American Psychological Association
San Francisco , August 17-20 2007
|Photo by Fenichel: 17 August 2007
|A Conversation With Aaron T. Beck and Frank Farley
A CONVERSATION WITH AARON T. BECK AND FRANK FARLEY
17 August 2007
For those who recall (or read here), this APA tradition began with a first-ever dialogue between Beck and Ellis, which was repeated a 2nd time before Ellis' health slipped away. The session began by noting Ellis' passing on July 24, and announcing a tribute session to him immediately after this event. There will also be a "wake" Sunday at 5.
Beck commented that "what was remarkable about Ellis is that he managed to break down so many of the old taboos", and he worked with patients in a "hands on" manner similar to the approach employed by Beck in many respects.
Dr. Farley opened today's dialogue with the simple question, "What's new?" Beck replied that he continues to be fascinated by the "application of cognitive therapy with schizophrenia". In the UK research has found that using "standard cognitive therapy but with adaptation" has been effective in treating schizophrenia, both the hallucinations and negative symptoms". He is now trying to import such research and treatment protocols to the US.
What Beck has found is an "intermediate variable between functioning and symptoms" which involves a "sense of failure". Using one his inventories he found profound examples of such sense of failure, "like holes in their head", where patients felt profoundly dysfunctional and unable to master their functioning so that their attitudes brought about social withdrawal and anhedonia. His response was to target the specific dysfunctional attitudes, not unlike Ellis' idea of ABC, but applied directly to hallucinations. The patient reacts to voices as if they are real, from the outside, and they can't do anything about it. The voices ruin everything, but all they can do is wait for them to go away, and just accept the helplessness. Meanwhile, evidence is accumulating which suggests that having these patients engage in purposeful, productive activities is helpful.
Dr. Farley asked for his reflections on his experience with John Nash (of "Beautiful Mind" fame), Nash having seemingly "self-treated" his schizophrenia eventually. Beck noted that "he's continued to progress despite the fact that he's a severe schizophrenic" and it is somewhat puzzling to fully understand why he has been so singularly successful. Beck, who had met with and assessed Nash a few years back, asked Nash for his ideas as to how he managed to cope on his own with such debilitating symptomology. As Nash described it to Beck, he (Nash) was traveling around Europe, having lost his passport and with no money left. He was destitute. He lost his family, lost his career... And even though he believed that saving the world was "his charge from God", he could see he wasn't getting anywhere. And so he decided he needed to change his behavior. "It seems he did cognitive therapy on himself"! Maybe too, Beck postulates, Nash had a large degree of "cognitive reserve", similar to people with mild TBI calling upon the undamaged areas of the brain to help function adaptively.
"Turning to Iraq", Dr. Farley segued (knowing that Beck has an interest and background in trauma/suicide ideation, including among soldiers), Beck was queried for thoughts on this still-relevant topic. Beck observed that a big issue in therapy with traumatized soldiers has been "loss of buddies". In fact, Beck wrote a paper during WW II about this, seeing suicidal ideation in response to feelings of guilt. There is obviously a great deal of trauma at this time too, among returning soldiers, to the point where "some people cry when they see a trash can on the side of the road - it looks like an Improvised Explosive Device." Others are not so impacted. The worst case seems to be where someone is "inundated with negative thoughts which persist". Here he again noted a relevant notion of Albert Ellis, that of "catastrophizing", adding that experience shows that outcome improves when such negative thinking is treated early on.
Beck was asked for any updates on his work with suicide intervention/prevention. He responded by citing a study which explored the efficacy of a 10-session intervention protocol and found a 50% reduction in repeat attempts among those in the treatment group. One contributing factor, he understands, may be that some of these patients would never have sought treatment on their own, certainly long-term treatment, in part based on life circumstances (mostly low SES). At the same time he credits much of the effectiveness in the "educational" component, particularly teaching of concrete strategies to employ in order to circumvent spiraling movement towards despair and acting out impulsively. As part of this protocol he introduces not only discussion and problem-solving steps but also the use of visual imagery, so that by the 9th session images (e.g., of the way they might try suicide) are intentionally introduced in order to teach ways of responding productively. And he "would be sure to ask if the patient who is suicidal uses imagery", such as seeing a noose on a tree, or whatever.
Returning to the notion he'd mentioned earlier, of an intervening variable between conscious thought and action, Beck noted that "in between an activating event and behavior, there are thoughts which the patient may not be aware of." As a clinical example he described a man who lashed out at his wife after a seemingly benign request to take out the garbage, which in fact activated a whole reservoir of anger about feeling (cumulatively) disrespected. So another technique which Beck employs would be to look for the fleeting thought which triggers the larger reaction. He might ask, "What were you thinking before you got angry, during the microsecond before the anger was triggered?"
Beck mentioned his interest in the latest APA Monitor where there is a study about the difficulty in treating obesity, and how meta-analysis suggests grim success rates for dieters (often regaining lost weight plus more). He wondered about ways in which we might help people to stay on a dietary regimen. (Perhaps some fleeting thought activates the trigger for food binging?)
Picking up on the "trigger" phenomenon and impulsivity, Farley asked Beck if anything new is on the horizon for treating Borderline personality disorder, widely seen as a difficult treatment group. Beck's reaction was that he would think along the line of personality disorder, or types, and then work with the beliefs and with coping strategies. He utilizes his own Personality Belief Questionnaire which helps identify, for example, dependent, or avoidant personality disorders. Above all (and here is his famous "hands on" approach!) Beck thinks it is vital to "put yourself in the shoes of a Borderline patient. How would YOU feel if you thought everyone is disgusted by you, or you have no control over anything?" Beck also employs this empathic approach with schizophrenics, to win trust, noting that he may not personally share hallucinations but would very much like to understand the person's experience.
Beck mentioned a study in Holland with 2 treatment groups: a schema-focused therapy versus a Kernberg-style, transference-oriented approach. The former produced better outcomes.
Taking audience questions, Beck responded to a question (mine) about suicide and imagery, citing the old axiom that risk may be higher when there is a clearly formulated plan. How does he handle it when there is such imagery, elicited during a session? Beck gave an example of using imagery throughout a scenario, but not only focused on the act of attempting suicide. In his example the patient has an argument with the boss and decides to go out for a drink. He ends up ruminating, when he's ready to go home, about how now he's going to get upset again going home to squalling kids and spouse, and so decides to have another drink, or go to a crack house, at which point he's on the road to visualizing suicide. One of the things which the patient is taught during the 10 sessions is making use of supports, tangible things like cards which specifically respond to crises points by providing clear instructions as to what to do or what not to do in response to such stressors. He also has clients prepare a "hope chest", with portraits of more positive possibilities, with friendly letters and so forth to look at. Beck uses a 10-step process, beginning with 1. Go to the hope chest; 2. Call a friend; and moving up a hierarchy to the point where #9 is "call your therapist" and #10 is "call 911".
Next came a comment and question from Jerome Singer, of Yale, who noted that "cognitive therapy's great strength is that it can be integrated with other modalities". Yet OTOH insurers and others are focused on more narrow "evidence based treatment". Another challenge lies in research, he reflected, as much of the research compares 2 types of treatments, for example CT versus pharmacotherapy. He wondered about Beck's thoughts here, considering a twofold question as well: 1) How should CT be practiced *ideally*? And 2) How is it practiced in the real world? Underpinning all of this is the observation that "patients are not homogeneous and neither are therapists".
Beck's response was to agree and amplify the point that psychotherapists "have to adapt to their own experience, their own personality, their own temperament".
With regard to Kernberg-style "transference"-based approaches, Beck made it clear: "I believe in transference; but I don't think you need to wait 2 years to address it! We talk about it right away." Continuing, Beck noted that "there are no 2 therapists that I've supervised who do therapy the same way." Farley agreed: "You can't manualize cognitive therapy"".
Another question was put forth about working with psychotic ideation: How would the therapist avoid becoming a part of the delusional system, for example seen as yet another persecutor?
Beck replied, "It is critical to establish trust early on. And if you're not the prescribing physician there's a much better opportunity". [The patient won't think you're poisoning or coercing them, etc., but you are simply talking and trying to help, so there's a better chance of trust.] "We never challenge the delusion," he added. Instead, "we try to get the therapist to key into the patient's frame of reference. For example, 'I don't have the same perspective but perhaps you could show me' what you are thinking/feeling."
Someone mentioned Beck's recent appearance on the Charlie Rose show - it is available on his website, charlierose.com, and having seen it myself I can recommend it as a very interesting panel discussion on Freud's legacy and today's modern thinking.
The question was put forth about what more might be said about the phenomenon of actual physiological changes in the brain resulting from therapy. Beck began by saying that "the brain reflects what's going on in the patient's life".
In terms of research, a Toronto study of CT versus pharmacotherapy utilized pre and post-treatment brain scans. Both types of treatment changed the brain but with CT the changes were "top down" while with drugs the change was "bottom up". More importantly perhaps, pharmacotherapy "does not change the brain permanently but CT does", and there is less likelihood of relapse with CT. Thus, while taking care to avoid being mis-quoted or to overstep the data, Beck shared that he believes from what he's seen that "cognitive therapy does seem to be a 'cure', sometimes."
The session ended with an invitation to join a memorial to Albert Ellis nearby, and I went to that, as did Beck and Farley, and many others. He was recalled both personally and professionally with great fondness, despite his well-known acerbic qualities and salty language. He was described as generous with his time (even as his health was drastically deteriorating) and completely dedicated to his mission, giving all the proceeds from his 85 books to his Institute.
One of Ellis' admirers, a publisher, said that Ellis' bibliography is available at impactpublishers.com or bibliotherapy.com
From 1951's "The Folklore of Sex" and 1958's "Sex Without Guilt", to his ribald songs, and efforts to get audiences to recite anatomical parts, his provocative yet humorous style broke taboos and earned him a worldwide reputation.
One speaker eulogized Ellis as "the greatest humanitarian since Ghandi".
Ellis founded RBT in 1955, during the heyday of psychoanalysis and behavior therapy. "For Al, the testing ground was meaningful experience".
Ellis was very into both psycholinguistics and ancient philosophers, this in a time of "absolutist" therapies, ranging from Rogers on one end to Freud on the other.
Film clips were shown, including a therapy segment, and a TV interview where Ellis commented that "the past is not critical" and "we stick largely in the present".
A big portrait of Ellis stood at the podium, and a large number of people turned up to watch, speak, and listen.
Albert Ellis, September 27, 1913 - July 24, 2007