Psychiatry & Psychotherapy Podcast - Cognitive Behavior Therapy (CBT) with Dr. Judith Beck

Episode Date: January 12, 2024

In today's episode of the podcast, we interview Dr. Judith Beck, a prominent figure in the field of psychology and author of the highly regarded textbook, Cognitive Behavior Therapy: Basics and Beyond, which is a staple in the academic journey of many students in psychiatry, psychology, counseling, social work, and psychiatric nursing. This book, translated into 20 languages, is a key resource in the U.S. as well as globally. Dr. Beck serves as the president of the Beck Institute for Cognitive Behavior Therapy, which she co-founded with her late father, Dr. Aaron Beck, who is considered the father of CBT. The Beck Institute is a non-profit organization based in Philadelphia. In addition to her leadership role, she is a Clinical Professor of Psychology in Psychiatry at the University of Pennsylvania, where she educates residents. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

to the podcast. I am joined today with Dr. Judith Beck. She is the daughter of the founder of CBT, Dr. Aaron Beck, and she is now the president of the Beck Institute for Cognitive Behavioral Therapy. She has authored a widely cited, widely used cognitive therapy textbook called Cognitive Therapy Basics and Beyond, which has been translated into 20 languages. She also is a clinical professor at the University of Pennsylvania where she teaches residents. And so today we are going to be talking about cognitive behavioral therapy. We're going to be talking about her book.

I also have with me an Australian resident in his final two years of residency out there in Australia. Adam, Bert. Adam, welcome to the podcast as well. Thanks for having me. Yeah, so I was thinking, Dr. Beck, we could start with you talking a little bit about the history of CBT. I know your father was initially working with depressed patients. He was psychoanalytically trained.

And somehow he found CBT in the midst of doing psychoanalysis. And I'm curious about that. Well, it's a pretty good story. And when I, you know, throughout this podcast, when we talk about CBT, I'm going to be talking specifically about the form of CBT or cognitive therapy that was developed by Aaron Beck back in the 1960s and 70s because there's actually lots of different kinds of CBT, but I'm really going to be focused on that one. Okay. So to start back even a little bit further, my father never intended to become a psychiatrist. He had decided that he would be a neurologist.

But this was during World War II or the Korean conflict, and there was a shortage of psychiatry residents where he was doing his residency, and the chairman of the department decreed that all of the psychiatry, all of the neurology residents had to do a six-month rotation in psychiatry. If not for that, who knows, maybe there would never be this form of CVT. when he first started to study CBT, he was quite skeptical about psychoanalysis because he was really a scientist at heart. And at that point, there was little, if any, data at all to suggest that the psychoanalytic theories were correct or that psychoanalysis itself would help people overcome their psychiatric disorders. But as he kept on training in psychoanalysis and as his mentors and his instructors and professors and his fellow residents persuaded him that he should really give psychoanalysis a try. And so at some point he decided just to kind of dive in headfirst. He went through two analyses, two long analyses himself. And he really was a regular psychoanalyst.

So when he first started, he had patients lying on the couch three to five times a week, pre-associating, while he sat back and made interpretations. Just kind of standard old-fashioned psychoanalysis. But being a scientist at heart, even though he had really bought into psychoanalysis at this point, He realized that in order to really gain currency in the scientific world, that the psychoanalytic theories would need to be validated by research. And so he embarked on a series of studies that he was sure would show that some of the psychoanalytic concepts were accurate. And he decided to look at the illness, the condition of,

He just happened to be seeing a lot of people who had depression. So he kind of embarked on a study of psychoanalysis of depression and decided to test the idea that depression was really the results of hostility turned inward toward the cell. And if this were accurate, then the dreams of patients who suffered from depression should show far more themes of hostility than the dreams of normal controls or people with psychiatric disorders other than depression. But what he found was actually the opposite, that people who suffered from depression had fewer themes of hostility. And in fact, the themes in their dreams seem to echo the themes in their thinking while they were awake. So they saw themselves

as deficient or defective in some way, they saw themselves maybe as unlovable or worthless, and certainly helpless. He then started, he didn't quite know what to make of this, except that being a scientist, he accepted the fact that his hypotheses were incorrect. And he thought, well, he would try to test another idea about psychoanalysis. and that is that people with depression have a need to suffer. So he theorized that if they had a need to suffer, that when they succeeded in a task,

they should probably feel worse than someone else who succeeded. So again, he did a trial comparing people with depression, with people without depression, and gave them a card sorting task. And he rigged the results of that. And he found that actually the people who were depressed who did well who succeeded in the task felt a little bit better than the other group. And then it was as if someone knocked down a set of dominoes. And he thought, well, if these psychoanalytic ideas don't explain depression, how can we understand it?

Now, in about this time, he had some interesting encounters in sessions with patients. And he describes one of them where he had a patient who had been free associating on the couch. And at the end of the session, she said, you know, Dr. Beck, I was feeling anxious the whole time. I was telling you these stories of what I've done in her sex life, you know, over the course of my adulthood. And he said, well, you didn't tell me that you felt anxious. Why did you feel anxious? I know, well, it's probably because you thought I was judging you, you know, thinking that maybe you were bad for having had all of these sexual experiences. And she said, well, I'm not really

sure. I think it was that I was afraid that I was boring you. And so this was, I think, one of the first insights he had that people often have two streams of thinking that can go on simultaneously. So we might have the stream of kind of directed, motivated thoughts. So people, for example, who are listening to us today might be trying to learn from things that I'm saying or fit it into what they already know. They're deliberately trying to think about the content of what I'm saying. But they might also have another stream of thinking, which he later called automatic thoughts. And these are thoughts that just seem to pop up into people's minds. They're not deliberately trying to think that. And so if I use our same example, then people who are listening to this

podcast today might be having these quick thoughts and maybe they're evaluating me and thinking, oh, she's not very interesting. Or maybe they're evaluating themselves. Gee, this is something I should have known. What's wrong with me? You know, this is such an important part of history. Why didn't I know this? And he recognized that it was these automatic thoughts. It seemed seem to just pop up into people's heads that are more closely connected to the emotions that they're feeling, the behavior they engage in, and sometimes their physiological response, than the actual situation itself. And that's what he called the cognitive model.

That it's not so much situations that directly cause us to feel or behave or our bodies to react in a certain way, but rather our perception of situations. of our, the meaning that we put to these situations, which pop up into our minds in what we now call automatic thoughts. Yeah. Okay, so I have two thoughts on that. One is, I think when I hear that of the Stoic philosopher, you know, we cannot choose our external circumstances, but we can always choose how we respond to them, which I know influenced him to some degree and also influenced Albert Ellis, who is a precursor. or maybe of CBT. My second thought is,

it sounds like transference when if a patient says, oh, I'm worried that you're bored. That sounds like a deeper transference, which I think I'm really trying to grasp, like, is it transference or is it, is it in a CBT terms, like, okay, you could say it's an automatic thought,

or is there more of a core belief system about herself, not being interesting? which is being transferred on to him. And how do you understand that from your perspective? Yes, it's the latter of what you said. So as it turns out, this woman had a core belief about herself. This was a very longstanding, deeply held belief that really cut across situations.

She didn't just have this kind of thought in therapy. She had this kind of thought in many different interactions that she had with a whole lot of different people. She has this deep belief about herself that she's boring, that she's not interesting, that she's not appealing enough to other people. And, you know, the wonderful thing is that when individuals have these kind of core beliefs about themselves and about other people, and when the beliefs are pretty pervasive, they are bound to show up in treatment from time to time. So in the psychoanalytic terms, we might call that transference. And if the therapist had a reaction and response, we might call that countertransference.

I prefer just to call it patients' reactions to therapists, especially patients' unhelpful reactions to therapists, or therapists, especially unhelpful reactions to patients. It has a slightly different connotation, I think, from the use of the word transference. But that's fine. We can also call it transference. Now, the question is, is what do you do about that? So this happens in the therapy session. Well, let me just say, if this had happened to me in the therapy session, I probably would have said, oh, it's so good you told me that. And then I would probably say to the patient, you know, it sounds like this could be a really important idea that you have.

would it be okay if we stop talking about what we have been talking and focus on this? Or I might say to the patient, do you think that we should focus on this thought that you now just told me or should we go back to what we have been talking about before? I'll come to think of if this is the end of the session, right? So it's the end of the session. How about we roleplay this and see how it goes? I'll be the patient and you be yourself, okay? And is this the, if it's at the end of the session, then it's easy because I just say,

wow, this sounds important. If it's okay, I'm just going to take a note about a note on this, and then I'm going to ask me next week if you think that it's something you should talk about. Let's say it's not the end of the session. Let's say it's the next session. Yeah. And, okay, so. Is it like the middle of the session or is it something that I brought up because we didn't have time to talk about?

at the end of the last session. Let's say it's the middle of the session, and I've been telling you something, but then I'm going to share with you this. I noticed that your faces, this is what would happen, is I would notice, David, that there was a change of affect.

I noticed that your expression changed, or you pulled back in your chair, something about your appearance changed. Maybe it was your tone of voice that changed. And I'm guessing that there might have been an important thought that you just had that led to that change of emotion. So I might say, oh, David, could I interrupt you just for a moment? Yeah. You looked just a little bit distressed as we were just talking.

And I wonder what was just going through your mind? I think I was worried that I was boring you. And I think I'm worried that I'm just uninteresting. Oh, well, it's so good you told me that. So first, straight off, I have to tell you, no, of course you weren't boring me. I mean, I find you as I find all of my clients, you know, very interesting. It's always interesting to me to try to figure out how to help you, you know, reach your goals and how to solve problems. So, but what, did I say something or did I look in a certain way that made you think that I was not interested?

You know, I don't know. It's something that's occurred to me a couple times in our sessions. And I just, I, I just wonder if I'm talking about something that's important enough to talk about. Or maybe it's just, um, Yeah, maybe it's just inherently uninteresting. You know, like you've heard it so many times or you've heard so many different patient's stories. And this is just, it just seems trite. It doesn't seem important enough to share. You know, so one possibility is that I didn't change at all, but you were kind of evaluating your own performance in a way of what you were saying to me in the session. It's also possible that maybe you think that. when I'm not making good eye contact

because instead I'm taking notes or something like that. But anyway, if it happens again, maybe you could notice, because if it is something that I'm doing, then of course I want to change that. Well, I appreciate you sharing that, no, but I do think it is I'm evaluating, when you said that, you're evaluating your performance,

that rings true. It's like there's something about wanting to perform, which is kind of, I feel kind of some shame about even saying that, feeling like I'm trying to perform here, but I'm paying you for this space, but I'm trying to perform, which just seems ridiculous to me. Let me ask you, it doesn't seem ridiculous to me at all. I think it will make perfect sense once we kind of figure out what belief is behind that. But can I just ask you this experience that you've just had with me,

where you are guessing that I felt uninterested? Am I the only person that you've had this experience with, or does this happen from time to time? No, it happens from time to time. So, yeah, I don't think it's only you. I think it's people who are in a position of power and authority. Let's see. You know, I know, I think just by your, you know,

the books that you've written and how popular you are, I think I just imagine I need to be on my game, and I just wonder if I'm not. Right. And so do I understand this, right, that when someone is in authority as you see me, that you want that person to think well of you? Yeah, yeah.

And if I, for example, well, of course I think well of you, But when I or people like me think well of you, then what does that mean about you? What does that say about you as a person? That I am worthy, that I am enough. And if I or someone like me doesn't think well of you, then what does it say about you? That I am unimportant. I am a failure. It feels lonely.

Yeah. Oh, I'm sorry. It sounds like those beliefs are really must be so painful for you to have. Yeah. Yeah, I feel some pain as we talk about it. Yeah. Well, David, it makes perfect sense to me that if you are kind of your sense of self and a good sense of self,

depends on how you think other people, especially people in authority, view you, then of course you'd want to perform well, right? Because if you perform well, you can at least feel okay about yourself, or at least during the performance you can feel okay. But on the other hand, if you don't perform well, and it sounds like these really painful ideas, like you're unimportant, your failure, you feel kind of lonely that those thoughts and emotions could arise.

Does that make sense to you now? Yeah, I think as you're saying that, it also comes to my mind that I think I had to perform growing up to get good things from adults. I don't know if that relates to it, but that came to my mind. Yeah, no, I bet that does. And so can I just suggest the following?

Okay. I think it is important for us to figure out how these beliefs developed. Sounds to me like you probably earned them honestly. You have a lot of experiences that would make them seem to be true. And it sounds like perhaps they were true to some degree when you were a kid. So it would be important to do that. And what I'd like to do before we do that, though, is to talk a little bit more about what's happening right here in the session with us.

Would that be all right? Okay. Yeah. If it wasn't okay with you, would you be able to tell me that? Would you be able to say no, Judy? I'd really rather talk about the childhood stuff now. that's a good question i think i would be able to say i think i'm i think i'm based on how you've responded earlier that it's okay to share some of these things oh gosh it's really important

for you to share these things it's especially important is if you ever disagree with me it's really important that you let me know and do you know the first thing that i'm going to say if you ever disagree with me? Say what I said a few minutes ago, which was, oh, it's good you told me that. Okay. So, David, you don't sound like you're a perfect mind reader because you were reading my mind and you were inaccurate a lot, right? Yeah, of course I'm not a perfect mind reader.

I also have to tell you, I'm not a perfect mind reader. Okay. And being a human being, I make mistakes. And, you know, I try not to. But chances are, over the course of the sessions that we see each other, I may make a mistake. And what's really important to me is that you feel safe enough with me to be able to just say that so I can correct it. And this may not have been your experience growing up. But what happens in this therapy session is that I always say, it's good you told me that when I get negative feedback.

Even if I disagree with it, it's still really important that, you know, a patient tell me that. So I guess what I'm feeling as you say that is that, okay, if you always say that, do you really believe it, you know? And why would you believe it if you always say it? Oh, so I always say it because I do believe it 100%. I have to say, now, I learned that. It's not something that I always did. When I was a young therapist or relatively new to the field and inexperienced, it never occurred to me to say that. that. And then, as I became more skilled and was dealing with individuals who had more complex problems,

I realized that one of the most important things was to help people feel safe. Because if I have patients and they come in and talk to me and they don't feel safe, then they're just not going to be able to get nearly as far as they could if they did feel safe. So you might, I don't know, have you noticed other ways that I've tried to help you feel safe? Um, I think you always start on time. And somehow that, that feels very good to me. Um, I think you, um, are willing to meet with me.

that that feels good and I think yeah I think you are open to being wrong I think you've you've shared and that's surprising to me because you're because you are successful and my experience of very successful people is they're not open to be wrong you be a successful therapist that's what you have to do so it's really it's a little bit different some in some ways from also do I do I come across in kind of a friendly manner to you? Yeah, yeah. Do you get the sense that I'm kind of just checking off boxes when we talk, but okay, we did that, we did that, we did that, or is it, is, do you feel as if I'm trying to draw you out, giving you a chance to speak? Um, you know, it's interesting. I had another therapist before you that I think was a CBT therapist as well.

it felt very sort of structured, overly structured almost. And I'm wondering how I know you're like, dad founded CBT, how you're kind of not structured, but you're a CBT therapist as well. I don't know if that makes sense to you. Yes, I think what I have learned to do is to combine the structure that's in my head

with a warm and friendly and open manner. And I've also learned when it's important to be structured and when it's important not to be structured. And one of the problems with CBT, to be honest with you, and since you're in the field, I'll share this with you, is that too many people work from a manual. Okay. And the way that we teach CBT and the way that I practice CBT is by conceptualizing the individual client. and figuring out what's going to be best for that client. So we'll always use the principles from the treatment manuals, the ones that have been established by research to be effective,

but I never use a treatment manual. Okay. There are too many individual differences. Yeah, I was wondering about that. I know you know that I practice in the field, and there's this book called The Great Psychotherapy Debate. and you know it talks about how like modality maybe not as important as the therapist and i think that's i'm i'm curious what your thoughts are on that and i i'll uh we'll pause our role playing for a second

i i did an episode on acceptance commitment therapy and um i like acceptance commitment therapy i'm not trained formally in it i know enough to know some of the principles but I had a resident on who had graduated, who was like a total fanboy, okay? And I don't think Neil Christopher would dislike me saying that about himself. But after we did the episode, we looked at all the randomized control trials comparing acceptance commitment therapy with CBT.

And on my website, I have this. And they're equivalent, or in some cases for depression, CBT seemed a little bit better. There was, I think, one or one slight, increase for anxiety disorders in one study for acceptance commitment therapy, but most of the studies showed they were pretty equivalent. Yeah. And so, but I feel like everyone learns CBT in, or everyone learns, you know, CBT in graduate school. But then it seems like they go on to this cool new, you know, whether it's like somatic therapies, which I haven't seen any somatic therapies

beating CBT or EMDR, which I was amazed recently when I read EMDR and CBT were pretty much equivalent, despite the, despite the hoo-rah, you know, in some of these conferences about EMDR. So yeah, I'm curious your thoughts where it's like, how do you make sense of this? And I see where you're leaning into in our sort of role-playing therapist effect. Like you as the therapist, bringing yourself seems very important. So anyways, okay, there's my thoughts. now you can reflect on it. So, see, there's a talk that I often give,

which is in that I'm giving it to, doing a grand rounds to a medical school in a couple of weeks. This, it's called CBT in 2024. And when I did it for another group, back in December it was CBT in 2023. But each time I give it, I change it a little bit because there's more and more and more new things happening. Anyway, CBC.B.

as practiced, as developed by my dad and refined by my dad and me and colleagues all over the world in 2024 looks quite different from cognitive therapy. It's quite different in some ways and quite similar in other ways to cognitive therapy for depression, which was the first kind of treatment manual, was the first textbook of CPT that my father and colleagues published in 1979. But there's been so many refinements since then. Okay. So the way that he practiced and I practice and we've now trained about, I know, 40,000 people since we opened the Beck Institute in 30 years ago. Wow. That's incredible. Is that we teach the, we teach CBT. We teach the theory behind CBT. And then a really big push is to have an individualized cognitive conceptualization,

an understanding of the patient's belief system. I'll just say it. I'll talk a little bit in a more complicated way in a few minutes, but understanding patients' beliefs. And then we use techniques from any evidence-based modality. So, you know, with a straightforward depressed patient, we can use pretty much standard CBT techniques. When we're talking about someone, say, with avoidant personality disorder, who's also depressed, we may use techniques from acceptance and commitment therapy, maybe some emotional regulation techniques from dialectical behavior therapy. We use techniques from positive psychology, from solution focus therapy, from motivational interviewing, from interpersonal psychotherapy. Oh, I'm probably

missing problem solving therapy, probably missing a whole bunch of them. So mindfulness, we pulled techniques from any evidence-based treatment in the service of helping with belief change, emotion change, physiological change when needed, and behavioral change. Did I say emotional change? Anyway, all of those two. So to me,

CBT is a way of understanding patients or clients. And there are certain cognitive and behavioral techniques that we use problem solving techniques we probably use with almost every patient. But then we also pull in

techniques from all of these other modalities. I think that that makes CBT the integrate of psychotherapy because you hear much more from in other psychotherapies, for example, acceptance and commitment therapy. There are certain things that you do and certain things that you don't do. And I think that's probably true of most of these other evidence-based treatments. Here's the formula. You're supposed to use this. You're not supposed to be doing these other things. and that just doesn't make sense to me. And I think some people are trained that way. And I think some people, I was once part of a panel discussion.

And I was amazed when someone else on the panel said, yeah, but you're taking techniques from our psychotherapy. And I said, yes, of course, because it's effective for this kind of patient, as if we were supposed to keep psychotherapies just pure in terms of technique. Hmm. That, okay, okay. Okay, and what's your specific thoughts on this idea of the therapist effect? Like, it's, it seems to me like there's a bell curve of therapists, even within CBT or within, like, other modalities, there's some therapists that are better than other therapists, some of it.

And I think what you were hinting at in our role playing was exactly what I've seen as, like, the best therapists are open to feedback. best therapists are interpersonally a little more nuanced or, you know, more experienced or like there's, it's like, it's hard to put a finger on it, you know, but I'm curious what your thoughts are with as that research has come. Yeah. Yeah. Forward. Go ahead. In CBT, this, you know, having a strong therapeutic relationship is essential, but it's not sufficient, not for most people. There probably are some people with more mild or mild to moderate symptoms where if you're a nice, kind person who's showing them attention, who really wants to hear from them, who's giving them some nice feedback, maybe that's enough, but at least for the patient population we see, that's not nearly enough.

And we have to use the technology. We need to use the techniques. For example, with depressed patients, we have to get them behaviorally activated. we have to get avoidant patients anxious patients to do exposure and off with some percentage of patients they won't engage in those kinds of productive actions if they don't like you if they don't trust you if you don't have credibility if they don't feel safe with you so part of developing this strong therapeutic relationship is so that patients will be willing to do the things that they need to do between sessions to get better. And we tell people it's not enough just to come and

talk for 45 or 50 minutes a week. That's not how people get better. The way that people get better is by making small changes in their thinking and their behavior every day. That's how they get better. and the small changes do not usually come about because you have a good relationship with the patient. They come about because you have a good relationship with the patient, and therefore the patient is willing to do what he or she needs to do outside the session. Okay. Yeah. I mean, I completely, I understand where you're coming from with that, because, like, yeah, if you get a patient exercising physically, let's say that's part of the behavior, behavior activation. That has its own effect size, right? Or eating right? I don't know if you've seen the

smile studies coming out of Australia. Actually, is it Australia or New Zealand? I don't know. Right. Yeah. But the effect size is amazing for changing diet, especially if the, especially if the patients have a very poor diet, high processed food diet. I can send you that study. That's wonderful. You may not know this, but I wrote, a couple of books for consumers on a CBT approach to weight loss and maintenance. I do know that, yeah. One of my areas of interest. I'm curious to get into that as well.

And here you're like, what are the main cognitions that keep people from losing weight? Okay, that's if they have the goal of losing weight. Let's say that. What do you think? Want to answer that now? Yeah, let's go. There are two categories in particular. One is the beliefs that lead to emotional eating because so many people who have difficulties

losing weight eat when they're distressed. And these beliefs are either I'm upset and the only thing I can do to feel better is eat and or they have the belief I deserve to eat because I'm upset. So that's one category. The other category are the beliefs that get activated when people deviate from their plan, from their eating plan. They, in their words, cheat. And one belief or cognition that's extremely problematic is, oh, I broke my diet or I cheated. Therefore, I might as well eat whatever I want for the rest of the day and start again tomorrow.

And one of the big things that people have to learn to do is when they make a mistake, to recognize that they've made a mistake, to remind themselves that it's just a mistake. You need to teach them not to be judgmental and be upset by a mistake. But on the other hand, to figure out what they need to do to get back on track immediately. and then afterwards they can go back and see how it was that they made the mistake and is there anything they can learn from the mistake the next time they're in this kind of situation what would they like to be able to tell themselves what do you think about like what if a patient says like well i think like growing up my attachment with food was the only way i comforted myself right yeah and what like what kind of category would that fit into Yeah. Well, so it's funny, just waiting for this podcast to start, I just got a new book called Distress Tolerance Made Easy. D. You see therapy skills for dealing with intense emotions in difficult times. But one of the things I often ask people is, who do you know who when he or she gets upset, that person doesn't turn to food?

And frequently, they'll say, oh, my boyfriend or my brother. or sister or, you know, my friend, so-and-so, and you say, and so when they're upset, what did they do instead? Okay. And then frequently, the person is stumped. I have no idea. So then we have them, you know, find some safe people that they can actually ask, and also I can make some suggestions. So I had a colleague who, every time he got really distressed, he would go to Trader Joe's, he would buy a gallon of ice cream. He would sit in his car and eat the gallon of ice cream.

And so he developed a behavioral plan where he would drive to Trader Joe's and he would call a friend instead. And he had like a list of friends. Yeah. So he would call me and then I would go to Trader Joe's and I would eat a gallon of ice cream with him. No, I'm joking. That's what I told him I would do if he really wanted me to. But at least that way he's not alone eating his ice cream. right? That's right. No, but like, I think like, yeah, I think there's something about...

There's so many things that it's so many kind of basic CBT skills that they can use a lot of DBT skills they could use a lot of eight acceptance of commitment therapy tools they could use. A lot of mindfulness-based CBT skills they could use, so... Okay. So how did you get interested in weight loss, CBT? Oh, it, you know, it was probably because I had struggled myself off and on for years and years with about 10 or 15 pounds. It wasn't a whole lot. But I finally figured out how to apply CBT skills to myself.

And once I did that, it was pretty easy. And that was like, I know, 15 or 20 years ago. Okay. So are you doing a mood log on yourself? Like, are you, like, physically writing it down? Or, like, do you just do it in your brain? What do you mean about eating? sure

yeah just in terms of eating no I never write down anything anymore but when I first started I did I think my question is like when you

are doing it on yourself when you do CBT on yourself do you write a mood log out like to write it out physically or are you to a place where you just like

it goes kind of through your brain I don't really need to do that anymore When I wrote the first edition of Cognotherapy Basics and Beyond, so that was published in 1995, and actually the latest version, which has a recovery orientation, which we ought to talk about, in 2020. That was published in 2020. But in the first one, 1995, I literally did what I would call thought records, where I put down the situation is writing this manuscript, automatic thoughts. This is so obvious.

People are going to criticize this. This won't be helpful to people. How did I feel kind of discouraged? And then I would use Socratic questioning. What's the evidence that this thought is true? That people won't like it. Well, I didn't have any at the moment. It was just kind of in my own head.

Is there any evidence on the other side? And I thought, well, you know, I have started supervising people. And every time they don't know something, that's how I know to put something in the book. Like, it was so obvious to me the difference between emotions and cognitions, and yet it wasn't to some of the people I was supervising. So then I knew that that should go in the book. So I started to have some evidence through the ideas I was getting from supervision of what people didn't know, what therapists didn't know,

that maybe it could be useful to people. So, you know, was the evidence true or not true? Is there any evidence? Is there another way of looking at this? Actually, that could be helpful to people. If the worst happens, how would I cope with that? What worse happens? No one will read it or people read it and criticize me and think poorly of me, but I won't even know that. So it won't really affect me. What's the best and most realistic thing that could happen? What would I, what advice would I give to somebody else who was in this situation and what should I do? So I literally did do some thought records. As I was writing, how do you do? records with patients. Really, I love how you went through that. Okay, can we slow that down a little bit? What about the cognitive distortions? Like, how do you apply like all or nothing thinking,

over generalization, jumping conclusions, mind reading? Where does that get applied? A lot of people, a lot of therapists, think that that's a central technique in CBT. I don't consider it a central technique. some people go through the list of distortions with patients, every single one of them. I don't do that. What I do is I listen to the patient's automatic thoughts, and when I see a pattern, like I see

all or nothing thinking, then I'll point it out, or if I see jumping to conclusions, or I see catastrophizing, you know, more than once. So once I see it like three times, it seems like. well, this is probably a pattern for this patient, then I may point it out and label it. Oh, okay. And some patients, I never label distortions with other patients actually really like it. So once I label a distortion, they might say, well, are there others? So if they're interested, yes, then I'll pull out the list and show it to them.

Again, it's a way of really individualizing for the client. but I find that a lot of clients get so overwhelmed by having a list of 10 distortions. It's just not all that useful for them. And our time in session is so precious. It's probably not worth the time with many of my patients anyway. Talk again about the imagining the worst outcome. How do you use that? So when this is particularly when people,

are catastrophizing, but even if they're just having kind of depressed automatic thoughts, then I might say, so now if the worst happened, how would you cope with that? So, for example, if the worst happened, let's see, someone that I saw yesterday, oh, the worst that would happen was that her mother would have this mistaken idea about her. And how would she cope with that? well, she could either try to explain it to her mother or accept the fact that her mother will never really see her in the unvarnished truth. When patients can see that somehow they'll be able to cope with the worst, then anything else feels more doable to them. Okay.

But we don't leave it at the worst. So what we really want people to do is to think of, gee, what's the most realistic outcome of this situation? Oh, yeah. But it's hard to go from worse to most realistic, because if you try that, usually they go from worse to a little less worse. So that's why I say, well, that's the, so that's the worst. And that's how you would cope. What's the best that could happen? And they usually tell you the more realistic.

And, you know, so maybe the best that could happen is, well, mom, I guess maybe she'll see my point of view. And I'll say, gee, I wonder if the best is, not only would she see your point of view. but it would so awaken her, taking the shades off of her eyes, that she'd be able to see you clearly in every situation. Yeah, I guess that would be the best. So then what do you think the most realisticness? Okay. I think that's the thing that made me interested in CBT

is listening to your talk, it's got a Marcus Aurelius flavor to it. It sounds a lot like stoicism in some. ways. And would you sort of consider it sort of in a way, I guess in part, sort of applied stoicism sometimes? I think it is. I think that there's, you know, my dad really pulled on, and he had studied philosophy in college and he pulled on many different philosophical streams. Probably stoicism is one of the earliest ones. You know, again, as David was saying earlier, and it's not situation so much for what we make of them. that is really what's important.

The meaning we derive from them. So I think it is the Stoic philosophers which helped influence his thinking on that. Yeah, I think as well, there's, in this Stoicism, specifically in regards to the worst outcomes, there's this kind of like, well, imagine death, right? And like, can you get used to this idea of like, yeah, you will die? And then dealing with fame, you know, the biggest fear

people who want to be famous is that they will be forgotten, you know? So it's kind of like, can you get used to this idea that you will be forgotten in a couple generations, you know, which I don't know how, I think it's that kind of line of thinking, it's a different sort of, it's a negative visualization, right? Which I don't think we really talk about in psychotherapy very much. But it helps for professional athletes, actually, and the ones that I've worked with. Well, that's interesting. specifically because it can take down the intensity of the burden of the sport right which can be all-encompassing to to create a negative visualization is visualizing a bad outcome and remaining calm in the midst of it

but i think there's another aspect of an instoicism which is like reducing the meaning intensity to be all-consuming to see the larger picture of the world and life. Anyways, we may be getting off topic here. Really, we're talking about changing perspective, which is what I think all good psychotherapies do. Adam, do you have any other questions that are just kind of, you wanted to make sure we get in?

I'll be honest, every question that I had has been answered, listening to you two talk. Especially, you guys' roleplay, that was impressive. that was that was really interesting to observe. I enjoyed the role play. Thank you for that. In all of our trainings, we always do spontaneous role plays. And always one of my favorite things to do.

I wonder if you'd like to hear a little bit about recovery-oriented cognitive therapy. Yeah, the part that I'm interested in is the meaning and the values sort of being central, central. And I heard your father speak at a conference years ago about this. And the thing that totally made sense to me was when he was talking about working with schizophrenic patients. And it was like coming back to what were the goals that this person had before their psychotic episode and the meanings and the values? And I remember, or just today I was talking to a patient who's still 50% psychotic. He's not as psychotic, but he's not as psychotic, but but he's still somewhat psychotic, right?

And it's coming back to like, what are his goals? And pre-psychosis, right? Which now seem only psychotically obtainable almost. You know, it's almost like he wants to jump to that place to be in that super important job without taking the small steps. Yeah. Yeah, so I'm curious. Yeah.

You could use that as an example. Yeah, that's a great example. So just in terms of terminology, well, let me just start back about 12 or 15 years ago, the director of behavioral health in the city of Philadelphia, where we live where the Beck Institute is, the director asked my father to develop CBT treatment for people with the most serious mental health conditions such as schizophrenia. So my father and Paul Grant, who was a close colleague who's now at the Beck Institute, and my dad undertook a study of schizophrenia, both in terms of the literature and in terms of going into psychiatric hospitals and community centers that helped community mental health centers and various agencies who worked with non-hospitalized people with schizophrenia. And they quickly realized that using standard CBT would not work with this population. And what's so remarkable to me is that my dad, probably at the age of about 88,

did a complete reversal of the technology of CBT in order to help people with schizophrenia. So instead of focusing on these individuals' problems, their symptoms, their delusions, their delusions, their isolation, you know, the very profound disconnection and so forth, they focused instead on providing these individuals with positive experiences and then helping them draw positive conclusions about these experiences in order to bolster their positive beliefs about themselves and other people and the future and the world. And to just piggyback on what you're saying, the first trick, though, is just to engage these individuals in treatment.

When you talk about the therapeutic relationship, sometimes it's enormously difficult to even get these individuals, let's say they've been hospitalized for 30 years, to even look you in the eye, much less say something out loud to you. And so they came up with all kinds of innovative ways. And we have a recovery-oriented cognitive therapy team at the Beck Institute who go out to these psychiatric hospitals where people may have been hospitalized for 30 to 40 years, and also work with ACT teams that go out into the community and help people who are both homeless. and suffer from schizophrenia and also the higher functioning people with schizophrenia.

So the first thing, though, if you're in the hospital, is just to engage them and help them see you as a safe, interested person. And so they'll do various things. I remember there was a patient that they talked about whose name was, we'll call her Diana. Diana had been in the hospital for about 30 years. she was one of the more difficult people on the unit. And when our team went in, they said to the hospital staff, tell us what Diana is like at her best.

When is she at her best? What is she doing? What kind of more positive beliefs do you think she has at that point? And so they described how she really kind of came alive in music group when she was willing to attend because she would sing along, she would tap her feet, She'd be clapping her hands. She'd be making eye contact. And they thought that this was really her at her best. And really her at her best was probably what she was like before she developed schizophrenia.

Anyway. So and then so what the therapist did was to go up to Diana and say to Diane, Diane, I wonder if you could help me. I want to buy a record for my aunt. She's about your age. And I'm trying to decide what kind of music she might like. Could I play you two songs and you tell me which one you think might be better for her? So then the therapist plays one from when Diana herself was in her early 20s before she was hospitalized. And then some very heavy metal rock music, or rap music. It sounded very discordant to Diana. Diana said, oh, I think the first one.

So that was like the first time that she spoke to the therapist. Anyway, the therapist kept on approaching Diana and asking for advice or asking for help or asking Diana wanted to do something with her. Another really terrific, I thought this was ingenious, a therapist did, but this was not Diana, it was another person. The therapist noticed that the patient seemed to be looking at the therapist's nail polish. She was wearing some unusual color. And the therapist then said, oh, do you like my nail polish? And the woman nodded, yes. This is a person who hasn't spoken very much in many years.

And she said, did you ever wear a nail polish yourself? And the woman nodded. And the therapist said, would you like me to bring a manicure kit to the next time I see you? And maybe I could bring a few colors of nail polish, and you could choose one that you would like. And the patient nodded. And so then the next time she comes in, she brings the stuff, she polishes the patient's nails. And as she's polishing the nails, the therapist is just kind of making small talk, just asking yes or no kinds of questions.

So wouldn't put it much of a demand on the patient. But by the end, the patient started to talk to her about her nails. And so the first thing to do is just to even get them engaged and have them see you as a helpful, friendly person. then you start providing experiences that you're doing together and helping the patient draw positive conclusions, such as, I guess I had more energy than I thought, or I guess I really was able to teach my therapist how to dribble a ball. I guess maybe people will be friendlier than I think, things like that. And once they've had more positive experiences and they're building up positive beliefs,

then we ask them about what are their aspirations for their life. Now, you could say what are your goals, but what my father and Paul Grant and other people found was that the only goals that the patient knew about were the staff goals. Take your medicine, take a shower, you know, you come to meal time on time, you know, things like that. So that's why they start calling them aspirations instead. And you ask people, you know, what do they really want? for their lives. What do they want their lives to be like? What did they want to be like?

And then even if the answers are delusional, that's okay because you want to ask the meaning of the aspiration. So you might ask your patient, so if you had this high status, high paying job, what would be the best part about it? And the patient might say, well, it would mean I could make my own decisions. You might say, oh, well, it would mean that I would be in control. Oh, it would mean I could tell other people what to do. Oh, it would mean I could feel good about myself. Oh, it means I could get a lot of stuff done. And these are everyday kinds of... Yeah, good desires, good aspirations. Right. Desires that you can help the patient meet even if he's still in the psychiatric hospital. But it gives you a clue as to where you should start working is how do I help this patient feel better about himself right here in the hospital?

How can I get him to feel like he's taking better control of his life? How could he perhaps, oh, another big one that psychiatric patients often say is, I would be able to help other people. And there are lots of opportunities that you could create on a hospital unit where one patient could help a staff member, could help the whole unit, could help other patients and so forth. So it's okay if these aspirations are out of reach because it's really the meaning that you want to help,

you want to help to help them figure out and then help provide experiences that could provide that meaning. Beautiful, yeah. It changes the everyday experience to be in alignment with the meaning underneath the aspirations. And so then you have a situation where maybe you're helping the staff members set out plates and napkins and silverware for lunch or something like that. So they have this experience and then you help them draw a positive conclusion, oh, I can help other people. So it then makes them feel better about themselves, increases their positive beliefs. Also, maybe, you know, other people can smile at me are nice to me.

Other people are happy when I help them, things like that. And so it's the cognitive model, but the positive side of it. So what's the situation? What's the positive belief? And what's the positive emotion they experience, the positive behavior they engage in? Maybe the positive impact on their physiology. And then you use kind of more standard CBT when the patient is trying to take a step that's important to him, that's in alignment with his goals, but he runs into trouble. And the trouble he runs into is usually either automatic thoughts that get in the way, just regular problems that get in the way, or a lack of skill that gets.

in the way. And so then you could, you know, this is much further down the line in treatment. This is much further treatment. But then you could use some more standard CBT techniques like problem solving, like responding to negative thoughts, like teaching them perhaps interpersonal skills. Beautiful. Yeah. That's really good. I think it is impressive that your dad at the age of 88 really kind of, you know, had that plasticity, right? He still had that brain plasticity to make that shift. I'm curious, on a more personal note, when he raised you, did he raise you in a more, was he doing mood logs with you growing up?

Or was he doing more of like, tell me your dreams and dream interpretation? So, well, it's, the answer is mostly no. I have to go back and say, so I was the second of four kids. kids. My mother was also a remarkable person because she did probably 90 to 95 percent of the care of the children and the household. It was a very traditional marriage in that way in the 1950s and the 1960s. And she went to law school when she had four kids under the age of 10 and became the first female judge on the appeals court in the state of Pennsylvania, where we live. But anyway. That doesn't sound traditional, but okay.

I think that the division of labor within the house was more traditional than it is these days. She sounds like an impressive person. Very impressive person. But anyway, so the one thing my dad did, I mean, there are two things that I really remember. One was he would say, he would often say, you know, problems are made to be solved. So I think we grew up with this optimistic kind of attitude in the house. house. And my mother, who probably didn't say that, but was a great demonstrator of problem solving. The other thing is, he used to be very interested in our dreams. And I never really believed in

dream interpretation until there was a dream that I had. It was like a week or so before I started graduate school. And I told him I had a dream that I was at the top of the Empire State Building, which used to be the tallest building in North America, and that I was looking over the edge and was very scared in the dream that I would fall off the edge. And he said something like, gee, what do you associate with this? Is there some big thing that's coming up in your life? And I said, well, starting graduate school.

And he said, so are you feeling anxious about starting graduate school? And I said, oh, my God, that's it. and it just so resonated with me. But that was the only time I remember his actually doing a dream interpretation, much less having it resonate so strong. Yeah, it clicked. It was a good connection, yeah.

It does feel like that for a lot of people. Even professionals listening to this, I imagine, can resonate with that feeling of, you know, venturing out and practice. or starting their own practice or going to the next level or seeing clients. That's why I think it's wonderful to study CBT because you can use all of the tools that you learn in CBT on yourself. In fact, that's what I always suggest that people do in cognitive therapy basics and beyond. Yeah.

That's all those suggestions. We also have a lot of online training courses and the first one is called Essentials of CBT. and in it, I direct people to use these CBT skills on themselves. So it's really, it's not how to treat patients so much as how do you conceptualize yourself and how do you use the tools on yourself? Because once you do that, you have a much greater understanding than of how to use more patients. Also, you can use self-disclosure and say, you know, when I get distressed, I pull out a thought record or something like that.

But you can only say if it's true because you have to be genuine with patients. Right, right. Yeah. No, I think it's really helpful to be able to do a mood log. I did in residency, I did about two months of partial, and it was very CBT intensive partial, where it was like every day we're doing mood logs.

Everyday patients would do mood logs, you know? So I had the binder, and I would go through it myself. Adam, any... I often don't use mood logs with patients. What I do instead is to teach them the cognitive model units using their own examples. And then I'll ask them, you know, if it's okay with them to try to, when they're at home, and they notice that they're feeling upset is just to write down what the situation is and if they can figure it out what was going through their minds.

And then if they can do that successfully when they bring it back, then I might give them a list of the Socratic questions, but maybe just circle one of them to try this week at home. And so I'm much more likely to, rather than giving them a formal thought worksheet, because a lot of people just don't like worksheets, I will hand write out these things for them. Or I might give them a typed list of questions, but also structure it in such a way that they're highly likely to be successful.

I won't ask them to do something for homework like a thought record until they show me in session that they can do it successfully. Okay. Pro tips. You know, one tip about how to, about what we used to call homework. Now we call it the action plan is to, if at all possible, to have the patient do it in session. Because if you can't even do it in session, there's no way he could do it at home. things that you can't really do in session, but maybe he could start something in session. Likely he or she will finish it at home.

Yeah, I think action plan is a good rebrand for a word that stirs up a lot of negative emotion in and of itself, right? I also tell you just a little bit about how to figure out what an action plan should be. Okay, yeah. So in the session, I'm discussing a problem with a patient. We finished discussing it, and I say to the patient, what would you like to remember about what we just talked about? And if they come out with a good summary, I'll say, oh, that's great. Do you want to write that down or do you want me to write it down for you?

If it's not that good, I might say, well, yeah, you know, I think that's close. I wonder whether it might be more helpful if you remember it this way. And if they like my rephrasing of it better, then they write that one down. Frequently, they'll just tell me one thing that they think is important to remember. And then I'll say, is there anything else that you'd like to remember? They don't come up with anything that I might suggest. Do you think it might be important for you to remember this or that? If they agree, then they'll write that down.

And if they haven't mentioned anything behavioral, like call my friend or whatever it was, we talked about, then I might suggest, you know, we also talked about your calling, your friend, surely, but if she's not available, can you think of anyone else you might be able to call? Would you be willing to write that down? And sometimes even, do you think it would be important to write down why it would be important for you to call her this week? We might have to write down the rationale. So it feels a little bit, yeah, it feels less like homework, more like,

taking the good of the session outside of the session. And it's what they see as the good of the session. Well, tempered by me if I think that they've got it wrong. It's so funny to go to the source of CBT, Judith Beck, to hear a very different sort of way of doing CBT than like I remember it being sort of shown to me, you know? I don't know, it just feels more natural. So I appreciate that.

It's quite possible, David, that when I was your age, I was doing CBT pretty poorly. I've gotten better and better and better as the years have gone on. But I do like to tell people that I'm so much of a better therapist than I was five years ago. Every five years I seem to have a leap. In the previous five years, it was really learning recovery-oriented principles and applying them to outpatients. In the next five years, well, I know. I've already started the next five years because I'm reading a manuscript about using CBT to heal racial trauma, something that is unbelievably important. I had some guesses about what should be done about that, but I didn't really know, and I'm learning so much from this manuscript.

with. So I think one of the things in the next five years is going to be a really deep dive into application of CBT to lots and lots and lots of other populations, different from the ones that I kind of deal with day and day. Excellent. Kind of wrapping up our time. Adam, do you have any sort of reflections, thoughts you wanted to say? No, I knew that was excellent. I really enjoyed sitting back and observing the discussion. It answered everything I wanted to know, and I think it was really great. Dr. Beck,

any sort of final reflections, pearls for the audience, listening in? There's so many things. So I'm just going to just drop a few things. One is I use self-disclosure with almost every patient in every session. There's some way that I can draw some kind of connection between the two of us. And yesterday, I had a patient who was talking about how something that his wife does drives him crazy,

and he gets angry about it, and it damages the relationship. And I talk about something that I do that I know drives my husband crazy, but how he handles it differently. So, you know, sometimes it's, oh, I didn't see that movie yet, but I really want to. What did you think about it? You know, so sometimes it's a much more minor kind of thing, but some way of drawing a connection. Interesting.

Another thing is I'm really hoping that people who are watching this want to learn more about CBT in 2024 and how different it is from CBT from 1979 or 1989 or 2019. There really have been some really important advances. People might be interested in signing up for our newsletter People can just go to Beacinstitute.org. We're a nonprofit organization. And we do an enormous amount of regional, national, and international training.

We got so lucky with the pandemic because we had already developed online courses. Oh, wonderful. And so when the pandemic hit, we moved to all our therapists. We only have three therapists, but all of us therapists went virtual, and our entire training staff went virtual. So now all of our workshops and our online courses and webinars and everything is virtual, which is really great. So people can find out about that. They can find out about getting certified by the Beck Institute or getting supervision.

I would say just going back to something that I've said a few minutes ago, which is, I think it takes a lifetime of learning to proficient in CBT. I know I learned from every patient that I see. And as I mentioned before, I really. feel like I make a pretty big jump every five years or so. And I've seen that throughout my career. And I certainly hope that I'm much further ahead in the year 2029 than I am right now, or I will have just stagnated. But the other thing I'd like to say is that I do think it's important for people to use the skills of CBT on themselves, particularly if you're too perfectionistic, you know, I think people are drawn to CBT because they're good problem solvers.

They really want to help people solve their problems. And it can be disheartening when you have a client whom you're not able to help or not able to help enough. And it's so important for therapists to be accepting of themselves and accepting of their own limitations and, you know, having aspirations to do better, but not to have that current expectations and to compare yourself to where you used to be and how far you'd come as opposed to how far you are from where you'd like to be. I always think that if you can at least develop a nice relationship with a patient, even if you can't help the patient enough, that may be enough for the patient be willing to seek out treatment elsewhere. And if you think that still that I'm yet at,

at the point where I can help every patient that I see you're really wrong. I had a young college student over the summer who was doing some virtual therapy with me at the insistence of her father. And no matter what I tried, I tried for three sessions, I just couldn't get her to buy into it at all. So if you think I can help every patient, you're wrong. I hope that, you know, she found me friendly and nice enough that if she feels that she really wants therapy, that she'll either reach out to me or to somebody else. But I think it's important for a therapist to be kind to themselves. And to use also lots of techniques from positive psychology and self-care.

Yeah. Wonderful. Excellent. Well, I will put the links to your organization and to your book on our document, we send out into my email address. And yeah, wishing you the best. Thank you so much for your time. It was such a pleasure. I felt like we could go on for another day or two. Maybe we can in the future.

I would love to have you back on. And we could maybe do a deep dive on perfectionism. That would be like really fascinating. Yeah. And I wish you the best of luck in your training. It's exciting to be starting where you are. Yeah. Absolutely.

I think he's got two more years until you're like fully a psychiatrist in Australia, right? That's how it works. Yeah, and I'm doing the last few years of our training is usually in a subspecialty. And I'm actually doing the Beck Institute training while I'm doing cases here and stuff. Oh, that's so wonderful. I'm so glad you're doing that. Yeah. So Adam, email me later when the training is over and let me know what we can improve on.

No worries. Awesome. All right. Take care. Bye-bye.