American Psychological Association
119th Annual Convention
Washington D.C., August 4-7 2011
CONVERSATION HOUR #2362 - A Very Special Event
A Hero of Psychology - Aaron T. Beck at 90
Dr. V.K. Kumar (U.Penn) welcomed the standing-room only crowd, inside the huge hall adorned with birthday balloons and party favors in honor of Aaron T. Beck's 90th birthday party. Dr. Kumar noted that Beck not only became the foremost authority on cognitive therapy but began within a context where biological and psychoanalytic models were considered gold standards. Dr. Frank Farley continued the introduction by noting that quite simply, Beck may be the "the world's greatest living psychiatrist - probably the greatest of all time."
Farley recalled some of his own experiences, such has having one of his classes invited by Beck to join him for tea and case conferencing, at his home. Back to the present - and future - Dr. Farley noted that now, at age 90, Beck is embarking on new projects and even "a whole new theory": "the genetic cognitive" model. Here now to share his current interests and reflections, and field questions by Farley and the assembled audience, Dr. Beck thanked and greeted the audience, to thunderous applause.
"Thank you for your plaudits", Beck said, graciously, and he proceeded to reflect on his general way of approaching treatment, distinct from, say, psychoanalysis. In working cognitively he develops a map of individual psychopathology and develops specific questions "not based on free associations, but the map." He noted that Ellis was a pioneer in developing his formal A-B-C model while he (Beck) was "somewhat independently... working on a cross-sectional model pertaining to depression." He discovered common underlying beliefs, such as "I'm helpless, I'm unloveable, I'm defective..." He soon understood that "conditional beliefs are subject to interpretation, same as core beliefs." While noting that for some in the audience "this is old hat" perhaps, he went on to describe some case vignettes which illuminate his treatment evolution over time, and some of the unique elements.
A patient comes in and says " I might as well give up".... Beck will immediately do "what some don't do", and ask for a concrete example.
Patient: OK, I came home last week and the roof was leaking. I felt terrible... helpless. The kids were upset. I felt a failure. Then my wife ran off without saying goodbye.
Beck: And how did you feel?
Patient: I'm unloveable.
That was the common thread, though of course different situations evoked different reactions and underlying beliefs also vary.
"So there's a belief, and affect and behavior" - and the cognitive therapist will "take a sort of snapshot" and then address the beliefs. Lately Beck uis "adding one thing" to his understanding of the ABC dynamic, and this is what he calls "the frost focus";.
As always, "what's critical is the belief", and belief systems are "absolutely unique to each person". But patients differ also in the extent to which they can be free of dysfunctional thinking, and for some they seem to have difficulty with getting outside the preoccupation and being able to address the beliefs (i.e.., in analytic terms, making them dystonic). The "frost focus... takes the patient's focus and his whole focus is absorbed on thinking 'I'm not good' and so on, and it causes withdrawal."
"If you can interrupt the vicious cycle - the more points at which you can intervene, the more successful you will be.
"
"What Ellis did not focus on: You have a separate set of beliefs leading to different types of disorders. The unique belief system, when activated, starts a cascade.... How does a 'generic model' work with other conditions?"
Beck, who has in recent years been having positive results working with some difficult populations (e.g., schizophrenia, BPD) using CBT, gave an example of working with someone who may be hallucinating. They are responding to a stimulus - and "nobody really knows where they come from" - but there are definitely a set of beliefs about "the voices". One belief may be that "they're overpowering, uncontrollable, omnipotent" "Once they have belief that it's uncontrollable it becomes uncontrollable. Once they believe they're omnipotent, they become so. The worst part: They think if they focus on it they can make it go away, but the more they do the worse it gets. So you want to shift the focus..."
Keeping in mind individual situations, there are a few techniques which Beck might employ. One might be a shifting of focus combined with support and and an effort to externalize the voices: "It's true that you're hallucinating and that's really too bad...." One can work with the beliefs then - and Beck's techniques have been proven effective across many studies, including with populations considered difficult to treat. With more intensely "frosted" (preoccupied) fixations, there are other strategies Beck might employ, such as the "look-point-name" technique of harnessing focus: "simple but effective. 'Look over there, there's a book on my shelf. Point. [action]. Name it.' The patient responds with the action and response, 'Oh, How Cognitive Therapy has Failed in my Life'. He likes it."
Beck: "How are the voices right now?"
Patient: "Less".
"So you can intervene at key points... Pick a condition and let's see if you can pick something and apply it."
Now, some questions from the audience, and some from Frank Farley:
QU- With so many turf wars, and the historical conflicts between say, psychoanalysis and CBT, is there any aspect with all the new approaches out there, of presenting in effect "old wine in new bottles"?
A- Some of this may really be "a manifestation of egocentricity more than real differences".
Beck himself has attended to various aspects of differing approaches, and fine-tunes and adds. He "just did a paper [being published in a psychoanalytic journal, reporting] on neurobiological aspects of cognitive behavior." He addresses the role of the prefrontal lobes and amygdala in this particular paper, while being aware that "psychoanalysts need to focus on analytic factors" including things like empathy and " common factors". Moreover, in terms of the unconscious, "Thoughts are not the same as the unconscious. The unconscious [comprises] a whole cauldron of id instincts."
QU- (Farley) - Is method more important than the 'relationship factor'?
A- "My fallback answer is that we need to look at this empirically. Technique... My beliefs are as follows - I'm giving it to you straight.
Mild to moderately impaired patients will get better based on 'common factors'. [But...] Common factors don't teach anything except that they're not being rejected and the therapist is caring. Fine for now, but what tools have been learned to help with the next bout of depression?" He knows too, from experience, that "with seriously depressed patients, my loving kindness [sometimes] made them worse." He gave the example of a sensitive poet who interpreted everything Beck said to show interest and empathy as proof positive that he was misunderstood and therefore wasting his time. Thus "You have to see. What's your attitude about taking a more active stance?" Sometimes "you can give empathy 'til the cows come home and they won't get better". Not from that alone....
QU - How did you manage to take on the entire system (psychoanalysis)?
A - "It's hard to objectify about yourself! So, subjectively... [My] first challenge was to prove that psychoanalytic theory was correct. Based on my research I became to believe that the basic tenets of psychoanalysis [repression, etc.] were incorrect." In confronting the backlash from true believers, "I already had a roadmap... I was never bothered." On the other hand "Ellis was a fireball" who generated all sorts of publicity - and attacks, with CBT at times being labeled "malpractice" and branded as "poppycock". Personally, he (Beck) found it all amusing. Now, in terms of of his latest challenge... [He was interrupted by a long applause - in recognition of his never-ceasing work on the next challenge.]
Beck's latest challenge, working with a collaborator in Philadelphia (Paul Grant?), is "to reduce recidivism". A recent study found that effective protocols with outpatients had lasting efficacy at 2 to 7 years post-intervention.
QU - (a professor from Malta) - I feel you are a father to us children! In one word, what is your mantra?
A- [reflects a moment] - Optimism.
QU - follow-up - And what if a patient's goal is 'transcendence'?
A - "I can only do what I can do. I do CBT but don't work with spiritual approaches. That's something beyond my pen, but that's something other people do.
QU - An existential psychology question Having led a rich life, and considered the 'meaning of life', what would your message now be?
A - "To keep things in proportion... I use terms like 'catastrophizing' and 'hyperbolizing'".
The audience was asked to think about disorders or issues they had questions about, like how Beck might apply his experience with depression and anxiety to other types of disorders ...
QU - Does Beck treat Alzheimers?
A - No, he does not consider it a psychiatric disorder, but an organic disorder.
QU - OCD?
A- Beck learned early on not to "argue" but he did not have a well-formed model in his early years. Now he realizes "what makes the obsession is the belief.... The first thought [with distress in the case of OCD] is 'it's terrible'. Then: 'it's uncontrollable'. And the third thing: 'it's going to get worse unless I do something about it.'" In the end we see prayers, rituals, all sorts of behaviors used to ward off anxiety. So Beck would take the same approach he uses with hallucinations, as in his earlier example, and "deal with the maladaptive behavior".
QU - Body dysmorphic issues?
A - "OK. Say a belief that my face is lopsided. It's terrible. People won't like me. ... They will interpret others' reactions in according with their belief: 'I'm ugly'.... They may start to withdraw, focus on faces ... a vicious cycle. "'
One more question on challenging applications?
QU - Veterans - PTSD, conversion symptoms, etc.
A - Two vets. Both encountered roadside bombs, and now have concentration and sleep issues. One has some executive function issues but takes Tylenol for headaches and adjusts, accepts his disability. The other gets headaches, feels everything to be terrible, and "catastrophizes". "Maybe he'll take something stronger. He focuses on the belief that he's spiraling down. He's anxious, irritable, has difficulty with concentration, and ultimately an invalid. It's not a different disorder; it's the beliefs."
QU - You met with John Nash [the subject of My Beautiful Mind, book and movie, with Nash played by Russell Crow.] Nash was a brilliant scientist who decompensated/hallucinated and allegedly self-treated himself to the point of tolerating hallucinations]. Thoughts?
A - That was years ago, so not recalled with fine detail, but the impression, from both formal and social interaction was that Nash was "an interesting person. A nice person. " They had lunch together. His sense was that "his affect isn't strong. He comes across as sharp. He comes across as a little like Asperger's, nothing more. He came out with a number of things [self-treatment strategies] which I would call cognitive therapy. At this point [when they met] he was on no drugs, no meds, he'd left Princeton and was in Europe, as 'envoy to the world' [his delusion], going from country to country without a passport or visa, getting thrown out." Then came the 'intervention'. Nash looked at his beliefs and decided, 'Here I am, trying to save the world and nobody's listening to me! Maybe it's not worth it.' And that was the first step towards recovery.... He heard voices and decided they were harmful. He decided not to believe them any more. He didn't eliminate them, he just moved them to the periphery. An 'elegant solution' ".
QU - You met with the Dali Lama. Do you see any parallels between Buddhism, "mindfulness", and CBT philosophy?
A - "Good question [and] I haven't thought about it for a while." His first impression was, as with Nash, that the man was very interesting, as were the circumstances, in this case meeting under enormous security and being looked over and scrutinized. He had come with a 1966 Life Magazine about the Dali Lama and done research on Buddhism prior to the meeting. Interestingly he found 15 themes which his own tenets share with Buddhism. For example:
-- "Negative thoughts can control you"
-- A big problem in humankind is a tremendous egocentricity
-- The 'distancing' phenomena in therapy is much like 'putting things aside' in meditation
In a way, Beck said, his discussion with the Dali Lama definitely related to 'mindfulness'. The Dali Lama seemed moved, in fact, as Beck presented his example of the pie chart approach he has used to help people achieve perspective (similar to notions of both "mindfulness" and also DBT). The example is described elsewhere in detail but involves a man who complains of having poor family relationships and catastrophizes about all the stresses in his life. Beck has him divvy up on a pie graph how terrible one aspect is - initially seeing 80/90 percent. Then he asks, how important is x, and y, and z, and ultimately the person is forced to see how their automatic belief is self-defeating and inaccurate....
This story serves as a parable about mindfulness, in fact, as well as about the malleabililty of beliefs. Beck told the Dali Lama that in his estimation "Ninety percent of all hostility is irrational." To his surprise, the Dali Lama cited this belief. Clearly Beck is mindful of some Truth.
QU - What were some of the influences in your thinking, among colleagues in psychiatry?
A- Beck's early years were in the context of a time when psychoanalysis dominated but there was to be an imminent "sea change". In particular he was influenced by the seminal work of Karen Horney, The Tyranny of the Shoulds. He also was engaged by the work of Adler. Interestingly, early on Ellis wrote to Beck and expressed interest in Beck's early work, emphasizing cognitive distortions in depression, and the implications for treatment. Beck reflected on their special relationship over time, graciously reflecting (while perhaps also reflecting Ellis' own assertions), "I would say this: He influenced me but I never influenced Ellis."
Adding to his thoughts about Ellis, with whom he met several times, only in recent years, at APA conferences [You can see reports here], Beck continued: "Ellis saw the 'shoulds' as rock bottom. I saw them as facets, or stepping stones.
Marsha Linehan [too] has a number of things to offer in terms of validation and acceptance, with Borderline patients.
In terms of theory I would say the British have added the most. Psychologists, mostly."
QU - Any advice for a new teacher, new psychologist?
You really have to know, if you're teaching abnormal or clinical psychology, you have to keep up and know everything that's going on. A few things we've learned from neurobiology that we can add to psychology. A long time ago I wrote that people who are depressed block out the positive. A passive thing. But neurobiology has found a [mechanism that] actually supresses positive responses. It's not like they put a tiny veil over anything positive.
In terms of global advice, Beck emphasized the importance of keeping things in proportion. And a second thing: "turning a disadvantage into an advantage". Perhaps a good example of his practicing what he preaches, in accordance with his "mantra" Beck shared that a few years back he had to give up tennis. But suddenly he found he had more time for things like reading, TV, etc., and now he would actually have lunch with his tennis buddies and "actually talk". [Beck also lessens library and office time by utilizing things like Skype and iPad!]
--
A few final congratulations and today's session came to an end. Happy Birthday Aaron T. Beck! Here is a living legend who has changed the face of psychotherapy, and certainly deserves the decades of admiration and respect he has enjoyed. Wishing many more years of sustained passion and clarity such as we have seen here today.
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2008 Convention Highlights:
Grand Theft Childhood | Opening | Malcolm Gladwell
| College Success, Love, Hate, More |
My Life With Asperger's
My Space, You Tube, Psychotherapy, Relationships... | Aaron T. Beck - 2008 | The Mind and Brain of Voters
2009 Convention Highlights:
Internet: Pathway for Networking, Connecting, and Addiction | Opening | Virtual Psychology & Therapy
| Q&A with Zimbardo
Seligman: Positive Education | Future of Internet Media | Sex, Love, & Psychology |
How Dogs Think
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
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