Essays - Autumn 2009

The Doctor Is IN

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At 88, Aaron Beck is now revered for an approach to psychotherapy that pushed Freudian analysis aside

By Daniel B. Smith

September 1, 2009


 

In the basement of Aaron Beck’s house, nine miles northwest of downtown Philadelphia, in a dimly lit, dusty, concrete-walled room dedicated to his archives, there sits a pink plastic box containing patient notes from a 40-year-old case of psychotherapy. Beck, a professor emeritus of psychiatry at the University of Pennsylvania, has short-cropped white hair, sharp blue eyes, and, at 88, a hunched and shuffling gait. He has been a practicing psychiatrist for 59 years. Among the thousands of patients Beck has treated during this time, this case rates as persistent but uncomplicated. The patient was in his mid-40s and had a good career, a loving wife, four beautiful children, and a trove of close friends. Privately, however, he struggled with an acute tendency toward self-criticism. He was of the type that can’t help but interpret neutral events as harsh reflections on his personal worth. He was forever searching for approval, and forever anticipating disapproval.

When the patient’s treatment began—the earliest notes date from the mid-1960s—the dominant psychotherapeutic approach in the United States was psychoanalysis. Sigmund Freud had made his first and only visit to this country in 1909, and in the half century that followed, his approach to mental suffering took firm hold of American psychiatry, splintering into a multitude of camps but always retaining a focus on the unconscious mind, the central feature of Freudian analysis. Beck was trained in this tradition. He was a graduate of the Philadelphia Psychoanalytic Institute, and from 1950 to 1952 he worked at the Austen Riggs Center, a world-renowned psychoanalytic hospital in Stockbridge, Massachusetts. Beck was an eager student. “I have come to the conclusion,” he wrote to a colleague in 1958, “that there is one conceptual system that is peculiarly suitable for the needs of the medical student and physician-to-be: Psychoanalysis.”

Fewer than 10 years later, Beck’s case notes betray none of this confident enthusiasm and not a hint that he had applied his training to his patient’s complaints. In the treatment, nothing analytic has survived. Whereas psychoanalysis uncovers deeply buried impulses, Beck is interested in those thoughts that lie barely concealed beneath conscious awareness. Whereas psychoanalysis uncovers the historical motives behind troubling emotions, Beck scrutinizes the present-tense logic of his patient’s emotions. And whereas psychoanalysis is ultimately pessimistic, seeing disappointment as the price for existence, Beck’s approach is upbeat, conveying a sense that, with hard work and determined rationality, one could learn not only to tolerate but to stamp out neurotic tendencies.

The patient is none other than Beck himself. The notes, and the self-therapy they trace, date from a period of his life when he was working, to the disdain of his analytic colleagues and the indifference of most everyone else, to develop the system of psycho­therapy for which he is now revered in the field of mental health. Beck is the inventor of cognitive-behavior therapy (CBT), whose guiding principle is that the driving forces of mental dysfunction are habitual, unrealistic, self-defeating ideas—“automatic thoughts,” in the clinical parlance—that, like tinted lenses, color one’s perceptions of, and therefore one’s reactions to, the external world. Today CBT is the most well-funded, deeply researched, popular, and rapidly growing psychotherapy in existence. It is taught in nearly every clinical psychology and psychiatric residency program in America, and it is the cornerstone of a new, $117 million program implemented by the U.S. Army to foster mental resiliency in soldiers. Beck, in turn, is today arguably the most well-known psychotherapist alive. His personal appearance and style—high-pitched speaking voice, open New England vowels (he was born and raised in Providence), and signature bow tie—are as eminently recognizable to those in the profession as the Freudian cigar and beard. In 2006, Beck won the Lasker Award, the most prestigious scientific honor in the United States, often referred to as the “American Nobel.” In 2007, he was short-listed for the actual Nobel, in physiology or medicine, although unlike every laureate in the 105-year history of the prize, he has never conducted biological research or invented a physiological or biological tool.

Beck’s enormous success stems in large part from CBT’s pragmatism and efficiency, features as well suited to the age of neuroscience as Freud’s work was well suited to the age of modernism. In contrast to the slow-going passivity of analysis, which traditionally unfurls over the course of years, the cognitive-behavioral therapist operates via a sort of laser-guided rationality. He begins by identifying the thoughts responsible for a patient’s distress in specific situations, and proceeds by questioning those thoughts to uncover the more general “core beliefs” that lie underneath. If a patient reports that he felt a pang of anxiety when his wife failed to kiss him on her way out of the house, for example, the therapist might question the patient until he uncovers the precipitating thought, “Maybe she doesn’t love me anymore.” If the patient can be led to question the evidence for or against this thought, and perhaps identify a more logical explanation for the missed kiss (“She was just running late”), the anxiety should decrease. A pattern of such anxious thoughts might uncover the core belief, “I’m not worthy of love,” which, if similarly chipped away at with logic, should make the patient feel lastingly better. Often, this very rapidly happens. In run-of-the-mill cases of depression and anxiety, the complaints for which most people seek out therapy, patients usually report a lessening of their symptoms after only 12 to 16 sessions.

The power of this approach has led it to be adopted, in one form or another, by a vast number of mental-health professionals. “Most psychotherapists, consciously or unconsciously, are doing a lot of the things that Beck pushed,” says the Nobel Prize-winning neuroscientist Eric Kandel. “They’re more directly involved, they’re giving more suggestions, they’re pointing out thought processes. Whether they call it Beckian or not, and whether or not they’re doing other things as well, they’re doing Beckian kind of stuff.” And yet, as Kandel and others are quick to point out, Beck’s revolutionary impact does not emanate from his development of CBT, but from the methodical way in which he developed it. “The crucial point is, Beck took a form of psychotherapy and he did a series of systematic, empirical studies that showed that it’s more effective than placebo, and that it’s as effective as antidepressant drugs in mild and moderate depression,” Kandel says. “And he wrote a manual for the therapy, a cookbook, so that others could do studies as well.” His rigorous, scientific, data-driven approach to psychotherapy represented, Kandel says, a “major, major advance” for the profession.

To understand why the introduction of scientific standards into the field of psychotherapy was groundbreaking, it is necessary to know what the scene looked like prior to Beck’s arrival. “From the early 1900s through the 1950s, people didn’t know what worked in psychotherapy and what didn’t,” says Donald Freedheim, professor emeritus of psychology at Case Western Reserve University and editor of A History of Psychotherapy. “There was a rule of thumb: about a third of patients got better, about a third got worse, and about a third stayed the same.” Without a reliable gauge of efficacy, therapeutic notoriety was conferred on those clinicians who, by sheer force of personality and persuasiveness of rhetoric, were able to attract the most acolytes, adherents, and patients. This “guru model” was precisely what Beck found unacceptable, and what he has dedicated himself to dismantling. He hasn’t been the only person to insist that psychotherapy rest on a foundation of replicable data—he wasn’t even the first—but he has been the position’s most dogged, visible, sophisticated, and influential proponent.

As a consequence, psychotherapy has been moving steadily from a model that is “eminence-based,” as a rueful saying has it, to one that is “evidence-based”—a powerful watchword in the field. Over the past several years, federal and state agencies in the United States and government-based health-care systems abroad have been spending hundreds of millions of dollars to disseminate psychotherapies for which there is a solid core of scientific evidence, while insurance companies have been encouraging the clinicians within their systems to practice “empirically supported therapies” (EST) above others. In short, more and more, Freud’s world of subterranean drives is becoming Beck’s world of scientific accountability.


Psychotherapeutic leaders have always tended toward the eccentric and extravagant. Carl Jung, in the words of Psychotherapy Networker, “lit his farts on camping trips, danced with tribal people in Africa . . . , and installed his mistress in his house (breaking his wife’s heart)”; Irvin D. Yalom, a pioneer of group psychotherapy, favors fedoras and beatnik turtlenecks and published a best-selling novel featuring Nietzsche; Albert Ellis, the so-called “Lenny Bruce of psychotherapy,” routinely yelled at his patients and was ousted from his own institute.

Compared to these figures—compared to almost anyone—Beck is modest, meticulous, and professorial. “Other than his bow ties, Tim just isn’t flamboyant at all,” Robert DeRubeis, the chair of psychology at Penn, told me. (Beck’s friends call him Tim, a diminutive of Temkin, his middle name.) “He’s not larger than life like a lot of other psychotherapeutic leaders.” When Beck delivers speeches, they are generally composed of scientific information and theoretical propositions, as if he were rehearsing the draft of a forthcoming journal article, which he often is. In conversation, he exhibits an expert therapist’s facility for patient listening—cocked head, furrowed brow, dedicated gaze—and when he talks, he does so meticulously, qualifying general statements, backing up his claims with evidence, and avoiding speculation. In January, during a long interview in his sunny, book-filled home, I asked Beck whether he had actively avoided taking on the role of . . . “the Buddha?” he interrupted me. “I definitely don’t want that role. And I’m still researching things out, I still have research grants. Whatever I say is always based on empirical study.”

By most accounts, Beck’s desire for precision is deeply rooted in his personality, so that the great mystery of his biography would appear to be why he ever pursued psychoanalysis, which for all the richness of its ideas never had much in the way of data to back it up. After graduating from Yale Medical School, in 1946, Beck specialized in neurology, a discipline whose procedures he found attractively exact. But the hospital where he was assigned had a shortage of psychiatry residents, and his superiors instructed him to do a six-month rotation in that field. It was a terrible fit. To Beck, psychoanalysis’s emphasis on invisible psychic forces seemed soft-minded and esoteric, more a faith than a medical discipline. Yet this very attribute also lent the field an alluring power. “The psychoanalytic mystique was overwhelming,” he told me. “It was a little bit like the evangelical movement.” Everywhere he turned, there were brilliant minds spouting brilliant-sounding theories. The psychoanalysts, whom he began to befriend, “had theories for everything. They could understand psychosis, schizophrenia, neuroses. Every single condition that came in, they could get a good, sound—apparently sound—psychoanalytic interpretation for.” When Beck questioned whether these interpretations had evidence to back them up, his friends suggested that unconscious resistances were preventing him from realizing the truth. Outnumbered and drawn by the intellectual wattage of his colleagues, he gave in.

Beck’s transformation was thoroughgoing but idiosyncratic. He read deeply into psychoanalytic literature, encouraged his friends to take to the couch, and underwent an absorbingly enjoyable two-year training analysis. (“How could you go wrong lying down on a couch for five hours a week and talking about yourself?”) The dominant form his passion took, however, was a desire for evidence, evidence that would prove to those who had not yet seen the light that psychoanalysis was valid. That he had no training in research and that no rigorous scientific studies of psychoanalysis had been conducted before does not appear to have daunted him. He simply tracked down academic scientists at Penn, where he was hired in 1956, who could teach him about good experimental design, and went looking for a theory to verify.

He settled on depression, which psychoanalysis attributed to a process known as “retroflected hostility.” In short, a person’s anger toward a loved one is deemed unacceptable by the unconscious mind, blocked by a defense mechanism from upwelling into consciousness, and redirected inward. (Still shorter: depressives suffer because they have a need to suffer.) Beck theorized that this taboo hostility could be found, and the overlying theory proven, by scrutinizing the content of patients’ dreams—Freud’s “royal road to the unconscious.” His study was rudimentary. He compared the dreams of patients who were depressed with the dreams of patients who were not.

First study, first failure. The dreams of the depressed patients weren’t characterized by hostility—in fact, they were less hate-filled than the dreams of the nondepressed—but by deprivation, disappointment, hopelessness: exactly what they felt in real life. In analytic terms, this was a perplexing finding, even downright invalidating. But Beck’s faith was strong, and he contrived a way to bend the results to his belief. The theorized hostility, he reasoned, must simply be more deeply buried than anyone had thought. It must manifest itself obliquely, in the form of unpleasant dreams, suicidal thoughts, and self-deprecation: a systemic masochism.

Beck might have stopped here, and become one of the many innovative but fundamentally traditional analysts that the profession generated throughout its heyday. But the scientists whom he’d turned to for his experimental education spurred him on by noting that all he’d proved so far was that depressives suffered—a monumentally mundane discovery—not that they had a need to suffer. Challenged, Beck devised a set of more empirical experiments based on the premise that depressives would actively court unpleasant experiences. In one study, a researcher subtly expressed approval and disapproval based on the types of words a patient chose from a multiple-choice questionnaire. Beck had a harder time accommodating the results of these experiments to his faith. Rather than seeking out failure, the patients sought out encouragement. They seemed to hunger for improvement. It was, he told me, “the first crack in the shell.”

The second crack, when it happened, split everything wide open. For years, Beck had been detecting, in the free-associative monologues of his analysands, a stream of thought that seemed increasingly consequential. He usually describes this discovery by telling about a promiscuous young woman whom he had been treating for more than a year at the University of Pennsylvania clinic, and whose habit it was to spend her sessions describing her lurid sexual encounters in great detail while Beck sat impassively in a chair behind her, taking notes. At the close of a typical session one afternoon, Beck asked his patient, in classic analytic style, “How do you feel?”

“Very anxious, doctor,” she replied.

Of course, Beck told her. That was because she was being forced to confront her deepest sexual impulses. When these impulses rose to her consciousness, breaking through her ego’s defense systems, they caused anxiety.

“You’re right,” she said. “That’s brilliant.” But she sounded tentative. Beck told her so.

“Actually,” she said, “I was afraid I was boring you.”

Beck was surprised. Fear of boring one’s analyst is not uncommon, but this patient had never mentioned it before. He asked her how often she thought she was boring.

“Oh, all the time,” she said. “I think it when I’m here with you, and I think it when I’m with everyone else.”

This was nothing short of revelatory. As engaging as his patients’ monologues could be, and as much emphasis as analytic doctrine placed on them, it was their mundane, reflexive, almost forgotten thoughts that now seemed to hold the true explanatory power. In this patient, for instance, the insidious belief “I am boring” explained why she slept around (afraid that she had nothing else to offer, she jumped into bed), why she wove dramatic stories in session (anything else might seem tedious), and why she was anxious. Once Beck realized this, he began to uncover similar thoughts in all his patients, as well as in his friends, his family, and himself. Our daily lives, he concluded, unwind to the accompaniment of a quiet but constant self-talk, through which all external events are filtered.

When Beck pieced together his experimental and clinical findings, in the early 1960s, he drew two conclusions about psychoanalysis. The first was that it was cruelly glacial. Psychoanalysis takes years, at the end of which the analysand typically feels much wiser about the roots of her misery but no less miserable. By homing in on his patients’ self-defeating thoughts, Beck found that he could alleviate symptoms in as few as 10 sessions. And the progress stuck. The second conclusion he drew was that psychoanalysis was a theory built on sand. Beck had been duped. “I concluded that psychoanalysis was a faith-based therapy,” he has said, “and that if I was going to practice or teach therapy, it had to be empirically driven.”


Beck’s turn against psychoanalysis wasn’t aggressive; he’s never had much of a taste for professional combat. Still, his foray into clinical research hardly ingratiated him to his colleagues. Even before he left the fold, the powerful American Psychoanalytic Institute rejected his membership application on the grounds that his mere desire to conduct scientific studies signaled that he’d been improperly analyzed. (The decision still has the capacity to make him angry: “It was just the height of stupidity . . . total thought control.”) And his fellow psychiatrists, after he left, treated him with an air of pitying condescension. “I was considered one of the deviates,” he says. “People used to say, ‘Poor Tim. He’s a good guy, he just needs more time on the couch.’”

Yet Beck was not intellectually homeless. By the early 1960s, academic psychologists had already accepted the idea that basic science could yield clinical insights—specifically, that studies of how rats learned and unlearned fear could be used to treat anxiety and panic in humans. These thinkers embraced Beck as an ally. Even more, they embraced him as an asset. Much of the public viewed behavior therapy, as the treatment that grew out of animal learning theory is called, as cold and unfeeling, an icy manipulation of stimulus and response. With his analytic background and interest in how the human mind processes information, Beck brought a much-needed warmth and nuance to the movement. He also brought a medical doctor’s access to large clinical populations and an uncommon talent for feeding the raw, messy data of psychic suffering into the clarifying machine of medical research. In 1972, Beck was invited to speak at a national conference of behavior therapists; accustomed to indifference, he brought 30 copies of a handout. Hundreds of people packed the room. Before long, behavior therapy had morphed into cognitive-behavior therapy, the lexical order reflecting a hierarchy of influence that still reigns today.

Beck’s alliance with the behaviorists proved both a clinical and a scientific boon. From them he borrowed the ideas that a therapist should carefully structure sessions and evaluate a patient’s progress as he proceeds; toward the second of these ends, he developed several patient questionnaires to measure the waxing and waning of symptoms over the course of therapy. Meanwhile, highly skilled young researchers flocked to Beck’s evocatively titled Mood Clinic, a leaky, decrepit set of offices with tattered chairs in the now-defunct Philadelphia General Hospital. (“You can do therapy in a barn” is one of Beck’s characteristically pragmatic sayings.) In just a few years, the setup had yielded a study that markedly raised the standards of research in psychotherapy, and did more to make Beck’s name in the field than anything before.

At the time, psychotherapists were beleaguered by the rise of psychotropic drugs, whose manufacturers had the vast resources needed to conduct large-scale clinical studies. Beck’s audacious gambit was to take on this balance of power directly, using what is still the gold standard of biomedical research, the randomized controlled trial, in which two or more treatments are rigorously pitted against one another. The study, which was published in 1977, assigned 41 depressed patients to 12 weeks of either CBT or imipramine, the best antidepressant of the day. In the end, the patients who’d received CBT were less symptomatic, less likely to have dropped out of treatment, and, upon follow-up, less likely to have slipped back into depression. It was the first time in history a psychotherapy had been shown to be more effective than drugs.

“It took an act of courage, I think, to subject his ideas to empirical scrutiny,” Ruth Greenberg, one of Beck’s earliest employees, told me. “I know it took courage, and that he was scared of it. But he did it.” She added: “He’s really a kind of ruthless empiricist.” Of course, the problem with ruthless empiricism, as opposed to charismatic boosterism, is that if you live by data you can die by data. In studying the effects of psychotherapy on depression the variables are after all vast, even endless, and the tiniest alteration in study design or slip-up in delivery can fundamentally alter the outcome.

Beck learned this lesson well in 1985, when the first results of a multi-site, multi-million-dollar trial of CBT for depression, organized and funded by the National Institute of Mental Health, began to trickle out. That the NIMH would even be interested in such a study was a testament to the growing prominence of Beck’s ideas. But he was skeptical. He felt that there were not enough experienced therapists to perform so large an experiment, and he withdrew his support. “It reminded me of the song of the Valkyrie,” he told me. “You can hear the drum beats, you know there’s gonna be disaster.” When the numbers were crunched, CBT was shown to be no better than drugs for mild depression, worse than drugs for severe depression, and without any real lasting effect.


The most damning of the NIMH results were published in 1989. And yet, since then CBT has only increased in popularity and influence. There are three main reasons for this.

First, a commitment to scientific standards of validity requires that negative as well as positive findings be considered contingent, just another drop in the empirical ocean, and Beck’s ever-growing legion of trainees, and trainees of trainees, have been adept at the act of scientific reconsideration. In 1990, a paper published in the Journal of Clinical and Consulting Psychology reported evidence of a clear relationship between the competence of the psychotherapists who participated in the NIMH study and their success in treating patients, confirming Beck’s early suspicions. In 1999, DeRubeis, the psychologist at Penn, compared the NIMH findings with three other studies of CBT versus medication for severe depression and found that in the aggregate, CBT came out on top. And in 2005, in a pair of widely publicized papers in the Archives of General Psychiatry, DeRubeis and Steve Hollon, a psychologist at Vanderbilt University, reported the results of a large clinical trial that compared CBT to a placebo and the popular antidepressant Paxil in patients with depression. In the short term, CBT was shown to be as effective as medication and, presumably because it served as a kind of psychological inoculation, it guarded against relapse 69 percent of the time, as opposed to 24 percent for medication.

Second, the NIMH study only raised questions about CBT for depression, and even before the results were published Beck was expanding his model into other areas of psychopathology. Freud launched psychoanalysis outward, moving from the neuroses to religion, humor, and the strictures of civilization. Except for an ambitious 1999 book, Prisoners of Hate, which attempted, without much impact, to apply CBT to ethnic conflict and genocide, Beck has cleaved to the pathological plane of experience. His method has been unapologetically linear: choose a new disorder or problem, work out how thoughts and beliefs influence its development and perpetuation, tweak the therapy to apply to the new problem, write a detailed treatment manual, do research, publish a book. There are now studies that show CBT’s effectiveness in treating anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, phobias, borderline personality disorder, bipolar disorder, anorexia, bulimia, and schizophrenia, as well as back pain, colitis, hypertension, chronic fatigue syndrome, marital distress, anger, and overeating. Beck has admitted, “I feel like a snake-oil salesman sometimes when people say, ‘What can it cure?’ and I reply, ‘What can’t it help?’”

Third, this accretion of data has spurred an insistence among the mental-health establishment that treatment decisions be based on solid scientific evidence, and this has in turn cemented CBT’s reputation as the most research-driven psychotherapy in existence. Indeed, the first formal expression of the “empirically supported therapies” movement—a 1993 task force report of a division of the American Psychological Association—was born out of a frustration that although scores of useful studies had been conducted, little of the resulting information had trickled down to psychotherapists in the field. As a remedy, the task force set out to develop a concise list of therapies that science had shown to be effective for specific disorders. In spirit, at least, the project was ecumenical: the task force members came from a range of theoretical backgrounds, including psychoanalytic, and the only allegiance the report avowed was a “commitment to empiricism.” But since the overwhelming majority of sophisticated clinical trials in the literature studied CBT, this ecumenicism was rhetorical. On the final list, 14 of 18 therapies given the gold stamp “well established” were cognitive behavioral. Cognitive-behavior therapy and “empirically supported therapies” were essentially synonymous.

Not surprisingly, psychotherapists who did not count themselves in the cognitive-behavioral camp weren’t pleased. Newly bristling under the thumb of managed care, they charged that the report was a devious attempt to convince insurance companies to fund only short-term treatments such as Beck’s. Others protested, more high-mindedly, that only philistines thought of psychotherapeutic change as something that could be measured, as though one were studying ferns or rocks and not the infinite human mind. (One indignant observer proclaimed that a therapist is “a disciplined improvisational artist, not a manual-driven technician.”) Still others pointed to their own scientific analyses that suggested that, for all the data gathered about specific therapies, there is no meaningful difference between types of treatment. In their view, the true engines of recovery are “nonspecific factors,” in particular the bond forged between therapist and patient.

The contentiousness sparked by the report has scarcely died down in the years since it was published. But, then, neither have efforts to implement the report’s findings and updates to those findings. In the past eight years, dozens of states have initiated programs to train mental-health professionals in empirically supported psychotherapies. In 2001, Congress created the National Child Trauma Stress Network, funded at more than $30 million a year, to disseminate empirically supported therapies to traumatized children and their families. Since 2005, the Veterans Administration, the closest thing America so far has to a nationalized healthcare system, has allocated more than $250 million a year to train therapists in ESTs in an effort to cope with the influx of traumatized veterans returning from Iraq and Afghanistan. All of these programs highlight CBT. The Army’s new resiliency program, meanwhile, will train more than one million active-duty soldiers, reservists, members of the National Guard, civilian employees, and military family members in Beck-inspired methods.

In England, the empirically supported therapies movement now benefits from full governmental support. In 2007, the British government announced it would be spending close to $300 million to train and employ 3,600 additional psychotherapists, primarily in CBT. This official endorsement has proved a powerful incentive for therapists not historically predisposed to empirical research to prove that what they do is valid. Peter Fonagy, one of England’s leading psychoanalysts and chief executive of the Anna Freud Centre, has called on his colleagues to end their “splendid isolation” from the mainstream and to adopt “a scientific attitude that celebrates the value of the replication of observations rather than their uniqueness.”


Beck keeps close watch on these developments, as he has throughout most of his career, from home, a bright clapboard colonial surrounded by a pale wooden fence. He operates from there, as he always has, like a general at headquarters—phoning instructions to his subordinates in the field, holding conference calls with foreign allies, drawing up bold plans for new projects, new disorders to conquer. His excursions from base occur less frequently than they once did, but one appointment he invariably keeps is a semi-regular meeting not far from his house at a training institute that holds his name, where he conducts a full session, broadcast on closed-circuit television, with a difficult or illuminating case. One late February afternoon, I was allowed to attend.

The client on the docket was a middle-aged woman who lived alone with her young son. As a child, she had been sexually assaulted; she had a string of failed relationships; her career had stalled; and, the previous November, her family had forced her to go to the hospital in reaction to a bout of aggressiveness and insomnia. “She still had fears that, based on a whim, they could commit her and take her son,” read a brief handed out to the assembled trainees.

The session was broadcast on a blank wall, the image small and fuzzy at the edges; the patient was equally anxious (“You’re big in the psychology field, so I’m a little bit nervous,” she told Beck) and brimming with excitement. When Beck asked her what she wanted to talk about, she responded, “God. And how God fits into psychology.” Tenderly, Beck coaxed her toward a more modest set of discussion topics. Together they assembled a list of five: her relationship with her son, her relationship with her family, her relationships with men, her dissatisfaction with her career, and her insomnia.

It was an ambitious slate to tackle in 50 minutes, but then this was more master class than focused lecture, and they moved through the subjects at a steady clip using Beck’s three-pronged approach. With each topic, he drew out the patient’s troubling thoughts with gentle but pointed questions, rephrased the often muddled response into a concise statement, and opened the assertion up to rational examination. Beck calls this process “collaborative empiricism,” but, of course, it has a more ancient precedent than the formally scientific. A cousin of mine, a psychiatric resident at the University of Pennsylvania, recently said to me, “Beck is the closest thing to Socrates I’ve ever met.” What he meant by this was something many people have observed: Beck’s passion is for ferreting out only those truths logical investigation will bear, nothing more.

Fewer people have observed what naturally follows from this comparison: a dedication to logic could be the seed of your own demise. Science is progressive, and already there is evidence to suggest that there may be more effective ways to treat mental illness than by scrutinizing thoughts. There is mounting interest, for instance, in how psychopathology can be mitigated by targeting the experience of emotion, a “low road” approach stemming from basic neuroscience research that contrasts with Beck’s cognitive “high road.” And in 2006, the results of a randomized controlled trial suggested that in CBT it is not the evaluation of thoughts but the changing of behavior that is doing the real therapeutic work.

Beck probably won’t live to see the day when these challenges supplant his work. A mountain of evidence will need to be gathered before CBT’s empirical altitude can be matched. But even his challengers believe that were he to see that day, he wouldn’t dispute it. David Barlow, a prominent anxiety researcher at Boston University, says of Beck: “He’d be the first person to put forth his theory and encourage that it be adopted, but he’s always accepted other people’s attempts to innovate. If, in fact, they could support their ideas with data.”

One thing that became apparent at the February case conference was how assiduously Beck has sought to inculcate this ideal not only in his field, but in the minds of his patients. After the session was completed, he shuffled into the room for a wide-ranging discussion. “What you might have noticed,” he said, in his tinny, sharp voice, “is that the approach I took during the session was to devise a hypothesis, gather data by way of experiments, see if the data confirms the hypothesis, and if necessary form new conclusions.” He paused and glanced around the room. “In a way, it’s really quite scientific.”


Daniel B. Smith teaches writing at the College of New Rochelle and is the author of Muses, Madmen and Prophets: Hearing Voices and the Borders of Sanity. His work has appeared in The Atlantic, Granta, and The New York Times Magazine.

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