Beck Cbt Pst and Future

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S P E C IA L A R T IC L E S

V O L U M E 6 { 1 4 9 }U M B E R 4 . F A L L 1 99 7

T h e P a st a n d F u tu re o f

C o g n itiv e T h era p y

A A R O N

T . B E C K , M . D .

The au tho r describes h is p ersonal odyssey in

cognitive -b ehav iora l therapy C B T ). H e

sha res h is e arlies t c lin ica l exp erie nce

responsib le for the evo lu tion of C B T and

review s the

app lica tion o f C B T to depre ss io n ,

anx ie ty, p ersonality d isorders , and

sch izophren ia . A ccord ing to the

au thor ,

th e

fu tu re o f C B T w ill b e tes ted w ith severe

psych ia tric d isorders s uc h a s s ch iz op hr en ia ,

b zola r d iso rder, and severe p ersonality

d isord ers; in the trea tm en t o f children and

adolescen ts; and w ith in the prac tice o f

prim a ry ca re.

(T h e jou rna l o f P sy cho th erapy P ractice

and R esea rch 19 97 ; 6 :276 -2 84)

I sta rted o ff m y psy ch iatr ic ca ree r do ing p sy -

cho an aly sis , an d it w as o n ly in the cou rse o f

tim e tha t I d r ifted in to a w ho le new area . W ha t

star ted m e in the cu rren t d irec tion w as so m e-

th in g tha t o ccu rred w h en I w as see ing a pa tien t

nam ed L u cy . S he w as on the cou ch , and w e

w ere do in g cla ssica l an aly sis . S h e w as p re su m -

ab ly fo llow ing the “ fu ndam en tal ru le” tha t th e

pa tien t m ust repo rt ev ery th ing tha t co m es in to

he r m in d . D u rin g th is se ssion , she w as rega ling

m e w ith desc r ip tion s o f he r va rio us sexu a l ad -

ven tu re s. A t th e end o f the se ssion , I d id w ha t

I usua lly do . I a sked he r, “N ow , h ow have you

been fee ling during th is se ssio n?” S h e sa id ,

“I’v e b een fee ling terr ib ly anx io us, doc to r .”

H er d iagno sis w as w ha t w as ca lled in tho se

days anx ie ty neu ros is an d d ep re ssiv e neurosis ,

so it w as n o t su rp ris in g tha t sh e w as fee ling

an x iou s. I sa id , “I t’s ve ry c lea r w h y y ou a re

fee ling anx io us. Y o u h av e th ese sexua l im -

pu lse s w hich a re th reaten in g to burst fo rth .

S in ce y our sex ua l im p u lse s a re unaccep tab le,

they cue o ff anx iety .” I sa id , “D o es th at soun d

righ t?” S h e sa id , “O h , yes. Y ou’re righ t o n ta r-

ge t.” I sa id , “D o yo u fee l b ette r no w th at yo u

kno w th is ?” S h e re sp ond ed , “N o , I feel w orse .”

I rep lied , “T hank you fo r b ein g so frank , bu t

can yo u tell m e a little b it m ore abo u t th is?”

S h e re sp ond ed , “W ell, a ctu ally , I th oug h t tha t

m aybe I w as bo rin g y ou , and n ow tha t you sa id

tha t, I th ink I rea lly w as b orin g you .” I a sked ,

“W ha t m ade y ou th in k th at you w ere b orin g

m e?” S he rep lied , “I w as th in k ing tha t all

F ro m the U n ive rsi ty of P en nsy lv an ia S ch oo l o f M ed icin e,

P h i lad elp h ia , P en nsy lva n ia . A ddress c orre spo nd enc e to

D r. B ec k , U n ive rsi ty o f P e nn sy lv an ia , R o om 75 4 S cie nce

C en ter , 36 00 M a rke t S treet , P h ilad elp h ia , P A 19 10 4 .

C opy rig h t © 19 97 A m er ica n P sych iatr ic P ress , In c.



B E :K 277

JO U R N A L O F P S Y C H O T H E R A P Y P R A C T IC E A N D R E S E A R C H

du rin g th e se ssion .” I sa id , “Y ou had a th oug h t,

‘ I am boring D r. B eck ,’ and you d idn ’t say it?”

S he rep lied , “N o , I neve r th oug h t to say tha t.”

I sa id , “Y o u h ad tha t thou gh t ju st th is o ne tim e ,

r igh t?” S he re spo nded , “O h , no , I a lw ays h av e

tha t thou gh t.” I sa id , “O h? T h at’s rea lly

strange . H o w co m e y ou neve r rep orted th is

b e fo re?” S he resp ond ed , “I t ju st neve r oc -

cu rred to m e tha t th is w ou ld be the so rt o f th ing

th a t y ou’d be in te re sted in .” I ask ed , “D id y ou

h ave an y fee ling w h en you had th is thou gh t?”

S h e rep lied , “W ell, th is is w ha t h as really m ade

m e anx io us.” I ask ed , “D o yo u eve r ge t th is

th oug h t w hen yo u’re n o t in the ses sion?” S he

said , “O h , I g et

it

w ith eve ry bod y . I’m a lw ay s

v e ry anx io us because I th in k tha t I’m bo ring

peop le.”

It occu rred to m e th at p e rhap s I had

m iscon stru ed the case and tha t sh e had the

basic p rob lem of hav ing to m ake an im pres-

s ion on peop le and b ein g re jected by th em ,

an d one o f he r co m pensa tio ns w as to try to

en ter ta in them . A ccord ing to the p resen t

D S M -IV diagn osis (w h ich w as n o t av a ilab le to

us th en ), she w o u ld a lso h av e a h istr ion ic p er-

son ality d iso rde r.

F IIF : I) l:\I;I.o I\IF :N r O F

0 (, N I V F T ii ii i v

I becam e ve ry m uch in te re sted in unreported

tho ugh ts o f th is k in d , an d I sta r ted ask ing o the r

pa tien ts ab ou t th is w hen they w ere free asso -

cia ting . P eriod ica lly I w ou ld ask , “W h a t o the r

tho ugh ts a re yo u h av ing rig h t n ow ?” T hey

w ou ld com e up w ith o th er thou gh ts tha t h ad

to d o w ith m e, ty p ica l transfe rence tho ugh ts

acco rd in g to psy ch oana lysis , bu t no t w ha t the

pa tien ts h ad been p rev io usly reporting . I

tho ugh t, “T h ere is a w ho le leve l o f m en ta tion

g o ing on tha t isn ’ t b ein g tapp ed th ro ugh ou r

c las sica l m e thod s.” C on sequen tly , I asked the

pa tien ts m an y tim es d uring the se ssion , “W ha t

a re yo u th ink ing rig h t now ?” an d often w ha t

they w ere th in k ing “ righ t now ” had to do w ith

the k in d o f im pression they w ere m ak in g on

m e or w ha t they tho ugh t m y a ttitud e w as to -

w ard th em . T hey w ere a lso exp erienc ing th e

k in d o f em o tion th a t yo u w o u ld exp ec t to g o

w ith a pa rticu lar tho ugh t. If a pa tien t h ad the

tho ugh t, “D r. B eck isn ’t pay in g a tten tion ,” then

the a ffec t w o u ld be ang e r. If th e pa tien t’s

tho ugh t w as, “ I’m no t g ettin g anyw here in the

therapy .

. .

I’m on ly g ettin g w o rse ,” th en the

a ffec t w ou ld b e sad ness. T h is ob serva tion g av e

m e a c lue th at so m e th in g c ru cia l w as g o ing o n

tha t I had been m issing .

In ternal

C omniun ica t ion

I s ta rte d exam in ing m y o w n au to m atic

tho ugh ts the ve ry nex t day w hen I w as try ing

to d rive o u t o f a p ark in g lo t on to a ve ry bu sy

stree t. I s ta r ted th e ca r fo rw ard an d all of a

sud den I fe lt

anx ious

and I stopp ed . I h ad th e

tho ugh t, “ je rk , you ’re a fra id to go ou t in to th e

traffic ,” an d I fe lt bad . T hen I sta rted fo rw ard

aga in an d I had the thou gh t, “B y go sh , you ’re

g o ing to ge t k illed if y ou go in to th is busy

street,” and I fe lt an x iou s an d sto pped . I f ina lly

d rov e th e ca r o u t a fte r an a lterna ting sequ ence

of anx ie ty -p rodu c in g and self-cr itic al th oug h ts .

I t occu rred to m e th a t p eop le m u st h av e a g rea t

m any such th oug h ts tha t they s im ply a re no t

reporting . T h is is w h en I a rriv ed at th e concep t

o f the

in te rna l com mun ica tio n system .

P eop le hav e au tom atic tho ugh ts th at they

u se to b roadcast ideas to th em se lves, b u t the se

a re no t th e k ind s o f id eas tha t they w ou ld m en-

tio n to o the r peop le . T h is k in d of in te rna l sys-

tem has to d o w ith se lf-eva lua tion , th ink ing

abo u t w ha t o the r peop le th ink o f y ou , self-

m on ito rin g , s elf-p red ic tion s, an d so o n . U n le ss

o ne sp ecif ica lly m ad e a “b iop sy ,” b ored in a t

th at ve ry m om en t o f the thou gh t, on e w o u ld

m i s s it . M any tim es I cou ld e lic it th is k ind of

th ink in g o nce I sw itched o ve r to face -to -face

in terv iew s. F or ex am ple , I w o u ld say som e-

th ing rea lly “b rillian t” to a p atien t an d the pa -

tien t w ou ld g et a ve ry sad expre ssion o n h is

face. I w o u ld ask , “W ha t w ere yo u th ink ing

rig h t th en ?” T he p atien t w ou ld say , “O h , Iju s t

thou gh t I m ust b e p re tty du m b if I hadn ’t

thou gh t o f tha t,” o r som eth ing to tha t effec t. I

w o u ld say , “T ha t’s ve ry in te res tin g tha t yo u are

co m paring y ourse lf w ith m e an d yo u are



278 C O G N IT IV E ThE R A P Y

V O L U M E 6 {149}U M B E R 4’ F A L L 19 97

pu ttin g you rse lf do w n .” T hen I w o u ld em ph a-

size , “E v ery tim e you ge t a th oug h t th a t m akes

these inv id ious co m parisons , be su re and re-

po rt it.”

T h is pa tien t d id becom e sens itiz ed to th is

p ro ced ure , and the re fo re I co u ld g et a w h o le

n ew da tabase to w hich I h ad neve r h ad access

be fo re . T h is co u ld b e ve ry he lp fu l in under-

stan d ing the pa tien t and a lso in try ing to c rea te

so m e ty pe o f trea tm en t strategy . Fo r a lon g tim e

I w o u ld g ive o u t w rist c licke rs and h ave th e

p atien ts c lick o ff the ir th oug h ts du ring the

cou rse o f th e d ay . S ince m ost o f m y prac tice a t

th at tim e w as w ith depre ssed p atien ts , I w ou ld

h av e them c lick ev ery tim e they had a nega tive

th oug h t. A t th e end of the d ay they m ig h t have

as m an y as a h und red . T he pa tien t w as ab le to

exam in e these tho ug h ts and eva lua te them .

S in ce th e tho ugh ts o ccu rred au tom a tically ,

w itho u t p rio r re f lec tion , an d w ere accep ted by

th e pa tien t as va lid , I ca lled them

automat ic

thoughts .

W hen L ucy w as hav ing these au tom a tic

th oug h ts in th e co urse o f the d ay , th ere w as a

d efin ite b ia s in he r th ink in g d irec ted ag ain st

h erse lf. If sh e w as in an y situ atio n in w h ich she

fe lt she w as n o t m ak in g a g ood im pression , she

w ou ld ge t the tho ugh ts , “T ho se peop le d on’t

lik e m e . T hey ’re re jec ting m e. I loo k fo o lish . I

loo k stup id ,” and so o n . T he re w as a p ervasive

cu rren t th rou gh all he r th in k ing tha t h ad to do

w ith he r nega tiv e self-co ncep t.

E rro neous T h ink ing

I a lso n o ticed tha t pa tien ts tend ed to m ak e

va rio us th ink in g e rro rs . O ne of the th in k ing

erro rs w as so m e th ing I ca lled

a rb itr ar y in fe re nc e.

L u cy to ld the fo llow ing sto ry : “ I really fe lt v ery

d iscou raged yeste rday , and I cam e to th e co n-

clu sion tha t y ou’re w ron g w h en you say th at I

d o have th e capac ity to have p eo p le like m e ,

becau se n obo dy ca lled m e yeste rd ay .” I sa id ,

“T ha t’s a v ery go od au tom a tic thou gh t, ‘N o-

bod y ca lled m e yeste rd ay .’ W ha t w as the

m ean ing of th at?” S h e sa id , “T h e m ean ing is

th a t no bod y lik es m e and tha t the re fo re I m ust

b e un lo vab le .” I a sk ed , “W h o are the p eo p le

w ho m yo u w ould hav e exp ec ted to ca ll yo u?”

S h e said , “W ell, th ere w as D o ris , the re w as

D olo re s, and the re w as C yn th ia .” I sa id , “T he

fact th a t they d idn ’t call you m ean t tha t

th ey d id n ’t like y ou?” S h e said , “T ha t’s rig h t.”

I sa id , “N ow , can w e th ink o f so m e a lterna tive

exp lan atio ns fo r w hy they m igh t no t h av e

called y ou?”

T h is approach w as so m e th ing new th at

h ad o ccurred to m e in the cou rse o f m y w o rk :

dep re ssed pa tien ts co nsis ten tly jum p to e rro -

neou s conc lusio ns. S h e sa id , “W ell, com e to

th in k of

it,

D oris is ou t o f to w n , D o lo re s sa id

she w asn’t fee ling w ell, and C yn th ia is m ore

depre ssed than I am . I shou ld be ca lling he r.”

W ha t w as in te re stin g w as th at im m ed ia te ly a f-

te r she m ade th is a lterna tive con stru ctio n of

the situ atio n , he r a ffec t ch an ged an d she fe lt

bet ter .

C og n itive P rim acy

T h is o bse rva tion led to m y n ex t con cep t,

som eth ing I ca ll

c og nitiv e p rim ac y

or

b ia se d p ro c-

essing.

O ne’s fee ling s are d ic ta ted , to a ve ry

large ex ten t, by the w ay one in te rp re ts exp eri-

en ces. W hen L u cy w as in te rp re tin g situa tion s

nega tive ly , she fe lt w orse. W h en sh e sw itched

over to a m o re rea lis tic in terp reta tion , sh e fe lt

be tter . N o t on ly he r a ffec t w as in f luenced , bu t

a lso he r behav io r. S h e becam e m ore an im ated .

S h e s tar ted th ink ing abou t a ll the g oo d th in gs

she cou ld do du rin g the d ay . I t w as ve ry o bv i-

o us th a t each tim e she w as ab le to eva lua te a

n eg a tiv e tho ug h t an d d ete rm ined w ha t

seem ed to b e in co rrect, un like ly , o r im p lau si-

b le, sh e w as ab le to in trod uce prop er co rrec -

tio n . S h e then felt be tte r and w as ab le to behav e

m ore adap tive ly .

I th en m o ved m y form ula tion s ov er to the

n o tion of co gn itiv e p rim acy . A t th is po in t I s till

con side red m yse lf an an aly st, and w hen I g ave

m y ta lks to ana ly tic g roup s I w ou ld say , “T h is

is rea l, pu re F reu d ian ana lys is because F reud

deve lop ed the w h o le idea o f the p rim ary pro -

ces s ea rly o n . D uring th at phase o f h is theo ry ,

he be lieved tha t th ink ing w as the really c r itica l

area in psych opa tho logy . L a ter on , F reud



B E C K

27 9


m ov ed to a m o tiva tion m o de l: im pu lse s

em erg in g from the id , from th e uncon sc ious,

w ere p re ssing to b urst ou t in to consc iou sness

and th en w ere de fen ded aga ins t b y de fen se

m ech an i sm s . ”

In th e co gn itiv e m ode l, tho ugh , I w as ab le

to d ispense w ith th e un w ie ldy concep t o f the

de fen se m echan ism s. A ccord ing to the cog n i-

tive m od el, p eo p le see th in gs the w ay they do

because th is is the d irec tion tha t the ir cog n itive

p rocessing takes them . T h ey m ay see th ing s

accu ra te ly w hen th eir cog n itive p rocessing is

r igh t o n ta rg et. I f they h av e som e typ e of m en -

ta l d iso rd er , th e cog n itive ap pa ra tus is sk ew ed

in on e d irec tion or ano the r. In the m an ic pa -

tien t, fo r exam p le , it is sk ew ed in an exagg er-

a ted po sitive d irectio n . In the depre ssive

pa tien t, it is skew ed th e o the r w ay . W hen I p re -

sen ted th is m a te ria l be fo re th e loca l ana ly tic

so cie ty , I sa id , “T h is is rea lly p sycho an a lysis ,”

and they sa id , “N o , th is is no long er an aly sis .

Y ou’d be tte r sto p callin g yo urse lf an an aly st.”

I h ad to fin d a new nam e fo r th is approach .

A t th at tim e I w as a ttrac ted to behav io r the r-

apy , so I tho ugh t I w ou ld ca ll m yself a behav io r

the rap ist. I end ed u p w ith the idea o f ca lling

m y ap proach cogn itive the rap y , because it

w as based on th e cogn itive m od el o f psy cho-

patho logy .

I m en tion ed ea rlie r th at I w o u ld have m y

pa tien ts use the clicke rs an d rep ort th eir au to -

m a tic thou gh ts to m e . I t tu rned o u t tha t th ere

w ere ve ry spec if ic th em es or co n ten t in th e

au tom atic th oug h ts th at co rresp ond ed to th e

va rious sy ndrom es. E ach syn drom e , w h eth er

it is o bsessiv e-com p u lsiv e d iso rde r , d elu siona l

d iso rd er , h is trio n ic pe rsona lity d iso rde r, d e-

p re ssion , anx iety , o r hyp ochon driasis , w ou ld

h av e its ow n specif ic co n ten t in th e au tom atic

tho ugh ts . T h at is , a p atien t w ith any o ne o f

th ese d iso rde rs w ou ld be in te rp re ting h is o r

h er ex pe rien ce , o r m isin terp re ting it, in a

u n iqu e and sp ec if ic fa sh io n . A depre ssed p a-

tien t w ou ld in te rp re t a s itu a tion su ch as som e-

b ody leav in g by say ing , “H e le ft b ecause I’m

u n lov ab le.” T h e an x iou s p atien t w ou ld th in k ,

“M ay be I am bo ring -and I m ay b ore o the rs

in th e fu tu re.” T he pa rano id pa tien t w o u ld say ,

“H e is rea lly abu sing m e becau se he is hos tile

to m e . I’ll f ix h im .”

E x am in ing B elie fs

A s I con tin ued w ith m y w ork , I fou nd th a t

th e se cogn itions w ere b ein g driven by certa in

id en tifiab le b e liefs . T he d ep re ssed p atien t’s be -

lie f w ou ld be som e th ing lik e th is : “P eop le gen-

e rally don ’t like m e , an d th ere fo re if I am in

an y situa tion w ith o the r peop le, they are go ing

to re ject m e .” T h e anx io us pa tien t w ou ld have

th e b elie f , “P eop le m ay o r m ay no t like m e ,

bu t if I’m in a situa tion w ith o th er peop le, the re

is a dang e r th at th ey w ill re jec t m e .” T h e pe rson

fee ls anx ious becau se h e or sh e pe rce ives d an -

ge r. T h e depre ssed p erceiv e eve ry situa tio n in

th e past a s b ein g a loss in som e w ay . T he p ara -

n o id pa tien t w ou ld have the b e lief , “ If peop le

re ject m e , it j u st sho w s w ha t a ro tten w orld w e

liv e in and w ha t a b unch of ro tters the re are .”

A s the rapy con tinued , it b ecam e im p or-

tan t no t on ly to g e t p eo p le to co rrec t th eir au to -

m a tic thou gh ts , b u t also to have them sta rt

ex am in ing th e ir be lie fs . T h is w as a m a jo r ad -

vance because peop le can h av e an in fin ite

num ber o f au tom atic th oug h ts and they cou ld

spend the re st o f th eir life try ing to co rrec t them

all. If they cou ld g et d ow n a little b it d eep er to

w h at w as rea lly con stru ctin g these thou gh ts ,

then w e cou ld g et a m uch b ro ad er b ase fo r the

therapy .

W hile w e w ere w ork ing w ith p atien ts , it

occu rred to us tha t no t on ly d id p atien ts have

d iffe ren t d iso rde rs , b u t peop le had d iffe ren t

pe rso na litie s th at co lo r the se d iso rde rs .’ O n e

of m y ex pe riences in d ica ted to m e tha t a pa r-

ticu lar w ay of lo ok in g at p eo p le ’s pe rso na lities

w ou ld be ve ry he lp fu l w hen do ing the rapy . A

yo ung cou p le cam e in to see m e fo r c r is is in -

terven tio n . T h ey had just b een m arr ied fo r a

few w eeks and w ere rea lly a t each o the r’s

th roa ts . T hey tho ugh t m ayb e th ey sho u ld sp lit.

I asked , “W ill y ou te ll m e w ha t’s beh ind th is?

W ha t’s h ap pen ing ?” T he h usb an d and w ife

then to ld m e th e fo llo w in g sto ry , each o ne fill-

ing in from his o r h er o w n standp o in t. T hey

reenac ted an ac tua l scen ario : T he hu sband





B E C K

28 1


in the ir life . W h en fixa ted th is w ay , they go

in to so m e th ing lik e a hy pno tic trance . W hen

th e p an ic pa tien t is hav in g a pan ic a ttack , he

o r she has the th oug h t, “T h is is terrib le . I’m

d y in g (o r h av ing an ep ilep tic a ttack o r fa in tin g

o r lo sing co n tro l) rig h t n ow .” P an ic -d iso rd e red

p a tien ts w ill say tha t hav in g a pan ic a ttack is

abso lu te ly the w orst expe rien ce th at they h av e

eve r had .

S om e of the sim plis tic m e thod s tha t w e

h av e u sed w ith the pan ic d iso rde rs a re no t

cu ra tive , bu t they a re sy m pto m re liev ing .5 O n e

m eth od is d istrac tion . I w ill a sk the pa tien t w ho

is h av ing a pan ic a ttack indu ced in the o ff ice,

“H ow m any fing ers d o yo u see righ t no w ?” o r

“W ha t’s m y nam e?” A s soon as th ey ge t d is-

tracted , they can sto p th e pan ic attack . T h is

techn iq ue does n o t h av e lo ng-te rm effec ts ,

s in ce the p an ic a ttack s w ill recu r . W e h av e to

g e t pa tien ts to reco nstrue w ha t’s g o ing on and

to see tha t th eir b elie fs tha t they a re dy ing and

so on are no t based o n any ev id en ce.

T he sam e o bse rv a tio n is tru e o f soc ia l

p hob ias . T he m a jo r w o rk on soc ia l ph ob ia s

is be ing do ne in O xfo rd rig h t no w .6 It is in -

te restin g tha t peop le w ith so c ial pho b ia do

n o t focus on o the r peop le ’s faces. T hey have

so m e k in d of in te rn al im age they a re p ro jec t-

in g on to o the r peo p le . B ehav io ra l an d cog -

n itive avo idance a re also ve ry im portan t.

M ich ael G e lde r has refe rred to th em un de r

th e ru b ric o f the “sa fe ty b eh av io rs” tha t peo -

p ie eng age in .

M any yea rs ago , I used to teach a course

to the p sych ia tric resid en ts on theo rie s o f

p sycho pa tho lo gy and system s o f p sycho the r-

apy . In tho se days , I cove red all o f th e sys -

tem s: behav io r the rap y , G esta lt th erapy ,

R og erian the rap y , and psy ch oana lysis . T h is

w as be fo re I h ad deve lo ped co gn itiv e th er-

apy . I s et u p so m e standa rds tha t I th oug h t

any system o f psycho the rapy sh ou ld try to

fu lf ill.7 T hese a re 1 ) a coh eren t th eo ry o f p er-

son a lity an d psycho pa tho logy , 2 ) em pir ica l

d ata to supp ort it 3) ope ratio na lized the rap y

tha t in ter locks w ith th e theo ry , and 4 ) em -

p irica l d ata to sup port the e ffec tiveness o f the

therapy .

D

F F I

N

I

N (; T

II F

CocNIi- I i :

Moii- : i .

R ecen tly a tax i d r ive r a sked m e w ha t I w as

go ing to do at the co nference h e w as tak ing m e

to , and I answ ered th a t I w as g o ing to d is cu ss

cogn itive the rap y . H e ask ed , “W ha t’s th at?”

and I sa id , “I t ha s to do w ith the w ay p eop le

ta lk to th em selv es.” H e sa id , “O h , I tho ugh t

tha t’s w hy they g o to a psy ch iatr is t in th e f irs t

p lace.” I s aid , “W ell, y es , b u t w e teach th em

ho w to an sw er them se lves.” T h at w o u ld b e a

sim ple d efin itio n o f cogn itive the rap y .

W hen I firs t w as w ork ing in th is a rea , I

de f ined cogn itiv e th e rapy in te rm s of the

strateg ie s tha t w e u sed . L ate r I dec ided tha t

w as inco rrec t because w e use a w ide v arie ty

o f s tra teg ie s . W ha t is th e co m m o n deno m i-

na to r? H o w d o w e se lect s tra teg ie s in a m ean-

ing fu l w ay ? I rede fin ed co gn itiv e the rap y in

te rm s o f th e co gn itiv e m o de l. T he co gn itiv e

m o de l h as n ow b een se t u p in te rm s of p sy -

ch opa th o log y in gene ral an d then fo r each

of the d iso rd ers .

W ha t is th e co gn itiv e m ode l? In ve ry sim -

p lif ied te rm s, the co gn itiv e m o de l sta te s th at

dy sfu nc tiona l d iso rde rs , p sy ch iatr ic d iso rde rs ,

an d p sycho lo g ica l o r behav io ra l d iso rd e rs a re

ch aracte r ized b y dy sfu nc tion al th ink ing , and

tha t th e d ysfunc tion a l th ink ing acco un ts fo r

the a ffec tive and behav io ra l sym ptom s. M any

of the stu d ie s now sh ow tha t irre spectiv e o f

the in te rven tion tha t is used , be it p ha rm a-

co the rapy , ana ly tic the rap y , in te rp erson a l

the rapy , o r cog n itive th erapy , w hen pa tien ts

ge t b e tte r th ere is an im prov em en t in the w ay

they th ink . T h e re is an im p ro vem en t in th eir

attitu des, a s m easu red , fo r ex am ple , by the

D y sfu nc tion al A ttitud e S ca le , o r in th e ir au to -

m atic thou gh ts .

O ne o f the m yths abo u t cogn itive th e rapy

is tha t em otion s are n o t im p ortan t in it. I have

alw ays th oug h t tha t em otio ns a re im po rtan t

an d tha t the the rap ist’s re latio nsh ip w ith the

pa tien t is ve ry im p ortan t. In te rpe rsona l re la -

tions a re a lso c ritica l. I h ave a lw ays tho ugh t th at

co gn itio ns d o no t cause d ep re ssio n ; th ey a re a

pa rt o f dep ress ion . E n v iro nm en tal ev en ts a re



2 82

C o ;N IT IV F : T H E R A P Y

V O L U M E 6 {149}

U M B E R 4 F A L L

1997

im portan t, and s im ple ra tion al rea son ing is n o t

eno ugh to chang e dys fun c tiona l th in k ing .

T h e m od e l o f d ep re ssio n , w h ich w e have

desc ribed in o ur boo k ,8 cen te rs on the cog n i-

tive tr iad , w h ich is sup posed to b e at th e co re

o f d ep re ssio n (irre sp ec tive o f the cau se o f de -

p re ssion ): the nega tive v iew of the se lf, expe -

rien ce , an d the fu tu re . T w e lv e yea rs ago , D on

E rns t, th en a grad ua te s tuden t at t he U n iv er si ty

o f Pen nsy lv an ia , rev iew ed all o f the stu d ie s o f

the cog n itive m od e l o f d ep re ssio n . T he re w ere

180 stud ie s and abo u t 2 20 co m parisons . A c-

co rd ing to h is rev iew , 2 00 of the ex pe rim en ts

sup ported th e co gn itiv e m od el. T w en ty e ithe r

d id no t su ppo rt it o r w ere con tra ry to it (u n -

pu b lished stud y , 19 85).

S

T R A T F ( ; I E S I N

Co G NI T I v E T H E R A P Y

S tra teg ie s , too , have b een cov ered in ou r va ri-

ou s b ook s.4 ’5 ’8 W e use a w ide v arie ty o f tech -

n iq ues, in clu d ing th e exp erien tia l te chn iques

an d w h at can be ca lled “conv ersa tion al” m e th -

ods . H ere is a v igne tte to illu s tra te the co nve r-

sa tiona l stra tegy .

O ne o f m y co lleagues cam e in to m y o ff ice

ab ou t 15 y ea rs ago , and h e look ed rea lly bad .

H e sa id , “T im , I kno w th at yo u are su ppo sed

to be an au tho rity on su ic ide . W ha t do y ou

th ink abou t ratio na l su ic ide?” I rep lied , “D o

you w an t to te ll m e w hy yo u are ask in g?” H e

said , “ I do n’t w an t you to do any th ing abou t

th is an d I do n’t w an t an y th erapy fro m yo u . I

ju st w an t to kn ow if yo u th ink I have grou nds

fo r ra tiona l su icid e.” I s aid , “W ell, te ll m e abou t

it.” B rief ly , he had b een o n a sab ba tica l. H e

h ad g o tten ve ry , v ery anx io us. H e w as g iven

ch lo rp ro m azin e fo r h is an x ie ty . A fte r tha t, he

go t in to a state w here h e w asn ’t th in k ing ve ry

w e ll o r m ov in g v ery w ell, an d he cam e to th e

con clu sion th at h is b ra in w as d ete r io ratin g . H e

w en t to see a neuro log ist, w ho sa id he had

so m e soft neu ro log ical s ig ns, bu t n o illne ss .

T he n eu ro log ist sug gested tha t m aybe he w as

dep re ssed . M y co lleagu e sa id , “N o , I’m no t.

M y bra in is de te rio ra ting and I just can ’t do

any th ing .”

H av ing to ld m e a ll th is , m y co lleague then

sa id to m e , “N o w , d on ’t y ou th ink , T im , tha t

is a goo d enou gh reaso n to k ill m y se lf?” I sa id ,

“W ell, I h av e to kno w m ore ab ou t it. C an yo u

te ll m e ju st w h y th is thou gh t is co m ing up a t

th is p a rticu la r m om en t? Y ou have had th is idea

abo u t b rain de ter io ra tio n now for seve ra l

m on th s.” H e sa id , “I’m giv in g a m a jo r lec tu re

in the p sycho b io lo gy of sch izop hren ia, an d I

k now I’m ju st go in g to m ak e a foo l o f m yself .

I can ’t poss ib ly p rep are th e m ate r ial. I don ’t

k now w h at to say , w h at to do . I t ju st occu rred

to m e th at ra the r than w a it and bu g ou t a t the

la st m inu te , I m igh t a s w ell w ip e it ou t n ow ,

sin ce , o bv io usly , th ings a re no t go in g to ge t

b ette r . T hey w ill on ly g e t w orse .”

P u tting o n m y na ive cap , I said , “G ee, the

psychob io log y o f sch izop hren ia . I th ink I k now

so m eth ing abou t tha t, bu t I do n’t kn ow if I

k now ev ery th ing .” H e sa id , “W ell, w h at do you

kn ow ab ou t it?” I said , “ I k now abou t the w ork

tha t the g roup s a re do in g on th e fam ily aspects ,

tha t th is is k ind o f a fam ily p ro b lem .” H e said ,

“T im , yo u be lieve tha t?” I sa id , “S ure. It’s in

the litera tu re.” H e sa id , “O h , T im . H o w n aiv e

can yo u b e? T ha t stu ff has been d isc red ited .”

I sa id , “ It really h as? W h at’s w ro ng w ith it?”

H e sta r ted lis ting fac to rs in sch izop hren ia: a ,

b , c , d . M eanw hile , I too k o u t a b ig pad and

sta rted w ritin g th is do w n . I s aid , “W h at abou t

the w ork a t Y a le , w h ere they do find tha t if the

ch ild w ith sch izoph ren ia has th ink ing d iso rde r,

the pa ren t also do es? It seem s to m e tha t’s re -

ally p re tty con clu sive .” H e sa id , “Y ou do n’t

read the lite ratu re . D idn’t y ou kn ow if they test

a s ib ling , th e pa ren ts do n’t sho w th e th in k ing

d iso rde r? It a ll ha s to d o w ith test an x ie ty .” I

said , “ Is tha t rea lly true? W ell, go lly . W h at

ab ou t the b io log y? C erta in ly , th e se ro ton in hy -

po th es is h as sh ow n itse lf.” H e said , “N o , no .

L e t m e te ll yo u a little b it abo u t dop am ine and

sero to n in .” T hen h e ta lked fo r abou t 25 m in-

u te s . M ean w h ile, I too k n o te s. A t the en d of

th e tim e , I s aid , “W ell, I g uess yo u w an t to go

now ?” H e sa id , “Y es.” I handed h im the pad

fu ll o f no te s . I heard tha t tw o w eek s la ter he

gave a brillian t lec tu re. I neve r saw h im aga in

p ro fessional ly .



B E C K

28 3


T his is w h at I call conv ersa tion al tech -

n iq ue , op era ting from the cogn itive m ode l. I

th ink y ou can in fer w ha t I w as th in k ing , w ha t

it w as th at had to be don e w ith so m ebo dy w h o

d idn ’t w an t to h av e th erapy . I d idn ’t g iv e h im

the rapy , I ju s t a sk ed som e inno cen t q uestions

to p rim e the m o re m a tu re asp ec ts o f h is p er-

son ality . O nce he d iscov ered tha t h e cou ld in -

deed fu nc tion , th e psy ch o log ica l basis fo r h is

dep re ssion d isappea red .

I H

I F U 1 ’ U B F 0 F

C 0 U N I ‘ F I V F ; T H F ; B A P 1

I th ink th at in th e 21st cen tu ry , p sycho the rapy

w ill flo u rish . I d on’t th ink tha t p ha rm a-

co the rap y is go in g to take ove r the f ie ld com -

p le te ly . T he re is n o q uestion tha t th ere have

been brillian t f ind ings in the b io log y of the

va rious d iso rde rs an d a lso in the deve lo pm en t

o f m any e ffec tive d rugs . H o w ev er , ph arm a-

co the rap y is n o t a panacea , and m y ow n pre -

d ic tion is tha t it w ill no t b ecom e a panacea. A t

leas t a t the p resen t tim e , o n ly abou t 60% to

70% of p atien ts , a t b est, g et b ette r w ith m ed i-

catio n . M ay be , w ith ve ry sk illed p sycho the r-

apy , som e of th e o the r 3 0% m igh t resp ond .

O ne m igh t say , “B u t th e b ad resp on de rs to

ph arm aco the rap y a re a lso g o ing to be the bad

resp on de rs to psych o the rap y .” H ow eve r , I

th in k the re is an a rea the re w here p sycho the r-

apy can sh arpen it s too ls and can p ick up the

no nrespon de rs , th e re frac to ry cases. In fact,

th is is be ing do ne in B rita in w ith case s o f re -

fra cto ry sch iz oph re nia .

O n e o f the m a jo r a rea s fo r psych o the rap y

in th e fu tu re is go ing to be trea ting ve ry se rio us

d iso rde rs , such as th e rap id -cy clin g b ipo la r o r

th e g en era l b ip o la r d iso rde rs , s ch izo phren ia ,

and v ariou s o th er ser iou s d iso rde rs tha t a re no t

to tally con tro lled by drugs .9 ”# {17 6}A n in tere sting

stu dy in w hich pa tien ts w ith acu te sch izo phre-

n ia w ere ass igned e ithe r to trea tm en t a s usu al

o r to co gn itiv e th erapy w as d one in B rita in re -

cen tly .”2 It tu rned o u t th at th e sch izop hren ic

p atien ts treated w ith cogn itive the rapy re -

q u ired on ly ha lf a s m uch tim e in th e hosp ita l

a s those w ho rece ived con ven tion al trea tm en t.

A num ber o f s tud ie s are no w g o ing on in B rit-

a in w ith pa tien ts w ith ch ron ic sch izo phren ia

and a lso w ith b ipo lar pa tien ts .

A no th er fea tu re o f psycho th erapy is tha t

it is all-pu rpo se . A pa tien t com es in w ith a com -

b ina tion , say , o f pe rso na lity d iso rd e r, pan ic d is-

o rd er , d ep re ssio n , anx ie ty , an d p arano id

a ttitud es. Y ou d o n o t have to g ive spec ific d rugs

fo r each o f these cond itions. Y ou can u se an all-

em b rac ing , all-pu rpo se p sycho the rapy to he lp

th e pa tien t deal w ith a ll o f th ese p rob lem s . In

fact, y ou m ay find som e com m on denom ina to r

th at is d riv ing each on e of these co m orb id co n-

d itions . It m ay b e th at the pa tien t’s basic p ro b -

lem is tha t he sees h im se lf a s he lp le ss . In

re spo nse to the be lie f, “I am h elp les s ,” the o ve r-

co m pensa tion is to becom e o ve rly agg re ssiv e,

to pe rce ive o th er peop le w ho are re sp ond ing

to th e aggres sion as p ersecu to rs . T he p atien t

s tar ts to fee l an x iou s abou t th is , an d th e anx ie ty

s tar ts to e sca la te . H is he lp less fee ling com es

in to h is tho ug h t, “ I can ’t con tro l th is an x ie ty ,”

an d then he h as a fu ll-b low n pan ic a ttack .

T he re are w ays o f d ea ling w ith each of

th ese com orb id d iso rd ers p sycho the rapeu ti-

ca lly , p rov ided yo u hav e the rig h t type o f

m od el. S o m e o f th e pe rso na lity d iso rde rs are

im prov ed w ith so m e of the m ed ica tion s, bu t I

do no t be lieve tha t th e rea lly sev e re pe rso na lity

d iso rde rs can be affec ted by any th ing bu t se -

rio us, s trenuo us, long -te rm the rap y .

C h ild ren and ado le scen ts , I th in k , w ill do

be tter w ith p sycho the rapy than w ith d rugs . A s

ye t, the re have been no so lid s tud ie s tha t have

fin ally dem on stra ted tha t d ru gs have b een e f-

fec tive w ith ad o le scen t dep ress ion . H ow eve r,

the re have been stu d ie s show ing tha t co gn itiv e

the rapy h as been e ffec tive w ith ado le scen t de -

p re55 l .3 S o the re is rea l ho pe .

P reven tio n is ve ry im p ortan t. W e fou nd in

our ow n s tudy of su icid a l pa tien ts tha t those

w ho receiv ed e ffec tiv e the rapy w ere m uch les s

like ly to com m it su icid e th an those w hose th er-

ap y , re tro spec tive ly , w as co nside red ine ffec -

tive .’4 W ork do ne b y S e ligm an an d h is g roup

sho w s tha t ear ly iden tif ic a tion of po ten tially

dep re ssive ch ild ren in schoo l o r in co lleg e can

fo re sta ll la te r d ep re ssio n .’5



V O L U M E 6

{ 1 4 9 }

U M B E R 4. F A L L 1 997

28 4

C o G N r r u v l T H E R A P Y

A t the p re sen t tim e at lea st, cog n itive the r-

apy and o the r p sycho the rap ie s (I am n o t lim -

iting th is to co gn itiv e the rapy ), a re m ore

effec tive than drugs fo r ce rta in d iso rd e rs , su ch

as p an ic, coca ine ab use ,’6and y ou th depres-

sio n . O n e o ngo ing s tudy , in p articu la r, is ve ry

encou rag in g : th ere is a g roup of psych o log ists

and correc tions o ffice rs in the U n ited S ta tes

and C anada w ho have sta r ted to u se cogn itive

p rog ram s w ith p risone rs . T he rec id iv ism rate

o ve r a yea r in o ffen de rs w h o have rece ived a

sp ecif ic cogn itive -b eh av io ral p ro g ram is o ne -

ha lf a s h igh as fo r those w ho ju st rece iv ed th e

stand a rd p rison trea tm en t.’7

O ne la st w ord abou t the fu tu re . I th ink the

th erap ie s have a ro le in treatin g the typ ica l

k inds o f case s w e a re all see ing no w , b u t they

a lso h av e a v ery sp ec ia l ro le in fam ily p rac tice .

S om e tim e ago , w e estab lish ed a lia iso n w ith a

hea lth m ain ten ance o rgan iza tion in P h ilade l-

ph ia. W e p u t ou r the rap ists rig h t in the o ff ice

o f th e fam ily ca re ph ysic ian . A s soo n as a p a -

tien t com es in w h o look s the lea st b it de -

p ressed , th ey g iv e th e pa tien t a dep res sion

scale o r an an x ie ty sca le to com ple te . O r if the

p rim ary ca re d oc to r says, “ I th ink th is pa tien t

has em otion al p ro b lem s, an d she is alw ays

co m ing in he re o r bo the rin g m e w ith te le -

pho ne calls . W hy d on’t y ou tak e a loo k a t

he r?” , th e the rap is t see s the p atien t rig h t aw ay .

A m az i n g l y ,

at

the p rim ary ca re leve l, pa tien ts

w h o w ou ld o rd ina rily tak e at lea st 1 0 or 1 2 v is-

it s

to

ge t be tte r w ere ge tting b e tte r in 3 or 4

v isits . I th ink tha t is w he re a lo t o f the rapeu tic

sk ill c an be app lied in th e fu tu re . W e w ill h av e

to w ait and see.

F

F

F R F

N C

F;

s

1 . B ec k A T : L o ve Is N eve r E n ou gh . N ew Y ork , H arp er

and R ow , 19 88

2 . Z e ttle R D , H errin g E L : T re atm en t u til ity of the socio-

trop y /a u to no m y distin ction : im plicat ion s fo r c ogn i-

tive the rap y .J C lii i P sych ol 199 5; 51 :28 0-2 89

3 . P eselo w E D , R o bin s C J, S an filip o M P , et a l: S o cio tro py

and a uto no my : rela tio nsh ip to an tid epress an tdru gtreat-

m e nt re spo nse and en do gen ous -no ne ndo gen ou s d ich o t-

om y.J A b no rm P syc hol 19 92 ; 1 01 :47 9-4 86

4 . B eck A T , F reem an A , et al: C ogn itive T hera py o f P er-

son ality D isorders. N e w Y ork , G u ilfo rd , 199 0

5 . B ec k A T , E m ery G , G re enb erg R L : A n xie ty D iso rde rs

and P ho bia s: A C og nitive P e rsp ect ive . N ew Y ork , B a -

s ic B o ok s, 1 98 5

6 . S alkov sk is P , C lark D M , G elder M : C og nitive b eha v-

io ur links in the p ers iste nce of pan ic . B e hav R es T her

1 99 6; 3 4:4 53 -4 58

7 . B eck A T : C ogn itiv e th era py : p as t, p re sen t, a nd fu tu re .

J

C on su lt C lin P syc hol 199 3; 6 1 :1 94-19 8

8 . B eck A T , R u sh A J, S ha w B , et a : C og nitive T he rap y

o f D e pre ssion . N ew Y ork , W iley , 19 79

9 . G arrety P , K uipers L , F ow le r D , et a l: C ogn itiv e b e-

h av iora l th erap y for dru g-resis tan t psych oses. B rJ P sy-

c h ia try 1 99 4; 67 :25 9-2 71

1 0 . K un gdo n D , T u rk ing ton D : C o gnitiv e B e hav ior T her -

a py fo r S ch izo phren ia . N ew Y ork , G uilfo rd , 1 994

1 1 . D rury V , B irc hw ood M , C och ran e R , et a l : C o gn itiv e

th era py a nd reco very from acu te p sy cho sis : a co n-

tro lle d tria l, I: im pa ct o n sy m p tom s. B rJ P syc h iatry

1 99 6; 1 69 :5 93 -6 01

12 . D ru iy B , B irch w o od M , C o chra ne R , et a l: C o gnitive

th era py a nd reco very fro m acu te psych os is: a co n-

tro lle d tr ia l, II: im pac t o n reco ve ry t im e. B rJ P sych i-

atry 1 996 ; 16 9:6 02-60 7

13 . B re n t D A , et al: A clin ic al tria l fo r a do lesc en t dep res -

sio n c om par ing cog nit ive , fam ily , an d sup por tive treat-

m ents. A rch G en P syc h ia try (in p res s)

14 . D ahlsga ard K K , B e ck A T , B row n G : Ina deq uate re-

sp onse to thera py as a pre d ic to r of su ic ide. S u icide and

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