American Psychological Association
123rd Annual Convention
Toronto, Ontario (CA), August 7-10 2015
Aaron T. Beck at 94
Conversation with Dr. Aaron T. Beck: 6 Aug 2015, APA Convention (Toronto)
Today at the Toronto Convention Centre, a huge ballroom was standing room only, as psychologists and students gathered to see and hear the legendary Aaron T. Beck. Dr. Beck is regarded as one of the most powerful influences in psychiatry/psychology and is is widely seen as the 'father of cognitive therapy'. Famed for his trail-blazing work in the assessment and treatment of depression, recently he has extended his treatment to some of the most difficult-to-treat populations, adopting and modifying treatment techniques which have proven successful in the treatment of schizophrenia. Beck -- see the report from 2014 where he expands on this -- sees value in many 'brands' of cognitively-based treatments, such as DBT and ACT. He encourages the use of an expanded tool kit of techniques. Both a pragmatist and a dedicated scientist-practitioner, Beck continues to push into new frontiers and exudes excitement and optimism about each new advance or revelation. That said, as context - here is today's discussion with Aaron T. Beck.
Dr. Farley said hello to the audience and to Dr Beck. Beck thanked everyone for coming, and apologized that he could not attend in person, adding that he's always enjoyed doing so, but he assured the audience that he hears the moderator and audience well, thanks to technology, and he was able to easily distinguish things like applause or laughter. With that the audience applauded loudly, mixed with some laughter as well, to which Beck responded, 'Great!'.
Frank Farley introduced Beck as a legend and a pioneer who some consider 'the Freud of our times'. He then
asked Beck if it's true he has recently turned 94. With a big grin, Beck replied, "that's right! I just made it.". [Applause]
Cognitive Therapy and Schizophrenia
Beck, who last year described feeling quite energized about this new direction in treating schizophrenia, was asked if he might update us on his recent work in treating schizophrenia with cognitive therapy, and if this might actually be a preferred treatment modality for schizophrenia in the future.
Aaron T. Beck:
This is the story... I really feel I may be delusional but I think we have a new breakthrough with chronic, regressed, low-functioning individuals with schizophrenia. So, way back when I first heard about mental illness, I heard things like 'lunatic', 'asylums', 'insane', 'crazy', and so on. And to my mind patients with this disorder were just a whole different species, as it were. They were individuals who were so far out of it that you wouldn't be able to communicate with them. They were 'obviously incurable' and so on. And then during my psychiatric fellowship I was assigned to an individual with chronic schizophrenia...So I figured I'm assigned, I don't know what I'm going to do with him. But anyhow I formed a relationship with him, talked about his delusions, And in the course of time he got better! And actually, the delusion went away. This was so unusual at the time that my chief asked me to write it up, and so I published it, I think it was in the Journal of Psychiatry, in 1952. [Beck, A.T. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952; 15: 305-312]
And that was the end of my flirtation with schizophrenia until the year 2000, when I was at a conference in Britain and I came across a poster session at this conference ['57 Patients with schizophrenia treated successfully'] I went wow! Because at that time it was still believed - and probably still is today - that the only way you can treat these individuals is with medication. But wow, here was a treatment, a psycho-social treatment, cognitive therapy, that was supposedly effective. And so I tracked these 2 individuals down - names were Kingdon and Turkington. And I then decided that schizophrenia - the treatment of schizophrenia, is really the treatment of the future, because if you can treat these very sick individuals with cognitive therapy, or any type of psychosocial interventions, then you could probably treat anybody.
However, the problem we came across was that while relatively mild/moderate functioning individuals were responsive, the people who were low functioning, who had a large amount of negative symptoms, simply were not very responsive. And at that particular time...I teamed up with Paul Grant, who at that time was a graduate student at the University of Pennsylvania, and we embarked on a long-term study - first finding out 'what are the are the negative attitudes, the dysfunctional attitudes, that these individuals have?'. Because we took the notion that this was not a biological disorder but was kind of a psycho-social-biological problem, and if you could knock off the psycho-social aspect of psycho-social problems that this might influence the biological problems.
Well, to our surprise we found that when we developed a treatment that was focused on the negative symptoms, on the very low functioning patients, that they started to get better! And so, we did a clinical trial. This time it was with low-functioning outpatients. And we found, to our pleasure, that these patients, these low-functioning patients, started to get better. Just working on their cognitions and their behavior and their affect, they started to get better. And when they started to function better, then the delusions and hallucinations started to recede into the background.
We published the study and at this point we were contacted by one of the states that was under a Federal mandate to improve mental services. We started to work in these hospitals, and we developed a particular strategy that I'd like to share with you. And we got really good results! So... when we went into a hospital we'd say, 'Send us your worst patients. We want to see absolutely the worst patients that you have', for 2 reasons: One was that if we saw one of the patients who was not as sick as the others, the therapists would say, 'this does not represent my patients'. So we'd say, well OK, so let's see your sickest patient. And then the second thing was, if we could successfully treat the sicker patients, then it would be comparatively easy to be able to improve the status of the less sick patients.
So, we worked in the various hospitals in the state of Georgia, and up to now we collected data on 350 patients.
And since data does count for something, we tried to find out just what happened to these individuals after 6 months of supervised training and treatment. Actually, we're training therapists to do the therapy. And after 6 months of supervised training and treatment 75% of the 350 patients got better.
And how do you assess 'getting better'? So, there are a number of behavioral indices which have been set up by NIMH, for adaptive improvement. This includes such things as being out of the hospital, clearly, making new friends, getting a job, living independently, going to school, and so on - all behavioral indices of improvement. And indeed, out of the 350 something like 25 of them, within 6 months, had full-time paid jobs. Now, I want to describe a little bit more about the patient population. I don't know how many of you have worked in state hospitals, but by in large the average length of stay is 10 years, and the people who are ten-year people are going to stay there for the rest of their lives - unless they step down to an equivalent, community-like, community service. But basically they're going to remain static for about 10 years, so just moving them along at all was quite [an] achievement. And so now we have moved into the state hospitals, in Pennsylvania.
A humanist-existential approach
So the question is, 'how do we do it?'. Well, first of all, to come up with what might be a shocking statement, which is that...
...the delusions and hallucinations are simply a camouflage. But underneath the delusions and hallucinations which everybody focuses on - professionals are always asking 'are you hearing voices today?' or 'do you still believe that you're God today?' - but if you address them as normal human beings, you can activate the normal part of the personality. And as you activate the normal personality, they start to look normal. They start to feel normal. They start to act normal. And so, [our treatment] was a kind of normative method.
Case studies: Engagement and Schizophrenia
So first we had to engage the patients. There was one chap, for example, who had been a basketball player, but he sits in his room all day long and he talks to the 'green people'. And these are actually voices that he communicates with. And it's very hard, very hard for the therapist to break through. But eventually, by talking about basketball, and then bringing in little basketball games, she was able to gradually get him engaged. And then lastly she reached the point with him where he was willing to take a walk with her while she was dribbling a basketball, and she managed to get him to go over to the court and then she started shooting baskets. And now he started talking for the first time and he said, 'you know, you're not doing that right. Let me show you how to do it.' So he started shooting baskets. And then the other patients in the gym see him shooting baskets and they want to play too. So the other people come up and first thing you know, he's getting into a game. And at this point he's crossed the line. He no longer is talking to the green people but he starts talking to real people.
So this is what I mean by engagement - finding something that's meaningful to the patient. But of course it varies from one individual to another.
[Beck describes an even more regressed patient, with delusions of being God and 'master of the universe', a patient who is aggressive and prone to primitive behavior, smearing her walls with feces, fighting with staff, etc. She is on 24-hour one-to-one watch.]
So what do you do with a patient like that? [Asking her name yielded a flood of grandiosity, about being God, having created the whole world, etc. It may seem a big deterrent, Beck noted, in trying to connect, this level of entrenched delusion and aggression.] What do you do with a 'master of the universe'? .... So the therapist asked our standard question, and this is the breakthrough question: 'What is good about being master of the universe? What is good about being God?' And she says, 'well, if you're God you can help people.' So there's a clue.... What else is good about being God? 'Well, you can connect with people.' [And what else?] She says 'well, if you're God you get respect'. Now you might have thought that if you're God that people are going to worship you, you can do miracles, you can move the world around. But no:
These patients have the same basic needs that you and I and everyone else has, which is the need to belong, the need to be respected, the need to have individuality.
And so the therapist then, says 'I see from the record that you were once a school teacher. Would you like to do something for the other patients where you can help them [get their high school equivalency diploma]? And she says no, she's not interested in that. But then we find out that she is interested in cooking. So when she goes into the kitchen she starts to appear...normal. Her face, her expression... She starts to do normal things and she's quite happy.
The first thing she did was bake some cakes. The next thing, she distributes cakes to the rest of the patients.
The next thing after that is she makes a souffle, which she also distributes to the patients. Well, then the patients say, 'we'd like you to teach us all of these cooking things that you have'. And she says O.K.
And now she assumes the role of a teacher.
She is back to the previous normal mode.
And as long as she is teaching them how to make all of these different concoctions, she is appearing very normal.
And the final thing that we just learned the other day, they are now forming a cooking club. And so, as time goes on, she's getting better and better. She's no longer smearing feces and she no longer needs continuous surveillance. And she's going to be discharged from the hospital.
And we do the same thing with other patients, finding out what it is that they really want, allowing them the initiative to be able to teach other people what they're doing... And then what's happened is they started forming clubs, and so we have a gardening club - people go outside. We have a computer club, and have a crochet club, that some of our own staff is participating in - we'll see if we can get the rest of the staff into all of that - and we have a travel club, where they talk about travel. The whole thing now is that not only are the patients activated into doing things they like, but that the personnel are also involved, so that big sense of inequality and inferiority that they have is now being erased, and that they are now beginning to feel equal to the other members of the staff.
So that gives you an idea as to where we're at. We have a lot more to talk about... maybe at a future date I'll tell you more about this.
But what I do hope is that all of you in the audience who haven't chosen your career paths will think of posts in public mental health as a way to go. Because there's no other field where you're going to be able to do so much good for so many people, and people who are at the very bottom of the ladder in terms of social deprivation and disadvantage. And you're going to bring them up to where they're going to be able to behave and feel and act like other human beings.
Q&A
Qu: Thank you very much Dr. Beck for your poignant reflection on this new perspective in treating schizophrenic clients.... My question is: First of all, coming from an existential/humanistic standpoint ... I find what you say extremely existential/humanistic. You're tuning into the client's perspective, what really matters to them, how they would like to live their lives ... and you're treating them, as you put it, like normal human beings. Which to me sounds very similar to the kind of work which R.D. Lang and his associates drew from in their 'safe houses', where they lived, in with clients, and it was basically about being with the clients and validating who they are as people, and not getting all caught up in pathologizing them.
My question is: (1) Are you becoming an existential/humanist? And (2) If not so much, how does this reflect your cognitive-behavioral work?
A: "That's a very good question. And actually the name of this division is the humanistic division. And I often title my talk as the 'The humanistic approach to schizophrenia'. So, basically my answer to your question is: yes, yes, and yes.
However, we do have a whole collection of methods which can achieve the humanistic goal, so part of it is behavioral, coaching, role playing, etc. You don't want to lose sight of various valuable strategies. But the goal is humanistic. And your attitude toward the patient has to be - in fact we don't even use the word 'patient'. We call them individuals. So we de-pathologize the entire approach here, but we use whatever is available in order to achieve the humanistic goal.
Qu: I work with schizophrenia. What you're describing sounds a bit like 'the recovery movement'. I'd point out that the U.S. is really lagging, behind Scandinavia, for example. More focus on the psycho-social.
A: It seems to me that people who have an open mind who are working towards the same goal often find that they're using the same approach, because the clinical approach is one which is humanistic. [Dr. Beck recommended a list-serv and a forthcoming book of his titled 'Recovery Oriented Cognitive Therapy for Low Functioning Patients'.]
Qu: Can you elaborate more on your observations about the '3rd wave' therapies?
A: You don't start by saying, 'I'm going to use xyz....' What are the patient's beliefs? If the cognitive processes are distorted, it will be seen in their behavior. Cognizant also of the 'interaction between genetics and life experience', it is not necessarily a simple matter of picking a diagnosis from a 'ready-made-map' so much as understanding the individual's situation. Then one may be set to make the decision:
"What strategy is best for this particular patient at this particular time?"
"Also, draw on your skills. Emphasize the person's values."
Beck may utilize any of several techniques or strategies - but all drawing from similar 'brands' such as DBT, and treatments which offer "validation, and also soothing."
"Mindfulness is something which is ubiquitous."
Qu: Can you share some advice to a new clinician?
A: First, keep an open mind. "Don't be blinded by your professors' frame of reference.... Get yourself trained in the various modalities....Don't work a technique to death." In the day, "I used to tape all my sessions to find out what I was doing wrong."
"Don't ever give up on a particular patient." You have to 'take an attitude' whereby you are focused on working together towards making some progress.
Qu: Can you address the role of beliefs, vis-a-vis culture? [Speaker works with Native Americans.]
A: ~ By being culturally sensitive, you're going to be more successful at understanding the person and their beliefs.
Qu: Are any diagnoses more amenable to'3rd Wave' approaches?
A: With a presentation of borderline personality features, for example, it may be important at the beginning to use a DBT approach. In working with schizophrenia, hallucinations, etc., which get in the way, it may be best to get back to 'standard cognitive therapies'.
Qu: Isn't the DSM particularly prone towards pathologizing?
A: You need to look at a person's 'problem'.
Dr. Beck offered a short case history, describing an 'over-controlling mother' (towards her daughter). Her daughter is 3, and does not talk. 'What should I do?' In this case, rather than demanding speech of the child and trying to figure out what's wrong, Beck's intervention was to suggest that the mother 'do the opposite of what you are doing now'. No diagnosis or pathology discussion, only the behaviors and beliefs.
'I am always energized by Q&A'
Qu: Where do you see technology going?
A: "Technology has been useful" Beck replied. He cited the work of Josh White, in developing a 'therapist's assistant', and applications in the area of 'hostility & violence". But, "you can boil it down to people getting trapped in a self-defeating attitude." He mentioned his book, Prisoners of Hate, where he describes the effects of demonizing the other, and acting on self-defeating beliefs. You can hear him address this dynamic in more detail HERE - http://www.fenichel.com/hate.shtml
Qu: I'm a school psychologist; what might schools do to alter these cycles or attitudes?
A: Support 'social-emotional skills' among our youth.
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Danny Wedding: Myths & Teaching Tools on Psychology & Mental Illness in the Movies
Phil Zimbardo: On The Stanford Prison Experiement
2010 Convention Highlights:
Online Support Groups & Applications |
Evidence & Ethical Practice | Opening Ceremony | Sir Michael Rutter: Resilience
Group Memory | Psychology in the Digital Age | Steven Hayes: What Psychotherapists Have that the World Needs Now
2011 Convention Highlights:
2011: eHealth Odyssey | Googling, Twittering, Poking | Zimbardo: Reflections + Enduring Lessons from 40 Years Ago: Stanford Prison Experiment
Opening | Avatar-based Therapy |
Canine Cognition: Chaser | Aaron T. Beck @90
| Cavanagh: Computerized CBT | Seligman: Flourish
PsychTech: Virtual & Augmented Reality |
Relationships 3.0 | POKE ME: Social Networks & Kids | Telehealth & Telepsychology Licensure - Barriers and Possible Solutions
2012 Convention Highlights:
Transmedia Storytelling |
Opening | 2012: Virtual Reality Goes to War
| DSM5: Q&A | Drew Westen: Dysfunctional Democracy
Howard Gardner: Multiple Intelligences
| Zimbardo: Anatomy of a TED Event
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