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Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD

New Study (1)Abstract

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.

 

Mott, J.M., Mondragon, S., Hundt, N.E., Beason-Smith, M., Grady, R.H., & Teng, E.J. (2014).Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. Journal of Traumatic Stress, 27(3), 265-273.doi: 10.1002/jts.21927.

Workshop Participant Spotlight – Sandra Pasek

Traveling to Beck Institute from Poland, Sandra Pasek works as a psychologist and life coach treating individuals with health issues. She is currently interested in incorporating CBT into her work of implementing holistic health in Poland because “CBT is proven, scientific, and you can see the results.”

 

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Sandra was excited to attend this workshop, CBT for Weight Loss and Maintenance because it focused on many of her interests that dieters struggle with across the world, such as coping with stress, losing weight, and maintaining healthy lifestyles. “No matter the country and geographic location, people all around the world face the same issues.”

 

Ms. Pasek enjoyed that this workshop used actual client examples to illustrate using structured treatment to help dieters avoid getting off track and maintain a weight loss plan. “I liked the real-life examples; it wasn’t just theoretical.” From this workshop, she learned help dieters “focus on what [they] did right” and give themselves credit for positive food and exercise choices, motivating them to make more healthy decisions. “Weight loss is not magic, it takes focus and determination.”

Effects of Psychotherapy on Trauma-related Cognitions in Posttraumatic Stress Disorder: A Meta-Analysis

New Study (1)Abstract

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma-related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma-related cognitions has been lacking. Therefore, the goal of our meta-analysis was to determine which psychotherapy most effectively reduces trauma-related cognitions.

Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma-focused cognitive-behavioral therapy as compared to nonactive or active nontrauma-focused control conditions of Hedges’ g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma-related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring.

We concluded that trauma-focused cognitive-behavioral therapy effectively reduces trauma-related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.

 

Diehle, J., Schmitt, K., Daams, J.G., Boer, F., & Lindauer, R.J. (2014). Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis. Journal of  Traumatic Stress, 27(3), 257-264. doi: 10.1002/jts.21924.

Disrupting The Downward Spiral of Chronic Pain and Opioid Addiction With Mindfulness-oriented Recovery Enhancement: A Review of Clinical Outcomes and Neurocognitive Targets

New Study (1)Abstract

Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.

 

Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.

Workshop Participant Spotlight – Dr. Ignacio Etchebarne

Dr. Ignacio Etchebarne

Dr. Etchebarne works as a clinical psychologist treating adults with anxiety and performs psychotherapy research. He is currently developing a research program in Argentina about CBT for Personal Growth. He was so excited to (finally) come to Beck Institute after completing supervision and consultation with multiple Beck Institute staff.

He combined this training, Teaching and Supervising CBT, with his presentation next week at the Society for Psychotherapy Research conference at the University of Pennsylvania, which has a theme of “Psychotherapy: improving adaptation from the inner life to the outer world.” His presentation will focus on psychotherapy for personal growth.

This workshop came at the perfect time for him, because he plans to begin providing supervision to new therapists. “I’m eager to start doing everything I learned” “This workshop is a must if you want to learn how to provide evidence based supervision and teaching in CBT.”

“It’s been so good, I learned so much about teaching in general that took me by surprise. It was shocking in a good sense, I was unconsciously confident.”

Cognitive-Behavior Therapy for Menopausal Symptoms (hot flushes and night sweats): Moderators and Mediators of Treatment Effects

New Study (1)Abstract

OBJECTIVE:

Cognitive-behavior therapy (CBT) has been found in recent randomized controlled trials (MENOS1 and MENOS2) to reduce the impact of hot flushes and night sweats (HFNS). In the MENOS2 trial, group CBT was found to be as effective as self-help CBT in reducing the impact of HFNS. This study investigates for whom and how CBT works for women in the MENOS2 trial.

METHODS:

This study performed a secondary analysis of 140 women with problematic HFNS who were recruited to the MENOS2 trial: 48 were randomly assigned to group CBT, 47 were randomly assigned to self-help CBT, and 45 were randomly assigned to usual care. Self-report questionnaires were completed at baseline, 6 weeks postrandomization, and 26 weeks postrandomization. Potential moderators and mediators of treatment effects on the primary outcome-hot flush problem rating-were examined using linear mixed-effects models and path analysis, respectively.

RESULTS:

CBT was effective at reducing HFNS problem rating regardless of age, body mass index, menopause status, or psychological factors at baseline. Fully reading the manual in the self-help CBT arm and completing most homework assignments in the group CBT arm were related to greater improvement in problem rating at 6 weeks. The effect of CBT on HFNS problem rating was mediated by changes in cognitions (beliefs about coping/control of hot flushes, beliefs about night sweats and sleep) but not by changes in mood.

CONCLUSIONS:

These findings suggest that CBT is widely applicable for women having problematic HFNS, regardless of sociodemographic or health-related factors, and that CBT works mainly by changing the cognitive appraisal of HFNS.

 

Norton, S., Chilcot, J., & Hunter., M.S. (2014). Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): moderators and mediators of treatment effects. Menopause, 21(6), 574-578. doi: 10.1097/GME.0000000000000095.

Core Beliefs and Assumptions in Posttraumatic Stress Disorder: A Case Example

Norman Cotterell, Ph.D.

Beck Institute for Cognitive Behavior Therapy

Mike, a 49 year old production packer, was involved in an accident and suffered 3rd degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh. 

Posttraumatic Stress Disorder (PTSD) refers to a problematic and prolonged response to traumatic events. Ehlers and Clark (2000) note its puzzling nature, identified by both inattention and hyper-arousal, by memories that won’t go away and others that cannot be found, and by both recklessness and an excessive desire for safety. Rothbaum (2006) describes it as a failure of natural recovery.

Mike’s initial response is matter-of-fact. He tells his wife, “Everything is fine.” He makes it through surgeries and skin grafts without much overt difficulty. But he doesn’t own up to any emotional distress. So he misses out on the emotional support that could have helped him process the trauma. Why does he fail to reveal his feelings? One key belief he holds is, “If I reveal any vulnerability, people will lose faith in me and view me as weak.”

Shortly after the medical procedures are finished, Mike experiences cognitive intrusions: flashbacks and nightmares. While these intrusions are distressing, what is more distressing is the special meaning he puts to them. “[They show] I can’t control my own mind.” Dissociative amnesia is further evidence to Mike of his loss of control.

His perceived loss of control leads to Mike’s experiencing intense and distressing negative emotions. He feels highly anxious, sad, and ashamed. “I should be able to cope. I’m weak.” The experience of negative emotion, too, leads Mike to feel out of control. His core beliefs — “I’m out of control. I’m helpless. I’m weak. I can’t function” — become fully activated. He sees himself as being in grave danger, not from an external threat, but from one that he cannot escape. No matter where he goes, his mind goes with him. Mike adopts a battlefield mentality. He is alert, on-guard, aggressive, unable to sleep. Because he views this extreme mentality as unwarranted(“It’s only a burned hand!“) — he takes these symptoms as proof of his weakness.

Mike also engages in extensive behavioral avoidance. He believes he must avoid all that he loves, or risk tainting it with insanity. He also engages in emotional avoidance through the use of alcohol. But avoidance fuels his belief of weakness. He is in a double bind: “If I avoid, I’m in control, I can function. But If I avoid, it means I’m helpless, defective, out of control. But if I don’t avoid, I’m in danger.”

To summarize, when individuals develop PTSD, they put dysfunctional meanings to their symptoms: intrusions, cognitions, emotions, avoidance, and arousal, among others. Their dysfunctional behaviors and the intensity of their emotions are understandable once we grasp the assumptions they are making. Their assumptions make sense once we comprehend the core beliefs that have become activated. The trauma itself doesn’t directly lead to PTSD; rather it is the meanings they attribute to the trauma, to their cognitive, emotional, physiological, and behavioral symptoms, and to their changed circumstances that are more closely tied to the development of the disorder.

Readings:

Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy 38, 319-345.

Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD. Oxford: Oxford University Press.

Morris, D. (2015). The Evil Hours. New York: Houghton Mifflin Harcourt.

Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321 – 329.

Rothbaum, B.O. (2006). Virtual Vietnam: Virtual Reality Exposure Therapy. (2006). In M. Roy (Ed.), Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Amsterdam: IOS Press.

US Dept of Veteran’s Affairs: How common is PTSD? PTSD: National Center for PTSD. (n.d.). Retrieved May 26, 2015, from http://www.ptsd.va.gov/PTSD/public/PTSD-overview/basics/how-common-is-ptsd.asp

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Are you currently using CBT to treat clients with PTSD? Does this case study resonate with you? Share your experiences on our Beck Institute Facebook page.

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