Beck, Aaron Temkin

1921-

AMERICAN PSYCHIATRIST, RESEARCHER YALE MEDICAL SCHOOL, MD, 1946

BRIEF OVERVIEW

Aaron Beck is one of the founders of cognitive therapy, a form of talk therapy that incorporates an information-processing model of human psychology rather than one based on instinct, motivation, or biochemistry. As of the early twenty-first century, cognitive therapy has become the reigning model of short-term psychotherapy in the United Kingdom as well as the United States, supplanting both psychoanalytical and behavioral approaches to the study and treatment of mental disorders. Beck has enjoyed widespread success and professional recognition. He was the only person, as of 2004, to have received research awards from both the American Psychological Association and the American Psychiatric Association. His honors include the Sarnat Award from the Institute of Medicine (2003), the Heinz Award for the Human Condition from the Heinz Foundation (2001), and honorary doctorates from Brown University and Assumption College (1995). An article that appeared in a French Canadian psychiatric journal in 2002 named Beck as one of ten individuals who "have changed the face of American psychiatry." He has also been listed as one of the five most influential psychotherapists since Sigmund Freud.

Beck's cognitive therapy may be categorized as a variant of constructivism, a term that has become increasingly popular among academic psychologists since the mid-1970s. Although theorists as otherwise different as William James, Jean Piaget, George Kelly, and Albert Bandura have been grouped together as constructivists, it is possible to identify several recurrent themes in their work. The psychotherapist M. J. Mahoney has listed five such common themes:

• Humans are active agents with the power to effect changes in their own lives. This theme stands in contrast to the view that humans are passively controlled by larger forces.
• Humans are actively engaged in ordering their experiences through assigning emotional as well as intellectual significance to them.
• These processes of ordering are primarily self-referential; that is, they underlie a person's sense of selfhood or personal identity.
• On the other hand, humans are not isolated individuals; they cannot be understood apart from their relationships to other people, larger communities, and symbol systems.
• Humans continue to grow and develop over the entire course of their lifespan.

These themes are prominent features of Beck's work as well as the writings of other constructivists.

In terms of the history of psychotherapy, Beck's contribution is the development of an effective form of short-term treatment well-suited to the age of managed care, cost containment, and evidence-based medicine. The future of cognitive therapy as a distinctive approach sharply set off from other forms of talk therapy, however, is less certain. As the integrative movement in psychotherapy continues to grow, the theories and techniques of cognitive therapy may simply be appropriated by therapists from a wide variety of backgrounds.

BIOGRAPHY

Early years

Aaron T. Beck was born in Providence, Rhode Island, on July 18, 1921, the youngest of five children. Both of his parents were Russian Jewish immigrants to the United States. Two of Beck's siblings had died before his birth, an older brother in childhood and an older sister in the influenza pandemic of 1919. As a result of these tragedies, Beck's mother was chronically depressed for several years and became overprotective of her youngest son. Beck came to think that he was a replacement for his sister, and that his mother was disappointed that he was not a girl. When Beck was seven years old, he broke an arm in a playground accident. The broken bone became infected, resulting in a generalized septicemia (blood poisoning) that kept him in the hospital long enough to miss promotion into second grade. Beck recalled later that he came to feel "stupid": "I was held back in the first grade and I always felt it was because I was dumb. Many years later I asked my mother and she said it was because I'd been sick a great deal."

Beck missed his friends and didn't like being a grade behind them. With the help of some tutoring from his older brothers, as well as his own determination, Beck not only caught up with his former classmates but ended up being promoted a year ahead of them. He regarded his success as a psychological turning point: ". . . it did show some evidence that I could do things, that if I got into a hole I could dig myself out. I could do it on my own." Beck eventually graduated at the head of his class from Hope High School and entered Brown University in the fall of 1938.

Beck developed several phobias in the course of his childhood. One was a blood/injury phobia, which he related to his experience with surgery for his broken arm at age seven. The surgeon apparently began to make the incision before Beck was fully anesthetized. During Beck's medical training years later, he had to fight anxiety and a tendency to feel dizzy while assisting with operations. He dealt with his blood/injury phobia by exposing himself gradually to the sights and sounds of an operating room, and by keeping busy while he was assisting with surgery. "I wasn't fazed at all as long as I was . . . doing something. I learned an awful lot from my own experience. As long as you're actively involved in something, anxiety tends to hold back."

A second phobia was fear of suffocation, which was apparently caused by a bad case of whooping cough, chronic childhood asthma, and an older brother who used to tease Beck by putting a pillow over his face. Beck's fear of suffocation also emerged in the form of a tunnel phobia; he would feel tightness in his chest and have difficulty breathing while driving through a tunnel. In addition he developed fears of heights and of public speaking. He maintains that he was able to resolve these fears by working them through cognitively. Beck also drew from his own experiences when writing his first book on depression, which he published in 1967. Beck was mildly depressed while he was writing the book, but regarded the project as a kind of self-treatment.

Beck's childhood and adolescence also included many positive experiences. He recalled during an interview in 2001 that he "was largely interested in nature" when he was growing up, becoming a bird watcher, learning to identify plants and trees, and eventually serving as a camp counselor and naturalist. Beck's parents encouraged his interest in science. He later credited these early explorations with stimulating his interest "in what makes people tick; particularly what makes them happy or sad, and confident or insecure."

Education

Beck was uncertain of his career plans during his undergraduate years; he majored in political science and English literature at Brown rather than chemistry or another premedical major. He also served as associate editor of the campus newspaper, the Brown Daily Herald. Because his scholarship did not cover all his expenses, he delivered newspapers, worked in the library, and sold Fuller brushes door-to-door in order to make ends meet. Beck graduated from the university magna cum laude in 1942. He won a number of honors and awards as an undergraduate, including the Francis Wayland Scholarship, the Gaston Prize for Oratory, and election to Brown's chapter of Phi Beta Kappa.

Following graduation from Brown, Beck went to medical school at Yale University, where he completed his degree in 1946. He was not interested in psychiatry at that point in his career; after receiving his MD, he served a rotating internship followed by a residency in pathology at Rhode Island Hospital. Beck then decided to specialize in neurology because he was attracted by the degree of precision that the specialty demands of its practitioners. While he was completing a required rotation in psychiatry during his residency at the Cushing Veterans Administration Hospital in Framingham, Massachusetts, he became interested in some of the recent developments in the treatment of mental illness. Beck then decided to become a psychotherapist.

PRINCIPAL PUBLICATIONS

• Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1967.
• The Diagnosis and Management of Depression. Philadelphia: University of Pennsylvania Press, 1973.
• The Prediction of Suicide. Bowie, MD: The Charles Press, 1974.
• Cognitive Therapy and the Emotional Disorders. New York: International Universities Press, 1976.
• Cognitive Therapy of Depression. New York: The Guilford Press, 1979.
• Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books, 1985.
• Love Is Never Enough. New York: Harper & Row, 1988.
• Cognitive Therapy in Clinical Practice: An Illustrative Casebook. London and New York: Routledge, 1989.
• Cognitive Therapy with Inpatients: Developing a Cognitive Milieu. New York: Guilford Press, 1992.
• Cognitive Therapy of Substance Abuse. New York: Guilford Press, 1993.
• The Integrative Power of Cognitive Therapy. New York and London: Guilford Press, 1998.
• Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.
• Scientific Foundations of Cognitive Theory and Therapy of Depression. New York: John Wiley, 1999.
• Cognitive Therapy of Personality Disorders, 2nd ed. New York: The Guilford Press, 2004.

Beck was originally trained in the theories and techniques of classical psychoanalysis. After finishing his residency in Framingham, Beck accepted a two-year fellowship at the Austin Riggs Center, a small private psychiatric hospital in Stockbridge, Massachusetts, which had been founded in 1919. The Center provided Beck with extensive experience in treating patients who needed long-term psychotherapy. When the Korean War broke out in 1951, Beck moved to Pennsylvania and accepted the position of assistant chief of neuropsychiatry at the Valley Forge Army Hospital. There he treated soldiers suffering from what is now termed post-traumatic stress disorder, or PTSD. Beck received his board certification in psychiatry in 1953, joined the Department of Psychiatry of the University of Pennsylvania in 1954, and completed his graduate training in psychoanalysis at the Philadelphia Psychoanalytic Institute (which changed its name to the Psychoanalytic Center of Philadelphia in 2001) in 1958. Beck remained at Penn until he retired from active teaching in 1992, when he was appointed University Professor Emeritus of Psychiatry. In addition to his teaching at Penn, he served as an adjunct professor at Temple University and the University of Medicine and Dentistry of New Jersey. He was also a visiting professor at Oxford University in 1986.

Beck has published over 465 books and articles as of early 2004. He has received funding for his various research projects from the University of Pennsylvania, the National Institute of Mental Health (NIMH), and the Centers for Disease Control and Prevention (CDC).

Early depression studies Beck developed cognitive therapy almost by accident in the course of his growing discontent with Freudian psychoanalysis. As a practicing therapist, Beck was aware that academic psychologists whose work he respected questioned Freud's account of depression because of the lack of supportive evidence from well-conducted studies. In addition, Beck had had difficulty with much of Freudian theory since medical school. His dislike was reinforced by a rebellious streak in his character and a self-acknowledged need for control. Beck told an interviewer in 1990, "I thought [psychoanalysis] was nonsense. I could not see that it really fitted.... there was a rebellious aspect [in me] I just couldn't control.... Being the youngest son probably had something to do with it." Beck initially dealt with his distrust of mainstream Freudianism by moving in the direction of the so-called neo-Freudians, a group that included Alfred Adler (1870–1937), Karen Horney (1885–1952), Harry Stack Sullivan (1892–1949), and Erik Erikson (1902–1994), who had been one of Beck's supervisors at Riggs. In general, the neo-Freudians placed a greater emphasis on social, interpersonal, and cultural influences in human development, and downplayed the significance of innate biological drives.

Freud had posited in Mourning and Melancholia (1917) that depression results from anger turned inward against the self, emerging outwardly as the patient's "need to suffer." Beck decided to set up a series of studies involving depressed patients, partly to collect data to convince psychologists of the soundness of Freud's hypothesis, and partly to design a brief form of psychotherapy that would target the core symptoms of depression. He received a research grant from Penn in 1959, and consulted two colleagues in the psychology department, Seymour Feshbach and Marvin Hurvich, for research methodology and statistical analysis. Beck then analyzed the dreams of 12 patients diagnosed with depression. The patients' dreams did in fact contain such themes as losing something of value, being prevented from achieving a goal, or appearing ugly, damaged, or diseased.

When Beck gave the depressed patients verbal conditioning and card-sorting tests, however, they reacted positively to successful outcomes, gaining self-esteem and performing better on subsequent tests. If Freud's theory of a "need to suffer" had been correct, the patients should have been upset by their successes. This discrepancy between psychoanalytic theory and research findings led Beck to reappraise his theoretical position. He went back to his dream study and began to compare the material in his patients' dreams with the verbal content of their interviews. In Beck's view, the comparison refuted Freud's notion of dreams as representing unconscious motivations and wish fulfillment. He recalled,

... it became clear to me as I went into it that the dream themes were consistent with the waking themes. It seemed to me a simpler notion about the dreams was that they simply incorporated the person's self-concept. Well, if it is just a question of the person's self-concept, you don't have to invoke the notion of the dreams being motivated.... If you take motivation and wish fulfillment out of the dream, this undermines the whole motivational model of psychoanalysis.

Following this reevaluation, Beck then constructed his first cognitive model of depression, which incorporated three specific concepts: the so-called cognitive triad; schemas, or stable patterns of thinking; and cognitive errors, or faulty information processing. According to Beck, the cognitive triad encompasses a depressed person's view of himself, his ongoing experiences, and his future, causing him (or her) to regard present experiences or interactions with others as defeats or failures, and to think of the future as one of "unremitting hardship, frustration, and deprivation." This triad of negative cognitive patterns then generates the emotional disturbances and loss of energy or motivation associated with depression. Next, Beck devised an approach to therapy intended to identify a patient's thought distortions, test them against the rules of logic and external reality, and help the patient correct the distorted patterns of thinking.

Extension of cognitive therapy Beck was cautious in extending his cognitive model of depression to other mental disorders; he has always been a methodical researcher, careful to restrict his claims to demonstrable results. For example, his first book on the treatment of depression recommended limiting cognitive therapy to nonpsychotic patients with unipolar depression who had not responded to or refused to take antidepressant medication. After the 1970s, however, the cognitive model was successfully applied by Beck's followers to a wide range of problems, including anxiety disorders, substance abuse, marital conflict, eating disorders, and anger management. One study reported that the interest in cognitive therapy among mental health care professionals increased 600% in the 16 years between 1973 and 1989. In the 1990s, cognitive therapists published outcome studies that reported success in treating psychotic disturbances and personality disorders—historically regarded as the most difficult mental disorders to treat.

Recent research interests Since the early 1990s, Beck has expanded his research interests to include such topics as human evolutionary biology and the movement toward psychotherapy integration. With regard to evolution, Beck has studied the works of anthropologists and experts in the biology of nonhuman primates in order to investigate the possible evolutionary roots of depression, anxiety, and personality disorders in humans. Beck's book on anger and aggression, Prisoners of Hate (1999), opens with an analysis of chimpanzees and hunter-gatherer societies for an evolutionary basis for empathy and social cooperation among humans. Similarly, the second edition of Cognitive Therapy of Personality Disorders (2004) contains a section on the relationship between affective or personality disorders and evolutionary survival "strategies."

The integrative movement in psychotherapy began in the late 1970s as the result of three factors: general dissatisfaction among mental health professionals with single schools of therapy; the failure of any one school to dominate outcome studies for all mental disorders; and demands for greater accountability from health insurers. Some of Beck's students had already begun to use techniques derived from Gestalt therapy in treating depressed patients, and Beck himself had started to acknowledge the importance of unconscious factors as well as the therapeutic relationship in conducting cognitive therapy. Since the early 1990s, Beck has maintained in his publications that cognitive therapy is the therapy that can integrate all the others, partly because its emphasis on cognition offers common ground with a range of other approaches, and partly because Beck's research has sought to demonstrate the capacity of cognitive therapy to successfully incorporate techniques from these approaches.

Marriage and family

Beck, who is known to family and friends as Tim (from his middle name), has been married for over half a century and is the father of four children. Beck married Phyllis Whitman in 1950. He had met her when she was an undergraduate at Brown and he was completing his medical internship. Phyllis worked as a newspaper reporter for several years after the marriage, but also completed degrees in social work and law while rearing their four children. She graduated at the head of her class from Temple University School of Law, taught law at both Temple and the University of Pennsylvania, and became the first woman judge appointed to the Superior Court of Pennsylvania in 1981. Beck frequently tried out his ideas on his wife during the years of his discontent with psychoanalysis, and credits her with suggesting the word "schema" to describe cognitive structures. He once paid tribute to Phyllis as "the balance wheel between my self-doubts and my runaway fantasies."

Beck's daughter Judith became a clinical psychologist and presently serves as director of the Beck Institute for Cognitive Therapy and Research in Bala Cynwyd, Pennsylvania, which was founded in 1994. She has published several books of her own on cognitive therapy and oversees training programs for cognitive therapists at the Institute.

THEORIES

Structures of human cognition

Beck defines cognitive therapy as "an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders . . . . based on an underlying theoretical rationale that an individual's affect and behavior are largely determined by the way in which he structures the world." According to Beck, the cognitive organization of the human mind consists of various levels of verbal or pictorial "events" that vary among themselves in terms of accessibility and resistance to change. Beck has identified four such levels:

• Voluntary thoughts. These are the most readily accessible group of cognitions and appear in the patient's stream of consciousness.
• Automatic thoughts. These cognitions are less accessible, often come to the surface when the patient is under stress, and may be difficult to block.
• Assumptions and values. These cognitions are associated with the meanings that patients attribute to situations and events.
• Schemas. Schemas are cognitive structures based on a network of core beliefs established by a person's early learning experiences. They operate below the level of conscious awareness, and are dormant until they are activated or triggered by specific events. The schemas then serve as filters or screens that determine the person's interpretation of the event.

Driving a car in the city offers a useful example of Beck's layers of cognitions. Someone who is approaching a four-way intersection might notice that a driver on the cross street is going through the stop sign. "That driver isn't even slowing down; I'd better be careful and start applying the brakes" would be a typical set of voluntary thoughts. "People like that are scary" might be the person's automatic thought. "It is important to be a safe and careful driver" would be an example of an assumption. "The world is a dangerous and unfriendly place," would be an example of a core schema that might be triggered by the need for a quick response to the other driver's behavior.

Main points Schemas, as Beck uses the term, vary in their extensiveness; their flexibility (the degree to which they can be modified in therapy); their density (the extent to which they dominate the person's cognitions); and valence (the degree of their activation at any given moment). For example, the schema of "feeling helpless" may be activated in some people fairly easily, in a wide variety of circumstances, and may be relatively resistant to change. In others, the "feeling helpless" schema may be activated only when the person is depressed, and it may be modified by therapy.

Beck distinguishes several different categories of schemas according to function and content:

• Cognitive schemas. These schemas deal with abstract thinking, interpretation of events, and memory or recall.
• Affective schemas. These schemas govern the emotions that arise from the person's cognitions.
• Motivational schemas. These are concerned with wishes and desires.
• Instrumental schemas. These schemas deal with making plans and preparing to take action.
• Control schemas. These are concerned with self-monitoring and acting or refraining from acting.

Beck regards these schemas as activated in the order of the preceding list. As an illustration, a person out hiking in the woods sees a snake slither across the trail in front of him. His memory tells him that some snakes are dangerous, and that he is not enough of an expert on snakes to know whether the one he just saw is poisonous or not (cognitive schema). He feels afraid (affective schema). He would like to run away (motivational schema). He prepares to turn around and go back (instrumental schema). He decides that the satisfaction he might have from proceeding with his hike is not worth the risk of snakebite, and turns back (control schema). This order is important, in that it reflects the belief of cognitive therapists that emotional responses to situations result from cognitive interpretations, not the other way around.

Schemas form interlocking sets that Beck calls systems. In cognitive therapy, it is a system that governs the sequence of events that begins with the person's reception and interpretation of a stimulus from the environment and ends with the person's behavioral response. In the preceding example, the hiker's perception of a snake and the possibility of injury produced an interpretation ("I'd rather not take the chance that the snake is poisonous"), which in turn led to his decision to return to his camp. Another hiker might interpret the same perceptions differently ("The snake might be poisonous, but I have a snakebite kit in my backpack and I know how to use it") and decide to stay on the trail.

Systems in turn may function as a group to form a mode. A mode, in Beck's usage, represents what he calls a "cognitive shift," which takes place when a person develops an anxiety disorder or depression. To give an example, Beck describes depression as a cognitive shift in which the patient "moves away from normal cognitive processing to a predominance of processing from the negative schemas that constitute the depressive mode." In other words, the "depressive mode" amounts to a systematic negative bias in recalling past events and interpreting present ones. Similarly, general anxiety disorder can be described as a cognitive shift into the "danger mode," in which memories and current events are interpreted in terms of threats to the self.

Explanation There are several features to note in Beck's descriptions of cognitions and schemas. The first is that he is relatively unconcerned with causality; that is, he does not attempt to explain the ultimate cause or origin of a patient's dysfunctional schemas. With regard to depression in particular, he allows that mood disorders may be related to genetic vulnerabilities, brain injury, or hormonal disturbances as well as dysfunctional thought patterns. In addition, he observes that the dysfunctional schemas may be triggered in adult life by a variety of psychological stressors, biochemical factors, or a combination of both.

Second, Beck's understanding of cognitions and schemas helps to explain his focus on the patient's present situation. In his early writings on depression, Beck explicitly contrasted his approach with the historical concerns of psychoanalysis: "In contrast to psychoanalytic therapy, the content of cognitive therapy is focused on 'here-and-now' problems. Little attention is paid to childhood recollections except to clarify present observations.... We do not make interpretations of unconscious factors." Beck did, however, modify his emphasis on the present when he turned from the treatment of Axis I affective disorders (depression and the anxiety disorders) to therapy with patients suffering from Axis II personality disorders. Cognitive therapists who work with this patient population spend more time exploring the patient's childhood memories.

A third point that Beck wished to emphasize is that exploration of the patient's cognitions and schemas lends itself to experimental testing. "[Cognitive therapists] formulate the patient's dysfunctional idea and beliefs about himself, his experiences, and his future into hypotheses and then attempt to test the validity of these hypotheses in a systematic way." This emphasis on empirical testing distinguishes cognitive therapy from psychoanalysis, in which the analyst's interpretations of the patient's dreams or free associations are difficult to either disprove or verify.

Another contrast between Beck's understanding of human cognition and the classical Freudian view is his focus on the accessibility and nonmysterious quality of the patient's thoughts. Whereas psychoanalysis regarded a patient's feeling and behavior as driven by unconscious motivations that the analyst had to uncover and piece together from the material that the patient brought to therapy sessions, Beck attempted to demystify the cognitive distortions that generate emotional distress and behavioral problems. One consequence of Beck's rejection of such Freudian notions as the unconscious or defense mechanisms is that the therapist can approach the patient's dysfunctional beliefs in a direct way, by simple questioning that draws out the patient's full point of view rather than by complex interpretations that may miss the mark entirely.

Examples Beck listed what he considered the major categories of "faulty information processing" that "maintain the patient's belief in the validity of his negative concepts despite the presence of contradictory evidence" as early as 1967. An example of each category is given:

• Arbitrary inference. In this pattern of thought distortion, the patient draws a specific conclusion in the absence of evidence to support it. A patient may say, for example, that her husband is going to divorce her because she is depressed in spite of his reassurances to the contrary.
• Selective abstraction. In selective abstraction, the patient takes a small detail out of context, ignoring other features of the situation and interpreting the whole on the basis of the detail. For example, a college student may conclude on the basis of one poor grade on a weekly laboratory report that she will fail the entire course and have to give up her dreams of medical school.
• Overgeneralization. A patient who is overgeneralizing draws a sweeping conclusion from one or a few isolated incidents and applies it across the board even to unrelated situations. A person who has trouble fixing a leaky faucet, for example, may decide that he is completely incompetent at any task involving manual dexterity or mechanical skills.
• Magnification/minimization. This form of thought distortion involves extreme exaggeration of the significance of a situation or event. For example, a patient diagnosed with obsessive-compulsive disorder tells her therapist that it is "absolutely horrible" to be unable to do everything well.
• Personalization. In personalization, the patient tends to interpret external events as relating to himor herself even when there is no logical basis for a connection, or takes more than his or her share of responsibility for a negative outcome. An example would be a professional baseball player who assumes that his fielding errors are the reason his team ended up at the bottom of its league.
• Dichotomous or black-and-white thinking. This form of thought distortion places all experiences in one of two absolute categories. People with borderline personality disorder, for example, typically categorize others in their lives as completely wonderful and loving or as hateful persecutors. Narcissists often assume that if they are not "the best" in some respect, they must be "the worst."

To uncover the cognitive fallacies that are skewing a patient's interpretations of other people and events, the therapist may use a type of questioning that Beck calls "cognitive probing" or the "downward arrow" technique. The patient is asked to recall a recent incident that illustrates one of his or her recurrent difficulties. Cognitive probing allows therapist and patient together to examine the patient's problematic patterns of reasoning as well as identify automatic thoughts and core schemas. The following is an example of the "downward arrow" technique in the treatment of a patient with avoidant personality disorder. The event that the patient brought for discussion concerned a workplace friend who had gotten absorbed in a lunchtime conversation with a third friend.

• Therapist: What went through your mind at lunch?
• Patient: Linda is ignoring me. [arbitrary inference, personalization]
• T: What did that mean?
• P: That I can't get along with people. [overgeneralization]
• T: What does that mean?
• P: That I will never have any friends. [magnification]
• T: What does it mean "not to have friends"?
• P: I am all alone. [core schema]
• T: What does it mean to be "all alone"?
• P: That I will always be unhappy. [core schema]

A case study of a patient diagnosed with obsessive-compulsive disorder provides an example of the way in which cognitive therapists encourage patients to test their assumptions and beliefs by behavioral experimentation in real-life situations. The patient was an engineer in his mid-forties with a history of chronic pain in his back, neck, and shoulders. He had begun to consider the possibility that the pain was at least partly caused by psychological stress. The patient was not only highly critical of himself, but also thought that others were critical and disapproving. The therapist asked the patient at one point what he might do to "find out if these thoughts are accurate or not." The patient replied that he could ask others what they were thinking, but added that they "might not like [his] asking." The therapist then suggested starting with someone who is "pretty honest and nonjudgmental."

• Therapist: Who do you think might fit that description?
• Patient: My boss is a decent guy and I'd really like to not have to worry that he is judging me all the time.
• T: Can you think of a relatively safe way you could ask your boss how he is feeling about you or your work?
• P: I suppose I could say . . . 'Jack, you seem to be concerned about something. Is anything bothering you about the way my project is going?'
• T: That sounds pretty good. Would you be willing to accept that as your homework for next week?

Over the next several weeks the patient kept a record of asking others what they were thinking when he thought they were judging him negatively. He found that with one exception, he had completely misinterpreted their thoughts or opinions.

Beck's continuity hypothesis

Main points Beck advanced what he calls his "continuity hypothesis" as early as 1976, when he published Cognitive Therapy and the Emotional Disorders. What he means by this phrase is that human behaviors can be placed at various points along a continuum instead of being divided sharply into "normal" and "pathological" behaviors. Beck's interest in evolutionary biology allows him to situate the continuity hypothesis within the larger framework of human evolution, and thus to describe dysfunctional attitudes and behaviors as potentially adaptive. He uses the example of a graduate student who fails an examination:

Although it is important to realize that anger [directed at the examiners] and anxiety are potentially adaptive reactions, they can become maladaptive when we exaggerate the degree of danger or the magnitude of an offense. The student who exaggerates his vulnerability during an oral examination may find that his mind goes blank and he performs just as badly as he feared he would.

The theoretical account of personality disorders in Cognitive Therapy of Personality Disorders discusses the origin of these Axis II syndromes in terms of "evolutionary-based strategies" that may have been necessary for survival in prehistoric times but are no longer adaptive in contemporary societies. The diagnosis of a personality disorder may reflect only a "bad fit" between a given individual and our present "highly individualized and technological society," rather than a clear-cut instance of untreatable psychopathology. Or, as Beck puts it in Prisoners of Hate, "The most hypersensitive reactors among us are destined to receive a psychiatric diagnosis, which serves as a mandate to receive help in moderating the exaggerated reactions."

Beck applied his continuity hypothesis to consciousness itself as well as to emotions and behaviors. Speaking in a 1991 interview, Beck openly disagreed with Freud's notion of "a thick concrete wall of repression" separating conscious thinking and feeling from unconscious wishes and drives. "Now my own notion is that consciousness is on a continuum. Some things are more conscious than others and some are less conscious.... When you drive your car, you're [ordinarily] not conscious of every single move you're making, but if you're focusing on it, then you do become aware of what you're doing." Otherwise stated, for Beck consciousness is not a unitary or either/or condition, but a flexible set of responses to the environment.

Explanation Beck's continuity hypothesis has systematic as well as practical consequences. In terms of his system of thought, the continuity hypothesis provides a bridge between schemas and cognitions on the one hand and what Beck calls automatic thoughts on the other. Beck's concept of automatic thoughts, which he defines as "brief signals at the periphery of consciousness," grew out of his early work with depressed patients. One patient undergoing treatment in 1959, when Beck was still practicing traditional psychoanalysis, reported a secondary succession of thoughts that occurred while he was free-associating and angrily criticizing Beck. The thoughts concerned feelings of guilt for verbally attacking the therapist. Beck was intrigued by the patient's account of his internal monologue and began asking other patients if they had thoughts during therapy sessions that they had not mentioned. On the basis of their replies, he elaborated his notion of automatic thoughts.

In practical terms, Beck's continuity hypothesis is helpful to many patients in that it removes some of the feelings of shame and social stigma that many associate with a psychiatric diagnosis. Instead of being placed on one side of a categorical wall that separates a patient from "normal" people, he or she can think of therapy as helping him or her to move along a continuum from a more to a less extreme position on the continuum. Interestingly, many of the strategies recommended to people in therapy for dealing with the stigma attached to mental disorders are essentially cognitive techniques.

Examples Beck's continuity hypothesis is the basis of a technique that some cognitive therapists refer to as the continuum technique. It is used specifically to challenge all-or-nothing thinking. Cognitive Therapy of Personality Disorders includes an example of this technique with a patient diagnosed with paranoid personality disorder. The patient was a radiologist who had an all-or-nothing view of competence; in his own words, a person was either completely "good at what he does" or a total "screw-up." The therapist began by asking the patient to describe a competent person, and then a "screw-up." He made a list of the qualities the patient associated with competence, such as "doing hard tasks well," "being relaxed while doing them," "catching and correcting mistakes," and "knowing one's limits," and a second list of their opposites. The therapist then drew a linear scale marked from "0" to "10," and asked the patient to rate himself on the continuum for each of the qualities he associated with competency. The radiologist quickly realized that he did not see himself as very relaxed at any time, and that neither he nor anyone else can function at their peak all the time. As the patient's view of competency became less polarized, the therapist then extended the continuum technique to his view of other people as either "completely trustworthy" or "totally malevolent, just like [his] family." Gradually the patient began to recognize that people, like skills, are not all-or-nothing packages, and he began to apply the continuum technique for himself to a range of social as well as occupational situations.

Emotions in cognitive therapy

Main points Beck has been criticized for paying insufficient attention to the role of emotions in treating mental disorders, although he did devote a full chapter in his landmark Cognitive Therapy of Depression to "The Role of Emotions in Cognitive Therapy." One important function of emotions in cognitive therapy is that they help patient and therapist to target core symptoms for the work of therapy rather than being distracted by relatively superficial issues. A strong emotional reaction during the initial interview and history-taking is usually evidence that the therapist has touched on a core problem. Beck also recommended the use of several techniques, including imagery work, sensory awareness, and flooding, as ways to identify the patient's core issues. His interest in these techniques goes back to his treatment of depressed Korean War veterans in the 1950s.

A second function served by the patient's expression of emotions during cognitive therapy sessions is stress relief, in that many people feel compelled to hide or suppress their feelings in the workplace or around family members. Beck notes that "Uninhibited crying seems to have some intrinsic therapeutic merit in many cases.... [the patient has] a sanctuary for self-expression without being judged." Beck adds that patients who find that they feel better after crying or expressing anger in the therapist's office are also more likely to stay in therapy.

A third aspect of the role of emotions in cognitive therapy is the therapist's utilization of state-dependent memory. State-dependent memory is a term that refers to the fact that people are better able to remember an event in their past if they are in the same emotional state that they were in when the event occurred. In order to help a patient retrieve the automatic thoughts that occur when he or she is anxious, for example, the therapist may try to recreate an anxiety-provoking situation during the therapy session. Other techniques related to state-dependent learning are discussed in Cognitive Therapy of Depression. They include scheduling therapy sessions at times when the distressing emotion is most likely to surface; for example, a patient who is bothered by feelings of loneliness might be asked to come in on a weekend or at night. In other situations, the therapist might visit the patient's home or enlist a family member or friend to use certain therapeutic strategies in the home situation.

Cognitive therapists do not, however, encourage the examination and expression of feelings to the extent practiced by experiential, or abreactive, schools of psychotherapy. An example of the experiential approach is the "primal scream" therapy practiced by Arthur Janov in the 1960s. Janov maintained that many physical as well as mental disorders result from early trauma, and can be relieved by expressing the pain and other strong feelings resulting from that trauma. Beck maintained that abreactive therapies encourage "the production of excessive, inappropriate emotional reactions," and do not help patients identify the distorted cognitions that underlie their painful feelings.

Explanation The role of emotions in human behavior is a major area in which cognitive therapy has evolved since the early 1970s. As cognitive therapy was extended from depression to the treatment of personality disorders, Beck and his colleagues began to recognize the extent to which the dysfunctional cognitive profiles that characterize these disorders are attached to, and perpetuated by, strong emotions. The second edition of Cognitive Therapy of Personality Disorders contains extensive discussions of the role of emotions in the therapist/patient relationship and the importance of helping patients cope with painful feelings.

Examples Cognitive Therapy of Depression contains an instructive example of an emotional outburst by a patient. The patient in this case was a depressed, 35-year-old married woman whose complaints included tiring easily and feeling physically weak. She initially described her marriage as "fine," adding, "I don't have any problems in my marriage." When the therapist asked her to describe some specific interactions with her husband, however, the patient began to sob. As she continued to describe her husband's behavior patterns, she cried uncontrollably. She then said, "You know . . . I think those things bother me more than I realized." She was able to link her sad feelings to such specific cognitions as "My husband always gets his own way," and "He is inconsiderate and doesn't care about what I want." This patient's course of therapy included some work on restructuring her relationship with her spouse as well as learning to identify the cognitions that were maintaining her depression.

An example of eliciting a state-dependent memory during a therapy session concerns a patient diagnosed with avoidant personality disorder. Guided discovery is often used with these patients, because they frequently report that their minds "go blank" when painful feelings are aroused. In this instance, the therapist had been doing an imagery exercise with the patient, asking her to imagine herself going out to eat with a friend. Suddenly, the patient stated that she didn't want to go on with the exercise. When the therapist asked her what she was feeling, she replied, "Depressed . . . and . . . real scared." The therapist continued, "What do you think will happen if you keep feeling this way?" The patient said that she would "freak out," "go crazy," and that the therapist would see her as "a basket case." The therapist reassured her that the feelings she was trying to avoid would "lead to some useful information" if she could stay with them just a little longer. Returning to the image of sharing a restaurant meal with her friend, the patient began to sob, and said she thought the friend would be angry with her. She added, "I'm a rotten person for making him so unhappy." Guided discovery was used for the next several sessions to help the patient develop greater tolerance for painful feelings as well as uncover other automatic thoughts.

Role of the therapist

Main points Beck describes cognitive therapy as a "collaborative enterprise" or "collaborative empiricism." What he means by these expressions is that the therapist works together with the patient to uncover the specific underlying assumptions that trigger the patient's emotional pain and motivational difficulties. The patient brings what Beck calls "raw data" to the therapeutic relationship, while the therapist offers guidance in collecting appropriate data and using them in therapy. The therapist is not regarded as an "expert" who knows the patient's mind better than she does herself; the patient is asked and expected to correct the therapist if he has misunderstood her. Beck emphasizes that the distorted cognitions involved in mental disorders are often idiosyncratic and cannot be deduced automatically from the event that has brought the patient into therapy.

BIOGRAPHY:

Albert Ellis

Albert Ellis (1913– ) is the founder of rational-emotive behavior therapy, or REBT. He did not set out to become a therapist, but majored in business at the City University of New York. Ellis graduated from CUNY in 1934, in the midst of the Great Depression. While supporting himself by managing a gift and novelty firm, Ellis hoped to become a great writer—but had little success in publishing his short stories and plays. He did discover, however, from conversations with friends that he had a flair for counseling. He entered the graduate program in clinical psychology at Columbia, earning his doctorate in 1947.

Ellis thought at the time of his graduation from Columbia that psychoanalysis was the most effective form of therapy. In the late 1940s, the American psychoanalytic institutes refused to accept trainees without MDs, but Ellis found a student of Karen Horney's who agreed to work with him. He practiced classical psychoanalysis for several years while teaching at Rutgers and New York University. Like Beck, however, Ellis found himself losing faith in Freud's ideas, and abandoned psychoanalysis altogether by 1955. Like Beck, Ellis was influenced by the Stoic philosophers and the neo-Freudians, and began to publish his early work on REBT in the 1950s. His landmark books came out earlier than Beck's. Guide to Rational Living was published in 1961, and Reason and Emotion in Psychotherapy appeared in 1962.

Unlike Beck, Ellis is not a researcher. He promoted his approach to psychotherapy largely through popular self-help books and workshops rather than through publications in professional journals. Some observers believe that Ellis did not have as much of an impact as Beck because he did not work in an academic or medical school setting. Beck credits Ellis, however, with advancing the recognition that thoughts and beliefs are much more accessible to patients than psychoanalysts had maintained. In addition, Ellis was the first to concentrate the work of therapy on the patient's present-day issues as compared to childhood memories or traumas. Beck has always acknowledged Ellis's influence on his work, beginning with his first major book on depression. In particular he derived his technique of Socratic questioning from Ellis.

REBT and cognitive therapy share several characteristics: the assumption that dysfunctional thinking is a factor in psychological distress; a focus on changing thought processes in order to bring about changes in feelings and behavior; and a time-limited concentration on specific target symptoms in therapy. There are also, however, several important differences between the two approaches: cognitive therapy seeks to correct the systematic biases in a patient's information processing as well as examine the content of specific dysfunctional beliefs; cognitive therapy allows for idiosyncratic beliefs, whereas REBT therapists tend to assume that the same set of "irrational beliefs" operates in everyone; and Beck tends to give greater weight to the role of life experiences in shaping a patient's beliefs while Ellis favors a biological basis for irrational thinking. Finally, Beck and Ellis disagree on what they consider the foundational problem in mental disorders: Beck believes that the ultimate source is fear, whereas Ellis follows Horney in referring to the "tyranny of the 'shoulds'," or in his own memorable phrase, "MUST-erbatory thinking."

Beck's concept of the therapist's role includes several innovations related to his model of collaborative empiricism:

• Testing the patient's beliefs against real-life experience. Along with Albert Ellis, Beck was one of the first therapists to invite patients to reevaluate dysfunctional thoughts or images by conducting behavioral experiments and considering alternative explanations of other people's actions. An example of this technique was described earlier.
• Socratic questioning. Cognitive therapists ask questions of their patients far more frequently than therapists trained in psychoanalytic techniques. Beck is careful to distinguish, however, between rapid-fire questioning that may come across to the patient as interrogation, and what he terms "Socratic questioning." This approach, which takes its name from the types of questions that the philosopher Socrates asked his friends to guide them to insight, is intended to be a nonjudgmental way for the therapist to model examination of one's cognitive patterns or previously unquestioned assumptions.
• Guided discovery. Guided discovery refers to the general process of teaching patients to discover their own misperceptions and flawed logic, as opposed to the therapist's arguing or disputing with them. Guided discovery is also used to help the patient learn to identify themes that distort his or her interactions in the present and relate these themes to past experiences.

The cognitive therapist takes an active role in the therapy process. Prior to the initial interview with the patient, the cognitive therapist is expected to plan a tentative outline of treatment based on the patient's history and his or her scores on one or more of Beck's diagnostic instruments. As is described in more detail under "Theories in Action," the therapist introduces the patient to the basic concepts and principles of cognitive therapy and gathers information about the patient and his or her dysfunctional thought patterns. In general, however, cognitive therapists are more active at the beginning of treatment than at the end, particularly when working with depressed patients.

Cognitive therapists are also highly directive; that is, they assign the patient tasks ("homework") to be completed before the next session, and may use a range of behavioral techniques to nudge the patient out of passivity. The collaborative aspect of cognitive therapy is very much task-oriented. Beck draws an explicit contrast between cognitive therapy and supportive or "relationship" therapies. ". . . [in cognitive therapy] the therapeutic relationship is used not simply as the instrument to alleviate suffering but as a vehicle to facilitate . . . carrying out specific goals." As will be illustrated below, patients in cognitive therapy are asked to think of specific changes they would like to see in their lives that require concrete actions: reducing or eliminating some of the symptoms of their disorder, improving management skills in the workplace or home, pursuing new intellectual or spiritual interests, tackling bad habits, and the like.

Explanation There are several rationales underlying Beck's view of the therapist's role. One is to maximize the benefits of short-term therapy. Homework assignments, keeping written records of dysfunctional thoughts, and similar tasks are thought to maintain and reinforce the patient's progress between sessions. In addition, the patient's use of logs or written notes provides him or her with a visible "track record" of progress. This record is particularly beneficial if and when the patient has a temporary setback during therapy.

A second rationale for Beck's emphasis on collaborative therapy is to restore the patient's sense of control or mastery. Depressed patients in particular frequently feel helpless or overwhelmed by their situation, and feelings of accomplishment or satisfaction serve to lift morale as well as counteract dysfunctional thoughts. A behavioral technique that cognitive therapists often use with depressed patients is keeping a schedule of activities, and rating each for mastery (completing the task) and pleasure (deriving enjoyment or fun from the activity).

The third rationale for such specific techniques as Socratic questioning and guided discovery is that they enable the patient to become his or her own therapist after formal treatment has ended. Given the high rate of recurrence or relapse among patients diagnosed with major depression (as noted in the 2001 STAR*D protocol, between 20% and 35% experience a chronic course of the disorder), the possibility that cognitive therapy may lower this rate is often used to recommend it.

Examples Beck's 1979 Cognitive Therapy of Depression contains an example of Socratic questioning used in treating a depressed graduate student worried about admission to law school by exploring the meaning she attached to it.

• Patient: I get depressed when things go wrong. Like when I fail a test.
• Therapist: How can failing a test make you depressed?
• P: Well, if I fail I'll never get into law school.
• T: So failing the test means a lot to you. But if failing a test could drive people into clinical depression, wouldn't you expect everyone who failed the test to have a depression? ....
• P: It depends on how important the test was to the person.
• T: Right, and who decides the importance?
• P: I do.
• T: And so, what we have to examine is the way . . . that you think about the test, and how it affects your chances of getting into law school. Do you agree?
• P: Right.

An example of Beck's use of guided discovery to uncover automatic thoughts as well as to draw connections between thoughts and feelings concerns a young man with an anxiety disorder. Asked to list situations that he found particularly upsetting, the patient had mentioned sports, playing cards with friends, and dating.

• Therapist: What thoughts go through your mind ... when you don't do so well at swimming?
• Patient: I think that people think much less of me, that I'm not a winner.
• T: And how about if you make a mistake playing cards?
• P: I doubt my own intelligence.
• T: And if a girl rejects you?
• P: It means I'm not special. I lose value as a person.
• T: Do you see any connections here among these thoughts?
• P: Well, I guess my mood depends on what other people think of me. But that's important—I don't want to be lonely.
• T: What would that mean to you, to be lonely?
• P: It would mean there's something wrong with me, that I'm a loser.

HISTORICAL CONTEXT

Cognitive therapy is rooted in philosophical systems dating back two millennia that are part of the high culture of the West as well as in medical and psychological research since Freud.

Classical Western philosophical tradition

Beck's interest in the humanities as an undergraduate led him to situate his approach to psychotherapy within the mainstream of Western philosophy, which has traditionally emphasized the role of human reason as the guide or governor of the emotions. He has explicitly mentioned his indebtedness to Greek and Roman Stoicism, the critical idealism of Immanuel Kant (1724–1804), and the phenomenology of Edmund Husserl (1859–1938) and Martin Heidegger (1889–1976). Stoicism numbered among its adherents such writers as Zeno of Citium (333–264 b.c.), Cicero (106–46 b.c.), Seneca (3 b.c.–65 a.d.), Epictetus (55–135 a.d.), and the Roman emperor Marcus Aurelius Antoninus (121–180 a.d.). One of Epictetus's sayings is: "People are disturbed not by things but by the view which they take of them." Similarly, Marcus Aurelius wrote in his Meditations that "If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment."

Previous dominance of the psychoanalytic model

As the preceding outline of Beck's medical training indicates, classical psychoanalysis was the basic model for practicing psychotherapy in the United States in the 1930s through the 1950s. Its influence was particularly strong in the Northeast, where Beck received his undergraduate as well as his professional education. This influence stemmed in part from the famous series of lectures that Freud had delivered at Clark University in Massachusetts in 1909. The Boston Psychoanalytic Society and Institute (BPSI) was founded in 1928, followed by the Philadelphia Psychoanalytic Institute and Society, where Beck received his training in the 1950s. At the time that Beck joined the University of Pennsylvania faculty in 1954, the only mainstream alternative to psychoanalysis was pharmacotherapy, or treating psychiatric patients with medications. Lithium carbonate had been found to be effective in treating mania by Australian researchers in 1948. Chlorpromazine (thorazine), the first of the effective antipsychotic drugs, had been discovered by a French surgeon named Henri Laborit in 1952. Psychotropic medications, however, proved to have several disadvantages that included the risk of addiction as well as other severe side effects.

Beck's dissatisfaction with the psychoanalytic method and his gradual divergence from Freudian presuppositions resulted in a period of professional isolation and some loss of grant funding. He later remarked, "One colleague [at Penn] told me [cognitive therapy] was like treating malaria with an electric fan." During this period Beck relied primarily on his wife and on Gerald Davison, a psychologist at the State University of New York at Stony Brook, for feedback and support. Another source of encouragement was Albert Ellis, who had also begun his career in therapy as a psychoanalyst, become disenchanted with the Freudian mainstream, and developed his own form of psychotherapy-rational-emotive behavioral therapy or REBT. Ellis first wrote to Beck in 1963 after reading one of his articles in the Archives of General Psychiatry. The two men have continued to communicate with each other and exchange ideas ever since. Beck even underwent a session of REBT with Ellis, hoping to cure his lifelong fear of public speaking—but neither felt the session was completely successful.

The cognitive revolution

The growing acceptance of Beck's theories within the therapeutic community during the 1970s was in part the result of the so-called "cognitive revolution" in psychology, in which psychologists began to move away from behaviorism and its model of learning as operant conditioning toward a model of learning as information processing. Jean Piaget's work on the process of childhood learning indicated that children perceive, remember, and learn to think in categories—such structures as number, quantity, volume, and space. Other researchers found that categorization appears to be both innate in humans and cross-cultural. Another structural psychologist whose work influenced Beck was George Kelly, whose two-volume Psychology of Personal Constructs (1955) proposed that psychopathology could be understood in terms of faulty information processing. Beck initially used Kelly's term "constructs" to describe his "schemas."

The cognitive revolution also included researchers who applied the information-processing model to social psychology, studying such processes as impression formation, decision-making, problem-solving, self-perception, and self-control. Beck was particularly influenced by the work of Donald Meichenbaum in cognitive behavioral modification and Albert Bandura (1925– ) in social modeling and self-regulation theory.

Managed care and evidence-based practice

Cognitive therapy has enjoyed renewed popularity in the early twentieth-first century because of its cost-effectiveness and long-term benefits. The rise of managed care and subsequent pressures for cost containment in the treatment of psychiatric disorders have made cognitive therapy the dominant model of psychotherapy in the United States. According to a 2002 article in the Washington Post, this dominance has caused resentment among psychoanalysts and practitioners of psychodynamic therapy. The reporter concluded, "Therapists feel they are being railroaded into a single school of therapeutic thinking—the one supported by managed care companies, which care less about patients than about holding costs down."

Similar comments have been made by therapists working in the United Kingdom, where the National Health Service's publication Treatment Choice in Psychological Therapies and Counselling is seen as promoting cognitive behavior therapy as the treatment of choice. One British psychiatrist remarked in 2002 that ". . . it is hard to escape the suspicion that cognitive behaviour therapy seems so far ahead of the field in part because of its research and marketing strategy rather than because it is intrinsically superior to other therapies."

Self-help groups and bibliotherapy

Another historical factor that has favored the growth of cognitive therapy since the 1970s is the rapid proliferation of self-help groups and the growing popularity of self-help books. Bibliotherapy, or the use of books to help people solve problems or train themselves in such techniques as those used in cognitive therapy, has become widely used since it was first discussed in the early 1980s. In addition, the Twelve Steps of Alcoholics Anonymous (AA) and similar groups (Al-Anon, Overeaters Anonymous, Gamblers Anonymous, etc.) have been described in the psychiatric literature as a form of cognitive restructuring that helps uncover the distortions of "stinkin' thinkin'" and the emotional problems associated with addictions. Beck has contributed to the self-help movement both theoretically and practically. His theoretical contribution lies in his emphasis on the collaborative aspect of the therapist/patient relationship and the therapist's role in teaching the patient techniques for thought monitoring and belief testing that can be used after the termination of formal therapy.

In practical terms, Beck and some of his students have written self-help guides and other books for the interested nonspecialist. In 1988 Beck published a book called Love Is Never Enough, which introduced the concept of couples' therapy as well as cognitive therapy within the framework of a guide written for the general public. David Burns, who completed a residency in psychiatry under Beck in the late 1970s, has published several self-help books based on the principles of cognitive therapy, including Feeling Good: The New Mood Therapy (1980), Intimate Connections (1985), and The Feeling Good Handbook (1990). Burns's books are often recommended as "homework" for patients in cognitive therapy. Lastly, Beck's work on the cognitive distortions underlying anger and violence, called Prisoners of Hate, appeared in 1999. While it is not a self-help book in the strict sense, Prisoners discusses the cognitive bases of spouse and child abuse, hate crimes, and terrorism in a clear and accessible fashion.

CRITICAL RESPONSE

Behaviorist criticisms

The earliest criticisms of Beck's work came from behaviorist psychologists, particularly Joseph Wolpe and B. F. Skinner, on the grounds that cognitive therapy is a form of mentalism, which may be defined as the belief that mental processes are autonomous and cannot be explained by an organism's behavior. Behaviorists have also criticized Beck for departing from basic science in his use of self-report paper-and-pencil questionnaires and his inability to demonstrate that cognitions are anything more than conditioned behaviors. Behaviorist critiques of Beck since the 1970s have generally focused on the uneasy relationship between cognitive therapy and behavior therapy. Most criticisms of cognitive therapy, however, have come from practitioners of psychoanalysis and psychodynamic psychotherapy.

Simplistic and technique-oriented

One of the most common criticisms of cognitive therapy is that it is superficial and consists of a "cook-book" or mechanical approach to psychotherapy. This line of criticism gathered force after 1979, when Beck published Cognitive Therapy of Depression. The book offered therapists an explicit description of the course of therapy, from a discussion of the structure of the therapeutic interview and a session-by-session outline of the treatment of a depressed patient to explanations of therapeutic homework and ways to focus on target symptoms. Beck's critics, however, used the book to argue that cognitive therapy is too technique-oriented, focuses too narrowly on short-term symptom reduction, underestimates the level of skill required to be a competent therapist, and oversimplifies the complexity of patients' problems. The cost-control emphasis of managed care has intensified this particular criticism of cognitive therapy. Practitioners of psychodynamic therapy in particular have maintained that they would rather treat fewer patients than be constrained by insurance companies who only allow as few as eight sessions of treatment.

Beck's reply to this criticism began to emerge in the 1980s, when the National Institute of Mental Health (NIHM) funded a multi-site outcome study intended to compare the effectiveness of cognitive therapy for depression with short-term interpersonal psychotherapy, which was based on a psychodynamic model. Beck was skeptical of the value of a multi-site study, but he did obtain a small grant to train therapists in cognitive therapy for three months. A major problem was that there was a far larger pool of therapists trained in psychodynamic therapy to draw from, and they quickly mastered the adjustments that were necessary to practice interpersonal psychotherapy. There were very few experienced cognitive therapists, however, and the trainees who completed Beck's three-month "crash program" barely met competency standards. The result was that cognitive therapy did not appear to be as efficacious in comparison to other treatment methods as other outcome studies had indicated. Beck subsequently regarded the NIMH study, which was published in 1989, as a setback. On the other hand, the fact that three months of training in cognitive therapy was clearly inadequate indicated that cognitive therapy is not just a matter of following an easily mastered set of techniques.

Beck's later publications have been careful to spell out that rote mastery of therapeutic technique is not enough to be a competent practitioner of cognitive therapy. Cognitive Therapy of Personality Disorders contains the following admonition:

... methods that are successful with at a particular time with a given patient may be ineffective at another time. Therapists must use their best judgment in designing treatment plans and selecting the most useful techniques . . . or improvising new ones. A certain amount of trial and error may be necessary.

Inadequate account of human emotions

A second common critique of cognitive therapy is that it focuses on cognition to the point of discounting the role of emotions in effecting change during psychotherapy. Other critics maintain that cognitive therapy is rationalistic in the sense of making a detached or common-sense attitude toward life as the implicit goal of therapy. Cognitive therapy does not, however, regard intellectual insight by itself as sufficient to bring about change, nor does it hold that all emotional distress is caused by dysfunctional thinking.

A related objection to cognitive therapy's approach to the emotions is that it encourages people to trivialize painful feelings or reinterpret them in inappropriately positive ways. One commentator refers to David Burns's popular book Feeling Good as an example of this reductionism, quoting Burns on the proper way to grieve for someone's death:

[Burns says] "You validly think 'I lost him (or her), and I will continue to miss the companionship and love we shared.' The feelings such a thought creates are tender, realistic and desirable. Your emotions will enhance your humanity . . . . In this way you gain from your loss."

My first thought on reading this was "Thank God I am not loved by David Burns." What about mourning? .... The new rush to "positivize" everything turns even death and mourning into a matter of gain.... David Burns' idealized mourner is a narcissist who is incapable of any deep feeling at all, or who has to distort emotion into a "desirable" channel before it can be felt.

Inadequate utilization of the therapist/patient relationship

A frequent criticism of cognitive therapy in its early years was that it neglected the therapeutic relationship as a locus of, or impetus for, change. Most researchers who took this position were either psychoanalysts or practitioners of psychodynamic therapy. Psychodynamic psychotherapy is itself a derivative of classical psychoanalysis and shares many of its presuppositions—specifically, that therapy works by bringing the patient's unconscious motivations into conscious awareness, by achieving insights into one's past, and by resolving emotional conflicts by working them through with the therapist. It is assumed that any relational problem the patient has with others will resurface in the therapeutic relationship, and will provide subject matter for reflection and behavioral change. The emergence and resolution of the so-called transference relationship is the centerpiece of psychoanalytically oriented therapies.

Beck's description of the patient's contribution to therapy as "raw data" has been criticized by followers of the psychoanalytic tradition as simplistic. They maintain that unconscious processes can shape the patient's presentation of the "raw data" of his or her experience. Since the rise of the integrative movement in psychotherapy, however, many cognitive therapists are more open to investigating the role of the unconscious in human experience and information processing.

Another factor that has led to a reappraisal of the therapeutic relationship in cognitive therapy is the extension of cognitive approaches to the treatment of the Axis II personality disorders. In contrast to Beck's straightforward statement in 1979 that cognitive therapists "do not make interpretations of unconscious factors" in therapy, the second edition of Cognitive Therapy of Personality Disorders makes explicit reference to the significance of the transference relationship: "The patient's emotional reactions to the process of therapy and the therapist are of central concern. Always alert but not provoking, the therapist is ready to explore these reactions for more information about the patient's system of thoughts and beliefs." It should be noted, however, that the reason given for exploring the transference is to strengthen the collaboration between patient and therapist rather than to provide insight or allow emotional release through the process of "working through" transference issues: "If not explored, possible distorted interpretations will persist and may interfere with collaboration." In addition, the book's extensive discussion of the therapeutic relationship is clearly concerned to avoid terminology associated with the psychoanalytic tradition: "To avoid confusion with psychodynamic assumptions and remain focused within the cognitive model, we refer to [transference and countertransference] simply as emotional reactions within the therapy process."

Reality-based depressions

One objection to Beck's theory of cognition is that people may be depressed without necessarily distorting reality. For example, a person who belongs to a socially marginalized group, or who has been severely disfigured in an accident, or has a physical handicap is not necessarily being illogical or irrational for feeling pessimistic about his or her future. In addition, some well-conducted studies have challenged Beck's hypothesis that depressed people are more prone to cognitive distortions that nondepressed people. In 1979, Lauren Alloy and Lyn Abramson of the State University of New York at Stony Brook performed a series of experiments that indicated that depressed subjects judged themselves and their circumstances more accurately than those who were not depressed. This postulate is sometimes known as depressive realism. Other studies carried out between 1979 and the mid-1990s also found that most people's self-understanding is not only inaccurate but skewed in an overly positive direction. In general, most people assume they have a greater degree of control over their lives than what reality warrants. A British critic of cognitive therapy has said

Aaron Beck's approach to depression assumes that far more control is possible; his "wrong thinkers" live in delusion as he sees it—and this may be his illusion.... [but] none of us cares to admit how little control we might really have over our own world. To see things too clearly may be terrifying.

Therapists from other schools argue that Beck tended to overlook the influence of environmental and family-based factors in depression, especially in his earlier work. In particular, therapists influenced by Virginia Satir or Murray Bowen's family systems theory often point out that many depressed people have one or more family members who are either unsympathetic to them, or seem to have a vested interest in maintaining the patient's depression. As the terms "identified patient" or "symptom bearer" suggest, the depressed individual may be carrying the burden of an extended family's collective dysfunction. Therapists who work out of a family systems orientation maintain that cognitive therapy for the identified patient does little long-term good if the patient must interact with others who tend to reinforce his or her distorted cognitions.

Beck began to reformulate his account of depression in the early 1980s to accommodate social factors. On the basis of work with outpatients in his clinic, he posited two major personality types with different vulnerabilities to depression, which he termed "sociotropy" and "autonomy." A sociotropic person, according to Beck, depends on harmonious social relationships for gratification, and is vulnerable to depression when significant relationships are lost or threatened. An autonomous person, on the other hand, has a strong need for achievement, desires freedom from control by others, and prefers solitude. This type of person is more likely to become depressed when he or she is frustrated or thwarted in attaining goals. Beck, however, incorporated this typology into his continuity hypothesis and asserted that these two categories represent the extremes of a continuum; they are not mutually exclusive.

Superficial view of major life changes

The short-term focus of cognitive therapy has led some observers to argue that its practitioners underestimate the hard work and suffering involved in major life changes. An example might be a junior college faculty member who recognizes that she is not going to get tenure in spite of an excellent record of publications and enthusiastic evaluations as a teacher. The external circumstances may include departmental politics, cutbacks in the number of tenured positions, older professors who do not wish to retire at the usual age, and many others. The instructor will have to make cognitive changes in the way she views herself, the world, and her place in it, but these changed cognitions are far more fundamental than correcting misperceptions or recognizing logical fallacies. In sum, major life transitions require more than merely cognitive alterations. As one of Beck's critics has put it, "Courage, endurance, and the acquisition of humility may [also] have something to do with making the needful changes."

In addition, cognitive changes themselves do not appear to be as straightforward and logical as Beck describes them. The creative processes in any human activity are still not amenable to scientific analysis. The junior faculty member in the example just given will have to work out a new way of understanding herself and her future, but she is not likely to arrive at this end by logic alone. Such qualities as imagination and faith are often involved in the complex and roundabout route that leads people to envision new possibilities for their futures. Profound changes in a person's life are not fully controlled by consciousness and rational will, nor are they always comfortable. Major life transitions require courage, as they can be intensely disturbing and frightening. It is commonplace in Twelve-Step group meetings that people often feel worse in early recovery than they did before entering the program. But there is little in the framework of cognitive therapy that allows for creative imagination in the process of change, or for fear and anxiety in the face of making the necessary changes.

Recent discoveries in cognitive science

Some observers note that discoveries about consciousness and the functioning of the human brain that were made in the 1980s and 1990s do not support Beck's notion of a close relationship between cognitions and emotions. The first such discovery was made in the course of so-called "split-brain" research. Split-brain research refers to studies carried out with epileptic subjects who have had a commissurotomy. In this procedure, the neurosurgeon cuts the corpus callosum, a band of tissue that carries nerve impulses between the two cerebral hemispheres, in order to control the patient's seizures. The researchers discovered that the human mind is not a unified entity, but consists of modules operating independently of one another. The parts of the brain that govern emotional states may have little to do with the parts that process information. What split-brain studies indicate is that consciousness cannot be an exact mirror of what is going on in the brain. Yet consciousness plays a central role in the theories underlying cognitive therapy.

Another area of research that raises questions about cognitive therapy is social psychologists' studies of cognition in relation to decision-making. Numerous experiments have shown that a person's explanation of how he or she came to a conclusion may be quite different from what was actually done. In addition, evidence has accumulated since the 1980s that there is no universal pattern of judgment and reasoning that holds true for all humans; rather, cultures play a role in shaping notions of cognition. These studies imply that cognitive therapy depends on a culturally limited view of reason and logic, and a correspondingly limited understanding of "dysfunctional thinking," rather than being based on a truly universal human characteristic.

THEORIES IN ACTION

Practice of cognitive therapy

Cognitive therapy is a highly structured form of short-term therapy. Practitioners who have been trained at the Beck Institute or have passed the certification examination of the Academy for Cognitive Therapy (ACT) follow a standard format for treatment, which will be outlined below. Standardization is an important feature of cognitive therapy, as Judith Beck explains:

A major goal of the cognitive therapist is to make the process of therapy understandable to both therapist and patient . . . [and] to do therapy as efficiently as possible. Adhering to a standard format (as well as teaching the tools of therapy to the patient) facilitates these objectives.

It is difficult, however, to estimate the actual number of therapists in North America and the United Kingdom who practice some form of cognitive therapy. As of late 2002 there were about 350 accredited cognitive therapists in the United States. Other practitioners are graduates of doctoral programs approved by the ACT (10 as of early 2004) or have trained at centers for cognitive therapy in New York, Atlanta, Cleveland, Huntington Beach, California, or Oxford, England, but have not yet taken the ACT's certification examination. Many therapists in the United States, however, practice "eclectic" or integrative therapy, using techniques derived from psychodynamic psychotherapy or other orientations as well as cognitive therapy. A survey published in a professional psychology journal in the early 1990s found that 68% of therapists surveyed identified themselves as "eclectic" therapists; 72% of these reported that they used a psychodynamic approach in their work, as compared with only 54% who made use of cognitive therapy. Therapists who described themselves as following one approach exclusively included 17% who practiced psychodynamic therapy and 5% who solely practiced cognitive therapy.

In terms of recognition by the medical specialty of psychiatry, however, cognitive therapy is now a required part of residency training. As of 2003, the Residency Review Committee for Psychiatry of the Accreditation Council on Graduate Medical Education (ACGME) mandated that all psychiatric residents be required to demonstrate competency in the practice of cognitive behavior therapy.

Preparation Practitioners of cognitive therapy are expected to gather as much information about the patient as possible prior to the initial interview, in order to make the most of the available number of sessions. The patient will ordinarily have had a thorough diagnostic examination to determine how the standard format of cognitive therapy should be adjusted for the patient. Most cognitive therapists will also ask the patient to complete the Beck Depression Inventory, revised version (BDI-II), the Beck Anxiety Inventory (BAI), and the Beck Hopelessness Scale (BHS) before the initial interview in order to obtain baseline scores on these instruments. The therapist then studies the patient's history, symptoms, level of current functioning, and presenting complaints in order to draw up a general plan for treatment and make a tentative conceptualization of the patient's problems. This cognitive case conceptualization is regarded as a critical and necessary blueprint for the therapist's interventions.

Initial interview Cognitive therapists cover a great deal of ground in the initial interview with the patient. Judith Beck lists the following as the therapist's objectives for this session: establishing rapport with the patient and gaining his or her trust; instructing the patient about the purpose and methods of cognitive therapy; teaching the patient about his or her specific disorder from the perspective of the cognitive model; reassuring the patient about the normality of his or her difficulties and "instilling hope"; discussing the patient's expectations of therapy and correcting them if necessary; gathering additional information about the patient's problems; and drawing up a list of goals for the treatment.

To meet these objectives, the cognitive therapist will set an agenda for the session; perform a mood check, which is usually done by administering the BDI; review the presenting problem with the patient and obtain an update covering the time period since the initial evaluation; educate the patient about cognitive therapy and his or her diagnosis; assign homework for the next session; summarize the session; and ask the patient for feedback. If the use of medications and/or substance abuse are issues for the patient, these are also placed on the agenda of the initial session.

Basic components of a cognitive therapy session Later sessions are based on the following structure:

• Brief update. This part of the session allows the patient to discuss significant events and his or her reactions to them since the previous session.
• Bridge from previous session. Here the therapist draws connections between the work of the previous session and the patient's present feelings or thoughts.
• Setting an agenda. Both the therapist and the patient contribute items for discussion during the session. Agenda-setting is done in order to cut down on the amount of unproductive conversation during sessions and help both parties focus on the patient's core issues. A typical agenda might include four or five items, such as "review the patient's activity schedule"; "begin to demonstrate relationship between thinking, behavior and affect by using specific experiences of patient"; "discuss the booklet on depression that was given to the patient to read at home"; and similar items.
• Homework review. As was mentioned earlier, homework is an integral part of cognitive therapy. Patients who associate the term with unpleasant school experiences may prefer to call these activities "self-help work." As with agenda setting, therapist and patient arrive at the list of items jointly. Bibliotherapy, usually a book on cognitive therapy written for the general public; monitoring one's activities; and keeping a record of mood changes and accompanying thoughts or images are common homework assignments. The therapist's primary concern is helping the patient to experience success by choosing activities that will increase his or her sense of mastery or satisfaction. Homework review allows the therapist to monitor and evaluate the patient's successes or failures—including feelings of success or failure, which may or may not be appropriate to the patient's actual accomplishments.
• Discussion of goals or target issue(s). Because cognitive therapy is a time-limited approach, clear focus is an essential aspect of the treatment plan. Therapist and patient together agree on a list of "core" or "target" symptoms that can be addressed over the course of a limited number of sessions. The symptoms that are targeted usually fall into one of two categories: those that the patient considers most distressing, and those that can be effectively treated. The symptoms may be emotional, motivational, physiological, cognitive, or a mixture of these. With regard to goal setting, patients are taught to think in terms of specific changes that can be described in behavioral terms ("keeping up with course work in school" or "planning more outings with my spouse") rather than vague generalities ("feeling better" or "feeling happier").
• New homework.
• Summary and feedback. At the end of each session the therapist summarizes what has happened during the session and asks the patient for feedback. Feedback serves several purposes: it reinforces the patient's role as an active participant in the work of therapy; it strengthens the rapport between the patient and the therapist; and it allows the patient to correct any misunderstandings or misinterpretations on the therapist's part. Some cognitive therapists provide their patients with written forms to fill out in the waiting room after the session.

Number and spacing of treatment sessions A typical course of cognitive therapy ranges between six weeks and four months in length, although patients with personality disorders or other severe psychological problems may remain in treatment for a year or longer. With the exception of severely depressed or suicidal individuals who need more frequent support, patient and therapist meet on a weekly basis until the patient begins to feel measurably better. At that point, the sessions are spaced further apart, once every two weeks and then once every three or four weeks toward the end of treatment. Judith Beck gives eight to 14 as an average total number of sessions, although her father's earlier publications mention an average of 20 to 22 sessions. Decisions about the spacing of sessions are made jointly by the therapist and the patient. The rationale behind less frequent sessions is that it provides the patient with more opportunities to solve problems alone and tests the growing ability to be his or her own therapist. After termination, patients are encouraged to return for "booster" sessions two or three times a year.

Medication A pamphlet published by the Beck Institute notes that some patients improve more rapidly with combination therapy, and that a consultation with a psychopharmacologist is often advisable to make sure that the patient is taking the right type and dosage of medication.

Training in cognitive therapy

Training in cognitive therapy is available to students in graduate programs in social work, clinical psychology, and psychiatric nursing as well as for medical students and practicing psychiatrists. About 20 of the 197 accredited programs in clinical psychology in the United States offer coursework in cognitive therapy.

The Beck Institute The Beck Institute, which was founded in 1994 and is presently directed by Judith Beck, offers a range of training programs and workshops for mental health professionals, as well as a speakers' bureau and videoconferences. An extramural distance learning program is available for clinicians working outside North America. Books, audiotapes, and other multimedia presentations on cognitive therapy can also be ordered through the Institute.

Professional organizations The Academy of Cognitive Therapy (ACT) was established in 1999 after a three-year process of consultation that involved the directors of 36 different training programs in cognitive therapy. The establishment of the academy was considered necessary to maintain a distinctive identity for cognitive therapy and to provide certification for qualified practitioners. The ACT's Web site states that

There has been confusion in the distinction between psychotherapy which incorporates some cognitive techniques, and cognitive therapy which is based on a cognitive conceptualization. Many therapists identify themselves as cognitive therapists when their practice does not reflect such an orientation. Consumers, agencies, insurance companies, and researchers may be misled by this self-appellation.

Research

Effectiveness of cognitive therapy Beck's research orientation is reflected in the fact that cognitive therapy is commonly regarded as "the most rigorously studied kind of talk therapy," according to one report. As of late 2002, cognitive therapy had been evaluated in at least 325 clinical trials. The Beck Institute conducts ongoing research projects, its most recent being an examination of the effects of stress reactivity and coping style on depressed patients being treated with cognitive therapy.

Judith Beck and one of her associates at the Beck Institute published a study in 2000 of 14 meta-analyses of the effectiveness of cognitive therapy. Their findings may be briefly summarized as follows:

• Comparison of cognitive therapy with antidepressant medications. Cognitive therapy was found to be somewhat superior to medications in the treatment of unipolar depression in adults. Follow-up studies a year after the end of treatment indicated, however, that only 30% of the patients treated with cognitive therapy had suffered relapses, compared to 60% of the patients who had been given antidepressants.
• Comparison with supportive or nondirective talk therapies. This category included two studies of adolescent depression and two of generalized anxiety disorder (GAD). Cognitive therapy was found to be "moderately superior" to supportive psychotherapies.
• Comparison with behavior therapy. Cognitive therapy was found to be equally effective as behavior therapy in treating adult patients diagnosed with depression or obsessive-compulsive disorder (OCD).
• Other studies. Cognitive therapy was found to be "somewhat superior" to other psychotherapies in treating sexual offenders. It was also found to be effective in treating patients with bulimia nervosa.

Critics of cognitive therapy maintain, however, that much of the research regarding the efficacy of cognitive therapy is not of the highest quality. James C. Coyne, a psychologist at the University of Pennsylvania who specializes in studying anxiety disorders and depression in cancer patients, stated as early as 1989 that ". . . in the large body of research that [cognitive therapy] has generated, the measurements that have been made have typically been crude, confounded, and incapable of supporting precise distinctions between possible cognitive concepts." As was mentioned earlier, the NIMH multi-site study done in the 1980s did not find any significant differences in recovery rates among patients treated with a tricyclic antidepressant (imipramine), a placebo, cognitive therapy, or interpersonal psychotherapy—although the findings were attributed in part to site differences.

In addition, some of Beck's early hypotheses have not been borne out by subsequent research. These include the notion that depressive thinking is per se irrational; that there is such a thing as cognitive vulnerability to depression; and the concept of the cognitive triad. With regard to the cognitive triad, Beck initially proposed that the interlocking schemas incorporating negative beliefs about the self, the world, and one's future are stable traits. Research indicates, however, that these schemas fluctuate with the patient's moods. Moreover, some researchers maintain that the notion of a triad is itself somewhat arbitrary, that Beck's model really has only two components—the self in relation to the patient's personal world, rather than the world in general, and the self in relation to the future.

The STAR*D study The Sequenced Treatment Alternatives to Relieve Depression study, or STAR*D, is a five-year research study of treatment alternatives for depression funded by the NIMH. STAR*D began in October 1999 and will conclude in September 2004. The study's findings are scheduled for publication in 2006. STAR*D has five major objectives:

• Determine the best next step in treating depressed patients who fail to respond to previous therapies.
• Compare the relative effectiveness and patients' acceptance of different treatments.
• Evaluate the long-term benefits of successful treatments.
• Compare the side effects and economic costs of different treatments.
• Determine the predictors of a given patient's response to specific treatments.

The STAR*D protocol published in 2001 noted that research has not yet established the proper place of psychotherapy in the care of patients diagnosed with major depression. Cognitive therapy, however, is the only form of psychotherapy included in the STAR*D study. It will be evaluated as a Level 2 treatment, either as the patient's sole form of treatment or in combination with citalopram (Celexa), a selective serotonin reuptake inhibitor. (All patients enrolled in STAR*D receive citalopram at Level 1 and are then switched to a different antidepressant medication, cognitive therapy, or citalopram plus one of the other therapies at Level 2.) According to the protocol, the study's selection of cognitive therapy as the sole form of psychotherapy to be compared with pharmacotherapy is its "substantial evidence of efficacy in RCTs [randomized controlled trials] for depression." It should be noted that one of STAR*D's principal investigators, A. John Rush, completed a residency in psychiatry at the University of Pennsylvania under Aaron Beck in 1975, and is listed as one of Beck's coauthors for Cognitive Therapy of Depression.

Suicidology One major area of research opened up by Beck's work on depression is suicidology. Beck's work has led to a standardization of the terminology for suicidal behavior, and his scales for the assessment of depression, hopelessness, and the risk of suicide (the Beck Scale for Suicide Ideation, or BSS) are widely used in clinical and research settings. In line with his general continuity hypothesis, Beck regards the risk of suicide as existing along a continuum ranging from occasional fleeting thoughts of "ending it all" to openly self-harmful behavior. Beck helped to establish hopelessness as the most important variable in predicting suicidal behavior; a cutoff score of nine on his Hopelessness Scale is considered predictive of the patient's eventual suicide.

Beck presented findings from 30 years of suicide research at a workshop sponsored by the Institute of Medicine (IOM) in 2001, including data from an ongoing prospective study of suicide prevention at the University of Pennsylvania. One significant finding concerned the fact that suicidal behaviors vary markedly across psychiatric diagnoses, particularly in patients diagnosed with Axis II personality disorders. A study of patients admitted to hospital emergency rooms in Philadelphia following a suicide attempt reported that 8.2% of the patients diagnosed with borderline personality disorder (BPD) committed suicide during a five-year period of follow-up, compared with 4.6% in patients diagnosed with major depression without a personality disorder. In addition to Beck's research group at Penn, a team of researchers at Vanderbilt University reported on the effectiveness of cognitive therapy in reducing the risk of suicide at the annual meeting of the American Psychiatric Association in the summer of 2002.

Case studies

The case studies that follow illustrate both the broad application of the principles underlying cognitive therapy and their accommodation to different DSM-IV diagnoses.

Cognitive therapy in treating depression Beck's Cognitive Therapy of Depression presents a summary of a typical course of cognitive therapy requiring 22 sessions to treat depression in a 36-year-old homemaker, married for 15 years to a sales manager for an automotive supply company. The couple had three children ranging in age from seven to 14. Two previous courses of therapy (marital therapy and treatment with antidepressants) had been ineffective. The patient's initial score on the BDI was 41. Prior to the first meeting, the therapist mailed the patient a copy of the booklet Coping with Depression, and asked her to read it before beginning therapy.

The first session was devoted to a review of the patient's specific symptoms of depression, with a focus on motivational and behavioral problems. The patient had mentioned suicide as a way to "unburden" her family, and had described herself as a "total failure" as a wife and mother. The therapist noted, however, that the patient felt the booklet had given her hope, and judged that she was not at great risk for suicide. The patient's initial homework consisted of filling out a life history questionnaire and keeping a log of her activities at home. This schedule was intended to provide the therapist with a baseline measurement of the patient's activity level as well as to give the patient a sense of mastery and accomplishment.

In sessions two and three, the therapist reviewed the patient's activity log with her, checking for indications of omissions or distortions. Since the patient appeared to keep relatively busy during the day, the therapist changed her homework to recording cognitions in sessions four and five, particularly cognitions associated with unpleasant feelings. Many of the patient's feelings of sadness, anger, or guilt were related to the thought, "I am an incompetent mother." The therapist discussed common themes in the patient's cognitions related to her husband in session five. She was convinced at that point that he would eventually abandon her because of her depression. In sessions six through eight, the therapist worked with the patient to focus her expectations of therapy. She had difficulty defining reasonable goals, speaking in vague generalities about being a "better wife and mother." An interview with the husband during these three sessions indicated that he genuinely cared for his wife, which helped the patient to recognize that she was misinterpreting the real situation. Homework for sessions five through eight consisted of an ongoing record of negative, automatic thoughts.

As the patient's symptoms began to lift, the therapist redirected the focus of the sessions toward recognizing and challenging the contents of and patterns in her cognitions. She began to work on her patterns of self-criticism and the assumptions underlying them. She came to recognize that she tended to think in terms of what she "should" do to please others rather than on what she "wanted" to do. Homework for these sessions included listing her "wants," particularly future goals. By session 14, her score on the BDI had dropped to 17. She started thinking about returning to work on a part-time basis. During session 16, the therapist detected the possibility that the patient might relapse. Her parents had visited, and she had noticed that her mother was quite critical of her father. The patient clearly regarded herself as being responsible for her father's well-being. She wondered whether she should take a job after all and was returning to her old dysfunctional thought patterns. The therapist made two important interventions at this point. One involved a review of the similarities between the patient's reaction to her parents' visit and her past thought patterns. The patient herself was able to see that she was "following the old pattern." The second intervention was another interview with the husband, who stated that he liked his wife's "new self" much better than the old one. This information strengthened the patient's motivation to continue with her new course of action. Her homework consisted of discussing her goals in greater detail with her husband.

Sessions 20 through 22 consisted of consolidating the gains of the previous sessions. The patient did in fact take a part-time job, and began to enjoy it after she worked through some initial anxiety. Follow-up sessions took place one, two, and six months after the termination of therapy. At the six-month follow-up, the patient's score on the BDI had fallen to 2, and she regarded herself as happier and more confident.

Cognitive therapy in treating wife battering Beck discusses the case of R, whom he describes as "a typical wife batterer," in Prisoners of Hate. R was abused by his parents in his childhood and teased by other boys in his peer group. He viewed the world as "filled with antagonistic people lying in wait for an opportunity to pounce on him." Although R had a comfortable relationship with his wife most of the time, any criticism from her or pressure to do chores around the house would activate his dysfunctional beliefs—that mild pressure from her meant total domination, and that criticism meant rejection—and he reacted with violence. Beck describes a typical incident. R's wife asked him to fix a leaky faucet. He replied, "Get off my back!" She then said, "I would if you'd act like the man of the house." R retorted, "I'll show you what a man is," and hit her in the mouth. After an attack of this sort, R was puzzled by and ashamed of its intensity. Therapy consisted of helping R recognize the beliefs that triggered his attacks.

Beck's treatment of R included asking him to look at the meanings he attached to his wife's remarks. The specific techniques included applying rules of evidence to the wife's behavior (was she invariably disrespectful of R?), considering other explanations for her behavior (might she be simply losing patience when he procrastinated?), examining his beliefs about the world, and modifying unrealistic expectations of others. In addition, Beck used guided imagery to lower R's distress level. He asked R to visualize his wife when she criticized him. R reported that he saw himself "shrink in size, with a scared look on his face." He saw his wife, on the other hand, grow taller and larger, and become very menacing. Beck then asked R to replace this intimidating image of his wife with a less threatening picture of her. R was then able to "reflect that she was not his enemy but was simply upset by his procrastination."

CHRONOLOGY

1921: Aaron Beck born in Providence, Rhode Island.

1938: Graduates from high school and enters Brown University.

1946: Graduates with a medical degree from Yale University.

1951: Korean War breaks out. Beck takes a position at Valley Forge Field Hospital and treats soldiers with post-traumatic stress disorder.

1954: Joins the Department of Psychiatry of the University of Pennsylvania.

1974: Publishes The Prediction of Suicide.

1988: Publishes Love is Never Enough.

1992: Retires from activing teaching at the University of Pennsylvania.

2004: Publishes Cognitive Therapy of Personal Disorders, second edition.

A third technique that Beck used during R's treatment was to substitute more adaptive beliefs in place of the old dysfunctional thoughts. R had already recognized that hitting his wife was not only a way to punish her, but also improved his mood temporarily by bolstering his shaky self-esteem. Beck then discussed "the value of violence as a mood-normalizer" with R. He asked the patient whether he was more of a man by hitting a smaller person, or "by being cool, taking insults without flinching and maintaining control of himself and the problematic situation." The patient was intrigued by this interpretation; he worked at changing his underlying belief from "A man doesn't take any crap from his wife" to "A man can take the crap without allowing it to get to him."

BIOGRAPHY:

David H. Barlow

As of 2004, David H. Barlow was Professor of Psychology and Research Professor of Psychiatry at Boston University as well as director of the university's Center for Anxiety and Related Disorders. Barlow is best known for his work in applying cognitive behavior therapy to anxiety disorders and sexual dysfunction. He has also published in the field of clinical research methodology. He is presently the editor of the journal Clinical Psychology: Science and Practice. Barlow's work in the treatment of anxiety disorders led to his selection as a member of the DSMIV Task Force and co-chair of the working group for revising the anxiety disorders categories.

Barlow describes anxiety as "a unique, coherent cognitive-affective construct within a defensive motivational system." At the core of the cognitive construct is "a sense of uncontrollability focused largely on possible future threat." Barlow bases his definition of anxiety as "loss of control over potentially challenging or threatening events" on his findings from research into sexual dysfunction over the past two decades. Once a person has become anxious, Barlow holds, his or her cognitions change, moving rapidly from appraisal of the threatening situation to assessments of one's ability to deal with the threat. As the anxiety level rises, further changes in the person's cognition become apparent, ranging from a narrowed focus of attention to interpretative bias in evaluating incoming information.

Since 1988, Barlow has worked out a "triple vulnerabilities" model to explain the development of anxiety disorders. The first area of vulnerability is a generalized biological vulnerability. The second is generalized psychological vulnerability related to early learning experiences of uncontrollability and unpredictability. These experiences help to form a cognitive "template" that increases the impact of later stressful events in the person's life. The third factor is a specific psychological vulnerability that focuses the person's anxiety on a specific object or event.

The most controversial part of Barlow's work, however, is not a theoretical but a clinical claim—that he can cure people suffering from anxiety disorders by forcing them to confront their terrors over a 10- to 12-week period. At the Center for Anxiety and Related Disorders, Barlow typically treats patients by not only exposing them to the stimulus that makes them anxious, but increasing the anxiety level until they have proved to themselves that they can survive the emotional experience of terror. His basic hypothesis is that the patient's problem is not the pain itself but his or her relationship to the pain. By accepting and even seeking out anxiety or depression, Barlow holds, the patient disarms his or her problem. One of Barlow's patients was a claustrophobic businessman who was assigned "homework" that involved shutting himself in a small space for as long as he could tolerate the anxiety. The man decided to lock himself in the trunk of his car. The first time, he had to leave after three minutes, but eventually worked up to spending half an hour in the trunk. At that point, he reported that he felt "bored." Although Barlow maintains that 85% of his patients are cured of their anxiety, some critics argue that his treatment is superficial and worse yet, it amounts to emotional torture.

By the time R left therapy, Beck had given him three specific methods he could use to control his violent impulses: the first was to leave the room for a "time out"; the second was to visualize his wife as vulnerable and upset rather than hostile and threatening; and the third was to remind himself that the way to "feel like a man" is to be calm and masterful when provoked.

Relevance to modern readers People diagnosed with a mental disorder are increasingly likely to be treated with some form of cognitive therapy—whether their specific problem is an eating disorder, substance abuse, an anxiety disorder, or a personality disorder. This likelihood is particularly high if they are diagnosed with depression; as we have seen, cognitive therapy is the only form of nonpharmacological treatment used in the ongoing NIMH STAR*D study of depression. The popular appeal and widespread use of cognitive therapy, however, are due only in part to economic and public policy considerations.

In addition, cognitive therapy has become a part of the intellectual backdrop of popular culture in the early twenty-first century. It is noteworthy that many current talk-show therapists and writers of self-help books put cognitive issues at the center of their work, even though they may differ from one another in other ways. For example, Nathaniel Branden's books on self-esteem all make the basic point that greater self-awareness—what Beck would call uncovering automatic thoughts—is a necessary step in building self-esteem. Phil McGraw's best-sellers are based on the notion that distorted perceptions and internal "filters" of experience require correction if people are to improve their "self-concepts." Much of what McGraw calls "labels" and "tapes" would be called automatic thoughts in Beck's terminology. Lastly, the emergence of philosophical counseling, which is a controversial descendant of Beck and Ellis's work, is associated with the notion that clearer thinking by itself can help people to turn their lives around.

BIBLIOGRAPHY

Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 2000.

Baumeister, Roy F. Evil: Inside Human Violence and Cruelty. 2nd ed. Foreword by Aaron T. Beck. New York: W. H. Freeman and Company, 1999.

Beck, Aaron T. Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1967.

Beck, Aaron T. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.

Beck, Aaron T., Arthur Freeman, Denise D. Davis, et al. Cognitive Therapy of Personality Disorders, 2nd ed. New York: The Guilford Press, 2004.

Beck, Aaron T., M. Kovacs, and A. Weissman. "Hopelessness and Suicidal Behavior: An Overview." Journal of the American Medical Association 234 (December 1975): 1146–149.

Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. Cognitive Therapy of Depression. New York: The Guilford Press, 1979.

Beck, Aaron T., and Marjorie E. Weishaar. "Suicide Risk Assessment and Prediction." Crisis 11 (November 1990): 22–30.

Beck, Judith S., Ph D Cognitive Therapy: Basics and Beyond. New York: Guilford Press, 1995.

Beck, Judith S., and Andrew C. Butler. "Cognitive Therapy Outcomes: A Review of Meta-Analyses." Journal of the Norwegian Psychological Association 37 (2000): 1–9.

Bienefeld, David, MD. "Personality Disorders." eMedicine, 30 December 2003. <http://www.emedicine.com/med/topic3472.htm>.

Branden, Nathaniel. How to Raise Your Self-Esteem. New York: Bantam Books, 1988.

Coyne, James C. "Thinking Postcognitively About Depression." In Arthur Freeman, et al., eds., Comprehensive Handbook of Cognitive Therapy. Cambridge, MA: Perseus Publishing, 1989.

Fancher, Robert T. Cultures of Healing: Correcting the Image of American Mental Health Care. New York: W. H. Freeman and Company, 1997.

Goldsmith, Sara K. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: Institute of Medicine and the National Academy Press, 2001.

Hazleton, Lesley. The Right to Feel Bad: Coming to Terms with Normal Depression. New York: Ballantine Books, 1984.

Holmes, Jeremy. "All You Need Is Cognitive Behaviour Therapy?" British Medical Journal 324 (2 February 2002): 288–94.

Leahy, Robert L., ed. Practicing Cognitive Therapy: A Guide to Interventions, 2nd ed. Northvale, NJ: Jason Aronson, 2001.

Mahoney, Michael J. Constructive Psychotherapy: A Practical Guide. New York: Guilford Press, 2003.

McGraw, Phillip C. Self Matters. New York: Simon & Schuster, Inc., 2001.

National Institute of Mental Health (NIMH). Challenges in Preventing Relapse in Major Depression. Bethesda, MD: NIMH, 2001.

National Institute of Mental Health (NIMH). Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study Protocol. Bethesda, MD: NIMH, 2001.

Needleman, Lawrence D. Cognitive Case Conceptualization: A Guidebook for Practitioners. New York: Lawrence Erlbaum Associates, 1999.

Plakun, Eric M. "Treatment of Personality Disorders in an Era of Limited Resources." Psychiatric Services 47 (February 1996): 128–30.

Rush, John A., Madhukar Trivedi, and Maurizio Fava. "STAR*D Treatment Trial for Depression." American Journal of Psychiatry 160 (February 2003): 237.

Scott, Jan, and Edward Watkins. "Brief Psychotherapies for Depression: Current Status." Current Opinion in Psychiatry 17 (2004): 3–7.

Seligman, Martin E. P. Learned Optimism. New York: Simon & Schuster, Inc., 1990.

Steigerwald, F., and D. Stone. "Cognitive Restructuring and the 12-Step Program of Alcoholics Anonymous." Journal of Substance Abuse Treatment 16 (June 1999): 321–27.

Sudak, D. M., J. S. Beck, and J. Wright. "Cognitive Behavioral Therapy: A Blueprint for Attaining and Assessing Psychiatry Resident Competency." Academic Psychiatry 27 (Fall 2003): 154–59.

Wahl, Otto F. Telling Is Risky Business: Mental Health Consumers Confront Stigma. New Brunswick, NJ: Rutgers University Press, 1999.

Weishaar, Marjorie. Aaron T. Beck. Thousand Oaks, CA: Sage Publications, 1993.

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Further readings

Barlow, David H. "The Nature and Development of Anxiety and Its Disorders: Triple Vulnerability Theory." Eye on Psi Chi 7 (Winter 2003): 14–20.

Beck, Aaron T. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.

Beck, Aaron T. Love Is Never Enough. New York: Harper & Row, 1988.

Burns, David D., MD. Feeling Good: The New Mood Therapy. Preface by Aaron T. Beck. New York: Signet Books, 1980.

Burns, David D., MD. The Feeling Good Handbook. New York: Plume/Penguin Books, 1990.

Duane, Daniel. "The Socratic Shrink." New York Times Magazine (21 March 2004): 36–40.

Ellis, Albert. Reason and Emotion in Psychotherapy. Secaucus, NJ: Lyle Stuart, 1962.

Simon, Cecilia Capuzzi. "A Change of Mind." Washington Post (3 September 2002): HE01.

Slater, Lauren. "The Cruelest Cure." New York Times Magazine (2 November 2003): 34–40.