A Conversation with Glen Gabbard, M.D.

Aaron T. Beck, M.D., President Emeritus

June, 2012

On Sunday, May 6, 2012, Aaron T. Beck, M.D., and Glen Gabbard, M.D., a leading expert in
psycho-dynamic theory and therapy, were featured in a special Conversation Hour at the
Opening Ceremony of the American Psychiatric Associations (APA) Annual Meeting in
Philadelphia. At this premiere session, Drs. Beck and Gabbard discussed similarities and
differences between cognitive therapy and psychodynamic therapy. The session was moderated
by Dr. John Oldham, Senior Vice President and Chief of Staff at the Menninger Clinic, and
President of the APA. Over a thousand people attended.
Prior to their discussion, the two experts exchanged emails. Below is an excerpt of a letter that
Dr. Beck sent to Dr. Gabbard:
Ive been thinking further about your comment regarding our noting the differences and
contrasts between psychodynamic therapy and cognitive therapy (as well as several striking
similarities). I thought that I would mention some of the aspects of the cognitive approach that
may not be usually included in the psychodynamic approach.
I. Structure of interview: We generally set an agenda and get feedback from the patient at
various points during the session and then give homework assignments depending on the
patients problems. The homework (which I actually label the Action Plan) may consist of
behavioral experiments as well as noting and evaluating beliefs and automatic thoughts. There
are a number of other components that we label collaborative empiricism (working with the
patients to test out their beliefs) and "guided discovery."
II. The cognitive model: We have two generic cognitive models. The first is the cross-sectional,
which starts with the beliefs that are incorporated into the schemas (same as your internal
representations). When these beliefs are activated, they influence the information processing,
and thus the meanings of particular internal or external events (similar to your model). We
emphasize the attentional focus, which generally attaches to the original stimulus (for example,
headache, obsessional thoughts, etc.) as well as its meaning. Finally, the sequence ends in
maladaptive behavior (avoidance, acting out, etc.)
The longitudinal or historical model attempts to explain what events in the patients life
(actually their interaction with genetic predispositions) led to the beliefs/schemas.
While the generic model is applicable to all disorders, each of the disorders has its own model
derived from the generic model. Thus, for example, the sequence in depression might be:
stimulus (not receiving an expected phone call) --> belief (People dont like me) --> specific

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interpretation (She doesnt like me) --> affect (feels sad) --> attentional focus (focuses on
thoughts of unlovability) --> maladaptive behavior (goes back to bed).
Thus, the various disorders differ in terms of the specific stimulus and the specific beliefs that
are activated. The model provides the framework of the case formulation.
III. Therapeutic approach: The therapeutic approach differs as to whether we are dealing with
a simple discrete disorder which is uncomplicated (depression, panic disorder, or obsessive-
compulsive disorder) or a more diffuse, complex disorder, such as comorbid depression and
anxiety, personality disorders, or schizophrenia.
For discrete disorders, the therapist is fairly directive. For panic disorder, for example, the
thrust is to reproduce the feared sensations in the office: a form of state-dependent learning.
Similarly, with OCD, exposure therapy is often indicated.
In the approach to complex disorders, the therapist is less directive and uses more exploratory
tools, explanation, and interpretation.
Finally, a word about the non-specific factors: It is important to have a strong therapeutic
alliance with all patients. In recent years, I have been supervising therapists with patients with
low-functioning schizophrenia. Engagement is absolutely crucial to any therapeutic intervention
with these patients. The initial engagement may consist of playing video games together, taking
a walk to Starbucks, or playing music that the patient likes. During the engagement process, the
therapist can use various techniques. Therapists need to be both creative and flexible in
developing the alliance and employing essential techniques to help patients progress.

Originally published in Cognitive Therapy Today Volume 17, Issue 2. June 2012.