RIP Aaron Beck, founder of CBT and reviver of the Stoics’ cognitive approach to therapy

Aaron Beck, who died today aged 100, was the founder of Cognitive Behavioural Therapy (CBT) — arguably the most influential and ubiquitous form of talking therapy today, one in which the NHS has put billions of pounds. CBT personally helped me to recover from social anxiety in the early Noughties.

I interviewed Beck back in 2007, when I was considering the relationship between liberalism and social anxiety. My thesis is that emotional problems like social anxiety are a product not just of an individual’s thinking, but of our society’s values. I sent Professor Beck a few questions, which he was kind enough to answer. We also discussed how Stoicism inspired his and Albert Ellis’ cognitive approach to therapy.

What is the relationship between the values of a society and the thought processes of an individual? Do you think western liberal society emphasizes the importance of fame and public approval more than other cultures, and this could lead to some specific emotional disorders, such as narcissism or social anxiety?

I wish I could answer all your questions, but for the most part they are beyond my level of competence. I am also loath to toss out an opinion that is not based on empirical evidence. There are several levels of analysis, all of them valid, by which one can understand emotional disorders. There is the societal level, the interpersonal level, the intrapersonal (or psychological) level, and the biological level. As a clinician, clinical researcher,and clinical writer, I feel competent to offer an opinion only on the clinical or psychiatric level.

To what extent do you think CBT has been accepted by the psychological and psychiatric communities? Is it more accepted to work for anxiety disorders than depressive disorders like, say, manic depression?

CBT has gradually been accepted more and more by the psychological and psychiatric communities. The big problem has been the shortage of trained cognitive therapists. However, this is gradually improving. But to answer your question, I believe that there is greater acceptance by the professional community, but there are not available therapists. I don’t believe that there is any difference in the acceptability of working with
anxiety disorder and with depressive disorders. In general, manic depression is more severe and generally requires medication in addition to cognitive therapy, so unless one is coordinating the treatment with a psychiatrist, it would be difficult to carry on.

Lord Layard, in the UK, has suggested that greater government funding for CBT is the solution to dealing to what he describes as an epidemic of emotional disorders in this country. Do you agree?

I am not sure that I agree with Lord Layard that there is an epidemic of emotional disorders in this country. I have seen no statistics that bear this out.

Albert Ellis suggested that children should be taught cognitive management techniques in schools. Perhaps it would be possible to teach them CBT, as well as teachings from Stoicism, Buddhism, and other traditions of cognitive management. What do you think?

I do think that cognitive management techniques could be taught in schools and have advocated them. Dr Marty Seligman’s group indeed has been doing exactly that.

You speak of using the ‘Socratic method’ in CBT. To what extent was Greek philosophy, particularly Socrates and the Stoics, an influence on your ideas, as it was on Dr Ellis? And how much of an influence was Ellis and REBT on your development of CBT?

Ellis and I developed our approaches independently. I believe that Albert Ellis independently wrote about the influence of Greek philosophers on his own writing.

I came across the notion of Socratic Dialogue when I read about it in my college philosophy course — I believe it was in Plato’s Republic. I also was influenced by the Stoic philosophers who stated that it was a meaning of events rather than the events themselves that affected people. When this was articulated by Ellis, everything clicked into place; however, I must say that I was looking at meaning prior to this. My work in psychoanalysis taught me that “unconscious” meanings were extremely important. Over the course of time I decided that the important meanings were quite accessible to consciousness when individuals focused on their automatic thoughts.

At one point, Dr. Ellis saw one of my papers, made contact with me, and subsequently he re-published these papers (from 1963 and 1964) in his institute. It was valuable having Ellis confirm much of what I had been writing. Both CBT and REBT are designed specifically for emotional disorders (rather than predominantly real-life philosophy). CT is similar to but also quite different from REBT. We have developed an extensive infrastructure of research to construct profiles and specialized treatments for each of the psychiatric disorders and have a vast number of empirical studies that support the validity of this approach. REBT has been very important in promoting the cognitive approach among practitioners and the lay public, but for the most part does not have empirical basis and has a generic treatment (“one size fits all”).

Finally, on schizophrenia, which I know is a very interesting area for CBT: I have a friend with schizophrenia, who’s had psychotic episodes where he thought he was surrounded by devils. He is terrified of going out of his ‘comfort zone’ in case the spirits lure him to hell. I tell him this is his mental illness lying to him, that God is unlikely to be that severe. But he says he will believe the evidence of his own eyes. so in some ways he’s being empirical, not irrational. How, in that situation, do you persuade someone to ignore the evidence of their own eyes and believe you? How do you get them to risk the wrath of God for the sake of social acceptance?

The treatment of delusions and schizophrenia is a very tricky one. One of the definitions of delusions is that they do not yield to corrective feedback from other people. Consequently, attempting to persuade an individual that the delusion is incorrect is obviously self-defeating. There is a whole body of literature on how to address delusions. In brief, questioning the patient like a journalist without indicating disbelief is one way. This tends to get the patient into a questioning mode. However, that approach is used much later in treatment. Initially, we train the patients to recognize their automatic thoughts and then lead them to recognize some of their non-psychotic misinterpretations. After a strong basis is made on this, we then lead them to consider the more paranoid interpretations of their experiences(which we have labeled as their “upsetting interpretations”). Thus, in treating delusions, we try to develop or enhance the patient’s skills in handling some of their emotional problems and then later apply these skills to the delusional misinterpretations. Another technique is something we call “behavioral experiments” — we might have the patient who is afraid of going out of his ‘comfort zone’ go with the therapist or a trusted person for a few feet or yards, or even further, just to test out whether he is vulnerable. This of course is dependent on the patient’s having a great deal of confidence in the therapist’s wisdom and trustworthiness. For further information on this topic, I suggest that you review the book by David Kingdon and Doug Turkington titled Cognitive Therapy of Schizophrenia.

For more on how Stoicism inspired CBT, see my book Philosophy for Life and Other Dangerous Situations