Interview with Aaron T. Beck, M.D.
Conducted by Sidney Bloch, May 4, 2004
Reprinted with permission from the Editor of the Australian and New Zealand Journal of Psychiatry An interview with Aaron (Tim) Beck
Conducted by Sidney Bloch on 4th May 2004 in Philadelphia
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 overprotective. 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 learned years later that it was a staphylococcus infection which had about a 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 desensitise 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”. 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 adolescence. 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 galvanise myself. I had a strong need to conquer whatever problems I faced.
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 realise them themselves, they could do so through their children.
SB: I understand your father was a committed socialist. Did this play any role in your thinking as an adolescent 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 interest in depression, was there was anything in your family life that may have stimulated you in that way?
AB: My mother was moody but I actually got interested 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 treatable. 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 neurology 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 became immersed in the subject. I toyed with the idea of staying in psychiatry long enough to determine whether psychoanalysis was a valid approach to understanding human behaviour. Although I kept on in psychiatry, I am still enrolled as a neurology registrar who has never completed his training program! Eventually I decided to find out for myself whether psychoanalysis 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 neuropsychiatry, 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. Moreover, 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 psychoanalytic structure that was imposed on us was extremely orthodox. Trainees were never expected to respond to patients’ questions. We would always respond to a question 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, reflective 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 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 Philadelphia. 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 mechanism 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 psychology and some in psychiatry, really did not believe this. I thought it would be interesting to try to demonstrate 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 depression. 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 ordinary 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 controls. 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 psychologist, 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 rationalised 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 concluded that these dreams were masochistic in content and still supported psychoanalytic philosophy. We then obtained a grant from the National Institute Mental Health to see whether hospitalised 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 hypothesized that depressed patients would court negative or aversive reinforcement as opposed to positive reinforcement 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 explanation 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.
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 themselves 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 a 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 teaching 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 themselves which they do not ordinarily share. On the other hand, thoughts usually communicated (ie. external) in psychoanalysis are of the kind that people do communicate 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 something 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 therapy, it had to be empirically-driven. Why the term cognitive? Because the cognitive revolution was occurring 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. I had published a couple of papers on a cognitive approach to depression in the Archives of General Psychiatry (Beck, 1964, 1963). One was empirical/clinical, the other theoretical. I then asked myself what I really knew about depression. I realised it was only what I had learned in my psychoanalytic training, during my residency and from my patients. I thought that if I were going to say anything 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 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 a depression inventory and included that too.
SB: I take 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 but a fuzzy one. People have said - I do not know if this is correct - that I was a rebel. And it is true that I did feel it was a rebellion against the autocracy of the psychoanalytic establishment. Psychoanalysis is comparable to an authoritarian type of religion where people have absolute 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 distasteful it became to me. If there was an emotional component in my rejecting psychoanalysis, it is that I do not like to be wrong. I did not want to be wrong by rejecting it totally and I do feel that I learned 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 interventions. When I came to deal with personality disorders it was clear I had to explore childhood material. Patients might become expert at correcting their cognitive 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 order to ascertain where their early perceptions were 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 minimises, even denies, the relevance of early aetiological influences. You have just mentioned that in 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 conditions, and that without pursuing early antecedent factors 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 childhood and later experiences. However, having said that, in our early work on depression, uncomplicated depression, it was not economically wise if we wanted to treat patients within 12 sessions to go back into childhood 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 anymore. They are treated by primary care doctors, given medication and improve within three months, just the same way as they would with cognive therapy. The patients we see today are complex and the theory we subscribe to becomes important 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 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 objectively 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 experiences with her father and then correct her anachronistic, childhood based beliefs.
SB: The last thing you said is interesting because the role of trauma has become a prominent theme in contemporary 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 following 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 childhood 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 disorganised and dysphoric. We only accept patients into treatment who are suicidal and meet borderline criteria. Our first study was uncontrolled, the one we are doing now 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 one. We did a follow-up study at six months. To our surprise, they no longer had this fear of abandonment. This tells us something. 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 learned enough and 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 experienced psychodynamic or eclectic practitioner for 6 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 cognitive 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 (eg. pain, anxiety, substance abuse, marital conflict, personality disorder). Is the same theoretical model being applied or are you acting empirically and pragmatically and modifying it to suit new patient groups?
AB: I can address your two questions almost simultaneously. 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 applications 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 considerably, 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 dysfunctional beliefs when they come for treatment because they feel secure in the therapeutic situation. |
