Beck's Cognitive Therapy: Distinctive Features [2 ed.] 0367519488, 9780367519483

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Beck’s Cognitive Therapy

Beck’s Cognitive Therapy explores the key contributions made by Aaron T. Beck to the development of cognitive behaviour therapy. The book describes the development of the unique model of therapy developed by Professor Aaron. T. Beck and his daughter, Dr. Judith. S. Beck. The first part on theory explains how the Becks understand psychological problems. The second part on practice describes the main methods and skills that have evolved in cognitive therapy. Updated throughout to include recent developments, this revised edition of Beck’s Cognitive Therapy will be ideal for both newcomers and experienced practitioners. Frank Wills has been a cognitive therapist, author, and trainer over many years. He has been keen to promote a pluralistic model of practice that is grounded in emotional and interpersonal, as well as cognitive, skills.

CBT Distinctive Features Series Editor: Windy Dryden

Cognitive behaviour therapy (CBT) occupies a central position in the move towards evidence-based practice and is frequently used in the clinical environment. Yet there is no one universal approach to CBT and clinicians speak of first-, second-, and even third-wave approaches. This series provides straightforward, accessible guides to a number of CBT methods, clarifying the distinctive features of each approach. The series editor, Windy Dryden, successfully brings together experts from each discipline to summarise the 30 main aspects of their approach divided into theoretical and practical features. The CBT Distinctive Features Series will be essential reading for psychotherapists, counsellors, and psychologists of all orientations who want to learn more about the range of new and developing cognitive behaviour approaches. Recent titles in the series: Mindfulness-Based Cognitive Therapy 2nd Edition by Rebecca Crane Emotional Schema Therapy by Robert L. Leahy Cognitive Behavioural Chairwork by Matthew Pugh Motivational Cognitive Behavioural Therapy by Cathy Atkinson, Paul Earnshaw Integrating CBT and ‘Third Wave’ Therapies by Dr Fiona Kennedy and Dr David Pearson Rational Emotive Behaviour Therapy: Distinctive Features 3rd Edition by Windy Dryden Beck’s Cognitive Therapy: Distinctive Features Second Edition by Frank Wills For further information about this series please visit www.routledge.com/CBT-Distinctive-Features/book-series/DFS

Beck’s Cognitive Therapy Distinctive Features Second Edition

Frank Wills

Second edition published 2022 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 Frank Wills The right of Frank Wills to be identifed as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifcation and explanation without intent to infringe. First edition published by Routledge 2009 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record has been requested for this book ISBN: 978-0-367-51948-3 (hbk) ISBN: 978-0-367-51947-6 (pbk) ISBN: 978-1-003-05579-2 (ebk) Typeset in Times New Roman by Deanta Global Publishing Services, Chennai, India

To Ann Hackmann, my former supervisor, tutor and mentor, who sadly is no longer with us, in body anyway. Also to my other former supervisors, Melanie Fennell and Adrian Wells, and to my current supervisor, Elaine Davies, who never forgets that the fnal letter in CBT stands for ‘therapy’!

Contents

Acknowledgement Introduction: From Kraepelin to Beck to us Part I THEORY 1 Aaron. T. Beck: His life and the development of the principles of cognitive therapy 2 Problem areas in psychological functioning are marked out by specifc cognitive themes and processes 3 Cognitive therapy addresses a variety of levels and types of cognition: We begin with Beck’s discovery of ‘automatic thoughts’ 4 Cognitive distortions play a key role in psychological problems 5 Cognitive organisation is underpinned by deep modes, schemas, beliefs, and assumptions 6 Cognitive therapy draws richly on evolutionary theory 7 Images also refect key elements of cognitive distortions

x 1 5 7 16 20 24 28 32 36

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ConTEnTs

8 Cognition, emotion, behaviour, and physiology interact with mutual and reciprocal infuence on each other 9 safety behaviours, including avoidance, overpreparation, and reassurance seeking, play a major role in maintaining anxiety 10 Understanding the role of negative biases in attention strengthens cognitive therapy 11 Metacognitive analysis strengthens our understanding of psychopathology 12 Mindfulness has added power and subtlety to cognitive therapy 13 Cognitive therapy is a formulation-driven and conceptualisation-driven form of psychological therapy 14 Beckian epistemology has a clear research process for developing appropriate therapeutic knowledge 15 Therapy protocols have played a role in the development of the cognitive approach Conclusion to Part I Part II POINTS OF PRACTICE 16 Cognitive therapy requires a collaborative therapeutic relationship 17 Cognitive therapists, like other therapists, use conceptualisations to tackle interpersonal and alliance issues 18 Cognitive therapy is, at least initially, a timesensitive and relatively structured form of therapy 19 Cognitive therapy is problem- and goal-orientated, and is focused, initially at least, on ‘here and now’ functioning

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40 46 50 54 58 62 69 73 77 79 81 85 89 94

ConTEnTs

20 Cognitive therapy has an educational focus and uses regular homework 21 Cognitive therapy has a well-identifed set of methods and skills 22 Cognitive therapy builds on the identifcation of unhelpful automatic thoughts 23 Cognitive therapists teach clients to evaluate and then respond to their negative thoughts 24 Cognitive therapists have developed methods for identifying beliefs and schemas 25 Cognitive therapy has methods for working on unhelpful beliefs and schemas 26 Cognitive therapy has been strengthened by including interventions focused on emotions and imagery 27 Cognitive therapists use a variety of methods to promote behaviour change 28 Cognitive therapy has developed new ways of working with cognitive processes, especially via mindfulness 29 Cognitive therapists are key participants in large systems delivering psychological therapy 30 Cognitive therapy aspires to be a unifying model: Both in terms of using concepts and skills from other therapies, and of offering them its own methods Concluding comments: Let’s all raise a glass to Aaron ‘Tim’ Beck Bibliography Index

98 102 109 113 118 122 128 133 137 141

146 150 153 170

ix

Acknowledgement

Many people have helped me along the Beckian Way. On this occasion, I would particularly like to acknowledge students and colleagues at the former University of Wales Newport. With regard to the book itself, I have once again had the wonderful editorial support from my darling wife, Annie. Annie has provided study support to students of as widely diverse subjects as Nuclear Physics and Existential Theology, so ‘Beck’s Cognitive Therapy’ offered very little problem to her! I would also like to thank my redoubtable and helpful reader colleagues, Elaine Davies, Janet Gray, Isobel Cook, and Emile Gardner. On the publication editing side, I would also like to thank Windy Dryden, Joanne Forshaw, and Daradi Patar for their guidance and support.

x

Introduction From Kraepelin to Beck to us

I began my career in mental health in 1971 – some 50 years after the birth of Aaron Beck. I can remember the forbidding atmosphere that still pervaded psychiatric hospitals in those days. I soon, however, became aware of more interesting ideas for helping patients than incarcerating them – first, mostly from the behavioural and psychodynamic perspectives. Though I found their ideas engaging, there was for me something fundamentally lacking in both of them. Then, a little later, I heard about cognitive approaches – first, George Kelly’s Personal Construct Theory and then, Albert Ellis’ Rational Emotive Behaviour Therapy (REBT). In 1982, I attended a course in which Beck’s work was discussed and I thought that it sounded very interesting – a little later, I saw Cognitive Therapy of Depression in the library of a college where I was teaching. Reading it in a library alcove and totally absorbed, I missed the library’s closing bell and was nearly locked in for the night. It took another ten years before I had the privilege of joining the second cohort to be trained in Beck’s cognitive therapy at the Oxford Cognitive Therapy Centre. I was supervised by Melanie Fennell, Ann Hackman, and Adrian Wells, and taught by, among others, David. M. Clark and Paul Salkovskis, all subsequently influential figures in the cognitive therapy field. For me, training in cognitive therapy was a transformative experience, both professionally and personally. This book distils the 1

InTroDUCTIon

experience of the subsequent 30 years of implementing cognitive therapy in practice. I have walked the Beckian Way – with all its satisfactions and all its challenges. Beck also was shocked by the conditions in the psychiatric hospitals that he first encountered. His first departmental chairman followed the ideas of Kraepelin – a major figure of pre-Second World War psychiatry – who believed that there were just two disorders, neither of which could be treated. This was, Beck wryly notes, “not a very favourable introduction to someone who wanted to actually help people” (Beck & Beck, 2011, p. 1). The Kraepelinian medical tradition symbolises the forbidding psychiatric institutions of my early years in the field.1 Beck determined that this spirit was not going to limit his vision of what might be possible for him and his patients. In the broader sense, this is the way we have all been travelling since Beck’s arrival on the scene. This book tells the story of how Beck and his followers have developed a set of theoretical concepts and practical ideas that built a major framework for contemporary psychotherapy and counselling. Although these concepts and ideas seemed very new at first, they were grounded in a profound respect for the psychotherapy process. Since the start, they have been continually tested and retested in the research of now several generations of researchers and in the reality of everyday work of practitioners such as his daughter, Judith Beck. Many have been inspired by Beck’s emphasis on being guided by the data and of taking nothing for granted. Despite reaching the age when many retire, Beck has continued to write and teach and has shown a refreshing tendency to rethink and update his work, literally right up to the time of this publication. Although his core ideas have endured, continued new developments have kept them alive and vital. He has never been afraid to let respected allies take his ideas and run with them, as has happened in many of the ‘third wave’ developments in cognitive behaviour therapy

2

InTroDUCTIon

(CBT).2 These twin qualities of continued openness and ability to cooperate with others have ensured that his ideas remain as relevant today as ever. Notes 1 On a personal level, this went even further back, since I had, in Chester ‘Asylum’, a sweet uncle, Ted, whom I used to visit as a young child. He had been institutionalised there since the 1920s. 2 This book follows the convention of regarding Beck’s cognitive therapy as the most influential model within the wider family school of cognitive-behavioural therapies.

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Part I THEORY

1 Aaron. T. Beck His life and the development of the principles of cognitive therapy Aaron Beck was born to a family of Russian Jewish origin in Providence, Rhode Island in July 1921. He supported the Boston Red Sox baseball team and has joked that it was their disastrous runs of form in the 1950s and 1960s that first made him think of studying depression1. He suffered serious illness as a young child but overcame these difficulties and became an energetic and determined person. His vigour is still evident and almost 100 years after his birth, he is still writing and giving interviews. He married Phyllis in 1950 and had three children, the second of whom, Judith. S. Beck, went on to become his major collaborator and will figure prominently in this book. After medical training, he gravitated towards neurology but in 1950 became, initially reluctantly, involved in psychiatry. Following the orthodox route of those days, he completed training in psychoanalysis but, whilst admiring that model, later moved away from it. It now seems that it was the authoritarian behaviour of his local psychoanalytic establishment more than the therapeutic method itself that pushed Beck away (Rosner, 2018). He did not like the way psychiatrists dismissed their patients’ capacity for ‘common sense’ and he seems to have longed to evolve a more democratic way of treating patients. The Beck family has a tradition of sympathy for the liberal politics of the Democratic Party, which from 1960 onwards supported the development of community mental health in the United States. This support came full circle in 2013 when Beck was given a Kennedy Forum award 2 to mark 50 years since the first community mental health act, describing 7

THEory

him as “one of the most influential individuals within community mental health” (Penn Med News, 28 October, 2013). From his earliest days, Beck showed curiosity and favoured empiricism. During his research on the concepts underlying psychoanalytic therapy, he slowly began to develop a cognitive basis for understanding psychopathology. After an intense period of research and experimentation focused on depression in the early 1960s, Beck published a landmark study, Depression: Clinical, Experimental and Theoretical Aspects, in 1967. The impact of this book led to trials of treatment based on cognitive principles at Beck’s Mood Clinic at the University of Pennsylvania. The trials produced notably good results and when Beck and his colleagues in 1979 published a book, Cognitive Therapy of Depression, based on their treatment protocol, this publication had a major, worldwide impact on the fields of psychological therapy and psychiatry (Weishaar, 1993). Beck’s work was by this time attracting international recognition and he proved himself very effective in inspiring others, in and beyond the United States – and perhaps especially in the UK. As he extended his approach from depression to some of the anxiety disorders (Beck & Emery, 1985), others extended it to areas such as obsessive compulsive disorder (Clark, D.A., 2019), posttraumatic stress disorder (Ehlers & Clark, 2000), schizophrenia (Kingdon et al., 1994), and many other psychiatric problems (Salkovskis, Ed., 1996c). Beck (1991) addressed a question posed 15 years earlier, “Can a fledgling psychotherapy challenge the giants of the field?” (Beck, 1976, p. 333). By 1991 he could answer in the affirmative. Beck has always claimed an even greater goal than establishing a specific model of therapy, namely to influence permanently the wider practice of psychological therapy and to push it towards more effective methods. Whilst this book aims to describe the development of Beck’s cognitive therapy model, it will in its second half also explore this wider goal. In 1994, Beck began to pull back from everyday work at the University of Philadelphia. He and his daughter, Judith, who had by this time trained as a cognitive therapist and was beginning 8

AAron. T. BECK

to write herself, co-founded the Beck Institute for Cognitive Therapy (later Cognitive-Behaviour Therapy3). Beck has continued to research and write widely and productively and to promote cognitive therapy internationally. Judith published an influential text, Cognitive Therapy: Basics and Beyond, in 1995 – with revised editions in 2011 and 2021. As he has negotiated his eighties and nineties, Beck has remained incredibly productive, with the pace of his work only dropping off somewhat. He now has over 600 publications and continues to give seminars and interviews for the Institute’s website, often available via YouTube. So, as ever with Beck, there is a good deal of necessary updating from the 2009 first edition of this book. In the final pages of his 1967 publication on depression, Beck offered the first description of what his cognitive therapy model would look like, including the principles on which it would be based. These principles were further elaborated on in his 1976 book, Cognitive Therapy and the Emotional Disorders, and again in Beck et al. (1979) Cognitive Therapy of Depression. They were formally stated as a set of principles in Chapter 10 of Beck and Emery (1985). Judith Beck has reviewed and represented these principles in her 1995 book, and again in its 2011 and 2021 revisions. The set of principles – listed below – has therefore been a consistent feature of Beck’s cognitive therapy for over 50 years and reliably differentiates it from other comparable models (Wills, 2008a). The principles therefore offer a valid template around which this book, which aims to review the model and its development, can be structured: a) Cognitive therapy is based on an ever-evolving conceptualisation. b) Cognitive therapy requires a sound therapeutic relationship. c) Cognitive therapy requires collaboration and active participation. d) Cognitive therapy aims to be time-sensitive. e) Cognitive therapy sessions are structured. 9

THEory

f) Cognitive therapy is aspirational, value-based and goal-oriented. g) Cognitive therapy initially emphasises the present. h) Cognitive therapy is educative, aiming to teach clients to be their own therapist, and emphasises relapse prevention. i) Cognitive therapy uses action plans (therapy homework). j) Cognitive therapy aims to use guided discovery and teaches clients to respond to their dysfunctional cognitions. k) Cognitive therapy uses a variety of techniques to change thinking, mood and behaviour. Table 1.1 charts the development of the form of these principles from 1985 onwards: Part I of this book – on the theoretical underpinnings of Beck’s Cognitive Therapy – will focus on elaborating the theoretical aspects of the key elements in cognitive therapy conceptualisation (principle a, above) – elements such as cognitions linked to specific problems, problematic cognitive schemas, negative thoughts, cognitive distortions, negative attentional factors, etc. Part II on the practice elements of Beck’s model will focus on methods and the more strategic factors involved in principles b through k, above. Further aspects of Beck’s life and research are highlighted through all these points, and a new factor will also be addressed – the implementation of CBT services via the Improving Access to Psychological Therapy (IAPT)4 project in the book’s conclusion. In the 2021 edition of her major text, Judith Beck has introduced some important new ideas and principles of cognitive therapy. To some extent these represent an updating of the model – and will, I think, make it more appealing to a wider group of therapists and counsellors. In particular, she has stressed the importance of using Rogerian counselling skills, including the strengths and adaptive beliefs of clients (NB: no longer ‘patients’5) in conceptualisations, exploring clients’ values and aspirations, and ensuring that CBT is culturally sensitive. 10

1. CT is based on an everevolving formulation of the patient and her problems in cognitive terms

7. CT aims to be time-limited 2. CT requires a sound therapeutic alliance

1. CT is based on the cognitive model of emotional disorders

2. CT is brief and time-limited 3. A sound therapeutic relationship is a necessary condition for effective CT 4. Therapy is a collaborative effort between TH & CL 5. CT uses primarily the Socratic method 6. CT is structured and directive

1. CBT treatment plans are based on an ever-evolving conceptualisation

1. CBT is based on an everevolving formulation of the patients’ problems and an individual conceptualisation of each patient in cognitive terms 7. CBT aims to be time-limited 2. CBT requires a sound therapeutic alliance

8. CT sessions are structured

8. CBT sessions are structured 11. CBT sessions are structured (Continued)

6. CBT stresses collaboration and active participation

2. CBT requires a sound therapeutic alliance

10. CBT is time-sensitive

Beck, J.S. (2020)

Beck, J.S. (2011)

3. CT emphasises 3. CBT emphasises collaboration and active collaboration and active participation participation

Beck, J.S. (1995)

Beck, A.T. & Emery, G. (1985)

Table 1.1 The development of the principles of Beck’s cognitive therapy.

AAron. T. BECK

11

12

Beck, J.S. (1995)

Beck, J.S. (2011)

9. The theory and techniques of CT rely on the inductive method 10. Homework is a central feature of CT

8. CT is based on an educational model

5. CT emphasises the present 9. CT teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs

7. CBT is aspirational, values-based, and goal-oriented 9. CBT is educative

Beck, J.S. (2020)

13. CBT uses action plans (therapy homework) 5. CBT emphasises the present 8. CBT initially emphasises the present 12. CBT uses guided 9. CBT teaches patients discovery and teaches to identify, evaluate, clients to respond to and respond to their their dysfunctional dysfunctional thoughts and cognitions beliefs

6. CBT is educative, aims 6. CT is educative, aims to teach the patient to to teach the patient to be her own therapist, be her own therapist, and emphasises relapse and emphasises relapse prevention prevention

7. CT is problem-oriented 4. CT is goal-oriented and 4. CBT is goal-oriented and problem-focused problem-focused

Beck, A.T. & Emery, G. (1985)

Table 1.1 Continued

THEory

10. CT uses a variety of techniques to change thinking, mood, and behaviour

10. CBT uses a variety of techniques to change thinking, mood, and behaviour

14. CBT uses a variety of techniques to change thinking, mood, and behaviour 3. CBT continually monitors client progress 4.CBT is culturally adapted and tailors treatment to the individual 5. CBT emphasises the positive

AAron. T. BECK

13

THEory

Norman Cotterell, an African-American therapist at the Beck Institute, has written (Cotterell & Friedman-Wheeler, 2020) that all must work for institutional, systemic and policy change if we are ever to mitigate the harms to people of color, and we believe psychologists can play an important role in effecting change at a systemic level … interventions at multiple levels (individual, community, systemic) may complement each other in the fight against racism. In June 2020, as America was embroiled in the turmoil that followed the killing of George Floyd, Judith Beck issued a strong press release about “the heart-breaking and frightening events that have unfolded in Philadelphia over the last week” and expressed “solidarity with individuals facing systemic injustice and those who have joined them in protest … today and every day” (https:// beckinstitute.org/letter-to-the-community, 6//6/20). The additional principles articulated by Judith Beck can renew the progressive agenda within cognitive therapy for our times but are especially important in the very latest evolution of the Beckian model – recovery-oriented cognitive therapy (CT-R: Beck et al., 2020; Beck, J.S., 2021). In her preface, Judith Beck (2021) describes her pleasure on completing this third edition and adds some nice personal touches – for example, she says that when she began as a cognitive therapist she was not very good at it. Her work and her new ‘third edition’ ideas are described throughout this book, especially in its second part. Notes 1 I have made a similar claim about my football (soccer) team, Tranmere Rovers FC (Wills, 2008b). 2 The award was presented to Beck by the then Vice President, Joe Biden. 14

AAron. T. BECK

3 This book follows the convention of regarding Beck’s cognitive therapy as the most influential model within the wider family school of cognitive-behavioural therapies. 4 It should be acknowledged that although CBT is a major part of the current IAPT service, it is not the sole type of therapy on offer. 5 ‘Homework’ (another unpopular word with therapists and clients) has become ‘action plan’.

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2 Problem areas in psychological functioning are marked out by specifc cognitive themes and processes By the early 1960s, Beck’s psychiatric career was underway, and, as he researched psychoanalytic concepts and focused his practice on depression, he experienced a succession of surprise discoveries and ‘light bulb’ moments that gradually cohered into the development of cognitive therapy. The first one came from restating the psychoanalytic theory of depression in different terms. There was, as the theory predicted, a theme of hostility towards the self but it was not in the nature of a motivational ‘need to suffer’ but rather a pervasive negative bias in the patient towards himself (Beck, 1967). Beck developed focused experiments (Weishaar, 1993) and one, for example, showed that not only did depressed patients not have a need to suffer but rather, they craved positive feedback and felt disturbed in its absence (Loeb et al., 1964). Beck gradually located the key themes of depression in patients’ thinking, attitudes, and beliefs. He elaborated sub-themes in self-hostility: low self-esteem, self-blame, deprivation, loss, defeat, overwhelming responsibilities, and the desire to escape, the latter including suicidal wishes – a set of aspects that constitute what we now know is the cognitive ‘architecture’ of depression. As a scientist who valued precision, Beck was dissatisfied by what he saw as the vagueness and esoteric nature of psychoanalytic concepts – and crucially, by their non-specific use to explain many widely different problems. As a novice therapist working within a psychodynamic ambience, I too noticed how often clients’ problems were attributed to the ‘oedipal complex’ – “We blame the mothers and all go happily home”, as one of my colleagues put it. Beck of course had patients with problems other 16

ProBLEM ArEAs In PsyCHoLogICAL FUnCTIonIng

than depression and noticed different themes in their thoughts and attitudes. In anxiety, the central theme was ‘personal danger’ and in hypomania, ‘self-enhancement’, and in hostile paranoid states, ‘accusations against others’ (Beck, 1963, p. 326). Beck describes how the ‘cognitive specificity’ hypothesis operates in terms of both understanding and treating problems in that, “Each disorder has its own specific conceptualization1 and relevant strategies … [for treatment]” (1991, p. 368). The concept – that specific thoughts can be linked to specific emotions and problems – was subsequently applied to an ever-widening group of psychological problems and has good empirical support (Clark & Steer, 1996). The different problems that therapists face therefore became increasingly marked out by specific cognitive themes. Beck elaborated on these themes and described the typical thoughts that went with them. Depressed clients, for example, reported thoughts tinged with loss (e.g., “Nobody wants me anymore”) and defeat (“I was crushed”). Anxious clients, however, reported thoughts of future threat, such as, “I will be hurt by this” and “I will not cope with it”. Hostile and angry clients reported thoughts about transgression and injustice. Transgressions might be sins of commission (“He treated me like dirt”) or sins of omission (“She seemed to forget that I have needs as well”). Knowing the style of these thoughts is very helpful for therapists, like having a good guidebook to a new city. The reader will note the frequent presence of interpersonal themes in these thoughts – though they can also be intra-personal, especially in critiquing the self, for example, “I am weak”, and “I’m a loser”. Even in these thoughts, however, one can discern implicit interpersonal themes, as they are often predicated on the existence of other people who are ‘strong’ and ‘winners’ and with whom clients may be comparing themselves – a frequent preoccupation for those experiencing psychological problems. Beck has inspired and drawn young researchers into his ‘group’ – both in the United States and internationally. The ‘cognitive specificity’ template was thereby extended over many decades. Research findings have verified these cognitive themes as 17

THEory

significantly discernable between different client problem groups (Clark & Steer, 1996). The list of specific themes now includes, amongst others, those listed in Table 2.1. Table 2.1 specifc cognitive themes in specifc psychological disorders

Problem area

Cognitive themes

Researchers/Authors

Depression Anxiety Panic

Loss, defeat Danger, threat Physical, mental catastrophe Inflated responsibility Permissive beliefs Self-criticism Fear of evaluation Impending threat

Clark, D.A. & Beck, A.T. (1999) Clark, D.A. & Beck, A.T. (2011) Clark, D.M. (1996)

OCD Substance abuse Eating disorders Social anxiety PTSD

Clark, D.A. (2019) Morin et al. (2017) Fairburn (2008) Veale (2003) Ehlers & Clark, D.M. (2008)

This simple table cannot represent the full scope of the cognitive architecture of these problem areas and readers are encouraged to go to the cited authors and to make themselves conversant with the richness of this work. The emphasis on cognitive content specificity is relatively unique to Beck’s cognitive therapy, even amongst other cognitive behaviour therapy (CBT) models. Dobson et al. (2018) argue that the cognitive content specificity hypothesis holds a crucial place in the theory and practice of cognitive therapy because it drives key elements of the therapist’s interventions. Whilst research has shown strong correlations between cognitive content and psychopathology, research to test causal links is less clear. Causality is of course complex and the cognitive therapy theory has increasingly adopted a ‘stress-diathesis’ – where ‘stress’ refers to a triggering factor in the here and now, and ‘diathesis’ to pre-existing vulnerabilities – model of causality (Beck & Haigh, 2014). Stress diathesis accepts that the aetiology (i.e., the set of causes) of depression, for example, involves multiple factors, cognitive and non-cognitive, including 18

ProBLEM ArEAs In PsyCHoLogICAL FUnCTIonIng

genetics, neurobiology, socio-economic, and health issues (Beck, 2008). Although not all these factors operate in all depressed clients, cognitive themes are more evident the stronger symptoms are. The cognitive specificity concept has served therapists well but it is now acknowledged that there is more ‘transdiagnostic’ (across disorders) overlap between different problems than was previously recognised (Harvey et al., 2004; Barlow et al., 2017). Although self-focus, for example, was identified as a key theme in social anxiety (Clark & Wells, 1995), Beck (2013) has however noted that “every disorder has some degree of self-focus” and we can think of chronic pain, health anxiety, OCD, and depression, amongst other problems, where this holds true. There is now also an aspiration to bring therapeutic models of psychological problems more in line with neuroscientific ones (Disner et al., 2011) – and to make psychological models more homogeneous and relevant (Beck & Haigh, 2014). Note 1 The words ‘conceptualisation’ and ‘formulation’ have similar meanings but can be used variably by different authors. Here Beck uses ‘conceptualisation’ to refer to building a general model for a specific disorder. This text will follow Judith Beck’s (2021) current use of this term for models of individual clients’ functioning and will use formulation for general models of disorder.

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3 Cognitive therapy addresses a variety of levels and types of cognition We begin with Beck’s discovery of ‘automatic thoughts’ Most practitioners will have had the experience of going to some trouble to learn a new approach or method, only to find it rejected – politely or otherwise – by a client who had seemed to be well fitted for its use. It is a moment of truth – will we have the grace and humility to be open to what the client is saying? Carl Rogers seems to have had such a moment when a client asked if he could put aside Rogers’, at that time, didactic approach so that the client could tell his story in his own way – leading Rogers to the ideas that crystallised into person-centred therapy (Thorne, 1992). Aaron Beck had a similar experience in 1956 and he, like Rogers, responded openly. This is one reason why I think of him as person-centred in the sense that matters most. This clinical experience, now well known, came to Beck with a female patient, who had previously had no trouble in using ‘free association’ to explore her sexual experiences in analysis (Beck, 1976, pp. 29–33)1. On this occasion, however, Beck sensed she was hesitant and his probes revealed that, rather than suffering from the effects of sexual repression, she had thought that she must be boring him and feared that he might “get rid” of her. Though she had at first half-heartedly assented with his psychoanalytic interpretation, he now realised that it was the automatic thought “I am boring him” that had driven her response. Furthermore, the thought made much more sense of both her main symptom – anxiety – and her wider psychological state. If she thought that she bored men, then this could explain her apparent difficulties in relationships with them. 20

CognITIvE THErAPy ADDrEssEs A vArIETy

Beck (1967) notes that the professional literature of that era rarely focused on the role of negative thoughts in psychological problems (Figure 3.1) so that it was unsurprising that therapists rarely reported finding them. These thoughts are automatic because they seem to come out of the blue in an involuntary fashion. They have a number of other characteristics that mean they act as potentially lethal causes of mental disturbance. They can, for instance, come, as we English say, like ‘London buses’, though in this case the buses are full of negativity, not cheery Cockneys. They run alongside the client’s more conscious thoughts. Although they are fleeting, they are also paradoxically enduring. They are highly plausible to the client – and can seem to be just how life is – that is, that the client really is “a failure that nobody wants”. They are closely linked to negative feelings – it would be hard to have such thoughts without feeling sad and low. Research evidence shows that non-depressed people are much less likely to have them and sufferers too, once depression remits, will have them more rarely. Often such thoughts seem to lack logic and supporting evidence – yet we can usually sense at least a grain of truth in them. Beck studied logic and rhetoric as a student and became good at spotting distorted thoughts and at helping clients to rethink them. Despite their often obvious flaws, negative thoughts can be difficult SCHEMA: provide the general ‘feel’ of the situation as perceived by mind, senses and ‘gut feeling’ CORE BELIEFS: Supply the belief content of the schemas, often in basic ‘black and white’ terms (I am good or I am bad) and orientate the person towards self, others and the universe/future. ASSUMPTIONS: Because the unconditional nature of core beliefs makes them uncompromising to hold (If one is bad, what is the point of trying anything?), assumptions may try to compensate for them and to make it worthwhile at least trying: e.g., ‘ I may be bad but I can get people to like me somehow then I can be okay’ (conditional beliefs). These new rules, however, carry the hazard of dealing with the actuality of people not liking one and therefore of seeing oneself as, by definition, ‘not okay’ NEGATIVE THOUGHTS: If schemas and beliefs are the chiefs of the cognitions tribe, NATS are the ‘injuns’ – ready to perform their negative duties at all times of day and night and in all weathers.

Figure 3.1 The nature and relationship of different types of negative cognitions

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to change – perhaps because they impair intellectual functioning so that access to evidence that is not negatively tinged is blocked. They are often in shorthand form – and, like sensational newspaper headlines, may have all the more impact because of that. As clients rarely report them spontaneously, it has become an essential skill for cognitive therapists to ask about automatic thoughts and to elicit images that may contain them (Beck, 1976). This proactive stance is perhaps justified by one of Beck’s favourite maxims: “there’s more to the surface than meets the eye” (Goode, 2000). He noted that the themes in automatic thoughts are idiosyncratic but show clusters of meaning that could be linked to the thinking of other clients with the same disorder – reflecting again the specificity concept. Although they showed pronounced ‘distortions’ they are highly believable to patients, especially when they are feeling distressed. Even when automatic thoughts are surfaced, however, there is still the crucial question as to their meaning – and this may not always be directly stated in the thought. For example, when a distressing event occurs, many people will describe their automatic thought as “Why me?” This question probably disguises an answer like “(because) I am a loser”, or, “(because) my life is doomed”. The therapist can get at these underlying meanings by asking clients why they think that it is happening to them. There is an obvious danger here, however, in that therapists can ‘fish’ for content too avidly and that compliant clients will give therapists what they seem to want. This is a delicate line for therapists to tread. The ideal solution is to stay with the actual words of clients. The salient material can, however, be hidden or difficult to talk about and clients may sometimes need help to express it. Beck (1976) devotes considerable effort to clarify that it is really the meaning in cognition that points to what therapists are interested in. Other models also focus on meaning, especially existential therapies (Cooper, 2016). Once meaning is considered, then the content of cognition moves closer to being connected to beliefs and values – and a different order of cognition than automatic thoughts. In his review of the development of cognitive therapy theory in its 22

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first 30 years, Beck describes this relationship between thoughts and beliefs: The internal representation of the meanings … constitutes a network of beliefs, assumptions, formulas, and rules … the relevant beliefs interact with the symbolic situation to produce the “automatic thoughts”. (Beck, 1991, p. 372) Early critics of Beck suggested that his emphasis on automatic thoughts offered only a superficial explanation of psychological problems and neglected other causes of depression, for example, the effects of childhood trauma and of relationship and socio-economic factors (Weishaar, 1993). Beck however has always emphasised the importance of deeper historically based cognitions – ‘rules of living’, assumptions, core beliefs, and schema – in psychopathology and treatment (Beck et al., 1979; Beck et al (2016) Beck & Haigh, 2014) – and these are the focus of Chapter 5. Note 1 Beck (1993) refers to a similar experience with an unaccountably angry male just prior to this one in 1956. It seems that we can nominate 1956 as the year of the ‘birth’ of cognitive therapy.

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4 Cognitive distortions play a key role in psychological problems Having watched Aaron Beck working live, I am in no doubt that he has a natural therapeutic touch, perhaps influenced in part by the fact that he has known and overcome suffering himself. When only seven years old, he had a serious illness and it was feared that he might die. Thankfully for us, he survived but, after months in hospital, he then struggled at school and was held back for a year. Deeply hurt by a teacher’s harsh comments, he began to think of himself as ‘dumb’. In retrospect, he realised that this was a distorted negative thought. With help from his family and his own brand of self-help, however, he eventually pushed ahead of his peers. Beck believes this was when he developed his characteristic ‘never say die’ attitude (Weishaar, 1993). Thirty-four years later he found himself in the middle of a battle in his department at the University of Pennsylvania – reflecting the wider conflict between American psychoanalysts and their critics – a struggle that eventually culminated in the removal of psychoanalytic terminology from the Diagnostic and Statistical Manual (DSM) in 1980. Beck took a sabbatical in 1962 to escape this troubling and tiresome conflict so that he could focus on developing his own ideas. His departure was hastened when the local psychoanalytic association refused his registration as an analyst for the second time – for the ironical reason that his patients had “all got better within a year” which, for the association, meant that he “was not really imbued with the whole psychanalytic ethos” (Beck, J.S, 2011b, p. 2) – leading the association to believe that his style of therapy was not properly psychoanalytic.1

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Beck’s sabbatical eventually lasted for five years of “splendid isolation” (Rosner, 2014, p. 734). Yet these were very productive years and one of their first fruits was his paper, ‘Thinking and Depression I; Idiosyncratic content and cognitive distortions’ (Beck, 1963). Beck’s light-bulb moment in the discovery of automatic thoughts also led him to recognise the importance of cognitive distortions. This recognition came when he noticed a client’s despondent look after he suggested to her that they should work together to overcome her problems. He then asked her what was to become the trademark cognitive therapy question, “What went through your mind … when I said that?” She reported thinking that he did not want to work with her – clearly a major and depressing distortion of what he had said. Beck (1976) distinguishes these distortions from the ‘delusions’ of psychosis but also sees the two phenomena on a continuum – with the degree of distortion and error increasing the more severe other symptoms are. Beck (1963, 1976) identified various types of distortion –for example, ‘personalization’ and ‘polarized thinking’ and added to their number in succeeding publications (Beck et al., 1979; Beck & Emery, 1985), forming a list of cognitive distortions that has become familiar in cognitive therapy texts, including: Over-generalisation: for example, clients describe more of their experiences as negative than is really the case. Arbitrary inference: for example, clients make negative judgements in a situation where other less negative interpretations are equally likely. Selective abstraction: for example, clients pick out one negative slice of information and ignore other more positive factors. Tunnel vision: for example, clients focus on a narrow range of factors that are likely to confirm their negative views. Black and white thinking: for example, clients put neutral ‘grey’ information into the category of the negative.

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Should statements: for example, clients have self-rules which demand high and perfectionistic standards from themselves. Magical thinking: for example, clients imagine that their ‘badness’ is transparent to all. Catastrophising: for example, clients over-exaggerate the potential dangers existing in everyday situations. Labelling: for example, clients accentuate negative aspects of situations or persons by attaching a stereotypical negative label to them. There is a fair degree of overlap in these categories and, without explanation, this may confuse clients and trainees (Wills, 2008b). It can, however, sometimes be useful to distinguish between them because some clients have ‘favourite’ distortions. Overall, it may be better, initially at least, to use a simplified list in which their main themes are identified (Emery, 1999; Wills with Sanders, 2013). Beck has advanced the understanding of negative cognition by disassembling it into parts but his writings also stress that these parts, such as cognitive distortions, are part of a holistic cognitive organisation. Everyone has distorted thoughts at times – if not frequently (Kahnemann, 2012) – but during psychological stress, distorted thinking appears to be more compelling. Alford and Beck (1997), for example, have described a fixated quality of negative cognitions – a quality that can result in clients being ‘locked on to’ them. Most of the distortions above can increase negative attention bias: a factor that only adds to the compulsive plausibility of negative thinking. Albert Ellis (1962) first described a concept of negative thoughts. Beck discovered them independently but when he read Ellis, he was struck by the similarity of their ideas and took much from Ellis’ work. One difference, however, is that Beck dissents from the view that negative thoughts are ‘irrational’, the term used by Ellis. I have preferred the use of the more pragmatic terms ‘helpful’ and ‘unhelpful’ thinking (Wills with Sanders, 2013) and see them as lying on a continuum – that itself may vary at different times and in different situations. 26

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It was interesting working with clients experiencing anxiety during the initial phase of the coronavirus epidemic in the UK, many of whom seemed to deal with fears about the epidemic as well as anyone else. Lockdown seemed to offer some of them a ‘reprieve’ from having to face some of their fears – for example, starting a new job. Lockdown also, however, gave them more time to ruminate on such fears but also to learn about how they ‘catastrophise’ such challenges. Recognising and working with this cognitive distortion allowed them to use this ‘lee2 time’ to embark on decisive ‘de-catastropishing’ work (Barlow et al., 2017) to overcome significant fears. Notes 1 In an interesting echo of his own childhood experience, Beck describes their decision as ‘so dumb, … really … dumb’ (Rosner, 2014, p. 752). 2 I.e., ‘sheltered time’.

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5 Cognitive organisation is underpinned by deep modes, schemas, beliefs, and assumptions Beck has described sensing by the early 1960s that he had the significant elements of his model in place – negative thinking processes, automatic thoughts, cognitive distortions, and implicit negative beliefs. These could gradually coalesce into something larger and more significant – in effect, a nascent form of cognitive analysis and therapy (Beck, J.S, 2011a). The schema concept has served as a lynchpin holding the model together. Beck first articulated the schema concept in his paper, ‘Thinking and Depression II: Theory and Therapy’ (Beck, 1964), which defined schemas as cognitive structures “used for screening, coding and evaluating impinging stimuli” (Beck, 1964, p. 562). Whereas in normal functioning healthy schemas help to orientate us in our lives, in psychopathology negative schemas have a strong tendency to fit data into predetermined and expected negative meanings. This definition was clinically useful but did not quite capture the dynamic nature of the schemas and it now seems that Beck himself was not fully satisfied with the definition and, typically of him, after 30 years of reflection, came to add the supplementary concept of mode (Beck, 1996; Beck & Haigh, 2014). Before describing ‘mode’, however, let us consider a more everyday analogy for the basic nature of schematic functioning. Everyone understands the personal experience of ‘having one’s buttons pressed’. When this happens, we find ourselves reacting quickly and strongly – with surging and disturbing emotions, that often result in rash, emotion-driven behaviour. Often we are left puzzled by why this happened. When others are concerned not to 28

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‘press our buttons’, they often advise each other to ‘tread on eggshells’ in our presence. ‘Buttons’ are usually related to our core schemas (Beck, 1964; Beck, J.S., 1995). The schema, however, is only a part of a wider modal response (Beck, A.T., 1996; Beck & Haigh, 2014). The mode in action involves continuous interaction between cognitive and other schemas – for example, emotional schemas with physiological schema correlates (raised emotions and a racing heart), and motivational and behavioural schemas (urges to act). The mode, especially in psychopathology, may well be primal, that is, linked to basic evolutionary interests, and can account therefore for the comprehensiveness, strength, and urgency of response. People ‘tread on eggshells’ because they are only too often aware of our vulnerability to react in this way and want to avoid the feared explosive reaction – for their and/or our sake. A primal reaction can be triggered by what may seem an innocuously trivial event. The more often these vulnerabilities are triggered, the more intense they become – the ‘kindling effect’ (Beck, 1996), like a spark that sets tinder ablaze. So far we have described schemas in terms of the activation of arousal and this is indeed the case with the angry and anxious modes (with accompanying schemas, beliefs, and thoughts). In the depressive mode, however, the modes and schemas show the opposite of arousal – the de-activation of arousal or the activation of ‘retardation’, shown in sinking, low feelings, and withdrawn behaviours. Schematic reactions are frequently rooted in early developmental factors, probably both neurobiological and experiential (Beck, 2008) – recall how Beck himself came to think of himself as ‘dumb’ following a major illness and loss of time in school. Such childhood experiences often occur in the narratives of clients. Melanie, for example, having been caught in heavy rain, arrived for therapy thoroughly drenched. Placed by a warming fire and handed a towel, she burst into a flood of tears that continued throughout the session. She described how during childhood her neglectful parents had frequently left her alone in a freezing cold house, 29

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once in an uncomfortably wet nappy. Even when they returned, they had ignored her cries for help, even scoffing at her. Now the combination of feeling drenched and the therapist’s small acts of nurturing kindness had triggered hyper-activation of a despair mode. The original traumatic event had occurred before she had acquired much language and was therefore stored mostly in bodily and sensory memory – in what Layden et al. (1993) have termed ‘the Cloud’. Schemas, however, are not directly observable so therapists need to develop consistent methods for discerning them so they can be fitted into case formulation and used in working with deeper client material. Yet it is also a ‘black box’ concept – generally we know what signal went into the schema ‘box’ and what reaction came out of it but are less clear about what happened inside it. This lack of clarity stimulated academic research, which has led mainly to yet further questions – for example, about the nature of schematic memory (Williams et al., 2007a). Researchers were stuck in a classic ‘chicken and egg’ dilemma since schemas were posited as pre-existing vulnerabilities but could not be shown to pre-exist the reactions that they gave rise to (Teasdale & Barnard, 1993). Beck (1996) addressed such criticisms by positing the existence of a superordinate concept that underpinned schemas, which he termed ‘the mode’. This new theorising seems to have taken him back to some uncompleted thoughts on his formative papers of the early1960s (Rosner, 2012). Rosner found Beck’s notes and drawings of that time and offers fascinating insights into how he was trying to use psychoanalytic thinking to devise a dynamic concept of schema. He seems to have reached an impasse and then put aside these efforts only for them to re-emerge in 1996 with the mode concept. Colleagues in the 1960s had challenged him to say more on how schemas developed and expanded. Beck (1964, p. 563) had referred to schemas being ‘filled in’ with further data from processing external events. This expression may well relate back to the psychoanalytic term ‘cathexis’ which was itself a Greek translation of Freud’s more down to earth German term, Besetzung, which 30

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translates as ‘occupation’ or ‘filling in’. Fundamentally, Beck seems to have been trying to find a dynamic explanation of the progressively strong activation which we have seen is so typical of schema functioning. Beck (1996) widens the concept of cognitive schemas to include matching emotional, behavioural, and motivational schemas. These schemas sit alongside cognitive schemas and are coordinated by a wider ‘mode’ – for example, ‘fear mode’ or ‘danger mode’ – and are activated by what he calls ‘orienting schemas’. These ‘protoschemas’, like our earlier mentioned ‘buttons’, are hyper-vigilant for even slightly familiar triggering events. In people with a sensitivity to criticism, for example, these vigilant antennae can detect the least hint of critical ambiguity in others and will then activate an ‘interpersonal danger’ mode, with schematic cognitions like, “He is a threat to me”. Additionally, the emotional and behavioural schemas will alarm and fuel drives for the person to defend himself. This expanded model is in my opinion a subtler and more nuanced description of schematic functioning and captures its dynamic nature better than the original single schema functioning model, and can greatly aid therapists’ empathic understanding of what it is like to be ‘in the grip’ of schema activation. Exemplifying how he continues to explore his ideas, even as he approaches his 100th birthday, Beck has used the mode concept in his Recovery-oriented cognitive therapy (CT-R) model, especially in relation to therapy for schizophrenic clients (Beck et al., 2020).

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6 Cognitive therapy draws richly on evolutionary theory The themes in this chapter are linked, in a number of overlapping ways, to the previous and next chapters on schemas and mental images respectively, and, to the practice chapter on working with emotions and imagery. First, emotions play key roles in evolutionary adaptation in both positive and negative ways (Power & Dalgleish, 2008). The last chapter highlighted the role of negative schemas, which can be triggered by hyper-activity in the emotional brain, especially in the amygdala. Emotional regulation plays a key role in relation to dealing with emotional upset – again for better or for worse (Leahy et al., 2011). The prefrontal cortex can function to temper negative emotional reactions but can also be overwhelmed, which may then allow the hyper-activated amygdala full rein to cause dysfunctional emotional symptoms and negative behaviours (Beck, 2008). Secondly, mental imagery often accentuates emotions and this may give direction to positive patterns of behaviour, but negative imagery can accentuate negative emotional and behavioural symptoms (Stopa, 2007). On the other hand, imagination and imagery also have evolutional advantage – allowing us to make plans for dealing with danger in a ‘virtual world’ (Wells, 2000, p. 30) that is, without facing the actual danger of practicing in the real world. An understanding of anxiety in evolutionary terms goes as far back as Darwin (1872). Beck, who has a long-held interest in Darwin and evolution (Weishaar, 1993), probably also entertained thoughts about evolutionary processes for some time, but, perhaps sharing some of Darwin’s well-known aversion to premature publication, refrained from writing anything himself until Anxiety disorders and phobias: A cognitive perspective (Beck & Emery, 1985). 32

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Just before that publication Beck had met and then initiated a correspondence with John Bowlby. In the third volume of his trilogy on attachment and psychopathology, Bowlby (1980) wrote about attachment and cognitive processes in depression. He made positive references to Beck’s contributions to this subject but criticised its lack of any account of the developmental aspects of these processes. In Boston later that year, Beck attended Bowlby’s presentation on cognition and psychopathology. The two men exchanged correspondence and ideas during 1981, noting the similarity of their ideas, and Bowlby concluded his letter by welcoming the convergence of their work. Bowlby was, as Beck had been, a free-thinking psychoanalyst and shared his interest in evolutionary theory.1 Beck, whilst admitting that Bowlby’s criticism was correct, said that he had gathered thoughts about developmental aspects of negative cognition for some years but had previously been reluctant to publish. Perhaps Bowlby’s approval now gave him the confidence to express his thoughts on the evolutionary aspects of anxiety as he developed his ideas in that area in the early 1980s. Other critics have pointed to the lack of a convincing underlying theory or ‘grand narrative’ in cognitive therapy theory (Weishaar, 1993). Many cognitive therapists are, however, happy to be regarded as pragmatists2 and may not feel a need for a theory that explains everything. Beck’s schema concept, however, reaches towards a deeper underlying theory and has a similarity to Bowlby’s evolutionary concept of attachment as it is ‘a working model in the mind’ that has pronounced survival value for helpless neonates (Holmes, 1993). When Beck (1967) first addressed depression he described the ‘paradoxes of depression’ – for example, how can a seemingly successful person end up as seeing herself as ‘a failure’? Beck and Emery, with Greenberg (1985) address similar questions about anxiety – how can the generally exquisite functioning of our nervous system also end up making us so miserable? They see cognition as a central process in evolutionary adaptation and yet when certain of its vital systems become hyper-active, it pushes us towards maladaptive thoughts, feelings, and behaviours and a pervasive sense of 33

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vulnerability. “Evolution favours anxious genes” (Beck & Emery, 1985, p. 132) partly because if we veer towards risk-taking, we risk a ‘false negative’ – that is, deciding not to react to a threat that turns out to be genuine – and thereby can face being “eliminated from the gene pool” (p. 4). The hyper-activity of vital cognitive systems can be triggered by primitive and egocentric modes in the cognitive system, which may then set off chain reactions in other systems. These anxiety-oriented reactions may well be hard-wired and there is a, as yet unresolved, debate over whether ‘evolutionary preparedness’ plays a role in that. Clark and Beck (2011) offer qualified support for the idea of preparedness but reject the notions of some of its advocates, such as Ohman and Mineka (2001), that these fear structures are impenetrable to cognitive interventions by citing the evidence of Brewin’s (1988) observations on how anxious subjects oscillate between non-conscious fear and conscious self-reassurance. Beck (1987) recognised the need to include the concept of attachment in the theory of depression via his idea that ‘sociotrophic individuals’ – those needing strong investment in relationships – will react more sharply to relationship loss, compared to ‘autonomous individuals’ who respond more to failure to achieve. This account also emphasises the advantage of submission after defeat in order to prevent further attack. Additionally, if one’s attachment figure is truly lost, then it will often be better to go into a transitional period of withdrawal rather than giving up on attachment completely or committing to another attachment too quickly. Such withdrawal has sometimes been called a ‘hibernation effect’ – a metaphor for conserving emotional energy and behavioural activity in order to survive a hard time. This response – which also links to grief – becomes problematic; however, when the sufferer is unable to re-emerge after hibernation – similar to how an ‘anxiety switch’ may get stuck in the ‘on’ position, the depression switch may be stuck on withdrawal. Beck et al. (2016) also applied evolutionary analysis to personality disorders and they describe ‘ethological strategies’ that are often problematic but might at some times have survival value. 34

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Dependence, for example, can be functional for a time when one is genuinely incapacitated but as an enduring behaviour trait, it may foster a dependent personality disorder, defined by leaving the person ‘prone to exploitation by predatory individuals’ (APA, 2013: DSM-V). Even the problematic aspects of dependence in dependent personalities may, however, have positive adaptational value in some situations, for example, an overwhelming threat that cannot be met within one’s own resources (Beck et al., 2016). The mode concept has now been further elaborated and related to contemporary neuroscience (Beck & Haigh, 2014; Beck et al., 2020). This encourages the idea that these insights might be more thoroughly applied in practice – where, for example, evolutionary explanations to clients have long been credited with the capacity to “demystify the problem of anxiety” (Beck & Emery, 1985, p. 261). We can therefore be more confidently hopeful that evolutionary concepts will inform the on-going development of cognitive therapy. Notes 1 Bowlby (1991) posthumously published a well-regarded life of Darwin. 2 “I think I am ultimately a pragmatist and if it doesn’t work, I don’t do it” (Beck, quoted in Goode, 2000).

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7 Images also refect key elements of cognitive distortions Although many people might associate the use of imagery with humanistic therapy, in actual fact Beck’s (1970a) first major discussion of the role of imagery came from reading about the ‘time projection’ method, described in 1968 by Lazarus, then a behaviour therapist (Rosner, 2002). Imagery was then being used in desensitisation – part of behavioural therapy for anxiety. Beck and Emery, with Greenberg (1985) describe the preoccupation of anxious clients with negative imagery – often fixating on a detailed internal ‘catastrophic movie’ – one that could be rerun each time they encountered anxiety-provoking situations – an example of what Alford and Beck (1997, p. 20) later referred to as ‘transfixed attention’. Beck considered that his 1970 paper on imagery did not attract much attention amongst cognitive therapists, who only began to use it much later (Weishaar, 1993). One key exponent of the use of imagery has been Judith Beck (2021), who devotes a comprehensive chapter to it, noting that images occur spontaneously in therapy but can also be specifically induced for therapeutic purposes. She stresses the ubiquity of images but also how it is easy for therapists to miss their significance: Many … (clients) … experience automatic thoughts not only as unspoken words in their minds but also in the form of mental picture or images … Imagery affects how we feel … more than verbal processes … I have found that … many CBT therapists … fail to identify and address their clients’ important distressing images. (p. 340) 36

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The experience of images is fleeting so that therapists need to take an explicit focus on them to capitalise on their therapeutic uses. Alford and Beck (1997, p. 70) use Epstein’s (1998) ‘cognitive-experiential self’ dual-process model to explain the two functions of guided imagery: 1) It activates meta-cognitive (rational) processing, and, 2) It is employed clinically to communicate with the experiential (automatic) system. ‘Staying with’ the image can give time for the slower rational processing system to ‘fine-tune’ what is happening in the more rapidly functioning experiential system. Beck (1970a) noted that interruption of negative imagery as part of a deliberate imagery exercise often results in the emergence of more positive images when the exercise recommences. He also describes how clients can be helped to disengage from such images by imagining a bell or other sound as a stop signal. Such disengagement often results in a drop in anxiety. Reiterating the image then often elicits more positive detail and meaning. The content of imagery can be highly specific. Wells (1997) describes the variety of images that occur to clients with social anxiety – for example, detailed pictures of how they think people perceive them. Sometimes these images are seen from the observer perspective – for example, the client sees himself looking embarrassed. This contrasts with images that are seen from the perspective of the self: – for example, the client ‘sees’ the other people reacting to him. Wells (2000) suggests using attentional strategies that can focus attention away from this negative self-focus to the reality of the situation. Judith Beck (2021) advocates helping clients to develop positive images – for example, with images of positive memories to increase client self-confidence when facing a job interview. She also describes ways of helping them to deal with negative images. Negative predictions are often accompanied by catastrophic images and are familiar in anxiety. One client suffered from severe travel 37

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phobias – road transport was difficult but just possible if carefully planned; sea and air travel had proved impossible. These phobias had prevented her from visiting a close relative who lived in the Channel Islands. One day she and her partner were driving near a Channel port. In a form of shock therapy, her partner told her that he had booked tickets for the car ferry to the island and they were going to embark there and then. She immediately went into a severe panic attack and experienced multiple catastrophic images of the ship sinking, being eaten by sharks and whales – all set in the midst of a tropical typhoon. In fact, her husband had not booked tickets but was just testing how she might react if he did – now he knew for sure! Judith Beck (2011a, p. 283) refers to the process of staying with, interrupting, and recommencing imagery as ‘following images to completion’. She also describes encouraging clients to imagine coping successfully with situations that they find difficult. The travel phobic client was struck by the absurdity of her images and began giggling, soon joined by her therapist. She then reported, “The sea is calm now”. It took considerable further work but she did eventually visit her relative in the Channel Islands and said that her change of mind began on the day she revealed the image described above. Negative imagery connected to memories has most often been described in relation to childhood trauma. Therapists such as Mary Ann Layden et al. (1993) and Ann Hackman et al. (2011) have followed the lead of Edwards (2011) in using active ‘imagery re-scripting’ of painful childhood and other traumatic experiences. Clients are encouraged to ‘unpack’ the detail of the image (Hackman et al., 2011). The cognitive content of images adds to the vivid impact of the negative meaning contained within them. As noted previously, images often enhance the ability to feel authentic emotion and it has been known for some time that the formula of experienced emotion and new information enhances the prospect of therapeutic re-processing (Foa & Kozak, 1986). Methods that aim to re-script imagery perhaps increase the ability for safe rehearsal of skills in the face of adversity, noted by Wells (2000) as a key way that working with imagery builds on the evolutionary 38

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advantage of imagination. Layden et al. (1993) suggest importing a helpful ‘safe adult’ friend into the image, running the scene again and allowing the ‘adult self’ or ‘empowered child’ to come to the aid of the ‘child self’ in the childhood trauma. Speaking of the abused person’s characteristic tendency to blame himself, Layden et al. (1993) comment: Once the adult patient is capable of understanding rationally that he is not to blame for the abuse … the process of trying to convince the ‘child’ of his innocence with imagery exercises may begin. (p. 86) Metaphorical images can also play significant roles in therapy. A client described his attempts to work on a persistently difficult problem as ‘rounding the Horn’. He explained that this saying referred to the vicious headwinds off Cape Horn that frequently blew sailing ships backwards, sometimes forcing them to sail the longer way round via the Cape of Good Hope. It turned out that both client and therapist had seamen forefathers who had made that journey – and the image featured again and again as they sought to ‘round the Horn’ of this client’s dilemma.1 In summary, Beck took imagery into cognitive therapy and encouraged others, including his daughter, Judith, to follow. The use of imagery has developed and helped cognitive therapy to be more emotionally grounded. Beck has once again shown himself open to endorsing the contributions of those who have followed his lead. Note 1 See Murphy (2004) on ‘rounding the Horn’.

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8 Cognition, emotion, behaviour, and physiology interact with mutual and reciprocal infuence on each other In the early 1980s, a heated debate in psychology contested whether cognition or affect had ‘primacy’ in human experiencing – that is, whether thinking ‘caused’ feeling or vice versa (Leahy et al., 2011). This was an academic debate but inevitably was also reflected in psychotherapy. Some critics of cognitive behaviour therapy (CBT) seized on findings that emotional reactions were too rapid to be preceded by thought to say that CBT was based on a fallacy – further proof that its practitioners just did not understand emotion. In a rather typically academic way, this debate rumbled on unresolved and then seems to have ‘dissolved’ (Lai et al., 2012). Leahy et al. (2011, p. 10) nicely summarise the current status of this question in therapy, “As with many dichotomised debates, there is some validity to both positions … there is considerable evidence that emotion and cognition are interdependent and that each can influence each other in what we might call a feedback cycle”. Therapists should, however, understand enough neuroscience to grasp the fact that negative emotion often arrives with great speed – along the ‘low road’, that is, without conscious awareness (Le Doux, 1996). In CBT this means that it can be hard for clients to identify automatic thoughts, linked for example to anxiety, so that they can sometimes doubt if cognition is involved at all. Ultimately, however, all parts of the brain connect and it is therefore likely that even the fastest emotions are influenced by overall cognitive organisation – probably along the lines suggested in the earlier description of Beck’s evolutionary concepts. 40

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In fact, Beck always saw the role of emotion in cognitive therapy as having two key elements (Weishaar, 1993, p. 57): Emotion is a source of information about how the self is being effected by the environment and is effecting the environment, and, Emotion is also part of the action tendency that helps to motivate adaptive behaviour. This is a theoretically integrative view, compatible, for instance, with the view of emotion in emotion-focused therapy (Greenberg, 2011). Emotion guides cognitive therapists to where the action is in therapy, that is, emotion helps cognitive therapists know that they have found the most important or ‘hot’ thoughts (Greenberger & Padesky, 2015) that reflect their appraisals of the impact of events on clients’ “personal domains … (and) … objects that … [they] judge(s) to be of particular relevance to [them]” (Beck, 1976, p. 54). Beck, however, did not follow Rational Emotive Behaviour Therapy (REBT) with regard to including ‘emotion’ in the name of the model and has sometimes said that the word emotion didn’t need to be stated there because its target was emotional – that is, the cognitive therapy of depression. This argument is, however, hardly convincing to therapists of other schools who can read the way that the role of emotions is understood in cognitive therapy wrongly. It has been suggested that a focus on cognition implies a lack of interest in emotion in therapy. Padesky (1994), however, tells an excellent story about Beck’s exposition on the relationship between thoughts and emotions that also reveals his rather impish sense of humour. She and Beck were giving a workshop to a group of therapists in the morning and repeating it to psychoanalysts in the evening. (At a) … workshop in the morning, he said, “Affect (i.e., emotion) is the royal road to cognition”. … you can’t do cognitive therapy without affect being present … in the evening … he said, “Cognition is the royal road to affect”. I just looked at 41

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him and smiled as he turned the message round to fit his audience, but, in fact, both were true. Affect and cognition are wedded to each other, so that you can use affect to … guide you to cognition, you can also use cognition to … guide you to affect. (Padesky, 1994) The key idea here is that emotion is where the action is and that cognition is mostly useful when it explains the appraising and evaluative dimensions that are key to understanding problematic feelings and behaviours. Recent writers on cognitive therapy such as Leahy et al. (2011) have suggested that some elements from emotion-focused therapy – especially perhaps the idea of ‘emotional schema’ (Greenberg, 2011) – can be integrated into cognitive therapy – for further discussion of this point, see Chapter 7, in Wills with Sanders (2013), which gives examples of how focusing on emotions with methods suggested by Gendlin (1981) and similar authors can be part of a wider approach to ‘cognitive-emotional processing’. The link to behaviour can be seen in Beck’s adaptation of the ABC concept in REBT, which carefully includes the behavioural consequences of unhelpful cognitions and beliefs (Dryden & Neenan, 2004). In the 1960s, Beck was keen to find allies and hoped to find them amongst behaviour therapists. Reflecting on this period, Beck (1976, pp. 335–6) commented: behavior therapy appeared at a propitious time for me. The behavior therapists’ emphasis on eliciting precise data from the patient, the systematic formulation of a treatment plan, the careful monitoring of feedback from the patient, and the refined methods of quantifying behavioural change were all useful tools in developing cognitive therapy… (however) … Insofar as the techniques of behavior therapy are employed … (it is) … with the perspective of a cognitive model.

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Beck drew on research that showed that much of the success of Wolpe’s (1958) systematic desensitisation procedure was due to the changes in the client’s attitudes (Brown, 1967). This drew an entertainingly robust and anti-cognitivist response from Wolpe himself (Wolpe, 1978) and characteristically even-tempered and clever respective rejoinders from both Beck (1979) and Ellis (1979)1. Beck’s (1970b) key paper on behaviour therapy focused on the understanding that behaviour change and cognitive change could reinforce each other. For example, one client who had the belief “My sister will not enjoy a visit from me whilst I am depressed” could test this out by visiting anyway – giving the sister a chance to disconfirm this negative idea. In the event, the sister was delighted to see her. A special application of understanding the relationship between behaviour and cognition came from Beck and his colleagues’ work with anxiety disorders. Here key behaviours that reinforce anxiety are identified: specifically, avoidance, reassurance-seeking, hypervigilance – all examples of ‘safety behaviours’ (Salkovskis, 1996a). The role of behavioural responses in both anxiety and depression provide the theoretical underpinning of the ‘behavioural experiment’; see this book Chapter 27. Whereas behavioural interventions in the treatment of anxiety work focus on de-activating certain behaviours that reinforce the anxiety reaction syndrome, the behavioural interventions in depression work on activating behaviour. Aaron Beck built on the work of Lewinsohn to promote more active and pleasure-seeking behaviours (Lewinsohn & Graf, 1973) to get depressed clients ‘up and running again’. Judith Beck (2021) emphasises the need to consider any planned activity scheduling or behavioural activation in the context of the client’s aspirations. CBT is really an integrative model – integrating behavioural and cognitive interventions – and this has played a crucial role in the evolution of CBT (Rachman, 1997). Thus emotions and behaviours – along with physiology – have been comprehensively linked

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SLEEP INTERVENTION: Sleep hygiene, etc.

NEGATIVE EMOTIONS: Sad, depressed

WITHDRAWN AND INACTIVE BEHAVIOUR

BEHAVIOURAL INTERVENTIONS: Activity scheduling; Graded task assignments, etc.

SLEEP PROBLEMS AND LACK OF SOCIAL CONTACT

MORE TIME FOR RUMINATION

NATS: ‘No one wants to see me’

NEGATIVE CORE BELIEFS: ‘I’m worthless’

MOOD MANAGEMENT: Pleasure predicting, etc.

COGNITIVE INTERVENTIONS: Thought records; Behavioural experiments, etc.

Figure 8.1 ‘Vicious cycle’ with potential interventions points (copy of Figure 4, p.89. Wills (2009) Beck’s Cognitive Therapy, first edition).

ATTENTIONAL STRATEGIES: Mindfulness; Attention training; Distraction, etc.

CORE BELIEF WORK: Continua, Historical tests, etc.

Theory

CognITIon, EMoTIon, BEHAvIoUr

with cognition and each other in mutually interactive ways – and this ‘hot cross bun’ (Greenberger & Padesky, 2015) stands at the heart of cross-sectional cognitive formulation. The relationship can also be presented as a ‘vicious cycle’ – shown in Figure 8.1 with indications of links to potential targets for intervention in cognitive therapy. Note 1 These three articles are particularly recommended to those who relish a good academic spat.

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9 Safety behaviours, including avoidance, over-preparation, and reassurance seeking, play a major role in maintaining anxiety It surprises some people that Beck’s fame in his own country has somewhat lagged behind his renown in the wider world. As late as 2000, I met American psychotherapists who claimed not to know of his work, including one from Philadelphia who had a relative who played tennis1 with him regularly, but had never realised the depth of his contributions to mental health. Beck has visited the UK and Oxford since the 1970s (Hollon, 2010) and built up good contacts with researchers, such as David. M. Clark and his colleagues, especially during and since a sabbatical visit in 1986. Additionally, staff from Philadelphia and Oxford exchanged regular visits ‘across the Pond’. Beck visited Oxford several times whilst I was undertaking cognitive therapy training there in the early 1990s and introduced one talk with a teasing yet appreciative joke that Oxford was now where one came to find out the latest in cognitive therapy. History will, I think, eventually show that the Oxford Cognitive Therapy Centre did play a crucial role in the expansion of cognitive therapy beyond the United States – starting with David. M. Clark’s work on panic and anxiety. Clark (1986) had been inspired by Beck’s work and now devised an influential cognitive model of panic disorder. Clark’s research looked at how panics were triggered and maintained. He suggested a pattern in which a sense of threat and apprehension activated bodily sensations, such as increased heart rate and sweating, and then triggered ‘catastrophic misinterpretations’ – such as I am having a heart attack, I will die, or, I am going mad. These catastrophic cognitions heightened the sense of danger and threat and increased the intensity of physical sensations – setting up a vicious 46

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cycle that might persist for some time. Once this kind of pattern was established, sufferers became hyper-vigilant for panic-inducing situations – for example, entering the brightly lit entrances of supermarkets is a commonly reported one – and vulnerable to developing full panic disorder. One puzzle, however, remained – why was it that panic sufferers did not question their misinterpretations when they did not have heart attacks, die, or go mad? The missing answer was suggested by the work of fellow Oxford researcher, Paul Salkovskis (1988, 1991), and his crucial concept of ‘safety behaviours’. The resulting theoretical model and treatment package for the cognitive therapy of panic has become one of the most effective psychological interventions in the current field (Clark, 1996). The concept of safety behaviour may have had its origins in ‘the safety signal perspective’ applied by Rachman (1984) to anxiety problems. For example, some phobic clients fear that harmless British spiders could injure them and conclude that avoidance of such spiders is necessary to keep safe. Other safety responses – such as sitting down or grasping a wall for support during a panic attack – might be less conscious. One client with a fear of heights agreed to an exposure behavioural experiment by walking across Brunel’s beloved Clifton Suspension Bridge, which lies almost 250 ft above the River Avon in Bristol. His therapist walked behind him on the narrow pedestrian walkway and was alarmed when the client started swaying and stumbling. The therapist then noticed that the client’s legs had become stiff and rigid, causing this instability. Stiffening his legs was probably an unconscious safety behaviour but the consequent instability heightened his anxiety. Encouraging him to loosen his limbs and ‘walk monkey’ probably provided an amusing spectacle to other pedestrians but resulted in a successful crossing and was thus a ‘corrective emotional experience’ for him – shown by his hearty laughter after reaching the other side of the bridge. The concept of panic beginning with misinterpretation and being maintained by safety behaviours was an impetus for further research on the role of safety behaviours in other anxiety disorders, 47

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such as social anxiety (Wells et al., 1995), OCD (Salkovskis & Kirk, 1997), health anxiety (Salkovskis & Bass, 1997), and many others (Harvey et al., 2004) so that safety behaviour is now recognised as a significant ‘transdiagnostic’ factor in therapy. Safety behaviours associated with social anxiety are particularly illustrative of how they can confirm negative beliefs and maintain the problem, sometimes in rather ironic ways. Wells (1997) describes, for example, how social anxiety is maintained by the belief that People think that I am boring (or stupid). This belief obviously has the capacity to make any kind of public speaking a major trial with traumatic potential. People may try to deal with this fear by putting immense effort into preparation, trying to ensure that they will not say anything embarrassing or stupid. An extension of this may be to speak more carefully and slowly – often to the extent that the audience will find such speech strange – unintentionally evoking the very thing that people with social anxiety most fear – that is, other people scrutinising them – truly a vicious cycle that can maintain and deepen the problem. Discussing how clients maintain their panic symptoms by catastrophic misinterpretations and safety behaviours, David. M. Clark, in a BBC programme in 1995, firmly rebutted the idea that these strategies are stupid, asserting that they make sense to clients and are simply the best solutions that are available to them in that moment. Rachman et al. (2008) acknowledge that client safety behaviours can inhibit therapeutic progress but also suggest that judicious use of them does not necessarily work against eventual disconfirmation of catastrophic predictions and may even facilitate positive outcomes in therapy for anxiety. Experiments that allowed clients to use ‘safety gear’ – for example when being exposed to (harmless) snakes – did not lead those who used it to have worse longterm therapeutic outcomes. The authors note that most people do routinely use safety gear in everyday life – an observation which had resonance during the Covid-19 pandemic. Therapists from other models have often commented that exposure treatment can appear rather harsh to them. It seems, however, that it is possible to 48

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keep the essential core rationale of exposure treatment whilst at the same time keeping it humane by allowing flexible and judicious use of permitted safety behaviours. Judith Beck (2021) discusses how to handle client safety behaviours that may interfere with exposure therapy and offers two separate rationales for situations arising in both standard and recovery-oriented cognitive therapy. A flexible and humane approach can also be taken with reassurance seeking – a prominent safety behaviour in many anxiety problems including health and other worries (Salkovskis & Warwick, 1986). Reassurance seeking can be a pattern that clients repeat with therapists. It can seem rather harsh to refuse completely any reassurance so perhaps the judicious use of ‘limited and regretful reassurance’ may be the tone to aim for (Wills, 2008b, p. 104). Note 1 Beck is said to be a tenacious player. For an amusing account of one of his games, see Marzillier (2010), pp. 126–7.

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10 Understanding the role of negative biases in attention strengthens cognitive therapy References to the importance of the attention paid to negative thoughts – as well as their content – have been gathering pace throughout this part of the book. The next three chapters will now develop a major focus on different aspects of attention and these foci will link to Chapter 28 in the practice section. Once he had clearly defined negative automatic thoughts (NATs), Beck (1964) started to sketch out what a therapeutic approach to them might look like. He was keen that clients should recognise, evaluate, and modify NATs in order that they should “gain some detachment from them” (p. 568). Early cognitive models did emphasise the importance of changing the content of negative thoughts though some critics pointed out that, firstly, such thoughts might be epiphenomena – factors associated with symptoms but without influence on them – and secondly, even if they had such influence, it did not necessarily follow that changing hem would help (Weishaar, 1993). Evidence on both questions would come with the work of David. M. Clark (1986, 1996) on the cognitive therapy of panic disorder but it also soon became clear it was not just the content of NATs that influenced emotional problems but also the way that people paid attention to that content. Some people could ‘shrug them off’ relatively easily whilst others became ‘locked on’ to them. Since clients were too fixed on negative thoughts, Beck’s (1976) early ideas, advocating helping them learn to ‘decenter’ or ‘distance’ from them, made sense. The importance of attention was also prefigured in an early piece of influential research by Rachman and De Silva (1978), which showed that many people shared similar obsessional thoughts to those reported by clients with OCD – but did not then go on to 50

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suffer from the syndrome. This finding suggested that non-sufferers experienced such thoughts but paid only light attention to them and were thus able to brush them off without undue effort. Later, Clark and Wells (1995) highlighted another kind of attention – exaggerated self-focus (a type of self-consciousness) that plays a significant role in the maintenance of social anxiety. Most therapists will have encountered this self-focus in clients – for example, a violinist with performance anxiety told her therapist how she avoided visual contact with the audience because she so feared their potential criticisms. Her self-focused attention, however, took a field perspective – that is, she imagined how she looked to the audience. These images were hostile and critical and fostered yet more social anxiety. As research increased over the wider area of psychological problems, it became clear that problematic attention – for example, attention biases – play a similarly malign role in many of them so that attention bias is now regarded as a ‘transdiagnostic’ factor (Harvey et al., 2004). This has been significant in the evolution of cognitive behaviour therapy (CBT) and has encouraged the development of new attention-based strategies such as attention training (Wells, 2009) and mindfulness (Segal et al., 2013 Hayes et al., 2004). In many ways these methods seemed like the ‘the next big thing’ in our field but the rest of this chapter will focus on how the problem of attention in psychopathology was prefigured in Beck’s work and can be seen regularly surfacing in it from the 1960s through to today. Beck’s (1963) seminal paper on the cognitive model, for instance, describes the formal characteristics of negative thoughts and also of their ‘processes’ (p. 566). Beck highlights the characteristic of ‘perseveration’ – that is, repetitive experience or activity without the appropriate stimulus – and notes that these thoughts are repetitive in both formal thinking and free association. This theme is elaborated in his next paper as he addresses his own question, “Why do patients cling so tenaciously to their negative thoughts?”, and, in his answer, we once again see his psychoanalytic concepts appear as he comments that, “It is hard to avoid the concept of energy” (Beck, 1964, p. 566). We saw this same process in our 51

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discussion of the role of ‘cathectic’ energy in schema formation in Chapter 5, now he hints at it here, and eventually names it in Beck (1976, p. 132) – the concept of ‘fixation’. The Freudian use of this term is actually a wider, more characterological concept but in Beck’s writing it captures the driven quality of how clients can fixate and lock on to negative thoughts in ways that can only enhance negative emotional reaction. The term reappears in Beck and Emery (1985) now as a type of anxiety – ‘fixation phobia’ (pp. 121–2) and the problem of fixated attention also is indicated in his five-step AWARE (acceptwatch-act-repeat-expect) procedure, which remarkably anticipates the acceptance and mindfulness ‘third wave’ more than a decade before it emerged. In a subsequent paper as he considers David. M. Clark’s (1986, 1996) seminal contribution to the cognitive therapy of panic disorder, Beck (1988) suggests that when suffering with panic, clients do “fix their attention” onto, as Clark suggested, catastrophic misinterpretations of bodily signals, and, that their subsequent inability to use problem solving skills “is associated with fixation onto the symptoms” (p. 92). Here the psychoanalytic term again captures the forceful energy of this reaction that so wrongfoots normal coping mechanisms. From this point forward, the term ‘fixation’ – now perhaps separated from its original psychoanalytic intent – is found regularly in Beck’s work. As he discusses schema and mode formation, for instance, he notes that “As the adaptive mode becomes cathected, it draws some of the charge away from the fixation on danger” (Beck, 1996, p. 16). Beck has won over 50 major awards for his work and several of them relate to his decades-long research on suicide prevention, described in his introduction to Wenzel et al. (2009). ‘Fixated attention’ and ‘cognitive stuck-ness’ on suicidal intent have been identified as robust predictors of lethality in suicide attempts and this understanding has led to a promising measure, the Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ, Adler et al., 2015) that aims to help mental health practitioners identify this potentially lethal factor at the earliest moment. 52

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Beck may use psychoanalytic terms – though for his own purpose – but he has largely avoided the kind of internal splits and dogmatism that has plagued psychoanalysis in some of its phases. He can listen to criticism and, congruent to his own theory, weigh the evidence and amend ideas when necessary. His review (Beck & Haigh, 2014) is a 50-year retrospective on cognitive therapy and remarkable example of its continual and open development. In this paper, Beck completes the modification of schema theory that began in his (Beck, 1996) paper on modes, adopts a transdiagnostic and dual-processing General Cognitive Model – and makes attentional modification a major new priority for therapy – now termed as ‘focusing interventions’ that ‘target the role of biased attention’ (Beck & Haigh, 2014, p. 17). The paper proposes an energy-based process in which attentional resources are drawn away from everyday normal functioning by cognitive errors and schema-driven, hyper-active attention biases and then attention floods into energising negative emotional patterns. Therapists can help clients to shift their attentional focus in ways that allow these schema-driven patterns to be reframed.

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11 Metacognitive analysis strengthens our understanding of psychopathology The Frontiers of Cognitive Therapy (Salkovskis, Ed., 1996c) was a multi-authored publication of a confident gathering of the clans of Beck. It looked back at what had been achieved in the first 30 years of cognitive therapy and forward to what might be achieved in the future. We have already described Beck’s contributing chapter – on the limitations of the original schema concept and how it could be ‘filled out’ by the idea of ‘mode’ – see Chapter 5. One of the problems identified with the initial schema concept was a failure to account for how schemas operated in normal, non-problematic functioning. Beck (1996) therefore posits an ‘adaptive mode’ in which the conscious control system activates reflective, metacognitive processes to counteract the way problematic functioning harms the sufferer. This perspective was recapitulated in a book the following year – Alford and Beck’s (1997) The Integrative Power of Cognitive Therapy – a more theoretical work in which ‘fixated attention’ and metacognition are further explored. Metacognition – ‘how we think about the way we think’ and ‘cognition applied to cognition’ (Wells, 2009, p. 1) –is bound to be a matter of interest to cognitive therapists as one of their main methods of change, cognitive restructuring, involves helping clients to reflect on their negative thoughts. Alford and Beck (1997) suggest that metacognitive functions of the more conscious ‘rational system’ can override the negative functioning of the more automatic ‘experiential system’ – using Epstein’s (1998) terminology. An important factor in a more balanced ‘cognitive-experiential self’ system is that it can resolve conflicts between short-term and long-term goals in an ‘emotionally intelligent’ way. Alford and Beck (1997) give 54

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examples of how this can be achieved in cognitive therapy for both panic and schizophrenia. From this point, Beck increasingly describes this rational, metacognitive capacity as being at the core of what he terms the ‘adaptive self’ (Beck, 1996; Beck & Haigh, 2014). In the wider field, however, it also became increasingly clear that metacognitive factors can work for better or for worse (Wells, 2009). Adrian Wells came to cognitive therapy from a background in academic psychology. After training in clinical psychology, he spent a year at Beck’s clinic in Philadelphia in the late 1980s and later joined the cognitive therapy research and teaching team at the Warneford Hospital in Oxford. Although an admirer of Beck’s work, his research psychologist’s eye was drawn to areas that he considered needed more substantive research – notably the schema concept, and psychological elaboration of attention and mental control processes. He started on this work in a coauthored book on attention and emotion (Wells & Matthews, 1994), which won the British Psychological Society’s (BPS) 1998 annual book prize. He developed fuller analysis of the role of metacognition in attention and mental control (Wells, 2000) and went on to develop Metacognitive Therapy (MCT; Wells, 2009). His approach has become increasingly popular in the CBT field and is sometimes regarded as a ‘third wave’ therapy, somewhat separate from Beck’s original model. He initially described his aims as expanding and elaborating the psychological cognitive element of cognitive therapy but now sees MCT as influenced by, but separate from, Beck’s model and chose to leave out the term ‘cognitive therapy’ in the title of his key text (Wells, 2009). Metacognitive factors are now regarded as a transdiagnostic feature of psychopathology. They are evident over a wide range of psychological problems and may be dealt with in similar ways across those areas (Harvey et al., 2004). Harvey et al. (2004, p. 221) ask and then answer an excellent question at the start of their section on metacognition, “What determines the selection of recurrent thinking …? … Since appraising any thought involves thinking about a thought, it 55

THEory

involves metacognition.” They describe two important aspects of metacognition – metacognitive knowledge/beliefs and metacognitive rules and routines associated with mental control and regulation. Wells (2000, 2009) addresses both of these elements, making especially significant contributions to mental control theory. Regarding beliefs, for example, he has posited that there are different types of belief that can play a maintenance role in worry and Generalised Anxiety Disorder (GAD) – what he terms Type 1 beliefs – ‘positive’ beliefs (‘Keeping thinking about danger keeps me safe’, and Type 2 negative beliefs (‘Keeping thinking about danger will drive me crazy’). ‘Positive’ and ‘negative’ here refer to the function that the believer ascribes to them, rather than the function they may actually fulfil. Regarding rules and routines, Wells (2009) describes how mental control is achieved through a web of different processes that make up the Self-Regulatory Executive Function (S-REF). When used with emotional intelligence and metacognitive awareness, the S-REF can function in an adaptive fashion, but when it gets high-jacked, for example, by negative attention bias, this can result in what Wells (2009) has termed Cognitive Attentional Syndrome (CAS), which consists of worry, rumination, fixated attention and unhelpful self-regulatory strategies and coping behaviours … (and) is marked by engaging in excessive amounts of sustained verbal thinking and dwelling in the form of worry and rumination. This is accompanied by a specific attentional bias by which attention is locked on to threat. (pp. 2–3) Here again are concepts that reflect ‘locked on’ negative functioning, ‘fixated attention’, and ‘morbid preoccupation’ (Wells, 2009). Once again, the sense is that problems arise not just because of the content of negative thoughts, as in supposedly ‘standard CBT’, but when people pay excessive attention to them – resulting in being 56

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fixed, locked on to, and preoccupied with them. This forceful and dynamic concept also resonates with ‘mnemonic interlock’ in memory (Williams et al., 2007a). Whilst Wells (2009) now sees his work as inhabiting a different space from his original Beckian approach (Wells, 1997), he still sees MCT as located within the wider cognitive behavioural perspective and most of the people who train in MCT see it as an additive training to cognitive therapy, rather than as a supplantive one (Atherton, 1999). It will be interesting to see how the training criteria and curricula contents of cognitive therapy and MCT evolve. The British Association for Behavioural and Cognitive Psychotherapists (BABCP) (Hool, 2010) core curriculum document currently includes Beckian cognitive therapy but, surprisingly, does not yet include MCT. This may be due to the fact that MCT evidence is still finding its way into the UK National Institute for Clinical Excellence (NICE) systems, after an initial report on MCT with GAD in NICE (2011).

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12 Mindfulness has added power and subtlety to cognitive therapy A friend visited whilst I was living in the beautiful countryside on the borders of England and Wales. He said he wanted to get up early the next morning to catch the dawn chorus and the sunrise. We duly got up in the pre-dawn darkness and went into the nearby woods so we would hear the chorus ringing through the trees. We then realised however that the best place to see the sunrise was from the top of a nearby hill and set off in that direction. Seeing that we would not get up the hill in time, we turned back to the woods but had already missed the dawn chorus by the time we got back. Afterwards we berated ourselves for our ‘mindlessness doing mode’ but then began to see the funny side of it and also remembered Jon Kabat-Zinn’s (Williams et al., 2007b: CD) words, “It is in the nature of the mind to wander and to think so it is bound to happen a lot. It is not a sign that you are doing anything wrong”. At the time of the COVID-19 pandemic, many found solace by spending more time at one with nature. Whilst there was much fear and grief, there were some positive aspects of the crisis – such as having more time to just be. On-going research suggests that both green environments and healthy exercise, together and separately, have positive effects on mental well-being (Barton et al., 2016). There are likely to be many different variables that contribute to well-being in this context but, from a psychological perspective, a key one does seem to be that of the restorative effects of fostering ‘effortless attention’, an idea pioneered by Stephen and Rachel Kaplan (1989). Our capacity for effortful, directed attention – for example, for focused work – is finite but can be restored by periods of effortless attention, for example when fascinated by the wonders of nature or whilst participating in mindfulness practice, a practice 58

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most associated with Buddhism (Thich Nhat Hanh, 1998). The lack of such mindful but effortless attention was the very thing that led my friend and I astray in the dawn – but condemning ourselves for this ‘failure’ might discourage us in the future – which is why it was helpful to concur with Kabat-Zinn’s advice and to say that we had had a valuable learning experience. Jon Kabat-Zinn (2001) is of course well known for developing Mindfulness-based Stress Reduction (MBSR) and for helping to bring similar methods to the Mindfulness-based Cognitive Therapy (MBCT: Segal et al., 2013). The link with cognitive therapy came when Zindel Segal and his colleagues were formulating an approach to prevent relapse in depression (Segal et al., 2013). They particularly wanted to target depressive rumination as the research indicated that the ruminative mind-set could be readily re-activated in people who had suffered from depression and was strongly implicated in depressive relapse. This vulnerability factor became more easily triggered the more depressive episodes that clients had experienced. Collaboration with Kabat-Zinn helped the research team to integrate methods he had designed to help clients with stress into the MBCT programme. Judith Beck (2021) and Segal et al. (2013) all emphasise that therapists who aspire to use the MBCT programme with clients need to do so after being well-grounded in the approach by both self-practice and a sound understanding of the psychological and neurological bases of rumination. Judith Beck stresses that practice can be informal, for example, “when eating or brushing my teeth, or taking a break from work. Looking at nature … helps me let go of anything on my mind, like work or current stresses in my life and appreciate my surroundings” (Beck, J.S., 2021, p. 276). Segal et al. (2013) draw from neuroscience to identify two particularly significant brain states – what they termed ‘driven-doing mode’ and ‘being mode’. Doing mode involves the capacity to focus and heighten attention when needed – for example, to solve problems. It is brilliant at performing this function – one that is highly advantageous to human beings. This kind of problem solving works best in contexts 59

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that are impersonal and external but is not so good and can even be toxic in contexts that are personal and internal – for example, when dealing with negative thoughts, feelings, and physical sensations. This context is obviously vital in dealing with mental health issues, but the doing mode then becomes driven – a word the authors added in the book’s second edition to distinguish this dysfunctional aspect from its functional mode in ordinary problem solving. Psychological problems arise when the doing mode “volunteers to do a job it cannot do” (Williams et al., 2007b, p. 40). This ‘tragic mismatch’ is a misguided attempt by sufferers to cope with depression – for example, trying to work out what is wrong in a way that only further activates a ruminative cycle. In contrast, the being mode is based on accepting and allowing experience, enhancing more mindful and reflective experience. This sense of not having to change things can help depressed patients to see their depressive experiences as events in the mind – and to avoid rumination by not over-reacting to symptoms. The aim of MBCT is therefore to foster disengagement from the driven doing mode – problematic negative depressive rumination – and engagement with the being mode by the ‘intentional use of attention’ by noticing that one can change attention with positive effect – even whilst experiencing depressive symptoms. The aim is not so much that one mode should predominate over the other but that they should be brought into a better balance. In our culture, this may often translate as giving peace a chance. Segal et al. (2013) are experienced cognitive therapists and see the development of MBCT as an extension of Beck’s work. As has been argued, Beck had implicitly advocated a type of attention based on overcoming fixation with acceptance in even quite early publications but has now explicitly recognised the role of mindfulness and more generally of what he terms ‘focusing’ in his model (Beck & Haigh, 2014). Beck (2005) drew parallels between cognitive therapy and Buddhism in preparation for his well-known meeting with the Dalai Lama1 (Beck, 2005). Melanie Fennell became involved in mindfulness research at the Oxford Cognitive Therapy Centre (OCTC) in Oxford and also notes this perhaps surprising 60

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coming together: “Cognitive theory … is … interestingly very congruent with Buddhist thinking” (Fennell, personal communication, 2020). Judith Beck (2021) has followed in this direction and has added a new chapter on using mindfulness in individual therapy to the third edition of her well-known text – further described in Chapter 28. Note 1 A recording of the meeting is available on YouTube.

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13 Cognitive therapy is a formulation-driven and conceptualisation-driven form of psychological therapy As Beck approaches his 100th birthday in July 2021, I also will pass some personal milestones of my own – in February 2021, 50 years since I saw my first client, and then in March, 25 years since accreditation as a cognitive therapist. I have seen thousands of clients from different backgrounds and with different problems and still regard it a privilege that clients allow me to enter into their inner lives. For example, I have always enjoyed playing and watching sports but now, having had sporting professionals as clients, I know that their lives are not as most sports fans imagine them to be. From this work, I have developed a ‘sports professional template’ that helps me to understand their frames of reference. I have seen hundreds of clients with anxiety problems and therefore also have an ‘anxiety template’. These two templates together give me a ‘sports person with anxiety’ template. In more technical language I have these general – or, technically termed nomothetic – formulations that help build an ‘individualised’ – technically termed idiographic – conceptualisation1 that helps to develop a model of treatment for this particular individual and problem. Cognitive therapists use both these ways of model-building. Formulations serve us well for research whilst conceptualisations serve us well for therapy with individual clients. Conceptualisations need to be sensitive to age, gender, ethnicity, socio-economic status, disability, and sexual identity (Beck, J.S., 2021; Beck, A., 2016; Iwamasa & Hays, 2019). In this book’s first edition, the conceptualisation chapter came first. The fact that it comes later here in no way implies that conceptualisation remains any less central to cognitive therapy. Placing its 62

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description here indicates rather a preference for allowing the client’s individual conceptualisation to build up naturally as the therapist gathers information and engages with the client’s cognitive, emotional, behavioural, and physiological responses to key trigger events – as described in the preceding chapters of this part of the book. Carefully building up conceptual information helps us to guard against being tempted to make stereotypical interpretations and premature conceptualisations – and we know that this is a problem across all psychotherapeutic models (Lomas, 2001). In my training work, I have found that trainees often report feeling that they should arrive at something like a final conceptualisation before beginning therapeutic interventions. The drive for a ‘conceptualisation’ (as an object or noun2) may however become a worry and can distract trainees from doing what they should be doing – continually listening and ‘conceptualising’ (verbs). This emphasises a vital point – that conceptualising should be an ongoing activity and its results – ‘a conceptualisation’ – should always be regarded as provisional and open to amendment. This is because clients may at any point reveal new information that then has to be integrated into the conceptualisation – sometimes such revision may send us in an entirely new direction. While conceptualising is obviously helpful for channeling what we know into the therapy process, it is equally helpful when it clarifies what we do not know. The conceptualisation process will be illustrated with case details – here and in other chapters – from a client, Sam, a health professional, who sought help with relationship difficulties between himself and his children. A generic type of longitudinal conceptualisation regarding him and his problems is shown in Figure 13.1. This format was implied in the work of Aaron Beck (for example, in Beck et al., 1979) but appears to have been first formalised in the writings of Judith Beck (1995). Longitudinal here implies that the current symptoms are shown in relation to each other but also in relation to the client’s history and beliefs. In contrast, a cross sectional conceptualisation – for example, in behaviour therapy – would mainly focus on the current symptomatology. In Figure 13.1, the client’s reported details are presented in a normal font whereas 63

64 Negative emotions: Hurt, sad and angry

Figure 13.1 The conceptualising process with client ‘sam’

Behaviour: ‘Loses it’, over-reacts and is aggressive (?).

Consequences: The children are resentful, unmotivated (?).

Negative appraising thoughts: They are taking the piss; They do not respect me; After all my efforts, I have failed to be an effective father (?)

Vicious cycle of current symptoms:

Trigger: Following a stressful shift at work, Sam comes home to find that his children have left the house very untidy, have not done the shopping as requested nor done any preparation for family supper.

Schematic beliefs: I must not rely on others (?): People who rely on others are weak, misguided (?). I should help my children to stand on their own two feet.

Early experiences/family history: Sam’s father had a very strict, military father and, possibly in reaction to this, he himself was quite laissez-faire(?). Additionally, Sam’s father became depressed and withdrawn – at least for some years – from the paternal role. Sam thinks he became quite autonomous in consequence. Later Sam and his father got on good terms again.

THEory

If the core beliefs derive from negative schemas, they will be tainted with the same negativity and may feed a false sense of values and self.

Allows quick assessment of situations If related to the person’s real or aspired values, core beliefs can provide a solid centre of identity.

SCHEMA: provide the general ‘feel’ of the situation as perceived by mind, senses, and ‘gut feeling’ CORE BELIEFS: Supply the belief content of the schemas, often in basic ‘black and white’ terms (I am good or I am bad) and orientate the person towards self, others, and the universe/future.

(Continued)

Problematic autonomy: Compulsively over-relies on self for care: Is not able to accept necessary help. Danger of stereotyped and overgeneralised judgments.

Adaptive autonomy: Able to look after self; Avoids unnecessary calls for help

MODE: basic orientations that either are ‘adaptive’ or problematic

Problematic

Adaptive

Basic elements of cognitive organisation

Table 13.1 sam’s functioning in relation to his cognitive organisation

CognITIvE THErAPy As PsyCHoLogICAL THErAPy

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ASSUMPTIONS: Because the The adaptive aspects of Sam’s approach to autonomy have served unconditional nature of core beliefs him well in many situations. He makes them uncompromising to is a valued member of staff of hold (If one is bad, what is the point work who can take responsibility, of trying anything?), assumptions be ‘can do’ and not bother may try to compensate for them management with unnecessary and to make it worthwhile at least complaints. trying: e.g., ‘ I may be bad but I can get people to like me somehow then I can be okay’ (conditional beliefs). These new rules, however, carry the hazard of dealing with the actuality of people not liking one and therefore of seeing oneself as, by definition, ‘not okay’. When his ‘autonomous thoughts and NEGATIVE THOUGHTS: If beliefs’ get him to be inventive and schemas and beliefs are the chiefs help him to ‘get the job done’, they of the cognitions tribe, NATS are are helpful. the ‘injuns’ – ready to perform their negative duties at all times of day and night and in all weathers.

Basic elements of cognitive organisation

Table 13.1 Continued

When they are not asking for proper help and giving others a bad time, they can generate a lot of unhappiness in him and in those around him.

The main downsides of Sam’s approach to autonomy come when he applies them to other people. If people let him down then he tends to assume that there is something wrong with them or with him (in not leading them correctly) when what he is asking may just be beyond them or they may extra help to ‘get it’.

Problematic

THEory

CognITIvE THErAPy As PsyCHoLogICAL THErAPy

details not yet known are identified with an italic font. Reasonable speculations about things we do not know are in italic print with a question mark. Identifying what we do not know at all and our best guesses is helpful because the question marks remind us to ask about these items in upcoming sessions. Table 13.1 shows foci for further inquiry into the client’s early and previous experiences and the beliefs and schemas that might echo themes in the client’s current problems. In a major paper that summarises his more recent theoretical thinking, Beck (Beck & Haigh, 2014) confirms that belief change remains at the heart of the cognitive therapy enterprise. Methods of belief identification and change are discussed in the Practice section. It is important here to clarify the different higher-order cognitions (beliefs, schemas, and modes) and the relations between them in Beck’s model: Modes are the general templates for evolutionary responses – especially for survival – and act as gathering places in the mind for groupings of cognitive schemas, emotional schemas, behavioural schemas, and physiological schemas. Cognitive schemas act as containers for related unconditional core beliefs and conditional intermediate beliefs (assumptions, attitudes, and ‘rules of living’). Negative automatic thoughts (NATs) may be influenced by all these ‘higher order’ elements of cognitive organisation. During the UK COVID-19 lockdown, Sam paused therapy for a few weeks as he could feel himself ‘going into battle mode’ in his hospital work and thought this would distract him from the problem originally presented. We identified that a normal ‘autonomy mode’ was an important part of his personality and that this pattern had been further activated by the lockdown. This mode contained both core beliefs – Autonomy is the safest way of being – and intermediate beliefs – If I become dependent, my survival depends on others – and ‘rules’ – I should not need to be told continually about what is important. These higher-order cognitions link naturally to the NAT – I should not have to keep telling my kids to be responsible. I wondered if Sam would return to therapy but he did so after he felt ‘on top’ of the new reality of treating COVID-19 patients. At first he struggled to see any potential for ‘negativity’ in any of the 67

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thoughts and beliefs reported above– until he reflected on that challenging question that most parents one day confront – should my children believe what I believe? Therein, as readers will doubtless appreciate, hangs a tale – one that will be discussed further when we explore ways of working with beliefs in Part II. Conceptualisations not only help us to understand but, as discussed earlier, help us to find appropriate targets for interventions. Kuyken et al. (2009) and Padesky (2020) have developed a set of guidelines for choosing between disorder-specific and transdiagnostic conceptualisations (Dudley et al., 2011) and also stress the need to include clients’ strengths and resiliencies as targets for understanding and treatment – a point also supported by Judith Beck (2021), who now advocates the benefit of having both a problembased conceptualisation and a strengths-based conceptualisation. Notes 1 There does not seem to be a universally agreed common usage for these two words but here I define them in what seems to me to be the most usual way for cognitive therapists so to do. 2 An example perhaps of ‘reification’ – ‘treating an immaterial thing as a material thing’.

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14 Beckian epistemology1 has a clear research process for developing appropriate therapeutic knowledge Beck has been skilled in making links with therapists and researchers – especially the young and ‘up-and-coming’ ones in the United States and internationally. He developed a particularly close relationship with the university psychiatry and psychology departments in Oxford, especially with staff of the Warneford Hospital (Kennerley et al., 2020). David. M. Clark (1996), still working then at the Warneford, describes the evolution of his cognitive model of panic from the mid-1980s onward. As we have noted, this model became one of the first major developments of cognitive therapy outside the United States. Clark’s panic model has been hailed as an exemplar of clear research based and empirically tested modelbuilding for the understanding and treatment of specific psychological problems. Clark explains how he and his colleagues built this approach using the research model developed by Beck, firstly, for depression, and then later for other areas. This research model has undoubtedly been influential in increasing rigour in psychotherapy research. It has been strikingly characterised by a strong ethical concern not to make claims for any form of treatment before efficacy research has shown it to be effective. Padesky highlights, the exponential effectiveness of [Beck] working equally hard in the areas of conceptualisation, empirical research and therapy applications. His discoveries and innovations in each area are enhanced by knowledge gained in the other two areas…. For example, beginning with the 1959 paper on dream content of depressed patients (Beck & Hurvich, 1959), his empirical work 69

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in the area of depression preceded development of his cognitive theory of depression, first published in 1967. His therapy, so familiar to us today, developed over the next 15 years. (Padesky, 2004, p. 12) D.M. Clark (1996) describes the characteristic processes by which Beck’s cognitive therapy has developed comprehensive approaches to models of specific psychological problems. The process has been refined as cognitive behaviour therapy (CBT) has expanded in terms of the numbers of practitioners and researchers involved in the multifarious treatment areas in which it is now being practiced. Clark describes the process as having five characteristic stages: 1) Moving from clinical insight to specify a simple clinical model for a particular problem area. 2) Experimental investigation of the model. 3) Detailed accounts of factors that prevent cognitive change in the absence of treatment. 4) Carefully chosen treatment procedures for targeting cognitive change. 5) Controlled trials of the effectiveness of those procedures. Anyone now attending a CBT conference will typically find hundreds of papers addressing these different stages in relation to most of the problems that psychological therapists are likely to encounter. Clark (1996) shows how he and others moved through the above stages to develop his cognitive model of panic disorder, beginning by developing experimental tests of its basic psychological constructs. Only when constructs were tested and established could the theoretical model be launched. Once the theoretical model was established, only then could testing of possible interventions begin. Interventions were first tested as stand-alone trials because it would have been premature and would have risked obscuring their true utility if they were tested as parts of a whole therapeutic package. As promising interventions began to shape up then, and 70

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only then, overall protocols could be developed and tested. D.M. Clark (2019) has stayed true to this model whilst leading the development of Improving Access to Psychological Therapy (IAPT) and this has greatly added to the project’s credibility – see Chapter 29. Initially, this process was essentially forged when Beck was often working alone and in ‘splendid isolation’ (Rosner, 2014) whilst developing the cognitive therapy of depression. Beck’s early research was on a relatively small scale and the way he recounts the story of his first major research trial is instructive of both his cautious attitude to research and his situation at that time (Beck, J.S, 2011b). As he was developing the cognitive therapy of depression, Jon Rush, then one of his students, told him that he should disseminate his ideas by doing a clinical trial. When Beck replied that he was not familiar with such methodology and, in any case, was not too concerned about disseminating his ideas at that stage, Rush offered to run the trial for him. Characteristically, when confronted by a bright young colleague, Beck quickly approved the idea. This style and method of research process pioneered by Beck and his allies has served the development of cognitive therapy well. CBT subsequently made regular use of this same pattern of research that has been vital in winning the confidence of necessary outside allies and agencies, such as practice and funding agencies – resulting in raising the credibility of the model. It may well be that this thorough and careful process for building effective psychotherapy methods will prove an equally, if not more, significant element of Beck’s legacy as cognitive therapy itself. A noteworthy feature of the whole process is the tight fit between each step and the way the steps build up mutual interaction of cognitive therapy theory and its practice: In science, the direction a discipline takes is determined by the conduct of systematic observations; however, these observations themselves are in turn products of the theoretical perspectives of scientists within a given cultural context. (Alford & Beck, 1997, p. 5) 71

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Psychological therapy has had a long-standing and on-going problem with bridging the gap between research findings and what practitioners actually do in practice (Teachman et al., 2012). Although therapy protocols are by no means the complete answer to this problem, they are probably a significant part of the solution. The use of protocols to guide the practice element of this research process has been noteworthy – though at times also controversial. Protocols attempt to forge the elusive links between theory and practice and the further discussion of this point in the next chapter provides a bridge to move readers into the second part of the book. Note 1 Epistemology can be defined as the theory or science of the method or grounds of knowledge.

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15 Therapy protocols have played a role in the development of the cognitive approach There is an apocryphal story of a witty Irish countryman who, when asked for road directions, replies, “If I were you, I wouldn’t start from here”. This joke reflects perhaps the fact that giving even simple instructions can often seem perversely difficult. For example, we may know a particular routine like the back of our hand but may struggle to explain it to others. If it is hard to describe simple road directions and routines, why did anyone think that writing something as complex as therapy procedures might not be infinitely more so? The end of the 1970s brought the first cognitive therapy outcome studies and the rapturous worldwide reception of Beck et al.’s (1979) Cognitive Therapy of Depression. This period can be seen as the end of the first phase of Beck’s creation of cognitive therapy. He had found his cause, was assembling his team, and now needed to disseminate sound procedures. Protocols would prove one way to do this. The first outcome study required a protocol (Rush, 1977) to counteract the ‘fidelity problem’ – that is, therapists in trials need to stay faithful to the principles they were asked to implement. Earlier research revealed that there was often a disconnect between what psychological therapists reckoned they did and what they actually did (Frank and Frank, 1993). To measure the effect of ‘cognitive therapy’ in a study we need to feel confident that the research therapists were following a common set of procedures that maintained ‘fidelity’ to the overall model. Researchers usually added an accompanying ‘manual’ to help participant therapists to use the protocol.

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The famous book by Beck et al. (1979) was based on the manual for the protocol used in the first outcome study (Rush, 1977). Thereafter, a process of ‘manualisation’ of therapy began and was soon popularised – not, as we would expect, without controversy (Cook et al., 2017). Cook et al. (2017) discuss the advantages and challenges of manualisation and evidence-based practice (EBP), concluding that ‘flexibility’ is required to make manuals and protocols work. We might however ask what degree of flexibility is required and how can we find it? Jacqueline Persons (2008, p. 150) writes that empirically supported treatments are based on “the average patient who participated in the clinical trial … (but that) … they do not provide information about the best treatment for the patient who is in the therapist’s office”. For her, the flexibility needed for the individual client is found in “the indivdualised case formulation that helps guide treatment planning for the individual patient” (Persons, 2008, p. 150). Many read Beck et al.’s 1979 book, acknowledged now as a ‘classic’, without realising that it was based on a treatment manual. In particular, it has many convincing client vignettes, gems of therapist wisdom, and even traces of humour. In subsequent decades the floodgates for manuals really opened, though few seemed written with the grace of Beck and his co-writers. I, like others, bought a stack of manuals, only to find them very hard to use. This seems often to be the case with more experienced practitioners (Cook et al., 2017). Protocols often seemed to me to have been written in dry prose, quite lacking in the frequent clinical tips and anecdotes that Beck et al. (1979) lace into their text throughout. There were also process problems when using them – for example, one usually has to see a client a few times before deciding which protocol to use. By then, the material of the protocol’s opening sessions may have been covered, leaving awkward decisions for the therapist about where to start – especially if later materials cross-referenced to now omitted ones. The protocol would sometimes recommend things that felt either wrong or mistimed for the client. Frustration mounted as one saw the manuals, now rarely used, sitting forlornly on one’s library shelves. 74

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In the early 2000s I read a therapy blog by Larry Beutler that seemed to make sense of this experience. Larry argued that it takes two years of more or less full-time use to really get the hang of using any single manual. He went on to say that generalist therapists, such as myself, see roughly 20 common psychological problems and then, with his tongue in his cheek, Larry added that it would therefore take at least 40 years to become competent, by which time many would be ready to retire!1 The idea of allowing oneself two years of concentration around a problem reminded me of something I heard when I first trained as a counsellor for people with alcohol dependency. An experienced supervisor on the training course said that trainees needed to work with about 50 clients with alcohol problems before they had seen most of the variations of presentation they would be likely to meet. Even for most specialist workers, working with 50 clients would take at least one or two years. These arguments focus on the role of experience in the development of competency. Furthermore, models of competency development stress that the higher stages – of ‘proficiency’ and ‘mastery’ – require practitioners to bring artistry, flexibility, and creativity to their work (Wills, 2015: Chapter 8). Egan (2017) posits a model of skill use based on discriminating the different skills that were most relevant to different stages of counselling. The development of such discrimination can be enhanced by using tape recordings of therapy sessions – a wellestablished tradition for the acquisition of skills and competencies in cognitive approaches (Padesky, 1996). Recordings have many uses – for training and assessment purposes and for monitoring skill use in any form of practice. The benefit of tracing links between skill use and consequent movement in therapy is perfectly captured by Rogers (1980. p. 127) in his account of the first use of recordings in therapy research: I remember the excitement of gathering round the tape recorder to listen and learn what happened when such and such an intervention was used. We learnt a lot from that. 75

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Precisely discriminated and identified skills can be written into protocols. When Beck and his colleagues wrote up the first treatment manual in the late 1970s, they provided the base on which much else has been built, including the Cognitive Therapy Scale (CTS: Young & Beck, 1980). The CTS, and its revision, the CTS-R (James et al., 2000) – both with accompanying manuals – allow skill competency to be measured and assessed and has therefore been used productively both in research, to ensure trial therapists, for example, have performed adequately, and in training, to assess whether trainees have reached required levels of competence to be certified or accredited. The CTS, discussed further in Part 2, was the first major attempt to take a systematic approach to these factors and has stimulated similar attempts in models other than cognitive behaviour therapy (CBT) (Barlow & Brown, 2019). Note 1 After an exchange of emails on this point, Larry subsequently regretted to tell me that he had recently re-calculated this and now thought that it took over 300 years to become competent in psychological therapy!

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Conclusion to Part I

A review of Beck’s ideas about therapeutic theory reveals them as wide-ranging and profound. As a man of ideas, he shows himself to be eclectic and pragmatic. At a time of increasingly narrow specialism in academic fields, Beck is open to ideas from any direction, and, in comparison with other similar figures, such as Freud, he is more inclined to respond to criticism. Though he has fought his corner, Beck has at times also responded to criticism by changing his position. He has been more rigorous and persistent in his empirical work than Rogers and Ellis, and has shown more diplomatic skill than either. The better comparison may be with Charles Darwin. Darwin’s theory is probably even more parsimonious and yet more elegant than Beck’s and perhaps surpasses the parsimony of all other scientists. Beck shared Darwin’s early physical frailty but was more robust in overcoming it. Beck’s theory has had enemies, as did Darwin’s, and he has shown more courage in putting it in the public domain than Darwin did. He is an amiable person – and yet, like Darwin, can show determination when needed – two qualities often hard to combine successfully. Whilst Darwin’s theory has profoundly shaped much modern science and thought, Beck’s theories have had more direct practical effects in relieving mental suffering. Beck and his associates followed up their work on depression (Beck et al., 1979) with a similar project on anxiety (Beck and Emery with Greenberg, 1985) and other problems with a similar 77

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blend of theory and description of methods. Always seeking out new ground, Beck took on an ever-widening set of interests in the final years up to his retirement as a full-time member of the staff at the University of Pennsylvania in 1994 and, thereafter, in his role at the Beck Institute. Such a wide set of interests and a bent towards theory has, I think, meant that it becomes somewhat harder to discern his ideas on how to practice the methods of cognitive therapy in his subsequent publications. He has, however, been somewhat relieved of this role by the emergence of his daughter, Judith. S. Beck, as an experienced cognitive therapist, signaled by her first major publication, Cognitive Therapy: Basics and Beyond, in 1995 – with second (2011) and third editions (2021). Her work will therefore feature, alongside her father’s, more frequently in the second half of this book.

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Part II POINTS OF PRACTICE Besides Judith, born in 1954, Aaron and Phyllis Beck had three other children, all born during the 1950s – Roy, a noted epidemiologist, Dan – like Judith, a cognitive behaviour therapy (CBT) practitioner, and, Alice, who, like her mother, became a Superior Court judge for Pennsylvania. It may be significant that Beck wrote less during his children’s early years, perhaps in part because of his commitment to the paternal role. Ever keen to get feedback from those around him, Judith Beck remembers her father running the concept of ‘automatic thoughts’ past her when she was an adolescent – her telling reaction was that it made sense but was hardly a ‘big deal’ (Weishaar, 1993, pp. 21–22). Judith graduated magna cum laude from the University of Pennsylvania and her first career interest was in teaching children with learning differences. She gradually became more interested in the psychological aspects of her work with children and their families and, after training in cognitive therapy and doing her PhD, in the late 1980s and 1990s she became a therapist at the Centre for Cognitive Therapy and then at the Beck Institute after its foundation in 1994. In a foreword to Judith’s first major book in 1995, Aaron Beck points out that, “The practice of cognitive therapy is not simple” but that Judith is, “eminently qualified” to guide its practice (Beck,

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J.S., 1995, p. ix). This makes it clear that from this point forward we have to think of two Becks in relation to the development of cognitive therapy.1 Note 1 We should also mention that Dan Beck is practicing and teaching CBT in the social work context.

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16 Cognitive therapy requires a collaborative therapeutic relationship It has sometimes been said that cognitive therapy does not have a concept of the therapeutic relationship – or at least, has little to say about it. The concept of the ‘therapeutic relationship’ holds a special place in the discourse of psychotherapy – with quite varied views of what it is. On the one hand, the therapeutic relationship is held to be the chief ‘common factor’ to all models and to be a decisive, if not the decisive determinant, of therapeutic effectiveness (Wampold & Imel, 2015). On the other hand, it is also a term that can be vague in usage and its importance may be conceptually susceptible to over-inflation (Feltham, Ed., 1999). Both Judith (2021) and Aaron Beck (Beck et al., 1979) describe the therapeutic relationship in terms that have much in common with those given in the work of Carl Rogers (1957, 1980). This has been re-emphasised with the recent development of Recoveryoriented cognitive therapy (CT-R; Beck, J.S., 2021). Unlike Rogers, however, they regard the ‘core conditions’ of empathy, warmth, and congruence, as necessary, but not sufficient, for change. A collaborative relationship is based on the desirability of ‘collaborative empiricism’ (Beck et al., 1979, p. 6) – in which the therapist has considerable skill in helping clients to identify and organise the ‘raw data’ of their experiences. From a cognitive theory perspective, one would expect individual clients to react differently to the therapeutic relationship based on their beliefs about relationships. Some clients, for example, may want the therapist to express a lot of empathy but others might wonder about the sincerity of that same degree of expressed empathy. Those who have experienced exploitation in important previous relationships may find it hard to trust 81

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the motives of both the therapist and her enterprise. Judith Beck addresses the implications of these client differences to describe the need for therapists to match them with variations in their own style: To engage fully in therapy, most patients need to feel that their therapists are understanding, caring and competent. Yet even when their therapists display these characteristics, some patients react negatively … Sometimes therapists need to vary their style, becoming more or less empathic, structured, didactic, confrontive, self-disclosing, or humorous. (Beck, J.S., 2005, pp. 14–15) In cognitive therapy, the client and therapist should ideally form a ‘team’ that unites and works together to solve the client’s key problems (Beck, J.S., 2021; Beck et al., 1979). To this ‘team’, the therapist brings a considerable amount of expertise and knowledge about psychological problems and processes of psychological change. This expertise may not, however, prove useful if it cannot be applied to the individual client’s life. Clients therefore also bring expertise about their own experiences to the ‘team’. Usually neither client expertise alone nor therapist expertise alone can succeed – success is most likely to come from uniting these two domains of expertise into a working partnership. Cognitive therapists do however largely endorse the personal qualities implied in the Rogerian ‘core conditions’ – but see them as creating a relationship within which the therapeutic work takes place. They also suspect that such relationships cannot be entirely non-directive because they are intrinsically rewarding and do influence clients (Beck, J.S., 2011a). Wills with Sanders (2013, pp. 30–31) have suggested that the relationship in cognitive therapy may be better termed ‘directional’ rather than ‘directive’. There is also evidence that cognitive behaviour therapy (CBT) therapists can combine the skills of giving direction, being empathic, and influencing clients as effectively as other types of therapists (Keijsers et al., 2000). For cognitive therapy to be effective, however, the 82

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therapist needs to have both conceptual and technical expertise as well as interpersonal skills (Padesky with Greenberger, 2020). Like humanistic therapy, psychodynamic therapy has placed a heavy emphasis on the therapeutic relationship as the vehicle of change – though for rather different reasons (Holmes & Slade, 2017). Psychodynamic therapists regard many client problems as being caused or exacerbated by unconscious wishes and motives. They believe that these unconscious wishes will themselves permeate the therapeutic encounter as ‘transference reactions’. Transference reactions are, in brief, client responses based on unconscious wishes and may elicit ‘counter-transference’ from the therapist’s unconscious. Thus the therapeutic relationship becomes an arena in which these transference and counter-transference issues can be ‘worked through’ and resolved. ‘Working through’ has been identified as a main activity of psychodynamic therapy (Holmes & Slade, 2017). The activity of ‘working through’ has traditionally been seen as a long-term process and this factor has therefore identified psychodynamic therapy as generally being longer term than other types of therapy. Wills (2015, pp. 38–39), however, offers an example of what ‘working through’ might look like in cognitive therapy informed by the importance of identifying and working with interpersonal schemas and core beliefs based on past experiences. The following chapter explores the way that working with core beliefs and schemas can, in ways similar to the idea of ‘working through’, help to identify and work through the way clients’ interpersonal difficulties may affect the dynamics of a cognitive therapy session (Beck, J.S., 2005). Aaron Beck has sometimes referred to himself as a ‘closet psychoanalyst’ (Edwards & Arntz, 2012) though ‘critical friend’ may perhaps be a better term. His approach to therapy includes a similar motivation to that of Ellis’ (Dryden, 1995) – away from the ‘inefficient’ aspects of dynamic therapy towards more ‘efficiency’. One way of seeing this is that Beck has encouraged cognitive therapists to be more ‘time-sensitive’ (Beck, J.S., 2021) – that is, doing much short-term work but also being open to the need for longerterm work. Nevertheless, psychoanalytic influences have become 83

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evident in cognitive therapy applications to areas characterised as having the potential for complex relationships, such as the cognitive therapy of personality disorders (Beck & Associates, 2016). We have already noted the evolutionary dimensions of Beck’s analysis of problems of this type – that is, that there are circumstances in which their associated attitudes may be more functional in certain situations – and we may also recognise that this can be a de-stigmatising factor in this delicate area. For example, a client who continually devolves decision-making to the therapist may be reflecting aspects of dependent personality disorder (APA, 2013: DSM-V). If therapists can gently help clients to identify the ways that this tendency may work against them, and encourage them to make other choices if they want to, then even work with these deepest of problems can stay within the style of collaboration. Judith Beck (2005) describes a number of case examples where such highly sensitive and collaborative work succeeds with clients who show aspects of personality issues or other challenging problems.

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17 Cognitive therapists, like other therapists, use conceptualisations to tackle interpersonal and alliance issues Conceptualisations can be used to throw light on the interpersonal issues that may arise in therapy, often by reference to the interpersonal beliefs explicit or implicit in the conceptualisation. For example, a client may believe that ‘People do not care about me’. Such a client can give up on the therapy because of this belief and may not then turn up for a scheduled session. The therapist then has to consider how to respond – and, in light of the core belief, might decide that the best way to disconfirm his belief would be to make contact quickly, encouraging him to come back to therapy. If the conceptualisation revealed a core belief that, ‘People keep telling me what to do and don’t let me make my own decisions’, the therapist might decide to play more of a waiting game and just see what unfolds. Interpersonal work becomes more crucial when working with clients who have wider and more pervasive negative patterns – sometimes defined as problems of personality (Beck, J.S., 2021). The diagnostic label ‘personality disorder’ has, for good reasons, proved controversial. Controversy has partly been fuelled by a misunderstanding of the term based on its associations with dangerousness and/or criminality. Only a small part of the spectrum of personality disorders, however, concerns such issues. Therapists who experience some unease about this kind of label may prefer the term ‘personality pattern’ – a view that can be justified by the fact that problematic personality patterns are more pervasive and ‘normal’ in everyday therapy work than is sometimes realised. Some therapists reject the DSM system of diagnosis and its implicit ‘medical model’ (Albee, 2000; Watson, 2019). Many cognitive therapists 85

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share such reservations but may be open to more pragmatic use of the DSM’s helpful elements – for instance, being able to recognise how the presence of one ‘symptom’ may suggest the possibility of another – for example, a client with borderline features may show impulsivity and may also have a fear of abandonment. Even so, many cognitive therapists are often as keen as others to de-stigmatise these ‘labels’. Beck (Beck et al., 2016), for example, has made a striking and de-stigmatising contribution to the treatment of such problems. They suggest that, like more ‘ordinary’ psychological problems, difficult personality patterns may be linked to evolutionary survival imperatives. It can, for example, be helpful to allow a certain degree of dependence on others when there are environmental shortages of essential supplies and/or when one’s capacity to access them has been impaired. Conversely, there are also times when celebration and an ‘expansive mode’ is justified by personal and social successes. The difficulty may not lie in the strategy itself but in the over-use of it. Beck et al. (2016) show that these patterns have specific and distinct cognitive profiles that can be engaged with in essentially similar ways as in standard cognitive therapy. Such work, however, is usually more long term and relies heavily on interpersonally skilled use of the therapeutic relationship (Beck, J.S., 2005, 2021). The key skills in dealing with such problems involve a series of clinical judgements: discerning problematic situations, deciding whether to act on them, and then formulating a therapeutic response. It is often wise to delay over-ready reactions and take the issue for discussion in supervision. A rule of thumb of waiting until a pattern has shown itself three times may be useful. It is also helpful for therapists to reflect on their own behaviour and consider whether we have been consciously or unconsciously provocative – perhaps operationalising questions suggested in this chapter. It would be a rare client or therapist who didn’t have buttons that are pushed sometimes. It is, however, sometimes desirable and necessary to react in the moment and then therapists can cultivate the skill of ‘immediacy’ 86

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(Wills, 2015). Immediacy involves therapists saying in a non-threatening way how they are experiencing their clients in the immediate moment. Therapists can then invite open discussion and reflection on what is ‘happening between us’. This might sound threatening but clients are often all too aware of how people experience them and it can be a relief for the therapist to bring it out into the open. At worst, these confrontations can get messy but at best they often have potential for breakthrough – the therapy ceases to be a ‘talking shop’ and may become a place where immediate experience is properly valued. Gill was a doctor in general practice who came to see a cognitive therapist to whom she had previously referred patients. She worked in a group practice that was going through a turbulent period of internal conflict. A number of her colleagues had made complaints about Gill’s abrupt and abrasive behaviour, which contrasted with the good will on which general medical practice relies to operate smoothly. Despite referring herself for therapy, she seemed very reluctant to be there and she made a series of cutting remarks that her therapist found quite hurtful and difficult to ignore. Eventually the therapist screwed up courage and offered Gill the comment, “Gill, I am wondering if you don’t suffer fools gladly and if you perhaps regard me as a fool”. Gill stopped in her tracks – but then smiled broadly and replied, “Yes – I am not being very easy, am I? Sorry”. Things proceeded more smoothly thereafter and this led to a discussion about Gill’s relationship with her father, who had been a naval commander in World War Two. He was a tough and brilliant military man and was renowned for ‘not taking fools gladly’ but, as Gill reflected, he was also appreciated for the ferocious care he took for the lives of his men – a combination characteristic of wartime leaders. Gill realised that she did see a kind of ‘wartime’ situation prevailing in her workplace that, in some ways, explained her attitude but ultimately also she recognised that she too, like her father, needed to show care for the lives of her ‘men’ – in this case, her male and female colleagues. Beck et al. (2016) describe these types of exchanges mainly in relation to working with personality problems but many therapists 87

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experience such patterns quite frequently with clients at all levels of therapy. Aaron (Beck et al., 2016) and Judith Beck (2005) tend to see these interpersonal ‘marker’ behaviours as being ‘driven’ by specific core beliefs – in Gill’s case, autonomy beliefs, such as ‘It is weak to need the help of others’ – so that using interpersonal strategies informed by the Becks’ work in this area can provide cognitive therapists with much help for working productively with such patterns. There are client negative reactions that may be hidden and this is why Beck puts great emphasis on eliciting feedback from clients: I may do or say something that is hurtful, rejecting or insulting to the patient … the client will need to tell this to the therapist … such reports are extremely valuable in giving us information that will help the therapy. In fact, these reports are often the most valuable material that we obtain in treatment. (Beck et al., 1979, p. 82) Thus, client feedback is also recruited into the enterprise of using our overall understanding of the client to tackle interpersonal and alliance issues that may influence the effectiveness of the therapy.

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18 Cognitive therapy is, at least initially, a time-sensitive and relatively structured form of therapy One side of therapy that seems to anger Aaron Beck is when it becomes so ‘esoteric’ that it fails to engage a wider public. Frude (2005; Price, 2013) advocates wider access to therapy via (mainly) CBT self-help books and likens government policy choices on provision as being between having expensive goods available to a few people and cheaper ones available to many. In order to achieve wider access, most therapy probably has to tend towards relative brevity and, if brief, then both structured and directional. In a “socio-economic climate that values shorter treatments and demonstrated efficacy” (Weishaar, 1993, p. 141), definitions of ‘long’ and ‘short’ therapy have changed. Definitions now coalesce around a range where ‘short’ is less than 20 sessions, ‘long’ – over 40, and medium – 20–40 (Ivey et al., 2011). In England’s Improving Access to Psychological Therapy (IAPT) – see Chapter 29 – ‘high intensity’ work is often defined as up to 16 sessions. Early results for cognitive therapy reinforced the notion that most clients respond well to relatively brief therapy – though some do need longer-term contact. Perhaps more of the latter group do now come for treatment, causing Beck’s comment, “Where have all the easy cases gone to?” (Intro to Beck, J.S. (2005) – a book sub-titled, What to Do When the Basics Don’t Work. Beck and Emery (1985) reiterate the desirability of fitting the number of sessions to individual problems and patterns but also reflect a brief therapy mind-set, “Long-term therapy for anxiety is unnecessary and is, in many cases, undesirable” and “the pace of

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therapy is relatively brisk” so that therapists should “rush slowly” but “move on quickly” (p. 171). They offer supplementary guidelines for keeping cognitive therapy time-limited: 1) 2) 3) 4)

Keep treatment simple, specific, and concrete. Emphasise homework. Stay task-relevant and use time-management. Develop a brief intervention time-set (1985, p.172).

Brevity is somewhat less emphasised by Judith Beck: CBT is time-sensitive. We used to say that CBT was shortterm … But the treatment for some conditions needs to be much longer. We try to make treatment as short-term as possible whilst still fulfilling our objectives. (2021, p. 21) Judith Beck’s shift in emphasis may reflect the evolution of longerterm cognitively based approaches, such as in Schema-focused Therapy (SFT: Young et al., 2003). Young et al. (2003) describe how SFT developed when assumptions underlying the ‘standard model’ of cognitive therapy – for example, that clients could make a therapeutic relationship relatively easily – did not fit a significant minority of patients with more difficult problems. When these assumptions are not met, therapy is likely to go beyond the range of 20 sessions. There is little research into the effects of different lengths of therapy amongst the general population (Roth & Fonagy, 2005). An exception was the series of Kaiser Permanente studies – a large cost-benefit analysis run over 25 years (Cummings & Sayama, 1995), which showed that for 85% of clients, much of the measurable benefits of therapy were achieved in the first ten sessions and ‘diminishing returns’ were evident thereafter. Significantly, however, this left 10% needing more than 20 sessions and 5% needing much longer-term therapy. 90

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Beck advocates ‘pacing’ therapy and this requires ‘sufficient control’, tempered by sensitivity to individual client needs, to optimise the appropriate use of time (Young & Beck, 1980, p. 8). Even therapists who prefer shorter-term work agree that some clients require long-term contact. The key estimate is of how large the latter group is (Cummings & Sayama, 1995). Structure is needed for both brief work – to keep things on track – and longer-term work – in order that therapy does not become, in Freud’s (1937) famous term, ‘interminable’. The cognitive therapist … titrates his degree of activity according to the patient’s apparent need for structure … The degree of activity and structuring requires an exquisite sensitivity to the client’s needs and reactions. No other aspect of cognitive therapy … requires as much skill. (Beck et al., 1979, pp. 65–66) The debate about structure is sometimes confused because ‘structure’ can be used in two rather different but inter-related ways. First, structure may refer to a series of behavioural steps to follow in a session. Cognitive therapy has a definite session structure to be followed quite closely. Table 18.1 shows how session structure has developed in the work of the Becks. Therapy structure offers helpful boundaries within which the clients’ issues can be safely contained. Therapy is still an unfamiliar experience for many clients and when they know the structure it can be easier for them to adapt to it. Alford and Beck (1997) argue that structure also enhances the collaborative transfer of learning from therapy to the real-life context. Structured sessions are directional in that they are structured to the end of goal attainment but both structure and direction should be negotiated with the client. Two aspects of the structure are especially helpful in conducting negotiation: agenda-setting (collaborative agreement of issues to be tackled in the therapy session) and taking feedback (hearing the client’s perception of the session). Some clients are resistant to 91

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Table 18.1 Cognitive therapy session structure

Beck, J.S. (2021) Initial phase 1. Mood check

Beck, J.S. (1995)

1. Brief update, mood check 2. Agenda setting 3. Setting the agenda 3. Update 2. Bridge 4. Prioritise agenda 4. Review homework Middle phase 5. Discuss Item 1 5. Discussion of agenda items & new homework 6. Discuss Item 2, etc. End phase 7. Summarise 8. Action Plan

Beck, A.T. et al. (1993) 2. Mood check 1. Setting the agenda 3. Bridge

4. Discussion of today’s items

5. Socratic questioning 6. Capsule summaries

7. Homework assignment 9. Elicit feedback 6. Feedback and summary 8. Feedback in the therapy session

structure or direction or both (Beutler et al., 1994). Responsiveness to clients’ reactions towards structure forms part of securing an interpersonal fit between the client and cognitive therapy. Whilst therapists should explore client resistance (Leahy, 2003), it is also helpful to make appropriate adjustments to structure and/or direction. All these moves help early contact with clients to inspire hope, a key objective then and throughout therapy (Beck, J.S, 2021). Secondly, ‘structure’ can refer to how therapists and clients weave new therapeutic narratives – into the ‘deep structure’ of the therapy (Ivey et al., 2011). Padesky (2004) recalls first observing Beck working and being disappointed by his lack of (i.e., the first 92

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type of) structure – before realising that he was following a less visible (second type of) structure. Structure is necessary for collaboration … therapists must themselves possess a theoretical rationale for specific treatment techniques. Otherwise, there is no structure on which to base the process of collaboration … (also needed are) … recommendations ‘in a meaningful and consistent manner … backed by a coherent rationale’. (Alford & Beck, 1997, p. 12) ‘Direction’ is another easily confused term, in this case with the Rogerian term, ‘directive’. Some argue that CBT is directive and thus works against client self-determination. By using the terms ‘offering direction’ and ‘being directional’ one can clarify that ‘accepting direction’ and ‘maintaining self-determination’ do not need to be mutually exclusive concepts. In practice therapists have to strike a balance between being directive and imposing structure on the one hand, and allowing the patient to make choices and take responsibility on the other. This balance involves deciding when to talk and when to listen; when to confront and when to back off; when to offer suggestions and when to wait for the patient to make his/her own suggestions. (Young & Beck, 1980, p. 8) In his demonstrations of therapy, Beck – as Padesky observed shows that it is possible to use structure and direction lightly. A structured and directional approach may be best for most clients, though it is important for therapists to step back from structure and direction according to the individual needs of clients. Beck has a strong drive to seek feedback (Weishaar, 1993). Eliciting honest client feedback – on individual sessions (‘How did this session go?’) and by periodic reviews (‘How are we doing after 6 sessions?’) – helps therapists to get the right fit of therapy to the individual client before them. 93

19 Cognitive therapy is problem- and goal-orientated, and is focused, initially at least, on ‘here and now’ functioning All therapy models have goals but the behavioural tradition has always held that such goals should be overt. Problem solving in cognitive therapy is one of the inheritances from the behavioural model (Beck, 1970b). The emphasis on problem solving can clearly be seen in Beck and Emery’s (1985) thoughts on an important rationale for brevity on how to keep therapy manageable, and for focusing on workable problems: many of the patient’s problems will remain unsolved at the end of treatment. By the time treatment ends, the patient will have enough psychological tools to approach and solve problems on his own. (Beck & Emery, 1985, p. 172) Such transfer of skills implies the aim for clients is to become their own therapists. Brewin (1996) concludes that the transfer of problem-solving skills is likely to be one of the most effective elements in CBT treatment. An advantage of cognitive therapy for depression is that it promotes relapse prevention by increasing the client’s ability to solve problems after therapy (Hollon, 1996). Jacobson and Hollon (1999a, 1999b) also show that much of the efficacy of cognitive therapy with depression may well lie in relatively simple problem-solving skills deliverable by nonspecialists. These findings are reflected in recommendations for the development of ‘low-intensity interventions’ for depression (Roth & Pilling, 2007). 94

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Beck and Emery (1985, p. 171) invoke the problem-solving spirit by characterising cognitive therapy as, “a task-orientated frame for getting down to business.” Other therapies do not have such a clear focus on ‘problem-solving’ as that presented for cognitive therapy. The problem-solving focus closely relates to the preference for briefer therapy. As both psychodynamic and humanistic therapy, especially in traditional form, do not have this short-term emphasis so they also seem to have characteristically different ways of solving problems, often focusing ‘on underlying mechanisms’ rather than overt problems. Various cognitive and behavioural approaches to problem solving have stressed concrete and specific steps in the process (D’Zurilla & Nezu, 1999). These concrete steps invariably focus more on managing overt problems better, rather than the more psychodynamic focus on modifying the ‘underlying mechanisms’ or the supposed origins of the problem. Overt problem solving is particularly helpful when it takes the client’s current problem-solving style into account. Humanistic therapists such as Rogers have favoured exploring round problems and looking for creative solutions. Gestalt therapy has been distrustful of ‘rational’ approaches to problems, suggesting that humans should ‘lose their minds and come to their senses’ (Clarkson & MacKewn, 1993). Some recent approaches to CBT have, however, suggested that ‘standard’ CBT may indeed have been over-rational in its approach to problem solving. Acceptance and Commitment Therapy (ACT) therapists (Hayes et al., 2003), for example, suggest it is important to consider what strategies clients have used previously to solve problems. Sometimes clients may be trying to use the therapy to buttress a dysfunctional solution, for example, to ‘prove’ to a partner that her ‘nagging’ is causing the client to abuse alcohol. It is therefore important to invest more effort in ensuring that clients really have ‘accepted’ their problems and are ‘committed’ to changing them with personal agency. Problem solving that preceded such efforts could easily prove premature and ultimately unsatisfactory. This does not imply abandoning rational problem solving per se but 95

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suggests it is important to understand that change processes may have non-rational elements. ACT therapists have also made a telling contribution in this area by stressing the importance of helping clients to clarify their values to ensure that goals are in line with them – also endorsed by Judith Beck (2021). When clients make even a small start on acting in line with their values, their therapy is already underway. This is especially helpful when the goal is something like ‘becoming a better person’ – a goal unlikely to be ever fully realised, whereas trying to live according to that value can help us to feel more fully alive. The initial short-term nature of much cognitive therapy may also have meant that it has tended to focus on more sharply defined problems in order to make best use of its more limited time perspective, following the behavioural focus on defining problems in concrete, often behavioural terms – allowing goals to be continually monitored via a ‘problem list’, which can also act as a guideline on when therapy may end (Persons, 2008). Judith Beck (2021) describes a variety of behavioural techniques to help clients cope better with situations. Behavioural tasks should be chosen according to the client’s formulation and may also serve as experiments to test beliefs. Cognitive therapists have not always endorsed the point that purely behavioural benefits may also accrue from such experiments. They have however advocated the view that behavioural methods are the techniques of choice in the early stages of the cognitive therapy of depression (Young & Beck, 1980, p. 19). The initial focus on present-time issues is one that does seem to distinguish CBT from other models, especially psychodynamic therapy (Wills, 2008a). Beck has, however, continued to stress that there are many commonalties between cognitive therapy and psychoanalysis. His initial criticism that psychoanalytic approaches “postulate an indirect connection between the source of fear (in anxiety) and the specific content of the fear that the patient experiences” (Beck, 1976, p. 166), however, would mean that, from his point of view, the targets for psychodynamic therapy of anxiety will also be indirect and therefore not as ‘efficient’ as they could be, in contrast with the rationale for the ‘economical’ nature of cognitive 96

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therapy. Part of this efficiency comes from the fact that “it is not necessary to get at ultimate causes of … (the client’s) … misinterpretation of reality – either in terms of their historical antecedents or present ‘unconscious’ roots” (Beck, 1976, p. 319). Judith Beck (2005) recognises that as cognitive therapy tackles more complex problems, this difference is not quite so sharp. There is debate about the different emphases of focusing on symptoms or focusing on ‘underlying’ issues. Persons (2008) sees such underlying issues in terms of the mechanisms that result from early experience and shape beliefs and assumptions. Interestingly, Persons et al. (1996) suggest that understanding the schematic conceptualisation of early experience can help psychodynamically oriented practitioners to be more open to CBT. Judith Beck (2021, p. 20) follows her father’s previous guidelines in that therapy with most clients, “involves a strong focus on the skills they need to improve their mood (and their lives)”. She suggests, however, that there are three circumstances when the therapeutic focus might switch to the past, when, a) clients indicate a wish to explore past issues, b) current problem-focused work falters, and c) it is particularly important to understand the origin of the ideas. Different balances can be struck between present and past focused work, and, now with the emergence of recovery-oriented cognitive therapy – future-focused work (Beck et al., 2020). Therapists differ on how they strike such balances – even when working with the same approach. The ‘uniformity myth’ (Kiesler, 1966) argues that differences within schools can be as significant as differences between schools. Given that Beck started in psychoanalysis, it is striking that the importance of past experience keeps coming back into cognitive therapy. It is still true, however, that most cognitive therapists deal with past experience differently from therapists working with other models. Both Aaron (Psychological and Educational Films, 1986) and Judith Beck, in her ‘Anne’ weight loss tape (Psychotherapy.net, 2010), however, exquisitely show how to deal effectively with client history in a focused yet sensitive way.

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20 Cognitive therapy has an educational focus and uses regular homework It is no surprise that cognitive therapy uses educationally focused interventions since the cognitive and behavioural approaches are predicated on learning processes. Consider a typical client in cognitive therapy – a depressed client who has suffered humiliation and now considers himself a ‘failure’ with no future. Classical cognitive therapy would see this problem as probably maintained by distorted thoughts and unhelpful beliefs developed at least in part from faulty learning experiences. Therapeutic interventions would aim to help him to undo unhelpful learning, develop helpful patterns of thinking and behaving, and have corrective emotional experiences. New learning in cognitive therapy is promoted by a wide spectrum of methods, ranging from simple information giving, teaching skills to clients, systematic psychoeducation, and experiential exercises (Wright, 2004). As has been noted, in the 1960s, Beck considered many of the treatments of depression ‘esoteric’ and unable to harness the ‘common sense’ that many clients bring to treatment (Beck, 1976). Had our depressed client come for cognitive therapy in Beck’s early trials, he would have been given a pamphlet, Coping with Depression,1 to read and discuss with his therapist (Beck et al., 1979, p. 90). This pamphlet was short and easy to read and contained ‘normalising’ information on depressive symptoms and the cognitive model of treatment for depression. This information aimed to help clients recognise and normalise what was happening to them, and to raise hope that things could improve within a reasonable time frame. Additionally, specific elements of such information may prove especially helpful for individual clients. One depressed client, for example, had been unable to work on her tax return the day before 98

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her session and concluded that she had ‘really lost it’. When her patient pamphlet told her that poor concentration was a ‘normal’ symptom of depression – a point her therapist reinforced in-session – she felt relief and hope that this could change in time. Beck et al. (1979) advocate encouraging clients to be sceptical about educational information – which should never be didactically delivered to them without respectful discussion. Neither should therapists assume that all clients will make the same sense of the information, and they should not assign written or digital information without having checked over the material first themselves. Even when therapists do check material, there can still be surprises. One client with contamination fears became upset by an OCD pamphlet which mentioned sexual obsessions – which proved repugnant and ‘contaminating’ to her – far from the ‘normalising’ effect intended by her therapist. With increasingly widespread availability of mental health information on the Internet, many clients will come with at least some information about their problems. This is generally, but not always, helpful and so should still be discussed – as already distorted thinking can be reinforced by poor sources of information. Systematic and programmatic psycho-education has its historical roots in the health provision services of the 19th century (Bhattacharjee et al., 2011). A particularly strong tradition of psychoeducation has developed in cognitive behavioural treatments for schizophrenia, where such programmes are regarded as essential precursors to therapy (Bauml et al., 2006). I think that Beck would be particularly pleased to note that his innovative work on strengths-based ‘recovery-oriented cognitive therapy’ for schizophrenia (Beck, 2018) has been adopted and combined with a large and successful psychoeducational programme in Munich (Schaub et al., 2016) in the very hospital of Emil Kraepelin, the nemesis of his early years in psychiatry cited in the opening page of this book. All methods which aim to develop empowering information for clients and patients in the psychological and physical well-being fields have to acknowledge that there are often powerful sources of unhelpful information. One area where this may be particularly true is in the field of food and diet. It is interesting, therefore, that 99

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Judith Beck (2008a) has recently applied a cognitive therapy ‘diet solution’ to the issue of weight loss. The number of chronically overweight people is now a major health concern in many countries. It has, however, become clear that most people who diet put the weight back on relatively quickly – in what has been called a ‘yo-yo pattern’. Science is now sceptical of most weight-loss diets (Mann et al., 2007). Judith Beck came to specialist work with weight loss, partly from her own experience of learning to eat more healthily and partly from the realisation that when working with clients for whom weight was a problem, they showed much of the same type of negative thinking that she had observed amongst her other clients. As she looked further into this, she realised that people who struggled with weight betrayed a specific negative cognitive profile as her father had uncovered for depression and anxiety decades before. This cognitive profile included such themes as resentment of people who seemed to not put on weight after eating the same food as themselves, and sabotaging and permission-giving beliefs – for example, “I have broken my diet a bit, I might as well go the whole way now”. Judith Beck (2008a) designed a six-week programme to offer psychoeducation and to help build a set of cognitive behavioural skills for clients before2 they started to change their eating patterns in a consistent manner – because these skills enhanced the chances of a positive outcome (Stahre, 2016) and it was too difficult to learn the skills and change one’s eating at the same time. She emphasises to clients that it is not their fault that they have developed this problem, rather they had simply never had the chance to learn these skills during previous attempts to lose weight. The main skill areas are maintaining motivation; self-monitoring and planning; identifying and responding to sabotaging cognitions; and tolerating hunger and cravings for food. In an instructive DVD (psychotherapy.net, 2010), Judith Beck conducts a very empathic consultation with a client with concerns about weight. As well as general educational input about food and bodily reactions to eating, she teaches the client skills, including 100

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getting her to write and use a cue card with the reasons why she wants to lose weight and also planning how she can plan to have small amounts of her favourite foods in her overall food plan. The client says that she has never thought of trying to lose weight this way and is clear that she is surprised by the user-friendly style of this process and that her hopes rise. It seems likely that such ‘positive surprises’ play a neurological role in therapeutic change (Schomaker & Meeter, 2015). Such behavioural changes may seem in some ways quite small and yet they resemble the graduated changes discussed in Chapter 27, picked up by Aaron Beck from Marvin Goldfried (Beck et al., 1979, pp. 132–133) that have become a key aspect of the Beckian style. Notes 1 An updated pamphlet with the same title and written by Judith Beck is available from the Beck Institute. 2 No food/diet plans are offered in this book but were added in her next book (Beck, J.S., 2008b).

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21 Cognitive therapy has a well-identifed set of methods and skills I came into counselling and psychotherapy at the time of the ‘counselling skills movement’ in the UK (Pearce, 1997) and found this emphasis on skills a useful counterweight to the tendencies within our profession that can make therapy seem esoteric and remote. The fact that cognitive therapy had a clear set of skills was a big part of its attraction for me. In the 1990s, I was involved in the project that introduced National Vocational Qualifications (NVQ) for Counselling and then attempted to do the same for Psychotherapy. The project for psychotherapy NVQs unsurprisingly was never completed but proved an interesting experience. On the first day, a large number of therapists gathered in London and were placed into modality groups to identify their specific skills and methods. By early afternoon, the CBT group had listed and defined around 20 core CBT skills and had time for tea and chatter before being called down to the large group end-of-day plenary meeting. It turned out that no other group had come even close to our progress.1 One group, for example, reported spending the whole day trying to define the words ‘therapist’ and ‘client’. Through several subsequent meetings, it became clear that the different modality groups were never going to be on the same page often enough for the project to be completed. I took this experience as confirmation that CBT had a rather uniquely clear view of its skills. Aaron Beck produced an early measure of therapist competence with the Cognitive Therapy Scale (CTS: Young & Beck, 1980, 1988) and this had helped the CBT group greatly in its NVQ tasks. The CTS was closely related to the set of principles described in

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Chapter 1 and the therapist competencies listed the seminal publication of Beck et al. (1979, pp. 404–405) and was also designed to act as a therapist competence measure for future trials. Later the scale was used as an assessment tool on CBT courses – and so is familiar to most CB therapists. Despite the considerable developments in the model, Beck offered no further revision of the scale after 1988 but some revisions have been added by a group of British trainers in the Cognitive Therapy Scale Revised (CTS-R: Milne et al., 2001). Each version of the scale has a helpful handbook that offers guidance on using them for assessment and in therapy practice. Further useful elaboration of assessment criteria has been added by Muse et al. (2014). The development and content of these different versions of the CTS is shown in Table 21.1. The descriptions of these skills and competencies have on the whole worked well when used for training purposes but they have not developed fully in line with the evolution of the cognitive therapy model (Roth & Pilling, 2007). Neither have they proved entirely successful when used in research work – especially in exploring the relationship between therapist competence and outcome (Branson et al., 2015). A significant gap in the development of cognitive therapy has, for me, been an over-focus on academic outcome research – with too little focus on process research on the implementation of CBT skills and methods (Wills, 2010). This has meant that practitioners have sometimes been unable to reference as much literature as they would really like on doing cognitive therapy. The counselling skills movement benefitted from a strong body of process research (such as Truax & Carkhuff, 1967 Rogers, 1980) – so that practitioners knew, for example, that if they reflected clients’ feelings and offered them empathy, clients would usually respond by opening out their frames of reference. Clear pathways through the counselling process were identified with markers in clients’ growth towards better psychological functioning – and these were immensely helpful for practitioners. We do not really

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104 3. UNDERSTANDING 4. INTERPERSONAL EFFECTIVENESS 5. COLLABORATION 6. PACING

3. Understanding 4. Interpersonal effectiveness 5. Collaboration

6. Pacing

7. Guided Discovery 10. Elicit NATS, & 8. Focus on Cognition 11. Test NATS

1. Collaboration and Mutual Understanding 4. Structured Therapy Time Efficiently 6. Questioning 8. FOCUS ON COGNITION

7. GUIDED DISCOVERY

2. FEEDBACK

2. Feedback

18. Rapport

1. AGENDA SETTING

1. Agenda setting

2. Establishing agenda 3. Elicited Reactions to Session and Therapist

CTS (Young & Beck,1988)

CTS (Beck & Young, 1980)

1979 Checklist (Beck et al., 1979)

Table 21.1 The development of the Cognitive Therapy scale

8. Guided Discovery 7. Focus key cognitions

4. Pacing

5. Interpersonal effectiveness 3. Collaboration

2. Feedback

1. Agenda

CTS-R (Milne et al., 2001)

6.3: Maintained focus

6.1: Pace: 6.2: Time management

7.3: Collaboration

7.1: Interpersonal style

1.1: Agenda items, 1.2: Feasible agenda 8.1: Feedback

Muse et al. (2014)

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5. Focused on Appropriate problem 12. Identify Assumptions 9. & 13. Appropriate CB techniques

10. STRATEGY FOR CHANGE

10. Application C 11. COGNITIVE & B techniques TECHNIQUES 12. BEHAVIOURAL TECHNIQUES

9. Strategy for change

9. CONCEPTUALISATION

10. Cognitive techniques 11. Behavioural techniques

9. Conceptual integration

(Continued)

3.1: Appropriate intervention targets; 3.2: Choosing suitable interventions. 3.3: Rationale for interventions. 3.4: Implementing interventions. 3.5: Reviewing interventions.

2.1: Coherent and dynamic formulation

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106 13. HOMEWORK

11. Homework

Overall assessment Overall assessment

Specific problems

8. Assigned homework

7. Summaries

Other: 15. Warmth; 16. Accurate Empathy: 17. Professional Manner

Specific problems

CTS (Young & Beck,1988)

CTS (Beck & Young, 1980)

1979 Checklist (Beck et al., 1979)

Table 21.1 Continued

6. Eliciting emotion

12. Homework

CTS-R (Milne et al., 2001)

Other – 5.1: Choosing suitable measures. 5.2: Implementing measures.

4.1: Reviewing homework. 4.2: Choosing suitable homework. 4.3: Rationale for homework. 4.4: Planning homework. 8.2: Reflective summaries.

Muse et al. (2014)

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have the equivalent of this in cognitive therapy. We do, however, have good tools for the task – for example, measures of competence and – because of the emphasis on using recordings of sessions in training and in everyday practice (Padesky, 1996) – vaults full of available data – via audio and visually recorded sessions. We have sometimes seemed to me to be ‘outcome rich but process poor’. This can lead to some, in my view, wrong turns in practice. Some ‘dismantling studies’ (for example, Gortner et al., 1998) have, for example, tested CBT with and without cognitive restructuring and concluded that, because there was no significant difference between the two conditions, cognitive restructuring is a superfluous activity in CBT. There are many counter-arguments here (see Carey and Mansell, 2009) and one is that cognitive restructuring is a difficult and subtle art and studies often do not seem to have any assessment of how well skills have been used – and this seems to be true of most outcome studies. Aaron and Judith Beck are intuitively talented cognitive therapists and their actual clinical work shows as much art as science. Aaron Beck has been involved in so many areas and projects yet he does not seem to have offered analysis of his own use of skills, apart from his many clinical insights and anecdotes, or to have offered research-based guidelines on how those skills are used in context and process, and could be promoted in others. We are fortunate therefore that his daughter, Judith, has written some full, rich, and clear descriptions of the use of skills and methods (Beck, J.S., 2021). After Beck retired from full involvement at the University of Pennsylvania in 1994, he and Judith set up the Beck Institute at Bala Cynwyd, Pennsylvania, an area originally settled by Welsh Quakers in the 17th century. Judith gradually took on a leadership role in the therapy arm of the Institute and is now its overall Director. Her publication list has grown and her writings reflect her significant contributions to practice in this most favourable of environments for cognitive therapy. Making the assumption that her descriptions of the current practice of the cognitive therapy model are likely to be very 107

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close to its founder’s preferences, special attention is paid to both his and her thoughts on skills and methods in this Practice section of the book. Note 1 The only other group that seemed to take a similar line to the CBT group was, interestingly, the short-term psychodynamic therapy group.

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22 Cognitive therapy builds on the identifcation of unhelpful automatic thoughts Judith Beck (2021) identifies three stages of addressing automatic thoughts (ATs) – identifying them (discussed here), evaluating and responding to them (discussed next). Laying out these three distinct phases is helpful because cognitive therapists, especially novices, can be so excited about hunting down ATs that they can rush things and then collapse these three stages into one. Rushing in may result in premature attempts to change the thought, making cognitive therapists seem overly directive – and clients confused or resistant. It is important also to express empathy for clients and to avoid the mistake of seeming to imply that clients’ thoughts are silly or irrational. Such over-haste is a mistake because it violates the fundamental principle of ‘collaborative empiricism’, which is, as we discussed in Chapter 16, the foundation of the therapeutic relationship in CBT. Judith Beck has said that many mistakes in CBT come when therapists cease to be their usual warm selves (Howes, 2009). It is important for therapists to identify automatic thoughts but also to help clients to become aware of ATs for themselves – often an important focus for early homework tasks. Beck (1976) stressed the importance of helping clients to ‘decentre’ – step away – from their negative thoughts. Therapists aim to switch clients from just the automatic mode to a dual processing system – that is, including both ‘automatic’ and ‘reflective’ modes – which is more reflective, slower, and more deliberative (Beck & Haigh, 2014). This switch can promote a sense of mindful curiosity in clients about how they are functioning. Such curiosity is the antithesis of, and useful counterbalance to, the kind of ‘fixated’ attention on negative thoughts 109

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that promotes disturbance (Beck & Haigh, 2014). It can therefore be helpful for therapists to cultivate a curious attitude in themselves in the hope that it might be mirrored to clients. Humour – though we must be wary of overdoing it – can sometimes help us to reframe or decentre. A client, Tom, was berating himself for being a “complete moron” and his therapist enjoyed a good enough relationship with him to offer the image of a tabloid newspaper headline reading Tom – Complete Moron – Official! He enjoyed this idea and subsequently often discussed how negative automatic thoughts (NATs) are like some tabloid headlines – crude, shorthand, and short on truth – but incredibly good at stirring negative emotions. Both Judith Beck (2021) and Aaron Beck (1976) have identified the classic cognitive therapy question as “What was going through your mind … (when you felt sad)?” This remains a great question and can be applied retrospectively when analysing situations that clients may report,1 or to an emotion that arises during the session. In-session work has an interpersonal flavour that often has more emotional ‘aliveness’ than retrospective examples (Wills with Sanders, 2013). As noted earlier, the presence of stronger emotional reactions signal ‘hot thoughts’ that may be driving clients’ problems (Greenberger & Padesky, 2015). Therapists should combine using good questions and probes with good quality listening as these skills in combination are more likely to find the core problem areas. Counselling and person-centred trainers have been particularly adept at teaching people to listen – and this skill and quality is not always emphasised enough in CBT. Human beings are wired to listen to each other and can show exquisite awareness when they seek to work out if someone they meet has, for example, the same political orientation or musical tastes as themselves – discerning themes in the smallest of hints of speech.2 Sometimes a preoccupation with what questions to ask can detract from good listening. The combination of solid listening skills and an awareness of key cognitions can facilitate a powerful therapeutic skill – what we might call ‘reflection of meaning and thinking’ (Ivey et al., 2013, p. 275), which can help clients to pay 110

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helpful attention to their thinking – with all the healing power that that can foster. It can be helpful to think of cognitive intervention skills as being on a continuum between directionality and non-directionality (See Figure 23.1) – as discussed in Wills, (2015, pp. 58–87). Some clients get the idea of ATs straight away – and this can result in the first steps of a change process. Some clients have gasped or laughed out loud when their ATs were identified – sometimes adding things like, “That’s crazy, isn’t it”. Rather than rushing in to capitalise on this, it is often better to just let the AT ‘hang in the air’ or to write it on a whiteboard and invite the client to ‘have a good look at it’ (Wills, 2015, pp. 70–72). It is not that directionality or non-directionality are inherently right or wrong – they both have their uses and together they offer therapists a range of options for crafting responses. If we start towards the non-directional end, however, we are less likely to batter down a door that is already open. The first aim in cognitive interventions is to create cognitive dissonance and once that has opened out, it may then be best to let the dissonance “do its work” (Wills, 2015, p. 74). More deliberative and directional work features in the next chapter. Some clients do struggle to identify their ATs and Judith Beck (2021) offers thorough guidelines on helping clients in this situation – for example, by defining their negative emotions more precisely to identify the key ‘hot thought’. Clients may be helped by ‘walking through’ trigger situations in slow motion – describing them as if they were happening right now. This usually elicits a more emotionally grounded way of telling the story and is therefore more likely to get closer to the salient AT – especially if we can identify the moment when it “kicked in” (Wills, 2019, p. 570). Some clients are more inclined to think in images and when they are disturbed, these images will often contain significant ATs (Beck, J.S., 2021). One client described how she had felt so upset whilst filling out a job application that she ripped it up. She could identify no thought related to this but then described a ‘horror show’ image that came into her mind moments before. In this ‘movie in her mind’ the interviewers grimaced and rolled their eyes 111

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as they looked at her application, suggesting to her that she was bound to fail to get the job. Judith Beck (1995) describes an empathic, collaborative process of helping clients to identify these thoughts – for example, writing the thoughts down together encourages clients by helping them to think that “we will figure it out together” (p. 79). The closer we get to the heart of the matter in CBT, the more important empathic collaboration becomes. Judith Beck (2021) reaffirms the importance of Rogerian counselling skills in establishing such empathy. Notes 1 Another type of significant NAT occurs when clients ruminate after a significant event – e.g., the use of ‘post-mortems’ by clients who are subject to social anxiety (Clark & Wells, 1995). 2 In the UK during 2018–9, the use of the word ‘Brussels’ invariably suggested that the speaker had strong views on ‘Brexit’.

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23 Cognitive therapists teach clients to evaluate and then respond to their negative thoughts Cognitive change often begins with an ‘Ah-ha’ moment of cognitive dissonance – when awareness of contradictory information sparks a rethinking of the whole situation. This may kick in at any stage during the process of cognitive intervention. Therapists can choose from a continuum of non-directional and directional interventions (see Figure 23.1) that range from just allowing the process to unfold with a light touch and ‘letting awareness do its work’ to enacting a more deliberative and directional intervention to ‘help awareness do its work’ (Wills, 2015, p. 79). From a Beckian point of view, all these interventions, some of which originated in other versions of the CBT family model (e.g., Hayes & Hoffman, 2018) – offer therapists different options and choices to ‘match this particular type of intervention to this particular client’ (adapted from Paul, 1969). A continuum of responses helps to avoid pushing too hard or too soon – a frequent cause of problems in the art of delivering cognitive interventions. The overarching skill that is common to most of these interventions is Guided Discovery through Socratic Dialogue (GD/ SD) – often pushed forward with analytic and evaluative questions (Wills, 2015, pp. 64–67). The client who thought he was a Non-directional cognitive interventions

More directional cognitive interventions

Acceptance, validation, compassion focus, mindfulness, defusion, metacognitive focus, restructuring, challenge

Figure 23.1 Continuum of cognitive interventions

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moron, for example, might be asked what potential behaviours would make anyone a ‘moron’ (analytic question) and which of his actual behaviours fitted that definition (evaluative question). Judith Beck (2021, p. 242) provides a list of basic evaluative questions that are both useful to have on hand in sessions and a good homework resource for clients. Her questions include those that probe evidence regarding the AT and those designed to promote an alternative balanced thought by asking, for example, what the client would say to a friend who had the same thought. It is useful to have lists of these questions and of the main cognitive distortions on hand – the latter can help clients to spot any of the distortions in their responses. Sam was a health worker who was struggling to cope with family pressures during the Covid-19 lockdown. He reported two ‘hot’ ATs that passed through his mind whilst dealing with his children – They don’t give a shit about me, and, They are taking the piss.1 He could understand that these thoughts ‘stoked up’ his negative emotions and identified the distorted over-generalisation in them. The reflection process itself can lead to spontaneous recognition of the distorted nature of ATs and/or generate more positive perceptions. Here, whilst reflecting on the first AT, Sam recalled returning home from a long hospital shift and his delight when his children brought him a glass of beer and handed him the TV remote control. The second thought, however, still seemed correct to him and the phrase ‘yes, but’ came into our dialogue. It is important to recognise the ‘grain of truth’ in any negative thought and his therapist agreed that teenage children may seem to ‘try it on’ at times. Judith Beck (1995, p. 124) suggests that ‘yes but’ answers usually indicate that we are in the wrong cognitive area. Further exploration with Sam uncovered another underlying AT – I should not have to keep telling them to do things. Sam had talked about his relationship with his own father during the conceptualisation stage. He described his father as a good person but also as one who became distant following difficulties in his workplace. As we explored that period, Sam described how – in response to his father’s seeming distance – he himself became more autonomous – looking after himself and ‘not 114

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needing to be told what to do’. The history suggested therefore that his hot thought was also represented at the level of belief – reflecting a general belief in the value of independently doing things for oneself. These beliefs seemed to make more sense of his reactions to his children and therefore offered themselves as key areas for further discussion. Sam eventually concluded that his children needed to develop their own ideas but could be helped to do so by ‘bouncing off’ his values. When Beck (1963, 1964) first introduced the concept of automatic thoughts, he offered what became a popular example – the situation in which someone you know ignores your greeting as you pass in the street. Most people can remember such an experience and most commonly report having thoughts like, ‘What have I done to offend him?’ (Fear, anxiety), ‘She must not like me’ (sadness), or ‘He is such a snob’ (anger). Rarely do people report a more benign appraising thought like, ‘She was probably just feeling distracted’. Considering our natural on-going responses to events like this helps us to see that GD/SD and its written version in a thought review sheet (Wills, 2013) is a formalisation of what our minds do naturally (see Figure 23.2). We often naturally seek evidence on whether we might have said or done anything that could have offended the other person – adding what would fit in the evidential status aspects of a thought review sheet after the triggers, thoughts, and feelings already been established in rows one to three. If we cannot think of anything significant, then we reach a more balanced conclusion – I can’t think of anything, he must have just been distracted – for column six and we may even add an action – I will check with a mutual friend – which would fit in the final row. Figure 23.3 offers a worked example of this scenario. Judith Beck’s first edition of Cognitive Therapy: Basics and Beyond, (1995, p. 125) clarified that the main use of such record sheets is to ‘fortify a more adaptive view point’ – that is, it is not necessarily the first point of call for achieving cognitive change. In the third edition, she acknowledges that thought review sheets can be unwieldy and advocates the additional use of simplified ‘testing 115

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Common sense steps Identification of problem Identification of meaning

Automatic thought sheets 1. Event 2. Emotion 3. Negative thought/s

Client example (simplified) 1. My boyfriend’s ‘cool’ reaction to my good exam result 2. Hurt, angry (85%) 3. He doesn’t love me. No one will ever love me

Possible distortion

4. Maybe I am mind-reading or catastrophizing this? Reflection on initial 4. Evidence supporting 5. He often does things like this My mum didn’t love me appraisal of meaning negative thought Reflection on initial 5. Evidence not 6. He does nice things sometimes supporting negative He finds it hard to respond to my appraisal of meaning thought overwhelming needs at times He’s a young man He may be a bit jealous Mum’s tried to make up for past wrongs Re-appraisal of 6. Alternative, 7. We both need to work on how to balanced thought asking for things and responding to initial meaning each other allocation Consideration of 7. Outcome 8. Emotional – feeling much less hurt and angry consequences of Behavioural: I can try assertively reappraisal asking for what I want without being over-emotional

Figure 23.2 Common sense processes in questioning a thought (Wills, 2015)

Trigger situation Emotional and behavioural response/s Automatic thought Cognitive distortion/s Evidential status of the thought/s Balanced adaptive thought/s Next time I can …

Dave ‘blanks’ me

Emotional: Hurt: angry and sad (75%)

He must not like me Mind reading. Selective abstraction. Confirms NAT: Disconfirms NAT: He blanked me Not like him. He is usually friendly Maybe he was distracted, I could ask him I could ask him or a mutual friend about what might have been going on here

Figure 23.3 Automatic thought sheet, worked example

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Behavioural: Silently curse him

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your thoughts’ written worksheets. We know that writing things down does strengthen learning – and handwriting may well outperform a laptop in this respect (Mueller & Oppenheim, 2014). Thought review sheets however do not always run true to plan. The main reported problem with them is that they produce intellectual rather than emotional conviction and clients often say things like, “I can see that I have succeeded at some things but I still feel like a failure”. There is evidence that helping clients to hear their negative thoughts in a more compassionate voice helps to detoxify them (Gilbert, 2010). It may however also be that intellectual belief generally does come first, followed only later by emotional belief (Dryden, 2004). Experienced cognitive therapists often point to the need for persistence with efforts to modify thoughts (Leahy, 2001). There are also guidelines for frequently occurring problems encountered during cognitive interventions (Beck, J.S., 2021; Wills, 2015). It can be useful for therapists to research their own therapy sessions, perhaps even as a series of ‘n=1’ case studies, and to track for themselves what use of cognitive reappraisal leads to effective change with which of their clients and, more generally, in their work overall. As we noted above, the ‘yes but’ problem can often be dealt with by searching for the deeper beliefs and rules of living which may be lurking below them – and it is to addressing this part of clients’ cognitive organisation that we now turn. Note 1 Such language may be difficult but it is therapeutically helpful to reflect it back to clients. Here I did, out of curiosity, eventually comment on Sam’s frequent use of the word ‘shit’. He said that he often felt that he lived “in a world of shit”, taking us on to the use of this phrase in the Vietnam war film, Full Metal Jacket. For a fascinating discussion of the ‘sacred and profane’ use of language in this film, see Bisson, 2012.

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24 Cognitive therapists have developed methods for identifying beliefs and schemas Most cognitive therapists agree that therapy aiming at schema modification should be informed by interpersonal sensitivity and conscious use of deeper aspects of the therapeutic relationship (Young et al., 2003; Pretzer & Beck, J.S., 2004; Beck, J.S., 2011). Therapists must be particularly alert for shifts in mood during sessions to identify energised schemas and so be ready to begin to work with them. Sometimes quite small incidents in therapy may signal interpersonally significant perceptions and schema activation (Safran & Segal, 1990), as in the following example: Tom was depressed and unhappy in his marriage and at work. His therapist invariably offered tea or coffee at the start of sessions. At the first session it so happened that the therapist had recently made percolated coffee and Tom accepted a cup – with great relish. At the second session, when he asked for coffee, the therapist gave him instant, the more usual fare. As the session went on, the therapist noticed that Tom had only taken one sip and was acting in rather an unhappy way, possibly even sulking. The therapist then used the skill of immediacy (“using reflective discussion to explore what is happening between the client and … [therapist] … at that moment” – Wills, 2015, pp. 50–51) to explore what was going on. Tom was honest enough to say that he had been really disappointed with the coffee and that it carried for him the meaning of being ‘not very special’. As therapy moved forward, this theme recurred quite frequently and it proved possible to link the feelings of being and not being ‘special’ to his developmental history. His parents had split when he was eight years old and his mother made him feel very special by giving him many treats – a strategy, he thought, 118

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to compensate for the absence of his father. Eventually, however, the day came when his mother had to put her foot down and say that he could not be given treats all the time. This was a profound experience – like ‘being expelled from heaven’ was how Tom put it. His sad memories of that day were represented in his schemas and beliefs and thus played a role in maintaining his depression. ‘Specialness’ and ‘privilege’ are usually identified as being at the heart of narcissistic personality disorder (NPD: Beck et al., 2016) and ‘entitlement’ schema (Young et al., 2003). The therapist, however, never for one moment thought of Tom as having NPD but might have given the name ‘loss of magical specialness’ to his schema. In Tom’s therapy it proved possible to talk quite lightheartedly of his ‘specialness’ at times. To the therapist’s quip, ‘I suppose you want champagne today’, he replied, ‘Have you got any caviar?’ These discussions played a role in loosening the grip of this schema and in overcoming his depression. This example suggests that our thinking about schema change should not be limited to schema therapy, focused as it is on long-term therapy with deeper personality problems. It is, however, important to acknowledge gains in the schema therapy model, especially in the treatment of Borderline Personality Disorder (Arntz, 2018). Arntz’s model of schema therapy also relies heavily on interpersonal work within a deeper therapeutic relationship. In addition, however, it has more deliberative technical interventions, which will not be described here because they are covered by an excellent book (Rafaeli et al., 2010) within the Distinctive Features series, of which this book is also a part. Rafaeli et al. (2010) also describe the role of the Young’s Schema Questionnaires in the identification of schemas. We may also note that the incident with ‘Tom’, described above, occurred in the second session of therapy – confirming Judith Beck’s (2021) observation that we will come across and perhaps even unconsciously work on adaptive and unhelpful core beliefs and schemas from the start of therapy without always realising or deliberatively focusing on them. As noted previously, the use of Guided Discovery through Socratic Dialogue (GD/SD) can draw 119

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out and elaborate schematic material. Even a small ‘incident’ – such as the choice of coffee – may point to core beliefs that may drive the action in clients’ problems. GD/SD questions led Tom to link his feelings about the coffee to beliefs about specialness. The belief, I should be regarded as special, is an interesting one – much paraded in love songs and even by football coaches.1 This may be, in the terms of Rational Emotive Behaviour Therapy (REBT), a permissible ‘preferential should’ (Dryden, 2004) – that is, ‘I would rather like my preferred choice of coffee’ – that would only be problematic as a demanding should – ‘Unless I am given the best coffee, I cannot be happy’. There is often an interesting link between core beliefs and the ‘if/then’ nature of intermediate beliefs or assumptions. The unconditional core belief, I am useless, often goes with a compensatory or redemptory belief like, If I please people, then they will think that I am worthwhile. The problem with Tom worked the other way round, he had a working assumption that, If people don’t treat me as special, it means that they don’t like me, that in turn led to a core belief, People do not seem to like me. Tom and his therapist chose to explore the intermediate belief first – as it often led him to feel depressed about his friendships, including his marriage at times. The therapist used a version of GD/SD that blended analytical questions – for example, ‘What do people do when they treat you as “special”? and, ‘What do people do when they show you that they like you?’ – and evaluative questions – for example, ‘Who in your life treats you as special/likes you?’ (Wills, 2015). New ground emerged from this in that there were many people who Tom thought did like him but did not treat him as special. For example, he had a group of friends, who placed great store on no-one being more special than anyone else, but Tom was forced to recognise that many of them really did like him. This was not a single curative insight and was reiterated frequently over the course of therapy. A key moment, however, came when Tom began to recognise that his demand for specialness had actually ruined some friendships by prompting some people to dislike him. As we noted previously, change can come at any stage in the therapeutic cycle of identification, evaluation, and modification. 120

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Explorative and less directional methods, such as GD/SD, then often give way to more deliberative and directional methods, designed for use with more entrenched beliefs and schemas, as described in our next chapter. Note 1 Jose Mourinho, who has managed, amongst other football clubs, Real Madrid and Manchester United, points out a therapeutically useful distinction in that he referred to himself as ‘a special one’ whereas it was the media that gave him the messianic title, ‘The Special One’.

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25 Cognitive therapy has methods for working on unhelpful beliefs and schemas Schema, and now mode, change – most often through working on their constituent beliefs, lies at the heart of Beckian cognitive therapy. We begin with the nature of belief change before describing attempts at deliberative belief modification. Most psychological research on belief change stresses its complexity (Connors & Halligan, 2015) and attempts to force it often seem to result in resistance (Leahy, 2003). Cognitive therapists, therefore, first need to promote reflective discussion that can foster a sense of dissonance around contradictory elements in clients’ narratives about their lives. Such dissonance encourages flexibility and growth but may also raise a sense of troubling inconsistency in the self – especially in people who suffer from psychological problems (Leahy, 2003). These factors should encourage therapists to feel empathic towards clients in the process of belief change in this fundamental aspect of self-concept. It can be helpful for therapists to suggest to clients that they can ‘turn these beliefs inside out’ and then ‘see if they fit any better’. A sense of humility also helps therapists not to assume their own beliefs are superior to those of clients. Previous discussion of problematic schemas identified the main difficulty as lying in negatively biased information processing. Padesky (1990) has referred to schematic functioning as a form of ‘self-prejudice’ – that is, negative schemas give privileged access to negative information and build firewalls against positive information. Judith Beck (2005) makes good use of a ‘shape-fitting’ analogy when she describes a model discussion with a client about how rectangular-shaped entrances give access only to rectangular (negative) information and refuse entry to 122

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triangular-shaped (positive) information. Modifying beliefs is like easing and widening the entrance portal and reducing rectangles and triangles into more admissible shapes – so that full information can enter our processing system. After these preliminary considerations, all new units of information can be entertained and then allowed or discarded according to their merit, allowing in turn better judgements of situations and more effective problem solving when problems arise. Sometimes, however, more deliberative methods are needed and Judith Beck (2021) describes a range of the main techniques. In the following case example, two of them designed specifically to target problematic beliefs – the ‘continuum’ and ‘historical tests’ – are described. Antoinette1 described a complicated childhood – with multiple rejections and consequent negative core beliefs. Her problematic functioning suggested borderline features – especially fear of abandonment and idealisation/devilisation of people close to her (Young et al., 2003; Arntz, 2018). She had a global belief that ‘People dismiss me’. The ‘continuum technique’ (Padesky, 1994) can help to bring flexibility to such global negative beliefs because it helps to chart ‘the middle ground’ between their absolute poles (Beck, 2021, p. 314). Since it is helpful to identify and use an adaptive belief, Antoinette and her therapist explored her belief using a continuum with ‘People who accept me 0%’ at one end and ‘People who accept me 100%’ at the other end (see Figure 25.1). The continuum in Figure 25.1 shows that people in Antoinette’s life took various positions on the chart – and certainly did not all dismiss her. She was, however, particularly sensitive to rejection by males in both her personal and professional life. She was a team

0% Accepting Uncle’s second wife: Aunt: Uncle (now): Mother? Some colleagues:

50% WG: Steve:

100% Accepting Most colleagues: Church friends Uncle (past)

Figure 25.1 Continuum method – Antoinette (worked example)

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leader of a social care team and had frequent arguments with Steve, her own immediate manager. Her therapy explored this relationship further by using the idea of a ‘criteria continuum’ (Padesky, 1994). Firstly, Antoinette answered the request to define an ‘accepting’ person with, “one who listens, is affirming, offers constructive criticism, and, likes my company”. The criteria continuum (Figure 25.2) was thus operationalised with this definition: From these two different continua, Antoinette realised that her relationships were too diverse to be characterised by a belief with just two poles – that is, that people either do or do not dismiss her. She enjoyed affirmation from female colleagues but acknowledged that they tended not to offer constructive criticism and so did not help to improve her performance at work. Steve, on the other hand, though blunt about some of her ideas, was ready to affirm and praise others. She admitted that she liked her ‘sparky’ relationship with him and said it helped her ‘raise her game’ at work. As therapy

Non-accepting

50%.

Does not listen to me

Accepting Does listen to me

Steve

Non-affirming

Affirming Steve (blunt rejections)

Steve (agrees with praise)

Destructively critical

Constructively critical

Blunt Steve (occasional)

Nice Steve (more often)

Does not like my company

Does like my company Sparky Steve

Nice Steve

Figure 25.2 Criteria continuum method – Antoinette (expanded worked example)

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deepened round this issue, she settled at work and soon moved to a job that was even better for her. Don2 came from a tough northern working-class background and had been brought up by alcoholic parents who, though occasionally loving, were often unreliable. Unsurprisingly he believed, I am not loveable, and, Other people are unreliable and untrustworthy. Don said that he longed for intimacy but as he got close to a potential partner, he felt a creeping fear of making himself vulnerable to a person whom he thought might well prove untrustworthy. Don’s approach-avoidance pattern puzzled potential partners, who could not understand how he could swing between ‘blowing hot’ and ‘blowing cold’ so often. This pattern was also evident with male friends and he once broke down after a friend failed to show up for a night out. Don identified events in childhood when his parents had very publicly let him down – and he recalled walking away from one occasion thinking, “I’ll never rely on anyone again. From now on, I will look after me first”. In therapy, Don explored his long-held belief that people were untrustworthy by using a ‘historical test’ (Greenberger & Padesky, 2015). He made a ‘life line’ chart (Figure 25.3) and plotted how the belief had operated at different stages of their lives. A transformative moment came for him when he remembered how his grandma helped him when things at home were particularly tough. It seemed that she knew how difficult things were at home and tried in her own way to provide some sanctuary: I would pop in to see her when I could… She made fuss of me, gave me cakes … there wasn’t always food back at home … Gran kept a jam jar on her mantelpiece and every time I visited she put a sixpence in it … in the Summer, she would take me on a trip to the seaside with that money … Every visit I measured how far up the jar the money went. Using Judith Beck’s (2005) analogy, this information entered his processing system and offered disconfirmation of his belief – not only did it show that there were people who cared about him but 125

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Grandma did what she could

Events where people proved trustworthy Some teachers helped

In tough situations in Ulster and the Falklands, most of the guys were solid

Some forces officers were nasty

“Some teachers got on my case” Some “hard cases” in the forces were nasty Gran continued to help when she could

20–29 I cut off from my parents

10–19 Parents just got worse

Figure 25.3 Life line – Don – worked example

0–9 Parents drinking and neglectful of children

Years Events where people proved untrustworthy Mates neglected me when they got married

30–39 Ellie was unfaithful, lied to me and then conned me

My therapist seems reliable

Elaine has been okay – so far

Some mates have stayed true

Things getting a bit better with parents

40–49 “I feel I cannot trust another woman”

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also people who made reliable long-term plans to back that up – the very thing that his parents fell down on. This was good cognitive therapy – but was not as striking as the deep emotional smile on his face as this long-neglected memory came into his mind. Notes 1 For further case description of work with this client, see Wills (2015), pp.134–152. 2 For further case description of work with this client, see Wills (2015), pp. 44–6.

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26 Cognitive therapy has been strengthened by including interventions focused on emotions and imagery In their review of the history of our understanding of the relationship between cognition and emotion, Power and Dalgleish (2008) assert that there has been a prevailing negative view of emotions, especially of their capacity to highjack rationality and rational behaviour in human beings. It is perhaps now easy to see in retrospect how many psychological therapists came to see Beck’s cognitive therapy as yet one more attempt to establish rational ‘mastery’ over emotion, leaving the humanistic approaches to hold the field as apparently the better advocates of a fuller emotional life. Mick Power, for example, comments: Cognitive science and the cognitive and cognitive-behavioural therapies can absolutely be congratulated for the benefits they have brought to academics, clinicians and clients … but … one thing has been left out in these great strides forward – … emotion. (Power, 2010. p. 2) In fact, Beck took little part in the debate of the 1980s over whether cognition held ‘primacy’ over emotion or vice versa – an academic debate that, like so many others, ran into the sand with but little resolution (Leahy et al., 2011). Aaron and Judith Beck have both stressed the absolute importance of empathy in therapy – and further admirably show that quality in their personal lives and therapy practices – the latter well illustrated in numerous audio-visual recordings. It would also, 128

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however, be true to say that they have seen emotionally-focused work as being mainly in the service of cognitive change. This is not because they view cognitions as the cause of emotions but because, as has been discussed earlier, they view cognitive organisation as holding a central place in the regulation of human reactions. Beck’s relatively narrow focus on negative emotions was probably related to his reluctance to speculate beyond his own findings. This position, however, has sometimes left cognitive therapists looking for more help to guide their responses to highly emotional clients who, for example, often find it difficult to report cognitions or for whom alternative rational thoughts seemed to cut no ice (Wills with Sanders, 2013; Wills, 2015). Furthermore, concepts and ideas about emotion have been developing rapidly – especially as the findings of neuroscience advanced and became more accessible (Le Doux, 1996; Gilbert, 2010; Peters, 2012). It was inevitable, therefore, that fuller approaches to emotion would find expression in cognitive therapy (Power, 2010; Leahy, 2015). Aaron Beck has remained a shrewd observer of the scene and inevitably integrated these new trends into his ‘general cognitive model’ (Beck & Haigh, 2014). The limited space available here allows only a relatively brief description of these, for me, captivating themes. We begin with the role of emotions in Beck and Haigh (2014), followed by Judith Beck’s (2021) helpful guidelines for working with emotions in the service of standard cognitive therapy and ending with brief reference to the wider perspective of Leahy (2015). Beck and Haigh (2014) see emotions as a vital element in the fabric of our adaptational lives – responding to positive opportunities for life enhancement as well as to threats. In the latter instances, a hyper-active response, with genetic aspects, may be triggered and this can highjack other elements of our functioning to destabilise us. The ups and downs of life mean that most of us vacillate somewhat between perceiving events as enhancing or threatening – both usually within normal ranges. Most of the time and, for most people, setbacks are relatively short-lived, but under prolonged hyperactivation of negativity, people may reach a stuck situation where intervention may be required. Beck and Haigh (2014) hold that the, 129

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“core cognitive therapy premise that dysfunctional thinking leads to increases in emotional distress and maladaptive behaviors” and, whilst acknowledging that aspects of negative functioning are automatic and non-conscious, they assert that research evidence – from outcome and neuroimaging studies –supports the effectiveness of cognitive therapy. Judith Beck (2021) offers helpful suggestions for tackling the previously mentioned issue that arises when clients seem unable to identify automatic thoughts (ATs) accompanying their problematic symptoms. Sometimes, for instance, this stems from confusion about thoughts and feelings. It is commonplace in modern communication, for example, to say, “I feel like he doesn’t like me” – a confusing amalgamation of an appraising thought – that is, ‘He doesn’t like me’ with an unstated emotion of, most likely, dysphoria. Pointing this out may seem pedantic so it can be a fine-line judgement for therapists – to assess both the degree to which it may be holding cognitive therapy back and of the robustness of the therapy alliance – whether or not to do so. Judith Beck (2021) takes a characteristically thorough approach to when a sharp distinction may help – and backs this up with written exercises – for example, listing client statements with AT elements and sorting them into categories by emotional problem and/or characteristic cognitive distortion. A similar exercise can be used with clients who find it difficult to label emotions – perhaps because it is hard for them to express or articulate emotion, or because they cannot distinguish between different degrees of emotion. A table matching therapist skills with emotional skills aimed for with clients is presented in Table 26.1. Judith Beck (2021) notes the importance of helping clients recognise their positive emotions. She suggests offering rationales for emotion-focused interventions to clients to ensure that cognitive therapy is focused on the most intense negative emotions that clients want to cope with and the positive emotions they most want to promote. Leahy et al. (2011) show a thoroughly Beckian pragmatism by including methods – such as cognitive defusion from Acceptance 130

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Table 26.1 Matching therapist and client skills in emotion-focused work

Therapist skills

Client skills

Facilitates expression of feelings Helps client understand the flow of feelings Teaches mindful attitude to feelings Helps client to use thinking to regulate feelings when appropriate Clarifies link between feelings and actions Clarifies links between feelings and values

Expresses feelings Accepts the flow of feelings Accepts and tolerates feelings Uses cognitive skills to regulate when appropriate Acts positively with feelings Uses feelings to live by highest values

and Commitment Therapy (ACT), and, compassionate imagery from Compassion-focused therapy (CFT) – from outside the Beckian fold to enhance his ‘emotional schema’ mode of cognitive therapy. As noted in Part I, imagery has a special role in evoking emotions and cognitive therapy has been adding imagery interventions in such vital areas as self-compassion (Gilbert, 2010) and traumatic memories (Hackman et al., 2011) and through Gestaltoriented chair work (Pugh, 2020; Wills with Sanders, 2013). Leahy has developed an original contribution with his concept of ‘emotional schema’, a concept influenced by his interest in social cognition. The idea of emotional schema is built not only on emotion itself but also from the idea that we hold beliefs and ‘rules’ about emotions – especially on their legitimacy and on how we should use or not use them. These rules often have a familial origin and most therapists have encountered clients who say things like, ‘We don’t do anger in our family – it is just not allowed’ or ‘My mum used to say that I should not be sad – it only makes those around you sad too’. These beliefs can often mean that when clients have perfectly legitimate reasons for being, for example, angry or sad, they may have difficulty in owning and/or expressing such feelings. Emotional repression may then cause further emotional distress and inhibit progress towards valued goals. Leahy (2015) 131

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joins with Marsha Linehan (1993) to stress the importance of both validating such emotions and facilitating appropriate expression of them. Many will find the growing interest in emotionally-focused cognitive therapy a refreshing development. Greenberg et al. (2019) describe emotionally-focused methods across the humanistic, psychodynamic, and cognitive-behavioural approaches, and suggest that there are more significant similarities between models than differences. The authors also express the hope that these approaches to emotion will one day form, “a coherent view of emotion and an agreed-on approach that will help people who suffer from emotional problems” (p. 3). An aspiration that I hope we can all support.

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27 Cognitive therapists use a variety of methods to promote behaviour change In a now well-known anecdote, Beck describes how on a ward round he came across a patient, “lying in her bed … ruminating … and feeling miserable” (Beck et al., 1979, p. 133). When the patient said she could not gain satisfaction from anything, he ascertained that she used to enjoy reading. Beck dug out the shortest book in the hospital library but when he gave it to her, she said she ‘knew’ she could not read it. He then suggested that she try just one sentence. She, of course, became engrossed and was then able to start a regimen of reading and “within ten days was well enough to return home” (Beck et al., 1979, p. 133). In this wonderfully parsimonious and ‘graduated task’ oriented cognitive behavioural intervention, the therapist reactivates a positive client behaviour and disconfirms unhelpful beliefs. What starts small, can get bigger and in this apposite example, it makes a significant difference. When Beck left his home in the psychoanalytic community, he briefly considered joining that of behaviour therapy. Wolpe’s (1978) hostile reception of cognitive therapy signaled that his efforts were not initially successful, though it was not long before younger and more open behavioural therapists began collaboration with him (Psychotherapy.net, 2012). As we saw in Part I, behaviour change has occupied a significant place in formulation and treatment – in both general and specific contexts such as the role of safety behaviours in anxiety. Cognitive therapists are open to using techniques from behaviour therapy: the main techniques being exposure therapy, graded task assignments, activity scheduling, self-monitoring,

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contingency management, behavioural experiments, and behavioural diaries (O’Donohue & Fisher, 2008). The main continuing dispute between cognitive and behaviour therapy involves debate about whether behavioural techniques are effective both in their own right and/or as reinforcement of cognitive change – for example, disconfirming problematic cognitions during ‘behavioural experiments’ (Bennett-Levy et al., 2004). Clients with panic disorder often believe that the symptoms of panic will drive them mad. If they can ‘face the fear’ by going into situations that have triggered past panic reactions and refrain from ‘safety behaviours’, they may begin to weaken this belief – bearing in mind previously described recommendations on ‘judicious’ balances between exposure and safety (Rachman et al., 2008). In this debate between cognitive and behaviour therapists, cognitivists have argued that adding cognitive elements to, for example, exposure treatments, enhance their effectiveness whereas behaviour therapists have argued that they made no significant difference. Each party can offer some supportive evidence for its case (Hayes & Hoffman, 2018). Brewin’s (1996) conceptual framework can help to find a way through this debate by suggesting a distinction between ‘situationally accessible’ and ‘verbally accessible’ knowledge. This distinction can help us to appraise the potential contributions of cognitive and behavioural interventions with different problems. Verbally accessible knowledge or insight – for example, in social anxiety, will be especially helpful to clients who can use reflective cognitive techniques. Situational knowledge – for example, with panic attacks, may, however, require a specific behavioural type of stimulus – for example, an element of exposure task, to provoke emotionally relevant knowledge and thereby ‘gut learning’. Emotional induction techniques – in which therapists deliberately invoke emotions (Siedlecka & Denson, 2018) may be required in several anxiety disorders, where discussion of fear experiences without some feeling of anxiety being actually present does not seem helpful (Foa & Kozak, 1986). Most behavioural change probably involves both discussion and experience but one of them may 134

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need more emphasis than the other for some problems and with some clients. Our focus here is mainly on behavioural experiments (Beck, J.S., 2021), which in cognitive therapy may work on two levels: firstly, at the level of the behaviour change itself – for example, helping depressed clients to become more active, and/or, secondly, at the level of cognitive change, for example, the client’s behaviour change leads her to revise her belief that she is incapable of being active again (Bennett-Levy et al., 2004). Wells (1997) has described the way behavioural experiments with overly self-focused attention can help in social anxiety. Clients involved in performing arts often report a crippling sense of selffocus and preoccupation with what audiences might be thinking about them. Performers’ self-focused imagery often includes ‘seeing’ hostile audiences. Their fear of this possibility prevents them from actually looking carefully at the audience. The relevant behavioural experiment can therefore be for clients to redirect their attention deliberately towards the audience – in order to counteract their negative self-focus. The result of this experiment is usually that they can now see audiences as more benign and as having a mixture of responses. Such experiments have several potential therapeutic gains – for example, learning more flexible ways to attend to events, building up positive behaviours based on accurate feedback, facilitating corrective emotional experiences, and enhancing the prospect of belief and attitude change, for example, lessening perceptions of others as hostile. Clark (1996) developed several useful behavioural experiments in the treatment of panic more oriented towards experiential change – including breathing into a paper bag and deliberately undertaking physical exercise to experience the ‘normal’ effects of changes in the levels of oxygen and carbon dioxide – as is also felt as unpleasant during panic attacks – and learning experientially that no harm results and balances are quickly re-established. Beck’s (1970b) landmark paper on the relationship between behaviour therapy and cognitive therapy paved the way for a strong behavioural strand in cognitive therapy and may have been key to the integration of the two approaches into CBT (Rachman, 1997a). 135

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He gave early impetus to the behavioural experiment concept and added promising methods to use in the construction of such experiments. These concepts have inspired other clinicians to expand this tradition, for example, in recent developments of Beck et al.’s (1979) behaviourally focused ‘activity scheduling’ methodology. Activity scheduling was designed to target withdrawn behaviours in depressed clients that add to the vicious cycle of depression. The method has now been enhanced by an updated version of Lewinsohn’s (1974) behavioural approach to depression. Newer behavioural approaches, such as Acceptance and Commitment Therapy (ACT), have stressed the importance of contextual function in behavioural work – now exemplified by the third wave of CBT development of behavioural activation (Martell et al., 2013). Martell et al. (2001) give telling examples of the importance of context – especially social and interpersonal contexts. One depressed man was scheduled to spend more time with his children. He appeared to enact this but did not report feeling any better for doing so. Later observation of him during this activity, however, revealed that, during it, he behaved in a distracted and cut-off fashion, failing to develop any significant communication with his children. When this was later corrected, the positive effect of the activation was much greater. Judith Beck (2011) adopted a similar contextual stance in her writing on behavioural activation, describing how therapists can ensure the relevance of activities by using Aaron Beck’s concept of ‘mastery and pleasure’ – stressing the importance of mixing some social activities that address the loss of pleasure in the lives of depressed clients with other activities that may not be so pleasurable but help clients feel a sense of mastery and self-efficacy. She also adds the innovative idea of encouraging clients to develop charts in which pleasurable and mastery experiences are rated and reviewed over time. This is helpful because activities that are pleasurable and mastery-enhancing may vary significantly over time.

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28 Cognitive therapy has developed new ways of working with cognitive processes, especially via mindfulness After first reading Beck’s work, it took me some years to find a thorough training in it. For a while I trained in Rational Emotive Behaviour Therapy (REBT) therapy – which included being a client and keeping homework notes. Stumbling on these long-lost notes recently, I identified a key therapeutic moment in the sessions. I had been feeling particularly stressed and discouraged at work after being bullied by a manager. I was fearful of losing my job and of feeling depressed. As I articulated these fears, the therapist said, “Well, it is a nice day out there”, and gestured my attention towards the window. I saw that it was a lovely summer day – with the sun high in a deep blue sky. My therapy notebook recorded that “a sense of relief ran through my body … I realised that, whatever else was happening in the world, right now I was safe and relaxed in that room and I would be soon be walking outside savouring the lovely afternoon”. At that time, little was said about the benefits of shifting attentional focus and mindfulness in therapeutic work but I suspect that the therapist’s move was intuitively oriented to it. My mind made a significant shift of attention away from a disturbing internal world to mindful appreciation of a benign external world – a ‘re-focusing’ (Beck, J.S., 2021) indeed. So far this book has discussed cognitive change largely with a convergent, left-brained vocabulary – for example, identifying, evaluating, and modifying. Changing cognitive processes additionally requires divergent, right-brained words – for example, noticing, watching, and reflecting. Such terms were evident in Beck and 137

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Emery’s (1985, pp. 323–4) AWARE strategy, in which clients are advised to accept anxiety and to develop that awareness by watching it without evaluation. The final step in AWARE is a cognitive content-based instruction to ‘expect the best’ – combining mindful attentional strategies with cognitive instructions. It became apparent, even in the early development of the model, that cognitive therapy with the content of obsessional and ruminative thoughts is often only partially effective. The problems these thoughts cause are exacerbated by the attention that clients pay to them. Almost 90% of people have thoughts similar to those afflicting OCD clients (Rachman, 2002). The difference between ‘normal’ and ‘abnormal’ obsessions lies in how people react to them. Most people can dismiss them without much bother but, for OCD sufferers, however, such thoughts are so objectionable and carry such negative meaning that they try to suppress them, and suppression usually only produces a ‘rebound effect’ that makes them yet harder to deal with (Abramowitz, 2018). Similarly, the content of worry does not differ much between sufferers and non-sufferers. Worry is functional – up to a point. People need to be concerned about things that can go wrong in their lives and would be ‘unready’ to meet difficulties if they did not prepare. Leahy (2005) distinguishes between ‘productive worry’ and ‘unproductive worry’. Worry is productive when it leads to reasonable action in relation to the problem but is unproductive when ‘ruminative worry’ prevents us from accepting the presence of the problem or blocks us from taking effective action in relation to it. It is, therefore, helpful not to ‘fight’ worries, intrusions, and obsessions but to develop a more accepting relationship with them. Rethinking our metacognitive beliefs about these negative processes helps to pay them less attention and to overcome them. Wells (2009) suggests ways of rethinking how we pay attention to negative metacognitive beliefs – such as ‘If I do not worry about work, I will not remember to do all I must do’ – and of being more ‘mindful’ about them. The first wave of work on mindfulness-based cognitive therapy was developed mainly within group settings (Segal et al., 2013). 138

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After an early paper from Melanie Fennell (2004), many cognitive therapists began to explore how what was clearly working well within the group setting could be applied to one-to-one therapy. Judith Beck (2021) addresses this issue and suggests some helpful ways forward. As the quotation at the head of this chapter suggests, she sees it as particularly helpful when clients have problems of fixated attention, and in her book she describes how she takes a client who ruminated a lot on self-criticisms through the mindfulness process. She notes that almost all therapeutic mindfulness practices are based on helping clients to learn to focus on their breathing, whilst realising that their minds are bound to wander. They should, however, try to learn the discipline of returning attention to the rhythm of the breath. She says that though the basic mindfulness process is the same, there are variations and that it is helpful for clients to review several different methods, now widely available in books, CDs, online, or on phone apps. With the client in her book, she builds mindful breathing exercises into a behavioural experiment. Firstly, she induces a ruminative mind-set in the client and then asks how he feels. Then she takes him through a mindfulness exercise before asking him to compare how he feels now compared to how he felt before. As he feels better, they agree to record her version of the exercise onto his phone. If clients have had a successful experience of mindfulness with their therapists voicing the pattern to follow, they will often prefer the therapist’s voiced version to a more anonymous online version. I appreciate Judith Beck’s very practical approach to mindfulness and find it helpful that she recommends that clients can try very brief periods of mindfulness practice to begin with. Five minutes is better than nothing and five minutes can become ten and ten can become yet more. The research on mindfulness suggests that keeping up practice after group participation is crucial to maintaining gains for clients (Segal et al., 2013). I know from my own experience,1 however, that it can be difficult to keep up with the practice at times – so that building back up to such practice by beginning with short periods is, I think, an effective antidote to the negative thinking such as, I cannot having to do full practice again! It is 139

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also very much in line with the theme of gradualism described in the last chapter. Judith Beck describes combining mindfulness with more formal cognitive therapy. Most interventions focused on cognitive processes do also combine mindful attention with some more direct cognitive work and it will be interesting to see how that balance develops over the years, especially in relation to ideas that have been independently developed within different versions of the CBT family of models, such as ACT and metacognitive therapy (Hayes & Hoffman, 2018). Note 1 Judith Beck, like most cognitive therapists, stresses the importance of therapists using mindfulness techniques with clients of keeping up their own practice of mindfulness whilst doing so.

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29 Cognitive therapists are key participants in large systems delivering psychological therapy Ideas about how cognitive therapy might be delivered at a service level are relevant to the consideration of Beck’s model as he has expressed interest in this direction for some time. He has also offered support for the world’s most serious effort in this direction – England’s1 Improving Access to Psychological Therapy (IAPT) project (Beck Institute, 2018). IAPT has been described as “the world’s most ambitious therapy project” (Testa, 2017), but a former employee has also suggested that “Aaron Beck might cringe if he knew how rigid CBT has become in England” (Roscoe, 2019). Views about the IAPT service, however, often quintessentially reflect the predictable views of its supporters and detractors.2 There seems to be sadly little common or middle ground. Opinions about IAPT may also reflect the split between rational/cognitive perspectives – in this context backed by impressive statistical analysis – and emotional/interpersonal perspectives. In relation to IAPT, the latter often take the form of a ‘cri de coeur’ about bad experiences of clients or workers of the service. I spent some years puzzling over these different views and then conducted a survey in 2013 (Wills with Sanders, 2013), which I have followed up since. I have reached the conclusion that these different sources of information all say something of worth about the project but need to be crosschecked against each other and then recast in the round. We will begin with a brief description of the project and its founding ideas, and then review some key statistics and views of both IAPT clients and workers in an attempt to reach a rounded view.

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It has been known for some time that only a small proportion of the people who could benefit from psychological therapy receive it – a pre-IAPT figure of 10% is often mentioned (Frude, 2005).3 The drive to improve access came from Lord Layard’s idea that increasing national happiness should become a social policy aim. Layard is an economist with influence in the Labour Party, and, especially at that time, with the then Prime Minister, Tony Blair. Layard (2006) eventually secured government commitment by proposing that increasing treatment for anxiety and depression could pay for itself from savings on welfare and health services. With the help of Beck’s close UK ally, Professor David. M. Clark, the service was shaped up and, after pilot projects, opened in 2008. It met its target to see one million clients in a year by 2017 – and achieved the target of 50% recovery rates that same year. The service and the rigour with which it has assessed its outcomes is clearly described in Clark et al.’s (2017) and Clark’s (2018) papers. IAPT data is open to public scrutiny and the project deserves credit for putting itself on the line in this way. Proposing happiness as an aim for a government service can sound Utopian or, even, dystopian, a la Brave New World. Where this aim has, however, found an echo in the zeitgeist is in the disillusion with having economic growth as the sole criteria for social progress, especially with a growing awareness of the environmental, health, and mental health costs of ‘hyper-capitalism’ (Kasser, 2003; James, 2007). The aim of the IAPT service has been to help clients overcome anxiety and depression with the presumption that this would make them happier – so ‘becoming happier’ may be a better-stated policy goal. Whilst many ancient sources of wisdom warn against the negative consequences of seeking happiness too forcefully, most, including the Dalai Lama with Cutler (1999) – with whom Beck had a dialogue in 2005, suggest that its gentle pursuit can be facilitated by both training the mind and cultivating compassion. From the start, critics of IAPT, however, have stressed its rigidity and bureaucratic nature. These points overlap with the familiar critique that the CBT model – a model which was given a central place 142

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in the project – is overly directive and, in this case, almost forced on clients for lack of alternative.4 Critics often point to examples of clients not being able to access the service or not progressing far into it when they do. This is an important point and is reflected in the statistical accounts of the service – in that around 40% of the referrals to IAPT do not go on to get substantial psychological therapy (Clark, D.M., 2018). This is often presented as a service failure but is really not at variance with its aims – on two counts. Firstly, the service begins with an assessment during which either party may decide that therapy is not needed or desired. Secondly, despite its critics, the service stresses that it is ‘person-centred’ and encourages client choice. Therapists in my study emphasised that clients could and sometimes did make, what for the therapists, seemed frustrating choices not to go on but that the IAPT service was firm about respecting these choices. A further convergence point of data focuses on the variations between different teams and areas. For example, although the average recovery5 rates have been around that of the target of 50%, local variations between 21% and 63% have been recorded (Clark, 2018). Research on these differences points to the quality of clinical leadership as an influence on outcomes (Clark, 2018). During my interviews, I noticed differences in morale between different staff and in different local offices. Staff who work in the initial steps of IAPT– mainly Psychological Wellbeing Practitioners (PWPs) who work mostly by telephone and/or online – found the work rewarding but onerous and often suffered from headaches and other symptoms of stress – part of a wider concern about emotional exhaustion amongst IAPT staff (Westwood et al., 2017). PWPs envied other staff their greater freedom of movement and control over their work. High Intensity (HI) therapists who work face to face with clients like other CBT therapists – sometimes complain about ‘having to stick to the protocol’ when their clinical instincts told them otherwise. Some even said that the over-emphasis on diagnostic labels discourages individual client conceptualisations (Binnie, 2015) – though therapists in other offices were surprised when I reported this to them. 143

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Apart from these more technical factors, I got the impression that ‘personal touch’ leadership was often greatly appreciated in the teams where it was available. One PWP offered this description of much-valued senior colleagues who “take the time to talk with us frequently and have given us autonomy over how we organise our room and the work we do in it”. In contrast to this personal type of touch, bureaucratic inflexibility and fixation with targets could often suck the life out of teams. Sometimes inflexibility came from further up the system – as shown by the British Association for Behavioural and Cognitive Psychotherapists’ (BABCP) protest against funding restrictions that lead to limitations in sessions (Roscoe, 2019). These were sometimes driven by conflict between one objective – having reasonable waiting times – and another – offering a full evidence-based service to clients. Overall, I consider that the service has shown reasonable awareness of these problems – which are perhaps inevitable in such a large project. The service has also shown resilience in its determination to tackle these problems and the ability to lobby in the right places to ensure that they are addressed. I do not therefore think that Aaron Beck would cringe if he came to take a closer look at IAPT – provided he took in a range of local offices. He would follow his normal patient and thorough research processes to identify both achievements and problems with the aim of solving problems and seeking improvements. If Judith Beck were also on that trip, I feel sure that she would keep whispering in his ear, “Don’t let them forget about the importance of individual client conceptualisation”. Notes 1 IAPT has not yet been implemented in other parts of the UK. 2 With the possible exception of Michael. J. Scott (2018) who, as a seasoned cognitive therapist of many years’ practice, has expressed important concerns about the style and outcomes of the current IAPT organisation.

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3 Even the large investment in IAPT has not even doubled that figure (Clark, 2018). 4 The IAPT has responded to critics by increasingly including other modes of therapy – though CBT has remained central. 5 IAPT statistics distinguish between ‘reliable recovery’ and ‘reliable improvement’ – 51% and 68% respectively in 2017 (Clark, 2018).

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30 Cognitive therapy aspires to be a unifying model Both in terms of using concepts and skills from other therapies, and of offering them its own methods Throughout this book, we have followed Beck’s career through its gradually expanding phases. We have seen him begin to develop his own way of working in an effort that gradually evolved into a distinct new model of therapy. In 1976, he asked whether this new brand of therapy could challenge the then-dominant psychodynamic and behavioural approaches and, by 1991, he was able to comment that cognitive therapy had earned “the right to enter the arena of controversy … alongside the giants” (Beck, 1991, p. 374). We have noted several times how important the building of a portfolio of positive research results was to this process and some in the CBT community began to assert that these results pointed towards CBT being a superior model. Beck has, however, never argued in these terms but has relied instead on stating the evidence and letting others draw their own conclusions. This stance probably points towards a natural humility in him but maybe equally importantly, he has been brilliant at building allies and often appears reluctant to make enemies, preferring to keep doors open to possible future collaboration. A constant theme in his work has been, “a quest for common ground” (Rosner, 2018, p. 27). Reading about his early career, one gets the feeling that Beck was genuinely affronted by the way the existing schools resisted developing more open and accessible services for the general public. He has continued to make the case for these kinds of changes in the world of therapy and, though controversial, Improving Access to Psychological Therapy (IAPT) in England does at least suggest 146

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some parameters for what might be possible. The irony that his wider vision has made more progress outside his native country does not escape him (Beck Institute, 2006). Beck has remained distinctly cool towards ‘schoolism’ in his approach to therapy. Again confirming his remarkable continuing productivity in his late 90s, his integrative interests are very visible in his most recent projects at the Beck Institute. He has constantly talked of the debt he owes to psychoanalysis (Rosner, 2014). We can note, for example, John Oldham’s description, in the Journal of Psychiatric Practice, of a ‘unique event’ that he planned for the 2012 annual meeting of the American Psychiatric Association (APA): entitled ‘Cognitive Therapy and Psychodynamic Therapy: More Alike than Different? A Conversation between Aaron Beck and Glen Gabbard’. There is now good evidence from randomized controlled trials that psychotherapy can be an effective treatment for conditions such as depression, anxiety disorders, personality disorders, and many others. Evidencebased medicine calls for standardization, when appropriate, of treatment approaches, and there are treatment manuals for a number of types of psychotherapy. But at times, it seems as if clinicians divide up into camps, each advocating for a particular therapy as if it is a competition and the goal is to pronounce the winner. But in fact, many types of psychotherapy share common elements .… In discussions with Beck and Gabbard prior to the APA meeting, it became clear that they endorsed the view that cognitive therapy and psychodynamic therapy share common aspects, while there are unique features differentiating the two approaches … the event was a huge success – thousands of attendees had the opportunity to hear a wonderful interaction between these two pioneers in the world of psychotherapy. (Oldham, 2012, p. 141) Another striking feature of Beck’s development in recent years has been his return to a long-standing ambition to offer more therapeutic 147

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hope to patients with schizophrenia (Beck, 2018). As noted earlier, Beck read and was impressed by Carl Rogers’ person-centred notions of therapy, especially in relation to the essential qualities of the therapeutic relationship (Beck et al., 1979). This thread remains evident in many other of Beck’s writings and especially in his description of his model for working with schizophrenic clients – which he terms ‘Cognitive Therapy for Recovery’ (CT-R). This model is person-centred and emphasises Rogerian counselling skills and dispenses with many of the more deliberative change methods stressed in his earlier writings and puts most of its emphasis on the use of the therapeutic relationship and the exploration of meaning, positivity, and empowerment in search of activating the ‘sweet spot’ of the client’s adaptive mode (Beck et al., 2020; Beck, J., 2021). This gentler and more positivity-oriented form of cognitive therapy is also being expanded beyond just therapy for schizophrenia (Beck, A.T.; Finkel, M.R.; Beck, J.S., 2020). I, too, have put much emphasis on trying to build bridges between cognitive therapy and other approaches and, in 2001, I was awarded a Fellowship from the British Association for Counselling and Psychotherapy (BACP) for this work. In general, I have experienced much more positive responses from therapists and practitioners on the ground than from the academic and theoretical leaders in other types of therapy – who often appear stubbornly stuck in the heavily armed trenches of their models – few of whom seem to show the openness of Aaron Beck. On the other hand, there has been an increased interest in integrative models of therapy and cognitive therapy generally shows up quite well in the syllabi of courses taught on this basis. Beck (Alford & Beck, 1997) has said that he thinks that cognitive therapy will eventually outlive its usefulness but will survive as a major contributor to a new more unified form of psychotherapy and counselling. There is evidence of this emerging already in a growing adoption of a common set of practices in the way that all therapies are being practiced and some of the key elements come from Beck’s work – for example, the use of mood measures, the use of formulation and conceptualisation, the use of homework, 148

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session evaluation, guiding (not forcing!) protocols, and the elicitation of client feedback – all of which make Beck’s hopes for launching a unified model of psychotherapy based on best practices seem less of a forlorn hope. He has continued, now also ably assisted by Judith Beck, to keep pushing this door open and – even though he is now approaching his hundredth birthday, we should never underestimate how much further he, and Judith, may take this.

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Concluding comments Let’s all raise a glass to Aaron ‘Tim’ Beck

In 2018 I visited the Freud museum in Vienna and was really struck by the fact such an important and influential idea had radiated out from Freud’s seemingly tiny therapy rooms there. In July 2019, the World Congress of Behavioural and Cognitive Therapies was held in Berlin and Beck’s 98th birthday happened to fall during it. Delegates were transfixed when he suddenly and unexpectedly welcomed them on a huge screen in a live and interactive contact piped in from Philadelphia. The delegates sprang to their feet clapping and cheering, one commented, “What a man! A true inspiration. Still engaged and encouraging after all this time” (Melanie Fennell, personal communication). I imagine that people there had a feeling similar to the one that I experienced in Vienna – such a powerful influence radiating out from this single human being. He had been the prime mover of the many different reasons that led many of them to gather in Berlin that day. I can be sure that the cognitive behavioural community will express even more joy on Beck’s 100th birthday on 21st July 2021. I know that some such plans are already in tow. I do hope though that on that occasion they will also be joined by people from outside the cognitive behavioural fold too and I would be honoured to think that my small efforts, here and elsewhere, might move one or two to do so. One does not have to think that Beck and his model gets everything right. I have articulated here how even I, an unreconstructed fan, think that whilst the development of research on 150

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theory and outcomes has been stunning, it has not always been matched by equally careful research into how best to practice cognitive therapy. This has sometimes left practitioners like myself wanting more on the complexities of applying skills in the context of varied clients in practice. To those outside the CBT community, our practice can sometimes look rather stilted. I and my colleague, friend and co-writer, Diana Sanders, have tried to address this gap in our books by writing for practitioners (Wills & Sanders, 1997, Sanders & Wills, 2003, 2005; Wills with Sanders, 2013) and some of them, both inside and outside CBT, have expressed some appreciation of this. One must suppose, however, that there are bound to be gaps in any great enterprise and it can be good for adherents to have to work some of it out for themselves, rather than wait for leading exponents to do all the heavy lifting. There is also so much of what is brilliantly positive in Beck’s truly voluminous work that even the most critical of reviewers must recognise at least a grain of truth in the assertion that, “… We’d be hard-pressed to find a therapist who has not in some way been shaped by Dr. Aaron Beck (Psychotherapy.net, 2012).” And then we can also appreciate the open, graceful and humble way Aaron and Judith Beck have gone about things …

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169

Index

acceptance 52, 60, 95, 114; Beck, Judith S. 2, 7, 19, 78, 92, 96, 99–101, 107, 110, 112, 113, 119, 122–123, 130, 135–136, 139–140, 144, 149, 151; conceptualisation 63; early life and career 8–9, 79–80; imagery 36–39; mindfulness 59–61; therapeutic relationship 82–83; weight loss therapy 99–102 Acceptance and Commitment Therapy (ACT) 95, 96, 130–131, 136, 140 action plans 15, 23 activity scheduling 44, 91, 133, 136 Alford, Brad 26, 36, 37, 54, 71, 91, 93, 148 American Psychiatric Association (APA) 35, 84, 147 anxiety 8, 17–18, 20, 27, 32–37, 40, 43, 46, 48, 52, 62, 77, 89, 96, 100, 115, 132–134, 138, 142, 147 Anxiety Disorders and Phobias: A cognitive perspective 32, 33, 35, 36, 77, 89, 90, 94, 138 Arntz, Arnie 83, 119, 123 assumptions 21, 23, 28–31, 66, 97, 107, 120–124 170

attachment 33–34 attention focus and strategies 10, 26, 36–37, 44, 50–59, 66, 109, 135, 137–140 audio recording of therapy sessions 75, 107 automatic thoughts/negative automatic thoughts (NATs) 20–23, 25, 28, 36, 40, 50, 67, 79, 110, 116, 130; evaluating and responding to NATs 113–117; identifying NATS 109–112; worksheets 116 avoidance 43, 46–47, 75, 135 AWARE strategy 52, 138 Beck, Aaron, T. 11, 24, 43, 63, 79, 81, 88–90, 92, 93, 97, 102, 107, 110, 128, 129, 136, 137, 141, 144–146, 148, 151; awards 7; democratic attitude 7, 89–90, 145; drive for efficiency 77, 96; early career 2, 7, 8, 16, 20–25, 30, 51–53, 115, 145; early life 7, 24–27, 29; empiricism 8, 10, 20, 68–71; humility 146; later career 8–9; making allies 2–3, 17–18, 69–72, 133;

InDEx

openness 2–3; pragmatism 35, 77; psychosis 147; relationship with UK 46; reputation 46; schemas 147; tennis player 42, 49; University of Pennsylvania 8, 24, 78, 107 Beck, Judith S. 2, 7, 19, 78, 92, 96, 99–101, 107, 110, 112, 113, 119, 122–123, 130, 135–136, 139–140, 144, 149, 151; conceptualisation 63; early life and career 8–9, 79–80; imagery 36–39; mindfulness 59–61; therapeutic relationship 82–83; weight loss therapy 99–102 Beck family 7–8, 79–80 Beck Institute for Cognitive Behavior Therapy 9, 14, 78–80, 101, 141, 146 behaviour 42–43, 96 behaviour change 96, 133–136 behaviour therapy 42–43, 133, 139 behavioural activation 43, 136 behavioural experiment 134–135 behaviour therapy 42–43, 133, 139 being mode 60 beliefs 28–31, 88, 118–133, 147; core beliefs 21, 23, 28–31, 44, 65, 67, 83, 85, 88, 119–120, 123; intermediate beliefs (assumptions), 67, 120 Bennett-Levy, James 134–135 Berlin 150 Beutler, Larry 75–76, 92 biases 16, 50–53, 56 Biden, Joe 33 Blair, Tony 142 Borderline Personality Disorder (BPD) 86, 119, 123 Bowlby, John 33, 35 breathing focus 149 Brewin, Chris 94, 134 Bristol 47

British Association for Behavioural and Cognitive Psychotherapies (BABCP) 57, 144 British Association for Counselling and Psychotherapy (BACP) 148 Buddhism 59, 61 Cape Horn 39 catastrophising 18, 26, 36–38, 46, 48, 116 cathexis 30–31, 52 Clark, David, A. 8, 17, 18, 34 Clark, David, M. 1, 8, 18, 19, 46–48, 50–53, 69–72, 79, 112, 135, 141–145 ‘Cloud, the’ 30 cognition, role of 20–23 cognitive behaviour therapy (CBT) 3, 10, 13, 15, 18, 38, 40, 43, 51, 55, 58, 70, 71, 78–80, 82, 89, 90, 93–97, 102, 107–109, 125, 136, 140–142, 145, 148; ‘third wave’ 2, 52, 55, 146 cognitive dissonance 111, 113, 122 cognitive distortions 24–25 cognitive organisation 26, 28–31, 40, 66, 67, 75, 117, 129 cognitive processes 50–53, 137–140 cognitive specificity concept 16–19 cognitive therapy: as integrative model 54, 146–149; principles of 9–15 Cognitive therapy and the emotional disorders 9–13, 19, 25, 96 Cognitive therapy: basics and beyond 9, 78–80, 82, 83, 96, 107, 111, 112. 113–115, 119 171

InDEx

Cognitive therapy for challenging problems 84, 87, 89, 97, 122–123, 125 Cognitive therapy of depression 1, 8, 9, 25, 73, 74, 98–99, 133 Cognitive Therapy Scale (CTS/ CTS-R) 70, 102–106 collaboration/collaborative empiricism 81–84, 93 ‘common factors’ in therapy 81, 96, 146–149 compassion focused therapy 117, 131 competency development 74, 103 conceptualisation 9–11, 19, 62–69, 85–88, 114, 143, 144, 148 congruence 81 continuum technique 123–125; criteria continuum 124–125 controlled trials 8, 70, 73, 113, 147 Cooper, Mick 22 core beliefs see beliefs ‘core conditions, Rogerian’ 81–82 coronavirus pandemic 27, 58, 67–68, 113 corrective emotional experience 135 counter-transference 83 criticisms of cognitive therapy 23, 27, 30, 33, 40, 42–43, 53, 77, 95, 145 cultural, social and ethnic sensitivity 10–14, 62 Cummings, Nicholas 90–91 Dalai Lama 60, 142 Darwin, Charles 32, 35, 77 decentring 50, 109 depression 7, 8, 16–19, 21, 23, 28–34, 41, 43, 59, 60, 69–71, 77, 94, 96, 98–100, 110, 136, 142, 147 172

Depression: Clinical, experimental and theoretical aspects 8, 21 Diagnostic and Statistical Manual (DSM) 24, 35, 84 dietary problems 99–101 directiveness/directionality 52, 93, 109, 111, 113–114 ‘doing mode’ 59–60 Dryden, Windy 10, 42, 83, 117, 120 eating disorders 18 educational focus 98–101 Ellis, Albert 26, 43, 77 emotion 32, 40–42, 128–132 emotion focused therapy 41, 132 emotional induction 134 emotional regulation 32, 129–131 emotional schemas 29, 42, 131–132 empathy 81–82 epistemology 69–72 Epstein, Seymour 32–35, 37, 54, 84 evolutionary influences 29 exercise 58 existential therapy 22 exposure therapy 133–134 feedback, client 42, 79, 88, 91–93, 114, 149 Fennell, Melanie 1, 61, 139, 150 ‘fidelity’ problem 73 fixation 52, 56 Foa, Edna 134 focusing in Beck’s Cognitive Therapy 53, 60, 62, 137 focusing in Gendlin’s model 42 formulation 11, 19, 30, 42, 45, 62–68, 74, 96, 105, 139, 146 Frank, Jerome 73 Freud, Sigmund 30–31, 52, 77, 91, 150 Frontiers of cognitive therapy 54 Frude, Neil 89, 142 Full Metal Jacket (film) 117

InDEx

Gabbard, Glenn 147 Gendlin, Eugene 42 general cognitive model 53, 129 Generalised Anxiety Disorder (GAD) 56–57 Gestalt therapy 95, 131 Gilbert, Paul 117, 129, 131 goal orientation 10, 12, 91, 94–97, 131 graduated task focus 101, 133 green environment in therapy 58 guided discovery through Socratic dialogue (GD/SD) 113, 115, 119–120 Hackmann, Ann 1, 38 Haigh, Emily 18, 19, 23, 28, 29, 35, 53, 55, 60, 67, 109, 110, 129 happiness 142 Harvey, Alison 19, 48, 51, 55 Hayes, Steve 51, 95, 113, 134, 140 ‘here and now’ focus 94–97 high intensity therapy 143, 147 historical test method 125–126 Hollon, Steve 46, 94 homework 10, 12, 15, 90, 92, 98–101, 106, 113, 117, 148 ‘hot’ thoughts 41, 110, 111, 114, 115 humanistic therapy 36, 83, 95, 128 hyper-capitalism 142 imagery 22, 32, 36–39, 41, 110–111, 131, 135 ‘immediacy’ 81 Improving Access to Psychological Therapy (IAPT) 10, 15, 71, 89, 141–146 Integrative Power of Cognitive Therapy 54, 90, 93 integrative therapy model 54, 148 internet 99 interpersonal aspects of cognitive therapy 57

Jacobson, Neil 94 Kabat-Zinn, Jon 48–49 Kraepelin, Emil 1, 2, 99 Kuyken, Willem 68 language, importance of 119 Layard, Richard 142 Layden, Mary Ann 30, 38, 39 Leahy, Robert 40, 42, 92, 128–130, 138 learning perspective 98 Lewinsohn, Peter 43, 136 lifeline method 125–127 ‘lockdown’ during coronavirus pandemic 27, 67–68 ‘manualisation’ in therapy 73–74, 85–86, 147 Marzillier, John 43 mastery and pleasure principle 136 meaning in cognitive therapy 22–23, 28, 37, 38, 110, 116, 118, 138, 148 metacognition 54–57, 114, 138 metacognitive therapy 54–57, 140 metaphors in therapy 34, 39 mindfulness 44, 51, 52, 58–61, 114, 137–140 mindfulness-based cognitive therapy (MBCT) 59–61, 138 mode concept 28–31, 34, 52–54, 67, 109 mood measures 13, 106, 148 Mourinho, Jose 121 narcissism/narcissistic personality disorder (NPD) 119 National Institute for Clinical Excellence (NICE) 57 neuroscience 7, 19, 35, 40, 59, 129 173

InDEx

obsessions 50, 99, 138 obsessive compulsive disorder (OCD) 8, 18, 19, 48, 50–51, 99, 138 Oxford/Oxford Cognitive Therapy Centre (OCTC) 1, 46–47, 55, 60, 69 Padesky, Christine 41–42, 45, 68–70, 75, 83, 92–93, 107, 110, 122–125 panic 13, 18, 38, 46–55, 69, 73 personality problems and disorders 34–35, 67, 85–88, 129, 149 Persons, Jacqueline 74, 96–97 phobias 32, 36, 47, 52 physiology 40–45 Power, Mick 32, 128 pragmatism 26, 33, 35 ‘primacy debate’ 40, 128 problem list 96 problem orientation 94–97 problem-solving skills 52, 59–60, 94–95, 123, 144 profanity 117 protocols for therapy 71–76, 143, 149 psychoanalysis/psychodynamic orientation 7, 11, 16, 20, 24, 30, 33, 51–53, 83–84, 96–97, 108, 132, 147 psychoeducation 98–101 Psychological Wellbeing Practitioners (PWP) 143–144 Rachman, Stanley 43, 47–48, 50–51, 134–135, 138 Rational-Emotive Behaviour Therapy (REBT) 1, 4, 41–42, 130, 137 reassurance-seeking 34, 43, 46, 49 174

recovery-oriented cognitive therapy (CT-R) 14, 31, 49, 81, 97, 99, 148 reflection 109–110, 116 research methods 69–72, 103, 107; outcome 73–74, 103, 107, 130; process 103, 107 Rogerian therapy 10, 82, 93, 110, 112, 148 Rogers, Carl R. 20, 75, 77, 81, 95, 103, 148 Rosner, Rachel 7, 25, 27, 30–31, 36, 71, 146–147 Roth, Andrew 80, 94, 103 rumination 27, 44, 56, 59–60, 112, 139 Rush, Jon 73 safety behaviour 43, 46–49, 133–134 Safran, Jeremy 118 Salkovskis, Paul 1, 43, 47–49, 54 Sanders, Diana 82, 110, 129, 131, 141, 151 Schema-focused therapy (SFT) 90, 118–121 Schema Questionnaire (Young) 119 schemas 21, 23, 28–31, 52–53, 65–67, 83, 118–122 schizophrenia 8, 31, 55, 99, 148 Segal, Zindel 51, 59, 60, 118, 138, 139 self-focus 19, 37, 51, 119, 135 self-monitoring 100, 133 skills orientation 97, 102–108, 110 social anxiety 18, 19, 37, 38, 51, 112, 134–135, 138 strengths-based approach 10, 68, 99 stress-diathesis concept 18–19 structure in therapy 89–93 substance abuse 18

InDEx

‘uniformity myth’ 97, 99–101 University of Oxford 69

weight loss 97, 100–101 Weishaar, Marjorie 8, 16, 23, 24, 32, 33, 36, 41, 50, 79, 89, 93 Wells, Adrian 1, 19, 22, 37, 38, 48, 51, 54–57, 112, 135, 138 Williams, Mark 30, 57, 58, 60 Wills, Frank 9, 14, 26, 42, 44, 49, 75, 82, 83, 87, 96, 103, 110, 111, 113, 116–118, 120, 127, 129, 142, 151 Wolpe, Joseph 43, 133–134 ‘working through’ 83 worry 56, 63, 138; ‘productive and unproductive’ 138

‘vicious cycle’ 44–46, 48, 64, 136 Vienna 150

Young, Jeff 76, 90–91, 93, 96, 102, 104, 118–119, 123

suicide 52 surprises, psychology of 101 therapeutic relationship/alliance in Cognitive therapy 9, 11, 20, 81– 84, 86, 90, 109, 110, 118–119, 148 time-sensitivity 89–93 Tranmere Rovers FC 14 transdiagnostic approach 19, 48, 51, 55–56 transference 83

175