A Pragmatic Man and His No-Nonsense Therapy

January 11, 2000

A Pragmatic Man and His No-Nonsense Therapy

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By ERICA GOODE

HILADELPHIA -- The session, Dr. Aaron T. Beck recalls, began like many others. The woman lay on the couch, describing her sexual encounters with men, while Dr. Beck, at the time a recent graduate of the Philadelphia Psychoanalytic Institute, sat behind her, scribbling in his notebook.
"How does talking about this make you feel?" he asked her.

'There's more to the surface than meets the eye.'

"I feel anxious," she replied.
Trained to probe the hidden conflicts underlying psychological symptoms, Dr. Beck responded with an interpretation.
"You are anxious because you are having to confront some of your sexual desires," he told her. "And you are anxious because you expect me to be disapproving of these desires."
"Actually, Dr. Beck," his patient replied, "I'm afraid that I'm boring you."
Arms crossed on his chest, red bow tie resplendent, pale blue eyes keen beneath a shock of white hair, the founder of the fastest growing, most extensively studied form of psychotherapy in America is telling this story to explain how he eventually came to leave Freud behind.
Sitting in his office at the Beck Institute for Cognitive Therapy and Research in Philadelphia, he offers a favorite maxim: "There is more to the surface than meets the eye."
The key to many psychological difficulties, Dr. Beck has found in 40 years of research and clinical work, lies not deep in the unconscious, but in "thinking problems" that are much closer to conscious awareness.

Sal DiMarco Jr. for The New York Times

Dr. Aaron T. Beck, a father of cognitive therapy, which has gained a wide following. at the Beck Institute.

In the woman's case, for example, it turned out that she engaged in an endless self-deprecating monologue, an inner voice constantly berating her that she was unattractive, uninteresting and worthless.
And these "automatic thoughts," as Dr. Beck calls them, led her to behave in self-defeating ways, like acting promiscuously because she did not think she had much else to offer, or engaging in histrionics in an effort to seem more interesting.
Cognitive therapy, developed by Dr. Beck after he abandoned psychoanalysis, is intended to help patients correct such distortions in thinking, often in a dozen sessions or fewer.
Dr. Beck calls the method "simple and prosaic," with no dredging up of lost childhood memories, no minute examination of parental misdeeds, no search for hidden meanings.
"It has to do with common-sense problems that people have," he said.
Patients in cognitive therapy are encouraged to test their perceptions of themselves and others, as if they were scientists testing hypotheses. They receive homework assignments from their therapists. They learn to identify their "inaccurate" beliefs and to set goals for changing their behavior.
It is an appealing package. And in an age when managed care closely monitors the consulting room, and most psychiatrists view drugs -- not talking -- as the treatment of choice for their patients, Dr. Beck's approach has been able to provide hard data in support of psychotherapy's power.

A Therapy Modified for Patient and Times

PHILADELPHIA -- Cognitive therapy was developed 40 years ago to treat people suffering from depression. But in the age of Prozac and other newer antidepressants, said Dr. Judith Beck, director of the Beck Institute for Cognitive Therapy and Research, "we don't see them in our offices anymore."
The patients who do seek cognitive therapy these days tend to have more longstanding, and more complicated, problems. And in response, the therapy is being modified and adapted to meet their needs.
In treating borderline personality disorder, for example, a cognitive therapist may ask patients more about their childhoods, hoping to find the "early conditioning experiences" that helped nourish their distorted beliefs about themselves and others.
And where someone with simple depression is likely to improve in 8 to 10 sessions with a therapist, said Dr. Aaron T. Beck, the founder of cognitive therapy and Dr. Judith Beck's father, patients whose problems are more global may remain in therapy for several months, a year, or longer.
One goal in such cases, he said, is "to try to teach them self-control, how to control their impulses."
The relationship with the therapist also becomes more important than in shorter-term therapies. For example, Dr. Beck said that a woman who sought help at the Beck Institute's clinic initially saw him both as an authority figure who would try to control her, and as a helper who had her best interests at heart.
His strategy in such cases, he said, is to talk to patients about their beliefs, and invite them to test out their perceptions, to see if they mesh with reality. If the patient believed Dr. Beck was trying to control her, for instance, he might ask: "How would you expect me to behave if that were case," and "What is the evidence in favor of this; what is the evidence against it?"
It is a method that Dr. Beck argues can help even with patients with severe psychotic disorders, like schizophrenia.
In the United States, treatment for schizophrenia is generally limited to the use of antipsychotic drugs, perhaps with addition of supportive counseling to help patients and family members cope. But Dr. Beck and other researchers are finding that when added to drug treatment, cognitive therapy can help psychotic patients, giving them more control over hallucinations and delusions.
Seven studies in England, Canada and Italy, Dr. Beck noted, have shown cognitive therapy to be effective for chronically ill patients who do not respond to drugs and for patients in the throes of acute psychotic symptoms.
In a review of the research, not yet published, Dr. Beck and Dr. Neil A. Rector, of the University of Toronto, concluded that patients with schizophrenia who improved through cognitive therapy "continue to experience fewer distressing symptoms, have lower relapse rates, spend less time in the hospital, and appear to have greater skills to negotiate setbacks than patients receiving routine care alone."
Cognitive therapists use many of the same techniques to treat psychotic patients as they do to treat less severely ill patients. But therapy sessions tend to be shorter and treatment is extended over a longer period, homework tasks are more focused and goals are more flexible, Dr. Beck and Dr. Rector noted.
The therapy, they pointed out, is not intended to "cure" delusions or hallucinations, but to reduce the distress they cause; for example, by challenging patients' beliefs that the voices they hear are omnipotent and cannot be disobeyed.
"The goal is to render the experience less threatening by altering the meanings associated with voices, rather than diminishing the hallucinatory behavior itself," the researchers wrote.
Cognitive therapy may work in schizophrenia, Dr. Beck speculated, because it helps patients gain access to their abilities to think logically and to organize their mental processes.
-- ERICA GOODE
Cognitive therapy's basic precepts are easily summarized in training manuals and its simplicity makes it an ideal research tool. And dozens of studies have shown it to be effective in treating depression, panic attacks, addictions, eating disorders and other psychiatric conditions. Researchers are also studying the therapy's ability to treat personality disorders and, in combination with drugs, psychotic illnesses like schizophrenia.
Therapists from around the world travel to the Beck Institute for training.
And mental health organizations like the National Mental Health Association recommend cognitive therapy to patients as one of the few forms of psychotherapy studied in large-scale clinical trials.
Yet every theory of the human mind in general springs from a human mind in particular. Freud, caught in his own Oedipal struggles, saw the unconscious as roiling with sexual and aggressive impulses. Fritz Perls, possessed of a biting wit and fond of confrontation, invited his patients to take the "hot seat." Carl Rogers, a former seminarian and by all accounts an empathic soul, argued that psychotherapy should be "client-centered."
And in its way, cognitive therapy -- practical, cerebral and to the point -- is also a fair reflection of the man who conceived it.
He is 78 now, an emeritus professor of psychiatry at the University of Pennsylvania, four times a father, eight times a grandfather.
Yet even as a younger man, his former students say, Dr. Beck, with his white hair and the bow tie he carefully affixed each morning, projected a grandfatherly air, offering a nurturing presence, a passion for collecting data, a conviction that evidence always trumps opinion.
Others in his position might cultivate the flamboyance Americans seem to expect of their therapy gurus. But Dr. Beck has more in common with Marcus Welby than Dr. Laura Schlessinger or John Bradshaw -- his currency ideas, not personal charisma. Soft-spoken and unexcitable, he wears a hat, chats amiably with strangers in elevators and uses words like "gosh" and "gal."
Asked to describe himself, Dr. Beck ticks off "kind, intelligent, creative, flexible."
"I don't need to be right," he says, "but I don't like to be wrong."
Dr. Jeffrey Young, a former student, now the director of the Cognitive Therapy Center of New York, recalls a debate with his professor over whether those who came to them seeking help should be referred to as "patients" or "clients." Dr. Beck had a simple solution: Ask people what term they prefer.
"I think I am ultimately a pragmatist," Dr. Beck says. "and if it doesn't work, I don't do it."
He encourages a similar philosophy in his patients, hoping they will eventually choose to let go of the self-defeating attitudes that tie their lives in knots. "It's a testable assumption," Dr. Beck tells a 30-year-old woman who believes, she told him, that "if I don't punish myself, God will be mad."
"You could see if you stopped punishing yourself and nothing happened," he suggests.
With patients convinced that they must always be perfect, that their bosses hate them, that their spouses are insensitive to their needs, he will question, gently, "Would you agree that it is against your best interests to have this belief?" He will ask: "What are the disadvantages to thinking this way?" He will wonder out loud: "Do you think it is possible to ignore these thoughts?"
It is a faith in the rational mind he has carried since childhood, growing up in a middle-class neighborhood of Providence, R.I., the third son of Russian Jewish immigrants, his father a printer with strong socialist beliefs who wrote poetry in his later years, his mother a forceful woman of unpredictable moods who had already lost two children.
He was a Boy Scout, an active child who, despite his mother's overprotectiveness, played football and basketball until at 8, he developed a dangerous staph infection after surgery for a broken arm, a complication that kept him in the hospital for more than a month.
He remembers the surgeon saying "he's not under yet," remembers a terrible dream of a series of alligators, each biting the tail of the next, the last alligator biting his arm.
He remembers his mother saying: "He will not die. He will not die." The boy himself never questioned that he would recover. But the surgery, Dr. Beck believes in retrospect, was a defining moment in his life, restricting his activities and forcing him to find quieter forms of entertainment, like reading.
The hospitalization defined his life in other ways, too. He developed a phobia of blood and injury: a hospital scene in a movie was enough to send his blood pressure plunging. If he smelled ether, he became anxious and began to faint.
He conquered his fears methodically, allowing logic to gradually triumph over irrationality. "I learned not to be concerned about the faint feeling, but just to keep active," he says.
With such a straightforward attitude toward his own psychology, Dr. Beck, was probably never meant to become a psychoanalyst; even now, his interest in how his childhood experiences shaped him seems minimal.
Freudian theory was ascendant in psychiatry departments across the country when he was a resident at the Cushing Veterans Administration Hospital in Framingham, Mass.
And like many of his peers, he pursued analytic training, graduating from the Philadelphia institute in 1958.
Still, he had some doubts. The lack of precision annoyed him: Though every analyst agreed that in neurosis there were "deep factors at work," no one, Dr. Beck discovered, could agree on exactly what those factors were.
He found work with patients exhausting, because the goals seemed so unclear. "The idea was that if you sat back and listened and said 'Ah-hah,' somehow secrets would come out," Dr. Beck remembers. "And you would get exhausted just from the helplessness of it."
Still, he completed his training and began taking patients in for analysis. But without any fanfare, he began to adjust the way he interacted with them.
The woman who worried about boring him, for example, he asked to sit up and face him, so that she could see his facial expressions and gauge his interest in what she was saying. He began to ask more questions, and to listen to the answers in a different way.
At the same time, at Penn, where he joined the faculty in psychiatry in 1954, Dr. Beck was trying to find empirical evidence for Freudian precepts -- and failing. With a colleague, he designed an experiment to test the link between depression and masochism, a basic psychoanalytic notion. But the researchers found no evidence that the depressed patients in the study somehow needed to suffer. Instead, Dr. Beck said, they simply showed low self-esteem, devoid of hidden motives. "They saw themselves as losers because that's the way they saw themselves," he said.
The cognitive approach to therapy that Dr. Beck ultimately developed -- influenced, he says, by thinkers like Karen Horney, George Kelly and Albert Ellis, whose rational emotive therapy struck similar themes -- was a major departure from the psychoanalytic fold. And it was not received warmly. Many analysts dismissed it as superficial; some suggested that perhaps Dr. Beck himself "had not been well analyzed."
There have been other critics, as well. Psychologists trained in classical behaviorism have opposed cognitive therapy's focus on "thoughts," which they said could not be measured objectively. Biological psychiatrists, like Dr. Donald Klein, director of research at New York State Psychiatric Institute, have argued that the therapy is simply a morale booster for depressed patients, not a specific treatment. Dr. Beck, for his part, has responded to each critique with a new raft of experimental data.
"He is an unusual person," said Dr. John Rush, professor of psychiatry at the University of Texas Southwestern Medical Center and a former student. "He is willing to test his own beliefs, just like he asks patients to test theirs."
Yet in the early years it often was lonely work, and it was his wife, Phyllis, now a Superior Court judge in Philadelphia, who buoyed him.
"She was my reality tester," he said. "She went along with the newer ideas I had, and that gave me the idea that I wasn't in left field."
Many decades later, she remains his closest confidante. But it is his daughter, Dr. Judith Beck, a psychologist who is director of the Beck Institute, who participates most closely in his work.
Scene: A suburban delicatessen, a corned beef sandwich, his daughter sitting next to him; a comfortable setting for Dr. Beck who, his colleagues and former students say, is in fact very shy.
"Do you remember that dream I had when I was going off to graduate school?" she asks him. "That I was up on the Empire State Building and I felt in danger of falling off."
"I do," he says. "And do you remember what I told you it might be about? That the higher you aspire, the greater you're going to fall?"
"It hit me as absolutely that was what it meant," she replies.
As institute director, she has come to know her father in a different way, to admire him as a thinker and a therapist, to work with him as a colleague. When she was a child, she says, he was always working; age has made him more tolerant, less driven, has turned him more toward family.
It has not slowed him down. He receives 10,000 e-mail messages a year, divides his time between Penn and the institute, is expanding his research into new areas. He plays tennis regularly, despite a recent hip replacement. His newest book, "Prisoners of Hate: The Cognitive Basis of Anger, Hostility and Violence," (HarperCollins, 1999) appeared last fall.
Retiring, he says, has never entered his mind.
"I think he has done a lot of cognitive therapy on himself," his daughter says.

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