American Psychological Association
New Orleans, August 10-13 2006
|Photo by Fenichel: 12 August 2006
|Aaron T. Beck in Conversation with Frank Farley|
A Conversation with Aaron T. Beck
12 August 2006
This very special presentation began with Dr. Frank Farley leading the audience in singing Happy Birthday (his 85th) to Dr. Beck. Farley then noted that he'd observed a hot discussion between Beck and another person sitting in the front row, Albert Bandura, and prompted the two legends to plan for a full-session discussion between the two of them in this forum next year. They agreed! You're hearing it here first.
Beck, referring in part to a discussion about theory and practice which he'd participated in the previous day (with his daughter as well), explained why it was necessary to develop a new framework beyond psychoanalytic thought, which was a question asked but only partially answered the previous day. He'd reflected on it and decided that the main departure, even though he fully believed in the importance of many aspects of the psychodynamically oriented approach including exploring some of the origins of what eventually become dysfunctional beliefs, psychoanalysis is oriented around Freud's own contention that "the cardinal feature of psychoanalysis is the focus on repression and the unconscious". Reaction formation and the other defenses which ward off painful/unacceptable unconscious experience comprise "the blueprint in which all the psychoanalytic and psychodynamic therapies are based." Of course there are similarities in approach, as both psychodynamic therapies and his own style of cognitive therapy are "both introspective therapies.... Freud put patients on the couch and used free association [and interpretation] so that repression would be identified. New therapies see a continuum. Some things are always going to be unconscious," he said, adding that some things (such as unimportant bodily states) *should* remain unconscious rather than cluttering up one's conscious awareness.
There are variations in how deep one can or should go in order to explore aspects which might fall under the general heading of transference, or resistance. For example, "If I'm talking right now, my thinking might be 'I want to get my point across'. And underneath that: 'I hope I'm getting my point across'. And under that, 'What a nice audience!'" But, it's not possible to focus on everything, all the time. A case study was presented as an example, following his own illustration above. A patient was asked what she was thinking. "I want to impress you." And how was she feeling? "Anxious". Beck proceeded to explore this and found that the patient also confessed to "a little fleeting thought that I might be boring you". Beck immediately gleaned important information from this, relevant to underlying beliefs and/or sense of self, and could see from this very early-on exploration of "transference" that this was an example of "thinking which is 'correctable' ... We try to correct dysfunctional thinking."
Beck feels there is "not always a need to discuss parents" or other aspects of childhood, though of course many beliefs do stem from earlier experience. "We try to get transference out of the way in the first 5 minutes" rather than using it as an ongoing vehicle for interpretation. He might ask "what are you thinking?"
Patient: "I'm annoyed I've been kept waiting." OR ... "You took me so quickly I must be seen as really sick". A lot of information is derived in this manner.
Beck presented several other case studies, which clearly reflected both his clinical acumen as well as his use of cognitive therapy in a way which draws on both subjective and objective experience. In one case he described how he did role-playing with a woman who felt rejected and devalued after her father died, as her mother seemed to withhold further love. Beck role-played the mother at first, being self-centered in describing her pain at losing her husband. Then the patient was asked to role-play her mother and was able to see now, her mother's point of view: "Yes [Mother], I realize how bad you felt when Daddy died, but think how it affected me too." It was like pricking an abscess, as she understood suddenly the dynamics behind her feelings and beliefs of being devalued. [Here Beck noted some related approaches such as "schema focused therapy".]
Someone in the audience asked how someone might know what sort of psychologist to choose, as a potential client. Beck noted that "the usual resources are on the Internet" -- just type in "psychotherapy" on Google and it will lead to sources such as the NIMH and other clearinghouses which discuss various types of available treatments.
Dr. Farley introduced the very topical and important area of terrorism (this was a week in which a huge plot was intercepted and US airports became tangled up in new security measures). Beck said that while he's not an authority in this specific area, it seems to him that hostility can be a defense. "When I look at 2 warring parties, what strikes me is that they have identical images of the other: We're saints, they're sinners, we're all good, they're all bad." (In passing, he later mentioned Kernberg and BPD concepts, and this example of "splitting" seems very relevant). The dominant belief is "we're all good, they're all bad". Returning afterwards to watch the international news, including interviews with citizenry in the Middle East, this us/them good/bad split is clear to see.
"With a moderate threat we [humans] try to moderate them. With extreme threat we try to exterminate it." He described how a colleague in Pakistan interviewed a Jihadist in Pakistan, and heard how "America is filled with expansionist people" and so on, all negative. In Europe there is negative opinion too, though less extreme. As for the terrorist groups, Beck reminded us that "groups are made up of individuals, and collective thinking can feature the same extreme reasoning. If you want it broken down to bare bones, it's a matter of survival." He cited one example of a leader scaring and rallying people: Hitler. "Nothing will get people aroused so much as thinking here is a danger to their self, or collective society." He mentioned that there are some DBT/empathy groups designed to bring groups together.
There was a question next about: schizophrenia.
"That's a very exciting area," replied Beck. "Cognitive therapy actually has a great deal to offer in terms of treating schizophrenia." Beck described a major study having been done in the UK and producing very powerful results. In fact, he mentioned several studies which compared CBT with or without pharmacological treatment.
A $10 million controlled study by Kady highlighted how 1/2 of all psychiatric patients don't take their medications anyway, out of discomfort, concerns about weight gain, Parkinson-like symptoms, or feelings of being drugged. As it happens, there is some evidence also that psychotherapy can help even without drugs, despite schizophrenia being a biological disease. Four subjects in the study did as well as those on medication, though they were not.
A Cornell study on brain changes found differences in the reactivity of the amygdala after undergoing a course of cognitive intervention.
Here a member of the audience asked about implications for children, whose developing brains are quite elastic. Beck cited 18 studies with depressed children whose parents were depressed as well.
A question was asked about computer based program, particularly a CD developed by the Wrights and Dr.(Aaron) Beck, who described how this CD been "used as a way of demonstrating automatic negative thinking". They found that utilizing the CD cut down subsequent visits (for f2f treatment) by 1/2. "So computer-assisted approaches can be effective. The Internet is being used effectively too, in some places where there are no therapists available: There are ways of transporting cognitive therapy across the airwaves."
Dr. Farley commented about various meetings of the minds, such as Beck and Bandura today, but also a few years back when Beck met and then interviewed John Nash, the brilliant -- and schizophrenic -- mathematician who was the subject of "My Beautiful Mind". On first meeting, Nash seemed quite "strange" and tangential. Two years later Beck had dinner with him and he seemed entirely "normal" despite being off drugs. Beck wanted to know the secret, and sought to do a very careful and sensitive interview/evaluation without any great risk of setting anything off. He found Nash to be quite "stable" with no evidence of fuzziness or cognitive slippage. So how did he recover? Beck reviewed the psychiatric history and symptomology. Not long ago, Nash had been in Europe, believing that he was on a mission to save the world. While he thought he had a proper goal, his wife and other significant others became estranged. He reasoned to himself that perhaps even though he was right in his goal, he should let it go, as "there were consequences". By the time the book (on which the movie was based) was written, Nash was no longer overtly psychotic.
Someone suggested to Beck that "maybe he was doing cognitive therapy on himself". Beck was of course curious about this prospect and eager to hear more from Nash himself. Nash was in fact happy to talk about himself, thinking it might help others. In addition he wanted to resume his lecturing in the area of math, in which he was brilliant. He was feeling more confident of having his thinking skills at his disposal now. He told Beck that before he knew he had gotten sick he wrote what he felt was a great article, which in fact received praise by reviewers. But later, some grad students pointed out serious flaws. At this point there ensued a bit of discussion of about schizophrenia and the family, Farley noting that Einstein's son was schizophrenic and was never visited by his father.
Dr. Farley turned next to the topic of suicide (which had been discussed the day before in Beck's presentation with his daughter.) Asked to briefly comment on the topic, Beck noted that in his experience, "often as depression clears up, suicidal ideation clears up. To prevent suicide you have to address one issue in particular: Hopelessness." Hopelessness is intimately related to suicidal ideation, for readily apparent reasons.
But aside from clinical experience, there is also empirical evidence, with a hopelessness scale proving to be a good indicator of suicide. Without hope, suicide becomes an attractive alternative to going on suffering eternally, in the experience of some. "In some people, the suicidal wish is a craving which is so strong, it's like that of a substance abuser. We need to provide ways of dealing with that."
Beck presented another case example, in this instance of someone with bipolar disorder, a very high-risk group. Beck went over the reasons for living versus reasons for dying with this person, and it was clear s/he had many reasons for living. He made a pie chart and asked "what percentage of you wishes to die?" At first he replied that the vast majority wished to die. He was then asked how much value his family and friends deserved, and after giving them value he ended up left with only around 10% of his pie suggesting the value of suicide.
Beck also employs the use of a "coping card", a sort of cue card summarizing problematic thoughts as they occur and facilitating use of a successful strategy. Beck's patient went rapidly into depression at times, and on one occasion it was severe, but he remembered and utilized the card. Beck noted that although widely employed as a strategy with suicide-oriented patients, contracts may be of little help where someone is really intent on suicide.
Beck cited a 10-session treatment study where it was found that cognitive therapy cut down re-attempts by 50%.
The question was asked, what about OCD, another prevalent condition where it would seem cognitive approaches would be appropriate.
Beck noted that "the mind can think of the most extreme things", with convictions about pending disasters, or moral convictions, etc., though with OCD the recurring obsessions can be looked at, the thoughts being "ego alien" rather than invisibly integrated. However, for reasons which can be readily understood with some reflection, "a ruminating person is at higher risk for suicide". [See above, for example, about hopelessness.] In fact, on a scale of suicidal ideation, "aside from hopelessness, planning was the most powerful predictor" of suicide efforts. In therapy, just talking about this planning can be very important. "You want to get the plan out in the open; if they can just talk about it they may be relieved" and the danger somewhat lessened as the pressure gets vented.
Farley, noting that we were in the presence of "the world's leading psychologist and leading psychiatrist", invited Bandura to comment on any of the discussion thus far.
Bandura conceptualized some of the dynamics of the case presentations as related to the "locus of treatment" having shifted away from psychoanalytic to cognitive factors. He presented his own case study, of a youngster with problematic anti-social behavior, living and being ejected from foster homes, due to fire setting and other behaviors. His inclination would be to "make a distinction between historical causes and contemporary causes", meaning that of course the youth may have had a basis for his feelings of rejection and mistreatment, but it was his response to situations now which were the problem. "The problem was what he had learned as a mode of behaving." He would provoke instructors, for example goading and insulting them. On one occasion Bandura left the room while with this youth, trusting him for a short time, only to return and find his walls mightily marked up and defaced. He began thinking about a "confirmatory loop": you trust him, he violates it. Understanding this gives us "something to work with. We aren't treating the past. His problem is the contemporary causes, not the historical. Look at the confirmatory loop." And thus is a somewhat different way of conceptualizing "here and now" cognition with a bit of behavioral analysis as well, seen through the lens of the "confirmatory loop".
Farley returned to Beck and asked if there were any new applications of CT he might share. Beck cited a study coming out of Lyons, France, which was looking at heart arrhythmia and a device being utilized to deliver a shock when needed. The study found that among patients who were given cognitive therapy, less shocks were delivered. His take on this is that reduction of anxiety was exerting a tangible impact on heart function.
In passing Beck mentioned some other work with high-functioning autistic adults, or Asperger Syndrome adults. The focus was on providing social skill training to try to ameliorate negative self-attitudes. (This makes good sense to me, as someone who has worked with Asperger children, teens, and adults; I discussed one case with Beck, after the presentation, where the complaint, in what I think is a clear cognitive example, was that "nobody wants to be my friend because they already have their friends", which became a self-fulfilling prophecy at times, or perhaps what Bandura referred to as a loop.)
More questions from the audience were invited. The first was from someone whose work centers on "creativity" and who noted that many people are resistant to medication as they believe it interferes with their creative edge, or output. Beck replied that he doesn't have a lot of experience in this precise area, but in his work with bipolar disorder he has encountered individuals who felt similarly, and hated taking lithium. He found that offering CT often could help, even despite the non-compliance with a course of medication. There was an additional problem with bipolar populations, unmedicated, seeking to stay in the hypomanic phase. There were "advantages and disadvantages" of doing this, most basically the inevitability that "if you go high, you're going to go low again".
Beck recalled treating one patient who was "depressed because he expected to win the Nobel Prize" but hadn't, and this consumed him. As with an earlier case presentation (above), Beck utilized a pie chart and asked the patient how important the Nobel Prize was to him relative to the entire 100% of his life (as represented graphically by the pie). The answer: It was 100%. "But what about the rest of your life?" OK, maybe 10% could be allocated to that. "And what about your marriage?" OK, another 10%, with the Nobel prize now occupying 80% of his life. And his friends, what were their value? 10%. And his children? "Oh gosh, they're terrific kids, though I haven't gotten much out of them." Now the focus shifted, as Beck sensed something important. "What was YOUR childhood like?" At this point the patient seemed ready to cry, and gushed out how he had himself felt neglected to the point of vowing that no matter what he would be a better parent to his own children. "So then, how important are your children to you?" 80%. After appraising this and the value of wife and friends, the importance of the Nobel Prize was now seen in context with life as a whole, and assigned 10% of the pie. In the end, this person "never got the Nobel Prize. But he is happier."
Bandura commented that he often encounters the dynamic of "regret" among patients, and underscored the importance of social relationships. "No one on their death bed ever regrets that they didn't spend more time in the office."
Beck was asked, after having referenced Linehan's DBT and Kernberg's object relations approaches to BPD, if the dynamic of "splitting" creates as difficult a time for him using CBT as it does for clinicians using other approaches, often finding it extremely difficult to achieve positive results due to the fragmenting and splitting. Interestingly, Beck's response began with highlighting the importance of patients feeling understood. He said that he admires Linehan's work with this population and in terms of the process, "she calls it validation. We call it empathy. I'm not sure of the difference. You need to really tune in -- [to the] patient's frame of reference. Once you have established a bridge, [then you] will look at the way a patient jumps to extreme conclusions." [This also seems consonant with the function of Beck's pie graphing, illustrating how things are relative.]
What Beck will also do is try to recreate experience in vivo (as he did in the early example of a role play). A patient for example might say "my husband told me [xyz]" and Beck's response would be to ask "how did you *feel*? You can't ignore feelings!" The patient, it turns out, felt rejected and tended to jump to extreme conclusions. (One day the husband was a total angel, the next he was a worthless devil, that sort of extreme splitting.) Beck might "reconstruct it", the event and context which caused this woman to become upset when her husband told her whatever, for example in this case the husband had indeed forewarned about an upcoming meeting but when he mentioned it was imminent she went into an extreme reaction. He spotlighted the sequence of events here, and dissected the husband's comment and then her reaction to it. This form of query, Beck said, is "something Ellis does so well." He continued: "It doesn't mean extreme thinking will go away. And sometimes it's valuable. But you [the person with this tendency, learns to] catch it and correct it. And oh yes, sometimes they set you up as omniscient. You have to calm that down, and become a partner.
The last question was about any special issues or considerations in working with older populations.
Beck noted that this population is often feeling bereaved. Some may have had no practice with social friendships and/or may now have lost their friends. He mentioned that one of the nation's highest suicide rates is seen in Dade County, Florida, home of a great number of elderly people. Many "have social isolation, medical problems, and a tendency towards depression". On a functional level you may find someone once active in playing tennis, who cannot now see the ball well enough to play, losing one of their greatest pleasures. Such people may benefit from *coaching*. "You need to make certain compromises, learn techniques" which work. He gave an example of one patient living with Parkinson's disease who was very self-conscious of his tremor and was anxious about picking up a beer mug. What he found is that he would shake less if focused on talking with his friends as he was drinking rather than on the beer mug. It did not need to be an "all or nothing" proposition, and the sense that it was could be lessened.
From here, as time ran out, a long queue formed, as seems always to be the case, as admirers and colleagues sought to offer comments, ask questions, take pictures, or get autographs. And that was this year's conversation, to be resumed next year with Bandura as a full participant!
Regards from the City of New Orleans, City of Hope.