American Psychological Association

111th Convention
Toronto, August 7-10 2003

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Photo by Fenichel: Aaron T.Beck, 7 August 2003

Getting it Right -- Legend Aaron T. Beck in Conversation with Frank Farley

This event was actually titled "Getting It Right -- Legends Albert Ellis (90) and Aaron T. Beck (82)". However, due to illness, Ellis could not be with us. Nevertheless, Beck - legendary pioneer in cognitive therapy for depression, and recently active in cognitive treatment of other serious disorders -- was there, and the audience was treated to a more in-depth Q&A with Beck than expected. After several questions by long-time moderator Frank Farley, Beck, who had been prepared to answer questions from Ellis and Farley, asked now if he could take questions directly from the audience. He got some excellent questions, diverse and often difficult. Beck unflinchingly complimented each question and proceeded to demonstrate a wide breadth of knowledge about a full spectrum of theories and approaches to treatment.

Before the presentation began, the audience was told about Ellis' health situation and how the discussion would proceed in his absence. Dr. Beck began by graciously acknowledging Ellis as "a major pioneer in the field of psychotherapy, a David who went out to slay Goliath; he gave no quarter". [Non Americans: "give no quarter" is an idiom meaning he remained 100% firm in what he said, never backing off...]

Questioning began with a request for Dr. Beck to say a few words about his thinking on terrorism, a big topic now and the subject of a new book by Beck.

"I've seen the dynamics of couples who hate each other and observed how they feel vulnerable, victimized.... Both people feel this..... Caesar said the same thing [and] similarly with terrorists, the only way they can defend their ideals is to attack first."

[Anyone else see a great similarity between his observation and that of Robert Sternberg?]

The next question was about cognitive therapy as a treatment technique for schizophrenia. Beck notes that his preliminary work and that which he's seen elsewhere, such as a major work in the U.K., has been "very exciting.... the addition of cognitive approaches to standard treatment manages to take the patient one whole step higher" according to outcome analysis. For example, cognitive therapy, for someone with "some functioning but with delusions or hallucinations... it can help attenuate" the symptoms. If someone has "only negative symptoms" such as listlessness, "it helps too".

Now it was time, at Beck's request, to hear from the audience.

Beck, who is an MD, was asked how he understands the brain physiology and how he thinks his verbally mediated treatments affect the brain as opposed to say, pharmacotherapy alone. Beck replied that "the physiological, neurochemical changes are the same with cognitive therapy versus pharmacotherapy. However, the *root* was different. To simplify, with pharmacotherapy it's subcortical but with cognitive therapy it's via the frontal lobes. But [the changes, despite the root] ended up in the same areas."

Asked next about treatment of Borderline Personality Disorder, which is commonly considered one of the more difficult therapeutic endeavors, Beck replied that in his experience, "each of our disorders has a particular paradigm or profile. With borderlines , based on in-depth analysis, we see acting out a great a deal, being destructive, and doing damage to things important in their lives." He sees the dynamic as often entailing a viscious cycle of stress leading to self-defeating behavior. "If the stress is great, perhaps it will lead to suicide. If feeling put upon, perhaps they will attack". The cognitive style is characterized by a "certain extreme ways of thinking" and a "dichotomous way of carving up their own lives and those of others, while seeing situations through black and white lenses. Everything is extreme, with at least one crisis every day. Like terrorists, they're all good and others are all bad-- but they can be the opposite too. They're all bad and others are all good." This can lead at worst to "slit wrists" but also, in everyday life, difficulties with "affect control and impulse control".

Beck described the underlying beliefs which are at the core of many problems. He referred to...

The 3 Attitudes:

1. "If I feel something strongly I should express it"
2. " I feel I shouldn't express myself but I have to" and
3. "If I express myself people will listen to me"

He might focus on this triad and has seen some successful treatments which entail a sort of "re-parenting" whereby discussion of these reactions might be underpinnings.

Beck answered some questions about Rogers (a "benign figure") and recalled that Ellis had ridiculed him once for being that benign figure during a session, someone who listens quietly and then returns the client to the same $!%# situation at home or work.

The next question came from someone who said that after studying Beck's work for years, and the work of Ellis, he's concluded that "Ellis talks a lot about must-erbation being the rock-bottom dynamic" which drives dysfunctional behavior. Beck recalled that "years ago Ellis wrote in a book that MUSTerbation causes mental problems", but the proofreader caught the "error" and corrected it, with the resulting statement not at all what Ellis intended. Beck went on to point out that the whole concept truly dates to Karen Horney's "Tyranny of the Shoulds" (one of my most profound influences, too!). "I should do this and others should do that... and they're tyrannized!" Beck noted that "shoulds are not inherently bad. We should get up in the morning, for example. But...we need to focus on rigid thinking with *dysfunctional* shoulds". As opposed to Horney or Ellis, for himself Beck said that "our rock-bottom is *fear*. 'I must avoid this'.... With borderlines, they feel very vulnerable so they have a whole series of demands on other people. As a way of protecting themselves." He said he's known patients who have made a point of counting and cataloging a long list of "shoulds".

Question: What about outcome research suggesting a role for the therapeutic relationship?

Answer: The relationship is *obviously* important. It gets lost in the cognitive approach. When I wrote my first book, the very first chapter was 'The Therapeutic Relationship'. A sense of affiliation has been worked out as very important. But where does it come in? Do I need to prove how wonderful I am or is it a technical problem? One study demonstrated the positive regard did not come in until *after* the technique. Or in other words, after the patient begins to feel better and see the therapy is working, they begin to feel better and to feel better about the therapist."

Question: Any long-term studies? How are the results?

Answer:"With pharmacotherapy sometimes very good, but with cognitive therapy, for example with depression, the relapse rate is lower. With schiziphrenia too, if in combination with pharmacotherapy." A five year study at his Center found continued improved functioning at 5-years follow up, which is a "very strong track record".

Question: Any thoughts on the role of "mindfulness" as it impacts on treatment?

Answer: Based on research it does have an important role and it may even be that meditation, in general, does. We need to do a controlled study", one group receiving mindfulness training and teaching to "decenter", and compare it with a control group.

A question was posed: Noting that Ellis tends to deal with surface cognitions while Beck tends to go deeper, how might Beck deal with a client's consciousness of splitting, aside from addressing the "victim" aspects. For example, DBT [See http://www.fenichel.com/behavior.shtml for a basic primer] as I now understand it, looks at the issues of control but also tries to teach skills to see how everything is *not* black and white, and that sometimes there are middle shades which can be stress-reducing and acceptable. [My question, and happy he said it was a good one!] :-)

Beck noted that "the Borderline can switch momentarily" so a careful approach is required. One approach which in fact Ellis might use is to "dimensionalize", to make something more dimensional than a simple good/bad judgement. For example, "I'm a terrible mother because I forgot to give my child lunch today. I deserve to die". OK, maybe "I'd say, on a scale of 100, where are you" in terms of being terrible. She'd say 100. So then he'd ask, "What then would you be if you cut off your child's arms and legs?" The hope is to force some "dimensionalizing", teaching her to "think dimensionally rather than categorically". Beck added that he might also offer an alternative conclusion rather than the mother being terrible and deserving to die. "Maybe I just forgot" to pack lunch on that day.

Question: How have cognitive approaches worked with pain management?

Answer: "Let's say someone thinks (1) 'I have a terrible back ache. I can't work on the yard.' The more thinking about it, the more pain. The next step is (2) thinking 'I'm a bad husband'. Finally this escalates to (3) 'I'm a bad husband and I can't do *anything*, I'm no good.' And then often this person begins exclusively focusing on pain." He is exploring this and currently co-authoring a book about this.

Question:Will we have an integrated therapy in the future or is cognitive therapy going to be the therapy of choice?

Answer: I once wrote an article, "Cognitive Therapy: The Integrative Model". Where therapies won't meet is in the theory. If we have the notion that the world is round and others say it's flat, one result can be compromise: The world is oblong.

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And that was that, Aaron Beck at the 111th APA convention, taking questions solo, while several times acknowledging Ellis too.

Coming soon: Cyberslacking (Young, Greenfield, Davis, Mastrangelo)

Regards from Toronto! An exciting place to be.
:-)

Michael