Depression

Beck initially set out to test the Freudian notion that depression is a consequence of “anger turned inward” (rage directed the introjected parent for not gratifying infantile desires) but soon came to conclude that no such unconscious motivation existed and that instead depressed patients actually believe that they were unlovable or inadequate. He developed a treatment that he named cognitive therapy that is as efficacious as and more enduring than antidepressant medications. It stands as the most often tested and most widely practiced treatment for depression.     

Cognitive Reappraisal

A central tenet of Beck’s cognitive therapy (or cognitive behavior therapy) of the emotional disorders is that change in negative thought and beliefs is necessary for clinically significant symptom reduction in anxiety, depression, and other psychological conditions. Cognitive restructuring, a uniquely Beckian innovation, is a treatment strategy that directly targets cognitive reappraisal as the change mechanism responsible for symptom reduction. This commentary considers the origins of cognitive reappraisal in Beck’s cognitive therapy through the lens of cognitive restructuring and what treatment process research tells us about the mechanisms of change in cognitive restructuring.     

Introduction to the Beck Commemorative Special Feature

My father, Aaron Beck (“Tim” to those closest to him), would have been proud of this special issue of Cognitive and Behavioral Practice, and so honored. Anyone who knew my father, knew he was a scientist at heart. His curiosity, intelligence, and humility made him a great scientist and a productive researcher. This introduction shares a personal perspective and context for his contributions, including his lifelong commitment to enhancing the evidence for cognitive and behavioral practice.     

Emotional Schemas

Beck's cognitive model has stressed the influence of cognitive processing in eliciting and maintaining emotional disorders. The concept of schema is extended in Emotional Schema Therapy to account for beliefs, assumptions, and strategies that comprise problematic theories of emotion that result in unhelpful strategies of emotion regulation and acceptance of emotion. In the present paper the central concepts of Emotional Schema Therapy are elucidated and research supporting the model is reviewed.     

A Rumination-Focused Cognitive-Behavioral Therapy Self-Help Program to Reduce Depressive Rumination in High-Ruminating Japanese Female University Students: A Case Series Study

The present case series reports the preliminary test of a rumination-focused cognitive-behavioral therapy (RFCBT) self-help program to reduce depressive rumination among Japanese female undergraduates. A workbook-type self-help program based on RFCBT was implemented with 39 participants showing a high tendency toward rumination/worry. Data from 30 participants who completed one or more modules were analyzed quantitatively. The results showed significant reductions of rumination, worry, and anxiety at post-intervention. Further, semistructured interviews were conducted with 13 participants who completed the program, and verbatim data were examined using content analysis. The contents found to be useful and difficult differed for each participant and each module. Based on these results, the future implementation and dissemination of RFCBT is discussed.     

Telehealth for Dialectical Behavioral Therapy: A Commentary on the Experience of a Rapid Transition to Virtual Delivery of DBT

Telehealth has been rapidly adopted to provide continuity of delivery of mental health services in light of COVID-19. However, the remote implementation of intensive treatments like dialectical behavioral therapy (DBT) has been vastly understudied. The aim of the current commentary is to describe potential obstacles, propose solutions, and discuss advantages of transitioning from traditional in-person to a virtual delivery format for full model DBT. We speak to these points at multiple levels of relevance to clinical scientists and practitioners: (1) considerations about the virtual delivery format, (2) considerations for the virtual delivery of DBT specifically, and (3) person-level considerations (e.g., client, clinician). We illustrate the commentary using examples of obstacles encountered and solutions identified during our DBT team’s rapid transition to telehealth in response to COVID-19-related shut-downs and discuss considerations for the extension of telehealth delivery of DBT going forward. We are hopeful that the rapid transition to telehealth delivery of mental health services in response to COVID-19 serves as a call to action for clinicians to adapt and leverage technology to deliver DBT on a broader scale to improve patient health outcomes.     

Long-Term Follow-Up of a Randomized Controlled Trial Comparing Acceptance and Commitment Therapy and Standard Cognitive Behavior Therapy for Anxiety and Depression

The present study represents one of the first comparisons of the long-term effectiveness of traditional cognitive behavior therapy (i.e., Beckian cognitive therapy; CT) and acceptance and commitment therapy (ACT). One hundred thirty-two anxious or depressed outpatients were randomly assigned to receive either CT or ACT, and were assessed at posttreatment (n = 90) and at 1.5-year (n = 91) follow-up. As previously reported, the two treatments were equivalently effective at posttreatment according to measures of depression, anxiety, overall (social/occupational/symptom-related) functioning, and quality of life. However, current results suggest that treatment gains were better maintained at follow-up in the CT condition. Clinical significance analyses revealed that, at follow-up, one-third more CT patients were in the clinically normative range in terms of depressive symptoms and more than twice as many CT patients were in the normative range in terms of functioning levels. The possible long-term advantage of CT relative to ACT in this population is discussed.     

Couple Relationship Education at the Transition to Parenthood: A Window of Opportunity to Reach High‐Risk Couples

This study evaluated if the transition to parenthood is a window of opportunity to provide couple relationship education (CRE) to new parents at high risk for future relationship problems. Fifty‐three percent of eligible couples approached agreed to participate in CRE and of these 80% had not previously accessed CRE. Couples were a broad representative of Australian couples having their first child, but minority couples were underrepresented. A third of couples had three or more risk factors for future relationship distress (e.g., cohabiting, interpartner violence, elevated psychological distress, unplanned pregnancy). Low education was the only risk factor that predicted drop out. The transition to parenthood is a window of opportunity to recruit certain types of high‐risk couples to CRE.     

Psychic skin: psychotic defences, borderline process and delusions

In this paper, I apply the concept of psychic skin to analytic work with people suffering from personality disorders and psychoses. When psychoses emerge, the defensive skin which protects the ego is breached and violent unconscious forces rip through the personality. Some of the patients diagnosed as schizophrenic with whom I work have identified with archetypal characters such as Christ, Satan, John Lennon and the Queen. I attempt to show how the adoption of these inflated personas can serve as secondary psychic skins. Such delusional identifications can provide a protective shield to hide the denuded self and prevent intrusion from the external world. Through clinical example, I try to demonstrate how these archetypal 'second skins' can preserve life until internal and external conditions make it possible for the self to emerge. I contrast such psychotic identifications with 'thin-skinned' and 'thick-skinned' narcissism as well as 'defences of the self' in borderline states where the psychic skin may be damaged but does not disintegrate. I also look at the ways in which Jung's own personal experience was different from this and how he managed to avert psychotic breakdown.