The leading text for students and practicing therapists who want to learn the fundamentals of cognitive behavior therapy (CBT), this book is eminently practical and authoritative. In a highly accessible, step-by-step style, master clinician Judith S. Beck demonstrates how to engage patients, develop a sound case conceptualization, plan treatment, and structure sessions effectively. Core cognitive, behavioral, and experiential techniques are explicated and strategies are presented for troubleshooting difficulties and preventing relapse. An extended case example and many vignettes and transcripts illustrate CBT in action. Reproducible clinical tools can be downloaded and printed in a convenient 8 1/2" x 11" size.
See also Dr. Beck's Cognitive Therapy for Challenging Problems: What to Do When the Basics Don't Work, which addresses ways to solve frequently encountered problems with patients who are not making progress.
New to This Edition*Reflects over 15 years of research advances and the author's ongoing experience as a clinician, teacher, and supervisor.*Chapters on the evaluation session and behavioral activation.*Increased emphasis on the therapeutic relationship, building on patients' strengths, and homework.*Now even more practical: features reproducibles and a sample case write-up.
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About the Author
Judith S. Beck, PhD, is President of the Beck Institute for Cognitive Behavior Therapy (www.beckinstitute.org), which provides state-of-the-art training in CBT and offers online courses on a variety of CBT topics, including Essentials of CBT: The Beck Approach. She is also Clinical Associate Professor of Psychology in Psychiatry at the University of Pennsylvania School of Medicine. She has written nearly 100 articles and chapters as well as several books for professionals and consumers; has made hundreds of presentations, nationally and internationally, on topics related to CBT; and is the codeveloper of the Beck Youth Inventories and the Personality Belief Questionnaire. Dr. Beck is a founding fellow and past president of the Academy of Cognitive Therapy.
Read an Excerpt
INTRODUCTION TO COGNITIVE BEHAVIOR THERAPY
A revolution in the field of mental health was initiated in the early 1960s by Aaron T. Beck, MD, then an assistant professor in psychiatry at the University of Pennsylvania. Dr. Beck was a fully trained and practicing psychoanalyst. A scientist at heart, he believed that in order for psychoanalysis to be accepted by the medical community, its theories needed to be demonstrated as empirically valid. In the late 1950s and early 1960s, he embarked on a series of experiments that he fully expected would produce such validation. Instead, the opposite occurred. The results of Dr. Beck's experiments led him to search for other explanations for depression. He identified distorted, negative cognition (primarily thoughts and beliefs) as a primary feature of depression and developed a short-term treatment, one of whose primary targets was the reality testing of patients' depressed thinking.
In this chapter, you will find the answers to the following questions:
What is cognitive behavior therapy?
How was it developed?
What does research tell us about its effectiveness?
What are its basic principles?
How can you become an effective cognitive behavior therapist?
WHAT IS COGNITIVE BEHAVIOR THERAPY?
Aaron Beck developed a form of psychotherapy in the early 1960s that he originally termed "cognitive therapy." "Cognitive therapy" is now used synonymously with "cognitive behavior therapy" by much of our field and it is this latter term that will be used throughout this volume. Beck devised a structured, short-term, present-oriented psychotherapy for depression, directed toward solving current problems and modifying dysfunctional (inaccurate and/or unhelpful) thinking and behavior (Beck, 1964). Since that time, he and others have successfully adapted this therapy to a surprisingly diverse set of populations with a wide range of disorders and problems. These adaptations have changed the focus, techniques, and length of treatment, but the theoretical assumptions themselves have remained constant. In all forms of cognitive behavior therapy that are derived from Beck's model, treatment is based on a cognitive formulation, the beliefs and behavioral strategies that characterize a specific disorder (Alford & Beck, 1997).
Treatment is also based on a conceptualization, or understanding, of individual patients (their specific beliefs and patterns of behavior). The therapist seeks in a variety of ways to produce cognitive change — modification in the patient's thinking and belief system — to bring about enduring emotional and behavioral change.
Beck drew on a number of different sources when he developed this form of psychotherapy, including early philosophers, such as Epicetus, and theorists, such as Karen Horney, Alfred Adler, George Kelly, Albert Ellis, Richard Lazarus, and Albert Bandura. Beck's work, in turn, has been expanded by current researchers and theorists, too numerous to recount here, in the United States and abroad.
There are a number of forms of cognitive behavior therapy that share characteristics of Beck's therapy, but whose conceptualizations and emphases in treatment vary to some degree. These include rational emotional behavior therapy (Ellis, 1962), dialectical behavior therapy (Linehan, 1993), problem-solving therapy (D'Zurilla & Nezu, 2006), acceptance and commitment therapy (Hayes, Follette, & Linehan, 2004), exposure therapy (Foa & Rothbaum, 1998), cognitive processing therapy (Resick & Schnicke, 1993), cognitive behavioral analysis system of psychotherapy (McCullough, 1999), behavioral activation (Lewinsohn, Sullivan, & Grosscup, 1980; Martell, Addis, & Jacobson, 2001), cognitive behavior modification (Meichenbaum, 1977), and others. Beck's cognitive behavior therapy often incorporates techniques from all these therapies, and other psychotherapies, within a cognitive framework. Historical overviews of the field provide a rich description of how the different streams of cognitive behavior therapy originated Introduction to Cognitive Behavior Therapy and grew (Arnkoff & Glass, 1992; A. Beck, 2005; Clark, Beck, & Alford, 1999; Dobson & Dozois, 2009; Hollon & Beck, 1993).
Cognitive behavior therapy has been adapted for patients with diverse levels of education and income as well as a variety of cultures and ages, from young children to older adults. It is now used in primary care and other medical offices, schools, vocational programs, and prisons, among other settings. It is used in group, couple, and family formats. While the treatment described in this book focuses on individual 45-minute sessions, treatment can be briefer. Some patients, such as those who suffer from schizophrenia, often cannot tolerate a full session, and some practitioners can use cognitive therapy techniques, without conducting a full therapy session, within a medical or rehabilitation appointment or medication check.
WHAT IS THE THEORY UNDER LYING COGNITIVE BEHAVIOR THERAPY?
In a nutshell, the cognitive model proposes that dysfunctional thinking (which influences the patient's mood and behavior) is common to all psychological disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they experience improvement in their emotional state and in their behavior. For example, if you were quite depressed and bounced some checks, you might have an automatic thought, an idea that just seemed to pop up in your mind: "I can't do anything right." This thought might then lead to a particular reaction: you might feel sad (emotion) and retreat to bed (behavior). If you then examined the validity of this idea, you might conclude that you had overgeneralized and that, in fact, you actually do many things well. Looking at your experience from this new perspective would probably make you feel better and lead to more functional behavior.
For lasting improvement in patients' mood and behavior, cognitive therapists work at a deeper level of cognition: patients' basic beliefs about themselves, their world, and other people. Modification of their underlying dysfunctional beliefs produces more enduring change. For example, if you continually underestimate your abilities, you might have an underlying belief of incompetence. Modifying this general belief (i.e., seeing yourself in a more realistic light as having both strengths and weaknesses) can alter your perception of specific situations that you encounter daily. You will no longer have as many thoughts with the theme, "I can't do anything right." Instead, in specific situations where you make mistakes, you will probably think, "I'm not good at this [specific task]."
WHAT DOES THE RESEARCH SAY?
Cognitive behavior therapy has been extensively tested since the first outcome study was published in 1977 (Rush, Beck, Kovacs, & Hollon, 1977). At this point, more than 500 outcome studies have demonstrated the efficacy of cognitive behavior therapy for a wide range of psychiatric disorders, psychological problems, and medical problems with psychological components (see, e.g., Butler, Chapman, Forman, & Beck, 2005; Chambless & Ollendick, 2001). Table 1.1 lists many of the disorders and problems that have been successfully treated with cognitive behavior therapy. A more complete list may be found at www.beckinstitute.org.
Studies have been conducted that demonstrate the effectiveness of cognitive behavior therapy in community settings (see, e.g., Shadish, Matt, Navarro & Philips, 2000; Simons et al., 2010; Stirman, Buchhofer, McLaulin, Evans, & Beck, 2009). Other studies have found computerassisted cognitive behavior therapy to be effective (see, e.g., Khanna & Kendall, 2010; Wright et al., 2002). And several researchers have demonstrated that there are neurobiological changes associated with cognitive behavior therapy treatment for various disorders (see, e.g., Goldapple et al., 2004). Hundreds of research studies have also validated the cognitive model of depression and of anxiety. A comprehensive review of these studies can be found in Clark and colleagues (1999) and in Clark and Beck (2010).
HOW WAS BEC K'S COGNITIVE BEHAVIOR THERAPY DEVELOPED?
In the late 1950s and early 1960s, Dr. Beck decided to test the psychoanalytic concept that depression is the result of hostility turned inward toward the self. He investigated the dreams of depressed patients, which, he predicted, would manifest greater themes of hostility than the dreams of normal controls. To his surprise, he ultimately found that the dreams of depressed patients contained fewer themes of hostility and far greater themes of defectiveness, deprivation, and loss. He recognized that these themes paralleled his patients' thinking when they were awake. The results of other studies Beck conducted led him to believe that a related psychoanalytic idea — that depressed patients have a need to suffer — might be inaccurate (Beck, 1967). At that point, it was almost as if a stacked row of dominoes began to fall. If these psychoanalytic concepts were not valid, how else could depression be understood?
As Dr. Beck listened to his patients on the couch, he realized that they occasionally reported two streams of thinking: a free-association stream and quick, evaluative thoughts about themselves. One woman, for example, detailed her sexual exploits. She then reported feeling anxious. Dr. Beck made an interpretation: "You thought I was criticizing you." The patient disagreed: "No, I was afraid I was boring you." Upon questioning his other depressed patients, Dr. Beck recognized that all of them experienced "automatic" negative thoughts such as these, and that this second stream of thoughts was closely tied to their emotions. He began to help his patients identify, evaluate, and respond to their unrealistic and maladaptive thinking. When he did so, they rapidly improved.
Dr. Beck then began to teach his psychiatric residents at the University of Pennsylvania to use this form of treatment. They, too, found that their patients responded well. The chief resident, A. John Rush, MD, now a leading authority in the field of depression, discussed conducting an outcome trial with Dr. Beck. They agreed that such a study was necessary to demonstrate the efficacy of cognitive therapy to others. Their randomized controlled study of depressed patients, published in 1977, established that cognitive therapy was as effective as imipramine, a common antidepressant. This was an astounding study. It was one of the first times that a talk therapy had been compared to a medication. Beck, Rush, Shaw, and Emery (1979) published the first cognitive therapy treatment manual 2 years later.
Important components of cognitive behavior therapy for depression include a focus on helping patients solve problems; become behaviorally activated; and identify, evaluate, and respond to their depressed thinking, especially to negative thoughts about themselves, their worlds, and their future. In the late 1970s Dr. Beck and his post-doctoral fellows at the University of Pennsylvania began to study anxiety, and found that a somewhat different focus was necessary. Patients with anxiety needed to better assess the risk of situations they feared, to consider their internal and external resources, and improve upon their resources. They also needed to decrease their avoidance and confront situations they feared so they could test their negative predictions behaviorally. Since that time, the cognitive model of anxiety has been refined for each of the various anxiety disorders, cognitive psychology has verified these models, and outcome studies have demonstrated the efficacy of cognitive behavior therapy for anxiety disorders (Clark & Beck, 2010).
Fast-forward several decades. Dr. Beck, his fellows, and other researchers worldwide continue to study, theorize, adapt, and test treatments for patients who suffer from an ever-growing list of problems. Cognitive therapy or cognitive behavior therapy is now taught in most graduate schools in the United States and in many other countries.
WHAT ARE THE BASIC PRINCIPLES OF TREATMENT?
Although therapy must be tailored to the individual, there are, nevertheless, certain principles that underlie cognitive behavior therapy for all patients. Throughout the book, I use a depressed patient, Sally, to illustrate these central tenets and to demonstrate how to use cognitive theory to understand patients' difficulties and how to use this understanding to plan treatment and conduct therapy sessions. Sally is a nearly ideal patient and allows me to present cognitive behavior therapy in a straightforward manner. I make some note of how to vary treatment for patients who do not respond as well as she, but the reader must look elsewhere (e.g., J. S. Beck, 2005; Kuyken, Padesky & Dudley, 2009; Needleman, 1999) to learn how to conceptualize, strategize, and implement techniques for patients with diagnoses other than depression or for patients whose problems pose a challenge in treatment.
"Sally" was an 18-year-old single female when she sought treatment with me during her second semester of college. She had been feeling quite depressed and anxious for the previous 4 months and was having difficulty with her daily activities. She met criteria for a major depressive episode of moderate severity according to DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; American Psychiatric Association, 2000). A fuller portrait of Sally is provided in Appendix A.
The basic principles of cognitive behavior therapy are as follows:
Principle No. 1. Cognitive behavior therapy is based on an ever-evolving formulation of patients' problems and an individual conceptualization of each patient in cognitive terms. I consider Sally's difficulties in three time frames. From the beginning, I identify her current thinking that contributes to her feelings of sadness ("I'm a failure, I can't do anything right, I'll never be happy"), and her problematic behaviors (isolating herself, spending a great deal of unproductive time in her room, avoiding asking for help). These problematic behaviors both flow from and in turn reinforce Sally's dysfunctional thinking. Second, I identify precipitating factors that influenced Sally's perceptions at the onset of her depression (e.g., being away from home for the first time and struggling in her studies contributed to her belief that she was incompetent). Third, I hypothesize about key developmental events and her enduring patterns of interpreting these events that may have predisposed her to depression (e.g., Sally has had a lifelong tendency to attribute personal strengths and achievement to luck, but views her weaknesses as a reflection of her "true" self).
I base my conceptualization of Sally on the cognitive formulation of depression and on the data Sally provides at the evaluation session. I continue to refine this conceptualization at each session as I obtain more data. At strategic points, I share the conceptualization with Sally to ensure that it "rings true" to her. Moreover, throughout therapy I help Sally view her experience through the cognitive model. She learns, for example, to identify the thoughts associated with her distressing affect and to evaluate and formulate more adaptive responses to her thinking. Doing so improves how she feels and often leads to her behaving in a more functional way.
Principle No. 2. Cognitive behavior therapy requires a sound therapeutic alliance. Sally, like many patients with uncomplicated depression and anxiety disorders, has little difficulty trusting and working with me. I strive to demonstrate all the basic ingredients necessary in a counseling situation: warmth, empathy, caring, genuine regard, and competence.
I show my regard for Sally by making empathic statements, listening closely and carefully, and accurately summarizing her thoughts and feelings. I point out her small and larger successes and maintain a realistically optimistic and upbeat outlook. I also ask Sally for feedback at the end of each session to ensure that she feels understood and positive about the session. See Chapter 2 for a lengthier description of the therapeutic relationship in cognitive behavior therapy.
Principle No. 3. Cognitive behavior therapy emphasizes collaboration and active participation. I encourage Sally to view therapy as teamwork; together we decide what to work on each session, how often we should meet, and what Sally can do between sessions for therapy homework. At first, I am more active in suggesting a direction for therapy sessions and in summarizing what we've discussed during a session. As Sally becomes less depressed and more socialized into treatment, I encourage her to become increasingly active in the therapy session: deciding which problems to talk about, identifying the distortions in her thinking, summarizing important points, and devising homework assignments.(Continues…)
Excerpted from "Cognitive Behavior Therapy"
Copyright © 2011 Judith S. Beck.
Excerpted by permission of The Guilford Press.
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Table of Contents
Foreword, Aaron T. Beck1. Introduction to Cognitive Therapy 2. Overview of Treatment 3. Cognitive Conceptualization 4. The Evaluation Session 5. Structure of the First Therapy Session 6. Behavioral Activation 7. Session 2 and Beyond: Structure and Format 8. Problems with Structuring the Therapy Session 9. Identifying Automatic Thoughts 10. Identifying Emotions 11. Evaluating Automatic Thoughts 12. Responding to Automatic Thoughts 13. Identifying and Modifying Intermediate Beliefs 14. Identifying and Modifying Core Beliefs 15. Additional Cognitive and Behavioral Techniques 16. Imagery 17. Homework 18. Termination and Relapse Prevention 19. Treatment Planning 20. Problems in Therapy 21. Progressing as a Cognitive Therapist Appendices Appendix A. Cognitive Case Write-Up Appendix B. Cognitive Behavior Therapy Resources Appendix C. Cognitive Therapy Rating Scale
Clinicians and graduate students in all of the mental health disciplines, including clinical psychology, social work, psychiatry, and counseling. Serves as a text in graduate-level CBT and psychotherapy courses.
Most Helpful Customer Reviews
Very good book, refresher for CBT. Easy to read.
I found this book to be helpful and informative with regards to Cognitive Behavior Therapy. Any one who is going into the counseling field will want to read this book.