CC Cognitive ognitive ognitive TT Therapy herapy herapy TT Today oday oday

A publication of the Beck Institute for Cognitive Behavior Therapy

Volume 17, Issue 3: September 2012
It is impossible, at tmes, to avoid fricton and misunderstandings in
the therapeutc relatonship, especially with Axis II patents. Accord-
ing to Strauss et al. (2006), the best outcomes occur when therapists
are able to repair therapeutc ruptures and the worst outcomes oc-
cur when therapists fail to resolve difcultes. In my clinical experi-
ence, I have found that patents beneft the most when their thera-
pists skillfully repair difcultes in the alliance and help patents gen-
eralize what they have learned from the experience to improve the
relatonships they have outside of treatment.
Several years ago, I treated Adam, a 28 year old male who sufered
from chronic major depression and borderline personality disorder.
Our frst major therapeutc difculty arose in the ffh session, which
(Contnued on Page 4)
Repairing Ruptures in the Therapeutic Relationship
Judith S. Beck, Ph.D., President
The questons I am most frequently
asked at workshops generally revolve
around my opinion of the new thera-
pies and how they may ft with cogni-
tve therapy.
At the outset, I should say the ap-
proach of cognitve therapy is not cut
in stone. What is relatvely invariant,
however, is the theory behind the
therapy. The theory is essentally
incremental as new advances are
made in psychology, biology, and
related felds. So, for example, there
have been many studies linking neu-
robiological mechanisms with basic
cognitve theory. This has led to a
more comprehensive neurobiological
paradigm for the system of cognitve
therapy.
1

In making comparisons with the
other therapies, partcularly the
third wave therapies, it is im-
portant to make a distncton be-
tween a system of psychotherapy
(which includes a well validated
theory and a validated therapy
derived from the theory) from a
set of strategies which do not have
solid theoretcal backing
1
.
While the core principles of the
cognitve theory have been well-
established, newer research over
the years have expanded the
boundaries of the original proposi-
tons. This has allowed a very
broad extension of the specifc
(Contnued on Page 2)
In this Issue
Comparing CBT with
Third Wave Therapies
Repairing Ruptures in the
Therapeutc Relatonship
Benefts of Using Cognitve
Behavior Therapy to Treat
Substance Abuse

Understanding Nonsuicidal
Self-Injury in People with
Borderline Personality Disorder
Calendar of our Upcoming
CBT Workshops


Comparing CBT with Third Wave Therapies
Aaron T. Beck, M.D., President Emeritus
Above, Judith Beck provides instructon and roleplays with a
partcipant at a recent Level II Workshop.
Our Level II: CBT for Personality Disorders and Challenging
Problems Workshop will be held twice in 2013, and will teach
partcipants how to implement -- or vary -- many structural
elements of CBT, in order to develop and maintain a strong
therapeutc alliance with the Axis II client and use the alliance
to achieve therapeutc goals.
Page 1






There are a variety of reasons why the products from the
refexive system are ofen incorrect, and at tmes irratonal.
When the second system is actvated, however, it can rapidly
modify the contents of the products of the frst system.
Therapists can feel comfortable with the applicatons of the
theory and the strategies utlized to implement the theory
because both the theory and the expansions and the thera-
pies derived from them have been validated.
2

Acceptance and commitment therapy (ACT), dialectcal be-
havior therapy (DBT), mindfulness, and therapy based on
relatonship variables (common factors) have a beginning
track record, but the theoretcal basis is ofen uncertain. The
relatonship of theory to the therapy is weak, and the theory
lacks evidence.
The literature shows that mindfulness techniques produce a
detachment from ongoing preoccupatons (de-centering) and
increased perspectve taking. In theory, this should actvate
the ratonal system (centered in the pre-frontal lobe) and
consequently atenuate the negatve automatc processing.
The acceptance component aspect of ACT and DBT acts in a
somewhat similar way. Dysfunctonal thoughts are accepted
simply as thoughts-- which enables the patent to acquire
some distance from them. Distancing, objectvity, and per-
spectve taking are related to the increased actvity of the
ratonal system.
Cognitve restructuring (as in CT) also includes distancing
from the negatve cognitons but, in additon, has a powerful
correctve impact on the negatve schemas, as well as rein-
forcing ratonal processes.
Finally, the relatonship factors approach includes the triad of
unconditonal acceptance, genuine warmth, and accurate
empathy. All of these can serve to improve the patents self
esteem and negate and undermine the negatve processing.
(Contnued on Page 6)
formulaton of numerous disorders, as well as new under-
standings of human nature, problems with everyday life,
and problems and difcultes between people and groups.
The underpinning of a successful theory not only facilitates
the development of new strategies, but insures durability.
A basic expositon of the theorys cognitve structures al-
lows for the development of techniques to modify these
structures in a durable way.
Because the original core theory and its expansion provide
a broad framework for human understanding, the cognitve
model is easily converted into specifc mini-theories appli-
cable to a wide variety of disorders and human problems.
Furthermore, these mini-theories are easily adapted to
specifc formulatons of a specifc case.
A useful way of conceptualizing individuals reactons to
events and partcularly to psychopathology is the
following:
Cognitve processing consists of two systems. The frst sys-
tem is refectve, automatc, and relatvely crude. It breaks
events into evaluatve categories (good, bad, threatening,
loss, gain) and is absolute. This system is also linked to
a u t o m a t c
memory. Since
it responds so
rapidly we can
call it the re-
fexive system.
A second sys-
tem, which we
can call the
refectve sys-
tem, is deliber-
ate and utlized
to correct the
errors or inac-
curacies in the
frst system, as
well as to solve
problems.
There already
are suggestons
of neurobiolog-
ical correlates
of these sys-
tems. Thus, the refexive system consists of excitaton of
the pathways leading from the thalamus to the amygdala,
hypothalamus, and the anterior cingulated prefrontal lobe.
In depression, the prefrontal lobes are deactvated where
as the rest of the circuitry is actvated. The trick is to focus
on mechanisms of acton. Where does each of the thera-
pies actually operate? The refexive system is ofen re-
ferred to as the automatc processing system and the
refectve system as controlled processing.
(Contnued from Page 1)
Page 2
Cognitve restructuring
(as in CT) also includes
distancing from the
negatve cognitons
but, in additon, has a
powerful correctve
impact on the negatve
schemas, as well as
reinforcing ratonal
processes.
Above, Judith Beck and Aaron T. Beck meet with Scholarship Contest win-
ners during our recent 3rd Annual Student and Faculty CBT Workshop.
Image courtesy of Diane Saccoccio / Imagepoint Studio






Although approximately 9% of Americans ages 18 years
and older meet criteria for a current substance abuse
disorder (i.e., alcohol or drug abuse or dependence; Comp-
ton, Thomas, Stnson, & Grant, 2007; Hasin, Stnson,
Ogburn, & Grant, 2007), only 10-20% of these individuals
seek treatment (Stnson et al., 2005). When people with a
substance abuse disorder enter treatment, between one-
third and two-thirds drop out prior to treatment comple-
ton (Dutra et al., 2008; Tzilos, Rhodes, Ledgerwood, &
Greenwald, 2009), and at least two-thirds, if not more,
relapse following treatment completon (Xie, McHugo, Fox,
& Drake, 2005). These statstcs suggest that addicton
treatments need to (a) be acceptable and tolerable to
those who are encouraged to seek them, and (b) provide
immediate beneft to those who enroll in them.

Cognitve behavioral therapy (CBT) has long been viewed
as a treatment-of-choice for substance abuse. It has the
potental to be especially acceptable and tolerable to
patents because it emphasizes autonomy, models respect
for individual diferences, and provides tangible cognitve
and behavioral coping skills for managing urges, cravings,
and emotonal distress (Wenzel, Liese, Beck, & Friedman-
Wheeler, 2012). Many cognitve behavioral treatments are
conducted from a harm reducton framework, rather than
from an abstnence-only framework (e.g., Sobell & Sobell,
2011), which could be atractve to patents who have not
yet achieved full readiness for change. CBT also has the
potental to provide immediate beneft to patents because
some cognitve and behavioral coping skills can be impart-
ed in as litle as one session (e.g., Wenzel et al., 2012).

The CBTs for substance abuse described in the literature
are quite heterogeneous; most share a few common com-
ponents (e.g., identfcaton of high-risk situatons), and, at
the same tme, most also have distnctve features (e.g., cue
exposure; cf. McHugh, Hearon, & Oto, 2010). An early
treatment manual authored by several prominent ACT
membersBeck, Wright, Newman, and Liese (1993)
(Contnued on Page 5)
Borderline personality disorder (BPD) is a serious and ofen
life threatening chronic psychiatric disorder characterized
by severe instability in intense emotonal experiences, rela-
tonships, and identty. BPD aficts up to 5.9% of adults,
approximately 14 million Americans (Natonal Educaton
Alliance for Borderline Personality Disorder [NEABPD],
2012). Approximately 55-85% of people diagnosed with
BPD engage in nonsuicidal self-injury (NSSI) (NEABPD,
2012). NSSI is defned as the direct, deliberate destructon
of ones own body tssue in the absence of suicidal intent
(Nock, 2009). The motvaton to engage in NSSI is complex
and varies from person to person. Recent evidence sug-
gests that NSSI frequently serves one of three functons:
Avoidance of aversive internal experiences, communica-
ton, and self-punishment. The fgure to the right demon-
strates how NSSI can functon as either a positve or nega-
tve reinforcement for the individual.
Individuals ofen explain that they engage in NSSI because
they perceive it to be a reliable and efcient coping strate-
gy that in the short term, meets a need they believe they
are unable to satsfy in other ways.
(Contnued on Page 8)

Understanding Nonsuicidal Self-Injury in People with
Borderline Personality Disorder
Amy Cunningham, PhD, Guest Contributor
University of Pennsylvania School of Medicine
Beck Institute Adjunct Faculty
Benefits of Using Cognitive Behavioral Therapy
to Treat Substance Abuse
Amy Wenzel, PhD, Guest Contributor
University of Pennsylvania School of Medicine
Beck Institute Adjunct Faculty
Page 3



Internal
Increase feelings
I was numb and
needed to feel
alive.
I was bad and
needed to feel
punished.

*Most associated
with PTSD and
depression
Decrease feelings
I felt overwhelmed
with shame and
needed it to stop.




*Most associated
with hopelessness
and suicide


External
Access help/
Communicate
No one would
listen to me untl I
cut myself.
Remove demands
They didnt realize
I cant do what they
ask of me untl I
showed them my
cuts.

(+) Reinforcement

(-) Reinforcement
* fgure adapted from Walsh, 2008





fell on a Friday afernoon. I had ques-
toned Adam closely at the beginning
of the session to make sure I had pro-
vided him with the opportunity to
name the problems he most wanted
help in solving. Nevertheless, he be-
came quite upset when I later told him
that we just had a few minutes lef in
the session. What do you mean, we
only have a few minutes lef, he
yelled. I didnt get a chance to tell
you that the neighbor who bullied me
when I was a kid is going to be visitng
his parents this weekend! I know Ill
see himhell be next door!

Quickly, I mentally weighed the ad-
vantages and disadvantages of ex-
tending the session. I decided against
doing so for two reasons: In additon
to being late for subsequent patents, I
would also have reinforced him for
angrily demanding extra tme for a
problem that I assessed would not
have a sustained, deleterious efect on
him. I told Adam I was sorry that we
didnt have tme to discuss this up-
setng problem and ofered to have
him come in again early the next
week.
Adam was visibly upset and angrily
told me that Monday would be too
late. You must really feel like Im
letng you down, I hypothesized to
him. Yes, you are! he responded.
Well, its good you told me that, I
said. Can I ofer you a choice? Would
you be willing to sit in the recepton
area and write me a leter right now,
while Im with my next patent, about
how much Ive let you down? But if
you dont want to do that, this is what
Id like us to do: Next week, when you
come in, Id like you to tell me all
about my letng you down and how
that has afected youand Id like to
do that frst, before we do a mood
check or set the agenda or
do anything else. . . What do
you think? Im not going to
sit and write you a leter, he
said, stll with substantal anger, but,
sure, Ill tell you in person next week!
This inital outcome was what I want-
ed: to get Adam back in the ofce so I
could repair the rupture.
True to my promise, at the beginning
of the next session, I invited Adam to
talk about my having ended the ses-
sion on tme the previous week, I
again positvely reinforced him for
letng me know that what I had done
was distressing to him, and expressed
my hope that we could set things
right. In a mater of fact way, I sum-
marized what he had told me accord-
ing to the cognitve model. So the
situaton was that I told you I was sor-
ry that you couldnt have extra tme,
and what went through your mind?
Obviously that you didnt care about
me, he replied. I ascertained that he
had believed this automatc thought
close to 100% on Friday and stll be-
lieved it almost as strongly. I ex-
pressed my belief that it would be
important for him to fnd out whether
his cogniton was 100% true or 0%
true or some place in the middle. He
agreed and I started a process of So-
cratc questoning: What is other evi-
dence that I dont care about you? Is
there evidence on the other side, that
maybe I do? Are there other explana-
tons for why I ended the session on
tme? Whats the efect of believing
that I dont care about you? What
could be the efect of changing your
thinking?
Throughout this episode of guided
discovery, I notced that Adams afect
was changing. He was becoming in-
creasingly less angry. Then he said,
But if you really cared, youd give me
100%. Oh, I said, and do you also
believe the conversethat if I dont
give you 100%, it means I dont care?
He said he did. We examined these
assumptons and then I asked him to
summarize our discussion. I guess
you couldnt really functon at work or
at home if you gave me 100% and
gave me extra tme or let me call you
every tme I was upset. I followed up
(Contnued from Page 1)
(Contnued on Page 7)
Page 4
Cognitve therapists dont
provoke confict in sessions.
But when strains or prob-
lems arise, they collect data
in the form of the cognitve
model (What was just
going through your mind?),
they positvely reinforce
patents for providing feed-
back, they conceptualize
why the problem arose, and
implement a strategy that
they believe will repair the
relatonship.
Above, partcipants at a recent workshop (CBT for Challenging Problems
and Personality Disorders) roleplay a challenging issue that might arise
in session.





emphasized the role of core beliefs (e.g., Im no good)
and addicton-related beliefs (e.g., Using helps me ft in)
in fueling situatonal cognitons (e.g., antcipatory and
relief-oriented expectatons, permission-giving thoughts)
that in turn infuence the likelihood of substance use, sub-
stance abuse, and relapse. It also incorporated coping
skills for managing urges and cravings. Other CBT proto-
cols have focused more heavily on skills building, such as
communicaton skills to build relatonships and refuse
alcohol and drugs (e.g., Kadden et al., 1992; Mont, Kad-
den, Rohsenow, Cooney, & Abrams, 2002), or have sys-
tematcally integrated principles from motvatonal inter-
viewing (e.g., Sobell & Sobell, 2011).

The literature on CBT for substance abuse can be challeng-
ing to sort out because some treatments consist of only
one or a few cognitve and/or behavioral elements, are
regarded as stand-alone treatments, and are sometmes
distnguished from other cognitve behavioral packages.
For example, contngency management is a behavioral
approach in which patents are provided with non-
substance reinforcers (e.g., money, vouchers for goods
and services) when they demonstrate abstnence, which
has been evaluated in numerous clinical trials (cf. Prender-
gast, Podus, Finney, Greenwell, & Roll, 2006). Although
contngency management does not incorporate other
techniques that are typically used by cognitve behavioral
therapists (e.g., cognitve restructuring), studies evalu-
atng this treatment are ofen included in meta-analyses
of CBT for substance abuse (e.g., Dutra et al., 2008), and
scholars have recommended that providers consider the
arrangement of social contngencies in their overall cogni-
tve behavioral treatment plan (McHugh et al., 2010). Sim-
ilarly, relapse preventon (Marlat & Donovan, 2005; Mar-
lat & Gordon, 2005), a cognitve behavioral approach that
helps patents gain skill in preventng high-risk situatons
that could trigger relapse, is itself a stand-alone treatment
that has been evaluated in the empirical literature (e.g.,
Irvin, Bowers, Dunn, & Wang, 1999) and has also been
incorporated into broader cognitve behavioral protocols
(Wenzel et al., 2012)

(Contnued from Page 3)
Over the past 20 years, CBT for substance abuse has been
subjected to much empirical scrutny. For example, a CBT
protocol that was heavily skills-based was evaluated in the
well-known Project MATCH for patents with alcohol abuse
and dependence (Kadden et al., 1992). Results from this
large trial indicated that CBT was equally as efcacious as
Motvatonal Enhancement Therapy and Twelve-Step Facil-
itaton Therapy, with all therapies associated with approxi-
mately 80% or more abstnent days and a massive reduc-
ton in number of drinks per drinking days across the frst
year following treatment (Project MATCH Research Group,
1997). A recent meta-analysis of a broad spectrum of CBTs
(including contngency management and relapse preven-
ton) for drug abuse disorders achieved an efect size in the
moderate range (d = 0.45; 95% CI = 0.27 0.63) when CBT
was compared to general drug counseling or treatment-as-
usual (Dutra et al., 2008). When results were examined as
a functon of drug type, it found moderate to high efect
sizes specifcally for the treatment of cannabis abuse and
cocaine abuse (ds = 0.81 [95% CI = 0.25 1.36) and 0.62
[95% CI = 0.16 1.08], respectvely). These efect sizes are
comparable to those calculated in meta-analysis compar-
ing CBTs relatve efcacy with supportve or nondirectve
therapies for other psychiatric conditons, such as depres-
sion and anxiety (Butler, Chapman, Forman, & Beck, 2006).

Several innovatons for CBT for substance abuse have been
described in the literature and are currently being evaluat-
ed empirically. Recognizing the high rate of comorbidity
between substance abuse and depression, Osilla, Hepner,
Muoz, Woo, and Watkins (2009) developed a CBT proto-
col for depression that is delivered by substance abuse
counselors in addicton treatment setngs. Preliminary
results indicate that this treatment is more efectve than
usual care in reducing depressive symptoms and decreas-
ing days of substance use (Watkins et al., 2011). Carroll
and her colleagues have developed a computer-assisted
skills-based CBT package, which is associated with fewer
positve urine specimens throughout the course of treat-
ment relatve to standard care (Carroll et al., 2008) and
enduring efects six months later (Carroll et al., 2009). Car-
rolls program of research is partcularly promising because
it has the potental to facilitate the disseminaton of CBT to
(Contnued on Page 9)
Page 5
(CBT) emphasizes autonomy,
models respect for individual
diferences, and provides tangible
cognitve and behavioral coping
skills for managing urges, cravings,
and emotonal distress.





Conclusion
1. What is the comparatve efcacy of CT and the third
wave therapies? A simplistc answer is that the compar-
atve randomized control studies have not yet been car-
ried out sufciently to come to a conclusion.
2. It is possible that a certain equivalence between the
therapies may occur in a well-designed study. However,
the equivalence at the end of treatment may be mislead-
ing. An essental feature of the efcacy of psychotherapy
is its durability over an extended period of tme, and
afer the comparison therapies have been discontnued.
The durability is measured by maintenance or improve-
ment in the outcome and a lack of relapse. Some studies,
for example, have shown an equivalence at the end of
treatment but a substantal diference in longer term
follow up (for example, a comparison of cognitve thera-
py and befriending with patents with schizophrenia).
3. A newer approach to the robustness of a therapy is
based on the complexity and richness of the underlying
theory. A robust theory, for example, can generate new
therapies or can draw on existng therapies that are con-
sistent with it.
4. Cognitve therapy has relied on a number of powerful
vehicles such as structured interview, feedback, acton
plan, and cognitve restructuring to implement cognitve
change (which is the important mechanism of change
derived from theory). However, the same theory can be
utlized to generate a variety of other techniques, partc-
ularly when the standard techniques are not appropriate
for a given patent or problem.
5. An essental characteristc criterion of a successful theo-
ry is that theoretcal constructs have been validated.
The underlying theory of cognitve therapy has been sub-
jected to hundreds of studies, almost all of which have
been supportve of the theoretcal hypothesis.
2

6. As compared to the third wave therapies, cognitve ther-
apy has a much richer theoretcal foundaton. Cognitve
therapy has shown such durability in many clinical com-
parisons with ant- depressant drugs. This has not yet
been demonstrated in any third wave therapies.
7. While cognitve therapy has relied on standardized ther-
apeutc strategies, for the most part, it is not bound to
these strategies and can (and does) adopt other thera-
peutc strategies when the standard ones are not consid-
ered appropriate.
8. The broad scientfcally validated theories underlying
cognitve therapy provide for a broad spectrum therapy
that can be applied to the broad spectrum of psychiatric
disorders for individuals seeking treatment.
9. So far as the third wave therapies are integrated into the
broad theoretcal and therapeutc system of CT, they can
be utlized in additon to, or in place of, the standard
approach.
References
Beck, A. T. (1976) Cognitve therapy and the emotonal disorders. Oxford,
England: Internatonal Universites Press.
Clark, D. A., Aaron T. B., and Alford, B., A., (1999) Scientfc foundatons of
cognitve theory and therapy of depression. New York, John Wiley and
Sons.
Disner, S. G., Beevers, C. G., Haigh, E. A. P., Beck, A. T. (2011). Neural
mechanisms of the cognitve model of depression. Nature Reviews Neuro-
science, 12, 467-477.
(Contnued from Page 2)
Student and Faculty Workshop: Multmedia Resource












Click above to view a video clip from Beck Insttute's recent CBT for Student and Faculty Workshop, during which Dr.
Aaron Beck reacts to a quote by Dr. Alan Kazdin on the current status and future of individual, face-to-face psycho-
therapy. Dr. Beck also discusses the efectveness of certain alternatve technologies that deliver CBT and the triage
approach to mental healthcare in Great Britain.
Page 6
Image and video clip courtesy of Diane Saccoccio / Imagepoint Studio





his summary, So maybe I do care about you even if I
dont give you 100? Yes, I guess so, he sighed. Okay!
Thats so important! I said. Im so glad you can see
that. He then agreed to have me write down his conclu-
sions.
I next asked Adam whether he had recently made the
original assumpton about someone else. He thought
about this for a moment, then said, Yes, I think so. I got
really angry at my brother a couple of weeks ago. We
were supposed to go to a baseball game together but he
called at the last minute and cancelled. . . Said his wife
wasnt feeling well. I then asked him some of the same
questons as those above, helping him examine the evi-
dence (pro and con) that his brother doesnt care about
him and reinforcing the alternatve explanaton that his
brother had provided. Following this, I asked him for his
conclusion. He does do a lot of things that show he cares.
I guess he has to take care of his wife sometmes, even if it
means breaking plans with me. I asked Adam how much
he now believed his inital assumpton: My brother didnt
give me 100% and therefore it means he doesnt care. I
guess I dont really believe it, he replied. I followed up.
So now we have two examples where it turned out that
an assumpton you hadthat caused you a lot of pain
just didnt seem to apply. . . What do you think of this for
homework: seeing whom else you might have been apply-
ing this assumpton to? Then we can look at these people
more closely together to see whether or not the assump-
ton applies to them.
This experience was quite valuable. First, it served as a
model for future sessions when Adam became upset over
my not grantng him special favors, and he was quickly
able to recall that his assumpton about my not caring was
inaccurate. Second, it was yet another opportunity for him
to see that just because he believed something didnt
necessarily mean that it was true, that believing it caused
him to sufer, and changing his viewpoint led to his feeling
beter. Third, it demonstrated to him that interpersonal
problems can be solved. Fourth, it gave me a glimpse into
how others in his environment probably experienced him
when his dysfunctonal beliefs about them became act-
vated. Finally, it allowed Adam to change his inaccurate
perceptons of important people in his life and laid a foun-
daton for improving those relatonships.
Cognitve therapists dont provoke confict in sessions. But
when strains or problems arise, they collect data in the
form of the cognitve model (What was just going
through your mind?), they positvely reinforce patents
for providing feedback, they conceptualize why the prob-
lem arose, and implement a strategy that they believe will
repair the relatonship. The experience becomes especially
useful if patents have drawn the same inaccurate conclu-
sions about the therapist that they have drawn about
other people.

(Contnued from Page 4)

Reference:
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Barber, J. P.,
Brown, G. K., Laurenceau, J.P., & Beck, A. T. (2006). Early Alliance, Alliance
Ruptures, and Symptom Change in a Nonrandomized Trial of Cognitve Ther-
apy for Avoidant and Obsessive-Compulsive Personality Disorders. Journal of
Consultng and Clinical Psychology, 74, 337-345.


Page 7
Welcome, Josh!
On Saturday, September 8th,
Joshua Busis Cohen was born at a
healthy 7 lbs, 9 oz! Baby and mom
Sarah are doing fne. Sarah is the
daughter of Dr. Judith Beck. Joshua is
her frst grandchild and Dr. Aaron
Becks third great-grandchild.
We wish everyone well and send
our congratulatons!





Experiental avoidance is one frequently cited motvaton-
al factor for engaging in NSSI. Avoided experiences can
include thoughts, emotons, somatc sensatons or other
internal experiences that are perceived as distressing. In
one study, ataining emotonal relief was the most com-
mon reported reason for engaging in NSSI (Brown et al.
2002). This functon is maintained and perpetuated
through negatve reinforcement (i.e., the removal of an
unwanted experience following a behavior increases the
likelihood that the behavior will reoccur). Therefore,
treatment eforts that target increasing the patents abil-
ity to understand, tolerate, and directly decrease the in-
tensity of internal experiences are key to overcoming
NSSI.
Communicaton is a second common motvatonal factor
in NSSI. Individuals engage in NSSI to communicate with
others, See how much pain I am in! and with them-
selves, My pain is real and I deserve to address it. Oth-
ers may view this functon as a form of manipulaton.
However, nonjudgmental understanding is key to helping
patents overcome NSSI. To this end, it is helpful to under-
stand how communicaton is reinforced among individuals
who engage in NSSI. It is ofen the case that their early
learning environments were invalidatng and that they
were only atended to or taken seriously when they used
extreme forms of communicaton. Thus, individuals who
engage in NSSI have learned that this behavior is the most
efectve means by which their needs are met.
Conversely, some individuals minimize their sufering, as
(Contnued from Page 3)
they fear abandonment or rejecton. These individuals
require extreme validaton of their pain before they per-
mit themselves to engage in self-care. Therefore, treat-
ment eforts that target accurate identfcaton of ones
personal needs and efectve communicaton of ones
needs are important. In additon, eforts aimed toward
increasing the individuals ability to engage in self-
validaton and explore negatve automatc thoughts
about self-care are likely to reduce NSSI.
The fnal functon of NSSI discussed in this artcle is self-
punishment. The core belief, I am defectve, is quite
common in BPD, and individuals who hold this belief ex-
perience internalized messages from their environment
that they are bad, wrong, or evil. Arising from these
beliefs are intense feelings of shame. Thus, individuals
believe they deserve punishment and will engage in NSSI,
a form of self-
punishment, to
temporarily relieve
themselves from
feelings of shame.
Treatment eforts
that target evalu-
atng beliefs about
the efectveness
of punishment and
the accuracy of
negatve automatc
thoughts and core
beliefs about the
self are necessary.
Given this brief overview of the functons of NSSI, it is
clear that a careful assessment of the functon of NSSI for
the individual (specifcally identfying all antecedent and
consequental events associated with an episode of NSSI)
is critcal for an accurate conceptualizaton and treatment
plan targetng the behavior. Moreover, the functons of
NSSI can difer from episode to episode. Therefore, as-
sessment of the behavior in each episode is imperatve
for a comprehensive understanding.
NSSI is a complex coping strategy used by many individu-
als with BPD to alter their internal experience. A compre-
hensive and nonjudgmental understanding of NSSI and
the factors that maintain it is a key component to reduc-
ing and diminishing self-injurious behavior among this
populaton.
References
Brown, M.Z., Comtois, K.A., & Linehan, M.M. (2002). Reasons for suicide atempts and nonsuicidal self-injury in women with borderline
personality disorder. Journal of Abnormal Psychology, 111, 198-202.
Natonal Educaton Alliance for Borderline Personality Disorder. (2012) Retrieved June 19, 2012, from htp://
www.borderlinepersonalitydisorder.com/understading-bpd/bpd-fact-sheet.
Nock, M.K. (Eds.). (2009). Understanding nonsuicidal self-injury. Washington, DC: American Psychological Associaton.
Walsh, B. Treatng Self Injury: A practcal Guide. Guildford Press, 2008.
Page 8
...treatment eforts
that target increasing
the patents ability
to understand, tolerate,
and directly decrease
the intensity of internal
experiences are key
to overcoming NSSI.





addictons treatment programs that might not otherwise
have access to providers who are competent to deliver
CBT. Finally, McHugh et al. (2010) reported that their
group is evaluatng the augmentaton of d-cycloserine, a
partal agonist of NMDA receptors that enhances gluta-
mate transmission, to improve extncton during cue expo-
sure. Thus, although the treatment of substance abuse
using any treatment approach, including CBT, is challeng-
ing, these and other innovatons in the feld have great
potental in enhancing CBTs efcacy, efectveness, endur-
ing efects, and applicaton to comorbid conditons.
References
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therapy of substance abuse. New York, NY: Guilford Press.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The
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Carroll, K. M., Ball, S. A., Martno, S., Nich, C., Babuscio, T. A., , & Roun-
saville, B. J. (2008). Computer-assisted delivery of cognitve-behavioral
therapy for addicton: A randomized trial of cbt4cbt. American Journal
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Carroll, K. M., Ball, S. A., Martno, S., Nich, C., Babuscio, T. A., & Roun-
saville, B. J. (2009). Enduring efects of a computer-assisted training
program for cognitve behavioral therapy: A 6-month follow-up of
cbt4cbt. Drug and Alcohol Dependence, 100, 178-181.
Compton, W. M., Thomas, Y. F., Stnson, F. S., & Grant. B. F. (2007). Prev-
alence, correlates, disability, and comorbidity in DSN-IV drug abuse and
dependence in the United States: Results from the Natonal Epidemio-
logic Survey on Alcohol and Related Conditons. Archives of General
Psychiatry, 64, 566-576.
Dutra, L., Stathopoulou, G., Basden, S.L., Leyro, T.M., Powers, M. B., &
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Hasin, D. S., Stnson, F. S., Ogburn, E., & Grant, B. F. (2007). Prevalence,
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Kadden, R., Carroll, K. M., Donovan, D., Cooney, N., Mont, P., & . Hes-
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DHHS Publicaton No. (ADM) 92-1895, Washington, DC: Government
Printng Ofce.
Osilla, K. C., Hepner, K. A., Muoz, R. F., Woo, S., & Watkins, K. (2009).
Developing an integrated treatment for substance use and depression
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Marlat, G. A., & Donovan, D. M. (2005). Relapse preventon: Mainte-
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Stnson, F. S., Grant, B. F., Dawson, D. A., Ruan, W. J., Juang, B., & Saha, T.
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(Contnued from Page 5)
Learn more about CBT for Substance
Abuse at a special 3-Day experiental
workshop* at the Beck Insttute:
CBT for Substance Abuse:
Individual and Group
Treatment Protocols
October 22-24, 2012
*Please note that enrollment is
limited to 42 partcipants.
Page 9





Dr. Aaron Beck meets with the winners of our
Third Annual Beck Scholarship Competton

At our recent CBT Workshop for Students and Faculty, Dr. Aaron Beck sat down with the winners of this years
competton to discuss their current research, goals, and specifc areas of interest related to CBT.
Our scholarship competton received more than 600 entries from around the world! The commitment to the
study and practce of CBT shown by all of the applicants was truly inspiring.
Congratulatons to our recent winners, and best of luck to all of next years applicants!
From Lef to Right:
Top Row: Cara Lewis, Charles Young,
David Ross, Rick Pessagno, Brian
Hall.

Middle Row: Rebecca Greif, Abby
Ross, John Guerry, Barbara Van Nop-
pen, Shannon Couture, Nina Martn,
Georgia Stathopoulou

Botom Row: Shari Steinman, Aaron
T. Beck, Darunee Phakao

Not pictured: Catherine Caska,
Agnieska Popiel
Page 10
On August 13-15, 2012, Beck Insttutes 3rd Annual
Cognitve Behavior Therapy Workshop
for Graduate Students and Faculty
drew 180 post-doctoral fellows, psychiatry residents, other graduate
students, and faculty from mental health, medical, and related felds
from 27 states and 10 foreign countries. The diversity of atendees
and their enthusiasm for CBT was remarkable.
We look forward to another successful workshop next year!
Images courtesy of Diane Saccoccio / Imagepoint Studio







Calendar of Upcoming CBT Workshops at Beck Insttute
Beck Diet Soluton: A CBT Program for Weight Loss and Maintenance
November 3, 2012 (For Dieters)
January 21, 2013 (For Dieters)
February 8, 2013 (For Diet Professionals)

Register early for any program you wish to atend. Each workshop held at Beck Insttute is limited to 42 partcipants
in order to provide opportunity for personalized instructon.
Find us on the web:
Cognitive Therapy Today
A Publication of the Beck Institute for Cognitive Behavior Therapy


One Belmont Avenue l Suite 700 l Bala Cynwyd, PA 19004-1610
PHONE 610.664.3020 EMAIL info@beckinsttute.org www.beckinsttute.org

To register for a workshop or inquire into custom training optons, please visit:
www.beckinsttute.org
Customized Training in CBT through the Beck Insttute
To meet your organizaton's unique training needs, Beck Insttute ofers several customized training optons onsite
or at the locaton of your choice. Our faculty will travel around the world to give workshops, presentatons and staf
training on a variety of topics in cognitve therapy for hospitals, professional associatons, managed care organiza-
tons, primary care physician groups, and similar organizatons, as well as at conferences and symposia. We also
ofer optons for training staf in cognitve therapy at inpatent/outpatent facilites. Our customized training focuses
on the practcal applicaton of cognitve therapy within your specifc setng.
Our executve director will consult with you to assess your organizatons needs. Following the inital assessment,
our faculty will work in consultaton with Dr. Judith Beck to develop the specifc learning objectves, curriculum,
class schedule and support materials. Workshops vary from one to fve days.
CBT for Depression and
Anxiety
October 1 - 3, 2012 SOLD OUT
December 17 - 19, 2012

CBT for Depression
(Core 1)
January 28 - 30, 2013
July 15 - 17, 2013

CBT for Anxiety
(Core 2)
February 18 - 20, 2013
September 16 - 18, 2013

CBT for Personality Disorders
and Challenging Problems
(Core 3)
November 12 - 14, 2012
March 18 - 20, 2013
CBT for Substance Abuse
October 22 - 24, 2012
April 15 - 17, 2013

CBT for Children and
Adolescents
March 4 - 6, 2013
June 24 - 26, 2013
October 7 - 9, 2013

Teaching and Supervising CBT:
A Workshop for Graduate Faculty
June 3 - 5, 2013

CBT for Schizophrenia:
A Recovery-Oriented Model
May 6 - 8, 2013
CBT for PTSD
November 4 - 6, 2013
4th Annual Student Workshop: CBT for Depression and Anxiety*
*to be held at a Philadelphia locaton to be determined
August 12 - 14, 2013