Origins of Dr. Aaron Beck’s Theory of Depression

During a recent Beck Institute Workshop, Dr. Aaron Beck discusses the origins of his theory of depression. He then describes several research techniques he employed to test the psychoanalytic hypothesis that depression is caused by inverted hostility.

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Modified Illness Perceptions Questionnaire Predicts Response to CBT for Psychosis

OBJECTIVE: Clinical responsiveness to cognitive behavioural therapy for psychosis (CBTp) varies. Recent research has demonstrated that illness perceptions predict active engagement in therapy, and, thereby, better outcomes. In this study, we aimed to investigate the psychometric properties of a modification of the Illness Perceptions Questionnaire (M-IPQ) designed to predict response following CBTp.

METHODS: Fifty-six participants with persistent, distressing delusions completed the M-IPQ; forty before a brief CBT intervention targeting persecutory ideation and sixteen before and after a control condition. Additional predictors of outcome (delusional conviction, symptom severity and belief inflexibility) were assessed at baseline. Outcomes were assessed at baseline and at follow-up four to eight weeks later.

RESULTS: The M-IPQ comprised two factors measuring problem duration and therapy-specific perceptions of Cure/Control. Associated subscales, formed by summing the relevant items for each factor, were reliable in their structure. The Cure/Control subscale was also reliable over time; showed convergent validity with other predictors of outcome; predicted therapy outcomes; and differentially predicted treatment effects.

LIMITATIONS: We measured outcome without an associated measure of engagement, in a small sample. Findings are consistent with hypothesis and existing research, but require replication in a larger, purposively recruited sample.

CONCLUSIONS: The Cure/Control subscale of the M-IPQ shows promise as a predictor of response to therapy. Specifically targeting these illness perceptions in the early stages of cognitive behavioural therapy may improve engagement and, consequently, outcomes.

Marcus, E., Garety, P., Weinman, J., Emsley, R., Dunn, G., Bebbington, P., Freeman, D., … Jolley, S. (December 01, 2014). A pilot validation of a modified Illness Perceptions Questionnaire designed to predict response to cognitive therapy for psychosis. Journal of Behavior Therapy and Experimental Psychiatry, 45, 4, 459-466.

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Integrating New Wave Therapies and CBT

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck discusses how new wave therapies can be integrated into the cognitive therapy (CT) framework. Dr. Beck describes when it is helpful to utilize newer strategies that encompass for example, acceptance and commitment therapy, mindfulness, and dialectical behavior therapy. Dr. Beck emphasizes the importance of using these strategies within the general theoretical model of CT and specific case formulation of the disorder in order to address patients’ specific needs based on their individual case conceptualization.

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Mental Imagery in Bipolar Affective Disorder versus Unipolar Depression during Times of ‘Positive’ Mood

OBJECTIVE: Compared to unipolar depression (UD), depressed mood in bipolar disorder (BD) has been associated with amplified negative mental imagery of the future (‘flashforwards’). However, imagery characteristics during positive mood remain poorly explored. We hypothesise first, that unlike UD patients, the most significant positive images of BD patients will be ‘flashforwards’ (rather than past memories). Second, that BD patients will experience more frequent (and more ‘powerful’) positive imagery as compared to verbal thoughts and third, that behavioural activation scores will be predicted by imagery variables in the BD group.

METHOD: BD (n=26) and UD (n=26) patients completed clinical and trait imagery measures followed by an Imagery Interview and a measure of behavioural activation.

RESULTS: Compared to UD, BD patients reported more ‘flashforwards’ compared to past memories and rated their ‘flashforwards’ as more vivid, exciting and pleasurable. Only the BD group found positive imagery more ‘powerful’, (preoccupying, ‘real’ and compelling) as compared to verbal thoughts. Imagery-associated pleasure predicted levels of drive and reward responsiveness in the BD group.

CONCLUSIONS: This study reveals BD patients experience positive ‘flashforward’ imagery in positive mood, with more intense qualities than UD patients. This could contribute to the amplification of emotional states and goal directed behaviour leading into mania, and differentiate BD from UD.

Ivins, A., Di, S. M., Close, H., Goodwin, G. M., & Holmes, E. (September 01, 2014). Mental imagery in bipolar affective disorder versus unipolar depression: Investigating cognitions at times of ‘positive’ mood. Journal of Affective Disorders, 166, 12, 234-242.

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Validation for Patients with Borderline Personality Disorder

During a recent Beck Institute Workshop, Dr. Aaron Beck explains that in recent years eastern philosophies and religions have had an increased influence on CBT and which have been incorporated into mindfulness based cognitive therapy, acceptance and commitment therapy, and dialectic behavior therapy. In discussing DBT, he emphasizes the importance of validation with borderline personality disorder patients.

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Computer-Assisted CBT (CBT4CBT) is Effective for Cocaine-Dependent Individuals on Methadone

OBJECTIVE: A previous pilot trial evaluating computer-based training for cognitive-behavioral therapy (CBT4CBT) in 77 heterogeneous substance users (alcohol, marijuana, cocaine, and opioids) demonstrated preliminary support for its efficacy in the context of a community-based outpatient clinic. The authors conducted a more definitive trial in a larger, more homogeneous sample.

METHOD: In this randomized clinical trial, 101 cocaine-dependent individuals maintained on methadone were randomly assigned to standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT, with seven modules delivered within an 8-week trial.

RESULTS: Treatment retention and data availability were high and comparable across the treatment conditions. Participants assigned to the CBT4CBT condition were significantly more likely to attain 3 or more consecutive weeks of abstinence from cocaine (36% compared with 17%; p<0.05, odds ratio=0.36). The group assigned to CBT4CBT also had better outcomes on most dimensions, including urine specimens negative for all drugs, but these reached statistical significance only for individuals completing the 8-week trial (N=69). Follow-up data collected 6 months after treatment termination were available for 93% of the randomized sample; these data indicate continued improvement for those assigned to the CBT4CBT group, replicating previous findings regarding its durability.

CONCLUSIONS: This trial replicates earlier findings indicating that CBT4CBT is an effective adjunct to addiction treatment with durable effects. CBT4CBT is an easily disseminable strategy for broadening the availability of CBT, even in challenging populations such as cocaine-dependent individuals enrolled in methadone maintenance programs.

Carroll, K. M., Kiluk, B. D., Nich, C., Gordon, M. A., Portnoy, G. A., Marino, D. R., & Ball, S. A. (April 01, 2014). Computer-assisted delivery of cognitive-behavioral therapy: Efficacy and durability of cbt4cbt among cocaine-dependent individuals maintained on methadone. American Journal of Psychiatry, 171, 4, 436-444.

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Practical Solutions for CBT Training and Certification

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck and Dr. Judith Beck discuss CBT training and certification in countries with vigorous, and often impracticable standards for CBT certification. As a practical solution, Dr. Judith Beck proposes a step wise training program for basic to advanced levels of certification and a corresponding triage system for patients.

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Pilot Study: Web-based CBT Adheres to Professional Practice Standards and Outcomes

Background: The primary objective of this pilot study was to demonstrate reliable adherence to a group cognitive behavioral (CBT) therapy protocol when delivered using on-line video conferencing as compared with face-to-face delivery of group CBT. A secondary aim was to show comparability of changes in subject depression inventory scores between on-line and face-to-face delivery of group CBT.

Methods: We screened 31 individuals, 18 of whom met the criteria for a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) diagnosis of mood and/or anxiety disorder. All qualifying participants had the necessary equipment (computer, webcam, Internet) for participation in the study, but could exercise their preference for either the on-line or face-to-face format. Eighteen completed the 13 weekly session intervention program (ten face-to-face; eight video conferencing). We coded adherence to protocol in both intervention formats and generated pre–post changes in scores on the Beck Depression Inventory Second Edition (BDI-II) for each participant.

Results: Application of the CBT protocol coding system showed reliable adherence to the group CBT intervention protocol in both delivery formats. Similarly, qualitative analysis of the themes in group discussion indicated that both groups addressed similar issues. Pre–post intervention scores for the BDI-II were comparable across the two delivery formats, with 60% of participants in each group showing a positive change in BDI-II severity classification (e.g., from moderate to low symptoms).

Conclusion: This pilot study demonstrates that group CBT could be delivered in a technology-supported environment (on-line video conferencing) and can meet the same professional practice standards and outcomes as face-to-face delivery of the intervention program.

Khatri, N., Marziali, E., Tchernikov, I., & Sheppard, N. (May 01, 2014). Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: a pilot study. Clinical Interventions in Aging, 765.

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CBT for Health Anxiety: A Meta-Analysis of Treatment Outcome and Moderators

The present investigation employed meta-analysis to examine the efficacy of cognitive-behavioral therapy (CBT) for hypochondriasis/health anxiety as well as potential moderators that may be associated with outcome. A literature search revealed 15 comparisons among 13 randomized-controlled trials (RCTs) with a total sample size of 1081 participants that met inclusion criteria. Results indicated that CBT outperformed control conditions on primary outcome measures at post-treatment (Hedges’s g = 0.95) and at follow-up (Hedges’s g = 0.34). CBT also outperformed control conditions on measures of depression at post-treatment (Hedges’s g = 0.64) and at follow-up (Hedges’s g = 0.35). Moderator analyses revealed that higher pre-treatment severity of hypochondriasis/health anxiety was associated with greater effect sizes at follow-up visits and depression symptom severity was significantly associated with a lower in effect sizes at post-treatment. Although effect size did not vary as a function of blind assessment, smaller effect sizes were observed for CBT vs. treatment as usual control conditions than for CBT vs. waitlist control. A dose response relationship was also observed, such that a greater number of CBT sessions was associated with larger effect sizes at post-treatment. This review indicates that CBT is efficacious in the treatment of hypochondriasis/health anxiety and identifies potential moderators that are associated with outcome. The implications of these findings for further delineating prognostic and prescriptive indicators of CBT for hypochondriasis/health anxiety are discussed.

Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A. J., & Powers, M. B. (July 01, 2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58, 10, 65-74.

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The Future of CBT

At a recent Beck Institute Workshop, Dr. Aaron Beck discusses the future status of CBT. Dr. Beck proposes that there will be one overarching theory based on the cognitive model with information from other disciplines, and empirically supported treatment methods for each disorder. Using the example of Chronic Fatigue Syndrome, he provides his vision of a triage model that would be used to determine level of care to treat patients with various disorders.

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