What's new in the third edition of Cognitive Behavior Therapy: Basics and Beyond?

0:12 hello my name is alan francis thanks for joining us today i'm professor emeritus former chair of the department of psychiatry at duke university i was chair of the dsm-4 task force with me today for what i think will be a very interesting interview is judy beck she's the president of the beck institute and i think probably in my experience the most magical person i've ever met and a great a great trainer or cognitive behavior therapist i have to admit to a great deal of bias in this interview full disclosure i'm not a neutral interviewer 40 years ago i was on the panel at nimh that approved the first grants in cognitive behavior therapy and at that point i was intrigued with it

0:57 partly because i felt i was doing it without knowing it partly because it was i thought a tremendous clinical innovation particularly because it could be easily taught and easily learned it could be done in a short-term context it was a terrific research tool and it would bridge the gap between research and clinical practice it has in its performance cognitive behavior therapy has far exceeded any of my imagination i think that in the 200-year history of modern psychotherapies there's never been a treatment that has done nearly as much to help millions and millions of people tens of millions of people and one of the intriguing and wonderful things about cognitive behavior therapy unlike most psychotherapies is it keeps changing

1:42 it keeps advancing expanding its indications to more and more patient conditions expanding its technical repertoire so that it can do more for the people it treats now tim beck has always been one of my heroes and his daughter proves that genetics works his daughter has the same kind of combination of intellectual rigor uh emotional empathy they're both great therapists and i'm very very much looking forward to this opportunity to find out more about the latest developments in cognitive behavior therapy so judy why don't you take it from there great well alan i feel that owes you a great death for um promoting cbt and funding its first outcome study so that was back in the 1970s and

2:28 my goodness how cbt has grown and flourished and changed since then although the basic uh cognitive model has never changed you know the cognitive model says that it's not situations that directly impact people's reactions it's their perception of situations what they're thinking about that's more closely connected to how they feel and what they do and sometimes to their physiological arousal and one really important part about cognitive therapy that has remained constant is that um one commonality among people who are suffering uh psychiatric disorders or psychological problems or many medical conditions with psychological components is that they have some distorted

3:15 thinking now traditionally what we have done in cognitive behavior therapy is to turn our attention to um experiences in which clients feel very distressed or act in a way that's just not all that helpful and we teach them to elicit their automatic thoughts the thoughts that just seem to pop up into their heads that led to this reaction and then uh sometimes not all the time but sometimes we would help them then evaluate their thinking not challenge their thinking but look at the evidence that their thought thinking was accurate or not accurate for alternative explanations and so forth more recently and this is what i have put in the third edition of cognitive behavior

4:01 therapy basics and beyond is more of a recovery orientation where we really are focusing more on people's positive experiences and their positive emotions and their adaptive and helpful thinking that lead to this more positive reaction could you go with it more what recovery is like how it smoothly complements and integrates with cognitive therapy so the recovery movement started maybe about 50 years ago maybe in the united states but i'm sure it's really international as well with the idea that people who had especially people who were diagnosed with serious mental health conditions

4:48 weren't being helped very much by trying just to decrease their symptoms but rather a different orientation was developed and that was recovery so recovering really means when people are living the life that they want to live when people are find meaning and purpose and a sense of safety and control a sense of competence and worth and those aspects of people's experiences are very much cultivated and emphasized and really the negative symptoms negative experiences are de-emphasized to some degree one of the goals is to help people who

5:35 are in a disconnected mode or you might say a depressive mode or just an unhelpful mode of being is to help them get into the adaptive mode and once they're in this adaptive mode then you see their thinking is much more helpful their behavior is much more helpful they're able to solve problems much more they're much more motivated they feel so much worthwhile and so forth how does that work in practice how do you combine the recovery aspiration with the techniques of cognitive behavioral therapy so my father um tim back or aaron beck is probably most people know him has been working for about the last 10 or 12 years with um colleagues at the beck institute

6:22 in our um recovery oriented cognitive therapy program to bring up this recovery orientation to people as i mentioned before with diagnosed with serious mental health conditions they work both with higher functioning um individuals who live in the community but especially in recent years they've been working even more with people who may have been hospitalized in a psychiatric hospital for 10 or 20 or even 30 years uh so i'll talk a little bit about that first and then i'll talk a little bit about how we apply some of the same principles when we're working with our outpatients at brownbeck institute the first um the first

7:10 challenge in working with patients who have been hospitalized for so long is kind of twofold one is engaging the uh patients themselves the other is engaging the staff of the hospitals because sometimes they have really just given up on these individuals believing that that there's nothing more that they can do for them uh so we very much have to work with the beliefs of the of the staff of organizations and one of the ways to do that is to ask the staffs to describe one of their one of the individuals they're working with who pose the greatest difficulties for them and then

7:56 they uh asked the staff when is this individual at his best what kind of situations when he's at his fast what does he look like what is he doing um and what do you think is important to him and then they teach the staff how to better engage the patient through experiences through creating experiences that can bring a sense of pleasure or accomplishment to these individuals sometimes they have to engage them just by playing name that tune or by taking them down outside of the basketball court and uh engaging in that kind of activity

8:44 taking a walk to mcdonald's um and and then really talking to them as people not as patients but finding out what they're interested in what their opinions are one wonderful way to do this is to find out um what some of the individuals talents at least had been before they were hospitalized and interview them show interest in that um uh if um if the staff themselves can um find something that the patient is better at than they are that's a wonderful way then of trying to equalize the relationship so having engaged the patient then they ask the patient what their aspirations are what they really want for their

9:30 lives what are they what are their hopes and dreams or if that's difficult for them asking them before they got hospitalized what was really important to them what did they hope for in their lives and then they get them to visualize um these aspirations really creating a very strong visual image in their mind trying to use all of their senses and then they interview them about this image what's happening in the image um what are they doing in the image are there other people in the image what are they thinking in this image now that they've reached their aspirations what's particularly good about this image what does it say about them what does it say about uh how other people are treating them

10:15 what does it say about their future it doesn't really matter with these patients who've been hospitalized whether the aspirations are realistic or not because what they really want to get to is what's the meaning of the aspiration what's so important about that aspiration and then they talk to the individual about what the individual could do this week right on the ward to try to get some of that good feeling to get some of that sense of purpose and meaning and there's a lot more to it than just that but but that's basically um what it is and again it's setting up these experiences where these individuals are able to draw positive adaptive conclusions about

11:01 themselves and they find that when these individuals are in these kinds of experiences when the environment has changed when people are responding to them differently they really get into the adaptive mode and as the pile of experiences kind of builds up they find that they're more and more and more in the adaptive road and many if not most of them have been able to move down to a lower level of care sometimes getting out of the hospital sometimes living in a protected uh shelter outside of the hospital and it just has revolutionizes their lives in some way so that's just a very short description of some of the things that they do

11:47 should i tell you a little bit about what how we apply that to our outpatients just in a moment but it seems that you and and tim are embodying what harry stack sullivan said even the sickest amongst our patients are more simply human than otherwise yeah well i think that's exactly right and that's that's what we try to get the staff of these hospitals that we're working with to see that they are human um and we try to depathologize their uh symptoms as much as possible in fact the people who have been in the hospital on exactly the same kinds of things as you and i do we want to have good relationships we want to have a sense that we're being competent and productive um we want to have a sense of purpose in

12:33 life it's really exactly the same things as everyone else wants and it seems a little mysterious sometimes when you look at their delusions or their hallucinations but if you look for the meaning behind these delusions and hallucinations you'll find um frequently it's a these individuals response to trauma to feeling scared to feeling unsafe so they develop a lot of coping mechanisms which just aren't all that helpful to them but when we put them in these supportive positive environments they find they don't need to use those coping strategies anymore i was trained in a biopsychosocial model but along the way i added the fourth thing the biopsychosocial spiritual model yes

13:20 people need meaning in life and therapy if it's going to be effective has to help provide it different meanings for different people but each person has to find his own way in his own meaning to make life worthwhile that's right and i'm afraid that that we didn't emphasize that enough at the beginning of cbt and i don't think we emphasized enough uh focus on not only uh alleviating uh symptoms but also trying to to create positive emotions right in the session itself and help people organize their weeks as much as possible to continue to have positive experiences one of the things that's absolutely amazing and wonderful about cbt again in comparison to all other

14:07 psychotherapies developed in the last couple of centuries is how much it's changed yeah your dad is in his 90s and he's coming out with a book next month too or very soon yeah he's been able to change his thinking and adapt to new patients new disorders new ways of looking at things throughout his whole life what what about cbt what about the two of you have made you so adaptable do you think oh i always think genetics has a plays a big role but i'm talking about my dad who's now 99 by the way and still going strong i was visiting him uh at his apartment a few days ago and he was talking to me about some of his latest uh theories about identi identity

14:54 disorder and uh bipolar disorder just fascinating um in any in any case i think one of his greatest characteristics has been that he's always been very curious but he's also been very scientific and he didn't take uh say this psychoanalytic dogma at face value after a few years of having been steeped in it uh you know he had decided that what he really needed to do was to demonstrate to the world especially to the scientific community that the concepts behind psychoanalysis were valid he thought this was really needed if psychoanalysis was going to gain currency in the more modern scientific world so

15:42 he did a series of experiments which did not turn out the way that he thought they would and i think what you know you said what qualities in my dad made for this adaptability i think it's when uh he gets information that doesn't go along with whatever he had been thinking or the thinking of the field at the time that he questions it he doesn't take it on faith and does more research to find out whether there are better explanations for the observations and i think both psychoanalysts you know and cbt therapists make i trained as a psychoanalyst and taught the freud course at the columbia institute for 10 years

16:28 and um one of the things that i speak to in psychoanalytic circles is that the greatest tragedy for psychoanalysis was rejecting your dad he was trained as an analyst i think he would have enjoyed being accepted as a sort of extension of psychoanalysis rather as a competitor and what happened was that the psychoanalytic movement solidified around a 1910 model it hasn't changed very much and is in effect more or less dying on the vine whereas your dad would have been a wonderful extension if they had instead of putting up barriers to him had invited him in if cbt were seen as a psychodynamic therapy which could be seen as it could be an annotation of psychodynamic principles to to new

17:13 problems and new ways of thinking seeing things in general would have been enriched and it would have saved psychoanalysis as an important contributor to our intellectual discourse and through our treatments at this point i think in psychoanalysis was not making your dad one of their leaders in the future and i i think actually what has also happened is that many psychodynamics psychotherapists now use many cbt techniques in their work um and especially when we're working with uh in cbt with clients who have personality disorders we do tend to spend more time in the past and trying to figure out how it is that um our patients develop certain beliefs

17:59 about themselves and the world and other people and how that's affecting them today although i think i might have a different answer for you in five years because also in our work at the back institute we're working with clients with personality disorders we're tending to spend less time in the past and much more time on this recovery orientation just helping them get the life that they really want although sometimes having the insight as to why they have some difficulties is important you know i think it's just important for people in general and also for patients to have kind of a coherent story about why they are the way that they are why their life has gone a certain way and so

18:44 i think that there are certain ideas from psychoanalysis which can be helpful in that aspect i think of course what cbt does and especially recovery oriented cognitive therapy is to say okay so that's now we have an understanding of course you believe this about yourself no wonder your life has gone this way but now what are we going to do about it how do you want to be different how do you want your life to be different i think any complete therapist should feel obliged to learn all the different techniques because no one technique works with every patient or even in the same session with the given patient it's important to be able to apply cognitive techniques behavioral techniques psychodynamic techniques and understandings as well as systems

19:30 and and family and group techniques and the way you see the world and the way you see individual problems now perhaps we can get to how does the recovery model apply to people who are healthy or seen in outpatient setting okay so um one difference is in the first session so instead of uh starting out by setting goals we tend to start out now by identifying values and we're incorporating a number of techniques as you were mentioning from other modalities such as acceptance and commitment therapy in this case so we help people identify their values what's really important to them in life and we go through just a number of categories to help them figure that out and then we talk a

20:16 little conversationally with them about that why is family so important to them what does it mean to them uh how important is productivity uh in what ways do they want to be able to express their productivity for example so we start out with their values then we talk about their aspirations how again the same kind of questions how do they want their life to be different um what do they want it to be like what are they really hoping for and then we ask some questions if they were able to lead this kind of life and be that kind of person what would be the best part about that what would it mean to them why would that be so important to them and then having identified the values

21:03 then we start talking about so what might be some of the goals for treatment some specific ways that you'd like to be different or you'd like your life to be different as a result of treatment so so we start out therapy a little bit differently and in each session there's um a slightly different model um still based on the cognitive model but the the um the content is a little bit different in traditional cbt we set an agenda at the beginning of every session after we do a mood check and so forth and we say what problem or problems do you want my help in solving today in the recovery orientation we're much more likely to say what are your goals for today's session

21:48 now the goals are actually the problems the flip side of the problem so the problem might have been i'm feeling really lonely and now the goal might be i want to have more connection um and and so we identified the goals prioritize them and let's say we start working on the first goal and then i want to get back to what we do differently at the beginning of sessions we identify a goal and we ask the patient what steps would you like to take this week you know toward this goal and we help them identify some specific steps and these so these steps are always aligned with we we ask them how are these steps aligned with your values and your aspirations because that's

22:34 very motivating for them and then we talk about what obstacles could get in the way what practical problems what lack of skills what cognitions could get in the way and then we use our standard cbt techniques and techniques from other modalities to help respond to those obstacles so rather than putting the focus on problems that the patient has encountered in the past week we're more likely to look ahead to the coming week what do you want to be different about this week what obstacles are going to get in the way so that's one difference let me tell you a little bit about another difference at the beginning of sessions so traditionally in cvt at the beginning of sessions we would do a mood check

23:21 now if we um we're de-emphasizing the assessment of negative symptoms to some degree but we're we're still giving out the that depression inventory and scales like that or our scales in the in the public domain we're not quite ready to give them up yet but we also ask them to assess their sense of well-being on a scale from zero to ten um currently and what was the range in the past week so we definitely want to put an emphasis on on well-being we also have traditionally asked for an update what happened between last session and this session that i should know and also what's coming up between now and next session that i should know when uh we ask those questions then patients undoubtedly will tell us the negative

24:07 things that happen their negative experiences um when they do we also want to make sure to say well what were some of your positive experiences this week when did you feel even a little bit better this week and then um we probably are going to spend more time at the beginning of sessions going over people's action plans and their positive experiences so often the the action plans is what we used to call homework and those are the steps that the client had identified the previous session that he wanted to take in alignment with his aspirations um so when the patients have successfully um completed an assignment or have some

24:54 other positive experience that they reported on we asked them what does that mean to you and especially what does that say about you that you were able to do this or what did it say about you that this person had such a positive reaction to you if they have difficulty with it then we might offer it um i wonder do you agree i think that that the fact that you were able to go out for a walk for a walk this week when you couldn't do that last week really shows that your motivation you must be a little bit more motivated that you were able to push yourself a little bit more did it show you that actually you're starting to be able to take a little bit more control over your life than you thought you could before so

25:39 just to summarize what's a little bit different in treating the outpatients is we start with values and aspirations we find out the best parts of those things and the meaning to the patient we have them imagine it and try to experience that positive emotion right in the session itself and then use that as a bridge to how can we help you get some of that positive emotion and positive experience this week what steps do you want to take he said it was a little difference but sometimes little things have tremendous impacts and what you're doing is switching what's foreground and what's background sporting with meaning and aspiration and goals and then getting to symptoms as

26:25 obstacles to realizing those goals but that shift is may make all the world of difference in terms of the kind of relationship that's formed and how the therapists and patients feel about each other and how they work together i think that's right we're uh we're collecting some data now so our our sense is there have been studies um with individuals diagnosed with serious mental health conditions to show that this is abbreviated ctr recovery oriented cognitive therapy that ctr is effective and now we're starting to collect that data at our clinic does anything get lost in the traditional cbt model starting it within this framework

27:11 or does it pretty much have the same impact only in a different context and frame so i think in five years we'll have a better answer to that i don't think we've lost anything because there's nothing that we do in traditional cbt that we couldn't do in a recovery orientation it's more i think a real shift of emphasis yeah how hard is it to learn um well as a teacher so we've we've only started uh there are two answers to that one is the recovery oriented cognitive therapy program that is now at the beck institute has been teaching this in inpatient settings and also uh

27:57 in outpatient settings for individuals diagnosed with a serious mental health conditions for um several years now and they've had great success in being able to train staff really at all levels in how to do this we've just started applying this more in our outpatient clinic and have now been teaching it in all of our online courses and now all of our workshops which happen to be virtual at the moment and i've also infused it in the third edition of cotton behavior therapy basics and beyond if people want to know more about it then there's a book my father is the first author paul grant and ellen and verso who are on our staff

28:43 at the beck institute are our co-authors along with a couple of other people and it's called recovery oriented cognitive therapy for serious mental health conditions and that's out in december of 2020. is this the new standard that the beck institute will be teaching yes so we're we're teaching it along with still teaching the traditional cbt and but uh giving a rationale for why people might want to try more of a recovery orientation we really need to have a more solid research before we really give up the more traditional cvt because there's so much research that show that shows that it's effective well you'll never be giving up traditional cbt you'll just be embedding it yes right that's correct how about the

29:30 hundreds of thousands of people who are now currently cbt therapists can they get it from reading the book well that's a great question because the book isn't out yet um we do have um uh online courses or we will soon in recovery oriented cognitive therapy um and uh we do an awful lot of training online for organizations as well so i think people pretty soon will be able to get a great degree of access to training in this but you know what people also really need is supervision and we have a terrific faculty who both teach and supervise in both cbt and ctr let's take the experienced

30:18 therapist so lots of people who have had years of doing cbt work they'll be fascinated by the book eager to learn more about how to apply it to their current practices do you think that if you have a good-hearted great spirited smart cbt therapist that just reading the book by itself would give them enough of a nudge in the direction that would allow them to be practicing this in the way you would like them to so that's an a good empirical question to which i don't have the answer i would certainly hope so um the books are pretty detailed in what you need to do and why and how to implement it with patients i just found personally so energized by the recovery orientation

31:05 i am really doing therapy much differently from how i did it five years ago although i also expect that five years from today i'll be doing it uh differently from precisely how i'm doing it today it brings up a larger question that wherever i go the complaint amongst referral sources is always that there's no one in my area who does cbt that as many people as you've trained and you fill the crucial niche not just here but all around the world there's a tremendous shortage of cbt therapists around the world and my guess is that not everyone will be able to take your courses the question is can someone go from reading the book if they have clinical experience to modifying their practice in a way that will make them more effective therapist i know you're going

31:51 to say because you're always really careful we don't have them but how about your heart you know i always think that more knowledge is better than less knowledge and i certainly over the years have met met many many people who were practicing cbt just by their exposure to the important books and when i discuss cases with them they certainly seem to be doing an excellent job so my guess is that therapists are probably on a continuum to begin with from really excellent therapists to those who maybe aren't so good i think the people actually who are drawn to do cbt are really have that um framework in their

32:36 mind it just makes sense to them you said at the beginning of our talk it just made sense to you and i think that that those individuals probably can get a great deal from books but you know there are also um many places in the world where community leaders are learning to do cbt so these are sometimes in villages in africa or in other third world countries where um say the women in the village are taught to do just some very basic cbt skills such as behavioral activation for other women who are depressed um very basic

33:21 questioning of their uh thinking um asking the the woman who's in distress well what advice would you give to someone else and they've actually had some really important and very good outcomes so i think that cbt can be extracted and applied and needs to be reformatted and adapted to the environment to various cultures to the diversity of human experiences i i found myself feeling like i spoke prose without knowing it when i started reading the books i never had training in cbt but for better or worse consider myself able

34:07 to do it partly because it came so naturally partly because i read about it and also the stoic philosophy connection uh your dad mentioned his debt to the stoic philosophers in the very early papers that's right why don't you elaborate on how that comes through this is not just the wisdom of tim beck and judy back this is the wisdom of the ages of the ages yes you know the stoic philosophers said that it wasn't events themselves that led to people suffering but yet it was their perception of these events and so you know these ideas have gone back such a long way and it's it applies not only to negative emotion and distress but also the positive emotion when we have a positive emotion

34:54 it's because we're thinking in a positive way and that's that's kind of the bridge i think where the cognitive model is the same among both the traditional orientation and the kind of a newer recovery orientation there's a lot of controversy in the literature about manual based therapies and particularly criticism of people just stick to the manual you're the horse's mouth how do you use the manuals and how do you recommend that other people use the manuals we teach people never to use manuals that it's important to understand the principles in the manuals and then have an individualized

35:41 conceptualization of the client and make that treatment right for that client the manuals are essential if you want to do randomized controlled trials because you have to make sure that the treatment is standard across patients and that's why they were developed but um we find that when people use manuals they just don't fit individuals very well the individual may have certain preferences may have comorbidities they may like certain parts of what the treatment is like might not like other parts most manuals we found too really don't talk nearly enough about the therapeutic relationship

36:30 tell us more about that well you know i personally think it's an act of courage for most people to enter treatment and i think therapists are better off if they assume that patients don't feel completely safe at the beginning of treatment and they do everything that they can to help the patient feel safer this is particularly important with people who've had negative experiences in therapy before or people who've had a history of negative relationships in their own life they may come to treatment with certain negative assumptions such as if i reveal my weaknesses my uh well the general um beliefs might be

37:17 if i reveal weaknesses people will criticize me and i'll get hurt if i uh listen to what other people say it will show that they're strong that i'm weak if i don't assert myself aggressively other people will walk all over me and they bring these general beliefs about other people and about relationships to therapy and so if they believe these things about other people of course they're going to believe these things about the therapist and so the therapist has to be really acutely aware of the patient's emotional experience in the session itself and when clients are starting to look a little bit more upset it's so important for therapists not all

38:03 of the time but at least some of the time to stop and just kind of gently interrupt and say you know you're looking a little bit more distressed what was just going through your mind now sometimes the patient is having negative thoughts about himself for example i'm too stupid to understand what my therapist is trying to say okay if he is very important to address those thoughts or the patient may be having some negative thoughts about treatment i just don't feel like this is right for me and of course we need to address that and sometimes the patient is having negative thoughts about the therapist my therapist doesn't understand me she's trying to control me she's telling me what to think she doesn't believe

38:48 me um she's being judgmental about me and so forth the first thing that we need to do once we identify patients negative thinking like this is to say it's so good you told me that really to positively reinforce patients for giving you negative feedback whether it's warranted or not it's important that they tell you because if they don't then you can't solve the problem so um you positively reinforce the patient for giving you negative feedback and then you have to plan a strategy now sometimes we therapists make mistakes i remember early on there was a patient i had and in the first session at the very end of the session

39:35 i asked for feedback as i do with every patient i said what did you think about today's session was there anything that bothered you or anything you thought i didn't understand and the patient said no no i think you understood yeah no i think it was a pretty good session and i said and just in case you had any negative feedback but you didn't feel comfortable telling me would it be okay if i give you this sheet to fill out and have five questions on it about the reaction to the session and she said pretty angrily i hate filling out sheets so i said oh so good you told me that i think i made a mistake i shouldn't have given this to you so i took the the sheet and i tore it up in front of her and i threw it out in the waste

40:21 basket because i really wanted to demonstrate to her that i would make the session right for her so it's so important to elicit feedback from patients either during the session when you notice um that the patient's looking a little distressed and certainly at the end of the session the human element is is the most important aspect of the treatment and you know whenever possible we positively reinforce patients so whenever we see them taking even the smallest steps toward getting better we we say isn't that good that you did that and again try to help them draw positive conclusions from it the i guess the the criticism has often

41:07 been that cognitive behavior therapists are slaves to the manual you're anyone who feels enslaved by manuals you've just freed well i hope so because i know that there are some agencies though where people are required to use manuals and i really wish they would require them to use the principles of the manuals but do an individual conceptualization there's a great misunderstanding about the role of manuals in the way the beck institute has used them for research not wanting them to be used slavishly for practice if you're following the manual you're going to be distracted from the patient so it has to be part of your background knowledge but not something that's on your mind each session that's exactly right what about duration

41:55 duration of treatment yep um so it varies quite a lot if there are no external constraints usually it's just a decision that patients and therapists make together once we see that patients are starting to do better they're taking the steps they need to between sessions their mood is improving then the therapist might put it on the agenda to talk about what do you think about the possibility of starting to space out sessions to maybe once every two weeks instead of once a week and if that works out well for a few weeks maybe go to once every three or once every four weeks so we we like when we um when therapy is nearing termination not

42:42 to go from weekly sessions to not to none but to space them out and we still like people to come back for booster sessions even if they're doing pretty well just to make sure that they're still using the tools that they learned in cvt now sometimes there are real constraints especially financial constraints and in that case it's very important to figure out with the patient maybe what are one or two goals that are the most important to them and focus very heavily on those goals and treatment and meanwhile whenever we teach them a skill such as how to identify and monitor their thinking is to teach them how this skill applies not only to this one goal that we're working toward

43:28 but to other goals as well uh you know i think it's unfortunate that there are some of these constraints there's a very interesting system that is going on has been going on in the uk for quite a number of years now it's iaf increasing access to psychological therapies and cbt is the primary therapy that's used in england um and their system actually makes a lot of sense to me they it's kind of a triage system i don't know if they would like my characterizing it that way or not but um a patient goes to his gp gp ascertains that the patient is just very mildly depressed the patient might be encouraged to take an online self-help course or go to a self-help group or do

44:17 some readings in self-help it's not unless they have moderate to severe depression that they might go up a level and so these would be seeing psychotherapists who are not the most highly trained but who are very well trained for example in behavioral activation for depression and it would only be the most seriously impaired patients who would see the most highly trained people so this is one way a very important way to be able to triage care i think in a way that makes more sense than we do in the united states maybe you could give us an overview of cbt around the world well this iact system is being used in a number of other countries maybe five or

45:03 six countries following the model um that is used in um great britain this was established by david clark and his team at oxford and now is used throughout the uk but in other countries as well it's very hit or miss in in other countries there are some countries like uh scandinavia in which cbt is very strong and psychodynamic psychotherapy is also very strong there is still a very strong tradition of psychoanalytic psychotherapy in south america although cvt has has been growing stronger and stronger there in the past 20 years it's also pretty strong in countries where there was not a psychoanalytic

45:49 base basis to begin with places like australia japan china new zealand places like that so a lot of it actually has to do with what traditional psychotherapy was used if traditional psychotherapy was used before cbt became established i've been amazed to watch the progress of cbt in japan yes it's been remarkable there were zero cbt therapists when he went back to japan in the late 80s and now there are several thousands yes i remember when he came to study with uh with my dad and me um and he's just dr ono has done such a remarkable job in that country and there are similar people in so many

46:35 different countries in in south korea many in china um many in the middle east uh you know i'm afraid i'm gonna leave some countries out but i have unbelievably wonderful colleagues throughout the world who are so dedicated to disseminating cbt and really keeping a very high bar in cbt one of the things speaking of high bar that the big institute is now doing is certifying people as cbt therapists and we're also starting to establish a program although it's not finalized yet to uh certify organizations to accredit organizations in cbt there are you know one of the big

47:21 problems in the field and you almost alluded to it before is that there are so many therapists who say that they do cbt when what they do isn't really recognizable by us absolutely and so one of the missions of the beck institute is really to um help people worldwide to improve lives worldwide through excellence in cbt innovation and uh training practice and research in cbt so we're hoping by raising the bar in certification that people all over the world will be able to reach a higher level of expertise and as we were kind of

48:06 alluded to before i don't think you can ever stop learning in cpt i'm so much of a better therapist than i was five years ago i sure hope i'm a better therapist five years from now so i think becoming expert in cbt really takes a lifetime and and one of my very important messages in cognitive behavior therapy basics and beyond and you know in all of our training is that you're never finished learning i still learn from every patient i see from every person whom i supervise i learn so much i'm so lucky to meet um even in this day and age with my dad face to face we discuss cases uh and also from my excellent colleagues at the beck institute so um i wish everyone were fortunate

48:52 enough to have the situation that that i'm in but um i think everyone would would have been well served to have your dad as a dad this is true he's a remarkable person maybe we should end on that though excellent well thank you so much aaron um for conducting this energy with me well i i think that what i take from this is that people can adapt what you have to offer to what they already do i think that's after full training yes you know there's almost nothing that that cbt would say that you can't do um other than debating patients degrade them you know act superior to them try to control them and so forth

49:38 um as long as you're not doing that you can work almost anything adapt almost anything within the framework of the cognitive model and just as britain has a step system with different degrees of intensity getting different degrees of response in the treatments in a way different therapists can have different intensities of exposure to your new model some of them may have only the resources to do it by carefully studying the book and then using it because it's a common sense approach it's a human approach it should be fairly easily brought into everyone's practice beginning trainee to the most experienced clinician your dad is right now not afraid to keep learning not afraid and other people will be able to avail

50:25 themselves of the more intense training that you're able to offer in a way the pandemic makes you even more available to people because more and more people are easily trained and accustomed to virtual communication and i think that will continue i just wanted to add that there one more um um one thing that i i added two things to this new edition of cognitive behavior therapy basics and beyond one is um i kept getting criticized in the first two additions and rightly so i think for using a patient who is too easy so in this third edition i have um a more severely depressed patient um and i also um throughout the book follow a patient

51:11 with who's very depressed who has borderline personality disorder features but the other thing that i've done that i had wanted to do for many years was to show videos of the patient so throughout the book there are opportunities to go to a website to stream so people can actually see what it looks like it brings up three thoughts one is the best way to learn to be a good therapist is to watch great therapists it's much easier to to learn from seeing them in action than this to reading about them in action you know the second thought that anyone can treat the easy patient easy patients get better on their own yeah the difficult patient that's most gratifying the patient who's hard for you to treat is a stretch makes you a better therapist

51:56 and at the end of your career you won't remember your triumphs with easy patients you remember the difficult ones they're the most precious to you in the long run and they're the ones who need our help the most say again those are the ones who need our help the most and the the most neglected and i think that adapting the treatment to the most severe patient is a wonderful legacy for your dad how many people in their 90s would tackle the toughest problems in psychiatry and come up with a very very practical answer that somehow or other eluded most people going back maybe since pinel who actually saw it the same way yeah and ellen and your dad had a lot in common and they're two of my heroes in psychiatry oh wonderful and you too judy thank you so much thanks so much bye-bye

52:53 you