PHILADELPHIA -- 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
"How does talking about this make
you feel?" he asked her.
"I feel anxious," she replied.
Trained to probe the hidden conflicts
underlying psychological symptoms, Dr. Beck responded with
"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
"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
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
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
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
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
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
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,
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
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,
And like many of his peers, he pursued
analytic training, graduating from the Philadelphia institute
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
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
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
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
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
Retiring, he says, has never entered
"I think he has done a lot of cognitive
therapy on himself," his daughter says.