Aaron Beck turned the world of psychiatry upside down

BAND FAR THE The youngest of Aaron Beck’s subjects, in the very partial list of patients he had treated for anxiety and phobias in his book “Cognitive Therapy and the Emotional Disorders” (1976), was an eight-year-old boy. This boy, after weeks in the hospital with near-fatal sepsis, became horribly disgusted with blood, and the smell of ether made him pass out. How was he treated? By learning, whenever he felt weak, to focus on other things, even naming all of the US presidents in the correct order. Feelings always followed him into adulthood, but then he confronted them head-on: by going to Yale Medical School, where the scent of ether was more or less infused into the walls.

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The eight-year-old boy was himself, and this childhood experience was his first contact with the idea that human thought moved in two parallel paths. Not conscious and deep subconscious, as Freud had taught, which was accepted wisdom in the 1950s when he entered the field, but rational and “automatic” thoughts, both on the surface. Automatic thoughts were helpful at times, such as when he was driving the car and simultaneously composing the next lecture for his students at Penn University, where he was a professor for half a century. They told her to swerve at a bump, or slow down, without interrupting her flow of ideas. But such thoughts were often distorted, blocking more rational explanations of the problems that inevitably arose in life.

A man may be worried, for example, that his wife has not said goodbye to him when he leaves for work. Did that mean she didn’t love him anymore? Was he really unlovable? The rational explanation could be that she had left some milk to boil on the stove. But the negative thoughts accumulated first and could lead to full-blown depression. A single misinterpretation could convince a beautiful woman that she was ugly and a teenager that she was fat, and the damage was done. Anxiety attacks and phobias weren’t usually triggered by the thing itself, like a high balcony, but by a vivid (and statistically highly unlikely) negative thought of falling over the rail.

He concluded that distorted surface thoughts, rather than Freud’s long buried childhood traumas and Oedipal desires, explained nearly all of the emotional turmoil. For each condition, he applied scientific rigor and simple New England common sense, in addition to writing clear and straightforward manuals for therapists. Over the years, his cognitive behavioral therapy (TCC) was found to be largely effective, requiring far fewer sessions than Freudian analysis and taking longer. It has become and remains the most popular treatment for depression and anxiety in the Western world.

His method was gentle and collaborative. He dressed neatly, with colorful bow ties, and his bright blue eyes were kind. Rather than having his patients lie down on a couch and associate freely, as Freudian analysts did, he invited them to sit at a small table directly in front of him, an intimate space that had no meaning. the space for a large box of tissues. He was less of a clinician than a friend who would help them sort things out together. Then, rather than being silent, he asked constant questions, gently stripping their thoughts to expose distorted ones, and probing his patients for evidence. The base of TCC was empirical, and it was Socratic: “You say you’ve lost everything, but what have you really lost? “What is the probability that you would die if you went out?” “When you told me this story, what really went through your head? That was his key question, finding the parallel tracks.

Once the fallacies were exposed, patients could begin to help themselves. They were told to take note of their day-to-day feelings and gather compensatory evidence for their negative thoughts. People with severe depression were trained to “master” by being given tasks that, although easy for most people, had become impossible for them: getting up, making a phone call. In 1952, he even treated with success a young schizophrenic convinced to be followed by agents of the government. “How would I know what they look like, to help you?” He asked the patient. The patient couldn’t say exactly. But as he was asked every week to describe the agents, they became fewer and fewer, until they disappeared.

Hard as it is to credit, this revolutionary in psychiatry had once been a devout Freudian. But he became more and more embarrassed by the lack of hard science, its mantras and ritualism and its cult of famous practitioners. People with depression, for example, would have turned their hostility towards a parent to themselves, but his study of their dreams showed no more hostility there than anyone else. Depressed and non-depressed might dream that they only found an empty Coke machine while wandering in the desert.

He himself wandered the desert for a time, retreating into private practice, taunted by Freudians and attacked by drug companies whose profits he threatened pills. During a trial in 1977 TCC showed better results than imipramine, the best antidepressant at the time. So he went on, busy recording patient data in his own diary, Cognitive therapy and research, when no one else would publish it. He was quite sure he was right.

But he was not immediately happy. For 40 years, he too has checked his mood twice a day in the Beck Depression Inventory and stored the results in his cellar. The point is that, although he had a great job, a loving wife and four beautiful children (one of whom, Judith, became a TCC clinician and co-founder of his Beck Institute), he still suffered from acute self-criticism. He cared too much about the approval and felt obligated not to get it. The treatment? An even more determined rationality.

At the end of his life, nothing deterred his positive attitude. As a boy, his distorted thoughts of blood and ether had been corrected by the fact that he was not dead and could take care of the future. As an old man, with his horizons narrowing, he had learned to see every mishap not as loss or the confirmation of a flaw, but as an opportunity. If it started to rain just as he was going out, so much the better! All the more time to write this next article and to spread the word even more widely.

This article appeared in the Obituary section of the print edition under the title “Up off the couch”

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