Applied History of Psychology/Cognitive Therapy - principles, theory, and key figure

Cognitive Therapy

Key Figure

Aaron Beck was born July 18, 1921 in Providence, Rhode Island, United States, to Russian Jewish immigrants. Beck’s birth, as the youngest of five children, was into a family marked by tragedy; a brother had already died in infancy as had a sister during the influenza pandemic in 1919. One consequence of these events was that Beck’s mother was severely depressed for periods of Beck’s childhood, providing him with his first exposure to a principal focus of his future career. Beck viewed himself as a replacement child, effectively easing his mother’s sense of loss. It seems fitting that Beck’s arrival apparently served as at least a partial cure for his mother’s depression, setting him on his life’s work at a very early age.

A childhood accident in which Beck’s arm was broken and became infected represents another important episode from which we can trace Beck’s later interest in and understanding of psychopathology. Beck’s condition had been serious and his recovery in hospital was long and arduous; he developed a number of phobias and anxieties as a result and his extended absence from school led him to believe he was stupid and inept (beliefs compounded by a harsh grade one teacher who held him back). But through self-help and hard work Beck eventually overtook his age-matched peers. Weishaar (1993) quotes Beck as recalling of his ‘comeback’, “psychologically it did show some evidence that I could do things, that if I got into a hole I could dig myself out” (p. 10). His school success over the next few years illustrated for the young Beck the power of disconfirming evidence in the face of negative thoughts and beliefs about oneself, a realization that became a corner stone of his later therapy model. As well, Beck considered the anger of this teacher and his mother’s mood swings to have been instrumental in developing his pronounced sensitivity to changes in others’ moods, a skill that his students and colleagues observed many years later to be a key feature of Beck’s therapy work (although somewhat less evident in his therapy writings).

It wasn’t until conversations many years later with David Barlow (the renowned behavior therapist and anxiety specialist) and his 1985 adaptation of his therapy model for anxiety disorders and phobias that Beck fully understood the phobias (of abandonment, of blood, and of surgery) he developed following his childhood accident and convalescence. Indeed, he wrestled with these for years, attributing his entry into medicine as partly an attempt to defeat them, and using his internship experiences on rotations in surgery and internal medicine to disconfirm the beliefs that underscored these phobias. Beck drew on his first-hand experience with phobias and anxiety, and also his bouts of mild depression (funding limitations and the loss of an office on campus marked a difficult period for him in the mid-1960s) as valuable experiences from which he gained insight as he wrote his books on the causes and treatment of there disorders (the first of which was published in 1967).

Beck graduated Phi Beta Kappa from Brown University in 1942 and completed his M.D. at Yale in 1946. Although initially interested in psychiatry, Beck could not embrace the Kraeplinian approach to psychiatry, which he found to be nihilistic. Nor was he wholly comfortable with what he considered to be the soft and esoteric approach of the Psychoanalytic School of Psychotherapy. His initial rejection of the latter reveals another key characteristic of Beck that set the stage for his venture toward an innovative theory of psychopathology and psychotherapy of his own. Weishaar (1993) quotes him as recalling, “It [psychoanalysis] was nonsense. I could not see that it really fitted. I always had a kind of rebellious thing… [but] this was probably the first time I was aware of it” (p. 14). His evidence-based training in internal medicine led him instead to pursue neurology with its precision and empiricism but a required rotation back in psychiatry meant his struggles with psychoanalytic thought and therapy were only really just beginning. However, he remained in psychiatry after the required six months, slowly ‘seduced’ by the manner in which psychoanalysts had interpretations and explanations for everything and by the promise of psychoanalysis as a cure for most conditions. Beck was even supervised by Erik Erickson, the renowned German psychoanalyst, during his two-year fellowship in psychiatry at the Austin Riggs Center in Massachusetts.

Beck was board certified in psychiatry in 1953 and began teaching in psychiatry at the University of Pennsylvania Medical School in 1954. After finishing his analytic training at the Philadelphia Psychoanalytic Institute he took a post as an assistant professor of psychiatry at Penn in 1959. At that point he set about researching the empirical basis of psychoanalytic theory, with the objective of convincing ‘hard-headed psychologists’, who Beck recognized as influential but rejecting of psychoanalysis, of its scientific validity. Beck focused on the dreams of depressed patients because he believed that the psychoanalytic theories of depression were both well-developed and testable (and he had a readily available depressed population with which to work). However, using procedures from experimental psychology (learnt from colleagues in psychology such as Seymour Feshbach), the collective evidence from these studies (which was quite the contrary to the retroflected hostility, need to suffer, and seeking of failure predicted by psychoanalytic theory), led Beck to view depressed patients instead as holding distorted views of themselves and reality. His research results matched his experiences with patients in therapy. Beck has pointed to the lack of empirical support as the reason for his moving away from the motivational basis and associated structures of psychoanalytic thinking. But according to his collaborator, Ruth Greenberg, his personality, particularly the aforementioned rebelliousness, would have undermined his ability to remain within the psychoanalytic fold for very long (Weishaar, 1993). Beck erred towards his own data rather than the psychoanalytic authorities of his day. Beck also liked to be in control, Greenberg recalled, something that he would have lacked while undergoing analysis himself; it is likely no coincidence that his Cognitive Therapy explicitly involves the patient in a collaboration with the therapist and makes the patient their own authority.

As he developed Cognitive Therapy, Beck drew on the work of psychologists (such as George Kelly and Jean Piaget in his initial formulations), finding support in the advances made with the emergence of cognitive psychology in the 1970s (including the work of individuals such as Albert Bandura), and later corresponding with fellow cognitively oriented theorists and therapists including Albert Ellis and Donald Meichenbaum. But what is interesting about his break with psychoanalytic thought and therapy is just how quickly and comprehensively he formulated his alternative model of psychopathology and therapy. As he recollects, “Within a couple of years, I really laid the framework for everything that’s happened since then. There’s nothing that I’ve been associated with since 1963 the seeds of which were not in the 1962 to 1964 articles” (Weishaar, 1993, p. 21). In coming up with Cognitive Therapy, Beck described the process as having involved, first, observing his patients and developing ways to measure his observations; second, advancing a theory to explain these observations; third, devising interventions to address them; and, fourth, designing research to confirm or disconfirm the whole enterprise. The development and use of measures in psychotherapy (among which the most well known are the Beck Depression Inventory, Beck Anxiety Inventory, and Scale for Suicide Ideation) represents one area in which Beck’s pioneering efforts made a huge and influential contribution to the field more broadly. A second area in which Beck’s contribution is clear is in evaluation research work. From the beginning, Beck emphasized the importance of empirical evaluations of therapy, with the first study of his own Cognitive Therapy published in 1977 by Beck’s close collaborator, Shaw, and a recent review of 16 meta-analyses by Beck and his colleagues appearing in 2006. A third area representing another of his major contributions is reflected in Beck’s publication in 1979 of what was, essentially, a therapist’s ‘how-to’ guide to the treatment of depression. This book was based on the early training manual and its revisions that Beck had used as he recruited and trained his team of psychiatrists and psychologists in his clinical and research endeavors. The manualization of treatment approaches has greatly facilitated the training of psychotherapists and, since Beck’s initial efforts, has become a mainstay of treatment program evaluation research today (Woody & Sanderson, 1998), affording researchers a means to introduce and monitor treatment integrity and fidelity and so discern what differences truly exist between models and approaches under scrutiny.

It should be noted, however, that Beck’s ideas and therapy weren’t the only developments that undermined the dominance of psychoanalytic thought in psychiatry. Biological models of psychopathology and pharmacological treatments were (re-)emerging in the 1960s too. Indeed, it is interesting to note that the two articles Beck published in 1963 and 1964 in the journal Archives of General Psychiatry (articles in which he first set out his theory of depression, his clinical observations and evidence in support of it, and its application to psychotherapy), appeared alongside numerous articles about the biological basis and assessment of depression (e.g., Gibbons, 1964; Kurland, 1964; Wechsler et al., 1963). Of course, Beck wasn’t alone in his desire to better understanding and treating depression but he was quite distinct from others, in that he was putting forward his ideas about the role of cognition (combining the patient’s internal experience, specifically their accessible thoughts and feelings rather than the subconscious motivations emphasized by psychoanalytic thought, with an emphasis on empiricism borrowed from behavior therapy) at a time when North American psychiatry was quite distracted by a paradigm shift that was already underway. Unlike Beck, his fellow ‘radicals’ in psychiatry (and their articles book-ending Beck’s in the 1960s) were struggling to give nature a place back at the table, turning from phenomenology to biological models and pharmacological treatments. It is of interest that these efforts eventually ushered in the renaissance of biological psychiatry in the 1970s (Shorter, 1997), with Beck’s work appearing conspicuously more at home in the context of the cognitive revolution in psychology, which also was taking place in that period.

It seems fitting to end this selective consideration of Beck’s biography and contributions as we started, by looking back at Beck’s family. Beck faced considerable resistance to his ideas throughout his career from the psychoanalytic and behavioral schools. Despite this resistance, and his own history of various phobias and depression, Beck was evidently a strong and determined individual, able to work for many years in relative isolation (although his preference has clearly been for collaborative efforts (see, for example, some of his key publications). It is in Beck’s parents that the source of these characteristics can be clearly seen. Turning first to Beck’s mother, Lizzie Temkin, we can see the same determination and autonomy that her youngest son showed later. The premature death of Beck’s grandmother meant Lizzie, as the oldest of nine, had to assume much of the responsibility of caring for the family, and she maintained her role as matriarch throughout her life. Although three of her brothers graduated from universities, her own aspiration to be a physician went unfulfilled. But her dominant and outspoken manner must have been an inspiration of sorts to Beck in later life as he persevered to develop and disseminate his research and psychotherapy.

In Beck’s father too, Harry Beck, a printer by trade, we can see the foundations of some of Beck’s characteristics. Harry was not nearly religious enough to endear himself to Lizzie’s father when their marriage was announced. This was, in part, due to Harry’s active involvement in the socialist movement (having been an anti-Bolshevik in his native Russia). Harry was also something of an intellectual in their Rhode Island community, serving as a regular host of meetings in which politics, philosophy, and literature were discussed, and later taking courses in literature and psychology at his son’s future alta mater, Brown University. All his sons inherited their father’s intellectual curiosity; Beck is known to have wide and eclectic reading interests. As well, it is interesting to note that just as his father regularly sought feedback on his poetry from his sons, Beck went on to regularly seek feedback on his ideas and manuscripts from his colleagues and students. Most notably in the context of these comments is the fact that Harry was a free-thinker, not merely someone who unquestioningly went along with prevailing wisdom and practice, just as his youngest son proved to be years later as a pioneer in the psychotherapy field.

Brief mention must also be made both of Beck’s prolific output (he has published over 500 articles and authored or co-authored 17 books, as reported on the website for the Beck Institute for Cognitive Therapy and Research), and also the plethora of major awards Beck has received over his lifetime (41 are noted on the Beck Institute website). These serve as testament to the considerable importance of his work. Of particular note are the awards he received from the American Psychological Association, in 1989, and from the American Psychiatric Association, in 2006, but also earlier and perhaps of greater historical interest, in 1979, at a time when the American Psychoanalytic School were strongly resisting the purging of its influence in the DSM (see Bayer & Spitzer, 1985) and whose adherents would not have been welcoming of any recognition of Cognitive Therapy. Indeed, Beck is the only individual to have been honored by both Associations.