In Cognitive Therapy and the Emotional Disorders, author Aaron T. Beck, revered today as the father of cognitive psychotherapy, takes the reader on a journey of discovery, presenting his unique approach to psychoanalytic therapy, the realizations that led to it, the principles on which it is based, and their validation through experiment.
Beginning his book with a basic introduction to his theory, Beck cites the history of several patients, among them a woman who upon walking three blocks from her home was suddenly seized with panic. Psychoanalysis, he then explains, would search for unconscious meaning to explain the woman’s reaction: “Being out-of-doors stirs up a repressed desire such as a wish for seduction or rape (Fenichel, 1945). The wish arouses anxiety because of its taboo nature” (Beck 26). The opposing school of thought, behaviorism, would search for a conditioning model instead, “… that at some time in the woman’s life she was confronted with a realistically dangerous situation, while simultaneously being exposed to an innocuous situation (such as traveling away from home) … “ (Beck 26). As if pushing her up a ladder, her thoughts of danger kept elevating her sense of anxiety. The accompanying physical manifestation of feeling close to fainting contributed further to her panic.
Whereas psychoanalysis and behaviorism relied on theory to explain the psychological event, Beck found that his approach relied on taking all relevant data into account. In effect, he discovered a principal that became the core of his cognitive therapy-that between the external (activating) event and the emotional consequences lies a chain of thoughts. This chain of thoughts, “our inner workings… can shut out or twist around the signals from the outside so that we may be completely out of phase with what is going on around us” (Beck 25).
Beck had been practicing psychoanalysis and psychoanalytic psychotherapy for many years before he came to realize the significance of a patient’s cognitions on his feelings and behavior (Beck 29).It was over years of work with patients that he began to develop the clinical method of “Tapping the Internal Communicator” (Beck 24)first through free association, and later, when he realized that some ideations were being censored or suppressed, by teaching his patients to focus on the streams of thought which were formerly ignored. As these were typically automatic and fleeting, each patient had to learn to be especially attentive to the internal conversations going on in his mind, often simultaneously with the main topic occupying his attention. Thus a patient who felt anxious during her sessions, in which she discussed sensitive sexual conflicts, on paying attention to her secondary and parallel stream of thoughts came to realized that her anxiety came not from the embarrassing topic under discussion but from worrying that she was sounding foolish to her therapist. The apparently less relevant, and often ignored, automatic thoughts had been responsible for the emotional reaction, which went away once the patient was reassured that she was expressing herself coherently and was doing an excellent job discussing a sensitive topic (Beck 32).
Beck’s discovery shone new light on the significance of what Plato dubbed the “Internal Dialogue” (Beck 38). It is by this automatic thinking that individuals monitor their thoughts, feelings, actions, debate alternatives and choose the best course of action, self-monitor and self-instruct. When a breakdown between fact and analysis occurs, the result may be as mild as stage fright in one who is over-monitoring himself, or as extreme as the obsessive compulsion that causes a patient to rub his hands raw in an effort to wash off unseen bacteria. Conversely, a deficit of self-monitoring can lead to excessive overeating and weight gain, even to the point where the patient is unaware of starting to eat (Beck 38). Learning from experience results in an internal dialogue of self-instruction aimed at achieving goals, as small as pausing for laughter after telling a joke, or as complex as succeeding in one’s job or being a good parent. And yet, self-instruction may over-mobilize a patient, as in the case of overachievers. Horney (1950)refers to such a state as “the tyranny of the shoulds”(Beck 39). Other types of self-instruction relate to avoidance of action, thoughts of escape, or to anger and the incitement to action, even self-punishment and self-reward. The internal dialogue takes many forms, and the rules by which an individual relates to these thoughts, as well as the syllogisms he draws from them, should be of particular interest to the clinician, concluded Beck. In them lies the answer to the riddle of “unpredictable, illogical behavior and abnormal emotional responses” (Beck 46).
A key to understanding the cause of emotions, Beck discovered, was the hidden meaning each patient ascribed to an event. Whereas psychoanalysis held the meaning to be rooted in an unconscious wish or impulse, and behaviorism attributed all emotions to a stimulus response, disregarding meaning altogether, Beck, through his cognitive approach, discovered that the manner in which each patient interpreted an event-the meaning he ascribed to it-was not unconscious or irrelevant. In fact, this meaning was crucial to understanding the emotional response. Take a case of apparently paradoxical sadness when a salesman on being promoted felt gloomy, or a middle-aged man after moving into his dream house felt anxiety. Once viewed in full context of the meaning each man attributed to the event, the salesman was revealed to be worried over having to relocate to the main office where he had no friends, and the homeowner to be fretting over the size of his new mortgage (Beck 60). Whether dealing with sadness or other emotions such as euphoria, excitation, anxiety or anger, the subjective meaning in the patient’s mind remained the missing link between reality and the emotional reaction, which the cognitive therapist could only uncover by tapping the inner dialogue.
Beck found these facts to hold true even when dealing with more complex emotional disorders such as depression, anxiety neurosis, phobias and obsessions, psychosomatic disorders and hysteria. Experimental studies repeatedly showed the benefit of therapeutic intervention during which the patient was taught to recognize how he consistently distorts his experiences, and how he may replace these with normal feelings and desires. Thus “the major thrust towards health [was] achieved by reshaping the patient’s erroneous beliefs” (Beck 131). The student who failed to win one competition and, therefore, concluded that he will forever fail in every competitive situation sunk into depression, certain that his whole life, past, present and future was doomed to failure (Beck 118)- The college instructor who before his first lecture to a large class experienced a state of acute anxiety commencing with his initial dread that he will do poorly, to feeling certain that he will embarrass himself, get fired, never find a job again and end on skid row, an outcast and a disgrace to his family (Beck 148)- The agoraphobic who (being afraid of open spaces) never agreed to go anywhere without the comfort of someone familiar close by (Beck 169)- The patient with a proven physical aliment who, because of psychosomatic factors, actually suffered disproportionately to his actual illness (Beck 201)- The man who was struck by a car and believed that his legs were run over, consequently developing hysterical paralysis of both legs(Beck 207)- All these patients and others were able to work through their emotional disorders some over weeks, others over years, by targeting the thought content that led to their on set, testing the rationality and likelihood of these thoughts, assessing other courses of action, using their imaginations in a constructive manner, demystifying their fears with understanding.
Even more startling, the study of the inner dialogue of patients confirmed that “common psychological disorders [centered] around certain aberrations in thinking” (Beck 213)-that patients suffering from the same disorder expressed similar errors of judgment, which lead to similar emotional reactions. When the patient showed signs of being able to introspect and reflect on his thoughts and fantasies, the cognitive technique proved a useful healing therapy, with the goal of targeting erroneous thinking such as distortions of reality and illogical thinking. The success or failure of the approach very much depended on the therapist’s ability to establish his credibility in the mind of the patient. Further, a key to success was not necessarily complete elimination of the problem, which might take a lifetime of therapy, but rather reduction of the problem to the point where it no longer interfered with the patient’s life. Add to this the patient’s learning experience, and past knowledge became his means of resolving future problems. Cognitive therapy, in essence, acted both as a present cure and future panacea (Beck 229).
According to Beck, the techniques of his cognitive therapy were tailored to fit human epistemology. Certain principals, he found, must therefore guide it. First, a patient must come to understand that “a perception of reality is not the same as reality itself” (Beck 234). Second, humans are fallible, the sensory data may be misinterpreted during the process of integration and differentiation, which make up the manner of human conception. E.g.: drugs can distort our sensory perceptions, emotions and physical state. Third, “reliable knowledge depends ultimately on having sufficient information, so that a choice can be made among alternative hypotheses” (Beck 234). Fourth, it is crucial to recognize “maladaptive thoughts” (Beck 235), which Beck defines as “ideations that interfere with the ability to cope with life… disrupt internal harmony, and produce inappropriate or excessive emotional reactions” (Beck 235). Fifth, the therapist will teach the patient to uncover his automatic thoughts, as through fantasizing the traumatic situation, or teaching the patient to consciously observe his reactions to certain events and then hone in on the gap between the stimulus and emotional response, where the relevant inner dialogue lies in the mind (Beck 240). Sixth, key epistemological steps to objective thought require “distancing, reality testing, authenticating observations, and validating conclusions” (Beck 243). Finally, after objective analysis of his thoughts, the patient should be in a position to question the “rules” (Beck 247) by which he lives and to change them where necessary.
In summary of his book, Beck cites numerous empirical studies which have shown the cognitive model of psychopathology to be successful. Velten (1968)and Coleman (1970) showed “that inducing a subject to focus on ideas of a self-enhancing or self-deflating content produced feelings of elation or sadness respectively, thereby confirming a central tenant of the cognitive theory”-that the content of a person’s thinking affects his mood (Beck 310).”The concept that meaning determines the emotional response to a situation [was] supported by Pastore (1950, 1952)” (Beck 311).Additional studies into anxiety have shown that automatic thoughts contributed to the arousal of anxiety (e.g.: Meichenbaum, Gilmore, and Fedoravicius, 1971). Irrational ideas have been shown to be a contributing factor in depression, as well as suicidal behavior, by Beck, Kavocas and Weissman (1975), and Lester and Beck (1975). Controlled studies have shown the efficacy of cognitive therapy, such as Taylor (1974), Shaw (1975), Rush, Beck, et al. (1975), Karst and Trexler (1970, 1972).
In drawing his book to a close, Beck once more returns to comparing his cognitive theory to the two giants in the field at the time of his writing, psychoanalysis and behaviorism. His comparison of his theory with psychoanalysis shows substantial areas of overlap. Both require introspection from the patient regarding thoughts, feelings and wishes. Both are concerned with uncovering “meanings” (Beck 313). And both “attempt to achieve structural change… by modifying the cognitive organization that produces unrealistic thinking” (Beck 314). However, Beck concludes, cognitive therapy is much more explicit in this regard, and “the cognitive therapist is more meticulous than the psychoanalyst in searching for, identifying, and examining faulty cognitive responses (automatic thoughts) and the underlying belief system” (Beck 314). Finally, both “depend on ‘working through’ intrapsychic problems” (Beck 314), though psychoanalysis refers to unconscious fantasies and motivations, which in themselves might be false. And yet the very process of chipping away at the patient’s maladaptive attitudes opens his thinking to reevaluation. This said, though cognitive therapy had grown out of psychoanalysis, Beck points out the crucial differences between the two: First, the cognitive therapist does not treat conscious experience as symbolic of unconscious fantasies. Second, the time required to collect data is relatively short. Third, the tenants of cognitive therapy can be (and have been) proven through empirical research. Finally, cognitive therapy in dealing with “commonly shared notions of human nature” (Beck 318) is much easier to teach than psychoanalysis, which relies on esoteric concepts.
Beck goes on to draw the similarities between cognitive therapy and behaviorism, as detailed in “Wolpe’s (1969) concept of behavior therapy” (Beck 321). In both, the therapist is more active during the interview process than in other psychotherapies, as well as more active in modifying responses and behaviors after a definition of the patient’s problem is attained. And both seek to alleviate the overt behavior problems in the patient, though the behaviorist focuses on the overt behavior only, while the cognitive therapist works to modify the maladaptive thoughts leading to it. This key difference translates to a different therapeutic approach, e.g.: the behaviorist might induce “a predetermined sequence of pictorial images alternating with periods of relaxation” (Beck 321), while the cognitive therapist will train “the patient to recognize his spontaneous verbal and pictorial cognitions (automatic thoughts)” (Beck 321.) Finally, though the tenants of behaviorism are equally easy to test empirically as those of the cognitive theory, unlike the latter, Beck stresses, the former do not “readily accommodate notions of internal psychological states” (Beck 322).
In conclusion, writes Beck, “the weight of evidence for cognitive therapy seems to warrant the admission of the newcomer into the arena of controversy” (Beck 337.) And indeed, his honest account of the years of research and thoughts that went into creating, developing, testing and validating his theory present a fascinating tale of a curious mind grappling with questions not yet solved in his field, sometimes not even asked, questions which only an original thinker could have posed, and a courageous soul put to the test. It is perhaps the greatest testament to its force that in less than three decades cognitive theory has changed the face of psychoanalytic psychotherapy irrevocably, charting a truer path into the depths of the human psyche.
- Beck, Aaron T. Cognitive Therapy and The Emotional Disorders. New York: Meridian, 1979.