American Psychological Association
Boston, August 14-17 2008
Photo by Fenichel: Aaron T. Beck 2008
Aaron T. Beck:
Continuing Discussion with Dr. Frank Farley
In what has now become a very popular and memorable tradition, Dr. Beck -- famed for his numerous "Beck Scales" and considered the "father of cognitive therapy" -- drew a huge crowd of admirers, including many psychology students. A psychiatrist by training, Beck was introduced as "the man who slew Freud". He immediately responded that in fact he had long *embraced* Freud, until he (Beck) "managed to take a risk" and defy some of the Freudian tenets, for which he "paid a price". But he was a believer. And now his own focus on belief itself has truly eclipsed Freud, as the introduction playfully suggested, because Beck's methods enjoy empirical validation.
Dr. Farley began by stating the obvious, that Aaron T. Beck really needed no introduction.
So he proceeded right to the presentation, also in the interest of time. (Beck had to leave a few minutes early.)
Beck began by commenting that "I always enjoyed having a dialogue with Albert Ellis" at these gatherings.
[You can get a sense of these historic discussions in the collection on my site, including the discussions in 2000 and 2002.]
Beck also acknowledged the presence of Debbie Joffe Ellis, Ellis' widow, who was here to hear Beck as well.
Dr. Farley invited Beck to share what's new and noteworthy for us to know about.
Firstly, Beck has 5 books coming out imminently, some new editions and some first releases. One coming out soon is on suicide. (He has apparently become very familiar with DBT and reality therapy and a few other approaches which are in sync with his own ideas and techniques.) A re-release is coming of his "first child" - his classic "Depression: Causes and Treatment".
Aside from being very busy with books, Beck has continued to become more involved with understanding and treating schizophrenia. He sees us have having gone through "the year of the brainless mind, when the focus was not organic but on thinking". It was thought that if we could identify and release unconscious drives, the symptoms, paranoia, could be resolved". He recalled the time when unconscious homesexual wishes were believed to be a root cause for psychoses.
He was feeling it was becoming a "dismal failure" continuing forward in this line, until about 10 years ago when, in the UK, he came across a study claiming that 78% of schizophrenics were being treated successfully - with cognitive therapy.
This was exciting, such a possibility, and he has continued to follow and expand on such studies.
One finding of the studies was that patients with the *positive* symptoms of schizophrenia (hallucinations, delusions, etc.) were indeed seen to be improving in daily functioning; however there was little impact on the *negative* symptoms (the "5 A's", such as anhedonia, asociality, etc.).
"The brainless mind had become the mindless brain", so it seemed. Now 95% of the emphasis involved diseases of the brain.
In the end, "drugs and therapy [together] seemed to be consistently more successful with the positive symptoms".
Psychotics, Beck said pointedly, do indeed have brains, but "they also are people, and they have attitudes and thoughts and beliefs, just like other people do."
Over time Beck would watch patients sitting and smoking, listlessly. He'd wonder about the sense of defeat, and the underlying belief that "there's no sense in taking a risk because I might fail. It's better not to do something then to do something because I might fail at it.".
Several brain-oriented studies suggest that a constellation of symptoms are related to neurological deficits:
- Negative symptoms
- Poor quality of life
- No goal seeking
- Giving up
In some controlled studies a "key factor" - in statistical terms one which soaked up much of the variance - was "negative attitude, probably stemming from actual failures, where the quality of life deteriorated."
So now, Beck was thinking, we have a "psychological hook" for a trigger of negative symptoms: "defeatism". But at the same time, "You can't talk a schizophrenic out of an attitude. You have to go at it indirectly".
What do they want? "They would like to work, have money, have relationships..."
Asked "what about hallucinations", can't these be especially distressing? Beck replied that the effect of them may not be as bad, in relative terms.
"One patient said he could no longer read, he was unable", due to his lethargy, &/or defeated attitude. That was his main complaint. He was given a paragraph to read, and he found he could do it. When this happened, "you would see a shift in attitude" and he became more active. "The more active, the more the attitude change, with change in behavior and in symptoms."
Beck is now doing a random/control study with a treatment and non-treatment group, testing this paradigm. Thus far he is seeing improvement, people beginning to get out and go to the library or gym, or possibly being able to attend a job training program or some type of work.
Treatment with former college students has shown success as they return to college. Also he is seeing some of the more listless patients moving from group homes into independent living situations. "The whole quality of life is improved. It's the most exciting thing so far."
The floor was opened to the audience who queued at an open microphone.
Here I'll just summarize:
Question on working with schizophrenics who function in the mildly MR range, who exhibit aggressive acts and behaviors, using CBT.
Answer: Emotional control is really a big facet. We have to train them in anger management. This can be done in a session, for example recreating the situation where they're frustrated, or easily angered, and simulate a situation. You may try to first convince the person that anger is unproductive. Teach them to use self-talk: 'It doesn't pay to express these feelings because I'm only going to get in trouble'. Learn to take a walk." Etc.
Beck used this to segue into an example of a case where there was serious dysfunction due to PTSD, a soldier back from war:
Patient: I'm irritable, I yell at my wife, I'm having terrible nightmares, flashbacks... I'm going to end up a deadbeat, or I probably will kill myself.
Dr: What led to this? Tell me what happened.
Patient: I can't do that sir; if I do I will cry.
Dr.: It's ok.
Patient. I can't even drive. If I see garbage cans it reminds me of roadside IED's. And I can't talk to people.
Dr.: Tell me about the flashbacks.
Patient: I came across 3 soldiers in Iraq, huddled around their comrade's body, just staring "catatonic"-like. He had a big gash in his head, brains exposed... The 3 soldiers began to talk with me about their lost friend and somehow started to feel better, talking about him.
Dr. B: You should feel *good*. You helped!
Pt: But I should have done more! I should have...
Dr.: Nobody could have reassembled his brains, nobody.
The soldier began to cry.
Dr: You did something good.
"He kept in therapy and his nightmares diminished, along with his flashbacks. It was all the guilt."
Q: from audience - I am a student in public health, and wonder about CBT applications in a preventive context.
Beck: Primary prevention is ideal. One of my colleagues - Seligman - is working in schools with children at high risk for depression. Ken Dodge did a study on children prone to act out in school [and] developed a psychoeducational program which did have an impact on acting out.
Very few psychologists and counselors have actually had training in CBT. We're doing training now with the VA, with the idea the counselors will be more helpful. This is secondary prevention. We need to be sure there is proper training. For 6 months they get stringent supervision [which includes use of taped session transcripts]. Right now, Philadelphia has a great Medicaid program.
Q: I work in a trauma center for terrorism victims. How do you deal with parents feeling guilty for the loss of a child?
A: It's not something I've specifically thought about... it's difficult. I once spoke to such a group of parents whose children were killed. It goes like this: 'If only... If only...' A boy took a shortcut on his way to school. Crossed the railroad tracks and was hit by a train. 'If only I'd gotten him up earlier'. Should've, would've, could've. The only thing I can think of is to go through what they think they would have done differently to get them to realize that they simply had no control over the situation and were not responsible.
Q: Is there a relationship between Seligman's work and CBT?
A: Actually we meet once a month and have these discussions. From a positive CBT perspective, we have to teach them what they have control over and what they don't, the positive part. That they *do* have control over some things. [Sounds like Ellis, too!]
Beck gave an example I'd heard before, but now (to me at least) it sounded more like DBT (with empathy!), with the "dialectic" component encouraging less extreme reactions. There was a distinguished patient of Beck's with a deep depression after having been passed over for a Nobel prize. Beck drew a circle on a blackboard and asked how important it was getting that prize, in his life. "Eighty percent", the patient said. "Do you have children?" Beck asked. "Fifteen percent".
"Do you have much to do with your children?" No, not really much opportunity...
"And how was growing up for you?", Beck asked the patient.
Pt: I didn't have much contact, actually.
Beck: And how did that make you feel?
Beck: Is it possible that your children feel like that too?
The patient began to light up and declared that yes, he was going to spend more time with *his* son than his father spent with him.
Beck: OK, so how important in your life is your son?
Beck: And do you enjoy time with friends?
Pt: Yes, I like to play tennis. OK, 40%
Beck: That's 100%. What happened to your wife?
And so it went until in the end things were more proportioned for a positive and realistic outlook.
"This is positive psychology in a CBT way", Beck said, getting at root causes directly through experience.
Q: How can we deal with fixed delusions?
A: First a disclaimer: It doesn't work with everybody. People with fixed delusions are not going to take kindly to being told their delusions are just delusions. (What Beck has done in such a situation is to avoid being patronizing but help establish a framework which is conducive, and positive.) The therapist says, I'm sorry, I really don't understand what you're saying, as I don't have the same experience.
The patient liked this, as he's not being told he's crazy and dismissed. The therapist continues: "You know, the more you empower yourself the less intrusions will bother you. " The clever patient asks, "Are you saying they're not real?" and Beck replies, "it doesn't matter if they're real or not". The therapy is the same. And the patient becomes steadily more active, and the symptoms lessen.
Beck recalled how one patient had become absorbed by the meaning of some letters he saw on a bus going by: G, O something, T something. It must be a cryptic message from G-d. Go to something! But where? It turns out the letters were GOTS - Greater Ontario Transit System.
Q: There are big debates on outcome studies, efficacy, etc. They say a relationship is a necessary but insufficient component of therapy. What do you think?
A: People with moderate depression can benefit from mostly supportive relation-based treatments, like Rogerian methods. "You can get some cognitive change with an empathic therapist. There's some kind of transformation. Acceptance works. With more severe disorders, however, acceptance doesn't carry it. Technique becomes critical.
With mild to moderate depression there are 'common factors'. Empirical evidence is that techniques matter."
Also, you can compare supportive vs. cognitive restructuring treatment. It may come out similarly. However, with supportive counseling only we see regression in a year, but with cognitive therapy they keep improving. It seems they develop the tools to deal with problems.
Q: How has your life experience colored your perception of the current political landscape?
A: Beck said he's only good at this after having a chance to speak to the players individually, and finding out what their "automatic thoughts and beliefs" are.
Q: I'm a grad student interested in the use of therapy animals, which have in fact been found effective in treating anhedonia, increasing ADL and socialization, etc.
Ever thought about this?
A: I have not, but I will!
Q: Where can one get training - besides the Beck Institute?
A: There is a network, and he can provide specifics on request. His daughter Judy is now doing the workshops at the Institute.
Q: Can you speak to the role of empathy in successful CBT?
A: "I think it's really critical. You can set an agenda, teach the tools of the trade, but with the more difficult patient you really need to be able to imagine yourself in the patient's shoes. 'What would I do?' 'How would I react if I failed?'" Incidentally, Beck added (to some laughter), "some of the best therapists may not be terrific researchers".
Q: Any brief therapy model for CBT?
A: Some patients get better in 1 or 2 sessions, others need a year.
Beck briefly mentioned some of the genetic work being done which may help future targeting of symptom treatment. It seems as if a "hyper-reactive amygdala" is somehow related to negativity. There are a few ongoing studies testing this.
Beck was asked about his experience with paraphilias, which was limited, although he had some experience with incest and has seen promising results working with the parents - for example focusing on the underlying belief of the father, e.g., "It's best for her, it prepares her for real life and and who better to do this than a father who cares for her?"
Q:Have you done any more work with Borderline patients?
A: DBT seems to have done quite well in the treatment of BPD. More has been done than with CBT. "It takes a long time to get the get the type of result you want". There's also "schema therapy, a CBT variant" which can also be long-term. "The psychologist has to be flexible, kindly but stern... and teach the patient self-control without being demeaning." In some ways, it is easier to work with schizophrenics, delusions and all, than borderline personality disorders.
INDEX OF 2001 APA Convention Articles:
Behavioral Telehealth | E-biz of Mental Health | 2001: A Cyberspace Odyssey
INDEX OF 2002 APA Convention Articles:
CyberSex & Cyber-Infidelity | Beck & Ellis 2002 | Behavior Therapy | CyberPsychology | E-Ethics
2003 Convention Highlights:
Full Text | Beck 2003 | Quality of Online Health Info | Sternberg's Vision
2005 Convention Highlights:
Opening Session | Pioneers of Behavior Therapy
Distinguished Elders of Psychotherapy | Legends Discuss Psychology | Online Clinical Work | Town Hall Meeting
2006 Convention Highlights:
Opening | Online Psychotherapy & Research
| Psychological Vital Signs
Advances in Cognitive Therapy
Brok on Chaplin |
Conversation with Aaron T. Beck - 2006 | Dr.Phil |
21st Century Ethics | Media: Town Hall '06
2007 Convention Highlights:
Humanizing an Inhumane World | Opening Session
| Albert Bandura |
Linehan, on Suicide
Psychology's Future | Conversation with Aaron T. Beck - 2007 | Evil, Hate, & Horror
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