Aaron Beck - Cognitive Therapy

Background and personal life

Beck was born in Providence, Rhode Island, US, the youngest of four children born
to Ukrainian Jewish immigrants. Beck was married in 1950 to Phyllis W. Beck, who
was the first woman judge on the appellate court of the Commonwealth of
Pennsylvania. and whose youngest daughter, Alice Beck Dubow, is also a judge on
the appellate court of the Commonwealth of Pennsylvania. Together they have four
adult children: Roy, Judy, Dan, and Alice. Beck's daughter Judith is a
prominent cognitive behavioral therapy (CBT) educator and clinician, who wrote the
basic text in the field. She is a co-founder of the non-profit Beck Institute. He turned
100 on 18 July 2021.

Education
Beck attended Brown University, graduating magna cum laude in 1942. At Brown he
was elected a member of the Phi Beta Kappa Society, was an associate editor of The
Brown Daily Herald, and received the Francis Wayland Scholarship, William Gaston
Prize for Excellence in Oratory, and Philo Sherman Bennett Essay Award. Beck
attended Yale Medical School, graduating with an MD in 1946.
He began to specialize in neurology, reportedly liking the precision of its procedures.
However, due to a shortage of psychiatry residents he was instructed to do a six-
month rotation in that field, and became absorbed in psychoanalysis, despite initial
wariness.

Early posts
After completing his medical internships and residencies from 1946 to 1950, Beck
became Fellow in psychiatry at the Austen Riggs Center, a private mental hospital in
the mountains of Stockbridge, Massachusetts, until 1952. At that time it was a center
of ego psychology with an unusual degree of collaboration between psychiatrists and
psychologists, including David Rapaport.
Beck then completed military service as assistant chief of neuropsychiatry at Valley
Forge Army Hospital in the United States Military.

Penn psychiatry
Beck then joined the Department of Psychiatry at the University of Pennsylvania
(Penn) in 1954. The department chair was Kenneth Ellmaker Appel, a psychoanalyst
who was president of the American Psychiatric Association, whose efforts to expand
the presence and relatedness of psychiatry had a big influence on Beck's career. At
the same time, Beck began formal training in psychoanalysis at the Philadelphia
Institute of the American Psychoanalytic Association.
Beck's closest colleague was Marvin Stein, a friend since their army hospital days to
whom Beck looked up for his scientific rigor in psychoneuroimmunology. Beck's first
research was with Leon J. Saul, a psychoanalyst known for unusual methods such as
therapy by telephone or setting homework, who had developed inventory
questionnaires to quantify ego processes in the manifest content of dreams (that
which can be directly reported by the dreamer). Beck and a graduate student
developed a new inventory they used to assess "masochistic" hostility in manifest
dreams, published in 1959. This study found themes of loss and rejection related to
depression, rather than inverted hostility as predicted by psychoanalysis. Developing
the work with NIMH funding, Beck came up with what he would call the Beck
Depression Inventory, which he published in 1961 and soon started to market,
unsupported by Appel. In another experiment, he found that depressed patients
sought encouragement or improvement following disapproval, rather than seeking
out suffering and failure as predicted by the Freudian anger-turned-inwards theory.
Through the 1950s, Beck adhered to the department's psychoanalytic theories while
pursuing experimentation and harboring private doubts. In 1961, however,
controversy over whom to appoint as the new chair of psychiatry—specifically, fierce
psychoanalytic opposition to the favored choice of biomedical researcher Eli Robins
—brought matters to a head, an early skirmish in a power shift away from
psychoanalysis nationally. Beck tried to remain neutral and, with Albert J. Stunkard,
opposed a petition to block Robins. Stunkard, a behaviorist who specialized
in obesity and who had dropped out of psychoanalytic training, was eventually
appointed department head in the face of sustained opposition which again Beck
would not engage in, putting him at bitter odds with his friend Stein.
On top of this, despite having graduated from his Philadelphia training, the
American Psychoanalytic Institute rejected (deferred) Beck's membership
application in 1960, skeptical of his claims of success from relatively brief therapy
and advising he conduct further supervised therapy on the more advanced or
termination phases of a case, and again in 1961 when he had not done so but outlined
his clinical and research work. Such deferments were a tactic used by the Institute to
maintain the orthodoxy in teaching, but Beck did not know this at the time and has
described the decision as stupid and dumb.
Beck usually explains his increasing belief in his cognitive model by reference to a
patient he had been listening to for a year at the Penn clinic. When he suggested she
was anxious due to her ego being confronted by her sexual impulses, and asked her
whether she believed this when she did not seem convinced, she said she was actually
worried that she was being boring, and that she thought this often and with everyone.

Private practice
Beck requested a sabbatical and would go into private practice for five years.
In 1962, he was already making notes about patterns of thoughts in depression,
emphasizing what can be observed and tested by anyone and treated in the present.
He strengthened the new alliance with the psychiatrist Stunkard, and extended his
links to psychologist colleagues such as Seymour Feshbach and Irving Sigel, thus
keeping abreast of developments in cognitive psychology, as he did also from the new
Center for Cognitive Science at Harvard University. He was particularly engaged
by George Kelly's personal construct theory and Jean Piaget's schemas. Beck's first
articles on the cognitive theory of depression, in 1963 and 1964 in the Archives of
General Psychiatry, maintained the psychiatric context of ego psychology but then
turned to concepts of realistic and scientific thinking in the terms of the new
cognitive psychology, extended to become a therapeutic need.
Beck's notebooks were also filled with self-analysis, where at least twice a day for
several years he wrote out his own "negative" (later "automatic") thoughts, rated with
a percentile belief score, classified and restructured.
The psychologist who would become most important for Beck was Albert Ellis, whose
own faith in psychoanalysis had crumbled by the 1950s. He had begun presenting his
"rational therapy" by the mid 1950s. Beck recalls that Ellis contacted him in the mid
1960s after his two articles in the Archives of General Psychiatry, and therefore he
discovered Ellis had developed a rich theory and pragmatic therapy that he was able
to use to some extent as a framework blended with his own, though he disliked Ellis's
technique of telling patients what he thought was going on rather than helping the
client to learn for themselves empirically. Psychoanalyst Gerald E. Kochansky
remarked in 1975 in a review of one of Beck's books that he could no longer tell if
Beck was a psychoanalyst or a devotee of Ellis. Beck highlighted the classical
philosophical Socratic method as an inspiration, while Ellis
highlighted disputation which he stated was not anti-empirical and taught people
how to dispute internally. Both Beck and Ellis cited aspects of the ancient
philosophical system of stoicism as a forerunner of their ideas, though Ellis wrote
more about this; both mistakenly cited Cicero as a stoic.
In 1967, becoming active again at University of Pennsylvania, Beck still described
himself and his new therapy (as he always would quietly ) as neo-Freudian in the ego
psychology school, albeit focused on interactions with the environment rather than
internal drives. He offered cognitive therapy work as a relatively "neutral" space and
a bridge to psychology. With a monograph on depression that Beck published in
1967, according to historian Rachael Rosner: "Cognitive Therapy entered the
marketplace as a corrective experimentalist psychological framework both for
himself and his patients and for his fellow psychiatrists."

Organizations
Beck is involved in research studies at the University of Pennsylvania, and conducts
biweekly Case Conferences at Beck Institute for area psychiatric residents, graduate
students, and mental health professionals. He meets every two weeks with
conference participants and generally does 2-3 role plays. He was elected a Fellow of
the American Academy of Arts and Sciences in 2007.
Beck is the founder and President Emeritus of the non-profit Beck Institute for
Cognitive Therapy and Research, and the director of the Psychopathology Research
Center (PRC), which is the parent organization of the Center for the Treatment and
Prevention of Suicide. In 1986, he was a visiting scientist at Oxford University.
He has been professor emeritus at Penn since 1992, and an adjunct professor at
both Temple University and University of Medicine and Dentistry of New Jersey.
In recent years, cognitive therapy has been disseminated outside academic settings,
including throughout the United Kingdom, and in a program developed by Dr. Beck
and Dr. Torrey A. Creed, with the City of Philadelphia[31] known as the Penn
Collaborative for CBT and Implementation Science
Cognitive therapy
Working with depressed patients, Beck found that they experienced streams of
negative thoughts that seemed to arise spontaneously. He termed these cognitions
"automatic thoughts", and discovered that their content fell into three categories:
negative ideas about oneself, the world, and the future. He stated that such
cognitions were interrelated as the cognitive triad. Limited time spent reflecting on
automatic thoughts would lead patients to treat them as valid.
Beck began helping patients identify and evaluate these thoughts and found that by
doing so, patients were able to think more realistically, which led them to feel better
emotionally and behave more functionally. He developed key ideas in CBT,
explaining that different disorders were associated with different types of distorted
thinking. Distorted thinking has a negative effect on a person's behaviour no matter
what type of disorder they had, he found. Beck explained that successful
interventions will educate a person to understand and become aware of their
distorted thinking, and how to challenge its effects.[23] He discovered that frequent
negative automatic thoughts reveal a person's core beliefs. He explained that core
beliefs are formed over lifelong experiences; we "feel" these beliefs to be true.
Since that time, Beck and his colleagues worldwide have researched the efficacy of
this form of psychotherapy in treating a wide variety of disorders including
depression, bipolar disorder, eating disorders, drug abuse, anxiety
disorders, personality disorders, and many other medical conditions with
psychological components. Cognitive therapy has also been applied with success to
individuals with anxiety disorders, schizophrenia, and many other medical and
psychiatric disorders. Some of Beck's most recent work has focused on cognitive
therapy for schizophrenia, borderline personality disorder, and for patients who have
had recurrent suicide attempts.
Beck’s recent research on the treatment of schizophrenia has suggested that patients
once believed to be non-responsive to treatment are amenable to positive
change. Even the most severe presentations of the illness, such as those involving
long periods of hospitalization, bizarre behavior, poor personal hygiene, self-injury,
and aggressiveness, can respond positively to a modified version of cognitive
behavioural treatment. Called recovery-oriented cognitive therapy (CT-R), the
approach focused less on the amelioration of symptoms, but instead, on empowering
the individual to identify and attain meaningful goals and a desired life.
However, some mental health professionals have opposed Beck's cognitive models
and resulting therapies as too mechanistic or too limited in which parts of mental
activity they will consider. From within the CBT community itself, one line of
research using component analyses (dismantling studies) has found that the addition
of cognitive strategies often fails to show superior efficacy over behavioral strategies
alone, and that attempts to challenge thoughts can sometimes have a rebound effect.
Moreover, although Beck's work was presented as a far more scientific and
experimentally-based development than psychoanalysis (while being less reductive
than behaviourism), Beck's key principles were not necessarily based on the general
findings and models of cognitive psychology or neuroscience developing at that time
but were derived from personal clinical observations and interpretations in his
therapy office. And although there have been many cognitive models developed for
different mental disorders and hundreds of outcome studies on the effectiveness of
CBT—relatively easy because of the narrow, time-limited and manual-based nature
of the treatment—there has been much less focus on experimentally proving the
supposedly active mechanisms; in some cases the predicted causal relationships have
not been found, such as between dysfunctional attitudes and outcomes.
Beck’s (1967) system of therapy is similar to Ellis’s, but has been most widely used in
cases of depression.  Cognitive therapists help clients to recognize the negative
thoughts and errors in logic that cause them to be depressed. 
The therapist also guides clients to question and challenge their dysfunctional
thoughts, try out new interpretations, and ultimately apply alternative ways of
thinking in their daily lives.
Aaron Beck believes that a person’s reaction to specific upsetting thoughts may
contribute to abnormality. As we confront the many situations that arise in life, both
comforting and upsetting thoughts come into our heads.  Beck calls these unbidden
cognition’s automatic thoughts.
When a person’s stream of automatic thoughts is very negative you would expect a
person to become depressed (I’m never going to get this essay finished, my girlfriend
fancies my best friend, I’m getting fat, I have no money, my parents hate me - have
you ever felt like this?). Quite often these negative thoughts will persist even in the
face of contrary evidence.
Beck (1967) identified three mechanisms that he thought were responsible for
depression:

1. The cognitive triad (of negative automatic thinking

2. Negative self schemas
3. Errors in Logic (i.e. faulty information processing)

The Cognitive Triad

The cognitive triad are three forms of negative (i.e helpless and critical) thinking that
are typical of individuals with depression: namely negative thoughts about the self,
the world and the future. These thoughts tended to be automatic in depressed people
as they occurred spontaneously.
As these three components interact, they interfere with normal cognitive processing,
leading to impairments in perception, memory and problem solving with the person
becoming obsessed with negative thoughts.

Negative Self-Schemas
Beck believed that depression prone individuals develop a negative self-schema.
They possess a set of beliefs and expectations about themselves that are essentially
negative and pessimistic.
Beck claimed that negative schemas may be acquired in childhood as a result of a
traumatic event. Experiences that might contribute to negative schemas include:

 Death of a parent or sibling.

 Parental rejection, criticism, overprotection, neglect or abuse.
 Bullying at school or exclusion from peer group.
People with negative self schemas become prone to making logical errors in their
thinking and they tend to focus selectively on certain aspects of a situation while
ignoring equally relevant information.

Cognitive Distortions
Beck (1967) identifies a number of illogical thinking processes (i.e. distortions of
thought processes). These illogical thought patterns are self-defeating, and can cause
great anxiety or depression for the individual.
• Arbitrary interference: Drawing conclusions on the basis of sufficient or
irrelevant evidence: for example, thinking you are worthless because an open air
concert you were going to see has been rained off.
• Selective abstraction: Focusing on a single aspect of a situation and ignoring
others: E.g., you feel responsible for your team losing a football match even though
you are just one of the players on the field.
• Magnification: exaggerating the importance of undesirable events. E.g., if you
scrape a bit of paint work on your car and, therefore, see yourself as a totally awful
driver.
• Minimisation: underplaying the significance of an event. E.g., you get praised by
your teachers for an excellent term’s work, but you see this as trivial.
• Overgeneralization: drawing broad negative conclusions on the basis of a single
insignificant event. E.g., you get a D for an exam when you normally get straight As
and you, therefore, think you are stupid.
• Personalisation: Attributing the negative feelings of others to yourself. E.g., your
teacher looks really cross when he comes into the room, so he must be cross with
you.

Strengths of CBT
1. Model has great appeal because it focuses on human thought. Human
cognitive abilities have been responsible for our many accomplishments so
may also be responsible for our problems.
2. Cognitive theories lend themselves to testing. When experimental subjects
are manipulated into adopting unpleasant assumptions or thought they
became more anxious and depressed (Rimm & Litvak, 1969).
3. Many people with psychological disorders, particularly depressive, anxiety,
and sexual disorders have been found to display maladaptive assumptions and
thoughts (Beck et al., 1983).
4. Cognitive therapy has been very effective for treating depression (Hollon &
Beck, 1994), and moderately effective for anxiety problems (Beck, 1993).
Limitations of CBT
1. The precise role of cognitive processes is yet to be determined. It is not clear
whether faulty cognitions are a cause of the psychopathology or a consequence
of it.
Lewinsohn (1981) studied a group of participants before any of them became
depressed, and found that those who later became depressed were no more
likely to have negative thoughts than those who did not develop depression.
This suggests that hopeless and negative thinking may be the result of
depression, rather than the cause of it.
2. The cognitive model is narrow in scope - thinking is just one part of human
functioning, broader issues need to be addressed.
3. Ethical issues: RET is a directive therapy aimed at changing cognitions
sometimes quite forcefully. For some, this may be considered an unethical
approach.