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Dr. David Van Nuys: Welcome to Wise Counsel a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys; I'm a clinical psychologist and your host.
On today's show we'll be talking about cognitive therapy and weight loss with my guest, Dr. Judith Beck.
Judith S. Beck, Ph.D. is the Director of the Beck Institute for Cognitive Therapy and Research in suburban Philadelphia and clinical Associate Professor of Psychology and Psychiatry at the University of Pennsylvania where she teaches psychiatry residents. She received her doctoral degree from the University of Pennsylvania in 1982.
Now, here's the interview.
Dr. Van Nuys: Dr. Judy Beck, welcome to Wise Counsel.
Dr. Judith Beck: Thank you.
Dr. Van Nuys: I know that for some time you've been working along side your famous father, Dr. Aaron Beck and that currently you're the Director of The Beck Institute For Cognitive Research and he's the President. And I very much want to focus on your own work, but I wonder if you'd mind if initially I ask a few questions about your father's contribution?
Dr. Beck: Sure, that's fine.
Dr. Van Nuys: Your father is widely acknowledged as the father of cognitive therapy and yet I'm aware that Albert Ellis was writing about the importance of what we tell ourselves early on. So, what's the historical relationship there?
Dr. Beck: My father and Albert Ellis were really working along parallel tracks and as far as I know they didn't have a lot of contact until after both had developed their ideas.
Dr. Van Nuys: Well, you know that happens sometimes that people have the same great ideas at about the same time; it's a well known phenomenon.
Dr. Beck: What was very important that both of them did was to put an emphasis on the here and now and also to emphasize the importance of people's thinking.
Dr. Van Nuys: Yes, that really seems to have been a major step and it's so widely accepted now. Before we go much further, how do you define cognitive therapy?
Dr. Beck: Cognitive therapy is generally a time limited psychotherapy that's based on the cognitive model. So, we understand people's distress in terms of how they're viewing their situations. A lot of people think that it's a situation that directly leads them to directly feel upset.
For example, my husband is late coming home for dinner and so that makes me feel angry. But, actually it's the thoughts that we have in particular situations that are more closely connected to our emotional reaction. So, it's the thought, "Oh, he shouldn't ever do this, he should be more considerate of me." It's those thoughts that are more directly tied to how we feel.
And often times when we're in distress we just aren't thinking very clearly. One important technique that cognitive therapy uses, among many, is to help people identify the thoughts that are leading them to feel distressed and then to evaluate their thoughts. Sometimes their thoughts are 100 percent true, but sometimes their thoughts are not true at all, or certainly not completely true. And when they learn how to change their thinking and to think more realistically they generally feel better.
Dr. Van Nuys: OK. What evolutionary stages has cognitive therapy gone through since your father's early articulation of it? I assume there's been some evolution in both theory and practice over time.
Dr. Beck: There has been a great evolution in both the theory and practice of cognitive therapy. My father started off as a psychoanalyst and did some research that he thought would validate psychoanalytic concepts of depression as being anger turned inward towards themselves.
But, actually he found out that that idea did not have scientific validity. He found that people who were depressed actually had fewer scenes of hostility and anger turned inward, in their dreams, than people who weren't depressed.
So, he started looking for other explanations of depression and found that people who are depressed had negative thoughts about themselves, their worlds and other people. He developed a treatment based on helping depressed patients change their thinking and behavior.
He did research that showed that cognitive therapy was affective for depressed patients, and he elaborated a conceptual cognitive framework to understand depression. After he did that, he and other colleagues turned their attention to looking for a cognitive formulation of anxiety disorders. And then did some outcome studies to show that cognitive therapy was affective for that disorder.
And then he and I and colleagues all around the world have now adapted the theory of cognitive therapy and the practice toward an enormous variety of problems. Not only psychiatric problems, but also medical problems with psychological components.
Dr. Van Nuys: Well, that's fascinating background; I didn't know that your father was originally a psychoanalyst. It seems like there are a number of pioneers who started off on the analytic couch and then they went off and struck off in a different direction. It's always surprising to me.
Dr. Beck: Well they did because that was what was taught in graduate programs and in psychiatric residency training programs at the time.
Dr. Van Nuys: Sure, even when I was in school, I was probably at one of the last vestiges of a very psychoanalytic program in clinical psychology. I'm not sure if they've changed in the intervening years or not.
Now your father, having been a psychoanalyst, he's an MD, a psychiatrist and you're a clinical psychologist. How did it happen that you decided to go a different route?
Dr. Beck: I went a whole different route all together at the beginning. Since I was a young child I wanted to be a teacher and I always thought that I would do that and I would do that for my career, and in fact, I started off in teaching. I taught learning disabled kids how to read. And I loved doing that and thought that I would stay in the field, but knew that I probably had to get another credential if I wanted to be able to do educationally related activities outside of being a classroom teacher.
So, I went back to school and started studying education, but about half way through decided that I was really a little bit more interested in psychology than I was in education. So, I studied both. And having come full circle now, most of what I do has something to do with teaching. One of the primary functions of my job is to teach others how to do cognitive therapy.
Dr. Van Nuys: Interesting, interesting. Now I noticed that the Beck Institute website uses the term cognitive therapy and many people talk about cognitive behavior therapy, or CBT, is there a difference?
Dr. Beck: Some people use the terms synonymously, and in fact in Great Britain where they really practice what we would view as cognitive therapy they always call it cognitive behavior therapy. Cognitive behavior therapy, though, in the United States might refer to cognitive therapy or it might refer to a more specific kind of treatment that has more of a behavior orientation, such as problem solving, therapy or response prevention therapy.
Those therapies have cognitive elements, but a stronger behavioral formulation. Cognitive therapy really starts with a cognitive formulation. So, we look at the ideas that lead people to feel distressed. We look for how it is that these ideas arose and how people have coped with these negative beliefs about themselves, their worlds and other people throughout their lives, particularly when we're talking about Axis II patients.
Dr. Van Nuys: Yeah, and maybe you should say what Axis II is because not all of our listeners will know what you mean by that.
Dr. Beck: Patients who have an Axis II diagnosis have what is called a "personality disorder." That means that they have had difficulties managing in relationships, perhaps at work, more or less for their whole lives. If they get depressed or anxious, those conditions might clear up, but they're still left with difficulties getting along with people, getting along in life.
Dr. Van Nuys: OK, thank you. I noticed that one of your functions at the Beck Institute is to direct research there. What's the cutting edge of cognitive therapy research these days?
Dr. Beck: We're not doing this kind of research, but the cutting edge has to do with neurophysiology. It's very interesting. There have been some studies recently that have looked at the brains of patients before and after treatment. So, for example, they've looked at patients who were depressed and then recovered from depression by using medication and they compared those scans with the brains of patients who were depressed who were treated with cognitive therapy and they found brain changes in both groups.
Interestingly though, the changes were different. For the patients who took medication, the change was from the bottom up in the brain and for patients who had cognitive therapy; it was from the top down. But, more and more studies are showing that cognitive therapy, even though it's a talk therapy, is really a biological treatment because there really are changes that take place in the brain as a result.
Dr. Van Nuys: That's interesting. When you say "the top down," I assume you're talking about sort of working the way from the cortex down towards the brainstem?
Dr. Beck: That's right.
Dr. Van Nuys: OK. That's a very interesting thing, isn't it? Because hearing that, that kind of makes sense.
Dr. Beck: It makes sense because we tend to start by helping people change their thinking, which is a primary function of the front of the brain.
Dr. Van Nuys: Yes, right. Yeah, it seems like there's such an explosion of new knowledge about the brain. It's just blowing everything wide open in lots and lots of different fields really.
Dr. Beck: There's a couple of studies that are going on now which are very important and are comparing how patients do with cognitive therapy versus other treatments in the long run. What they've found in depression, for example, and this happened time after time, is that if you are treated with medication, you are twice as likely to relapse in the coming months or years as if you had cognitive therapy.
It just makes sense. Cognitive therapy is so concerned with relapse prevention. We not only help patients change their thinking. For example, we teach them how to do it. We not only help them solve problems, we teach them how to solve problems.
Dr. Van Nuys: Yes. It's almost like that Chinese proverb of teaching a man to fish versus giving him a fish.
Dr. Beck: That's exactly right.
Dr. Van Nuys: Yes. I see that you've written a book called "The Beck Diet Solution: Train Your Brain to Think like a Thin Person." Long term weight loss has been regarded as a fairly intractable problem, despite all the diet books that are out there. Tell us about your approach.
Dr. Beck: In Beck Diet Solution, I don't provide a diet itself. Now, in a book I'm working on right now, I do provide a diet, but in the Beck Diet Solution, I didn't. It was a psychological approach to losing weight. It's a six week program and every day, you learn a different thinking skill or behavioral skill and some of these skills, you just need to learn once and some you're going to practice every day for the rest of your life.
Dr. Van Nuys: Now, is this based on research?
Dr. Beck: There has been some research that was done in Sweden that gave this kind of program to a group of outpatients who was a randomized controlled trial. So, some patients got the treatment and some were just on the waiting list. They found that with this treatment, patients lost on an average of about 18 pounds over 10 sessions of treatment and they were able to keep the weight off for an additional 18 months. In fact, they lost an average of about five pounds more. This is in comparison to people who didn't get the treatment who were on the wait list who actually gained weight during this period of time.
Dr. Van Nuys: Well, that sounds pretty encouraging. What drew you to this line of research and practice? Was weight ever a problem for you?
Dr. Beck: I gained and lost the same 10 or 15 pounds many times in my life until I finally put into practice what I had been helping some of my patients with. I found that really the missing ingredient in weight loss programs is the emphasis on changing people's thinking and I'll give you some examples.
People have very good intentions of staying on a diet, but they have these sabotaging thoughts that creep up into their minds. For example, they might think, "Oh, I know I'm not supposed to eat that chocolate chip cookie, but it looks so good. I hardly ever get to have it. I'm tired, it'll perk me up. I'm upset, it will calm me down. Everyone else is eating it. It's not really that big. I already exercised today. No one is watching me. It's a holiday."
So, people have these sabotaging thoughts over and over and over again that get in the way of their reaching their goal. They also have certain unhelpful ideas about hunger, for example. Most people who have struggled with dieting actually are a little bit afraid of being hungry. They don't know that hunger is normal, that it's natural, that most people without a weight problem experience at least a little hunger everyday and that hunger doesn't get worse and worse and worse until they can't tolerate it anymore.
One of the things that I have them do is to set-up what I call a "discomfort scale." So, I help them think of experiences in which they were really severely uncomfortable. For example, after surgery. Then a situation in which they were moderately uncomfortable. So, that might be a very bad headache or stomachache. Then a situation in which they were only mildly uncomfortable. So, maybe that's like a very mild toothache.
Then what I ask them to do if their doctors OK it, is just to go from breakfast to dinner one day without eating anything at all and then to measure every hour on the hour how uncomfortable they are according to the scale. Are they severely uncomfortable, moderately uncomfortable or only mildly uncomfortable?
Every single one of them finds that their discomfort of hunger never gets above mildness. In fact, that within each hour the hunger actually comes and goes. So, the discomfort ranges from zero to mild. So, they proved to themselves that they can tolerate hunger that it's not an emergency and that if they either distract themselves or just go on to do some other task, the hunger will quickly fade.
Dr. Van Nuys: That's an interesting approach. Your subtitle, "Train Your Brain to Think Like a Thin Person," seems to discount hereditary or metabolic issues. Aren't these an important part of the picture for many people?
Dr. Beck: These are an important part of the picture and I advise people to go on diets if they have a health problem or if they're not eating in a healthy way or if they are continuing to gain a little bit of weight every year and it looks like they're going to have a health problem. Then I think, they should be very mindful about what they eat.
A lot of people have the idea that they should be able to go on a diet very short term, deprive themselves and then go back to their old way of eating. They don't realize that if you lose weight on 1600 calories and then you plateau for a very long time, the minute you start eating 1700 or 1800 calories, your weight is going to start to go up again.
One of the things that I do is to ask people to set a weight loss goal of only five pounds. When they reach that goal, they can think to themselves, "Is it reasonable for me to continue and try to lose another five pounds?" If they do that, then at that point they can say, "Is it reasonable for me to go on and try to lose another five pounds?"
Most people will not get as thin as they absolutely want or if they do, they probably won't be able to sustain it because biology and genetic factors are so important.
Dr. Van Nuys: Yeah. I think, I've run into my own sort of lower limit as I've tried to do that and the yoyo effect that you talked about there that's kind of well-known to people who try to diet and they seem to lose weight and then come back up and lose it again, come back up and lose it again.
Dr. Beck: Yeah, what I...
Dr. Van Nuys: Yeah, go ahead.
Dr. Beck: I'm sorry. What I suggest is that people eat as many calories as they can in a very nutritious way and still lose between half a pound and two pounds a week. Then, when they plateau for quite a long time, they can cut their calories by no more than 200, if it's reasonable to keep up this lower level of calories for their whole lives and then they'll start to lose more weight.
But, I ask people never to go below 1600 calories because in my experience, people can sustain a lower calorie level for a few months or even a couple of years, but not beyond that. So, there's no sense in cutting your calories enormously, losing weight and then gaining it back.
Dr. Van Nuys: OK. Again, in reference to your subtitle, "Train Your Brain to Think Like a Thin Person," do thin people really think differently than overweight people?
Dr. Beck: They really do. They really think differently from people who struggle with their weight, from people whose weight goes up and down, this kind of yoyo dieters.
Dr. Van Nuys: Yeah, what's the difference?
Dr. Beck: For one thing, they don't eat necessarily according to what other people eat. People who struggle with dieting continually have these kind of thoughts, "Oh, it's not fair that I can't eat what my friend is eating. I should be able to eat like him." Thin people are much more attune to what their hunger is and they're not so easily influenced, either by what other people are eating or a commercial they see on television or the smells that are coming from the corner bakery.
Dr. Van Nuys: Interesting.
Dr. Beck: They tend to eat when they're hungry and then they tend to not have the idea that they should eat continuously or whenever they want, but that they should eat at mealtimes.
Dr. Van Nuys: I wonder if there are changes over the lifespan because I used to think like a thin person [laughs] and now, I think, like not a thin person.
Dr. Beck: Well, what happens especially is when people start to restrict their eating; they start to really think differently from other people. Another characteristic of people who struggle with dieting is that they think it's a good idea to become a little bit overly full. They really do fear hunger and they often have the thought, "If I eat a whole lot of this meal, then maybe I won't get hungry before the next meal."
This is different from naturally thin people who feel uncomfortable when they get overly full. They're not worried about when the next meal is going to be or what they're going to eat. They know that whatever happens, they'll be able to tolerate the hunger and that they'll eat eventually.
Dr. Van Nuys: Yeah. Is there some kind of metabolic shift that happens somewhere around or after middle age because it seems like...
Dr. Beck: Oh, there is. Everyone's metabolism slows down. If you eat the same number of calories and don't increase your exercise, you're likely to gain 10 pounds every decade of life.
Dr. Van Nuys: Yeah, OK [laughs]. I think, I know that. On your website, you mention some of the key areas that people struggle with. Maybe you can give a few words of advice on these? The first is avoiding cheating. What's your advice about that?
Dr. Beck: What people need to do is to learn how to plan in advance what they're going to eat and then to learn how to stick to that plan, no matter what. One technique for doing this, for motivating themselves to do this, is to have a list of all of the reasons they want to lose weight and to read that list over and over and over again and especially when they're in situations where there's tempting food around that they hadn't planned to eat.
It's also important for them not to have such a bad deprivation mindset. They ought to say to themselves, "OK. Well, I didn't plan to have this chocolate chip cookie today, but I can always plan to have it tomorrow." Another notion that dieters need to learn is that it's not really the calories themselves that are so important as the habit.
So, there are some programs that say never let yourself get hungry. Always, you can have as much of these unlimited vegetables as you want. The problem with that is that people then never learn how to just tolerate hunger. They also need to focus on the habit itself. Every time you eat something that you hadn't planned to eat... So, let's say you have an extra helping of mashed potatoes or you have a few bites of ice cream. It might not even be that many calories, but you're strengthening your giving in muscle.
What you have to do to be a successful dieter and maintainer is to get very strong distinct food that you are not supposed to eat at the moment. Every time you resist some food that's tempting to you, but you haven't planned to eat, you build up this habit of resisting. Every single time you give in, even if you just have a few cooked in corns, you are building not your giving in muscle. In order to have long term success your resistance also has to be very strong and your giving in muscle has to be very weak.
Dr. Van Nuys: How about dealing with stress and strong negative emotions without turning to food, which [inaudible].
Dr. Beck: This is another characteristic that some people don't share with people who struggle with their weight. Certain people usually don't even think of turning to food when they are upset. What I think of my [inaudible], my dieters who do turn to food when they are upset, I ask them what you think other people do who don't turn to food. And they usually get quite puzzled and say 'I don't know.' What the [inaudible] mystery is the people who don't turn to food when they upset try to solve a problem might call friends, might go out for a walk or might distract themselves in some way. Or they might take some meditation, they might do yoga, they might do some relaxation exercises or some deep breathing.
So, just because you're upset doesn't mean that you should eat. In fact, it's the one time when I tell people they should not follow their plan. Let's say it's lunchtime and you're very upset. I advise dieters to wait, to calm themselves down first and then eat. So, dieters have to change the rule for themselves from "If I'm upset, I should eat" to "If I'm upset, I shouldn't eat."
Dr. Van Nuys: OK, that makes sense. What about people motivating themselves to exercise?
Dr. Beck: The same kinds of sabotaging thoughts that get in the way of following a diet get in the way of exercise, such as, "Oh, it's OK if I skip exercise today because I'm tired, I'm rushed, I'm stressed, I'm having too good a time doing other things. It won't really matter."
The truth of the matter is it can. We're building up the resistance muscle in exercise. We want people to make a good exercise plan and then learn to follow it no matter what and not give in to these sabotaging thoughts and say, "Oh, it's OK to skip it."
Now, when people are non-exercisers, what I try to get them to do is just to take a five minute walk seven days a week because I want them to have the idea that exercise is an essential part of good health. Exercise actually doesn't burn off nearly as many calories as most people think and I don't advise that people eat more on days when they do exercise and less when they don't.
I pretty much want people to learn how to eat about the same amount 365 days a year and also, do at least a five minute walk 365 days a year and then build up to more strenuous exercise at least a few times a week.
Dr. Van Nuys: Yes. What about eating out and vacations and holidays and special occasions? They seem to come in clusters where there just seems to be one excuse after another because of special events and so on.
Dr. Beck: There are so many special events.
Dr. Van Nuys: Yeah [laughs].
Dr. Beck: There's your birthday, there's the birthday of everyone in your family, there's the birthday of all your friends, there's the birthday of all your co-workers.
Dr. Nuys: Exactly.
Dr. Beck: There are anniversaries, there are conferences, there are vacations, there's business travel.
Dr. Van Nuys: Yes.
Dr. Beck: There are parties, there are holidays, there are so many special occasions that what people need to do is to come up with a special occasion rule for themselves. The rule might be, "During any week, I can eat 300 calories more at whatever special event I want, but that's all." If they eat 300 calories more at every event, it's either going to slow down their weight loss or prevent them from losing weight. So, they just have to make a reasonable decision in advance.
Dr. Van Nuys: OK, that sounds good. What about eliminating overeating, binging and backsliding because that's often an issue for folks?
Dr. Beck: It is. The sabotaging thought that people have is, 'Oh, well, I cheated. Since I broke my diet, I might as well eat whatever I want for the rest of the day and then start again tomorrow." What I do is to ask people to think of an analogy. If you ran a red light and got a traffic ticket, would you go ahead and run red lights for the rest of the day? Well, of course, you wouldn't. You would never compound one mistake with more.
It's really the same with dieting. What we teach dieters to do is to get back on track immediately after they've eaten one thing that they thought that they shouldn't. I draw a little pyramid for them that show... Let's say they eat a little piece of cake with icing, it might be 300 calories. That piece of cake is not even going to show up on a scale at the end of the week, but if they say to themselves, "Oh, I shouldn't have eaten that. I might as well eat whatever I want now," they might go on to eat ice cream, pretzels, chips and so forth. Then the extra amount of food really is going to show up on the scale and probably the next day.
So, we teach dieters exactly what to do when they get off track. One of the important skills that they learn in the Beck Diet Solution is to develop little 3X5 cards for themselves on which they write very important things to remember. So, for example, one of the cards might say, "I can eat whatever I want whenever I want or I can be thinner. I can't have it both ways." Another card says, "If I get off track, I give myself credit for stopping whenever I stop and go back to the basic skills of motivation right away."
Dr. Van Nuys: Well, these sound like great tips. As we wrap things up here, is there anything else you'd like to say about either cognitive therapy in general or your approach to permanent weight loss?
Dr. Beck: I'd like to talk a little bit about cognitive therapy in general. People always ask me, "Well, should I try cognitive therapy? Should I try another treatment?" and I always say to them, "I think, it's a good idea to look at the research to make your decision about what to do." For example, if you had a terrible sore throat and you went to the doctor and found out that you had a bacterial infection. You would want the medication that is shown by research to be the most effective for sore throat.
You wouldn't want the doctor to say, "Oh, well, I kind of like this medicine" or "Maybe you'd want to try that." You'd want him to give you his best recommendation based on what research says. I think, the same is really true whether we're talking about people who are depressed, who are anxious, who have eating disorders, who want to lose weight, who have a substance abuse problem, who have migraine headaches, who have insomnia and so forth. I really encourage consumers to take a look at the research to decide what should be at least the frontline treatment to try first.
Dr. Van Nuys: OK, excellent recommendation. Well, Dr. Judy Beck, thanks so much for being my guest today on Wise Counsel.
Dr. Beck: My pleasure. Thank you.
Dr. Van Nuys: I hope you enjoyed this interview with Dr. Judith Beck. You can find out a lot more about the Beck Institute and cognitive therapy by visiting the Beck Institute's website at www.beckinstitute.org. You'll find links there to books, CDs and other helpful materials. If you're interested in Dr. Beck's approach to weight loss, I'd refer you to her site at http://diet.beckinstitute.org/ and "Beck" is spelled B-E-C-K.
Dr. Van Nuys: You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.