The Story of Psychology (115 page)

This sounds simplistic, but it has proven to have considerable appeal. After a slow start, and despite opposition by dynamically oriented therapists, it began to catch on during the 1960s through Ellis’s own ceaseless promoting, the growth of cognitive therapies in general, and the incorporation of RET in textbooks of cognitive and behavioral therapy. Ellis’s practice grew ever busier. In 1959 he had founded an Institute for Rational-Emotive Therapy, bought a building on East Sixty-fifth Street in Manhattan to house it, and from then on kept the building filled from morning to late evening with clients, students, and staff.

By the 1970s, although Ellis, his students, and his methods were often
attacked in professional journals, RET institutes were being founded in other cities and in Europe. In 1982, a survey of eight hundred clinical and counseling psychologists published in the APA’s
American Psychologist
showed that Ellis was regarded as currently the second most influential psychotherapist (the first was Carl Rogers, of whom more shortly), and a review of references in three counseling journals found Ellis the most cited author in the early 1980s.
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In 1985 the American Psychological Association gave Ellis its Award for Distinguished Professional Contributions, saying, in part:

But the field of psychotherapy has always been one of many new developments and shifts of popularity. Over the past two decades, Ellis’s key idea has been borrowed, adapted, and practiced within a host of differently named methodologies (generally in a less aggressive manner) by many others. By 2002, the APA annual convention included a roundtable titled “Will the Real Behavior Therapy Stand Up?” Dr. Ellis said on that occasion that his version was the first, and, in his view, still the most effective, but that “the entire field of psychotherapy is more eclectic since the 1980s,” that “behavior therapy has become more multi-modal,” and that the future would be one in which “everyone is stealing from everyone… Within ten years I predict that all behavior therapies will be equally efficacious.”
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To conclude this narrative on a rather dismal note, a few years after the APA roundtable, Ellis and the board of directors of his institute fell into a nasty dispute over administrative issues, and in 2005 the board forced him out. He continued, embittered but undaunted, to practice REBT elsewhere in New York City until his death two years later. Despite his ouster, he was still the winner, because his basic method, the rational treatment of mental and emotional ills, has become one of the arrows in the quiver of most psychotherapists, whatever their major orientation.

The therapist, who has done the most to advance and develop cognitive therapy did not originally owe anything to Ellis but later incorporated his fundamental premise—and often acknowledged his indebtedness to him. He is Aaron “Tim” Beck, whose name conjures respect and admiration throughout the world of contemporary psychotherapy.

At about the same time that Ellis was publishing his first papers on RET, Beck, a psychiatrist on the faculty of the department of psychiatry at the University of Pennsylvania, was taking his first step along a similar route. At that time a youthful man of modest height with a dense thatch of straight hair and a disarming smile, Beck practiced psychoanalysis, but in his own life he had earlier used behavioral and rational techniques on himself to conquer two severe phobias. As a child, he had had a series of operations, and from then on the sight of blood would make him feel faint. By the time he reached his teens he decided to defeat the phobia. “One of the reasons I went into medicine was to confront my fear,” he has said, and in his first year in medical school he made himself watch operations from the amphitheater and in his second year elected to be a surgical assistant. By making himself experience blood as a normal phenomenon, he dispelled his fear. Later in life he similarly tackled a fear of tunnels, manifested as involuntary shallow breathing and faintness (he attributes the phobia to a childhood fear of suffocation caused by a bad bout of whooping cough). He got rid of the fear by pointing out to himself repeatedly that the symptoms would show up even before he entered a tunnel. Proving to himself that they were unrealistic, he gradually reasoned the fear away.
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Beck, until his late thirties, believed in and used psychoanalytic therapy with his patients. He was particularly interested in depression, which, according to psychodynamic theory—as he interpreted it—is the result of hostility choked back and turned on oneself, where it takes the form of a “need to suffer.” The depressed person satisfies this need by behaving in ways that provoke others to reject or disapprove of him or her.

It troubled Beck that the theory was not well accepted by many psychiatrists and psychologists, and he set out to gather data from his own clinical experience to validate it. At first the evidence seemed to support the theory, but after a while he noticed contradictions and anomalies in his data. In particular, the depressed patients he was studying seemed not to be trying to be rejected by others but to win acceptance and approval. Beck underwent a loss of faith. “This marked
discrepancy between laboratory findings and clinical theory,” he has written in retrospect, “led to an ‘agonizing reappraisal’ of my own belief system.”
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Beck, looking for a new faith, caught a glimpse of one when he resumed the study of the dreams of one depressed patient. In those dreams the patient was always a failure, unable to achieve some goal, losing an object of value, or appearing diseased, defective, or ugly. Beck had formerly interpreted the dreams as expressions of a wish to suffer; now he had an epiphany:

By means of a series of tests, Beck found that the patient “had a global negative view of himself, the outside world, and the future, which apparently was expressed in the wide range of negative cognitive distortions.”

That being so, he reasoned, it should be possible “to correct his distortions through the application of logic and rules of evidence and to adjust his information processing to reality.” Perhaps not just this patient but most patients could be healed by such therapy. As Beck has said, quoting the humanistic psychologist Abraham Maslow, “The neurotic is not only emotionally sick—he is cognitively wrong.”
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This concept is the basis of the cognitive therapy of depression that Beck developed and wrote about in journal articles in 1963 and 1964, and in a 1967 book,
Depression: Clinical, Experimental, and Theoretical Aspects.
Later, through years of weekly conferences and case discussions with colleagues in the department of psychiatry, he extended the use of cognitive therapy to other neurotic conditions, and still later adapted it to the treatment of problems in couples’ relationships.

For some years Beck’s ideas were ignored and he was considered something of a pariah in the profession. But by the 1970s, as cognitivism pervaded psychology and, to some extent, psychiatry, his ideas were absorbed into the major theories of personality and behavior. A growing number of clinicians began relying on his methods, especially with depressed patients, and over the years some of them have modified or added to Beck’s formulations and worked out their own versions. Beck, not a self-promoting person, is still not widely known among the psychologically attuned laity, but within psychology and psychiatry he is generally
acknowledged as the creator of cognitive therapy. In his version and others it is now one of the leading treatments used in the United States. About a third of all psychotherapists are primarily cognitive or cognitive-behavioral; many others use cognitive-behavior therapy part of the time.
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Cognitive therapy did not spring full-grown from Beck’s brain. He himself says that it owes something to the cognitive revolution in psychology and to the behavior therapy movement, which, to the extent that its therapy requires the patient to think about the mental steps needed to achieve change, is partly cognitive. Beck did not know of Ellis’s RET when he first conceived of cognitive therapy, but he has said that Ellis’s work played a major part in the development of cognitive-behavior therapies.
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Although Beck’s system has some resemblances to Ellis’s, Beck has been more decorous, gentle, and supportive than Ellis in his personal style. Beck also differs from Ellis in that he offers a more detailed cognitive theory of the neurotic disorders. In discussing depression, for instance, he has identified and labeled three causative factors:

He has made similar analyses of the cognitive distortions responsible for a number of other neurotic and even psychotic disorders.

Beck’s cognitive therapy involves much more than merely pointing out to the patient his or her cognitive distortions. A crucial part in getting the patient to recognize the distortions is the therapist-patient relationship; Beck makes much of the need for the therapist to be warm, empathetic, and sincere. He has employed a variety of cognitive and behavioral techniques, among them role playing, assertion training, and
behavior rehearsal.
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He has also used “cognitive rehearsal.” He would ask a depressed patient who cannot carry out even an old, familiar, well-learned task to imagine and discuss with him each step in the process; this counteracts the tendency of the patient’s mind to wander and offsets the sense of incapacity. Patients often report that they feel better as a result of completing a task in imagination.

Beck also assigned “homework.” The patient, between sessions, had to monitor his or her thoughts and behavior, make deliberate efforts to alter them, and carry out specific tasks. This not only overcame the patient’s inertia and lack of motivation but also yielded actual accomplishments that tended to correct the patient’s incorrect belief that he or she was unable to achieve anything. Toward the same ends, Beck also often asked the patient to write a weekly report of his or her activities and tell the degree to which each was gratifying.

The crucial work of the therapy, however, was examining, in the office sessions, the patient’s ideas and correcting his or her cognitive distortions. Beck’s manner of doing so was very different from Ellis’s. One severely depressed woman told Beck, “My family doesn’t appreciate me,” “Nobody appreciates me, they take me for granted,” and “I am worthless.” Her evidence was that her adolescent children no longer wanted to do things with her. Here is how Beck led her to test the reality of her view of her children’s feelings: