The past, present and future of cognitive behavioural therapy with Dr Judith Beck

Australian Psychological Society

The ‘daughter of cognitive behavioural therapy’ outlines new approaches to this foundational therapy and shares predictions for how it might evolve over time.

When Dr Judith Beck was growing up in 1950s/60s Philadelphia, she had no idea how famous her father was.

“To me, he was always just dad,” says Dr Beck, who is speaking at an APS CPD Approved webinar on 15 May.

She knew he worked long hours; she knew he was a psychiatrist and professor; and she knew he’d written one or two books, but she didn’t have a sense of the revolution he’d brought about in the field of mental health.

Her father, the late Dr Aaron Beck, is often referred to as ‘the father of cognitive behavioural therapy’ (CBT). But it wasn’t until she was an undergraduate at the University of Pennsylvania that she got a sense of her father’s influence on the field of psychology.

Dr Judith Beck, Beck Institute

“I took a basic foundational psychology course with Martin Seligman, and he passed out the ‘Beck Depression Inventory’ for us to fill out. Seeing my dad’s name on this test that was going out to 200 undergrad students was my first inkling that maybe he was pretty well-known.”

This ‘inkling’ became a known fact for Dr Beck when her father asked her to accept an award on his behalf.

“It was from the Philadelphia Psychology Society. He had laryngitis, so he prepared his remarks and asked me to deliver his speech at the ceremony. The person who introduced my father spoke of all the reasons why he deserved the award, and I was thinking to myself, ‘Wow, I didn’t know he did that!’ That was a real awakening for me.”

Following in her father’s footsteps had never been part of her original plan – Dr Beck originally trained and worked as a teacher. But when she was in graduate school studying education and psychology, she “decided to give psychology a try”. And many people will be glad she did, as the work she went on to do in collaboration with her father has benefited psychologists and patients alike throughout the world.

What is recovery-oriented CBT?

In 1994, Dr J. Beck and her father opened the non-profit Beck Institute for CBT.

“Our mission is to improve lives worldwide through excellence and innovation in cognitive behaviour therapy and recovery-oriented cognitive therapy.”

Around 15 years ago, Dr A. Beck and his colleague Paul Grant were asked by the city of Philadelphia to develop treatment plans for some of its most vulnerable citizens.

“These were people who had serious mental health conditions like schizophrenia and bipolar disorder. So my father, Paul and their colleagues, who are now at Beck Institute, did a study of schizophrenia and looked at CBT for psychosis.

“They recognised that the standard CBT approach probably wouldn’t work very well [for those people], particularly with those who had been hospitalised for 20, 30 or 40 years. So they developed a different take on CBT, which was to emphasise the positive and encourage the strengthening of positive beliefs, adaptive behaviours and positive emotions.”

Dr J. Beck then took the principles of recovery-oriented CBT and applied them to individuals with less complex mental health conditions, such as anxiety and depression.

“One of the first things you need to do with a recovery orientation, with outpatients, is find out what their aspirations are. How do they want their lives to be? How do they want to be? What are their key values? Then we use these aspirations and values as a motivator for them to do the hard work of treatment.”

In a recovery-oriented CBT session, Dr Beck will seek to learn not only about the challenges or difficulties of her client’s past week, but also when they felt better.

“Then we help them re-experience the positive emotions they had felt and draw adaptive conclusions about those experiences.”

For example, she worked with a client recently who was suffering from long-term depression and had recently found the energy to take herself outside for a walk.

“I was able to help her draw the conclusion that maybe she can do more than she thinks and that she deserves enormous credit for doing something that was so difficult for her, that she was able to overcome all of those negative thoughts that got in the way of taking a walk, that taking a walk helped her feel better, not worse.

“We find that it’s not enough for patients to just have positive experiences. We have to help them draw positive conclusions to strengthen their positive beliefs.”

When working with clients with more complex mental health conditions, such as those who’ve been hospitalised for long periods of time, Dr Beck says it’s important to take time to develop trust.

“It’s a matter of engaging with them in a positive experience together. For example, you might listen to music and play ‘name that tune’ or bring an animal into the ward so they can pet or groom a dog, for example.

“It’s very important to engage the patient in order to get them in an adaptive mode because they’ve been in a maladaptive mode for so long. When they’re in adaptive mode, the psychopathology seems to fall away, at least for the time they’re working with you.”

In short, recovery-oriented CBT is less about focusing on the psychopathology and more about zeroing in on positive elements and addressing negative psychopathological symptoms, behaviours and emotions when they interfere with taking valued action, she says.

“Our mission is to improve lives worldwide through excellence and innovation in cognitive behaviour therapy and recovery-oriented cognitive therapy.” – Dr Judith Beck

How CBT has evolved over time

Since her father put CBT on the map, Dr Beck says there have been “so many important evolutions of CBT”.

“I get a little distressed when I hear people talking about CBT as if it should be practised the way it was first developed in the 1970s and 1980s because there has been so much progress.”

Applying a recovery-orientation is just one advancement, she says.

“Another is the recognition of the importance of adapting CBT for the individuals’ culture, socioeconomic status, level of education, societal environment, family situations, sense of spirituality – so many different adaptations are needed.”

This is why, at the Beck Institute, they teach trainees not to use treatment manuals alone, but to make an individual conceptualisation of each client by using the principles outlined in the manuals and applying them flexibly.

“A third element is a very strong emphasis on the therapeutic relationship. My father devoted an entire chapter to this in his first book on how to treat depression, which was called Cognitive Therapy of Depression, back in 1979.”

If you don’t have a solid relationship with your client, they’re less likely to do the important work in between sessions, to share what’s really on their mind, or attend all their sessions, says Dr Beck.

“[Treatment manuals] don’t do a very good job of telling you what to do when there are problems in the therapeutic relationship. They don’t tell you how to avoid a problem and they don’t tell you what to do when a rupture occurs or how to make use of that rupture so the client can learn something important.”

By way of example, she refers to a client of hers who became angry with her after Dr Beck told her there were only a few minutes left of their session.

“In the next session, we discussed how upset she was with me and I found out she has an assumption that if people care about her, then they give her 100% and if they don’t give 100%, she thought that meant they don’t care about her.

“We were able to help her evaluate our relationship and she found out, in the course of our discussion, that I did care about her. Then I was able to help her generalise what she had just learned to other important relationships outside of therapy.

“This is why my father and I have always recognised the importance of the therapeutic relationship, but there has been much more emphasis on that in recent decades.”

Integrating CBT with other modalities

Dr Beck refers to CBT as “the integrative therapy”, as it pairs well with most other evidence-based treatments.

“In my book, the third edition of Cognitive Behaviour Therapy: Basics and Beyond [2020 edition], I talk about how to integrate mindfulness into CBT, as well as dialectical behaviour therapy techniques and acceptance and commitment therapy techniques.

“A lot of people think cognitive therapy is just a psychotherapy that uses cognitive and behavioural techniques, but that’s not the definition we use.

“Our definition is that CBT is a psychotherapy based on a cognitive model – that the way people perceive situations is more closely connected to their reactions, behaviours, emotions, than the situation itself.”

Treatment is based on that cognitive conceptualisation, and then psychologists can draw on techniques from a variety of evidence-based practices, she says.

“That could be compassion-based therapy, schema therapy, positive psychology, strength-based psychotherapy, interpersonal psychotherapy or others. We’re not limited in techniques, we just need to have a good rationale for why we want to use a particular technique with this particular patient, and base that on our cognitive conceptualisation.”

The future of CBT

Looking to the future, Dr Beck sees CBT being delivered in different and unique ways.

“One way will be through technology. For example, the IAPT system [Improving Access to Psychological Therapies, IAPT] in the UK uses a triage system where the least symptomatic people might use a computer program or go to a support group. It’s only people who are more symptomatic who might then see a therapist, but perhaps that’s someone who’s mostly trained in behavioural activation for depression.

“Then the clients with the most difficult problems are seen by psychologists and psychiatrists.”

She imagines more systems like this will crop up over time as a way to meet the increased demands for mental health support. In some instances, this is already happening.

“We’re seeing CBT delivered by paraprofessionals. For example, in Zimbabwe they have ‘friendship benches’ where respected women in the community are taught how to do some basic problem-solving and behavioural activation with people in the neighbourhood who come and sit on a bench to talk.”

Another example of this is in Pakistan, where peer counsellors work in primary care settings to help people experiencing depression or anxiety, she says.

She also thinks cognitive science advancements will help psychologists align their CBT approach with a client’s specific circumstances and personal context.

“I always say that I’m a much better therapist today than I was five years ago, and I certainly hope to be a better therapist five years from now. Learning CBT takes a lifetime, there’s always more research and evidence to shed light on mechanisms of action – for example, what we should be primarily focusing on with an individual client.”

Her strongest prediction is that recovery-oriented CBT will become even more common.

“If the research continues to show that it makes us more effective, I think people from all over the world will learn the principles of recovery-oriented cognitive therapy and integrate them into their work.”

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