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A pioneer in psychotherapy research:

Aaron Beck

Sidney Bloch

Australian and New Zealand Journal of Psychiatry 2004; 38:855–867

SB: I gather you grew up in a Jewish family, your parents having migrated to the United States from Russia. What was it like for you? Did that experience influence you in choosing to study medicine? AB: I grew up with loving parents, which was a problem when I was in psychoanalysis; I could not recall any unpleasant experiences in growing up. I was the youngest of three siblings. My parents actually lost two children before I was born. A sister died in the influenza epidemic of 1920, and in a way I was a replacement for her. If anything, my mother was very over-protective. The most traumatic episode in my childhood was when I broke my arm and developed septicaemia. At one point they were thinking of amputating my arm, but then thought that it wouldn’t work. I learnt years later that it was a staphylococcus infection which had about 95% mortality in those days. Obviously I recovered and still retained my arm but the impact on me psychologically was that I developed an intense fear of surgery and a blood injury phobia. For many years if I saw anything related to surgery or to injury, I would become faint and occasionally I almost toppled over. One of my ambitions was to overcome this fear. I did so eventually through exposure and willpower. When I went to medical school I often experienced feelings of faintness but I would go to the operating room to desensitize myself. Eventually I was able to overcome the problem. This may have been one of the roots of my later thinking that it was possible to overcome very disabling symptoms. SB: You could have gone another route and concluded:

‘Medicine is not for me; I am one of the faint-hearted’.

Sidney Bloch, Editor and Professor

Australian and New Zealand Journal of Psychiatry . Department of Psychiatry, University of Melbourne, St Vincent’s Hospital, Victoria, Australia. Email: s.bloch@unimelb.edu.au

This interview was conducted in Philadelphia by Sidney Bloch on 3 May, 2004. My sincere thanks to Professor Beck for participating so willingly in this interview.

Did you think this through or was it an unconsciously determined decision? AB: Everything is retrospective. I tended to face and meet challenges throughout my childhood and adoles- cence. The greatest learning experience I ever had probably though was as a Boy Scout. I had to learn things that were quite difficult for me – lifesaving, swimming half a mile, and things of that nature. I think that if there was any pattern in my life it was going out and meeting challenges that lay before me. I think I was conscious of that and I would galvanize myself. I had a strong need to conquer whatever problems I faced.

I was conscious of that and I would galvanize myself. I had a strong need to

Aaron Beck

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INTERVIEW WITH AARON BECK

There was also a family tradition of scholarship. For example, both my brothers excelled in their particular fields and had done very well in school. It was part of the ethos of the family to push ahead and do whatever you could do. Part of that probably was from my immigrant parents who came to America looking for opportunities. While they were not able to realize them themselves, they could do so through their children. SB: I understand your father was a committed social- ist. Did this play any role in your thinking as an adoles- cent and young adult? AB: My father’s socialism projected the idea that one could make a better world wherever one lived. While I was not an activist myself, I did believe in democratic values and this has been a major theme throughout my life. SB: Turning to your mother, I read somewhere that she was a moody person. Given that you developed an inter- est in depression, was there anything in your family life that may have stimulated you in that way? AB: My mother was moody but I actually got inter- ested in depression for totally practical reasons. When I first started clinical practice most of my patients were depressed. If I was going to be interested in any area it probably would have been anxiety and phobias because of my personal experience of them. SB: You chose psychiatry as a lifetime career. I am curious why you went up this route given that you did a residency in pathology. Was that a competing option? AB: I actually went into psychiatry by accident. When I was in medical school I was very much turned off by the subject because I felt that it did not provide answers for anything. Our Professor of Psychiatry, Eugen Kahn, was a student of Kraepelin and believed that there were only two basic diagnoses, schizophrenia and psychopathic personality, and neither was treat- able. At the time I was very much interested in organic medicine and took a two-year internship in order to cover every aspect of medicine, from paediatrics to mental illness. I decided later that in order to achieve a strong grounding in physical illness I should do a residency in pathology. I also concluded that neurol- ogy was the field in which I wanted to work. I spent a year in it. Then, because there was a shortage of psychiatry trainees, all neurology trainees had to spend six months in psychiatry. I was actually pushed into psychiatry against my will. Freudian psychiatry was reaching its zenith at the time. The entire service was involved in psychoanalytic theory and therapy. It seemed to me that psychoanalysis did perhaps have the answers to everything but that one could not get those answers unless one had been analysed or, at least, had become immersed in the subject. I toyed with the idea

of staying in psychiatry long enough to determine whether psychoanalysis was a valid approach to under- standing human behaviour. Although I kept on in psychiatry, I am still enrolled as a neurology registrar who has never completed his training program! Even- tually I decided to find out for myself whether psycho- analysis did have all the answers by obtaining training as an analyst. SB: It sounds to me like this was tantamount to taking up a challenge and dealing with it directly. Would it not have been easier to remain in neurology, even neuro- psychiatry, since you did a stint in the army in that area? AB: I began to think that neurology was too easy since it was so precise, with everything well laid out. More- over, there weren’t many successful treatments in those days. I wanted to plough new fields, discover whether psychoanalysis could yield answers, and then proceed to test out the answers. SB: After a period of training in what seems a fairly conventional setting, a veteran’s administration hospital, you moved to Austen Riggs, a distinctly unusual place. What motivated you? AB: When I was in psychiatric training, the psycho- analytic structure that was imposed on us was extremely orthodox. Trainees were never expected to respond to patients’ questions. We would always respond to a ques- tion by posing another question such as: ‘What do you mean by that?’ The therapist was expected to be a blank screen and not to disclose anything about themself. This seemed to me unrealistic. I was attracted to Austen Riggs because it embraced a much more liberal humanistic attitude, maintaining a tradition Dr Riggs had originated in the asylum. The exposure I had there was indeed at the very liberal cusp of psychotherapy. Even though there was a psychoanalytic thrust to the type of therapy done, it was sensible and humanistic. I learned a great deal. Many leading American therapists worked at Austen Riggs at the time, among them Erik Erikson and Robert Knight. I learned much from them and was able to weave this knowledge into my therapy later. SB: What was Erikson like? AB: Erikson actually supervised me on one of my cases. I learned particularly how childhood themes could play themselves out in adulthood. Erikson had a very easy manner and I think I adopted a thoughtful, reflec- tive demeanour, which can be most helpful with some patients. SB: He seems a very popular figure, certainly among Australian trainees. They see him as coherent and logical in the way he describes the effect of social factors on psychological development. AB: What stood out for me was his aesthetic approach to human problems. As you probably know, Erikson was

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an artist before he became a psychoanalyst. One could see the artistic temperament and the related approach he used. I found I could add my own repertoire of skills to this. SB: You decided to train in psychoanalysis and enrolled in the Philadelphia Psychoanalytic Institute. AB: I got my formal analytic education in Phila- delphia. Austen Riggs was the background. I was enthusiastic because it seemed to reveal whole worlds about which I had no intimate knowledge. I found the experience exciting and intriguing. I finished up fairly rapidly. I had a few residual problems but felt these would resolve in time. I was a strong believer during and after my psychoanalysis that this approach was for everyone, and I tried to persuade my friends to become analysed. SB: Were there any aspects you were unhappy with? AB: I think one of the downsides was that I became too preoccupied with myself, but this was something I only became aware of later. I was looking introspectively for all kinds of psychodynamics and probably was not as good a spouse and father as I could have been. SB: Did that create a tension in you? AB: I looked forward to the introspection because it was a voyage of discovery and I kept looking for more and more things. However, I never did find the holy grail that would reveal the answer, not only to my own human nature but also to the human nature of everybody else. I never succeeded in making the great psychoanalytic discoveries – the primal scene, the Oedipus complex, psychosexual development – and so felt unsuccessful. I did however, keep trying until my psychoanalysis was completed. SB: You then got interested in depression. You say there were plenty of depressed patients to be treated. It seems that you were challenged to determine whether Freudian ideas about melancholia could be tested and validated. AB: I thought the most elegant, plausible theory in psychoanalysis concerned depression, that it played out logically. You could take the whole set of depressive phenomena, such as self-criticism, courting of rejection, loss of appetite, loss of sleep, suicidal motives and immobility, and readily explain it by the psyche turning against itself. Certain unacceptable impulses, usually hostile, would hit up against a particular defence mecha- nism and therefore not be expressed but be turned in against oneself. And this could explain all the features of depression. Many people, particularly in academic psy- chology and some in psychiatry, really did not believe this. I thought it would be interesting to try to demon- strate to non-believers that there was truth in Freud’s formulation.

SB: You obtained funding from the National Institute of Mental Health in the 1950s and 1960s to study depres- sion. What did you investigate? AB: I first did a clinical study, without funding, and decided that the answer to validation of psychoanalytic concepts lay in tapping into unconscious mechanisms. These by definition would not be accessible in ordi- nary interviews or even projective tests but through dreams. So I elicited a series of dreams from depressed and non-depressed patients and developed a manual through which we hoped to show that the depressed group had more hostility in their dreams than the con- trols. This would then fit the credo we had then that patients harboured hostility. The hostility could not be expressed directly but got channelled into the dream. The scoring of dream content was done by a psycholo- gist, blind to the identity of the patients. A serious anomaly emerged in that the depressed patients had less hostility than the non-depressed controls. We rational- ized that the patient still had the hostility but it was beneath the surface, and came out in the dream as a range of unpleasant experiences. We therefore con- cluded that these dreams were masochistic in content and still supported psychoanalytic philosophy. We then obtained a grant from the National Institute of Mental Health to see whether hospitalized depressed patients had similar dream content. We asked a large number to describe their dreams and compared them with the dreams of non-depressed patients. The depressed sample again had more masochistic dreams, a form of cross- validation. However, sceptical psychologist colleagues brought up the point that we had not proven depressed patients’ need to suffer, the basis for the masochism. We therefore set up several experiments in which the need to suffer was examined directly. Specifically, we hypothe- sized that depressed patients would court negative or aversive reinforcement as opposed to positive reinforce- ment compared to non-depressed patients. It turned out that far from this being the case, the depressed group actually sought out positive reinforcement. This was a little link in the chain of my beginning to question the whole psychoanalytic structure, but it was only one of the links. SB: I remember reading your articles on hopelessness and suicidality. Were seeking out positive reinforcement and hopelessness related? AB: Looking at hopelessness came later, as an expla- nation for suicidality as well as for other symptoms. To reconcile these two components, patients can feel hopeless but still seek solace, and even though feeling hopeless they certainly do not seek punishment. We found that hopeless people did not seek punishment but looked for positive reinforcement.

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SB: I have treated many depressed patients over the years and certainly the more severely depressed do talk about how useless they feel, how they have been terrible mothers and the like. I suppose that I remain wedded to the idea that a self-punitive quality prevails. Are you saying that this is not so or that there is more than one type of depression? AB: I think our conflicting points of view could be better understood in terms of the new formulations I

developed, which is that people will behave or feel according to the way they perceive. Thus, if a person perceives herself as bad and useless, she might want to punish herself or she might not. The key thing is not the motivational aspect of wanting to punish oneself but the self-perception. What we would focus on then is the sense of uselessness per se , which I think is itself a powerful belief. Perhaps I have put the cart before the horse or you have put the cart before the horse, but I would say the cognition comes first. SB: Have we reached the central role of cognition in your approach? Where does that begin to feature in your

research?

AB: A number of trends were taking place. I was only

a part-time researcher. I was also seeing a lot of

depressed patients. Over the course of time it became apparent to me that the way the patients viewed them- selves was at the core of the way they felt about themselves. If they viewed themselves negatively they would feel negatively about themselves. When I made my sea-change, it was a kind of quasi-experiment – if you change the way people think about themselves, such as a mother considering herself as useless, we could address that in a wide variety of ways. Changing this thinking changes the motivation, the inertia, the

self-punitiveness, and the negative affect. In actual fact

I was testing an hypothesis and confirmed that by

getting patients to test reality regarding their negative beliefs, we were able to turn around their depressive symptoms.

SB: What were your thoughts about psychoanalysis at this stage? AB: I started off believing that I was going to practise psychoanalysis for the rest of my life but when I started observing patients’ automatic thoughts, I thought it much better to have them sit up so that I could look at their expression and non-verbal communication. I would ask them what was going through their mind at that time. And that is where I got my raw data. When asking patients what they were thinking, they would say: ‘I think that I am boring you’ or ‘I am stupid’ or ‘I do not make sense’ or ‘You are not going to like me’, and so on. These were clues to what was going on in their minds outside of therapy.

When I focused on these negative thoughts, patients got better fairly soon, in 10 or 12 sessions. Patients whom I thought would be with me for a year or two or three reported: ‘I am finished Dr Beck; you have helped me a lot and I do not need you any more.’ My clinical load shrunk enormously. At that point Professor Stunkard, the Chairman of the Department of Psychiatry, offered me a full-time job. I got into research and teach- ing from that point onwards. SB: Before we talk about your research career, can you reminisce about your role as a psychoanalyst? AB: Let me respond with a clinical illustration. A woman patient is on the couch and she spends the entire time talking about her sexual escapades. At the end of the session I do what I think analysts are meant to do –

I ask her how she feels. ‘Very anxious’, she responds.

This makes good sense, I say, because you have these sexual impulses but since they are forbidden, they rise to consciousness and break through your defences, and this causes anxiety. And she says: ‘You’re right; that is brilliant’. But she has a tentative tone in her voice. I indicate that she seems tentative. She replies: ‘Yes, I was afraid that I was boring you’. I seize on that. ‘You have been here all these months and this is the first time you have told me about your fear of boring me.’ ‘It had never occurred to me to reveal this’, she retorts. I ask how often she thinks like this. ‘All the time. I think it when I am with you and when I am with other people.’ I then noted that other patients also were not reporting what they thought. It then occurred to me that there are two types of communication: internal and external. Internal refers to the automatic thoughts people have about them- selves which they do not ordinarily share. On the other hand, thoughts usually communicated (i.e. external) in psychoanalysis are of the kind that people do communi- cate to other people. At this point I thought that if I was going to get at what I call automatic thoughts, I ought to sit them up so that we could talk back and forth. I also discovered that I was having automatic thoughts. I had not been aware of them until I started focusing on them. That is how I abandoned the couch. This fitted into the cognitive model I was gradually formulating and also gave me an approach to therapy.

While these things were happening, I had to do some- thing about what was then the dominant theory of human

nature, psychoanalysis. In order to address the question whether this cognive model fitted better with the data than did psychoanalysis, I went through everything that

I had learned in psychoanalysis as well as looked for

empirical data to support psychoanalytic hypotheses, from psychosexual development to the concept of the ego. I concluded that psychoanalysis was a faith-based therapy and that if I was going to practise or teach

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therapy, it had to be empirically driven. Why the term cognitive? Because the cognitive revolution was occur- ring in psychology at the time and I was picking up a lot of its terminology. SB: I assume this work culminated in your first book, published in 1967, Depression: clinical, experimental, and theoretical aspects . AB: Let me tell you how I happened to write the book.

interventions. When I came to deal with personality dis- orders it was clear I had to explore childhood material. Patients might become expert at correcting their cogni- tive distortions but there was still a layer of self-criticism that we could not get at in the usual way. It became important to see what could account for this. We had to get patients to relive their childhood experiences and then look at these through the eyes of a mature adult in

I

had published a couple of papers on a cognitive

order to ascertain where their early perceptions were

approach to depression in the Archives of General Psy- chiatry [1,2]. One was empirical/clinical, the other theoretical. I then asked myself what I really knew about depression. I realized it was only what I had learnt in my psychoanalytic training, during my residency and from my patients. I thought that if I were going to say any- thing about the subject and be true to my own ethos, I ought to know much more. I decided to review the entire literature. Once I got into that, I thought that in order to

incorrect and then, in a state of emotional arousal be able to correct them. The patients were instructed to leave images of early formative experiences, recognize how their childish interpretations were no longer valid, and reframe them as a mature adult. So I have carried over various psychoanalytic notions. SB: I think your critics may argue that the cognitive approach minimizes, even denies, the relevance of early aetiological influences. You have just mentioned that in

learn this material systematically I ought to turn it into a book. The first part actually is a review of biological, psychological and psychotherapeutic aspects; and the second my own cognitive theory of depression. I also brought in my research findings. I had already developed

the personality disorders you have had to think this through and you have described it very precisely. I suppose the critics would contend that this does not only apply to personality disorders but to all clinical condi- tions, and that without pursuing early antecedent factors

depression inventory and included that too. SB: I take it the book was a milestone in your career. Your subsequent story is very well known because dozens more research papers and many books emerged. Did you actually say to yourself at this point: I am an empiricist, this cognitive approach seems to hold, the psychoanalytic one has disappointed me and I must break with one and embark seriously on the other? Or did you retain certain psychodynamic ways of thinking? AB: You are posing two questions. There was a break

a

and only looking at negative schemata in the present, we are missing whole chunks of relevant data. How do you respond to such criticism? AB: Firstly, in terms of theory – a therapist can have a theory about ultimate causality but does not have to prove it in a given case. Regardless of cause (genetic, neurochemical, psychological) we believe we can correct the condition by correcting the present-day effects. At our clinic, where we see complex cases, however, we always do a formulation which is based on

but a fuzzy one. People have said – I do not know if this

childhood and later experiences. However, having said

is

correct – that I was a rebel. And it is true that I did feel

that, in our early work on depression, uncomplicated

it

was a rebellion against the autocracy of the psycho-

depression, it was not economically wise if we wanted to

analytic establishment. Psychoanalysis is comparable to an authoritarian type of religion where people have abso- lute control of the faith and there is no place for dissent. Everything is predetermined. The more contact I had with the psychoanalytic establishment, the more dis- tasteful it became to me. If there was an emotional component in my rejecting psychoanalysis, it is that I do

treat patients within 12 sessions to go back into child- hood material. We found that by using simple devices like structuring the patient’s day, correcting cognitive distortions, and so on, we did get them better. We do not see those types of patients any more. They are treated by primary care doctors, given medication and improve within three months, just the same way as they would

not like to be wrong. I did not want to be wrong by rejecting it totally and I do feel that I learnt a number of important things from psychoanalysis which other schools were not aware of. Transference is one of these things, and I do deal with transference in my work. The second is looking for themes across all the patient’s disclosures, except that as a cognitive therapist I look for more or less conscious themes rather than those being repressed or being represented in a distorted way. The third aspect is to listen and then make appropriate

with cognive therapy. The patients we see today are complex and the theory we subscribe to becomes impor- tant in treatment. Nonetheless, we do not spend as much time delving into childhood material as we would if we were doing psychoanalysis. Moreover, we only deal with this aspect when it is specifically relevant to what is bothering the patient currently. SB: Can we take an example of these sorts of patients, those with deep roots if you like? Say someone has been emotionally neglected or abused in childhood, what sort

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of recognition will you give to that and how will it play

a role in your approach? You say you will only go as far

as you need to go because your purpose is to get them well, but given a certain type of childhood history, what do you do with data like abuse? AB: The patient gives the history and usually recovers relevant memories (we do not, I believe, have to deal with unrecovered memories). In doing a formulation, we try to see what the connection could be, at least theoretically, between childhood experiences and adult beliefs. For example, a woman’s main complaint is that she cannot establish relationships with men, with the result that she feels depressed a good part of the time. She not only wants to get over her depression but would like to get more out of life. Not to oversimplify, she wants to have a relationship with another man. We then find out that she was abused as a child by her father. We would say something like this: ‘What kind of attitude do you think you developed towards your father?’ This is similar to what psychoanalysts might do. She might say that she thought he was mean and horrible and rejecting. We would ask her to relate that to the present: ‘Who is the last person you had a relationship with?’ She might reply: ‘I haven’t been able to get close to many since they reject me’. ‘Is it possible that you have a view of men you get close to that they are hostile and rejecting?’ Her reply: ‘I do think they are’. We would then suggest we focus objec- tively on what the man is like. In so doing, we would deal with the past but try to identify what beliefs have emanated from past experiences and how these play out today. We would then try to correct them in today’s world. That might not work though, in which event we would have to go back and have her relive her experi- ences with her father and then correct her anachronis- tic, childhood-based beliefs. SB: The last thing you said is interesting because the role of trauma has become a prominent theme in contem- porary psychotherapy, both theory and practice. You say that if there is a need – in other words it is empirically determined – and your standard approach doesn’t hold

for a particular patient, you will go beyond it. I am still unclear what the work entails. AB: We think in terms of time-limited therapy. Therefore, if we reach a certain benchmark by follow- ing the standard approach, we stay with that. If we do not reach the benchmark, we will go further and apply

a wide range of strategies. This varies from patient to

patient but we follow a hierarchy starting with the standard model, then the modified standard, and then the revised, modified standard, and so on. But basically what I have been interested in is testing out how things go. In order to answer your question I have to tell you

what I have actually been doing. We developed a manual for suicidal, borderline personality disorder patients, which we consider a tough challenge. This contains different strategies, including going into child- hood material. Many strategies however, deal with the here and now, such as the patient’s self-destructiveness, poor impulse control and affective dysregulation. Indeed, most of the manual covers the present because these patients are very disorganized and dysphoric. We only accept patients into treatment who are suicidal and meet borderline criteria. Our first study was uncon- trolled, the one we are doing now is controlled. Patients are in therapy for a year, at the end of which most of them no longer meet diagnostic criteria for borderline personality disorder. There is one feature, however, in which none of them have improved at the end of treatment – the fear of abandonment. They are still afraid they cannot live in the world on their own. We did a follow-up study at six months. To our surprise, they no longer had this fear of abandonment . This tells us some- thing. Long-term therapy can go on indefinitely, as long as patients are afraid they cannot make it on their own and the sympathetic therapist is not going to throw them to the wolves. By contrast, in a clinical trial, you have to end at a given point. It turns out that patients who terminate therapy in this way have learnt enough and have acquired resources to deal with things on their own and continue to improve without needing the therapist to back them up. SB: Is it made explicit that treatment is of one year’s duration? AB: They have to sign a consent form which stipulates they will have one year followed by a couple of booster sessions. And if they want more therapy they will have to seek it elsewhere. We are now doing another study with borderline patients. They are randomly assigned to an experienced cognitive therapist or to an experi- enced psychodynamic or eclectic practitioner for six months only. This sounds very brave but we found in our earlier study that most of the improvement occurred in the first six months. Moreover, healthcare insurance commonly runs out at the end of six months, a highly realistic constraint. SB: I suppose all treatments today are buffeted by such economic realities. There are two other aspects of cogni- tive therapy that I want to pursue now. The first is whether there is a generic model; the second concerns indications. The approach is being applied to a growing range of clinical conditions and situations (e.g. pain, anxiety, substance abuse, marital conflict, personality disorder). Is the same theoretical model being applied or are you acting empirically and pragmatically and modi- fying it to suit new patient groups?

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AB: I can address your two questions almost simulta- neously. Is there is a generic cognitive model? I never actually used that term until an Oxford colleague stated that they were applying the generic cognitive model in their work. Let me define cognitive therapy to clarify the matter. The model stipulates that people have certain dysfunctional beliefs which generally originate early in their lives; they do not come overnight. (This is not true of PTSD, which can originate at any time.) These beliefs, particularly when activated, can but do not necessarily, dominate their behaviour and feelings and displace other aspects of the personality. Cognitive therapy is based on this cognitive model. The applica- tions to a variety of disorders are derived from the generic model but based on a formulation of the unique features of the different disorders. Techniques vary con- siderably, again depending on our specific formulation of the type of disorder. In depression, for example, the patient comes with many kinds of dysfunctional ideas, which we call ‘hot cognitions’. It is easy to address the beliefs since they are right on the surface. By contrast, people with panic attacks do not have these dysfunc- tional beliefs when they come for treatment because they feel secure in the therapeutic situation. The problem then is to get to the hot cognitions. We try to activate their panic beliefs by precipitating a mini attack. For example, we will have the patient over- breathe for a period so that they feel faint. They will then have images of themselves having a stroke or heart attack, collapsing, ending up in a graveyard, and so on. Thus, we reproduce the panic attack, but to a lesser degree, and get the patient to reframe their catastrophic interpretations on the spot.

Now to your other question – does cognitive therapy lose its real definition by being used in so many different areas? I used to find it awkward when people would say:

‘Well, how many conditions can cognitive therapy treat?’

I would have to reply: ‘I do not know because it hasn’t

been tested out in a wide variety’. Originally, the only things I could speak to were depression, anxiety and panic disorder. However, people who trained with me or with my former students have used the cognitive model until it now encompasses practically every psychiatric condition

that I can think of, medical conditions with psychological overlay, and so on. I feel like a snake salesman sometimes when people say: ‘What can it cure?’ and I reply: ‘What can’t it help?’ It has been used in people who have had a stroke or a heart attack, in diabetic patients who have psychological problems. A former student has even used

it in Asperger’s disease. I now have to cross that off the

list of conditions for which it can’t be used. SB: Hearing this makes me anxious on your behalf because, as you know, the criticism made against

psychoanalysis was that it could explain and deal with everything; it was going to be a panacea. Given my inherent scepticism, healthy scepticism I hope, it worries me when I hear that a single approach, albeit with modifications, is applied to so many states. I think that, empirically, it may help but this may have nothing to do with the conceptual principles claimed by its proponents but be attributable to non-specific factors like instilling hope and the others examined systematically by Jerome Frank over three decades. I surmise that these non-specific factors are fundamental rather than incidental. Do you share my worry on this issue? AB: I think you are with the compact liberal majority and I in the minority. There are two things to stress here. Psychoanalysis explained everything and was the answer for everything but the criterion for its acceptance was faith. Whatever my colleagues and I have stated has been based on empirical data, using the same canons of science applied to other spheres of medicine. Thus, if chemotherapy is found to do better than placebo, that’s generally accepted. Controlled conditions are extremely important. With cognitive therapy we must ensure that all the non-specific factors, which are actually specific, are addressed. In my very first paper, a report on a clinical trial [3], we controlled for every non-specific factor we could think of. If patients in both groups have the same level of expectations and other factors such as the personality of the therapist are controlled, then you can assess the effectiveness of the specific technique. Jerry Frank and I had many discussions about the role of non-specific factors. I think he goes overboard on them. It is true that if one compares cognitive therapy with another type of psychotherapy, the so-called placebo response can contribute a certain degree of variance to improvement, as is the case with drug therapy. Similarly, the question, as with drug therapy, is whether cognitive therapy adds anything to the placebo effect. This can only be decided empirically by comparing it with another type of therapy where these variables, such as empathy of the therapist and patient expectancies, are taken care of. It is interesting how these non-specific factors operate. Rob DeRubeis has conducted an unpub- lished study in which cognitive therapy was compared with medication and patients asked in advance which type of therapy they thought was better – biological or psychological. They also indicated whether they regarded depression as a psychological or biological disorder. We thus can determine the link between patients’ beliefs and outcome. If they believe in the biological and are assigned to medication the effect should be congruous and they should do well. If they are assigned to the other group, the effect will be incongruous. In fact, patients’ beliefs did not have any impact. Biologically-orientated

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patients not only did as well in psychotherapy as they did with drug therapy, but also gave a congruent answer at the end of treatment. We may infer that the specific aspects in the therapy altered their beliefs. SB: I take it that the principles of science and corre- sponding systematic research are your safeguards? AB: Yes, safeguards that are bolstered by the many people who, through doctoral or other programs, exhibit an interest in clinical trials and outcome. I referred to my current and former students in this context but a wide assortment of people who have not been trained by us and have no allegiance to cognitive therapy are achiev- ing similar results. I believe this takes care of investiga- tor bias. SB: If we go back to the 1960s, would you have anticipated that decades later you would be seeing your model applied so widely? AB: No. Originally, I thought that the formulation in my 1967 book would suit about seven or eight condi- tions, including anxiety, depression, obsessive compul- sive neurosis, hysteria and acute anxiety attacks (later called panic). In essence, the neuroses. I did not have any formulation for psychosis. Since I saw a theory behind the therapy, I expected these neuroses would respond. I did not envisage effective cognitive therapy for psycho- sis. This form of treatment has now evolved in the UK, Canada and Australia. British researchers, for example, with whom I have talked, learnt how to apply cognitive therapy to depression and then translated it to deal with psychosis; this is not a dilution. Anybody who has learnt how to do cognitive therapy with depression can learn how to apply it to psychosis. SB: Psychosis is clearly a big jump. Even Freud doubted he could deal with it. The question I posed earlier about the limits of cognitive therapy becomes even more pertinent when some colleagues claim they can alter delusions or lessen the impact of hallucinations. What do you think? AB: This is an empirical question. Very few psycholo- gists or psychiatrists in the US would even consider the possibility that any kind of psychosocial intervention could seriously modify ingrained phenomena like hallu- cinations, negative symptoms and thinking disorders. When I lecture in the US on this topic, people with a strong adherence to a cognitive model for, say, depres- sion do not buy into it and later, out of respect, conceal their obvious scepticism. It has been practically impos- sible to get American funding for empirical trials. A widespread scepticism definitely prevails that anything as organic as schizophrenia could possibly be addressed by a psychological intervention, be it cognitive therapy or any other type. This is quite understandable. How- ever, I think it is based on a misconception about the

brain. Neuroplasticity shows that even people with severe brain damage can compensate well. The notion that a biologically-based disorder like schizophrenia cannot be helped by psychotherapy is based on errone- ous conception of the way the mind works. This is notwithstanding the fact that following a paper I pub- lished over half a century ago [4], I did not treat psycho- sis again (until recently). Now, when colleagues use the cognitive model in psychosis, it does make sense and I can describe how the theory can be applied. For instance, delusional thinking will affect a patient’s interpretation of reality. One way to deal with this, and it is only one approach, is to train the patient to look at the evidence for his interpretation. The therapist can start with: ‘What kind of problems do you have today?’ The patient might reply: ‘I got into a fight with my wife and I decided she is going to leave me’. ‘What is the evidence for that?’ We can ask about, and train them to deal with, non- psychotic interpretations. It is perfectly possible, having established a therapeutic relationship, to test psychotic beliefs. British cognitive therapists have been marvel- lous at this and are miles ahead of their American counterparts in devising behavioural experiments. The Oxford group is due to publish a book on behavioural experiments in cognitive therapy. Let me illustrate. A patient felt she had an implant in her brain and that it was dominating her thinking, controlling her actions and making her hallucinate. The therapist asked her: ‘How long have you had this implant?’ She thought it had been inserted into her brain in a surgical operation seven or eight years previously. ‘I am puzzled about what is powering this implant’, the therapist comments. ‘Batter- ies, I guess’, she states. He asks whether batteries could last that long? The patient does not know. This is an example of guided discovery, one of the fundamentals of cognitive therapy. ‘How could we find out,’ asks the therapist. ‘I suppose we could go to Radio Shack’, she suggests. And she did and, of course, learned that the batteries would be dead by now. She obviously believed she had this implant, but there were gradations in the intensity of the belief. When she was disturbed it would go up to 100%, when improved drop to 40%. One day she sustained a head injury and had a skull X-ray. The doctor, showing her the plates, reassured her they were perfectly normal, and she could not see any implant, so experience put the delusion to rest. Thus, patients can be helped by gradually using sophisticated reality test- ing. I think this is still cognitive therapy because we are dealing with cognitive distortions. It takes artistry and sensitivity, and you should not push the patient too fast. I want to mention another thing. We worked with a group of patients who had been psychotic for at least

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30 years, some longer. They were offered psycho- education, part of which was stress management. They learned how they misinterpreted situations and devel- oped appropriate coping strategies, both aspects of cog- nitive therapy. By the end of therapy their hallucinations, delusions and negative symptoms had all improved. Stress management is an important part of therapy. SB: Are these not behavioural interventions? Are you not taking aspects of behaviour and using techniques like stress management to modify them? Would it not be prudent to conclude that this is not cognitive therapy as you have formulated it over 40 years but a range of behavioural strategies which you are using empirically. AB: Well, for starters, behavioural therapy did not work with the symptoms of schizophrenic patients. It might reinforce doing various objective tasks but not carry over to real life. The essence of our cognitive interventions is based on the cognitive model and the focus is on what they are thinking. People are stressed by their exaggerated interpretations of situations. But we can use behavioural components in order to change thinking; that was true from the outset. In our book on depression [5], an early chapter covers behavioural acti- vation. By getting patients to act, they are able to change their beliefs that they are helpless and inadequate, and this is a powerful thing. I owe a lot to the behaviour therapy movement which I became aware of early on in my thinking. I credit behaviour therapists for their highly structured interviews. They set an agenda and would look at the process of what was going on during the therapy session. They would also look at goals. I incor- porated all these aspects into my work after my 1967 book. The approach has been called cognitive behaviour therapy by some people and I accept the term. But the behavioural dimension is not based on conditioning theory, rather on cognitive theory. We use behavioural techniques not to satisfy reinforcement theory but to modify beliefs. We also deploy experiential methods. For instance, we treat panic in such a way that the patient actually experiences in the session that the panic is not disastrous. Now with the psychoses, we are using strate- gies that are similar to what we would apply in depres- sion but take into account that these patients have very strong beliefs and are easily alienated if one doesn’t take that into account. It requires more sensitivity than it might with a straightforward depression. SB: You have alluded to an issue I intended to raise later: how vital is the ‘B’ in CBT? When reading your work you refer to cognitive and to cognitive behavioural. I have never been clear what weighting you give to the behavioural component. Is it truly behavioural or is it more a series of techniques and strategies which arise from various theoretical sources.

AB: This question comes up all the time. The term cognitive behaviour therapy is an historical accident. The first term I used for the treatment I was devising was ‘insight’ therapy, with ‘cognitive insight’ in parenthesis. What I thought of as insight was not into the unfathom- able unconscious but about what was going on at the level that was accessible. At the same time I was developing the cognitive model and corresponding tech- niques, a group in the behaviour therapy movement became very interested in dealing with a variety of problems rather than just snake phobia and the like. However, they found that strict behavioural methods did not work for a condition like depression. They began to use the term ‘cognitive behaviour therapy’. Cognitive behaviour therapy today encompasses a wide range of approaches, with the common denominator probably being that they take beliefs and thinking into account. At one end is the large B/small C – for example, relaxation therapy, feedback, aversive conditioning and so on. At the other end is the pure cognitive restructuring we have been talking about, with behavioural strategies utilized only if necessary. Let me give you an example. Jack Rachman started out as a behaviour therapist but became more ‘cognitive’ with time. In essence, he began to use cognitive restruc- turing more and more and taught this to his students. When they got positions elsewhere they adopted the term Rachman was using, namely cognitive behaviour therapy. They in turn were heavily influenced by the cognitive therapy movement and some eventually adopted the cognitive model in toto . They became, in my opinion, pure cognitive therapists. They still used a behavioural component. The behavioural experiments they incorporated could be called cognitive experiments , since cognitions are tested out in real life. The patient who thought she had a brain implant would test that out by finding out about the batteries. SB: Although it doesn’t seem to worry you what it is called, I am pursuing this because of my impression that the behavioural school was waning in the 1970s, welcomed the cognitive revolution, and perhaps even appropriated a bit to themselves. AB: I would summarize the situation as follows: the first generation of behaviour therapists began to call themselves cognitive behaviour therapists as part of a transitional process. The next generation may still use the term, perhaps anachronistically, but do so because it is traditional. In effect, they are pure cognitive therapists with the behavioural component used, as you say, simply as an adjunct. SB: Aaron, may I now ask you about influences on the way you think about your work overall. I notice that when you have written about influences you have

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mentioned a series of philosophers and people like Adler, Rank, Rogers, Horney, Kelly and of course, Albert Ellis. The range seems broad. AB: All these were undetected influences. I saw some of these antecedents only when I began writing about cognitive therapy. The most profound influences of the people I read were Horney and Adler (later, Ellis). As I have read further, I have realized there is truth to the expression: ‘There is nothing new under the sun’. I can

see antecedents in people like Kant. I picked up the

notion of a schema from psychologists who had read Kant. In many ways I am second or third generation removed from the original philosophers. I only found out about Epitectus, for example, when Albert Ellis brought

him to my attention.

SB: Why Horney? AB: In Our inner conflicts and The neurotic personal-

ity of our time , she dealt with types of conflicts which were accessible and understandable. From a theoretical standpoint Kant stands out because of his concept of schemas. SB: It is ironic that you cite Horney since she is mostly forgotten. When you say there is nothing new under the

sun, do you think there is a need for every generation to

discover something that has been there but perhaps has

to be addressed afresh? AB: I do think about it and I am always amazed at how little present generations know about the past. SB: This is a convenient bridge to ask you something more personal. I hope you don’t mind. I see from your

CV that you are 83 years old. Most people of that age

would say they had ‘done their thing’ and would relax a bit. You are beavering away at all your pursuits as much as ever. I well remember meeting you in 1980 in Oxford for the first time; nothing has changed in terms of your abundant mental acuity and energy. Do you have a view about ageing? AB: I can only speak for myself. I know that practi- cally all my colleagues from medical school days who are still around have retired. That is not something that I think about. It is no more on my horizon now than it was when we first met a quarter of a century ago. I keep looking ahead. You will be interested to know that trying to make sense of schizophrenia in cognitive terms is the biggest challenge I am facing right now. I have written several papers on the theory of delusions [6] and halluci- nations [7] and one on cognitive approaches to negative symptoms. My next big task is to complete a cognitive formulation for schizophrenia as a whole, which takes its major organic defect into account but tries to show how responses to this defect lead to delusions, etc. The defect in itself has never satisfactorily explained why people have delusions, hallucinations and negative symptoms.

In my opinion, inability to cope with the psychological reaction to the defect contributes to the variety of schizophrenic symptoms. We have no unifying theory of schizophrenia. There are theories for delusions, for dis- organization, for all sorts of things. My ambition is to formulate a unifying psychological theory. I do not think of age or my past history or what I may have or have not accomplished. It is as if I am starting afresh, starting on a new venture. SB: This is most inspiring. I think psychiatry is going through a difficult phase because of economic constraints on what we can offer society. We face uphill battles. On the other hand, exciting things are going on in neuro- biology, genetics, the psychotherapies, epidemiology. It seems to me that psychiatry is like Janus. If you look one way it appears as bright as can be; if you look the other way it is dismaying. If there was a message you could pass onto our younger colleagues embarking on their careers in psychiatry, what would it be? AB: Although much of what is happening to our younger colleagues is dictated by cultural and economic trends which may be beyond their control, I do have something I wish to offer them. I have always liked to unify different fields. Given my background in neurol- ogy, I do not see a conflict between neurology and psychology. But if you look at the training of contempo- rary psychiatrists for example, the two domains are totally distinct. If psychiatry is to survive as a discipline, a merging of the concepts of neurology and psychology will need to occur. For example, it has been shown that schizophrenic patients who are under stress have increased dopamine and then show more disorganization of thought. What causes the stress? They may be react- ing to stressors that all people face. The key question is what the patient makes of the stressful stimulus which produces a biological reaction, which in turn produces a psychological reaction, which is the disorganization of thought. The neuropsychiatrist can deal with each of these steps, including the last, since people who are disorganized in their thinking can be brought back to normal by helping them to deal more effectively with the stress. The artificial dichotomy between neurology and psychiatry, I would argue, works against psychiatrists. While I would like to be positive, I have to be honest and say that if something is not done, our field will go to neurologists and psychologists, with psychiatrists falling between the cracks. SB: I must say that I have never seen evidence of neurologists wanting to take on our patients. Neurolo- gists seem to be interested in organic conditions like strokes, movement disorders, cerebral tumours. As for psychologists, would it make a big difference if they, rather than psychiatrists, did the sort of work you have

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outlined? Some people argue that the psychotherapies, for instance, do not need a dozen years of medical and psychiatric training. AB: My allegiance is to psychiatrists and I would like to see them taking over psychotherapy to a larger degree. However, current trends show psychologists moving into that area. The probable outcome will be a new discipline called medical psychology, where people obtain a com- bined medical/psychology degree, which qualifies them to do medical psychotherapy. I hate the idea of going to different professionals for pharmacotherapy and for psychotherapy. I would like to see the two combined in one person. My answer therefore would be medical psychology, or psychological medicine, which I think was once a popular concept in Britain but did not come to anything. SB: In looking back at your long and distinguished career, you have won many prizes and awards. Is there one that stands out, one which you think testifies to something important in your contribution? AB: I am probably most pleased with being voted in as a member of the Institute of Medicine (a branch of the National Academy of Sciences) a prestigious organiza- tion made up of all the medical specialties. What it meant to me was that cognitive therapy was recognized as a legitimate discipline in the whole range of medical specialties. SB: You have stuck to your guns in all sorts of ways, but especially by developing a way of working psycho- therapeutically and then, painstakingly, chipping away at it. You have also been on the faculty of the University of Pennsylvania for decades and haven’t moved around from one place to another as is so often the case with American academics. Is there something about this way of living that is important to you? AB: I certainly like stability and I have never felt the need to go away from this straight path I have been on. But there are other things. It was good for my family to stay put all these years. My wife is a judge, a state position she would lose if we ever moved. There are other extraneous factors but I think the key personality variable has been my need for stability, consistency, regularity and predictability. SB: You mention your family. You have four children, one of whom has become prominent in the cognitive arena in her own right. I gather you work together at the Beck Institute. AB: My daughter, Judith, is the director of the insti- tute, which is a carryover from the Centre for Cognitive Therapy which I directed for several decades. I basically work for her as a consultant. I see patients that therapists would like my help with. My interviews with patients are through closed circuit television so that other staff and

clinicians from all over the city and in many cases, from other countries, can observe and discuss them. Judith also consults me on various practical and theoretical questions. SB: And your work at the University of Pennsylvania still continues? AB: We are engaged in several clinical trials in our new unit called the Psychopathology Unit. Six mental

health professionals, four research assistants, a couple of clerical staff and I make up the research team. We have been awarded a centre grant to investigate suicide prevention. This will involve several studies of cognitive therapy to prevent subsequent suicidal behaviour in people who are highly suicidal. We are also carrying out

a controlled trial of cognitive therapy with borderline

personality disordered patients. A third study is of cog- nitive therapy in conjunction with pharmacotherapy to treat patients with schizophrenia. These three major studies are among the most difficult and challenging I have ever done. SB: Obtaining a centre grant at the age of 83 must be

a record. AB: I would say so! I am not sure if the reviewers actually looked at my age when they gave me the grant. SB: Returning to the other members of the family, have they followed in your footsteps? AB: Interestingly, each one of my four children worked with me at some stage and three of them have ended up in careers closely associated with my own. Roy helped me with a clinical trial as a high school student! He went on to become a neuro-ophthalmologist and is involved in a number of multicentre clinical trials. He

is a superb statistician and also has a PhD in epidemiol-

ogy; he can therefore deal with all the variables that go into clinical trials. SB: You mentioned another son? AB : Daniel is a cognitive therapist in Boston and has participated in several clinical trials, including treatment of psychosis and hypochondriasis. Our other daughter, Alice, a lawyer, has followed in her mother’s footsteps, and teaches at one of the local universities. SB: Don’t they say that behind a successful man stands

a good woman? Your wife of course has enjoyed a

career in her own right but I have read somewhere that she has played an important role in your work? AB: My wife was the first woman to be elected to the Appellate Court in the State of Pennsylvania. At the dinner for the new judges, I was asked to say a few words. I said that behind every successful woman is a tender-loving, devoted spouse! In fact, my wife has always encouraged me in my work. At one time there were only two people with whom I could discuss my ideas – my wife and my daughter Judith, who was just a

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teenager then. Judith would say: ‘Dad that sounds very sensible’. It seems obvious, not just coincidence, that she ended up as a cognitive therapist. SB: You mention only these two supports. Was there a time when your colleagues were dubious about what you were up to? Did they regard you as a renegade from the analytic ranks? AB: I was a renegade. Although my colleagues at the University of Pennsylvania were always respectful, they were not particularly interested in what I had to say. Many of them were working in biological research, for example, and my area was so totally different. They eventually became interested and Mickey Stunkard, the chairman, was always most supportive. SB: Psychiatry does not have many figures who create a whole new way of thinking. I predict that when the historians come to talk about the second half of the 20th century they will refer to a Beckian revolu- tion. I hope, however, that we won’t have Beckian therapists. I believe that was the problem we had with Freud. We got stuck with Freudianism instead of with an area of academic discourse. It strikes me that in the midst of your tremendous contribution you are quite humble. AB: Other people have said that too. It produces cog- nitive dissonance in me because I do not perceive myself as the great contributor that some people seem to state. Instead, I see myself as somebody who is trying to come to grips with many problems and that once I have a tentative solution I forget about them and move onto the next one. SB: Perhaps you are expressing your humility now? AB: I do not try to be humble; it is not a concept that I think about. I do not think of myself as modest or immodest. These dimensions do not figure in my think- ing. What I do think about is how far cognitive therapy can go, and whether other approaches may be more effective in the future. I have been asked where cognitive therapy will be in 10 years time. I reply that we may not even be using the term. We may be back to using the term psychotherapy as the preferred concept, which will include all the most powerful ingredients identified in different approaches to cognitive therapy. I want to add something else here. Many people have asked me what the difference is between cognitive therapy and existen- tial or humanistic therapy. My answer is that I consider cognitive therapy as a very humanistic therapy. With the old kind of ‘simple’ depressions, you could not detect too much of the humanism in the therapy, although the goal was to relieve suffering. In many ways these depressions could be treated mechanically. You gave people a schedule of activities and you worked out their distorted cognitions. As we deal with more complex

cases today the humanity of the therapist becomes extremely important. Therapists who are good at the technical end of cognitive therapy fall flat on their faces when it comes to the more complex case. Empathy, sensitivity, considerateness – together with the ability to put them together with technical aspects – is the combi- nation needed. These fine therapeutic qualities – warmth, adaptiveness and so on – plus technique is the most powerful set of requirements. SB: We have been conversing the whole morning. I wish we could do so the whole afternoon! I understand you have a full schedule of activities. I shall have to return another time. In any event my colleagues and I will need to learn about the findings of your current research program. On behalf of the Journal’s readers, can I express my heartfelt gratitude to you for enabling us to have this encounter today. I personally shall cherish the experience for a long time to come. AB: This has been a rewarding experience for me. It has given me a chance to reflect on what we have done and what still needs to be done.

Books published by Aaron Beck

Alford B, Beck AT. The integrative power of cognitive

therapy. New York: Guilford, 1997. Beck AT. Depression: clinical, experimental, and theoretical aspects. New York: Harper and Row, 1967. Beck AT. The diagnosis and management of depres- sion. Philadelphia: University of Pennsylvania Press,

1967.

Beck AT. Cognitive therapy and the emotional dis- orders. New York: Meridian, 1976. Beck AT. Love is never enough. New York: Harper and Row, 1988. Beck AT. Prisoners of hate: the cognitive basis of

anger, hostility, and violence. New York: HarperCollins,

1999.

Beck AT, Clark D. Cognitive psychotherapy: Anno-

tated guide to the psychiatric literature. New York: APA Press, 1996. Beck AT, Davis DD, Freeman A. Cognitive therapy of personality disorders (2nd Ed.) New York: Guilford,

2004.

Beck AT, Emery G, (with Greenberg RL). Anxiety

disorders and phobias: a cognitive perspective. New York: Basic Books, 1985. Beck AT, Freeman A and associates. Cognitive therapy of personality disorders. New York: Guilford,

1990.

Beck AT, Resnik HLP, Lettieri DJ, eds. The prediction of suicide. Bowie, MD: Charles Press, 1974.

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Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford, 1979. Beck AT, Wright FW, Newman CF, Liese B. Cogni-

tive therapy of substance abuse. New York: Guilford,

1993.

Clark DA, Beck AT. Scientific foundations of cogni-

tive theory and therapy of depression. New York: Wiley,

1999.

Scott J, Williams JMG, Beck AT. Cognitive therapy in clinical practice. London: Croom Helm, 1989. Winterowd CL, Gruener D, Beck AT. Cognitive

therapy with chronic pain patients. New York: Springer,

2003.

Wright J, Thase M, Beck AT, eds. The cognitive

milieu: inpatient cognitive therapy. New York: Guilford,

1993.

References

1. Beck AT. Thinking and depression: Idiosyncratic content and cognitive distortions. Archives of General Psychiatry 1963;

9:324–333.

2. Beck AT. Thinking and depression: Theory and therapy. Archives of General Psychiatry 1964; 10:561–571.

3. Rush AJ, Beck AT, Kovacs M, Hollon SD. Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research 1977;

1:7–37.

4. Beck AT. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry 1952; 15:305–312.

5. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford, 1979.

6. Beck AT, Rector NA. Delusions: a cognitive perspective. Journal of Cognitive Psychotherapy 2002; 16:455–468.

7. Beck AT, Rector NA. A cognitive model of hallucinations. Cognitive Therapy and Research 2003; 27:19–52.