Volume 12 Issue 1

Spring 2007

From the Director Judith S. Beck, Ph.D.

A Cognitive Therapy Weight Loss Group
For Cognitive Therapy and Research

About our President Aaron T. Beck, M.D.

The Albert Lasker Award Reception and Speech
On November 6, 2006, the University of Pennsylvania celebrated Dr. Aaron T. Becks lifetime achievements, most notably his receipt of the Albert Lasker Award for the development of Cognitive Therapy. Often referred to as Americas Nobel, the Lasker Award is the nations highest honor for outstanding contributions to clinical medical research. This was not only a major personal honor for Dr. Beck but also a tremendous one for the University and its Department of Psychiatrywhich Beck joined in 1954. Dr. Joseph Goldstein, chairman of the Lasker jury, described cognitive therapy as one of the most important advances if not the most important advancein the treatment of mental diseases in the last 50 years. Over 300 of Dr. Becks former medical students, current and past colleagues, friends, family and admirers attended a special reception and paid tribute to Dr. Beck and his half-century of contributions to science and medicine. In his introductory remarks, Dwight L. Evans, MD, Ruth Meltzer Professor and Chairman of the Department of Psychiatry said about Dr. Beck (Tim as he is affectionately known): Tim is a revolutionary and a pioneer. He revolutionized our understanding and treatment of depression and other psychiatric disorders. He pioneered the development of Cognitive Therapy to treat these maladies, and he made seminal additions to our understanding of suicide classification, assessment, prediction and prevention.Tim continues and extends a wonderful Penn Psychiatry legacya legacy that began with one of our countrys founding fathers, Dr. Benjamin
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We have a new project here at the Beck Institute. Our diet coordinator and I have been running a weight loss group for the past few months, using a program outlined in The Beck Diet Solution (a new book I wrote for consumers, applying CT to weight loss). The principles of Cognitive Therapy, especially with its emphasis on relapse prevention, fit so well with the problems of obesity and being overweight. Over the last 20 years, while working with my psychiatric patients who had a goal of losing weight, I learned how to help people change their thinking so they could make permanent changes in their eating behavior. Our group consists of ten dieters (without psychiatric problems) who initially weighed between 180 pounds and 292 pounds. Everyone has lost weight, between 8 and 44 pounds as of mid-March. Two women have even lost all of the weight they had wanted to and are now in maintenance. We recommend that dieters choose whatever healthy, nutritious diet they want. We teach them how to modify the dietin advance, not on the spur of the momentto make it suit their tastes and lifestyle better. We also help them set up and implement an exercise program of their choice. Then we teach them the skills they need to continue to exercise and to stay on their diet, and later a variation of it, for life. And each step of the way, we help them change their dysfunctional thinking. Maria, a 38 year-old office manager, is typical of many of our dieters. In the beginning of our program she weighed 241 pounds. She had started dieting at age 20 and had tried 5 different diets on at least 10 different occasions. She
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Inside This Issue:

The Lasker Award . . . . . . . . . . . . . . . . . . . Page 1 Directors Corner. . . . . . . . . . . . . . . . . . . . . Page 1 Dr. Becks Lasker Acceptance Speech . . . . Page 2 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . Page 4 Blog Update . . . . . . . . . . . . . . . . . . . . . . . . Page 5 Speaking Engagements. . . . . . . . . . . . . . . . Page 6

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Cognitive Therapy Weight Loss Group Continued

(Continued from page 1)

once lost 60 pounds in 8 months but started to gain it back within 3 months. Maria had a hectic schedule, a demanding job, and two young children. She wasnt doing any exercise at all. Before she began our program, Maria often ate too quickly, mindlessly, and more than she had planned. She frequently gave into cravings and ate past the point of fullness. She sometimes felt a sense of unfairness that she wasnt supposed to eat as much as others were eating and a sense of helplessness, believing she couldnt control her eating. She overate when she was feeling distressed, when she was at social events, and when she was eating something she found delicious. She often had permission giving thoughts such as, Its okay to make an exception and eat this food that Im not supposed to because Ill start being good again tomorrow. At the onset of our group, Maria chose a well-balanced, nutritious diet, so we didnt have to help her with sabotaging thoughts such as, I have to eat as little as possible, or Ill only be on this diet for a limited period of time so it doesnt matter if its not all that healthy. We did have to help her figure out how to create time and energy for exercise. She had to modify her idea, I have to put everyones needs before my own, in order to keep to her exercise program. Maria historically had a lot of

difficulty dealing with cravings. We had her do some experiments to change her idea from, If Im craving, I have to eat, to Cravings are uncomfortable but they pass. I can make them pass sooner by firmly saying, No choice, and getting busy doing something else. She also learned to remind herself, I can give into cravings or I can lose weight but I cant do both. Maria went from almost always giving into her cravings to rarely, if ever, giving in; each time she resisted, she further strengthened her confidence that she could do so the next time. Maria now reports that she never feels helpless or out of control of her eating. Maria has motivated herself daily to stick to her diet by reading a card each morning and whenever she is tempted during the day. The card lists all the reasons she wants to lose weight. She also uses the card to get herself to exercise, which she now consistently does three days a week. When other pressures threaten to intrude on her efforts toward dieting and exercise, such as children making demands when shes on her fitness machine, Maria reminds herself, I deserve to be thinner, and she is able to put herself first. One of the biggest changes Maria has made is to become aware of, and enjoy, every bite that she takes. She says that she never eats any more just because shes sad, lonely, or bored. She no longer thinks, Its ok to eat this because its free; everyone else is eating it; Im celebrating; no one is watching; I dont care. Instead, every time

she eats, she does so sitting down, slowly, and making sure to be mindful of every bite. When sabotaging thoughts creep back, she is able to counter them in much the same way she responds to cravings: by telling herself No Choice! and reading other coping cards. In the past she often had trouble turning down food when her family urged it upon her, not wanting to upset her relatives. Maria has now gotten adept at firmly refusing offers of food by reminding herself that she could accept food from her family, or she could be thinner, but she cant have it both ways. Maria has now lost over 40 pounds and is so pleased with how shes doing. Shes no longer ashamed of her body, doesnt shy away from being photographed, and thoroughly enjoys buying new clothes. Maria is confident that she will be able to maintain her new lifestyle changes permanently, and so she is also confident that she will continue to lose weight and keep it off permanently. Maria is just one good example of how effective the techniques of CT are for permanent weight loss. Whats been missing in other approaches to dieting has been the focus on helping people learn to identify and respond effectively to the thoughts and beliefs they have that interfere with doing what they (usually already know they) have to do to lose weight and keep it off.

Lasker Award Reception and Speech Continued

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Rushwho is recognized as the Father of American Psychiatry. Tim, of course is now recognized as the Father of Cognitive Therapyand all of us here at Penn Psychiatry are also delighted and thankful that he is also the Father of Dr. Judith Beckthe Penn Psychiatry legacy continues. The evenings other speakers included, Executive Vice President for the Health System and Dean of the School of Medicine, Arthur H. Rubenstein, MBBCh, who welcomed attendees and extended greetings on behalf of Penn Medicine and the entire Penn community; as well as former Provost of the University, former

President of Brown University, and current President of Carnegie Corporation of New York, Vartan Gregorian, Ph.D., who reminisced about their long-time friendship and professional association over the years. Dr. Beck has won numerous other awards, including the Heinz, the Cummings Psyche, the Sarnat and the Lienhard Award; published more than 500 articles, and written or co-authored 17 books. For more on his distinguished career, visit: http://mail. med.upenn.edu/~abeck/ biography.htm 2

Dr. Becks Acceptance Speech:

I thought I would tell you the inside story of my Road to the Lasker. It was a hilly and sometimes uphill journey, a number of blind alleys, but also, surprisingly, smooth movement. This all started in 1952 during the Korean War when I decided to volunteer for active duty in the Army. I visited the Pentagon, and the Chief of Psychiatry was so surprised that a doctor was willing to volunteer for service that he gave me my choice of where to be stationed. He mentioned Japan, Alaska, and Korea.
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Lasker Award Reception and Speech Continued from page 2

I said that, all things considered, I would sooner be in Philadelphia. I have always been enamored with Philadelphia, one of the great cities of the world, and particularly have been impressed by the University of Pennsylvania and its Medical School, one of the great institutions. In 1954, I joined the clinical faculty and started to teach. Fast forward to 1959: I was fascinated by the idea of applying the scientific method to the problems of psychiatry. I was totally innocent of research design and statistics at that time. However, to paraphrase: It takes a University to raise a researcher, and I received a lot of help from my colleagues in the Department and also those in the Department of Psychology. I was particularly intrigued by depression. At that time, the study of depression was a wide-open field. There were a lot of theories but not much solid evidence. Even the biological studies were fragmentary and inconsistent. As I looked at depression, I realized that it is a mystery wrapped in an enigma wrapped in a paradox. The paradox is that depression violated most of the canons of human nature. The survival instinct is reversed -- people, instead of trying to cling to life, want to end it. Maternal instinct is blotted out -mothers lose all interest in their children. And the pleasure principle is nullified -- patients no longer get pleasure and sometimes get even pain from the activities that used to bring them gratification. I decided to apply the scientific method to the dreams, the beliefs, the thoughts, and the behavior of depressed patients. I thought that I could really make sense out of my findings. The inner meaning seemed to be the total negativity in the thinking of the depressed patients. In short, they seemed to live in an alternate reality. They saw their past, present, and future through warped lenses and attached negative meanings to everything. They could only think of past failures, insurmountable problems in the present, and future futilities. We did a number of studies which more or less confirmed this formulation. I then wondered: Would it be possible to apply the scientific method to therapy? Typically, I would reframe the hypothesis of the depressed patient (for example, that he was a total abysmal failure) and then go through the following procedures: What is the evidence? Is there counter-evidence? Are there alternative explanations? We would then carry out behavioral experiments to determine whether he was just as helpless and ineffective as he thought he was. Of course, the experiments generally proved that his thinking was incorrect, and he was then able to modify this more in keeping with reality. When I applied these methods to clinical practice, the patients depression started to clear. Indeed, within 10 or 12, or 14 visits, the patients would say, Thank you Doctor. I have to say goodbye; Im feeling all better. The result of this was that my more conventional treatment, which would last a year or more, became reduced and thus my practice shrank. At that time, my good friend Mickey Stunkard, who was by then Chair of the Department of Psychiatry, decided to invite me to come aboard to take a fulltime job. The next step in evaluating whether the therapy was really a valid approach was to conduct a clinical trial of depression, which did turn out to be successful, and was repeated at many other centers, and thus did establish that cognitive therapy was a reasonable new form of treatment for depression. We then went on to develop formulations and then treatments, successively, of anxiety, phobias and panic attacks, and substance abuse with clinical trials, which by and large, also turned out to be successful. I was fortunate to have trained a brilliant group of researchers who then expanded the application of cognitive therapy both in terms of disorders and also geographically across the globe. In rapid succession, cognitive therapy was then applied to 3 eating disorders, obsessive-compulsive disorder, and even schizophrenia. So I have come to the end of the Road to the Lasker. However, I do not believe that this is the ending or even the beginning of the end, but more of the end of the beginning. There is much more that needs to be done. Whatever value we have added to the treatment of psychiatric disorders is diminished by the fact that it is has not been extended to most of the people who want and could benefit from this treatment. Our next step is dissemination to community mental health centers and elsewhere. Finally, I believe cognitive therapy has something to offer the prevention of disorders. Work has already been done showing that adolescents at high risk for schizophrenia can be treated and their onset of psychosis delayed if not totally eliminated. The same kind of work has been done with high-risk patients for depression and anxiety. We are currently engaged in a prevention of suicide project and there is some hope that cognitive therapy can be applied indirectly to prevention of heart disease, hypertension, and other ills related to obesity. My daughter Judith Beck has now taken up the rein and is doing work in this area.

For information about becoming a certified cognitive therapist, please visit the Academy of Cognitive Therapy website: www.academyofct.org Or email info@academyofct.org Academy of Cognitive Therapy One Belmont Avenue, Suite 700 Bala Cynwyd, PA 19004 Tel: 610-664-1273 Fax: 610-664-5137

Cognitive Therapy for Anxiety Disorders: A Discussion of Recent Empirical Developments Part 1 Amy Wenzel, Ph.D., University of Pennsylvania
In my previous article, I highlighted theoretical and empirical developments in cognitive theories of anxiety disorders that were published after Beck and Emerys (1985) seminal work, Anxiety Disorders and Phobias: A Cognitive Perspective. These cognitive theories generally suggest that anxious individuals are characterized by the maladaptive activation of danger schemas, composed of beliefs and assumptions about the likelihood of danger and their own resources for coping with it, which in turn bias the manner in which threat-relevant information is processed. In the present article, I discuss innovative cognitive constructs and methodologies that extend beyond the core features of anxiety proposed by Beck and Emery that are relevant to the contemporary understanding of cognition and anxiety. Imagery Over 15 years ago, Ottaviani and Beck (1987) reported that patients with panic disorder experience frightening imagery that accompanies negative automatic thoughts during instances of acute anxiety. However, only recently have clinical scientists studied anxiety-relevant imagery in a systematic manner. Wells, Clark, and Ahmad (1998) reported that patients with social phobia recall memories of social situations primarily from an observer perspective, which limits the degree to which they attend to aspects of others behavior in these memories that potentially would disconfirm negative beliefs about their performance. Hirsch, Clark, Mathews and Williams (2003) demonstrated that anxious symptoms increase and objective performance decreases when individuals with social phobia hold negative, rather than neutral, images in their mind during social interactions. These recent studies confirm Becks notion that imagery is an important cognitive mechanism that maintains anxiety symptoms. In a different line of research, Borkovec and Inz (1990) demonstrated that worry is associated with avoidance of aversive imagery, which reduces the likelihood of activating relevant fear structures and processing emotionally incongruent information (cf. Stoeber, 1998). Thus, results from the body of studies examining anxiety-relevant imagery raise the possibility that the activation of threatening images plays a substantially different role in different pathologies. Scripts One of my own lines of research has focused on the assessment of schema content in order to provide empirical validation that threat-relevant schemas exist in individuals with anxiety disorders and that they are indeed abnormal as compared to the schemas of nonanxious individuals. I adopted the script approach from the cognitive psychology literature, which regards schemas as comprising knowledge stores of the stereotypical events that typically occur in common situations. In these studies, I instructed socially anxious and nonanxious participants to write scripts, or ordered sequences of events that occur in potentially threatening situations, such as going to a party or going on date. Based on Beck and Emerys (1985) cognitive theory of anxiety, I predicted that the scripts of socially anxious participants would be composed of anxiety-relevant events as compared to the scripts of nonanxious participants. Contrary to expectation, I found that socially anxious and nonanxious participants listed almost identical events in their scripts, suggesting that the knowledge store of the events that occur in threatening situations is not abnormal in socially anxious individuals (e.g., Wenzel & Holt, 2003; Wenzel, in press). However, when I examined the emotional tone of the manner in which socially anxious participants communicated these events (e.g., go to party reluctantly), I found that their sequences were characterized by more negative affect than the sequences of nonanxious participants. Results from these studies suggest that anxious individuals have adequate knowledge of the expected events that occur in threatening situations but that they may access and interpret this information in a negative manner. Implicit Associations Recently, anxiety researchers have applied the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) to examine fear-related cognitive structures, or schemas, in individuals with specific phobias. The IAT is a reaction time computer task that measures the strength of associations between concepts in memory, which is another indicator of schematic processing. In Teachman, Gregg, and Woodys (2001) investigation of spider and snake fears, participants were presented simultaneously with four category labels on the computer screen: a target and adjective on one side (e.g., spiders, bad) and another target and the opposite descriptor on the other side (e.g., snakes, good). Pictures representing one of the two targets are presented in the center of the screen (e.g., either spiders or snakes), and participants are instructed to indicate which side of the screen matches with the pictures. The rationale behind the task is that stimuli are classified more quickly when the target and adjectives match participants automatic associations (e.g., spiders and bad) than when they are mismatched (e.g., spiders and good). Teachman et al. (2001) found that spider fearful participants reacted faster to associations between spiders and negative descriptors than between snakes and negative descriptors, and snake fearful participants demonstrated the opposite pattern. In a follow-up study, Teachman and Woody (2003) reported that these implicit associations are attenuated following psychotherapy, suggesting that the structures of anxiety-relevant schemas are changed with successful psychosocial interventions. Thus, the Implicit Association Task has the potential to yield data that defines the parameters and structure of maladaptive schemas associated with anxiety disorders. Part 2 of this article will appear in the next issue of Cognitive Therapy Today. References are available upon request by emailing beckinfo@beckinstitute.org

Blog Update: WWW.CTTODAY.ORG Takes Off

Beck Institutes blog traffic has been steadily increasing since we started posting last fall, and weve been especially glad to hear positive feedback from consumers who have questions about Cognitive Therapy. Our Cognitive Therapy Myths post generated lots of discussion: we began by describing various misunderstandings about Cognitive Therapy (CT) - for example, that CT does not involve behavior change, and that it only deals with surface layer problems. Some of our readers wrote back with myths we had never even considered, like the idea that excessive use of CT can turn you into an unemotional robot-like human! (See CT Myths category on the right side of our blog page for details.) So far, weve been trying to vary our blog topics to meet the interests of both professionals and consumers. Weve been following CT developments around the world, including Germanys policy of licensing therapies and providing reimbursement for approved therapies (including CBT), and Australias introduction of a universal mental health care rebate (which also applies to CBT). (See the CT Worldwide category.) Another main focus of the blog is providing up-to-date Research Results. We cant believe the number of new CBT-related studies that are emailed to us and mentioned in the news all the time. On the blog, we try to highlight some of the most interesting studies with the most widespread appeal, give a summary, and provide links to the actual study. Weve posted CBTrelated Research Results on Workplace Stress, OCD, Back Pain, ADHD, suicide, the effect of mandated use of Empirically Supported Treatments in a community clinic, Seasonal Affective Disorder, Gambling, Insomnia, Depression after ECT, Anxiety among women with Breast Cancer, Children and Adolescents with OCD, and fatigue among cancer survivors. This list is only going to get longer. Whats great about blogs is that they have a category system embedded in the software, so that we can easily keep a running list of Research topics that weve blogged about and both consumers and
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professionals can find CBT-related data about disorders they are interested in. We imagine that in the future, this list will be an especially valuable resource. (See the Research Results category.) Were also trying to keep a personal touch on Cognitive Therapy Today especially since we like to connect with all of our current and former trainees around the world! When we have events at the Beck Institute, we often take pictures and post them on the blog. There are currently photos of Aaron T. Becks Lasker Award Reception, and some of our training workshops. (See the Photos category.) Weve also posted links to video footage of Aaron Beck, including his appearance on the Charlie Rose Show and a Youtube clip in Spanish! (See the Videos category). When we looked at our site statistics we found that many people were searching for Aaron Beck Interviews and Aaron Beck Videos. The CT Today blog is now one of the primary sources that pops up when people want to find these items. Please spread the word about www.cttoday.org to your colleagues and anyone else who might be interested. And we welcome your comments and ideas!

Beck Institutes 5-Day Cognitive Therapy Workshop Dates

May 14 -18, 2007 (full) July 16 - 20, 2007 (full) September 24 - 28, 2007 November 5 - 9, 2007 February 25 - 29, 2008 April 7 - 11, 2008 For more information on our training programs, please visit our website: www.beckinstitute.org

SPEAKING ENGAGEMENTS
March 23-25, 2007. New York, NY. Fifth Annual Psychiatric Annals Symposium. Speaker: Judith S. Beck, Ph.D. Workshops: Cognitive Therapy for Personality Disorders; Enhancing Medication Adherence with Cognitive Therapy. Website to register: https://www.slackinc.com/meetings/psyann/ny/ register.htm/ March 30, 2007. Perry Point, M.D. Chesapeake Health Education Program. Speaker: Judith S. Beck, Ph.D. Workshop: Cognitive Therapy for Personality Disorders. Website to register: http://www.chepinc.org/upcoming_events/course.asp?id=06-65/ April 13, 2007. Lakewood, NJ. 2nd Annual Counseling Psychology Spring Conference Georgian Court University. Speaker: Leslie Sokol, Ph.D. Workshop: Cognitive Therapy with Challenging Clients. To Register, Contant Special Events at GCU, 732-987-2263 May 5-6, 2007 - Athens, Greece. Mediterranean College. Speaker: Leslie Sokol, Ph.D. Workshops: Day 1 - Cognitive Therapy for Depression; Day 2 Cognitive Therapy for Anxiety. To register, contact Dr. Marsha Koletsi. Tel.: 210.8899600. Email: mkoletsi@medecs.gr May 19-24, 2007. San Diego, CA. American Psychiatric Association Annual Meeting. Speaker: Judith S. Beck, Ph.D. Workshops: Teaching Cognitive Behavior Therapy to Child and Adult Residents. Symposium: Cognitive Therapy as part of Brief Therapies: An Update for Clinicians. Case Conference: Cognitive Therapy for Depression. Website to register: http://www.psych.org/edu/ann_mtgs/am/07/index.cfm May 20-24, 2007 Hong Kong. Castle Peak Hospital, Institute of Mental Health. Speaker: Leslie Sokol, Ph.D. 5-Day Cognitive Therapy Training. To register, contact Ms. Amy Chow, Public Affairs Manager. chowcs@ha.org.hk June 20-24, 2007. Indianapolis IN. American Academy of Nurse Practitioners (AANP) Annual Conference. Speaker: Judith S. Beck, Ph.D. Workshop: Cognitive Behavior Treatment for Weight Loss and Maintenance . Website to register: http://www.aanp.org/Conferences/Conferences.asp June 29, 2007. Harrisburg, PA. Pennsylvania Psychological Association Annual Convention. Award Recipient: Judith S. Beck, Ph.D. Distinguished Contributions to the Science and Profession of Psychology. Website to register: http://www.papsy.org/resources/ce_convention/ convention.html July 11-15, 2007 . Barcelona, Spain. World Congress of Behavioural and Cognitive Therapies. Speaker: Judith S. Beck, Ph.D. Workshops: Cognitive and Behavioral Techniques for Weight Loss and Maintenance; Cognitive Therapy for Personality Disorders. Website to register: http:// www.wcbct2007.com/ August 17-20, 2007. San Francisco, CA. American Psychological Association Annual Convention. Speaker: Judith S. Beck, Ph.D. Symposium: Using Cognitive Restructuring to Enhance Psychotherapist Self-Care. Workshop: Cognitive Therapy for Personality Disorders. Website to register: http:// www.apa.org/convention07/ October 7-9, 2007. Washington, DC. Nation Nursing Centers Consortium (NNCC) - 6th Annual Nurse-Managed Health Centers Conference. Speaker: Judith S. Beck, Ph.D. Workshop: Using Cognitive Behavioral Techniques for Weight Loss and Maintenance. Website: http://nncc.us/ conference/NNCC_2007conference.html

FOR TRAINING OPPORTUNITIES AT THE BECK INSTITUTE, VISIT www.beckinstitute.org

Cognitive Therapy Today

Beck Institute for Cognitive Therapy and Research One Belmont Avenue, Suite 700 Bala Cynwyd, PA 1900419004-1610 Telephone: 610.664.3020 Fax: 610.664.4437 Email: beckinst@gim.net Website: www.beckinstitute.org
Editor-in-Chief: Judith S. Beck, Ph.D.

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Inside this issue:

The Albert Lasker Award Reception and SpeechAaron T. Beck, M.D. A Cognitive Therapy Weight Loss Group Judith S. Beck, Ph.D. Cognitive Therapy for Anxiety DisordersAmy Wenzel, Ph.D. Blog Update: WWW.CTTODAY.ORG Takes Off