Table Of ContentCOGNITIVE THERAPY: BASICS AND BEYOND
COGNITIVE THERAPY:
BASICS AND BEYOND
Judith S. Beck, Ph.D.
Foreword by Aaron T. Beck, M.D.
The Guilford Press
New York London
1995 The Guilford Press
A Division of Guilford Publications
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Last digit is print number: 20 19 18 17 16 15 14
Library of Congress Cataloging-in-Publication Data
Beck, Judith S.
Cognitive therapy : basics and beyond / Judith S. Beck ; foreword
by Aaron T. Beck.
p.
cm.
Includes bibliographical references and index.
ISBN 0-89862-847-4
1. Cognitive therapy.
ÿ20I. Title.
[DNLM: 1. Cognitive Therapy—methods. WM 425.5.C6 B393c 1995]
RC489.C63B43
1995
616.89’142—dc20
DNLM/DLC
for Library of Congress
95-12521
CIP
To my father,
Aaron T. Beck, M.D.
Foreword
Foreword
FOREWORD
W
hat is the purpose of this book?” is a natural question raised by
the reader of any book on psychotherapy and to be addressed
in the foreword. To answer this question for readers of Dr. Ju-
dith Beck’s book, Cognitive Therapy: Basics and Beyond, I need to take the
reader back to the early days of cognitive therapy and its development
since then.
When I first started treating patients with a set of therapeutic proce-
dures that I later labeled “cognitive therapy,” I had no idea where this ap-
proach—which departed so strongly from my psychoanalytic train-
ing—would lead me. Based on my clinical observations and some
systematic clinical studies and experiments, I theorized that there was a
thinking disorder at the core of the psychiatric syndromes such as de-
pression and anxiety. This disorder was reflected in a systematic bias in
the way the patients interpreted particular experiences. By pointing out
these biased interpretations and proposing alternatives—that is, more
probable explanations—I found that I could produce an almost immedi-
ate lessening of the symptoms. Training the patients in these cognitive
skills helped to sustain the improvement. This concentration on
here-and-now problems appeared to produce almost total alleviation of
symptoms in 10 to 14 weeks. Later clinical trials by my own group and
clinicians/investigators elsewhere supported the efficacy of this ap-
proach for anxiety disorders, depressive disorders, and panic disorder.
By the mid-1980s, I could claim that cognitive therapy had attained
the status of a “System of Psychotherapy.” It consisted of (1) a theory of
personality and psychopathology with solid empirical findings to sup-
port its basic postulates; (2) a model of psychotherapy, with sets of prin-
ciples and strategies that blended with the theory of psychopathology;
vii
and (3) solid empirical findings based on clinical outcome studies to
support the efficacy of this approach.
Since my earlier work, a new generation of therapists/research-
ers/teachers has conducted basic investigations of the conceptual
model of psychopathology and applied cognitive therapy to a broad
spectrum of psychiatric disorders. The systematic investigations explore
the basic cognitive dimensions of personality and the psychiatric disor-
ders, the idiosyncratic processing and recall of information in these dis-
orders, and the relationship between vulnerability and stress.
The applications of cognitive therapy to a host of psychological and
medical disorders extended far beyond anything I could have imagined
when I treated my first few cases of depression and anxiety with cogni-
tive therapy. On the basis of outcome trials, investigators throughout the
world, but particularly the United States, have established that cognitive
therapy is effective in conditions as diverse as posttraumatic stress disor-
der, obsessive–compulsive disorder, phobias of all kinds, and eating dis-
orders. Often in combination with medication it has been helpful in the
treatment of bipolar affective disorder and schizophrenia. Cognitive
therapy has also been found to be beneficial in a wide variety of chronic
medical disorders such as low back pain, colitis, hypertension, and
chronic fatigue syndrome.
With a smorgasbord of applications of cognitive therapy, how can
an aspiring cognitive therapist begin to learn the nuts and bolts of this
therapy? Extracting from Alice in Wonderland, “Start at the beginning.”
This now brings us back to the question at the beginning of this fore-
word. The purpose of this book by Dr. Judith Beck, one of the new gen-
eration of cognitive therapists (and who, as a teenager, was one of the
first to listen to me expound on my new theory), is to provide a solid ba-
sic foundation for the practice of cognitive therapy. Despite the formida-
ble array of different applications of cognitive therapy, they all are based
on fundamental principles outlined in this volume. Other books (some
of them authored by me) have guided the cognitive therapist through
the maze of each of the specific disorders. This volume will take their
place, I believe, as the basic text for cognitive therapists. Even experi-
enced cognitive therapists should find this book quite helpful in sharp-
ening their conceptualization skills, expanding their repertoire of thera-
peutic techniques, planning more effective treatment, and
troubleshooting difficulties in therapy.
Of course, no book can substitute for supervision in cognitive ther-
apy. But this book is an important volume and can be supplemented by
supervision, which is readily available from a network of trained cogni-
tive therapists (Appendix D).
Dr. Judith Beck is eminently qualified to offer this guide to cognitive
therapy. For the past 10 years, she has conducted workshops and case
viii
Foreword
conferences and has lectured on cognitive therapy, supervised numer-
ous beginners and experienced therapists in cognitive therapy, helped
develop treatment protocols for various disorders, and participated ac-
tively in research on cognitive therapy. With such a background to draw
on, she has written a book with a rich lode of information to apply this
therapy.
The practice of cognitive therapy is not simple. I have observed a
number of participants in clinical trials, for example, who can go
through the motions of working with “automatic thoughts,” without any
real understanding of the patients’ perceptions of their personal world
or any sense of the principle of “collaborative empiricism.” The purpose
of Dr. Judith Beck’s book is to educate, to teach, and to train both the
novice and the experienced therapist in cognitive therapy, and she has
succeeded admirably in this mission.
AARON T. BECK , M.D.
Foreword
ix
Preface
Preface
PREFACE
W
hile presenting workshops and seminars both nationally and
internationally over the past 10 years, I have been struck by
three things. First is the growing enthusiasm for cognitive
therapy, one of a very few unified systems of psychotherapy that have
been empirically validated. Second is the strong desire of mental health
professionals to learn how to do cognitive therapy in a consistent way,
guided by a robust conceptualization and knowledge of techniques.
Third is the large number of misconceptions about cognitive therapy,
such as the following: that it is merely a set of techniques; that it
downplays the importance of emotions and of the therapeutic relation-
ship; and that it disregards the childhood origin of many psychological
difficulties.
Countless workshop participants have told me that they have been
using cognitive techniques for years, without ever labeling them as such.
Others, familiar with the first manual of cognitive therapy, Cognitive
Therapy of Depression (Beck, Rush, Shaw, & Emery, 1979), have struggled
with learning to apply this form of therapy more effectively. This book is
designed for a broad audience, from those mental health professionals
who have never been exposed to cognitive therapy before to those who
are quite experienced but wish to improve their skills of conceptualizing
patients cognitively, planning treatment, employing a variety of tech-
niques, assessing the effectiveness of their treatment, and specifying
problems that arise in a therapy session.
In order to present the material as simply as possible, I have chosen
one patient to use as an example throughout the book. Sally was my pa-
tient when I started writing this book several years ago. She was an ideal
patient in many ways, and her treatment clearly exemplified “standard”
xi
cognitive therapy for uncomplicated, single-episode depression. To
avoid confusion, Sally and all other patients mentioned in this book are
designated as female, while therapists are referred to as male. These des-
ignations are made to present the material as clearly as possible and do
not represent a bias. In addition, the term “patient” is used instead of
“client” because that designation predominates in my medically ori-
ented work setting.
This basic manual of cognitive therapy describes the processes of
cognitive conceptualization, planning treatment, structuring sessions,
and diagnosing problems which should prove useful for any patient. Al-
though the treatment described is for a straightforward case of depres-
sion, the techniques presented also apply to patients with a wide variety
of problems. References for other disorders are provided so that the
reader can learn to tailor treatment appropriately.
This book could not have been written without the ground-breaking
work of the father of cognitive therapy, Aaron T. Beck, who is also my fa-
ther and an extraordinary scientist, theorist, practitioner, and person.
The ideas presented in this book are a distillation of many years of my
own clinical experience, combined with reading, supervision, and dis-
cussions with my father and others. I have learned a great deal from ev-
ery supervisor, supervisee, and patient with whom I have worked. I am
grateful to them all.
In addition, I would like to thank the many people who provided me
with feedback as I was writing this book, especially Kevin Kuehlwein,
Christine Padesky, Thomas Ellis, Donald Beal, E. Thomas Dowd, and
Richard Busis. My thanks to Tina Inforzato, Helen Wells, and Barbara
Cherry who prepared the manuscript, and to Rachel Teacher, B.A., and
Heather Bogdanoff, B.A., who helped with the finishing touches.
xii
Preface
Contents
Contents
CONTENTS
Chapter 1. Introduction
1
Chapter 2. Cognitive Conceptualization
13
Chapter 3. Structure of the First Therapy Session
25
Chapter 4. Session Two and Beyond: Structure and Format
45
Chapter 5. Problems with Structuring the Therapy Session
63
Chapter 6. Identifying Automatic Thoughts
75
Chapter 7. Identifying Emotions
94
Chapter 8. Evaluating Automatic Thoughts
105
Chapter 9. Responding to Automatic Thoughts
125
Chapter 10. Identifying and Modifying Intermediate Beliefs
137
Chapter 11. Core Beliefs
166
Chapter 12. Additional Cognitive and Behavioral Techniques
193
Chapter 13. Imagery
229
Chapter 14. Homework
248
Chapter 15. Termination and Relapse Prevention
269
Chapter 16. Treatment Planning
284
Chapter 17. Problems in Therapy
300
Chapter 18. Progressing as a Cognitive Therapist
312
xiii
Appendix A. Case Summary Worksheet
315
Appendix B. A Basic Cognitive Therapy Reading List for
Therapists
319
Appendix C. Cognitive Therapy Reading List for Patients
(and Therapists)
322
Appendix D. Cognitive Therapy Resources
323
References
325
Index
331
xiv
Contents
Introduction
Cognitive Therapy: Basics and Beyond
Chapter 1
INTRODUCTION
C
ognitive therapy was developed by Aaron T. Beck at the University
of Pennsylvania in the early 1960s as a structured, short-term,
present-oriented psychotherapy for depression, directed toward
solving current problems and modifying dysfunctional thinking and be-
havior (Beck, 1964). Since that time, Beck and others have successfully
adapted this therapy to a surprisingly diverse set of psychiatric disorders
and populations (see, e.g., Freeman & Dattilio, 1992; Freeman, Simon,
Beutler, & Arkowitz, 1989; Scott, Williams, & Beck, 1989). These adapta-
tions have changed the focus, technology, and length of treatment, but
the theoretical assumptions themselves have remained constant. In a
nutshell, the cognitive model proposes that distorted or dysfunctional
thinking (which influences the patient’s mood and behavior) is com-
mon to all psychological disturbances. Realistic evaluation and modifi-
cation of thinking produce an improvement in mood and behavior. En-
during improvement results from modification of the patient’s
underlying dysfunctional beliefs.
Various forms of cognitive–behavioral therapy have been devel-
oped by other major theorists, notably Albert Ellis’s rational–emotive
therapy (Ellis, 1962), Donald Meichenbaum’s cognitive–behavioral
modification (Meichenbaum, 1977), and Arnold Lazarus’s multimodal
therapy (Lazarus, 1976). Important contributions have been made by
many others, including Michael Mahoney (1991), and Vittorio Guidano
and Giovanni Liotti (1983). Historical overviews of the field provide a
rich description of how the different streams of cognitive therapy origi-
nated and grew (Arnkoff & Glass, 1992; Hollon & Beck, 1993).
Cognitive therapy as developed and refined by Aaron Beck is em-
phasized in this volume. It is unique in that it is a system of psychother-
apy with a unified theory of personality and psychopathology sup-
ported by substantial empirical evidence. It has an operationalized
1
