The Evolution Of Psychotherapy

The Third Conference

Jeffrey K. Zeig

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780876308134
• eBook ISBN: 9781317736905
• Topic: Psychology
• Subtopic: Diseases & Allergies
• Index: Psychology

A collection of papers from the third Evolution of Psychotherapy Conference. The Evolution Conferences are organized by The Milton H. Erickson Foundation. The Erickson Foundation is a nonprofit educational organization.

First published in 1997. Routledge is an imprint of Taylor & Francis, an informa company.

SECTION II

Cognitive-Behavioral Approaches

Cognitive Therapy: Reflections

Aaron T. Beck, M.D.

Aaron T. Beck, M.D., D.M.S.

Aaron T. Beck is a University Professor Emeritus of Psychiatry at the School of Medicine of the University of Pennsylvania. Dr. Beck is the author of ten professional books and 300 articles published in professional and scientific journals. He received his M.D. in 1946 from the Yale School of Medicine. Dr. Beck is the recipient of numerous professional honors and serves on many editorial boards. He has received a number of research grants and his areas of special research interests are the psychopathology of psychiatric disorders, prediction of suicide, and the cognitive therapy of depression and other disorders. Dr. Beck is one of the originators of cognitive therapy.

INTRODUCTION

There was a time in my life when I was really alone in thinking about cognitive therapy, or some type of short-term therapy, as a new approach to depression and some of the other psychiatric disorders. There was really nobody I could speak to, nobody who was really interested, except my wife, Phyllis, and my teenage daughter, Judith. And when I told Judy about it, she said: “Dad, that does make sense to me.” Thus reassured, I persevered and ultimately was rewarded by Judy’s own evolution as a cognitive therapist, researcher, and author. I have previously described the evolution of cognitive therapy (Beck, 1967). In this chapter, I will present an overview of psychotherapy and cognitive therapy. Then, I will review some of the myths about cognitive therapy. Finally, I will present some of the newer formulations of cognitive therapy.

AN OVERVIEW OF PSYCHOTHERAPY

Turning to the field of psychotherapy in general, we note that very often a particular technique is elevated to the status of a psychotherapy in itself. Somebody in the 1950s counted up 200 psychotherapies; by the 1960s it was up to 300; and the last count that I heard of, it was up to 450 psychotherapies! Every time a clinician comes out with a new technique it is likely to be labeled a “psychotherapy.”

In the past, I have outlined what I consider are the basic requirements for a system of psychotherapy to be considered a “system” rather than simply a “technique.” This does not mean, of course, that some of the novel techniques cannot be useful, but these cannot be regarded as fully developed psychotherapies.

As indicated in Table 1, the first requirement for a system of psychotherapy is a theory of personality and psychopathology. Theory is critical in terms of understanding patients. If you were an especially skilled surgeon, you would need a knowledge of anatomy, pathology, and physiology in order to operate. If you did not have a knowledge of anatomy, you might start working on the liver but end up in the aorta! In other words, you have to know where you are going, and how to get there.

TABLE 1

Standards for a System of Psychotherapy

1. A theory of personality and psychopathology. 2. Empirical data to support the theory. 3. Operationalized therapy that interlocks with the theory. 4. Empirical data to support the therapy.

The second requirement is empirical data to support the appropriate theory of personality and psychopathology. Investigators have spent years, if not decades, working in the vineyards trying to devise experiments to test various cognitive concepts, whether directly related to cognitive therapy or to cognitive psychology (which is probably the basic science of cognitive therapy).

The third requirement for a system of psychotherapy is an operationalized therapy that interlocks with the theory. You should be able to derive the therapy readily from the theory. There should be a congruence between what you are thinking and what you are doing. There have been many theories of therapies through the ages in which there was no congruence between theory and therapy. A historical example is Mesmer’s technique and theory of “animal magnetism.” In such a case you might as well discard the theory and just stick to the therapy. There also should be empirical data to support the therapy itself, a point that I will return to subsequently.

Finally, a complete system of psychotherapy should stipulate the mechanisms of improvement. Symptomatic improvement, for example, may result from the modification of dysfunctional thinking, but durable improvement comes from modification of the underlying beliefs, or, as we say technically, from schematic change, from actual modification of the schémas themselves.

MYTHS ABOUT COGNITIVE THERAPY

Many times people talk about a “revision of standard cognitive therapy.” In one sense, there is no such thing as standard cognitive therapy; that is a myth. There is a specific cognitive configuration for every specific disorder, and within each specific disorder there is a specific therapeutic application for the specific patient. While there are general broad principles of cognitive therapy across all conditions and a large set of strategies to choose from, there is no one cognitive therapy. Our 1979 book on cognitive therapy for depression outlines in detail what happens in depression (Beck, Rush, Shaw, and Emery, 1979), but it doesn’t tell us how you treat drug addiction, sex offenders, panic disorder, or multiple personality disorder. You need a specific cognitive model and specialized techniques for each of those conditions.

Another myth is that cognitive therapy is simply a set of techniques aimed at identifying and correcting “irrational thinking.” This is wrong on two counts. First, as shown in Table 2, cognitive therapy is defined in terms of the cognitive model (or theory) of psychiatric disorders. This model then serves as a kind of map to guide the therapist in selecting the kind of interventions that seem most appropriate at a particular time for a particular patient with a particular set of problems. While the specific cognitive techniques provide a powerful vehicle for effecting cognitive change, they are not the only—or always the best—methods for a particular patient at a particular time. We also use experiential, dramatic, and conversational strategies, depending on the patient’s needs at a particular time. A popular but naive and simplistic definition asserts that cognitive therapy is simply a technology aimed at changing people’s thoughts. But the model, rather than the specific technique employed, is the hallmark of cognitive therapy.

TABLE 2

Definition of Cognitive Therapy

1. Cognitive therapy is defined in terms of the cognitive model rather than the specific techniques employed. 2. The model stipulates that psychological disorders are characterized by dysfunctional thinking derived from dysfunctional beliefs. 3. Improvement results from modification of the dysfunctional thinking and durable improvement from modification of beliefs.

I can illustrate this definition with a specific example. I once was consulted by a college professor, with whom I simply had a conversation for 45 or 50 minutes. He came in highly suicidal and wanted to carry out what he considered a “rational suicide” based on his supposed intellectual deterioration, presumably the result of “brain damage” due to a tranquilizer he had taken. I simply engaged him in a conversation regarding the kind of projects he was engaged in and asked him to critique the work of other investigators. Although his thinking was retarded at first (due to depression, not brain damage) he became quite animated in his exposition of his work. After he was able to give me a comprehensive and lucid description of his work for 30 minutes, he was no longer suicidal. Without my having to point it out, it became obvious to him that his mind was still functioning very well and it was consequently not “necessary” to end his life. At the start, I had an idea of his problem—his erroneous belief that he was deteriorating—and I used a kind of cognitive map to guide me in questioning him and drawing him out. There was nothing in what I did that a novice would call “standard cognitive therapy.” Yet, through this experiential exercise, the patient’s fundamental erroneous belief about himself was corrected, and he could view himself and his future more realistically.

To address another myth, we do not consider the thinking associated with particular disorders as “irrational. “In their present circumstances, the patients’ idiosyncratic thinking may be problematic, dysfunctional, or maladaptive—but not irrational. Under other circumstances (in the face of imminent danger), the exaggerated thinking of the anxious patient, for example, could be adaptive, even life saving.

Another myth is that “cognitions cause psychopathology” or “cognitions cause depression.” In reality, cognitions do not cause depression, nor do they cause any other disorder. However, as an expression of information processing, they are centrally involved in psychopathology just as they are in normal functioning. The cognitive model stipulates that dysfunctional thinking is the essence, is the core, not the cause of psychological disorders. You might ask “If cognitions do not cause depression, what does cause depression?” We don’t really know exactly what causes depression. Part of the answer depends upon what you mean by “cause”—whether you are thinking at a molecular level, an interpersonal level, or a strictly intrapsychic psychological level. I think the best way of looking at this issue is that there are many possible determinants of depression and they vary enormously from one person to another. Some are continuously cycling bipolar patients who have an overriding endogenous component. You would think that because their disorders are so biological and they do respond to some degree to the appropriate cocktail of drugs, psychological interventions would not help. In fact, psychological interventions in conjunction with drug treatment do help; the drugs tend to produce a ceiling on the highs and also floors under the lows, but they are not perfect. We find rich cognitive material, just as rich as in the reactive depressions, and are then able to utilize cognitive therapy to help the patients along. However, even though cognitive events are instrumental in fluctuations of the disorder—and cognitive interventions may help—there is no justification for concluding that the psychopathology is “caused” by cognitive factors.

Long ago (Beck, 1967) I discussed the negative cognitive triad in depression and showed the relationship between patients’ perception of themselves, their future, and their own personal world on the one hand, and the various symptoms of depression. What is new in my latest version is the notion that when a person is experiencing a wide variety of motivational, behavioral, and somatic symptoms, these particular experiences in themselves are processed cognitively (so there is a continuous feedback loop). If the patient is inclined to stay in bed and to neglect her family and work, for example, her observations of these behaviors and somatic symptoms are then “translated” by her information processing into: “I am lazy; I am an irresponsible person; I deserve to be punished” and a vicious cycle is established. The dysfunctional thinking involves not only cognitive distortions but an uncontrolled fixation upon some topic of concern (for example, danger).

Dysfunctional thinking in the specific disorders is derived from specific dysfunctional beliefs, and we cannot overemphasize their importance. It is possible to modify people’s distorted thinking, for example, without ever touching their basic belief structure. As a consequence, they may improve symptomatically but within a few weeks or months they relapse and return to therapy. Patients with panic disorders, for example, may recover from their panic attacks but they still have agoraphobia, because a basic belief, such as “If I go into a supermarket or subway, I may have a heart attack and die,” has never been dealt with adequately. All that has been affecting these cases has been the catastrophic thinking during the time of the panic attack itself, but not the avoidance-producing beliefs. You have to be able to elicit the related beliefs and test them out.

We may not know that dysfunctional beliefs exist in these various psychopathologies until we start to explore them. For example, at one time I thought that eating disorders were simply problems with eating and I did get some pretty good symptomatic relief from cognitive therapy with some of these patients. But then it turned out that many relapsed after a period of time, because I had not been aware that these patients generally had a negative self-image—a negative core belief about themselves. To get a sustained improvement and prevent the development of anorexia nervosa in bulemic adolescents, we had to explore the beliefs about the self.

Another fallacy is that the cognitive model asserts that individuals operate on cognition alone. This is the myth of “exclusive cognitivism.” In cognitive therapy we think of the total personality. We emphasize the word “cognitive” because the theory and therapy are based on an information processing model. The first bit of information that comes into the human apparatus has to pass through the information processing system. Irrespective of whether the stimulus appears internally, as, say, a pain in the stomach, or externally as, say, a menacing animal approaching us, a stimulus first has to go through the information processing system if it is to affect the organism. But the model also stipulates that when there is something wrong with information processing, whether it is due to drugs like the bromides or LSD, it is going to cause a disturbance in the other components of the personality, in the affective, the motivational, and the behavioral domains. So when you are working with an individual patient you have to look at him or her as a totality, not simply in terms of his or her “distorted cognitions.”

Another problem that has posed difficulties is the “contextual vacuum” fallacy. You may read or hear that cognitive therapy deals just with cognitive distortions, whereas interpersonal therapy, say, deals with the interpersonal context, to which I respond: “What do...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Milton H. Erickson Foundation
• Acknowledgments
• Welcoming by Elizabeth M. Erickson, B.A
• Convocation Speech by Jeffrey K. Zeig, Ph.D
• SECTION I. ANALYTIC THERAPIES
• SECTION II. COGNITIVE-BEHAVIORAL APPROACHES
• SECTION III. CONTEMPORARY APPROACHES
• SECTION IV. ERICKSONIAN APPROACHES
• SECTION V. EXPERIENTIAL APPROACHES
• SECTION VI. FAMILY THERAPISTS
• SECTION VII. PHILOSOPHICAL APPROACHES
• SECTION VIII. STATE OF THE ART