Volume 12 Issue 2

Fall 2007

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

The Importance of Experiential Learning in Dieting
Patients whom we treat for a variety of psychiatric disorders or psychological problems sometimes express the sentiment: I understand what youre saying on an intellectual level, but in my gut, I still believe...[a dysfunctional idea]. Often they need experiential techniques to address this emotional level of thinking. Weve found the same to be true of dieters. Most dieters have heard stories of people surviving without food (due to a plane crash or hunger strike) for a week, but they still believe that something deleterious will happen to them if they get too hungry. They need to demonstrate to themselves that they will survive being hungry, that they have tolerated far worse discomfort than hunger, and that hunger actually comes and goes; it does not just get worse and worse. That is why we suggest, with medical clearance, that dieters pick a day to refrain from eating between breakfast and dinner. Many dieters are astounded by the experience and report that this seminal event eliminated their fear of hunger. Many dieters have also heard that it can take up to 20 minutes after a meal for satiety to set in. Yet when their food is gone and they dont feel full, they often feel anxious and take second helpings or plan to eat a greater quantity of food (such as vegetables) to fill themselves up. An important experiment, which they generally need to repeat several times, is to deliberately eat a meal very quickly, set a timer for 20 minutes, and go about their usual routine. This kind of experience is often quite surprising to them as well. They find that they have become full in the interim. Their anxiety decreases and they are able to stop loading up their plates at meal time.
(Continued on page 4 )

From the President Aaron T. Beck, M.D.

Anger, Hostility, and Violence
One can hardly read or hear the latest news without learning of glaring examples of hostile, destructive aggression: murders, rapes, and torture. We also hear of mass killings, terrorist attacks, and civil wars. Despite the various forms of such hostile aggression and the broad range of settings, there are certain common denominators across all these actions. Let us start with a simple, everyday example of an individual with a short fuse. Jon impatiently waits for service in a restaurant. He notices that people at another table, whom he believes placed their order after he did, are being served. He becomes furious at the waiter and starts to yell at him. He ends up being asked to leave. His experience is not unusual - except that he has less than average control. A microanalysis of Jons reaction, a patient of mine, shows a series of steps. In Jons mind, he was unjustly treated and the waiter deserved to be punished. The sequence as it played out in the reenactment in therapy was the event, a rapid interpretation, He does not have respect for me, followed by a hurt feeling. What Jon was conscious of was He has no right to favor the other customers. But what actually caused his rage was the hurt from being disrespected, which struck at a longstanding hypersensitivity. The steps in such acute reactions are first the event, then a negative, personalized interpretation, then a hurt feeling, blaming the hurt on the offender, and finally, consequently, the urge to punish him. The key to understanding the intensity of his rage was that he felt diminished. This feeling was so quickly overshadowed by his anger that
(Continued on page 5)

For Cognitive Therapy and Research

Inside This Issue:

Experiential Learning in Dieting . . . . . . . . . Page 1 Anger, Hostility, and Violence . . . . . . . . . . .Page 1 Powerful Distortions from Combat . . . . . . . Page 2 Anxiety Disorders . . . . . . . . . . . . . . . . . . . Page 3 Speaking Engagements. . . . . . . . . . . . . . . . Page 6

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The Power of Cognitive Therapy to Change Powerful Distortions from Combat

A former extramural fellow was kind enough to allow us to reprint the following description of a cognitive intervention with a veteran suffering from PTSD. He notes the power of Cognitive Therapy to change even powerful distortions about his wartime experiences.

Captain: I havent slept in 3 months, Sir. Therapist: What keeps you from sleeping? Captain: I have many stressful things in my life, Sir. My wife wants to leave me. She says Im not the same person she married. She says I am changed by combat in Iraq. I have a very short temper; I get angry, very angry over little things. I have no time for nonsense. I cant drive under bridges I think a bomb will be dropped on my car. I drive down the middle of the highway. Trash on the side of the road looks like an IED. Therapist: What exactly keeps you from sleeping? Captain: A picture comes into my mind when I close my eyes. Therapist : Describe the picture. Captain: I dont think I can without crying, Sir. Therapist: Do officers need permission to cry? Captain: An officer can never cry in front of his men, Sir. Therapist: You may cry in front of me, if you wish. I admire you for serving in battle. I feel like I am on sacred ground when I talk with a person like you. Captain: (staring deeply into my eyes for a long time, a stare of recognition of caring) Thank you, Sir. Therapist: You may describe the picture when you feel ready. It does not have to be today. Captain: I need to tell you now, Sir. Therapist: All right.

Captain: I was a convoy commander. We had had a good day. We all came back to our FOB (forward operating base) without a casualty. My uniform was covered with sand. I turned in my vehicle and took a shortcut across the FOB. Just as I passed the Medical Aid Station two soldiers came up to me dragging a wounded soldier between them. Sir, Sir, save our brother, Sir. They must have thought I was a medic because I was in front of the Aid Station. I looked down to the wounded soldier. I could see part of his brain dangling out of his head. I froze for a moment. I didnt know what to do or say. They kept pleading with me to save their brother. Almost immediately the medics came up and took the wounded soldier away. Thats the picture, Sir. Therapist: What happened next? Captain: What do you mean, Sir? Therapist: What happened to the two soldiers? Captain: They stayed with me. Therapist: Were they your soldiers? Captain: No, Sir. I had never seen them before. Its almost funny but they would not leave me. Therapist: Can you explain that more fully? Captain: They just wanted to talk to me. Their commander came up and told them to move on but they stayed with me. We just walked together and talked. Therapist: What did you talk about? Captain: I asked them to tell me about their battle brother. They were very close to him. Therapist: What did you say? Captain: I told them they had to remember his smiling and laughing and the good times and closeness they shared. Therapist: Did you help them?

my commander came up later and asked me what was going on. She wanted me to move on until I told her what happened. Therapist: I believe you were very helpful to those two young soldiers. Captain: Thank you, Sir, but I didnt save their brother. Thats the bad picture I see when I close my eyes. I froze. I did not save their brother. Therapist: Were you there to save the wounded soldier? Captain: Thats what Ive been thinking, Sir. Therapist: Ten neurosurgeons kneeling on the ground next to the wounded soldier could not have saved him, Captain. Captain: Really, Sir? Therapist: Could you have been there for another reason? Captain: Like what, Sir? Therapist: You tell me, Captain. Captain: You mean I was there for the two soldiers, Sir? Therapist: They will never forget you. That night the Captain slept. He attended group therapy and continued CT for about 3 months. I saw him in the gym just a few weeks ago. He was smiling and pumping iron; sweat covered his muscular body. Therapist: How are you doing Captain? Captain: Im fine, Sir. Therapist: Tell me what helped you. Captain: I got my sleep back. I got my thinking straightened out. And I got back into exercise. Therapist: How is your marriage? Captain: We are just fine, Sir.

Captain: Yes, Sir. I think I did. Actually, 2

Cognitive Therapy for Anxiety Disorders: A Discussion of Recent Empirical Developments Part 2
Amy Wenzel, Ph.D., University of Pennsylvania
Part 1 of this article appeared in the Spring 2007 issue of Cognitive Therapy Today. To access Part 1, please visit our website www.beckinstitute.org
Self-Focused Attention In my previous article, I indicated that there is robust empirical evidence to suggest that anxious individuals exhibit attentional biases toward threat in their environment, such that they detect potential danger more quickly than nonanxious individuals and focus their attention on threat at the expense of neutral or safety stimuli. However, in social phobia an additional type of attentional bias is at workthat of self-focused attention. Specifically, when socially anxious individuals are in a potentially embarrassing situation, they turn their attention onto themselves instead of monitoring their environment (Hope, Gansler & Heimberg, 1989). This shift of attention impairs performance in some instances, increases negative affect, and activates negative cognitions (Woody, 1996). This line of research raises the interesting notion that more than one type of attentional bias is at work in social phobia, each of which may be amenable to treatment with cognitive therapy (Woody, Chambless & Glass, 1997). Thought Control Thought suppression is the attempt and act of eliminating unwanted thoughts from awareness. In general, thought suppression studies demonstrate that most individuals are unable to fully reduce particular thoughts from awareness when instructed to do so. Moreover, most individuals experience a higher frequency of unwanted thoughts following efforts to keep them out of awareness than they would if they had never attempted suppression, a phenomenon called the rebound effect (e.g., Wegner, Schneider, Carter & White, 1987). The rebound ef fect is o f te n d escr ib ed as paradoxical (cf. Wegner et al., 1987), as individuals who use thought suppression as a self-control strategy may actually increase the frequency of the intrusive thoughts they are attempting to eliminate. The paradoxical effect of thought suppression has been proposed to be an analogue of psychopathological processes such as obsessionality and rumination (Rassin, Merckelbach & Muris, 2000). Thought-action fusion is the belief that unacceptable thoughts and beliefs have a tangible influence on the world (Shafran & Rachman, 2004). Likelihood thoughtaction fusion is the belief that having an unacceptable thought increases the probability of the adverse event occurring, whereas moral thought-action fusion is the belief that having an unacceptable thought is almost the equivalence of having carried out that act. According to Shafran and Rachman (2004), instances of thoughtaction fusion reflect an inflated perceived responsibility for harm. Moreover, the importance of these thoughts is interpreted in an exaggerated manner. Although empirical work with clinical samples in this area of research is sparse, the studies that have been conducted suggest that thoughtaction fusion is relevant to many anxiety disorders, including obsessive compulsive disorder and generalized anxiety disorder, as well as depression. Problem Solving A line of empirical research conducted in the 1990s assessed the degree to which pathological worry inhibits e f f e c t i ve p r o b le m s o l v i n g a n d implementation of solutions. Contrary to expectation, this research determined that worriers and non-worriers have similar problem solving skill (e.g., Davey, 1994). However, worriers have more problematic problem solving orientation, in that they report low confidence in their problem solving abilities, little perceived control over the problem-solving process, and a general intolerance of uncertainty over whether and when the problem will be resolved (Dugas, Freeston & Ladouceur, 1997; Ladouceur, Blais, Freeston & Dugas, 1998). This maladaptive problem solving orientation inhibits the application of otherwise adaptive problem solving skills. Conclusion All of the constructs described in this article are compatible with Beck and Emerys (1985) cognitive theory of anxiety. Assessment of anxiety-relevant images has the potential to add to the already rich taxonomy of negative selfstatements that have been documented in various anxiety disorders. The script and implicit association methodologies have begun to provide empirical validation for schema construct, which is the central component of Beck and Emerys cognitive model. Consideration of selffocused attention and its relation to attentional biases toward external threatrelevant stimuli lends to a finer-grained conceptualization of cognition in social phobia. Investigations into thought suppression, thought-action fusion, and problem solving highlight possible distortions that limit patients capacity for information processing. Thus, the time is ripe to integrate these literatures and apply them to our basic cognitive models of anxiety to provide another layer of description, explanation, and prediction. In the third article in this series, I will shift focus and discuss advances in the literature pertaining to cognitive therapy for anxiety disorders,

considering the manner in which research examining cognitive theory has clinical relevance.
Please see page 5 for references.

Experiential Learning in Dieting continued from page 1

Although dieters generally know that it is important to eat a healthy, well-balanced diet, they often believe that it does not really matter what they eat, as long as they restrict their calories. We ask them to do certain eating experiments so they can experience for themselves why it does matter. For example, if they are accustomed to eating mostly simple carbohydrates for breakfast, we suggest that they have breakfasts that contain the same number of calories, but that instead contain protein and some fat, with little or no carbohydrates. We might also have them contrast how strong their hunger and craving are an hour after eating a sugary snack as compared to a protein-rich snack (such as nuts) with the same number of calo r ies. Once the y d o these experiments, they become convinced that they need to eat in a more healthy, hunger-satisfying way. Some of our dieters catastrophize about displeasing other people. For example, they are reluctant to turn down friends, family members, or co-workers who offer them food that they are not supposed to eat. They believe that others will have a strong negative reaction. We roleplay gentle but firm assertiveness with them and encourage them to decline food that is not on their plan. Again, dieters are often surprised to find that most people do not really care or that their disappointment is fairly minimal and transient. Dieters often have misinformation. They believe that the scale should go down every single day, when, in actuality, we have found that a persons weight often fluctuates plus or minus two pounds. Even when they have held their caloric intake and exercise constant, dieters weight never goes consistently down every day, due to water retention, hormonal changes, or other physiological processes. Even when dieters receive this information, they still tend to catastrophize when the scale goes up. They fear that something has gone wrong, that they will not continue to lose weight, and therefore, that it is not worth the effort to keep dieting. They need the experience of tracking their weight daily so they can see, over and over again, that their weight does come down after short plateaus or weight gains. Seeing is believing. Information alone is often insufficient. We have to provide meaningful learning experiences for our dietersand other patients, too.

Reference: Beck, J. S. (2007). The Beck Diet Solution Weight Loss Workbook, Birmingham, AL: Oxmoor House.

Congratulations to Dr. Aaron T. Beck!

Were delighted to announce that Dr. Beck received the following awards in 2007: the American Counseling Association's Presidential Award in March, the American College of Physicians' William C. Menninger Memorial Award for Distinguished Contributions to the Science of Mental Health in April, an Honorary Degree of Doctor of Science from the University of Pennsylvania in May, and the APA Division 12 Lifetime Achievement Award in recognition of research in suicide and behavioral emergencies in August. On October 6, 2007, Dr. Beck will be named a Fellow in the American Academy of Arts & Sciences, in recognition of outstanding contributions to his profession, the nation, and the world. He also accepted an honorary membership in the Dutch Association of Behavior and Cognitive Therapy. On November 14, 2007, Dr. Beck will be honored at the University of Pennsylvania's Awards of Excellence Banquet. He has been selected by a committee of his peers to receive the William Osler Patient Oriented Research Award for his groundbreaking research which led to the development of Cognitive Therapy. This award recognizes outstanding achievement for research in which the investigator directly interacts with human subjects. 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

Anger, Hostility, and Violencecontinued from Page 1

Continued from page 1

Anxiety Disorderscontinued
REFERENCES

he did not recognize it at the time. When we pinpointed this problem in therapy, he realized how unreasonable his interpretation was. He realized that the other party had actually ordered sandwiches, which did not require much preparation time. This sense of being diminished in some way (hurt, frustrated, threatened) is the initial factor in hostility towards other individuals, ethnic groups, and nations. A series of stages occur in chronic conflict between individuals and groups. First is the framing of the other person or group as bad and the self as the innocent victim. This paradigm of the innocent self and the guilty other is the common denominator across most kinds of violence. Take a chronic marital war (as in the movie The War of the Roses). Each has the image of the self as good, correct, and vulnerable, and the other as vicious, wrong, and dangerous. These concepts often take the form of visual images with the other appearing with a sneering, evil facial expression. The entire personality of the other is reduced to the two-dimensional picture of sheer wickedness. Now let us look at violence between groups of people. People are the same whether involved in hostility toward another individual, as members of a terrorist group, or as soldiers in an army. The motivation to injure, immobilize, or kill the other group stems from the collective self-image of themselves as good, right, and vulnerable -- and innocent victims -- and the other as bad, evil, and dangerous. The others need to be punished or eliminated. Some data to support this comes from studies of conflicting groups. Israeli and Arab adversaries have the identical mirror image of each other. Similarly, Republicans and Loyalists (Catholics and Protestants) in Northern Ireland had the same violent images of each other. These conflicts culminate in killing the adversary.

However, people do not start off wanting to kill their adversaries. They go through a series of stages reflected in their image of the enemy: detachment, dehumanizing, and demonizing. The common denominator is the Image of the Enemy. He or she is bad, dangerous, and powerful. I am good, innocent, and vulnerable. In group violence, the collective self image is the same: We are innocent victims, they are the victimizers. Hitlers speeches which brought the populace to a frenzy contained statements such as, The other countries have oppressed Germany and want to crush us. The Jews are vermin, have infected and dominated us and need to be eliminated. The image of heterogeneous individuals as a group becomes homogenized something we call group think. The usual individuality succumbs to pressure to conform. All others behavior is formed by the image, and in attacking their image, we destroy the individual. The leaders of a nation, army, or terrorist group employ various tools of indoctrination to achieve the goal of inducing their followers to kill. It was discovered during the Korean War, for example, that the American soldiers were sparing in their use of ammunition. Most frontline soldiers did not fire at all. Consequently, in preparation for fighting in Vietnam, the soldiers were trained to fire repeatedly at targets portraying evillooking North Vietnamese. This procedure gradually reduced the soldiers inhibitions but also helped to fix the Image of the Enemy. Torturers also appear to go through similar stages of desensitization (or conditioning). In the present conflict in Iraq, there is the same kind of indoctrination. There are possibilities for the cessation of violence. In Northern Ireland, important work has been done at the infrastructure of society i.e. within the workplace, in labor unions, and in sports teams, to bring about understanding and reconciliation. A similar approach can be used in other trouble spots to advance the goals of peace and tolerance. 5

Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. Borkovec, T. D., & Inz, J. (1990). The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behaviour Research and Therapy, 28, 153-158. Davey, G. C. L. (1994). Worrying, social problem solving abilities, and social problem solving confidence. Behaviour Research and Therapy, 32, 327-330. Dugas, M. J., Freeston, M. H., & Ladouceur, R. (1997). Intolerance of uncertainty and problem orientation in worry. Cognitive Therapy and Research, 21, 593-606. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual differences in implicit cognition: The Implicit Association Test. Journal of Personality and Social Psychology, 74, 1464-1480. Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. (2003). Self-images play a causal role in social phobia. Behaviour Research and Therapy, 41, 909-921. Hope, D. A., Gansler, D. A., & Heimberg, R. G. (1989). Attentional focus and causal attributions in social phobia: Implications from social psychology. Clinical Psychology Review, 9, 4960. Ladouceur, R., Blais, F., Freeston, M. H., & Dugas, M. J. (1998). Problem solving and problem orientation in generalized anxiety disorder. Journal of Anxiety Disorders, 12, 139-152. Ottaviani, R., & Beck, A. T. (1987). Cognitive aspects of panic disorder. Journal of Anxiety Disorders, 1, 15-28. Rassin, E., Merckelbach, J., & Muris, P. (2000). Paradoxical and less paradoxical effects of thought suppression: A critical review. Clinical Psychology Review, 20, 973-995. Shafran, R., & Rachman, S. (2004). Thought-action fusion: A review. Journal of Behavior Therapy and Experimental Psychiatry, 35, 87-107. Stoeber, J. (1998). Worry, problem elaboration, and suppression of imagery: The role of concreteness. Behaviour Research and Therapy, 36, 751-756. Teachman, B. A., Gregg, A. P., & Woody, S. R. (2001). Implicit associations for fear-relevant stimuli among individuals with snake and spider fears. Journal of Abnormal Psychology, 110, 226-235. Teachman, B. A., & Woody, S. R. (2003). Automatic processing in spider phobia: Implicit fear associations over the course of treatment. Journal of Abnormal Psychology, 112, 100-109. Wegner, D. M, Schnieder, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5-13. Wells, A., Clark, D. M., & Ahmed, S. (1998). How do I look with my minds eye: Perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631-634. Wenzel, A. (in press). Schema content for social and evaluative situations in social phobia. Cognitive Therapy and Research. Wenzel, A., & Holt, C. S. (2003). Situation-specific scripts for threat in socially anxious and nonanxious individuals. Journal of Social and Clinical Psychology, 22, 145-168. Woody, S. R. (1996). Effects of focus of attention on social phobic anxiety and social performance. Journal of Abnormal Psychology, 105, 61-69. Woody, S. R., Chambless, D. L., & Glass, C. R. (1997). Selffocused attention in the treatment of social phobia. Behaviour Research and Therapy, 35, 117-129.

SPEAKING ENGAGEMENTS ENGAGEMENTS SEE WEBSITES FOR REGISTRATION INFORMATION

November 2-3, 2007. Dominican Republic. Centro de capacitacion de Psicologia clinica. Workshop: Cognitive Therapy. Speaker: Leslie Sokol, Ph.D. Website: www.worldwidetrainings.com November 9, 2007. Lakewood, NJ. Georgian Court University. Workshop: Cognitive Therapy for Challenging Problems. Speaker: Leslie Sokol, Ph.D. Website: www.georgian.edu/public_events/cognitive_therapy/html November 15-18, 2007. Philadelphia, PA. Association for Behavioral and Cognitive Therapies (ABCT) Annual Convention. Workshop 15: Cognitive and Behavioral Techniques for Weight Loss and Maintenance. Speaker: Judith S. Beck, Ph.D. Panel Discussion 17: Expanding the focus of training in CBT. Speaker: Judith S. Beck, Ph.D. Clinical Intervention Training 3: Intensive Cognitive Therapy Supervision for Clinicians and Trainers. Speaker: Leslie Sokol, Ph.D. Website: http://www.abct.org/ December 3, 2007. Washington, DC. National Health Wellness Prevention & Fitness Conference. Panel Discussion: We want to lose the weight, dont we if so, how can we change and why? Speaker: Judith S. Beck, Ph.D. Website: http://www.consumerhealthworld.com/nhwpcf07/# January 12, 2008. Wynnewood, PA. Pennsylvania Society for Clinical Social Work. Workshop: Cognitive Therapy for Depression. Speakers: Judith S. Beck, Ph.D. and Daniel T. Beck, LICSW. Website: http://pscsw.org Institute for the Advancement of Human Behavior (IAHB) Speaker: Judith S. Beck, Ph.D. 10 Workshops: The Beck Diet Solution: Teaching Dieters Cognitive Therapy Skills for Lifetime Weight Loss and Maintenance. Dates and Locations: October 5, 2007. Towson, MD October 6, 2007. McLean, VA November 27, 2007. San Francisco, CA November 28, 2007. Concord, CA November 30, 2007. Woodland Hills , CA December 1, 2007. Los Angeles, CA February 1, 2008. Portland, OR February 2, 2008. Seattle, WA February 7, 2008. Dallas, TX February 9, 2008. Houston, TX. Website: http://www.iahb.org/html/beck_diet.html June 12-19, 2008. Rome, Italy. International Congress of Cognitive Therapy. Workshop: TBD. Speaker: Judith S. Beck, Ph.D. Website: http://www.iccp2008.com/index.htm

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Inside this issue:

Anger, Hostility, and ViolenceAaron T. Beck, M.D. Experiential Learning in Dieting Judith S. Beck, Ph.D. Cognitive Therapy for Anxiety Disordersby a former BI Extramural fellow Cognitive Therapy for Anxiety Disorders Amy Wenzel, Ph.D.