things that you attend to in addition to cognitions, even going so far as talking about psychodrama.

JB: That’s right. An intellectual focus is not enough for some people, and they need more experiential exercises or activities in session and between sessions to change their cognitions at the gut level. One way to do this is through using methods such as imagery and psychodrama, which seem to tap into a different part of the mind than simply the intellectual part.

DK: You focused on personality disorders during your talk, and I think ACA members would be interested in knowing how you got interested in Axis II diagnoses.

JB: From the very beginning, some of my clients with common presenting problems such as depression and anxiety didn’t seem to make enough progress with standard cognitive therapy treatment. As it turned out, it was often because they had some significant personality pathology that I wasn’t attending to. When I was able to understand their underlying beliefs, treatment went much more smoothly.

I find that many Axis II clients hold beliefs in one or more of four areas. The first area has to do with engaging in treatment, such as, “If I engage in treatment, I’ll have to make myself vulnerable to my therapist. I’ll have to acknowledge that I have problems, and I’ll have to change. If I listen to my therapist, it will mean that she’s strong and I’m weak.”

Another area involves beliefs about negative emotion. “If I start to feel badly, I’ll start crying and I won’t be able to stop. I’ll lose control. I’ll end up in the hospital.”

A third area is about problem solving. “If I even try to solve my problems, I won’t be able to. I’ll just fail, so what’s the use of even trying?”

A fourth area has to do with getting better. “If I get better, something bad will happen. I’ll lose my therapist. I’ll have to go back to work. People will have higher expectations of me. I’ll have to face the fact that I’m in a bad relationship.”

DK: Changing the topic from psychopathology and personality disorders to a more developmental focus, many ACA members are school counselors. I know CBT is as applicable in schools as it is in any other setting and thought you might want to speak to that.

JB: Sure. In fact, my father and his colleagues have just published a new book, Cognitive Therapy for Adolescents in School Settings. A number of research studies have demonstrated that CBT is effective in working with children and adolescents. One study, for example, showed that when you give CBT in a group format in schools to kids at risk for depression, they’re less likely to develop depression.

CBT is also relevant for working with teachers. Teachers often have certain ideas that lead to burnout or to less than optimal relationships with their students. Cognitive therapy can be helpful in identifying and changing these maladaptive ideas.

DK: What are some of the common cognitions that you see associated with teacher burnout?

JB: It’s similar to professional burnout in general and related to putting unrealistic demands on themselves: “I should be able to help every child. I should do a perfect job [and] never make mistakes with my students. If I show any weakness to my colleagues or the administration, then they’ll think very badly of me.”

DK: What cognitions might teachers have about students that interfere with their performance?

JB: Sometimes, teachers not only have unrealistic expectations of themselves, but they also have unrealistic expectations for their students: “Students should always do their best. They should appreciate what I do. They should listen to me. They should never give me a hard time.”

DK: What specific cognitions have you seen in students that impair or affect their school performance, grades and attendance?

JB: Some students are highly sensitive to control. They have the idea, “It’s terrible if anyone tries to control me.” It’s all-or-nothing thinking. We see it show up in therapy, and it can show up in classrooms: “If I do what the teacher tells me to do, it means that she’s in control and I’m weak, and that’s intolerable to me.” The student may then develop conduct problems. Of course, we see lots of kids with anxiety, too. “I have to do a perfect job. What if the teacher evaluates me negatively? What if my peers evaluate me negatively?”

DK: It certainly seems like school counselors could benefit from training at the Beck Institute.

JB: We’ve had quite a number who’ve gone through one of our programs. We’re actually having a special workshop on CBT for children and adolescents in October 2011 and another in 2012.

DK: How do you see CBT being relevant for diversity and multicultural populations?

JB: A number of studies have shown that CBT is effective with different cultures. Sometimes, the therapist has to vary the relationship or adapt some techniques, but the basic conceptualization stays the same. When counselors are unfamiliar with a particular culture, it’s important that they find out whether maladaptive ideas are idiosyncratic to the individual or whether they actually represent a belief of the culture.

For example, in the Chinese culture, there is a belief that it’s very important to always show the utmost respect to one’s parents and not do anything that would make the parents unhappy. A counselor who is unfamiliar working with the Asian culture might not recognize that at first and be surprised to find the belief pretty intractable. Understanding that it’s also a cultural belief is helpful.

DK: In that situation, how do you help Chinese clients deal with that cognition, when to stop pleasing their parents might cause their parents to get upset because of a violation of cultural norms?

JB: We have to look for evidence in a specific case that the feared outcome is likely to happen, and if it did happen, how the client could cope. We might see whether the client is having all-or-nothing thinking about the situation. We might talk about whether some other people in the same culture might have a more moderate idea. We might examine the advantages and disadvantages of upsetting parents. Ultimately, one individual might be willing to do a behavioral experiment to see what happens, but another individual might make the decision, “I’m not going to upset my parents. Let’s see how else I can reach my goal.”

DK: So you find that the concept of faulty cognitions applies to virtually any culture?

JB: We suspect it might. That’s what research is showing so far.

DK: During your keynote, you emphasized recording with clients and talked about the research that shows 40 percent of what physicians say to their clients goes in one ear and out the other.

JB: Forty to 70 [percent], actually.

DK: I thought it might be interesting to hear a little bit more about that and how you think that applies to counselors.

JB: Anything we want a client to remember is recorded in some way. Either we take notes for clients, have them take notes, or we have them make a short recording that they can listen to every day. What is contained in these notes, whether they’re verbal or written, are the most important things for the client to remember.

As an example, let’s say a depressed woman has isolated herself. We’ve talked about her automatic thought: “My friends don’t want to spend any time with me.” When we evaluate that thought, it turns out that there’s very little evidence that it’s accurate, and there seems to be another, more realistic explanation: that her friends are very busy and she actually has not — because she’s been so depressed — reached out to them at all. The client gains this new understanding in the session and she feels better.

Now we want her to remember it during the week so that she’ll be willing to go ahead and call her friends. We might ask, “What do you think would be important to remember this week from what we just discussed?” If she comes up with a good summary, we’ll say, “That sounds important. How about we record that?”

DK: Do you use any particular guidelines for how often clients should listen to the recording or read therapy notes?

JB: We try to get people to do it daily. We want them to look at these changes in thinking every single day. Otherwise, you can have a wonderful session and the client can really have changed her thinking and feel better … but by the next day, she has forgotten everything.

She’s also probably been having these negative thoughts for quite a long time, so it’s very important for her to be rehearsing these new ideas on a daily basis. One of the things we tell people is that it’s not enough just to come to therapy and talk. You’re going to learn things in therapy: new ways of thinking and new ways of behaving that you’re going to practice every day. That’s how people get better — by making small changes in their thinking and behavior every day.

DK: Another really interesting thing you said during your talk was, “We want clients to become their own therapists.”

JB: That’s right. Not only do we want to help clients change their thinking, we want to teach them how to do it themselves. We aim to be as short term as we can. That’s another reason to send them home with notes or recordings that they can refer to a year from now or five years from now.

DK: Switching gears, you talked during the keynote about CBT and weight loss. Do you see this as an area counselors can get into?

JB: I think it’s a really great area for counselors.

DK: What would the keys be for counselors in helping people who are overweight to lose weight?

JB: As I described in several self-help books on dieting and maintenance, dieters need an emphasis on changing their cognitions, such as “It’s bad to be hungry.” “It’s unfair that I have to restrict my eating.” “It’s OK to eat this food I hadn’t planned to eat because I’m tired/I’m stressed/it’s free/no one is watching.” “I cheated. Oh well, I might as well eat whatever I want for the rest of the day and start again tomorrow.”

To make permanent changes in their eating, people need to change their thinking. Counselors need to anticipate dieters’ dysfunctional thinking and help them practice adaptive cognitions so they can maintain functional eating habits for the rest of their lives.

DK: What is a typical day like at the Beck Institute?

JB: We are primarily a training institute. We have a clinical practice, but we spend much of our time planning workshops on a variety of topics onsite in Philadelphia or sending speakers to organizations worldwide. We are developing an online program, and we’ve gotten very involved in social media through Facebook and Twitter and blogging.

We also have a supervision program. Mental health professionals send us an audiotape or, if they’re doing therapy in another language in another country, a translated transcript every week or two and then receive supervision either by phone or e-mail. We get therapists from all over the country and all over the world: Europe, the Middle East, Asia, Africa, Australia, South America — every continent but one.

DK: If ACA members want to find out more about how they could get involved in training at the Beck Institute, how would they do that?

JB: We would be very pleased for them to visit our website at beckinstitute.org and, if they want, to sign up for a complimentary quarterly e-newsletter.

David Kaplan is ACA’s chief professional officer. Contact him at dkaplan@counseling.org.

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