Cognitive Therapy for Challenging Problems

337 Pages·2005·3 MB·English

by  Judith S. Beck Phd

COGNITIVE THERAPY
FOR CHALLENGING PROBLEMS
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Cognitive
Therapy
for Challenging
Problems
WHAT TO DO
WHEN THE BASICS
DON’T WORK
Judith S. Beck
Foreword by Aaron T. Beck
THE GUILFORD PRESS
New York London
©2005JudithS.Beck
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Cognitivetherapyforchallengingproblems:whattodowhenthebasicsdon’twork/
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2005007221
To my family
About the Author
Judith S. Beck, PhD, is the Director of the nonprofit Beck Institute for
Cognitive Therapy and Research in suburban Philadelphia and Clinical
Associate Professor of Psychology in Psychiatry at the University of Penn-
sylvania. Dr. Beck directs the three major functions of the Beck Institute:
education, clinical care, and research. She currently divides her time
betweenadministration,supervisionandteaching,clinicalwork,program
development, research, and writing. She is a consultant for several
National Institute of Mental Health research studies and often presents
workshops nationally and internationally on a wide variety of cognitive
therapytopics.Dr.BeckistheauthorofthewidelyadoptedtextbookCog-
nitive Therapy: Basics and Beyond, which has been translated into 12 lan-
guages; coauthor of Cognitive Therapy of Personality Disorders, Second Edi-
tion; and coeditor of the Oxford Textbook of Psychotherapy. She has also
written numerous articles and chapters on various applications of cogni-
tive therapy. Dr. Beck is the current President of the Academy of Cogni-
tive Therapy.
vi
Foreword
ThisvolumebyDr.JudithS.Beckisamajorcontributiontotheliterature
addressing cognitive therapy with patients who have difficult problems.
Through her own work with patients and her supervision of other thera-
pists,Dr.Beckhasbeenabletodelineatethetypicalproblemsthatthwart
the progress of therapy and discourage therapist and patient alike. Until
fairly recently these problems were considered manifestations of “resis-
tance,” “negative transference reactions,” or “passive–aggressive tenden-
cies” by many therapists. In response, many therapists are inclined to
simplythrowuptheirhandsinfrustration,notknowingwhattodonext.
Instead of yielding to these obstacles in therapy, Dr. Beck has consis-
tently reframed these difficulties as identifiable, well-recognized prob-
lems with specific boundaries and characteristics. By categorizing the
problemsintospecificdomains,shehasprovidedareadilyavailablekeyto
theircomplexities.Dr.Beckhasthusdrawnonhervastexperiencetoout-
line the appropriate approach for each of the difficulties: (1) conceptual-
izing the problem in terms of the patient’s developmental history, core
beliefsandassumptions,anddysfunctionalcognitionsandbehaviors,and
(2) designing relevant strategies and techniques to solve the problem.
Sinceeachproblemisdifferent,itisnecessaryfortherapiststoadapttheir
therapeutic strategies accordingly, as artfully outlined in this volume.
The burden on the therapist was not always as heavy. In the early
years of cognitive therapy, we were able to focus simply on our patients’
here-and-now problems and prescribe relevant techniques. For depressed
patients, this consisted of behavioral activation through activity schedul-
ing, completing dysfunctional thought records, and engaging in practical
problemsolving.Ingeneral,thedepression(oranxietydisorder)haddis-
appeared by the 10th session and we scheduled one more simply for
relapseprevention(Rush,Beck,Kovacs,&Hollon,1977).Astimepassed,
vii
viii Foreword
however,thedurationofsessionsforpatientswithcomorbiddisordersor
complex or chronic problems (such as those described in this book)
extended to 15, 20, 25, or even more sessions.
The patients began to receive the diagnosis of personality disorder
in addition to their depression, anxiety, or panic disorder. Today the
average patient seeking treatment at the Beck Institute for Cognitive
Therapyisreceivingatleasttwopsychotropicmedicationsandpresentsa
history of limited response to pharmacotherapy or previous psychothera-
py. At the core of this relative impermeability to therapy is the diverse
array of therapy problems so beautifully described by Dr. Beck.
Wherehaveallthe“easycases”gone?Wehavepuzzledoverthismys-
tery for some time. Our hunch is that most patients respond reasonably
well to their first-line treatment—by primary care doctors or psycho-
pharmacologists. The relative nonresponders eventually may be referred
for cognitive therapy, which now represents a secondary—or even a
tertiary—level of care. As reconceptualized by Dr. Beck, the problems of
the patients in this group represent a challenge rather than a burden to
the psychotherapist. She has succeeded admirably in showing the thera-
pist how to meet this challenge as well as to relieve the burden.
Of course, I cannot complete this introduction without acknowledg-
ingmyspecialrelationshiptoDr.JudithBeck.Asisgenerallyknown,she
was practically born into cognitive therapy. By the time she reached ado-
lescence, my theory and practice of cognitive therapy had pretty much
crystallizedbuttherewaspracticallynobodywithwhomIcouldcheckout
myideas.SoItriedthemoutonmyteenagedaughter,whoreassuredme,
“They make good sense, Dad.” I made no efforts to encourage her to fol-
low in my footsteps. After college she embarked on a successful career in
special education. However, I imagine that cognitive therapy still “made
goodsense”sinceshedecidedtomakeacareershiftintoclinicalpsychol-
ogy with a specialty in cognitive therapy. I am particularly proud of her
first volume, Cognitive Therapy: Basics and Beyond, designed primarily for
beginningcognitivetherapists,andthepresentvolumeforadvancedcog-
nitivetherapists.Bothvolumeswill,Iamcertain,beaboonfortherapists
and patients alike.
AARON T. BECK, MD
REFERENCE
Rush,A.J.,Beck,A.T.,Kovacs,M.,&Hollon,S.(1977).Comparativeefficacyof
cognitivetherapyandimipramineinthetreatmentofdepressedoutpatients.
Cognitive Therapy and Research, 1, 17–37.
Acknowledgments
How lucky I am to have Aaron Beck as my father, mentor, and teacher.
Obviously I would not have written this book without his development of
the field of cognitive therapy. Reading his collected works; discussing
research, theory, and practice with him; observing him treating patients;
watching him teach; and reviewing cases with him have helped shape my
developmentasacognitivetherapypractitionerandteacher.I,likecount-
lessmentalhealthprofessionalsandclients,owehimanenormousdebtof
gratitude.
Many other individuals have also played an important role in the
writing of this book. First there are my primary coaches, cheerleaders,
and feedback providers: my mother, Phyllis Beck; my friend, colleague,
andright-handwoman,NaomiDank;myhusband,RichardBusis.I’dalso
like to acknowledge my children, Sarah, Debbie, and Sam, who managed
to grow up in the many years it took me to write this book; they don’t
know how much I’ve learned from them.
IalsoowethankstomycolleaguesAndrewButler,NormanCotterell,
Leslie Sokol, and Chris Reilly at the Beck Institute. Discussing cases with
them over the past 10 years has helped me sharpen my thinking and
expand my horizons. My colleague Cory Newman made many valuable
suggestions that enriched the manuscript, as did my extremely patient,
kind, and very helpful editor and friend, Kitty Moore, of The Guilford
Press. I am also grateful to my patients, supervisees, students, and the
innumerableworkshopparticipantswhoprovidedmewithcaseexamples
of challenging problems.
ix