Seattle Anxiety Specialists - Psychiatry, Psychology, and Psychotherapy

Psychiatrist: Aaron T. Beck

Overview

Aaron Temkin Beck, MD, (1921-2021) is an American psychiatrist that has been globally recognized as the father of cognitive therapy (CT).[1]   

Beck was born on July 21, 1921, in Providence, Rhode Island. He attended Brown University, majoring in English and political science, graduating magna cum laude in 1942. Beck then attended Yale Medical School, attaining his M.D. in 1946. In 1954, Beck joined the Department of Psychiatry at the University of Pennsylvania, later becoming Professor Emeritus at the University of Pennsylvania.[2] He has been a visiting scientist of the Medical Research Council at Oxford and a visiting professor at Harvard, Yale and Columbia.[3]

Beck has participated on review panels of the National Institute of Mental Health, served on the editorial boards of many journals and lectured internationally.[4] He further served as Director of the Center for the Treatment and Prevention of Suicide, President of the Beck Institute for Cognitive Therapy and Research, and Honorary President of the Academy of Cognitive Therapy,[5] which is a nonprofit organization of more than 800 certified cognitive therapists and 100 general members worldwide.[6]

In addition to his contributions to the development and validation of cognitive theory and therapy, Beck has also solidly established himself in the area of psychoanalytic test construction. With his colleagues, Aaron Beck has developed some of the most well-known and frequently utilized self-report instruments available for research and practice. Notably, the most prominent of these measures is the Beck Depression Inventory-II, which assesses the severity of depressive symptoms.[7]

With 629 publications from 1948-2016 based on a myriad of topics (focusing on cognitive therapy, suicide and depression)[8] and recipient of over 50 prestigious academic awards,[9] Aaron Beck is listed among the 10 individuals who shaped American psychiatry and is considered one of the five most influential psychotherapists of all time.[10]

Background  

In the 1950s, when Dr. Beck was beginning his career in psychiatry, the field had been dominated by psychoanalytic theory. The psychoanalytical view regards that relationships and circumstances of one’s early life continues to affect them through adulthood, with human behavior resulting from both unconscious and conscious (e.g., rational) motives. In an effort to make one’s unconscious, conscious, psychoanalysts and patients typically engage in sessions seeking to understand and resolve (or mitigate) the conflicts at the root of suffering.[11]

Initially utilizing the psychoanalytic method, Beck began developing an alternative approach while working with depressed patients. Over time, he found many patients were prone to automatic streams of negative thought. Building on the insights of two predecessors (psychologists George Kelly and Albert Ellis) Beck developed a theory of depression based on the way people process information. Beck’s theory noted that individuals sometimes interpret external events in a biased or distorted way, which may contribute to their mood disturbance.[12]

In the 1960s, Beck became interested in validating various psychoanalytic concepts to make them more accessible to the scientific community. With depression the focus of his research, Beck documented themes of rejection, defeat, deprivation, and sensitivity to failure in the thoughts and dreams of depressed individuals. Noticing that depressed mood was typically preceded by very rapid negative thoughts, he found that by helping people to become aware of these thoughts, test their validity and modify unhelpful cognitions, depression would improve.[13]

In 1963, Beck published a paper in which he identified specific cognitive distortions. Such distortions included: catastrophizing (i.e., imagining something is worse than it actually is) and overgeneralization (e.g., generalizing a specific incident into a general principle – such as stating “everything goes wrong” when one thing has gone awry.) The following year, Beck formulated a new therapy which could help patients learn to recognize their automatic thoughts and cognitive distortions, to then consciously evaluate and correct them.[14]

This therapy was eventually coined “cognitive behavioral therapy” (CBT), as it addressed both cognition and behavior. While this type of therapy has undergone refinement over the years, the focus remains the same, with the aim of CBT seeking to modify one’s biased-thinking and observable behaviors by assisting people to become more aware of them.[15]

Dr. Michael Craig Miller (Editor-in-Chief of Harvard Mental Health Letter) notes that while CBT was initially used only to treat depression, this modality has grown in scope[16] and has been found to be effective in hundreds of clinical trials for many different disorders.[17] CBT is now used to treat virtually every type of psychiatric disorder, including anxiety disorders (such as panic disorder and phobias), bipolar disorder, personality disorders, eating disorders, and substance use disorders. Regarding depression, CBT has been found to be as efficacious as medication, but with a more durable effect. CBT is being tested in the treatment of schizophrenia and somatoform disorders. Further, it has also been shown to be useful in helping people without psychiatric disorders to gain greater insight into their thinking as well as more control over their reactions - thus, improving one’s mental health.[18]

CBT’s Theoretical Components

Depression

While Beck was initially committed to the theory and therapy of psychoanalysis, he felt that, “For psychoanalysis to be accepted by the larger scientific community, it would require a solid base of evidence.” He therefore sought to test the central psychoanalytic proposition that depression was caused by inverted hostility. In other words, if someone experienced unacceptable anger towards another, but repressed this unacceptable anger, it would be expressed in the form of self-criticism, negative expectancy, suicidal wishes, and depressed mood.[19]

Working alongside Marvin Hurvich, a psychology graduate student at the University of Pennsylvania, Beck prepared a scoring manual for hostility in dreams, and Hurvich blindly scored a sample of dreams from patients with depression as well as a control group of patients who were not depressed. Results indicated that patients with depression showed less hostility in their dreams than did the non-depressed individuals. These results posed a dilemma for the team as they seemed to invalidate the theory of inverted hostility. However, after examining the content of dreams for a second time, Beck and Hurvich found that the dreams of the patients with depression consistently portrayed the dreamer or the action in the dream in a negative way. Conversely, this consistent finding was not evident in the dreams of the non-depressed patients. Reasoning that one’s hostility was unable to penetrate through the dreams, it still exists at an unconscious level, assuming the form of a need to suffer. Labelling these dreams as “masochistic” they found that using this negative portrayal of the dreamer as a symbol of the need for personal suffering, in stark contrast in those with depression from those without.[20]

In the early 1960s, Beck worked alongside Jim Diggory and Sy Feshbach from the Department of Psychiatry at the University of Pennsylvania. Conducting a number of experiments, their work was based on the premise that, “if patients with depression had a need to suffer, they would perform better after a negative experience than after a positive experience.”[21-23] For example, failure at a task or continuous negative feedback would lead to better performance than would a positive experience on a task.

The results of their experiments turned out to oppose the team’s hypothesis. Compared with non-depressed individuals, the individuals with depression performed significantly better after a positive experience than they did after a negative experience. Realizing that the concept of masochism as an explanation for the negative content in the dreams was probably a fallacy, Beck came to find that, “Dreams simply represented the way the dreamer perceived the self.” I.e., dream content manifests as a replication of an individuals’ self-image which is actualized in the waking state. Embarking on a larger-scale study of depressed individuals, Beck found that dreams consistently portray a dreamer in negative images, consistent with their conscious negative self-image.[24]

Beck utilized the findings of his dream studies and experimental research as a base to explore supportive evidence for the various tenets of psychoanalysis. He reviewed Freud’s concepts regarding the unconscious, repression and the other defense mechanisms, which was described as, “consisting of a jumble of unacceptable impulses and fantasies that are held in check by repression and other defense mechanisms.” Beck noted that although it was clear that cognitive processing can take place without awareness (as indicated by various experiments on subliminal bias, etc.), he could find “no substantial evidence for the kind of drives and fantasies alluded to by psychoanalysts nor evidence for the frank exhibition of the supposed unconscious material.” Beginning to doubt this keystone of psychoanalytic theory, he examined the bases of psychoanalytic therapy (e.g., infantile memories and the existence of transference of parental images onto therapists.) Again, he found the data to be weak and subject to other interpretations. Continuing his work, Beck found, “As I pursued my investigations, the various psychoanalytic concepts began to collapse like a stack of dominos.”[25]

Automatic Thoughts

In a talk before the Academy of Psychoanalysis, titled “There Is More on the Surface Than Meets the Eye,”[26] Beck sought to demonstrate the notion that many of patients’ ideas that were regarded as unconscious were, in actuality, conscious. Discovering the existence of what he termed “automatic thoughts,” Beck found that when his patients focused on everything that was going through their minds, they had thoughts that they had not been acutely aware of previously. Over time, he observed that these previously unreported thoughts played an important role in the person’s affect and attitudes about the self, others, and their future. Beck noted that, in 1960, he became disillusioned with the formal psychoanalytic approach of patients lying on the couch and free associating – and decided to ask the patients to sit up. Carrying out more of a collaborative conversation, this slight shift in therapeutic approach and delivery, led Beck to perceive it as, “obvious… that these (automatic) thoughts often constituted an important bridge between the external stimulus situation and the individual’s emotional experience and their behavior.”[27]

The illumination of automatic thoughts laid the groundwork for a theory of human psychopathology. In parallel to noticing the existence automatic thoughts, Beck found that when he focused on his own reaction to a particular stimulus, he became aware of those automatic thoughts. “When I experienced either anxiety or anger, I would have an intervening automatic thought, the content of which explained the particular emotion. Thus, themes of threat or anxiety led to anger, loss led to sadness, and gain led to exhilaration. When I was able to put all of this together, I had an “a-ha” experience. I felt as though I had discovered something new. I also observed that the automatic thoughts actually were exaggerations or even misconstructions or misinterpretations of a situation.” For example, a person’s hesitation to an invite might be misinterpreted as a slight, inciting anger. However, when searching for evidence for that thought, it may be very weak or nonexistent. Automatic thoughts, therefore, may form a bridge to one’s affective experience, generally existing as distortions that fit one’s diagnosis.[28]

Beck found that automatic thoughts can serve a useful function, even though they are generally covert. For example, they enable one to more-easily multitask as thoughts emerge as self-instructions guiding one’s actions. However, when Beck asked his patients to focus on their automatic thoughts, he found that the content varied according to their major psychiatric problem or diagnosis: the more severe the disorder, the more conscious these automatic thoughts became. For example, those with depression reported automatic thoughts generally themed around self-criticism or regret. In more severe cases of depression, automatic thoughts occupied a majority of their stream of consciousness. Similarly, those with anxiety experienced thought content filled with fears and those with obsessional neurosis tended to have repetitive, automatic thoughts of an imperative nature (e.g., perform a repetitive action). While Beck found there to be no diagnostic category for patients with anger issues, they reported automatic thoughts with the same general theme of unjustified loss, challenge, or threat.[29]

Initially, Beck sought to train his patients to focus on and recognize their automatic thoughts. In interview sessions, he asked his patients to examine the validity of their thoughts, which he noted tended to generally constitute misinterpretations or exaggerations of a situation (i.e., cognitive distortions.) When they were able to correct any misinterpretation by looking for evidence, considering alternative explanations, or evaluating the logic of the conclusions, his patients began to get better.[30]  

The Evolution of Cognitive Therapy

Beck recognized that individuals tend to have a system of beliefs that, when triggered by a particular situation, form as an automatic thought that is properly or improperly interpreted. Based on this, he sought to construct a theory of normal thought processes and psychopathology.[31] When deciding the proper way to label individuals’ beliefs and automatic thoughts, he first considered using the term “construct.” He found, however, the term “schema”, derived from Piaget’s work, seemed to offer more possibilities and thus used schema to describe the structure that, when triggered, produced the automatic thought. Following Piaget’s lead, Beck ascribed the following characteristics to the schemas: permeability/impermeability, magnitude, content, and charge. Beck noted that, “Permeability/impermeability indicated receptivity to change, magnitude was the size of the schema relative to the person’s general self-concept, and content described the basic theme. When the charge of the schema was low, the schema was essentially deactivated but became activated again when a stimulus congruent with the content of the schema became activated or, in psychopathology, when the schema was activated to varying degrees during the course of the episode.”[32]

Expanding on the concept of schemas, Beck developed a number of instruments that measured idiosyncratic beliefs for major depressive disorders and problems such as depression, suicide, anxiety, substance abuse, anger and hostility, couples problems, and, more recently, schizophrenia – formalizing the Beck Depression Inventory.[33,34] Noting that these various psychological variables had previously been poorly defined, Beck sought to develop a measure of the psychiatric disorder before attempting to identify the beliefs, the characteristics of each disorder, and the therapy adapted to modify the maladaptive beliefs. For each disorder, the diagnostic instrument could be used to identify the primary psychopathology and be a partial outcome measure.[35]

Once the maladaptive beliefs were identified for a given disorder, Beck proceeded to develop a therapy for said disorder. To test the clinical utility of the assigned beliefs for a given disorder, Beck conducted clinical trials and presented the findings via publications, to provide material for other practitioners to utilize. He noted that in addition to identifying the primary problem and working to rewire maladaptive beliefs and biases into more adaptive ones, another key factor in the success of any of the adaptations of cognitive therapy is the working relationship with the therapist. Beck commented that, “In the most severe problems, such as personality disorders—borderline personality disorder and schizophrenia, for example—the forging of the connection with the patient involves a kind of partnership or comradeship in many cases.”[36]

Regarding schizophrenia, Beck and his team has made significant progress in the treatment of this disorder. They found that even the most severe cases, involving long periods of hospitalization, bizarre behavior, poor urinary and bowel behaviors, self-injury, and aggressiveness, are amenable to treatment and subject to positive change.[37,38] Most notably, they found that psychotic features such as delusions, hallucinations, and bizarre behavior actually disguise a normal personality and that the task of a therapist is to activate that normal personality. Although differences exist between traditional cognitive behavior therapy (CBT) and Beck’s therapeutic approach for schizophrenia (i.e., recovery-oriented cognitive therapy, or CT-R), this therapy uses many of the basic tenets of CBT, including personalizing a cognitive formulation for each unique individual, working through negative and dysfunctional beliefs, and discussing strategies to achieving meaningful goals.[39]

Since the inception of CBT, the practice has expanded globally due to its efficacy in treating a multitude of disorders. A 2015 survey indicated that CBT is the most broadly-used form of therapy in the world.[40] In addition, in the United Kingdom, CBT has been employed as the dominant modality of therapy in the Improving Access to Psychological Therapies (IAPT) program within the National Health Service (NHS), treating more than 500,000 people per year with a variety of mental-health concerns, including depressive and anxiety-related disorders.[41] David, Cristea and Hofmann (2018) note that, “This substantial focus on dissemination and training of quality CBT clinicians from every continent has been fundamental to the overall acceptance of CBT as the “gold standard” of therapy.”[42] Beck reflected, “Although my personal research has been focused primarily on psychological disorders, it is also necessary to give credit to the innovative researchers who have successfully used CBT to treat a number of medical disorders that even I would have previously written off as impossible to target with psychotherapy. These include diabetes, dementia, hypertension, irritable bowel syndrome, insomnia, and skin diseases.”[43]

Discussion  

For over 50 years, Beck’s cognitive model has provided an evidence-based way to conceptualize and treat various psychological disorders. In 2014, Beck and Haigh published an article which noted weaknesses of the former modality and sought to explain the Generic Cognitive Model (GCM) which could explain any pitfalls of the former theoretical framework. The GCM represents a set of common principles that can be applied across the spectrum of psychological disorders. This updated theoretical model provides a framework for addressing significant questions regarding the phenomenology of disorders not explained in previous iterations of the original model.[44]

Specifically, Beck and Haigh note that disorders were formerly organized into modes: for example, a depressive mode, an anxiety mode, etc. However, there remained many features of psychological disorders that required explanation. Additionally, Beck’s previous writings did not account for goals, normal adaptations, and mechanisms of activation and deactivation of schemas. Finally, Beck and Haigh note the apparent autonomy of bipolar disorder and endogenous depression had previously not been explained.[45]

The GCM, therefore, reflects several important innovations to the original theoretical model, including: the continuity between adaptation and maladaptation; the concept of schema activation; the integration of dual processing into the model; the concept of early detection and orientation of incoming stimuli in information processing by relatively crude schemas (protoschemas); the processing of vital stimuli by specialized primal schemas; and an expanded theory of modes, which provides the substrate for manic episodes and endogenous depression. The GCM includes a theoretical account and an applied clinical approach. Beck and Haigh note that, “Theoretically, the model is a coherent representation of the underlying psychopathology (e.g., maladaptive functions expressed in symptom formation), which provides testable hypotheses that can be modified to influence the clinical model.” As the theoretical model has been translated into an applied approach for use by clinicians, it can therefore be used in an applied approach to determine the psychological configuration for a particular disorder, develop a case formulation, and choose among a variety of interventions.  While some of these are highly specific for a particular problem, others can be used across a wide variety of disorders.[46]

In an ever-seeking quest for knowledge and in an attempt to develop and refine the field of psychotherapy, Aaron Beck eloquently notes, “As I look back over the past 65 years, my professional life has been filled with what I can best describe as a continual series of adventures. For the most part, the challenges that I’ve confronted were of my own making: Like Theseus in the labyrinth, whenever I seemed to find a solution to a problem, I was confronted with another problem (to solve/figure out).”[47]    

Contributed by: Jennifer (Ghahari) Smith, Ph.D.

References

1 “Aaron T. Beck, MD,” Beck Institute: Cognitive Behavioral Therapy. (accessed 12-15-2020). beckinstitute.org/team/dr-aaron-t-beck/

2 “Aaron Beck,” Psychology. (accessed 12-15-2020). psychology.iresearchnet.com/counseling-psychology/history-of-counseling/aaron-beck/

3 “Aaron T. Beck, MD,” Beck Institute: Cognitive Behavioral Therapy.

4 Ibid.

5 “Aaron Beck,” Psychology.

6 “Aaron T. Beck, MD,” Beck Institute: Cognitive Behavioral Therapy.

7 “Aaron Beck,” Psychology.

8 “Dr. Aaron T. Beck Publication List,” Beck Institute: Cognitive Behavioral Therapy. (accessed 12-16-2020). beckinstitute.org/wp-content/uploads/2016/09/A.-Beck-Pub-List-9.16.pdf

9 “Aaron Beck Awards,”  Beck Institute: Cognitive Behavioral Therapy. (accessed 12-16-2020). beckinstitute.org/aaron-beck-awards/

10 “Aaron Beck,” Psychology.

11  “Commentary: Dr. Aaron T. Beck’s Enduring Impact on Mental Health,” Harvard Health Publishing: Harvard Medical School. (accessed 12-14-2020). health.harvard.edu/newsletter_article/dr-aaron-t-becks-enduring-impact-on-mental-health

12 Ibid.

13 “Aaron Beck,” Psychology.

14 “Commentary: Dr. Aaron T. Beck’s Enduring Impact on Mental Health,” Harvard Health Publishing: Harvard Medical School.

15 Ibid.

16 Ibid.

17 “Aaron T. Beck, MD,” Beck Institute: Cognitive Behavioral Therapy.

18 “Commentary: Dr. Aaron T. Beck’s Enduring Impact on Mental Health,” Harvard Health Publishing: Harvard Medical School.

19 Beck AT. A 60-Year Evolution of Cognitive Theory and Therapy. Perspectives on Psychological Science. 2019;14(1):16-20. doi:10.1177/1745691618804187

20 Beck, A. T., Hurvich, M. S. (1959). Psychological correlates of depression: 1. Frequency of “masochistic” dream content in a private practice sample. Psychosomatic Medicine, 21, 50–55.

21 Loeb, A., Beck, A. T., Diggory, J. (1971). Differential effects of success and failure on depressed and nondepressed patients. Journal of Nervous and Mental Disease, 152, 106–114. doi:10.1097/00005053-197102000-00003

22 Loeb, A., Beck, A. T., Diggory, J. C., Tuthill, R. (1967, September). Expectancy, level of aspiration, performance, and self-evaluation in depression. In Proceedings of the 75th Annual Convention of the American Psychological Association (Vol. 2, pp. 193–194). Washington DC: American Psychological Association.

23 Loeb, A., Feshbach, S., Beck, A. T., Wolf, A. (1964). Some effects of reward upon the social perception and motivation of psychiatric patients varying in depression. The Journal of Abnormal and Social Psychology, 68, 609–616. doi:10.1037/h0044260

24 Beck, A. T., Ward, C. H. (1961). Dreams of depressed patients: Characteristic themes in manifest content. Archives of General Psychiatry, 5, 462–467. doi:10.1001/archpsyc.1961.01710170040004

25 A 60-Year Evolution of Cognitive Theory and Therapy.  

26 Beck, A. T. (1963a, November). There is more on the surface than meets the eye. Lecture presented in The Academy of Psychoanalysis, New York, NY.

27 A 60-Year Evolution of Cognitive Theory and Therapy.  

28 Beck, A. T. (1963b). Thinking and depression: I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324–333. doi:10.1001/archpsyc.1963.01720160014002

29 A 60-Year Evolution of Cognitive Theory and Therapy.  

30 Ibid.

31 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: Meridian.

32 A 60-Year Evolution of Cognitive Theory and Therapy.  

33 Beck, A. T., Steer, R. A., Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77–100. doi:10.1016/0272-7358(88)90050-5

34 Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. doi:10.1001/archpsyc.1961.01710120031004

35 A 60-Year Evolution of Cognitive Theory and Therapy.  

36 Ibid.

37 Grant, P. M., Bredemeier, K., Beck, A. T. (2017). Six-month follow-up of recovery-oriented cognitive therapy for low-functioning individuals with schizophrenia. Psychiatric Services, 68, 997–1002. doi:10.1176/appi.ps.201600413

38 Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N. M., Beck, A. T. (2012). Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of General Psychiatry, 69, 121–127. doi:10.1001/archgenpsychiatry.2011.129

39 A 60-Year Evolution of Cognitive Theory and Therapy.  

40 Knapp, P., Kieling, C., Beck, A. T. (2015). What do psychotherapists do? A systematic review and meta-regression of surveys. Psychotherapy and Psychosomatics, 84, 377–378. doi:10.1159/000433555

41 Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology, 14, 159–183. doi:10.1146/annurev-clinpsy-050817-084833

42 David, D., Cristea, I., Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry, 9, Article 4. doi:10.3389/fpsyt.2018.00004

43 A 60-Year Evolution of Cognitive Theory and Therapy.  

44 Beck AT, Haigh EA. Advances in cognitive theory and therapy: the generic cognitive model. Annu Rev Clin Psychol. 2014;10:1-24. doi:10.1146/annurev-clinpsy-032813-153734

45 Ibid.

46 Ibid.

47 A 60-Year Evolution of Cognitive Theory and Therapy.