Beck Therapy Approach

Judith S. Beck

Beck Institute for Cognitive Therapy and Research, University of Pennsylvania

I. Description of Treatment II. Theoretical Basis III. Efficacy IV Summary

Further Reading

GLOSSARY

automatic thought An idea that seems to arise in one's mind spontaneously, in verbal or imaginal from.

belief One's basic understandings of oneself, one's world, and other people.

cognition A thought, image, rule, attitude, assumption, or belief.

cognitive distortion A type of thinking error.

schema A relatively stable and enduring mental structure that exerts a significant influence over one's processing of information.

Cognitive therapy is a system of psychotherapy, based on a comprehensive theory of psychopathology and personality. Its theoretical underpinnings have been empirically supported, and the therapy itself has been demonstrated to be effective in over 325 outcome studies for a wide range of psychiatric disorders. Treatment is based on specific cognitive formulations of each disorder and on the individual cognitive conceptualization of each patient. Cognitive therapy tends to be time limited, problem solving oriented, and structured. Both patient and therapist are quite active. The treatment emphasizes having patients learn to identify and modify their distorted or dysfunctional thoughts and beliefs and to change their dysfunctional behavior. In doing so, patients' mood, symptoms, functioning, and relationships improve.

I. DESCRIPTION OF TREATMENT

Cognitive therapy is based on the cognitive model that describes the relationship between people's perceptions and interpretations of situations and their reactions (emotional, behavioral, and physiological). When people are in distress, their thinking is often characterized by faulty information processing; their perceptions are often invalid, or not completely valid. For example, a depressed woman makes only two mistakes when word processing a long document at work and thinks, "I can't do anything right." This thought is called an "automatic thought," because it seems to pop up spontaneously in her mind. Before therapy, she may have been only vaguely aware of these kinds of thoughts, if at all. She may have been much more cognizant of her reaction: her affect (sadness), her dysfunctional behavior (leaving work early), and/or her physiological response (heaviness in her body).

In therapy, patients learn to cue themselves when they notice their negative reactions so they can identify their automatic thoughts. Then they learn techniques of evaluating the validity and utility of their thoughts. When they correct their distorted thinking, they have a more positive reaction: their affect lifts, their behavior becomes more functional, they have an improved physiological response. Much of the therapy is organized around helping patients directly change their thinking and behavior and solve problems.

Treatment varies somewhat from disorder to disorder and patient to patient, though there are several basic principles described elsewhere by the author.

1. Cognitive therapy is based on an ever-evolving formulation of patients and their problems according to a cognitive framework.

2. Cognitive therapy requires a sound therapeutic alliance.

3. Cognitive therapy emphasizes collaboration and active participation..

4. Cognitive therapy is goal oriented and initially focuses on current problems.

5. Cognitive therapy is educative and emphasizes relapse prevention.

6. Cognitive therapy aims to be time limited.

7. Cognitive therapy sessions are structured.

8. Cognitive therapy teaches patients to identify, evaluate, and respond to dysfunctional thoughts and beliefs.

9. Cognitive therapy uses a variety of techniques to modify thinking, mood, and behavior.

These principles are described below.

Cognitive therapists conceptualize patients in cognitive terms, that is, they seek to understand how patients' beliefs give rise to specific thoughts in current situations and influence their reactions. When patients have longstanding personality problems, therapists also seek to understand how patients have historically interpreted events, often since childhood, and how these interpretations have influenced (and still influence) their ideas about themselves, their worlds, and others.

Therapists also identify the maladaptive behavioral "coping" strategies patients develop to get along in the world. For example, a therapist hypothesized that because of genetic predisposition and early abuse, Beth developed the belief that she was bad and defective. Fearful that others would view her negatively, she developed the coping strategy of always putting on a good face. Otherwise, she believed, people would see her "real" self and reject her.

Treatment is based on an ever-evolving conceptualization as therapists collect additional data to confirm, disconfirm, or modify their hypotheses. A Cognitive Conceptualization Diagram (Figure 1) aids therapists in concretely formulating their conceptualization. Therapists check out their conceptualization with patients to ensure they are on the right track.

A strong therapeutic alliance is an essential part of cognitive therapy. Therapists build the alliance by working collaboratively with the patient as a "team," demonstrating care, concern, and competence; providing rationales before using various strategies; summarizing patients' narratives to ensure accurate understanding; checking hypotheses and formulations with patients; solving problems; eliciting feedback at the end of sessions (and during sessions, if they infer a negative reaction); and helping patients quickly to reduce symptoms.

It is often more difficult to establish a strong therapeutic alliance with patients who have dysfunctional relationships outside of therapy. They often bring dysfunctional beliefs about themselves and other people to the therapy relationship (e.g., "If I trust other people, I'll get hurt."). When such a belief interferes with a "standard" approach, therapists help patients elicit, test, and respond to patients' distorted ideas about the therapist and about therapy.

Therapists as well as patients are quite active during the therapy session. Therapists continually engage in Socratic questioning, as they ask patients open-ended questions to collect data, elicit key thoughts, uncover the meaning of their thoughts, identify beliefs, test the evolving conceptualization, and evaluate thoughts and beliefs. Collaboration is an important principle of cognitive therapy: therapist and patient work together to identify and understand the patient's problems and perspectives. They collaborate in setting goals, defining and solving current problems, and devising tests to assess the accuracy of their thinking.

Initially the focus is on the present, helping patients identify and modify their thinking about distressing situations, solving problems, and changing behavior. Toward the middle of therapy, there is an additional emphasis on modifying maladaptive beliefs. In the final stage of therapy, relapse prevention strategies are emphasized. In actuality, therapists use relapse prevention strategies from the beginning of therapy, as they not only help patients change their thinking and behavior but also instruct patients in how to do so themselves. An important goal of therapy is to teach patients to become their own therapists.

Cognitive therapy is generally a relatively brief form of psychotherapy. Most straight-forward depressed and anxious patients achieve remission with six to twelve sessions of therapy (weekly at first, then spaced further

COGNITIVE CONCEPTUALIZATION DIAGRAM

Patient's name: Sally_Date: 2/22

Diagnosis: Axis I Major depressive episode_Axis II_ None

Relevant Childhood Data

Compared self with older brother and peers Critical mother

Core Belief(s)

Fm inadequate.

Conditional Assumptions/Beliefs/Rules

Conditional Assumptions/Beliefs/Rules

(positive) If I work very hard, I can do okay, (negative) If I don't do great, then I've failed.

(positive) If I work very hard, I can do okay, (negative) If I don't do great, then I've failed.

Cognitive Conceptualization Diagram
FIGURE 1 Cognitive Conceptualization Diagram. From Judith Beck, Cognitive Therapy: Basics and Beyond. © Judith S. Beck, 1993. Reprinted with permission of Guilford Press.

apart). Patients with more complex disorders, comor-bid diagnoses, severe or chronic symptoms, or personality pathology may require (sometimes significantly) longer treatment.

Cognitive therapy sessions generally follow a certain structure. At the beginning therapists obtain an objective and subjective account of patients' symptoms, general mood, progress, and behavior in the past week.

They jointly set an initial agenda; patients are asked to label the most important problem(s) they want to work on during the session. They make a "bridge" from the previous session, asking patients to recall important conclusions from the previous session, significant events during the past week, and what they gained or learned from the self-help assignments ("homework") they did. They also ask patients whether they predict any special problems will arise in the coming week.

This additional data often leads to additional agenda items. The agenda is collaboratively prioritized. The session is then organized around the problems on the agenda. Patients and therapists collaboratively decide which problem to focus on first. In the context of discussing a problem, therapists gather data to refine their conceptualization and teach patients skills, such as identifying and critically evaluating their distorted thinking and using behavioral and problem-solving techniques. Homework assignments are also generated by the discussion.

Before moving on to another problem, therapists ask patients to summarize their conclusions from the discussion and ensure that they are likely to do the agreed-on assignments. At the end of each session, patients summarize the most important points of the session, and therapists elicit their feedback about the session.

Cognitive therapists use many different types of techniques to modify patients' thinking, mood and behavior, including

• Cognitive: identifying, evaluating, and modifying thoughts, images, and beliefs

• Behavioral: activity monitoring and scheduling, skills training, graded tasks, distraction, exposure, response prevention

• Problem solving: specifying problems, responding to automatic thoughts and beliefs that interfere with problem solving, brainstorming and choosing solutions, implementing solutions and evaluating outcomes

• Emotional: regulation of affect through engaging in self-soothing activities, relaxation, controlled breathing, distraction, seeking support, reading therapy notes

• Physiological: medication (if indicated), exercise, reducing caffeine and other drugs, focusing externally instead of internally

• Interpersonal: correcting faulty beliefs, learning communication, assertiveness and other social skills, solving interpersonal problems (bringing family members or significant others into therapy, if indicated)

• Environmental: weighing advantages and disadvantages of making changes in living or work environments (if indicated), responding to thoughts that interfere with making needed changes

• Supportive: demonstrating empathy, regard, caring, acceptance, and accurate understanding of patients' internal reality through verbal and non-verbal responses

• Experiential: roleplaying; using imaginal techniques to respond to automatic thoughts in the form of images; inducing images to heighten affect (to uncover key cognitions) or to reduce affect; restructuring the meaning of traumatic events through the re-experience of key memories in imaginal from in the presence of heightened affect, then using guided imagery and/or psychodrama techniques

• Psychodynamic-like: helping patients identify and evaluate automatic thoughts that arise and dysfunctional beliefs that become activated during the therapy session, particularly dysfunctional ideas about the therapist or therapy, then guiding them to generalize what they learned to relationships outside of therapy; drawing connections between beliefs (learned earlier in life and maintained throughout the patient's life) and his/her interpretations and reactions to current situations

These techniques, whether they are specifically cognitive in nature or not, result in cognitive change. Much of the therapeutic work in cognitive therapy, however, is devoted toward directly identifying and modifying inaccurate or dysfunctional thoughts and assumptions. Therapists often use a worksheet, the Dysfunctional Thought Record (DTR) to help patients record and respond to their thoughts and assumptions in a structured way (Table 1).

Although DTRs are used with many patients, they generally are adapted for (or discussed verbally with) patients who might not be able to grasp them fully. Patients are encouraged to use questions such as the following to help them evaluate and devise alternative responses to their dysfunctional thinking:

• What is the evidence that my automatic thought is true? What is the evidence on the other side, that my automatic thought might not be true, or not completely true?

• What is an alternative explanation or an alternative viewpoint?

• What is the worst that could reasonably happen and how would I cope? What is the best that could happen? What is the most realistic outcome?

TABLE 1

Dysfunctional Thought Record

Directions: When you notice your mood getting worse, ask yourself, "What's going through my mind right now?" and as soon as possible jot down the thought or mental image in the Automatic Thought Column.

Date/time

Situation

Automatic thought (s)

Emotion(s)

Adaptive response

Outcome

1. What actual event or stream of thoughts, or daydreams or recollection led to the unpleasant emotion?

2. What (if any) distressing physical sensations did you have?

1. What thought(s) and/or image(s) went through your mind?

2. How much did you believe each one at the time?

1. What emotion(s) (sad/anxious/ angry/etc.) did you feel at the time?

2. How intense (0-100%) was the emotion?

1. (optional) What cognitive distortion did you make?

2. Use questions at bottom to compose a response to the automatic thought(s).

3. How much do you believe each response?

1. How much do you now believe each automatic thought?

2. What emotion(s) do you feel now? How intense (0-100%) is the emotion?

3. What will you do (or did you do)?

Friday, 2/23 10 A.M.

Talking on the phone with Donna.

She must not like me any more. 90%

Sad 80%

Tuesday, 212 7 12 PM.

Studying for my exam.

I'll never learn this. 100%

Sad 95%

Thursday, 2/29 5 P.M.

Thinking about my economics class tomorrow.

Noticing my heart beatingfast and my trouble concentrating.

I might get called on and I won't give a good answer. 80%

What's wrong with me?

Anxious 80% Anxious 80%

Questions to help compose an alternative response: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) What's the worst that could happen? What could I do to cope? What's the best that could happen? What's the most realistic outcome? (4) What's the effect of my believing the automatic thought? What could be the effect of changing my thinking? (5) What should I do about it? (6) If (friend's name) was in the situation and had this thought, what would I tell him or her? From Judith Beck Cognitive Therapy: Basics and Beyond. ©Judith S. Beck, 1995. Reprinted with permission of Guilford Press.

Questions to help compose an alternative response: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) What's the worst that could happen? What could I do to cope? What's the best that could happen? What's the most realistic outcome? (4) What's the effect of my believing the automatic thought? What could be the effect of changing my thinking? (5) What should I do about it? (6) If (friend's name) was in the situation and had this thought, what would I tell him or her? From Judith Beck Cognitive Therapy: Basics and Beyond. ©Judith S. Beck, 1995. Reprinted with permission of Guilford Press.

TABLE 2 Typical Thinking Errors

Cognitive distortions

1. All-or-nothing thinking (also called black-and-white, polarized, or dichotomous thinking): You view a situation in only two categories instead of on a continuum.

Example: "If I'm not a total success, I'm a failure."

2. Catastrophizing (also called fortune telling): You predict the future negatively without considering other, more likely outcomes. Example: "I'll be so upset, I won't be able to function at all."

3. Disqualifying or discounting the positive: You unreasonably tell yourself that positive experiences, deeds, or qualities do not count. Example: "I did that project well, but that doesn't mean I'm competent; I just got lucky."

4. Emotional reasoning: You think something must be true because you "feel" (actually believe) it so strongly, ignoring or discounting evidence to the contrary.

Example: "I know I do a lot of things okay at work, but I still feel like I'm a failure."

5. Labeling: You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

Example: "I'm a loser." "He's no good."

6. Magnification/minimization: When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive.

Example: "Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn't mean I'm smart."

7. Mental filter (also called selective abstraction): You pay undue attention to one negative detail instead of seeing the whole picture. Example: "Because I got one low rating on my evaluation [which also contained several high ratings] it means I'm doing a lousy job."

8. Mind reading: You believe you know what others are thinking, failing to consider other, more likely possibilities. Example: "He's thinking that I don't know the first thing about this project."

9. Overgeneralization: You make a sweeping negative conclusion that goes far beyond the current situation. Example: "[Because I felt uncomfortable at the meeting] I don't have what it takes to make friends."

10. Personalization: You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior.

Example: "The repairman was curt to me because I did something wrong."

11. "Should" and "must" statements (also called imperatives): You have a precise, fixed idea of how you or others should behave, and you overestimate how bad it is that these expectations are not met.

Example: "It's terrible that I made a mistake. I should always do my best."

12. Tunnel vision: You only see the negative aspects of a situation.

Example: "My son's teacher can't do anything right. He's critical and insensitive and lousy at teaching."

From Judith Beck, Cognitive Therapy: Basics and Beyond. Adapted with permission from Aaron T. Beck. Reprinted with permission of Guilford Press.

• What is the effect of my believing this automatic thought? What could be the beneficial effects of changing my thinking?

• If [name of specific close friend or family member] were in this situation and had this thought, what would I tell him or her?

Teaching patients to identify their typical cognitive distortions, or types of thinking errors, also helps them understand the relative invalidity of many of their negative thoughts (Table 2). When emotionally distressed, people tend to make many more errors in their interpretations of events than usual. Matthew, for example, consistently displayed all-or-nothing thinking ("Either I'm the best or

I'm a failure."), mind reading ("They [his co-workers] are probably laughing behind my back."), fortune telling ("I'll never catch up.") and labelling ("I'm a total loser.") Other techniques used to help patients evaluate their automatic thoughts include:

• behavioral experiments (where patients directly test thoughts or assumptions such as, "If I try to get more done, I'll just fail.")

• imagery work (using imagery techniques in response to spontaneous, negative images)

• coping cards (collaboratively composing statements, graphics, or pictures for patients to read during the week to remind themselves of important learnings from previous sessions)

After patients learn the skill of modifying their automatic thoughts, therapists start emphasizing their cognitions at the belief level. An intermediate level of belief contains attitudes, rules, and assumptions that may have been understood, but unexpressed, before therapy. Therapists often seek to understand patients' intermediate beliefs in assumption form. For example, Peter had a dysfunctional attitude, "It's terrible to make a mistake." His rule was, "I can't make mistakes." His assumption, which was more easily subject to a behavioral test was, "If I make a mistake, terrible things will happen."

Core beliefs are a deeper level cognition. They are rigid, overgeneralized, global, dysfunctional, and largely inaccurate understandings that people have of themselves, their worlds, and other people, such as "I am unlovable," "I am helpless," "Other people will hurt me," "The world is a hostile place."

Key dysfunctional beliefs can be identified in several ways. Sometimes patients (especially depressed patients) express their beliefs directly, as automatic thoughts ("I'm a complete failure.") Beliefs may be inferred by examining the consistent themes in automatic thoughts across situations. Cynthia, for example, had frequent thoughts such as, "Mary won't want to spend time with me," "No one will want to talk to me at the party," "My friends don't really know me very well," "If I try to get closer to Jane, she'll reject me," and "People don't seem to like me much." One of Cynthia's central beliefs, expressed indirectly in the thoughts above, was that she was unlovable.

A third way to uncover beliefs is to ask patients the meaning of their typical automatic thoughts: "If this automatic thought is true,...

Many of the techniques used to help patients evaluate their automatic thoughts can be used to evaluate core beliefs as well. Before working on belief modification, however, therapists present an explanatory model to patients, so they can better understand why they are absolutely convinced of the validity of a belief, even though the belief may be inaccurate or largely inaccurate. An information processing model helps them understand how and why they easily assimilate data confirming their core belief but ignore or discount positive data that disconfirm their belief. Patients learn, with their therapists' help, to bring this kind of information processing under conscious control. Much of the therapy from this point on is directed toward helping patients develop alternative

(more accurate and functional) perspectives of negatively perceived events and to become aware of, and process without discounting, positive data and events.

Other methods for the modification of core beliefs about the self are the use of extreme contrasts ("How much of a failure are you compared to [a specific person whom the patient sees as an extreme failure]?"), metaphors, and cognitive continua (which help patients see that their beliefs are at an extreme, instead of on a continuum). Therapists may help patients recall childhood events from which their core beliefs arose (or through which their beliefs became strengthened) and then evaluate the validity of those beliefs at that time and at the current time. This process allows patients to restructure the meaning of important childhood or adolescent experiences at an intellectual level. They may need experiential techniques to restructure the meaning at an "emotional" or "gut" level.

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