How can cognitive behavioral therapy be adapted to different cultures and address larger social issues?
Judith S. Beck, PhD, is president of the Beck Institute for Cognitive Behavior Therapy (CBT) (beckinstitute.org), a nonprofit organization that provides state-of-the-art training and CBT certification to individuals and organizations, offers online courses on a variety of CBT topics, conducts research, and serves as a leading global resource for CBT. She is also Clinical Professor of Psychology in Psychiatry at the University of Pennsylvania Perelman School of Medicine. Dr Beck has written over 100 articles and chapters as well as books, workbooks, and pamphlets for professionals and nonprofessionals, including Cognitive Behavior Therapy, Third Edition: Basics and Beyond and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work. She has made hundreds of presentations nationally and internationally on various applications of CBT and is the primary developer of the Beck Institute’s online CBT training courses, which have been taken by health and mental health professionals in over 130 countries. Dr Beck maintains a clinical caseload at the Beck Institute’s in-house clinic in suburban Philadelphia, helping clients who are experiencing a range of challenges.
Aftab: CBT has had its fair share of criticisms over the years, and I have heard that Aaron T. Beck, MD, frequently engaged with (and at times even collaborated with) his critics. Is it accurate to say that your father’s ideas were not initially accepted by the mental health field? Do you think there are meaningful ways in which the field of CBT has benefitted from this engagement with the critics?
Beck: From the very beginning, CBT (or cognitive therapy as it was initially called) was not accepted by the psychoanalytic community, though my father’s ideas were favorably viewed among some psychologists, especially behavior therapists. He had originally trained as a psychoanalyst and then recognized that the theoretical constructs of psychoanalysis needed to be validated by research if psychoanalysis was to be accepted by other scientific fields.
At the time, he fully expected that his research would support the basic psychoanalytic tenets of depression. But he found the opposite. Most psychoanalysts rejected this research and later his development of cognitive therapy. More than a decade later, he found he was unable to get his first randomized controlled trial comparing imipramine with cognitive therapy for the treatment of depression published in journals. Initially he was also criticized by some behavior therapists but praised by others who integrated cognitive techniques into treatment. Throughout the years, my father has used valid criticism to refine his theories and treatment. For example, he has added a focus on processes as key agents of change. Depending on the cognitive formulation of the problem or disorder, and the individualized conceptualization of the disorder, he has supported including techniques from other evidence-based treatments. CBT has benefitted from legitimate criticism, and treatment has become more effective because of it.
Aftab: There appears to be considerable debate regarding manualized therapy in real-world clinical practice outside of research. Manuals have an understandable role to play in research settings, but to what extent should manuals constrain clinical practice? I might add here that during my own psychiatry residency training, I was taught CBT by a wonderful psychologist who emphasized basic principles of CBT and stressed the importance of developing an individualized CBT formulation to guide treatment, and I sometimes wonder how different that experience would have been if he had relied on manuals instead.
Beck: There are various forms of CBT and to be clear, what I am talking about is the type of CBT developed by my father in the 1960s and 1970s (and refined ever since). At the Beck Institute, we do not use manuals in treatment, and we do not usually endorse the use of manuals outside of research settings. As you mentioned, manuals have a place in clinical trials to ensure that protocol therapists are delivering the same treatment to research subjects. Without manuals, the strong evidence base for CBT would not exist. But in real world settings, patients are complex. For example: they frequently have comorbidities and differ in individual characteristics such as culture, education, developmental level, socioeconomic status, and so on. Good CBT therapists tailor treatment to each individual patient, guided by their cognitive conceptualization, the patient’s presenting problems, strengths, aspirations, and goals for treatment. The treatment plan is developed, and the therapeutic interventions are selected in collaboration with the patient.
Aftab: Should CBT in clinical practice be restricted at the outset to a certain number of sessions (say 10-20 sessions) the way it is done in research settings? Or is CBT in clinical practice intended to be more open-ended and goal-dependent? My clinical observation is that when duration of CBT is not individualized and when the number of sessions is capped beforehand (often due to insurance restrictions or administrative reasons), a substantial number of patients are forced to end therapy without having experienced meaningful improvement.
Beck: CBT in clinical practice should not be limited to a certain number of sessions. Many patients with straightforward cases of depression or anxiety can experience significant improvement within 6 to 12 sessions. However, patients with personality disorders, medical conditions, trauma histories, environmental stressors, and other complex conditions usually need a longer course of treatment. Of course, in practice, not all patients are able to complete a longer course of therapy due to monetary or practical constraints.
It is important that therapists understand and make every effort to work within these constraints, by being transparent with patients about their progress and making therapy as efficient as possible. We tell all our patients that it is not enough to come to therapy and talk for 50 minutes a week. The way they get better is to make small changes in their thinking and behavior every day. When therapists and patients finish discussing a problem or goal, therapists ask patients what they want to remember and what they want to do in the coming week. Then therapists motivate them to complete these Action Plans (formerly termed homework) between sessions to maximize the benefits of CBT and prevent relapse without prolonging treatment. Booster sessions, appropriately spaced in the weeks and months following the conclusion of treatment, are an effective way to ensure patient progress is maintained and that patients continue to practice their skills, and cope with new challenges that arise.
Aftab: Since the initial development of CBT for depression, we have seen the development of CBTs for a multitude of indications and special populations. Where has CBT been successfully applied over the decades?
Beck: This question has been answered by research. Hofmann and colleagues did a review of meta-analyses a few years ago.1 They found that CBT has been most successfully applied to anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. They also noted the efficacy of CBT in the treatment of depression, substance abuse, psychotic disorders, bipolar disorder, insomnia, personality disorders, criminal behaviors, and distress related to medical conditions. While most studies focus on adults, other studies show similar results for children and older adults. In addition, research has established the efficacy of appropriately tailored CBT in a multitude of settings: schools, residential programs, inpatient units, long-term psychiatric hospitals, forensic settings, community-based settings, and primary care and specialty medical clinics, to name a few.
Aftab: CBT for psychosis (CBTp) has emerged as a standard recommended treatment for schizophrenia in clinical practice guidelines such as by the National Institute for Health and Care Excellence in the United Kingdom and the American Psychiatric Association in the United States. Despite these recommendations, the availability of and access to CBTp remains limited. What are some of the difficulties that specialized interventions such as CBTp face with regards to dissemination, and what can be done about it?
Beck: One challenge with the dissemination of specialized treatment, perhaps especially one like CBTp, is the lack of availability of individual therapy within different treatment services. While those who are especially help-seeking or those who have the support of family or other loved ones may be able to access a private practice provider, there are many individuals who cannot. In state hospitals, on community teams, in the forensic system, in residences—this is where you see many individuals who are given serious mental health diagnoses. These services often do not have the resources to offer individual therapy. Even if they did, a portion of the individuals are not help-seeking or not interested in a treatment focused on symptoms they do not see as obvious problems.
My understanding is, that as currently practiced, CBTp is primarily conducted by licensed clinicians, the vast majority of whom are psychologists. In the community and hospital settings where most care is delivered, there are many staff from other disciplines where CBTp training is not offered (social workers, licensed counselors, recreational and art therapists, occupational therapists), not to mention nonlicensed and paraprofessional staff such as direct care and peer specialists whose scope of practice does not include CBTp.
Paul Grant, PhD, and my father developed recovery-oriented cognitive therapy (CT-R) to address these limitations.2 While it can be delivered as an individual therapy, CT-R also is a very efficient group approach. It can be the basis for the therapeutic milieu and the basis of treatment planning and team-based work. Licensed and nonlicensed professionals from all disciplines can do it. It is applicable in more settings, especially those that are low-resourced. CT-R uses the cognitive model to understand how individuals get stuck and then employs powerful interventions to engage them and collaborate with them to pursue the life of their choosing.
Aftab: The development of CT-R appears to be a productive integration of 2 seemingly quite different traditions, cognitive therapy on one hand, and the recovery movement on the other. What does the recovery model add to the traditional practice of CBT?
Beck: The power of CBT lies in the cognitive model that helps providers understand problems (eg, depression, anxiety, aggressive behavior, hallucinations, delusions, and negative symptoms) in terms of beliefs about the self, others, and the future. CBT includes specific interventions to address maladaptive beliefs and promote adaptive beliefs; it produces continued relief from distress and enables adaptive behavior.
Arthur Evans, PhD, in his previous role as commissioner of the department of behavioral health in Philadelphia, challenged my father and Paul Grant, now the codirector of the Recovery-Oriented Cognitive Therapy Program at Beck Institute, to develop a strong CT-R program for individuals diagnosed with serious mental health conditions who had historically been denied access to evidence-based practice and often languished in institutions. These individuals frequently do not seek help, do not engage in services easily, and can be very distrustful of care providers. The literature shows that they have the poorest outcomes in terms of life expectancy and quality of life.
In CT-R, the first step is to discover the individual behind the problems. Care providers focus less on psychiatric symptoms and more on identifying the life their patient wants to be living. The cognitive model turns out to be a great tool to conceptualize someone’s best self. CBT’s strengths are applied then to the whole individual. The CT-R team at Beck Institute has discovered ways to operationalize recovery principles: connection, trust, hope, purpose, and empowerment. And an age-old observation, that there are times when even the most withdrawn individuals seem more relaxed and connected to others, led to constructing the adaptive mode. This provides the framework for the strategy and interventions of CT-R, in which resilience and empowerment are emphasized. My father is first author on a recent book, Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions,2 which shows practitioners how to practice this adaptation. And I have described how to apply CT-R principles to individuals with acute disorders in the third edition of Cognitive Behavior Therapy: Basics and Beyond.3
Aftab: How crucial is the therapeutic relationship in the successful practice of CBT? To what extent is the therapeutic benefit of CBT a result of its specific technique vs a result of common factors such as a good therapeutic relationship?
Beck: The therapeutic relationship is paramount in CBT. One common misconception about CBT is that it is cold, rigid, and overly intellectual, and that a strong therapeutic relationship is not required. This could not be further from the truth. Good CBT therapists practice the Rogerian counseling skills of genuineness, warmth, and empathy, and they instill hope by being realistically optimistic about the patient’s situation. This is particularly important because CBT emphasizes collaboration between the patient and the therapist, both on the overarching goals of treatment, and on the issues discussed in session and the specific interventions selected. For the collaboration to be successful, the therapist must convey an accurate understanding of the patient, and the patient must trust the therapist and feel safe. CBT therapists ask for feedback at the end of each session and during the session when they notice a shift in patients’ affect. They respond to negative feedback by praising clients for being open with them. Then they conceptualize the difficulty and collaboratively plan a strategy to correct the problem. The number one rule of the therapeutic relationship, which I tell all of my trainees and psychiatric residents I teach is, “Treat every patient at every session the way you’d like to be treated if you were a patient.”
Aftab: Cognitive therapy focuses in part on the identification of cognitive distortions and negative automatic thoughts and schemas as targets of therapeutic change. In recent decades, the role of social and structural factors (such as racial inequalities and poverty) in the development of depression and other psychiatric disorders has also been recognized. There is a common criticism that sees CBT’s emphasis on locating dysfunction internal to the psyche as a way of erasing or ignoring the contributions of social injustice to psychological distress. What are your thoughts on this issue?
Beck: A patient’s cognitive conceptualization must take into account external factors that contributed to the development and maintenance of their disorder. These external factors include family history, socioeconomic status, education level, and racism or discrimination (either experienced or witnessed). Fortunately, there is much more literature and training available now that can help therapists understand the influence of social and economic factors on mental health and the development of disorders such as depression, substance use, and PTSD, among others. Much-needed work is being done by researchers around the world to adapt CBT to different cultures and populations, from different socioeconomic backgrounds, and in different settings. This is an important area for continued research and training.
Aftab: I encounter a variety of different attitudes with regards to the psychotherapy traditions, with different therapists having different views on how compatible and complementary these various psychotherapy traditions are, and whether clinicians should align their practice along a single orientation or multiple orientations. What are your views on how the different psychotherapy traditions relate to each other, and what is your advice to therapists with regards to the plurality of psychotherapy orientations?
Beck: In CBT, we incorporate techniques and interventions from other psychotherapeutic modalities, including acceptance and commitment therapy, dialectical behavior therapy, and mindfulness-based approaches, but our cognitive conceptualization of the patient according to the cognitive model always informs the selection of interventions. This is different from practicing eclectically. We follow the evidence and always use the best and most current research to guide our treatment decisions and select interventions.
Aftab: Dr Beck is one of the most influential figures in psychiatry and psychology and continues to do remarkable work even at the age of 100. Can you tell us about the work he is engaged in these days? What do you see as his most important legacy?
Beck: My father still works with his research team, formerly at the University of Pennsylvania and now at Beck Institute, on the development and dissemination of CT-R. He has developed several new theoretical models that underlie the treatment and apply broadly to various diagnoses. While I do think CT-R will be a key piece of his legacy, we should not forget that before him, there really was not a concept of evidence-based psychotherapy. It is because of his work that we now know talking therapies can be effective, and in some cases, even more effective than medication.
Aftab: What do you think the future of psychotherapy is? What would you like it to be?
Beck: A number of years ago, a colleague asked my dad whether he expected cognitive therapy to eventually dominate the field of psychotherapy. He responded, “I hope good therapy eventually dominates the field of psychotherapy. Just good therapy.” My father has always said, and I agree, that if significant research demonstrates greater support for the theoretical framework and treatment of a different psychotherapy, then that psychotherapy should supplant CBT. So far that has not happened. To the contrary, as the years have gone by, there is more and more support for CBT conceptually and in treatment efficacy.
In terms of the future of CBT, I think we will continue to use research from other fields (such as neurobiology, evolutionary biology, and cognitive science) to refine theory and guide therapy. We will continue to seek out what treatments work best for whom under what conditions. We will have a stronger emphasis on identifying key processes to target core mediators and moderators based on testable theories.
I think CBT will continue to be adapted for more problems, diagnoses, and conditions. We will train many kinds of caregivers, teachers, front-line workers, police, and even politicians. More and more health care providers, such as occupational therapists, physical therapists, primary and specialty care providers will use CBT. Eventually, if the US adopts a single-payer medical system, I think we will see a triage system like the Improving Access to Psychological Therapies program in the UK and other countries. We will see innovative ways to deliver treatment, such as by grandmothers sitting on friendship benches in Zimbabwe or lay counselors in primary care in India. We will see a greater use of technology for self-administered and computer-assisted therapy by way of apps and computer programs and a greater use of texting and telehealth services. We will also see applications of technology to better deliver training and supervision of trainees and for monitoring and evaluating therapists.
And if research continues to confirm the efficacy of CT-R, I predict that we will see principles of CT-R incorporated into the treatment of all individuals, regardless of diagnosis, severity of condition, setting, care provider, or delivery method.
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.
Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He can be reached at firstname.lastname@example.org or on twitter @awaisaftab.
Dr Aftab and Dr Beck have no relevant financial disclosures or conflicts of interest.
1. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.
2. Beck AT, Grant P, Inverso E, et al. Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions. Guilford Publications; 2020.
3. Beck JS. Cognitive Behavior Therapy: Basics and Beyond. Guilford Publications; 2020.