January 11, 2000

A Pragmatic Man and His No-Nonsense Therapy

PHILADELPHIA -- The session, Dr. Aaron T. Beck recalls, began like many
others. The woman lay on the couch, describing her sexual encounters with
men, while Dr. Beck, at the time a recent graduate of the Philadelphia
Psychoanalytic Institute, sat behind her, scribbling in his notebook.

"How does talking about this make you feel?" he asked her.

"I feel anxious," she replied.

Trained to probe the hidden conflicts underlying psychological symptoms,
Dr. Beck responded with an interpretation.

"You are anxious because you are having to confront some of your sexual
desires," he told her.

"And you are anxious because you expect me to be disapproving of these
desires."

"Actually, Dr. Beck," his patient replied, "I'm afraid that I'm boring you."

Arms crossed on his chest, red bow tie resplendent, pale blue eyes keen
beneath a shock of white hair, the founder of the fastest growing, most
extensively studied form of psychotherapy in America is telling this story
to explain how he eventually came to leave Freud behind.

Sitting in his office at the Beck Institute for Cognitive Therapy and
Research in Philadelphia, he offers a favorite maxim: "There is more to the
surface than  meets the eye."

The key to many psychological difficulties, Dr. Beck has found in 40 years
of research and clinical work, lies not deep in the unconscious, but in
"thinking problems" that are much closer to conscious awareness.

In the woman's case, for example, it turned out that she engaged in an
endless self-deprecating monologue, an inner voice constantly berating her
that she was unattractive, uninteresting and worthless.

And these "automatic thoughts," as Dr. Beck calls them, led her to behave
in self-defeating ways, like acting promiscuously because she did not think
she had much else to offer, or engaging in histrionics in an effort to seem
more interesting.

Cognitive therapy, developed by Dr. Beck  after he abandoned
psychoanalysis, is intended to help patients correct such distortions in
thinking, often in a dozen sessions or fewer.

Dr. Beck calls the method  "simple and prosaic," with  no dredging up of
lost childhood memories, no minute examination of parental misdeeds, no
search for hidden meanings.

"It has to do with common-sense problems that people have," he said.
Patients in cognitive therapy are encouraged to test their perceptions of
themselves and others, as if they were scientists testing hypotheses. They
receive homework assignments from their therapists.

They learn to identify their "inaccurate" beliefs and to set goals for
changing their behavior.It is an appealing package. And in an age when
managed care closely monitors the consulting room, and most psychiatrists
view drugs -- not talking -- as the treatment of choice for their patients,
Dr. Beck's approach has been able to provide hard data in support of
psychotherapy's power.

Cognitive therapy's basic precepts are easily summarized in training
manuals and its simplicity makes it an ideal research tool. And dozens of
studies have shown it to be effective in treating depression, panic
attacks, addictions, eating disorders and other psychiatric conditions.
Researchers are also studying the therapy's ability to treat personality
disorders and, in combination with drugs, psychotic illnesses like
schizophrenia.

Therapists from around the world travel to the Beck Institute for training.
And mental health organizations like the National Mental Health Association
recommend cognitive therapy to patients as one of the few forms of
psychotherapy  studied in large-scale clinical trials.

Yet every theory of the human mind in general springs from a human mind in
particular. Freud, caught in his own Oedipal struggles, saw the unconscious
as  roiling with sexual and aggressive impulses. Fritz Perls, possessed of
a biting wit and fond of confrontation, invited his patients to take the
"hot seat." Carl Rogers, a former seminarian and by all accounts an
empathic soul, argued that psychotherapy should be "client-centered."

And in its way, cognitive therapy -- practical, cerebral and to the point
-- is also a fair reflection of the man who conceived it. He is 78 now, an
emeritus professor of psychiatry at the University of Pennsylvania, four
times a father, eight times a grandfather. Yet even as a younger man, his
former students say, Dr. Beck, with his white hair and the bow tie he
carefully affixed each morning, projected a grandfatherly air, offering a
nurturing presence, a passion for collecting data,  a conviction that
evidence always trumps opinion.

Others in his position might cultivate the flamboyance Americans seem to
expect of their therapy gurus. But Dr. Beck has more in common with Marcus
Welby than Dr. Laura Schlessinger or John Bradshaw -- his currency ideas,
not personal charisma. Soft-spoken and unexcitable, he wears a hat, chats
amiably with strangers in elevators and uses  words like "gosh" and "gal."

Asked to describe himself, Dr. Beck ticks off  "kind, intelligent,
creative, flexible."

"I don't need to be right," he says, "but I don't like to be wrong."

Dr. Jeffrey Young, a former student, now the director of the Cognitive
Therapy Center of New York, recalls a debate with his professor over
whether those who came to them seeking help should be referred to as
"patients" or "clients." Dr. Beck had a simple solution: Ask people what
term they  prefer.

"I think I am ultimately a pragmatist," Dr. Beck says. "and if it doesn't
work, I don't do it."

He encourages a similar philosophy in his patients, hoping they will
eventually choose to let go of the self-defeating attitudes that tie their
lives in knots.

"It's a testable assumption," Dr. Beck tells a 30-year-old woman who
believes, she told him, that "if I don't punish myself, God will be mad."

"You could see if you stopped punishing yourself and nothing happened," he
suggests.

With patients convinced that they must always be perfect, that their bosses
hate them, that their spouses are insensitive to their needs, he will
question, gently, "Would you agree that it is against your best interests
to have this belief?"

He will ask: "What are the disadvantages to thinking this way?"

He will wonder out loud: "Do you think it is possible to ignore these
thoughts?"

It is a faith in the rational mind he has carried since childhood, growing
up in a middle-class neighborhood of Providence, R.I., the third son of
Russian Jewish immigrants, his father a printer with strong socialist
beliefs who wrote poetry in his later years, his mother a forceful woman of
unpredictable moods who had already lost two children.

He was a Boy Scout, an active child who, despite his mother's
overprotectiveness, played football and basketball until at 8, he developed
a dangerous staph infection after surgery for a broken arm, a complication
that kept him in the hospital for more than a month. He remembers the
surgeon saying "he's not under yet," remembers a terrible dream of a series
of alligators, each biting the tail of the next, the last alligator biting
his arm.

He remembers his mother saying: "He will not die. He will not die."   The
boy himself never questioned that he would recover. But the surgery, Dr.
Beck believes in retrospect, was a defining moment in his life, restricting
his activities and forcing him to find quieter forms of entertainment, like
reading. The hospitalization defined his life in other ways, too. He
developed a phobia of blood and injury: a hospital scene in a movie was
enough to send his blood pressure plunging. If he smelled ether, he became
anxious and began to faint.

He conquered his fears methodically, allowing logic to gradually triumph
over irrationality. "I learned not to be concerned about the faint feeling,
but just to keep active," he says.

With such a straightforward attitude toward his own psychology, Dr. Beck,
was probably never meant to become a psychoanalyst; even now, his interest
in how his childhood experiences shaped him seems minimal.

Freudian theory was  ascendant in psychiatry departments across the country
when he was a resident at the Cushing Veterans Administration Hospital in
Framingham, Mass. And like many of his peers, he pursued analytic training,
graduating from the Philadelphia institute in  1958.

Still, he had some doubts. The lack of precision annoyed him: Though every
analyst agreed that in neurosis there were "deep factors at work," no one,
Dr. Beck discovered, could agree on exactly what those factors were.

He found work with patients exhausting, because the goals seemed so
unclear. "The idea was that if you sat back and listened and said 'Ah-hah,'
somehow secrets would come out," Dr. Beck remembers. "And you would get
exhausted just from the helplessness of it."

Still, he  completed his training and began taking patients in for
analysis. But without any fanfare, he began to adjust the way he interacted
with them.

The woman who worried about boring him, for example, he asked to sit up and
face him, so that she could see his facial expressions and gauge his
interest in what she was saying. He began to ask more questions, and to
listen to the answers in a different way.

At the same time, at Penn, where he joined the faculty in psychiatry in
1954,  Dr. Beck  was trying to find empirical evidence for Freudian
precepts -- and failing. With a colleague, he designed an experiment to
test the link between depression and masochism, a basic psychoanalytic
notion. But the researchers found no evidence that the depressed patients
in the study somehow needed to suffer.

Instead, Dr. Beck said, they simply showed low self-esteem, devoid of
hidden motives. "They saw themselves as losers because that's the way they
saw themselves," he said.

The cognitive approach to therapy that Dr. Beck ultimately developed --
influenced, he says, by thinkers like Karen Horney, George Kelly and Albert
Ellis, whose rational emotive therapy struck similar themes -- was a major
departure from the psychoanalytic fold. And it was not received warmly.
Many analysts dismissed it as superficial; some suggested that perhaps Dr.
Beck himself "had not been well analyzed."

There have been other critics, as well. Psychologists trained in classical
behaviorism have opposed cognitive therapy's focus on "thoughts," which
they said could not be measured objectively. Biological psychiatrists, like
Dr. Donald Klein, director of research at New York State Psychiatric
Institute, have argued that the therapy is simply a morale booster for
depressed patients, not a specific treatment. Dr. Beck, for his part, has
responded to each critique  with a new raft of experimental data.

"He is an unusual person," said Dr. John Rush, professor of psychiatry at
the University of Texas Southwestern Medical Center and a former student.

"He is willing to test his own beliefs, just like he asks patients to test
theirs."

Yet in the early years it often was lonely work, and it was his wife,
Phyllis, now a Superior Court judge in Philadelphia, who buoyed him.

"She was my reality tester," he said. "She went along with the newer ideas
I had, and that gave me the idea that I wasn't in left field."

Many decades later, she remains his closest confidante. But it is his
daughter, Dr. Judith Beck, a psychologist who is director of the Beck
Institute, who participates most closely in his work.

Scene: A suburban delicatessen, a corned beef sandwich, his daughter
sitting next to him; a comfortable setting for Dr. Beck who, his colleagues
and former students say, is in fact very shy.

"Do you remember that dream I had when I was going off to graduate school?"
she asks him. "That I was up on the Empire State Building and I felt in
danger of falling off."

"I do," he says. "And do you remember what I told you it might be about?
That the higher you aspire, the greater you're going to fall?"

"It hit me as absolutely that was what it meant," she  replies.

As institute director, she has come to know her father in a different way,
to admire him as a thinker and a therapist, to work with him as a
colleague. When she was a child, she says, he was  always working;  age has
made him more tolerant, less driven, has turned him more toward family.

It has not slowed him down. He receives 10,000 e-mail messages a year,
divides his time between Penn and the institute, is expanding his research
into new areas. He plays tennis regularly, despite a recent hip replacement.

His newest book, "Prisoners of Hate: The Cognitive Basis of Anger,
Hostility and Violence," (HarperCollins, 1999) appeared last fall.

Retiring, he says, has never entered his mind.

"I think he has done a lot of cognitive therapy on himself," his daughter
says.

By  Erica Goode
Copyright 2000 The New York Times Company

janet paterson
52 now / 41 dx / 37 onset
a new voice: http://www.geocities.com/janet313/
613 256 8340 PO Box 171 Almonte Ontario Canada K0A 1A0