In this episode of Practice Matters, Rachel is joined by Professor Judith Beck, President of the Beck Institute for Cognitive Behaviour Therapy and one of the most influential voices in the field.

Judith discusses her personal and professional journey into CBT, the legacy of her father Aaron T. Beck, and the evolution of cognitive therapy from its traditional roots to recovery-oriented cognitive therapy (CT-R). Judith also shares insights on the importance of the therapeutic relationship, strategies for validating clients, managing hopelessness, and adapting CBT across cultures and how therapists can look after themselves, continue learning, and stay connected.

Resources and links mentioned in this episode:

• Beck Institute for Cognitive Behavior Therapy
• Subscribe to the Beck Institute newsletter
• Cognitive Behavior Therapy: Basics and Beyond (3rd edition, 2021) by Judith S. Beck

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If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy.

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This podcast was edited by Steph Curnow

Transcript:

Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioral therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, I'm really delighted to be joined by Professor Judith Beck. Professor Beck is president of the Beck Institute for Cognitive Behavior Therapy and clinical professor of psychology and psychiatry at the University of Pennsylvania Perelman School of Medicine. She has published prolifically on CBT, including key texts that are to be found on the bookshelves of almost every CBT therapist with a desire to hone their craft. And they really do guide us through the basics and beyond.

Judy, welcome to the podcast.

Judith Beck: Thank you for having me.

Rachel: I’m fortunate to have met you previously during a brief period of study at the Beck Institute many moons ago now. However, I imagine that I feel about spending time talking to you about CBT the same way normal people might feel about chatting to celebrities, given that of course your CBT royalty, your father being Aaron T. Beck, also widely regarded as the father of CBT and that you've worked so closely with him to develop the field. It might perhaps seem inevitable given that background that you would end up in this work, but you clearly could have chosen any number of career pathways. Can you tell us a little bit about your personal and professional journey to where you are now?

Judith Beck: So I've always loved children. And when I was probably six or seven, I decided that I wanted to be a teacher. And so when I went to the University of Pennsylvania, I studied education to become a teacher, but I took a lot of psychology courses as well. And I taught kids with learning disabilities for a while and then decided that if I wanted to have a career or met my career as a teacher, I really had to go back and get a professional degree, a master's degree. And so I went back to school and got a master's in educational psychology. Then worked as a supervisor for a little while and decided that I should really probably get a PhD. And it was toward the beginning of my PhD program that I became more interested in psychology and in my father's work. And I really think that I must have been at least subliminally influenced by my dad when I was a teacher and when I was a supervisor. At the beginning when I started to consider going into this field, I had kind of a naive idea and it was an automatic thought. I thought, I just don't know if I'm cut out to be a psychologist because I've always been such an intuitive teacher. I didn't really need someone to teach me how to teach, especially when it came to teaching kids with learning disabilities. It was just quite natural for me to know how to take something that was complicated and break it down and speak to my young students in a way that they could understand. So I thought, how could I learn to be a psychologist? I'm not intuitive at all about how to do that.

Rachel: So if it requires some learning, then it can't be for me.

Judith Beck: That was my thought at the time. And fortunately it turned out to be wrong. And then I started to learn really in detail about my dad's work, and it all made so much good sense to me. And what's interesting is that I've really come full circle. For a while, especially at the beginning, I was primarily a CBT therapist. But then I really became a CBT teacher. And most of my activities now, or many of my activities at the Beck Institute have to do obviously with training and teaching other people to use CBT.

Rachel: So you started by integrating psychology into your education and you've come full circle in now you're integrating education into your psychology.

Judith Beck: That's right. You sometimes people draw interesting conclusions. More than a couple of people have said, well, you probably didn't go into psychology initially because that's what your father was doing. And I said, no, no, no, it wasn't a reaction to my father. It was just that I was always drawn to working with young children. And that's what I did as a teacher.

Rachel: When talking about families, I've often spoken on this podcast previously about how as both a psychologist and a mother, I hope that my professional skills give me skills and insights as a parent that I might not otherwise have. But mostly it feels like I'm just more aware of the many, many ways in which I'm failing as a parent and setting my kids up with all kinds of dysfunctional assumptions about how the world works. I wonder how it was growing up in the Beck household. Was there lots of practice and reflection on CBT principles?

Judith Beck: Well, I grew up in the late 1950s and 1960s and I didn't go to university until 1971. And it was really through the later 60s and into the 70s that my father was developing cognitive therapy. But my parents had a very traditional marriage. My father worked all of the time and my mother who actually went to, did something extraordinarily unusual. She went to law school when she had four kids under the age of 10. There were three women in her very large class. Women just didn't do that in those days. It was starting in probably 1961 or 62. Despite the fact that she was in school and then developing her own career, she really had probably 90 % of the care of the kids and the household and organization and so forth. We did have dinner every night, though, as a family. My father stopped work long enough to do that. But we didn't really talk about his work very much. There was one memory that I have that I've told a number of people about, that's when I was someplace around 10, 11, 12 years old. And my father said, Judy, I have a new idea I'd like to run by you. And then he described the cognitive model. That's not a situation that directly influences your reaction, but rather your interpretation of that situation, the thoughts that go through your mind. And so he told me that, and he gave me an example. And he said, what do you think? And what I said out loud to him was, well, yes, that makes sense. But in my own mind, my automatic thought was but that's so obvious. So I think I probably began thinking like a cognitive therapist fairly early on, although we really rarely discussed his work. I knew my both parents were unusual, my mother being in school and becoming a lawyer. And I knew my dad was unusual because he wrote books. And I didn't have any friends who's fathers or mothers wrote books.

Rachel: To be fair, I think I've got teenage boys and most of what I say either seems extremely obvious to them or totally ridiculous. I mean, at the other extreme, but it's lovely to hear about your mother as well. Cause obviously we all know so much about your father's work, but obviously two very inspirational, hardworking parents who, you know, work with a love of learning and an interest in doing things in the world. So fantastic. Well, glad he got past you, Judy, because if you'd said it sounds like rubbish, maybe we never would have had CBT. So I'm glad you were one of the first audiences.

Now, regular listeners to the podcast will by now be familiar with our podcast challenge. We love a good formulation here at Practice Matters in good CBT style, but because we're an audio podcast, it has to be done unlike almost everything we do in CBT without boxes or arrows or other visual aids. So here's your challenge. Can you give us a brief explanation of how the cognitive model explains psychological distress develops and is maintained without any of those aids.

Judith Beck: Sure, so the first thing I want to say is that automatic thoughts do not cause depression. Depression is caused by so many different factors and it's important to take a biopsychosocial view of the development of depression. Automatic thoughts are probably an important precipitating factor among others that ultimately lead to the development of depression. I'm just gonna use depression as an example. But the automatic thoughts don't themselves cause depression. Okay, so the easiest way to talk about a formulation is by presenting a case. So I'll do that very quickly. I had a patient who lived in the Midwest in the United States and her husband got a job in Philadelphia. So they moved a thousand miles away to Philly and she was really struggling. She had so many losses. She lost the physical and emotional proximity to her parents and her sisters to whom she was really close. The same goes with her small but tight-knit group of friends. She lost her church and her church community. She obviously lost her job because she had moved. She lost the kind of the comfort and the safety of the apartment that they had been living in and the neighborhood. And then she moved to Philadelphia where she doesn't know anybody, where the neighborhood isn't nearly as safe, where she doesn't have a job, where she doesn't have family nearby, where she doesn't have a church in that community. And she really feels the losses very deeply and becomes very sad and is overwhelmed by the thoughts of what she has lost and how she can't regain them. She makes a few attempts to integrate into her new community. She gets a job at a nearby shop, but she gets fired after a couple of months because it really was a poor match for her skills. She and her husband look around but can't really find a church that they feel comfortable in. She tries a little bit to meet her neighbors, but they just seem very unfriendly to her. And then she begins to really isolate herself. She begins to avoid things like going out. She even starts avoiding going to the grocery store, so she doesn't feel quite safe leaving the apartment without her husband. And then ultimately she becomes depressed. Once she's depressed, these maintaining factors of avoidance and isolation keep the depression going. So when I first started to see her, of course I do a thorough evaluation and in the very first session and in part of the evaluation as well, I start to hear her automatic thoughts. So her husband comes home and says he has found out that there is another store nearby where she might be able to get a job and she thinks, but if I get that job, I'll just fail at it. And she felt very sad and then her behavior was not to get the job. Why did she have that thought? Well, she had that thought because when she lost the first job that she had tried in Philadelphia, and in fact, she had had some similar experiences when she had lived in the Midwest, her belief of incompetence got activated. And this is a very painful belief to have. And so it makes sense then that she would avoid activities where she thought that she might fail. And the way that we understand the connection between these core beliefs and these coping strategies, these unhelpful patterns of behavior are in our intermediate beliefs, especially her assumptions.

One of her broad assumptions was if I try to do anything challenging or difficult I'll fail at it because I'm so incompetent. Another kind of key automatic thought this is the last one that I'll get because you said to be brief. Her husband and she get invited to a dinner by one of his co-workers and when he tells her about it, she thinks Well, what's the use of going? I have nothing to offer other people. I have nothing to say. I won't fit in. I'll just have a terrible time. Again, she felt very sad, and she really wanted to avoid going. Why did she have that thought? Well, it's because she really had some very deep doubts about herself. She had a core belief of unlovability that got activated when they moved to Philadelphia. And again, we could see some just roots of how this started given some childhood and teenage experiences that she had. So her belief that she is unlovable gets activated. Her specific belief was, I don't fit in. But once that belief got activated, then you saw again a lot of avoidance and isolation. And her belief was if I try to interact with other people, they'll just see that I'm so unlikable or that I have nothing to offer them, that I just don't fit in. So in this way, the depression gets maintained when she's even aware of these automatic thoughts, which is sometimes before treatment starts, but certainly much more after treatment starts. When she even became aware of her automatic thoughts, she didn't think to question them, she just accepted them as valid. And then they had a really profound effect on her emotions, on her behavior, and also on her physiology. She described how when she was feeling very depressed and sad and hopeless, her body just felt so heavy.

Rachel: So when those core negative ways in which we can view ourselves get activated by, as you said, in that situation, huge loss, we can get stuck in these patterns of thinking that just keep us there and maintain and those behaviors that maintain that.

Judith Beck: That's right.

Rachel: In preparation for talking to you, Judy, I invested in the third edition, as you know, of your seminal book, Cognitive Behavior Therapy: Basics and Beyond. Perhaps unfairly assuming that I would be almost over familiar with the content because, you know, I've read the first edition, you know, maybe for the first time about 20 years ago, genuinely have gone back to it time and time again. But what I actually found was there was so much more to digest and learn, particularly with respect to shift from what you term in the book, traditional CBT to recovery oriented cognitive therapy or CTR. Instead of going back to basics, it felt a little bit more like sort of back to the future. I was learning all the time reading through that. And I hope we'll dig into this throughout the podcast. But as a starting point, I wonder if you could articulate for our listeners the basics that have stayed the same. Are there immutable principles of the cognitive model and CBT that are sort of set in stone.

Judith Beck: Before I start, I think I should make a distinction between cognitive behavior therapy that's carried out by psychotherapists, psychologists, other mental health professionals, and CBT interventions, which are programs usually that use cognitive and behavioral techniques but don't necessarily do the whole therapy. But for now, I'll stick to what is immutable about cognitive behavior therapy. So there really are two things. One is you must have a very strong therapeutic relationship with the client. And if you don't, they may not come back to the next session or they may get very little from treatment. The other is you must conceptualize patients according to the cognitive model. So those two things are immutable. And because we don't limit ourselves to cognitive and behavioral techniques, if we're using a cognitive conceptualization, there may be a rationale for using techniques from any evidence-based treatment. So, for example, I will often use techniques from acceptance and behavior therapy or from dialectical behavior therapy, especially when clients engage in a dysfunctional thought cycle, such as rumination and depression or obsessive thinking or worry and anxiety disorders. So CBT is not defined by its use of cognitive behavioral techniques. It's defined by its reliance on the cognitive model as an organizing theory to help guide treatment

Rachel: So it's formulation or conceptualization driven techniques rather than technique driving therapy.

Judith Beck: within a strong therapeutic relationship, exactly.

Rachel: And we're going to return to the therapeutic relationship later on in the podcast. We’re looking forward to talking a bit more about that. One of the most obvious changes between the additions of your Basics and Beyond book is the title change from cognitive therapy to cognitive behavior therapy. What's developed do you think in our understanding of the importance of the B in CBT?

Judith Beck: Well, actually the B appeared in the second edition of Cognitive Behavioral Therapy: Basics and Beyond. And we were very much influenced by the term CBT as it was being used in the UK and in other places. And we realized that people were so much less familiar with the term cognitive therapy than cognitive behavior therapy. So I want to say two things about this. One is behavioral techniques were essential from the very beginning of cognitive therapy. And in fact, in one of his books in the mid-1960s, my father describes what we would now call behavioral techniques. And in his first real book about how to practice cognitive therapy of depression, he also very much emphasized behavioral activation and behavioral experiment. So the B is nothing knew. You know, I think if we had it to do over again, we probably should call it cognitive behavioral emotional therapy because so many people think that emotion is not an important part of the treatment when actually the whole reason we have the treatment is so that people can have an improved emotional response.

Rachel: It's often sort of an accusation here leveled at CBT. It's not really about the emotions. And as I mentioned earlier, there's a noticeable shift in what you explained in the overall emphasis of CBT. So it appears to have largely changed if I'm right in my reading in terms of time orientation. In fact, you make that quite explicit in how you describe that move from traditional CBT to recovery oriented cognitive therapy. So for those listeners who have yet to encounter that distinction, can you explain a little bit about the difference?

Judith Beck: Sure, let me just start with saying what recovery-oriented cognitive therapy is. So it was originally developed by my dad and Paul Grant, who's now our director of cognitive therapy recovery-oriented programs at the Beck Institute. And they developed it as a treatment for people with a diagnosis of serious mental illness, such as schizophrenia. And while they developed the treatment for individuals with schizophrenia of any severity, they really have focused a lot on how to adapt CBT so that it's appropriate for people who have been hospitalized. And they recognize that with this kind of patient, you obviously couldn't use more standard CBT techniques. And the first thing that they had to do was to figure out how to establish a good relationship with the patient. And that's really the major focus of the first part of treatment, along with helping patients draw positive conclusions about positive experiences. So a lot of the treatment has to do with engaging in positive experiences that the patient is interested in along with the therapist. So together they will listen to music, or they will play basketball or they'll walk to McDonald's. And as they're engaging in these positive experiences, the therapist really just engages in everyday human conversation with the patient. What they found was that when the patient is engaging in these pleasurable everyday activities with the therapist, the psychopathology tends to fall away, at least for that time when they're actually present with the therapist. After the activity, the therapist helps the patient draw positive conclusions about the experience. What did you think about our time that we spent at McDonald's? Did you find that you actually did have enough energy to walk there even though you didn't think that you would? Did you find that people were actually nice to you when you were there because I know you that you were a little bit concerned that they could be very mean to you Is this something you might like to do again? So this was this is just the beginning of what is done in a recovery orientation and the focus is much less on reducing the negative symptoms that the clients have, much less on reducing the psychopathology and much more on developing and reinforcing positive beliefs. And the notion of recovery means that we want patients to feel more connected, to feel safe and secure, to feel confident and empowered to have hope and purpose and real sense of meaning for their life. So the thrust of the therapy is a little bit different. We still work from the cognitive model. And now if I can talk for a minute about how I've translated this to working with outpatients who have depression, anxiety, PTSD, substance abuse, eating disorders, and so forth.

So I find that it's possible to shift at least to some degree away from reducing the psychopathology to increasing the focus on developing positive beliefs. And we do this in several different ways. One is, instead of when we're setting the agenda asking patients, what problem or problems do you want my help in solving today? We’re much more likely to say, are your goals for today's session? Or what's your goal for this week? Now the goal is really just the flip side of the problem. So the problem they might say is, I've been feeling so lonely. And the flip side of that is the goal is I'd like to interact more with people. So we set up in that way. We also ask when we ask for an update between the last session and this session, And patients almost always tell us the negative parts of it. I had actually started doing this, and I think mentioned this in the second edition of the Basics and Beyond book. It's very important to ask patients, so what are some of the positive things that happened between last session and this session? What positive interactions did you have with other people? What kinds of things were you able to get done? When did you feel even a little bit better? When did you have positive emotions? Anyway, we don't ask all of those questions, so we would ask some of those questions and then help patients draw conclusions about those experiences. We often will pick one of the experiences and try to get the patient to envision it again as if it's happening right now and try to get some of that positive emotion right in the session itself. Now I had actually recognized the importance of this long before I knew anything about recovery oriented cognitive therapy. Because I realized that when you ask people about their positive experiences, it puts them in a more positive mood, which makes them more conducive to participating with you in the therapy session.

Rachel: and able to be more creative and expansive and how they think.

Judith Beck: Absolutely. That's right. You're able to maybe consider other points of view more easily. And I didn't know what I was actually doing was helping them get into the adaptive mode. So in recovery oriented cognitive therapy, there's a very important distinction. And I think it really helps no matter what kind of patient you're working with to conceptualize when they are in the maladaptive mode, when their negative beliefs are activated when their expectations are negative and when they then engage in maladaptive behavior as opposed to the adaptive mode when their more positive beliefs are activated, when they have more positive expectations and then are able to behave in a more functional way. What I didn't know that I should do, which I now know, is to go further than just ask about the positive experiences but instead to help them draw conclusions about these experiences. So what does it say about you that you were willing to even try to go to your neighbor's party? What did it mean to you, a way about you, that some of the neighbors seemed friendly to you? What did it mean to you that you summoned the energy to be able to do something that you thought you just couldn't do? And so we help patients very indirectly try to develop and then strengthen their positive beliefs, particularly these positive beliefs about themselves, but also about other people in the world and the future. Okay, I'll just say one more application of recovery-oriented cognitive therapy to whatever kind of patient that you're seeing. And that is we tend to ask patients what steps- first of all, very early on in treatment, we help them identify what their values are, what's really most important to them in life. And we have them tell us what their aspirations are, what their big dreams are for their lives, how they really want their lives to be, how they really want to be in the future. And frequently we'll have them imagine a day in the future when they've achieved these aspirations and go through the day finding out what are they thinking, how are they have been feeling, what are they doing, so forth. So I'm setting the agenda with the patient and I'm saying what are your goals for today's session, what are your goals for this week? And then when we prioritize and when we get to the first one, I say, so if your goal is to feel more connected to people, what step or steps would you like to take this week? And then the, or, I'm more likely to say, what would it be good for you to take this week? And then I work this out with the patient and then we find out what obstacles could get in the way. And as they express the obstacles, that's when I'm using a CBT traditional conceptualization and techniques. So I have to conceptualize the obstacle that might get in the way, is this a problem at the situation level where we can do problem solving about it? Are there automatic thoughts that might get in the way? Do we need to address those thoughts, find out whether they're accurate and helpful or perhaps the opposite? Might they have such a strong emotional reaction that that would become, negative reaction that that would become an obstacle? Do we need to use some emotional regulation techniques here? Is there some behavior that would be good for them to engage in? That's part of the step that they want to take. But it's not that they have thoughts that would get in the way, but maybe they lack the skills, so we have to do some skills training. Or maybe this is an anxiety patient, and they will be overwhelmed with their physiological reaction and we have to do some psychoeducation about that and maybe teach them some techniques to quiet their body. So we use the more traditional CBT as we're helping them overcome obstacles to taking the steps that they want in this coming week.

Rachel: So I hear what you're saying. You're not sort of throwing out those core skills of traditional CBT of looking at those automatic thoughts or those skills deficits that people might have working through those. I can see that that sort of shift from even how you were describing starting out a session, you still have your update, but then you're asking about what's gone well, what's been good about this week. Is that ever challenging in terms of thinking about invalidating the struggle that people might have experienced? Often patients come wanting to talk about, this has all been so difficult. What do you find as you've made that shift that helps kind of refocus without invalidating, but rather sort of hope inspiring and motivating your patients?

Judith Beck: So it's very important that we're always aware of the patient's emotional reactions as they're sitting in session with us. And hopefully if they're feeling invalidated, we'll be able to pick that up. There'll be some expression on their face, their body language might change, their tone of voice or their choice of words might change and so forth. And if we do pick up that there's a negative reaction, most of the time we're probably going to stop and say, you're looking a little bit more distressed right now. What is just going through your mind? And hopefully they feel safe enough with us to say, well, I don't really like what you're saying. I feel invalidated or I think that you're not recognizing how difficult my life has been. And then the first thing that you should say as soon as you hear negative feedback, is it's good you told me that. And it is good that the patient told you that because if the patient is having negative thoughts about you, you need to know what they are so that you can solve the problem. Now sometimes there are automatic thoughts about you might be right and sometimes there are thoughts about you might be wrong, but you still need to say it's good that you told me that. When clients feel invalidated, it might be then you have to conceptualize how much you think they can tolerate. It might be a good idea to say, well, it's good you told me that. I'm sorry that it seems as if some of the questions I've just been asking you haven't been very helpful. Would it be okay if we switched to talking about blank instead? So I might do that in one case. In another case, I might say, would it be okay if I tell you why I've been asking you this question? And then I'd like you to decide whether you think I should continue doing that or whether you think that it's just not going to be helpful at all and we should do something else. So as any problem that comes up, first I have to gather some information about it, like finding out what the thoughts are, and then I have to conceptualize it and figure out what to do. So there are some patients who are so incredibly hopeless at the beginning of treatment, they're almost aggressively hopeless. And trying to do things like talking about their aspirations isn't going to get you very far. Now here's where recovery-oriented cognitive therapy comes in. When this happens, it's highly possible that the patient is in a maladaptive mode. So the patient's negative beliefs are highly activated, their expectations are highly negative, their predictions are highly negative and so they're going to engage in behavior that is probably unhelpful in therapy. So you think to yourself, okay, this patient's in the maladaptive mode, how could I get this patient into the adaptive mode? And one way of doing that is by changing the conversation completely and in fact becoming more conversational. You probably need to have a bridge before you get them talking about something that might bring them into the adaptive mode if they're being aggressively hopeless. So first you might need to really validate their negative experiences and of course they're going to feel this way. You can see how difficult these beliefs were. But you might be able to throw in a different question, such as, as a teenager when you're having all of these negative beliefs, was there someone in your life who seemed to be better than these other people? Who might some of those people have been? Did you have any friends or neighbors? Or maybe the parents of some of your friends was, were there some people in your community or maybe in your religious, in a religious setting or maybe some family outside of your immediate family. Was there anyone who's a little bit more positive? And can you tell me about some of your memories about that person? And as the patient begins recovering some positive memories, it's possible that that will get them into enough of an adaptive mode that you can go back to probably not talking about aspirations at this session, but back to doing some constructive work. So again, using the adaptive versus maladaptive mode as a conceptual framework, I think is also very useful. It's very hard to do work with clients when they are in an extremely negative maladaptive mode.

Rachel: I'm hearing as threads running all through that, that's staying very attuned to the emotion in the room, the therapeutic alliance, the collaborative process, really working together with the client, validating, but then the subtle shift, taking people into that different mode. You mentioned the shift in focus on values and aspirations and CBT always had goals at the start of the course of therapy. But it seems like there are these new steps, rather than going sort of directly from problems to goals, we're asking more about values and aspirations intervening. What's the rationale there, Judy? And can that be a bit of an ask when someone's very deeply depressed and maybe suffering from long-term mental health conditions to even know what their aspirations might be?

Judith Beck: Yes, especially if someone is suffering from a severe mental illness. The therapist probably isn't going to get to aspirations until kind of the middle part of treatment. The beginning part is just engaging, connecting, participating together in positive experiences, drawing positive conclusions. And the patient with serious mental health illness really needs to have a strong trust in the therapist before the therapist starts asking questions about aspirations and values. You can do it much more quickly usually with someone who's an outpatient. It is more difficult with someone who is constantly in a maladaptive mode, and you may need to wait until they start operating a little bit more in the adaptive mode. The reason for identifying values and aspirations is first of all it just gives you more insight into the patient and what's really important to the patient. But you can also then use it for motivation. So you might say, how would working on your resume fit into your values or your aspirations. Or you might say, does working on your resume fit in with your aspiration to be a nurse's aide in the future? So when you touch on, when you link up difficult changes the patient needs to make with why it's important to them personally to do it, they're more motivated to do it.

Rachel: it sort of debunks another myth I think about CBT that it's not person-centered, that somehow it's symptom centered.

Judith Beck: Yes. Yes.

Rachel: An important piece of intervention in your work is described as psychoeducation about depression as an illness rather than a personal failing. Sometimes as we develop the cognitive conceptualization, I've known patients to maybe misinterpret this as or processes through their maladaptive schema to suggest further evidence of failing. So it's my fault that my dysfunctional thinking or my inability or failure to implement positive coping strategies and responses to problems or negative thinking is bringing down my mood or retarding my progress or causing relapse. How do you maintain the focus on what a client can do to improve their mood whilst not inadvertently implying it's their fault that they're experiencing low mood?

Judith Beck: I think the way to do this is whenever you are conceptualizing for a patient to use words such as no wonder. So, well no wonder you didn't want to go to the dinner with your husband's co-worker. It makes perfect sense to me that when you had the thought I won't have anything to say, I won't fit in, I have nothing to offer them that of course that thought would make you feel sad and discouraged and then of course you wouldn't want to go. And it also makes perfect sense to me why you would have those thoughts in the first place. Can you see that almost anyone who had these kind of experiences in their childhood and when they were teenagers might grow up with an idea such as I don't fit in or I'm not very likeable? No wonder you developed that idea. It also makes sense to me that that idea must have been very painful and that one way you've tried to cope with those painful feelings is to isolate yourself and avoid a lot of social interaction. Do you think I got that right?

Rachel: It sounds so much less adversarial, much more, I'm putting myself in your shoes and understanding where this is coming from. And I know almost this could have happened to me.

Judith Beck: Yes, exactly.

Rachel: So those of us first in the traditional mode will be used to starting with lots of activity monitoring and scheduling and these spawning dozens of automatic thought records. You can end with a sort of thick file at the end of therapy with lots of these forms filled in. But one of the technical shifts in recovery-oriented CT appears to be that shift in emphasis from mood diaries, activity monitoring and ATRs towards problem solving and behavioural experiments? Is that right?

Judith Beck: That is true and it is especially true when someone has a really serious mental illness.

Rachel: I'm reminded when you're talking about the origins of the learning around the recovery-oriented CT of something that Helen Macdonald, who I know you know well is the Senior Clinical Advisor at the BABCP said to me recently about her background in mental health nursing. And they used to call the cognitive therapy, this is weekly therapy sessions, hit and run therapy. Whereas actually being with the clients all the time, you learn so much more about how that sits and what's happening moment to moment. And of course it makes perfect sense that there would be such rich learning that can then be translated back into our outpatient setting.

Judith Beck: Yes, but I also like to say that there have been randomized controlled trials that show that this more hit and run approach, that is the use of cognitive behavioral techniques without the whole cognitive conceptualization can really help people when it's delivered well.

Rachel: Could you say a little bit more about that? What you mean by the kind of without the cognitive conceptualization and how that might be applied?

Judith Beck: One of my favorite examples are the friendship benches in Zimbabwe. I'll give you two examples. Randomized control trials have shown that this use of cognitive behavioral interventions without the conceptualization has been effective. And this is what the program consists of. The researchers teach some of the older women in the community, people they call grandmothers, how to do some basic problem solving and activity scheduling. And then the grandmothers sit on a bench in the community, often near the health clinic, and people who are referred from the health clinic or just referred through word of mouth through people in the community come and sit on the bench, one by one and talk to the grandmother and the grandmother is really able to help them reduce their symptoms of depression and anxiety. They also, the grandmothers may encourage the person to go to a peer-run support group. Sometimes the support group has activities such as weaving baskets that then individuals can sell and make a little bit more pocket money. So here's the use of people within the community to deliver cognitive behavioral interventions that are effective. So that's one example. Another example is there have been a few randomized control trials in community programs in large urban cities in the United States to reduce gun violence. And they find that they need to use paraprofessionals who may not ever have graduated from high school even but who are members of the community, often they were gang leaders themselves. And they do a lot of outreach in order to try to get some gang members to come to the community center, where they teach them some basic cognitive and behavioral techniques. And they've been able to reduce gun violence in a statistically significant way.

Rachel: So, and it sounds like there's something important to both those examples about who is delivering the therapy.

Judith Beck: Yes, in many of the international kinds of programs like there is a WHO, a World Health Organization program in Pakistan and India that teaches mothers how to do some basic CBT techniques with new mothers who have postpartum depression.

Rachel: It leads nicely to think about cultural adaptions of CBT. You've articulated that the foundational cultural values and underpinning assumptions are sort of rationality, the scientific method and individualism. And I guess we can assume that those continue to predominate the approach at Beck Institute. You've also pointed out however, that alternative assumptions and values might predominate in other cultures, for example, emotional reasoning, emotional expression, collectivism or interdependence. So how well does CBT adapt for clients that are grounded in different cultures and is it as effective for everyone?

Judith Beck: So this is a research question and the research that I have read has shown that if CBT is appropriately adapted, that it can be just as effective.

Rachel: And what does appropriately adapted look like if that doesn't sound like a ridiculous question, because by definition, I guess that's different depending what's adapting to, but are there principles we can draw on?

Judith Beck: Well, yes, I think there are. And I think that the way that you start is by asking yourself a series of questions. If you have a client who's different from you, and it doesn't have to be a different culture, but different from you in any way, maybe a different gender identity, a different religion, a different socioeconomic status, a different age, a different academic achievement. In so many different ways, you need to ask yourself questions. But especially when they're from a different culture, you need to conceptualize both the positive strengths of that culture for this specific client, but also the negative impact of their culture on them. It may not be the negative impact of their own culture, although it could be it may be the negative impact of the wider culture, especially if they're not from the dominant culture of that community or of that country. And the basic question you need to ask yourself is, what do I already know about this client's culture? And what do I not know? And specifically about the client, what is this client's racial or cultural identity? I don't want to draw conclusions or I don't want to make assumptions about that without really knowing. What has their life history and their cultural history been? Have they faced structural barriers? If so, what impact did that have? What are their positive and their negative experiences related to all of these differences; culture and race and religion and age and so forth. How has culture affected their connection to their immediate community and to the wider community? And then how has their culture affected their beliefs about mental health, their beliefs about mental illness and how mental illness should be treated. Then in terms of a more traditional cognitive conceptualization, their beliefs about themselves, their world, their futures and other people. Also, how does their culture affect their values and their aspirations and their relationships? And then I think you need to ask yourself kind of based on this enhanced conceptualization, what changes might you need to make in terms of the therapeutic relationship, in terms of assessing this client, in terms of the structure of treatment, in terms of the nature of their action plan assignments between sessions. So I think that you start by having cultural humility, recognizing what you don't know or what you don't understand, and then spending the time to find out. It's also important to guard yourself against making microaggressions. So things that might upset the patients, that might not upset a patient who is of the same culture as you have. But then again, you just, need to watch for their negative reactions as they're sitting with you in the sessions and ask them what they were thinking and then positively reinforce them when they give you this negative feedback.

Rachel: So again, staying really attuned to the emotion in the room. Staying for a moment with the foundational values. I was very privileged to meet your father briefly at the Beck Institute and I asked him a question which judging from his reaction may have left him a little bit concerned about my ethical and moral framework. Let me explain. Considering the classification of dysfunctional core beliefs around helplessness, unlovability and unworthiness and the implicit faith within the work that we do have that every client is competent, lovable and worthy. I wonder on what grounds this faith in the verdict commas or confidence is based. When I asked your father, I remember he probably very wisely quoted the declaration of independence and truths that are self-evident about human beings. But just, and just to be clear, it's not that I'm in doubt about this or that I think my clients are a bunch of losers or something like that, but maintaining that sort of philosophical perspective, I'm curious, how would you answer that question? What are the underpinning assumptions about every individual's lovability, worth and competence based on? How can we always have that confidence?

Judith Beck: So I think a different question is a little bit better, which is how can we help clients develop their or better develop their confidence, their lovability and their worth? So I guess in saying that, it doesn't presuppose that they have a great deal of these qualities. But because human beings are always capable of growth, I think with very skilled therapists, they can help patients improve. Of course, we need to work on the things that the patient wants to work on. But I think that, you know, most people really want the same things in life. They want to feel empowered, respected, they want to feel connected to other people, they want to feel in control of their lives, they want to feel safe, and they want to feel successful. And it may be that in working toward these kinds of goals, you may be able to inspire them to behave in a way that is more lovable, confident, and or worthwhile.

Rachel: That makes a lot of sense, much like if someone is born into a very abusive environment, they might learn to behave in ways that don't appear in that light or draw the kind of responses that they would want from other people. And they're actually learning to work towards those would would inspire a different kind of behavior.

Judith Beck: Yes, think that's right.

Rachel: When we're thinking about the basics outlined in the Basics and Beyond book, they seem most consistently applied throughout the book to the depressed mood. But much of the structure and many of the techniques will be applicable across presentations. And in the UK, CBT is generally taught in terms of generic theoretical procedural principles, but with a strong emphasis on disorder specific models. What are your thoughts about this and the application of disorder specific versus more generic or transdiagnostic approaches in CBT?

Judith Beck: I think there are certain transdiagnostic principles that we use in CBT. Before we were talking about the importance of the therapeutic relationship and the cognitive conceptualization, there are other transdiagnostic practices such as structuring recession, focusing on specific problems or goals, using techniques and then teaching the techniques to the client for relapse prevention having the client do self-health activities between sessions that we used to call homework and that we now call the action plan because Americans don't like homework.

Rachel: Brits don't like it either

Judith Beck: So there are certain trans-diagnostic principles that we use. This also gives me the chance, I'm going to get to your question in a moment, but it also gives me the chance to say that the way that we teach CBT at the Beck Institute is not to use a treatment manual because treatment manuals aren't person-centered, as you mentioned before, and don't take the individual characteristics of the patient into consideration. One patient who presents with panic disorder may look quite different from another patient who's has panic disorder but is comorbid for substance abuse, for example. Treatment manuals don't generally teach you how to develop a strong therapeutic relationship either. So we think it's very important to always start with an individualized conceptualization of the patient. Having said that, it's very important to use the principles that have been established in research to be effective for specific disorders. So if I have someone who has a panic disorder and a substance abuse problem, I have to figure out with them, together with them, where we should start working. Now, they may want to work on the panic disorder first. I may think it's more important for them to reduce their substance use first or vice versa. In any case, I'm going to start if the patient has a strong desire where the patient wants and see how far we get with that. And if we don't get very far, then she might be willing to switch to what I think should go first. But it's very important for me to use the principles that research has established to be effective in treating both panic disorder and in treating substance abuse.

Rachel: And I think often one of the best ways we win the trust and develop the relationship with our clients, with them seeing some benefits from what we're doing, which of course comes often from doing those evidence-based approaches and they get some of the quickest progress in those areas, don't they?

Judith Beck: They do, and it's wonderful when they agree with you where the two of you should start working, but it doesn't always work out that way.

Rachel: And we've talked a little bit about this already, but one accusation that has been leveled against CBT over the years at times is that it is somehow a technical or mechanical application of techniques. And you very clearly said it's not about techniques, it's about the conceptualization and the techniques applied in service of moving people forward with their conceptualization in mind. But also that it doesn't pay enough attention to the interpersonal aspects of therapy or the use of the therapy relationship as a vehicle for change. From what you've been saying, and also, you know, have a whole chapter of that devoted to that in your book and your cognitive therapy for challenging problems book says a lot more about the therapeutic alliance and therapeutic relationship. You say it's where you start your teaching and you come back to ways in which the therapeutic relationship might create blocks or stuck points in therapy. Can you say a little bit more about the importance of the relationship in the model and how you do build that with your clients.

Judith Beck: Well, the first thing I want to say is that my father devoted an entire chapter to the therapeutic relationship in his very first book on CBT treatment, Cognitive Therapy for Depression, back in 1979. So it does drive me a little crazy when I hear the myth that CBT doesn't care about the therapeutic alliance because it was there from the very beginning. And then when I was one of the co-authors on cognitive therapy for Personality Disorders. We recognize this was in 1980, the absolute importance of having a strong focus on the therapeutic alliance with people who have personality disorders because they bring such distorted views about themselves and other people to the therapy session. For example, they see everybody else as being demeaning and mean to them well you fall into the category of everyone else so of course they're going to see you that way too at the beginning and you have to strongly demonstrate how you are different from other people who they've experienced. Anyway, when I teach residents at the University of Pennsylvania psychiatric residents, in the very first session we discuss the therapeutic relationship and I, as a result of this discussion, I ask them to write themselves a coping card to read before every session. And they generally write down four different things. This is what I'm going to say now is just kind of a summary of a lot of the different things that they write down. But the first thing is, that they should treat every patient at every session for the rest of their career in the way that they would like to be treated if they were patients. The second one is they should be a nice, warm human being in the room with the patient and do everything they can to make the patient feel safe. The third thing is to recognize that clients are supposed to have problems and pose lots of challenges. That's why they're clients. And then the fourth one is to have reasonable expectations, both for their clients, but also for themselves. This is actually their first experience using cognitive behavior therapy, and they've had very little experience up to this point in using psychotherapy in general. They've mostly learned assessment and medication approaches. And so I always tell them, I think that you should aim to get maybe a C or a D job. This is an American grading system of A and B all together, since you're going to be getting to start working with your first cognitive therapy patient. You could try to get about an A minus or a B in terms of developing a nice relationship with them, but overall, if you expect yourself to get an A, then you're either going to be demoralized or you'll be very anxious because it's not reasonable to expect that you can get there right at the beginning, but do you view every patient as an opportunity for you to learn more?

Rachel: I really love this coping card. took a picture of it and I carry it around with me now. Cause I think if it is ever a time where I would get frustrated with a patient not getting progress, it links directly back to that other point that you have about actually expectations of myself. The frustrations actually displays frustration that I'm not doing a good enough job with them. So I love this, this, this, this has become my flash card before sessions. And it does, you know, always links to the challenges that the work can present for us as therapists. Actually, there's a lot going on internally for us because we come to this work as whole human beings, not just as technocrats as we've talked about, you know, it's about our human relationship. What are your thoughts on how we look after ourselves as CBT therapists and does recovery oriented CT have anything to say about that?

Judith Beck: I am incredibly lucky because every other week at the Beck Institute we have a case conference and I get to present my most challenging cases and get feedback and so do the other therapists. I just think it's incredibly important for CBT therapists not to work in isolation and if you don't have a case conference like that, it's for you to seek out other like-minded CBT therapists and to start one. One important part of self-care is feeling confident. So that's why I'm starting with competence, but I'll talk about some other things too. We used to use the cognitive therapy rating scale to rate our clients. And then we realized a number of years ago that the scale was developed by Jeff Young and my dad back in 1980 and really didn't reflect some of the very important changes in the field since then. So we worked together at the Beck Institute to develop a revised scale. It has the same 11 items as before, but each of the rating criteria for an item have been specified in far greater detail. So we call this the Cognitive Therapy Rating Scale Revised. We actually have an online course, Cognitive Therapy in CBT and Practice that takes you through each of the items on the CTRSR and gives role play examples of better fulfillment of a criteria for a certain question or a certain item and one that's not quite as good. So I think it's always important to increase your confidence. One way of doing that is through a case conference. Another way of doing that is through listening to your entire sessions and rating them.

Rachel: And I love the idea, Judy, that you still go to these case conferences and have challenges to present, because that will be so encouraging to people. I mean, you've literally written the book, but you still get stuck. That's brilliant.

Judith Beck: One of the things that I always tell therapists is that, of course, I haven't been able to help every patient. Now, I've gotten better as I've gotten more experienced. And I'm also incredibly lucky because part of my job means that I have to read a lot of research. I have to go to a lot of conferences and attend a lot of presentations. I have to really keep up with the field. So that really helps my confidence quite a lot. But there are still patients with whom I struggle. And, you know, I'm very honest with patients. If I think that this actually just happened earlier this year, I was treating a patient with a very unusual and challenging case of OCD. And I thought I just wasn't doing a good enough job. And I described acceptance and commitment therapy to him and said, you know, I've been using some of these techniques, but I'm not as good as someone who was originally trained in this, and I wonder whether you might want to see someone like that. And he said, okay, so I'll think about it. Let me do a little research though. And then he decided to switch, and I thought that was wonderful. So I'm hoping that I will get some feedback from him. And since then, since him, I have been doing a deep dive into acceptance and commitment therapy and am now using it much more and much more effectively with a number of my patients. Yes, so everybody faces challenges and it's really important not to work in isolation about that. But in other ways, it's just incredibly important for us to do the same kind of self-care as we prescribe to our patients. I think everybody needs to take a lunch hour and if you can split that hour into three parts, so much the better. I know, one part is good nutrition, one part is connection with other people, people who aren't patients and the third part is perhaps taking a walk or getting a little bit of quick exercise or even doing a mindfulness exercise, something like that. So self-care is very important. When I was a beginning CBT therapist and I had three little kids at home and a husband who was much busier in his career than I was with mine, I used to feel overwhelmed at times and I got really wonderful advice from my mother who said, it looks to me like you need to under schedule yourself. You're now scheduled up for almost every hour of every day, but then something always happens. One of your kids gets sick, the washing machine breaks, there's always something. And she said, you know, the worst that would happen is if you under schedule yourself, you might have an hour to read a book or to have some extra time with a friend or something like that. So I think that CBT therapists who are too devoted to their jobs should take this idea of under scheduling and see whether that might be a helpful instrument to their work.

Rachel: Another wonderful piece of from the Beck household from a woman who did a law degree with small children herself.

Judith Beck: That's right.

Rachel: I struck reading the book about some of the differences in flexibility and constraints there may be around CBT provision depending on the context. These are not just the constraints that mean that therapists can't take a lunch hour, but these are the constraints around whether, for example, they can increase session frequency for their patients or taper therapy towards the end or offer a booster sessions or offer their patients a chance of coming back at the later time if they need to. What difference do you think that kind of flexibility makes to therapy outcomes?

Judith Beck: That’s a research question and I don't think it's been researched at least I haven't seen any research on this. I think it would be a really important question to ask and know and along with that again are I would also say at least in the United States a big constraint among many agency therapists is that they have to use a treatment manual. So all of these are really important constraints and I wish that someone would do more research on this so that we can see the impact on it. It probably will turn out that it's not very cost effective. However, if you are working for an agency that mandates certain things and mandates that you can't do other things, obviously you have to work within that and then try to be creative. So one of the things that I do, for example, is if patients have difficulty, in the past, the difficulty was probably both financial and also time-related. Now, because I treat many patients virtually, the time constraint is no longer so important because they don't have to take the time to travel in order to see me. But some patients actually do better, and financially might work out better for them too if they could have half a session with you twice a week or half a session every week instead of one session every other week. It also depends on the agency or the organization you're working for. But I have two clients right now who email me every single day. And sometimes the email is just, yes, I did my action plan or no, I didn't and this is what got in the way. Or for another patient, it might be, here are the three things that I'm so grateful for today. When I think that a patient is unlikely to follow through with an action plan unless they have some extra motivation, then I may offer them something like that. There are some creative ways that you can get around some of these barriers that organizations put up.

Rachel: And sometimes people worry about that kind of constant communication that it's going to sort of transgress certain boundaries or, or, or blur boundaries. And suddenly you might be corresponding with a patient 10 times a day. How do you manage that in those kinds of cases?

Judith Beck: Oh, so then that just becomes a problem for us to discuss at the next session. And I talk about the importance of, and this has happened to me, the importance of limiting the email to what we've agreed on. And I say, a large part of this rationale is that I just want you to focus on that. And when you put down the other things, then it dilutes your focus. Now if you want to put down the other things and keep a running list and bring it to our next session, that would be fine. And then we can figure out whether you think it's important to go over those things or whether you have other things that are even more important to go over.

Rachel: Certainly my experience of emailing clients is that they've been very respectful of that and it's been absolutely, so helpful to reiterate messages that we've emphasized in session to get homework done and just to encourage them and that is particularly in those early stages when motivation is such a big issue. We often talk about what a privilege it is to have a window into people's lives on this podcast. Cause we, we, do one of the best jobs, don't we? We get to meet so many fascinating, interesting people and watch them actually grapple with big challenges in their life  and see how they manage that and how they come through. What have you learned from the people you've worked with, the clients, the patients you've worked with and, and how has the work made a personal difference in your life or the focus of your work?

Judith Beck: So the one memory that I have on this topic was a woman who I was treating for depression. This was fairly early in my career. She was very angry at her husband because he was working very long hours. And he had a professional job. I think he was an accountant, something like that. But her role model for this was her father, who came home every day at 5.30 and had dinner with the family. And now her husband, who was in his first job after university, was not coming home until seven, eight o'clock or so. And they had little kids and she just really felt overwhelmed, but she's also angry that he was coming home late. And I helped her conceptualize his job as an 8.30 to 8.30 job. He didn't have an 8.30 to a 5.30, not like her father did. His job at this point in his career was 8.30 to 8.30. This was after I established that the husband at least, believed that this was what he had to do. And it rang true to me given what I knew about accountants and other actually accountants themselves that had been patients of mine. So we talked about how he was really working shift work like her father was. It was just that it was a longer shift. And then when she stopped being mad at him, then allowed her to focus more on asking for help from him over the weekend, what reasonable help she could ask for him in the evenings, and also how she might be able to get help from other people, the family, her friends, and so forth. So this was really useful to me when my husband finished law school and then became a first-year lawyer at a law firm and pretty much an 8.30 to 8.30 shift. And here I was, I had three little kids at home too. So that was just really useful to me.

Rachel: I’m understanding more about why you needed to under schedule.

Judith Beck: That's right. That's right. That's those two things connect. Yeah.

Rachel: I wonder, Judy, I know there's always so much going on at the Beck Institute and you are always so prolific in what you're writing and researching and teaching and thinking about. What do you think are the next frontiers for CBT? What are the weaknesses? What problems have we not solved? Why do we need to be humble as you put it earlier? And what are the exciting developments you see ahead?

Judith Beck: Well, I'm most excited by the, again, the use of cognitive behavioral interventions in different cultures, in different countries, different populations of people. So I told you about a couple of them, but there are lots more. What really excites me is the possibility of combining community member counselors, so lay counselors who are part of the community, who know the community, who are steeped in the culture of that community and so forth. Being able not only to learn some basic cognitive and behavioral techniques but also being able to use artificial intelligence or online therapy programs or apps with people with mental illness. There are just millions and millions and millions of people in the world who have mild to severe mental illness, who have no access to any kind of psychotherapy or medication, for example, much less cognitive behavior therapy. And I think the new technology combined with the know-how of lay counselors is going to be very powerful for people. I've tried some of the CBT apps that use artificial intelligence and pretended that I was a client. And I was really impressed on how they do basic problem solving and behavioral activation. It was really amazing. Now, we have to be incredibly careful about this. There have been at least two people who have died by suicide after engaging with an artificial intelligence program that reinforced what they were saying and all of their negative ideas and their wishes to die and things like that. But I think that those problems probably can be overcome. I think there are some people, people are going to be on a continuum from those who can benefit just from an artificial intelligence program that acts as a chat box, a therapy avatar. And those who don't benefit in the least and really need a person-to-person connection. But I think a lot of people are going to be in between.

Rachel: So you don't think we're out of a job yet?

Judith Beck: We are not out of a job yet and I'm not sure we will ever be out of a job for people whose difficulties are really quite complex and long-stayed.

Rachel: I'm kind of struck by that sort of maybe parallel to driverless cars. You know, a lot of the time they can where it's very procedural and the rules are very clear. They can be safer than a human driver, but when there's a kind of very problematic, maybe ethical decision, which way does the car swerve? It's a classic one, isn't it? If it needs to avoid one pedestrian or another or these issues which are much more drawing on our human instincts and emotions and that perhaps there is a lot more depth there that we need to understand.

Judith Beck: You know, we also are going to need to keep on doing research in neuroscience, in cognitive sciences, and other related sciences that are going to help us deliver CBT for various disorders more effectively. And then we're going to have to figure out how to translate the principles in these research studies into a technological format that's useful for people. So I think especially researchers are never going to be out of a job.

Rachel: And it's so interesting what you're saying about the adaptions to other cultures and other people embedded in different communities delivering that. Because I guess reciprocally we will learn so much more again about how to advance our therapy, much like, you know, the recovery-oriented CT coming from working in different settings. learn, we learn again, don't we? We can take when we adapt what we do to another setting, the adaptions often come back and give back.

Judith Beck: That's a very good point, something that I hadn't thought of. But yes, it really is reciprocal in terms of this kind of learning.

Rachel: And Judy, if people want to learn more about your work, obviously we're going to put links to the books, et cetera, in the show notes. Where can they access training or how can they get involved in what's going on in the Beck Institute?

Judith Beck: So the easiest thing is just to visit our website. We have a lot of information about CBT and we have information about our training programs. We have on-demand online courses and webinars and live virtual workshops. We’re actually having our first in-person workshop in September in Philadelphia. We haven't had one since before COVID. It'll be the first one in five and a half years. We have a supervision program and we have a certification program. So the easiest thing is to look at our website. The second thing that takes a little bit more effort is to sign up for our newsletter that's on the website. And in every article we talk a little bit about some of the cutting-edge advancements in CBT and have clinical therapeutic tips. And if you want to just find out more about what's going on in the field, you can sign up for our newsletter. If you want to go beyond that, then we might take a look at the third edition. It has to be the 2021 edition of Cognitive behaviour therapy: Basics and Beyond. And I'm hoping that a lot of people will want to look at the book that my father and Paul Grant and colleagues wrote, Recovery-Oriented Cognitive therapy for Serious Mental Health Conditions. Even if you don't treat people with SMI, I think you'll learn a lot about that. I took the principles from that book and inserted them into the third edition of Basics and Beyond. But that's really the source to find out more about that.

Rachel: And are you planning a new edition of the cognitive therapy for challenging problems?

Judith Beck: So I imagine that I will eventually, in the last few years I spent most of my time developing these online courses. So, but I would like to get back to that book that was mostly on personality disorders. That was really fun to write once I figured it out, but it was really hard to write. And I knew what problems I needed to talk about because for years I had given workshops in many different countries on cognitive therapy for personality disorders. And I would always start by asking, what are the challenges you face? Or actually, it didn't have to be on personality disorders. With any disorder that I was talking about, what challenges have you faced in working with clients with this diagnosis? So I had a whole list of them, but I couldn't figure out how to organize that material. It took me about five years to figure it out, but then I did. And it was so obvious. First you do the therapeutic relationship. No, maybe I did cognitive conceptualization first. Then you do the therapeutic relationship. Because if either of those aren't solid, then the therapy just isn't going to work. And then after that, it was easy. Problems with structuring the session, problems with identifying automatic thoughts, problems with getting clients to do their action plans, and so forth.

Rachel: So maybe, maybe when you've got the time and energy, you'll come back and talk to us about the next edition of that book.

Judith Beck: I'd like to recovery-oriented principles into my next edition of that book.

Rachel: Well, one thing's for sure, you're not going to stop teaching soon, are you, Judy? It's in your DNA and your bones.

So I don't need to tell you Judy that in CBT we like to summarize and think about what we're taking away from each session. So I wonder if in time-honored fashion you would like to say what key message you would like to leave folk with regarding the work we've been speaking about today.

Judith Beck: I really think that to be an excellent CBT therapist, it takes a lifetime. I still learn from every single client that I see. And I found in my own career, about every five years, I make some kind of leap. In the last five years, last 10 years, it's been with a recovery orientation. But I think that you can never stop learning. There's just so much going on. There's so much so many ways to increase your competence that I just would like to encourage cognitive behavior therapists to take a lifetime view of learning. And I think that's really what makes CBT so exciting. There's always some new things to try. You can be so incredibly creative about it. It just takes some study.

Rachel: And I can certainly vouch for that. 20 years after reading the first edition, not that I've even scratched the surface of what there is to know about cognitive therapy, but it's been so brilliant to talk to you today, Judy. Thank you so much for your time.

Judith Beck: Well, thank you. really enjoyed this conversation so much.

Rachel: And thanks to you, our listeners, for listening to another episode of Practice Matters. And until next time, take care of yourselves and take care of each other.

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