Beck's Cognitive Therapy in Theory and Practice

 I didn't want to let 2021 pass by without noting another major loss in the world of psychology, Dr. Aaron Beck, who passed away in October of this year at the age of 100. The bow tie in the picture above was one of Dr. Beck's defining visual characteristics! He was known as one of the fathers of Cognitive Therapy (along with Albert Ellis, who developed similar methods independently of Beck around the same time in the 1960s), which later became the core of the cognitive-behavioral approach that dominates modern psychotherapy. 

Beck's Cognitive Therapy has a few defining characteristics that differentiate it from other strands of CBT within psychology: First, it relies on the idea that your thoughts determine your behavior, although in this model the term "thoughts" is sometimes loosely defined to include things like perceptions and attitudes as well as conscious narratives that can be expressed in words. Second, Beck proposed a "negative cognitive triad" of beliefs that he felt underpinned most psychological problems: negative beliefs about oneself, about the world, and about the future. For example, a negative belief about oneself might be "I am unlovable," while a negative belief about others might be "people can't be trusted," and one about the future might be that "things are never going to get better." Of these three, negative beliefs about the future might the the most pernicious -- a questionnaire measuring that type of belief, the Beck Hopelessness Scale, has been found to reliably predict suicide attempts. A final characteristic of Beck's flavor of cognitive therapy is its sense of optimism, the idea that most problems are ultimately fixable, that "life is a comedy rather than a tragedy." All of these components, like the "cognitive" element of CBT itself, fit squarely within what I describe as the Narrative mind.

I had the chance to meet Dr. Beck on one occasion when I was studying in Philadelphia, and his personal sense of optimism was the characteristic that struck me the most. The format was a Tuesday afternoon tradition at the Beck Institute (now led by Dr. Judith Beck, Aaron's Beck's daughter). Dr. Aaron Beck would solicit difficult cases from therapists under his supervision, and would choose one of the patients to provide with a personal consultation. Meanwhile, a group of therapists (and therapy students like me at the time) would gather in a conference room to watch the session live via closed-circuit TV. Afterwards Dr. Beck would come in and debrief with the group. In the session that I saw, the patient was a professional person whose work was impeded by significant anxiety symptoms. Dr. Beck listened to him talk about his problem for a few minutes, then interrupted him to ask more about the nature of the work. "Am I right in assuming that you have certain rules or protocols that you follow in this type of situation?" he asked, and the patient said yes. "And are you following those protocols?" Again, yes. "So," said Dr. Beck, "it seems like you have been unlucky recently with results, but you are doing the right thing. Do you agree? Or is there something else you could be doing differently?" The patient couldn't think of anything. "Well, then it seems like you just need to keep doing what you are doing until your luck turns around. I'm sure that will happen eventually. What can we do to help you feel better about your work in the meantime?" The patient gave him some ideas, until Dr. Beck interrupted again: "Hang on, I want to write a few of these ideas down. It helps me sometimes to write things down." He pulled an index card out of his pocket and took notes. At the end of the session, he gave the card to the patient and advised him to consult it when he started to feel anxious. They shook hands, and the session ended with the patient saying how much better he felt.

It was a brilliant application of the methods we were learning in school (of course it was, Dr. Beck invented them!), and watching him work I could label the various things he was doing. "Oh, there he is identifying antecedents, beliefs, and consequences. Here he is brainstorming solutions. Oh, look, that's a coping card." But none of the conversation seemed like Dr. Beck was following a cookbook the way we students did. Instead, he was having a very natural, caring, and human conversation with a fellow person about struggles and worries. The fact that he had a model in the back of his mind explaining the origin of the patient's problems just never came up in the discussion. (Some cognitive therapists do believe that teaching the patient the cognitive model is a crucial element of therapy, but in the one session that I saw Dr. Beck didn't do it). Even though Beck's Cognitive Therapy is often regarded as a "technical" approach to therapy (as opposed to the more "relational" psychodynamic approach), I was most struck by Dr. Beck's skill in what we call the "common factors" of therapy -- e.g., connecting with people, communicating a sense of caring, providing a way forward, and conveying a sense of hope. He was a virtuoso at those interpersonal skills, which psychology has historically celebrated in its master therapists. These are Intuitive-level skills that rely on common human experiences such as social connection and persuasion, which complemented Dr. Beck's Narrative-level arguments and ideas. Whether the Narrative or the Intuitive elements were more important I couldn't say, and indeed psychotherapy research is equivocal on the matter.

Dr. Beck kept very active in the field of psychology until the end of his life. I heard him speak again at an American Psychological Association conference in 2016, where he again conveyed a great sense of optimism about people's potential to overcome their problems. At that time he was speaking about the problems of nations and cultures rather than individual people, but he again said that the key was to change our beliefs about one another, to recapture a sense of optimism for the future, and ultimately to see ourselves as people who are all connected to one another. Longtime readers of this blog will know that I have my doubts about the cognitive model's assertion that thoughts are the primary determinants of behavior. But when it comes to Dr. Aaron Beck I have no qualms in saying that psychology lost another legendary figure this year, one whose work will continue to inform and be an example to others.