Capita selecta - augustus 2006
The Earliest Beginnings of Cognitive Therapy
by Aaron T. Beck, M.D.
Many people have asked how I "discovered" cognitive therapy,
so here it is!
After I graduated from the Philadelphia Psychoanalytic Institute in 1959, I
was eager to validate the psychoanalytic concepts in order to make them more acceptable to the scientific community. I decided to focus on depression, since that was the most frequent disorder in my practice. It was obvious at that time that the way to go was to look at the basic psychoanalytic constructs of retroflected hostility. According to a simplified psychoanalytic theory, the depressed individual experienced unconscious rage against other close persons, but since the rage was unacceptable, it was repressed and turned against itself. This was the notion of retroflected hostility. The question was how to validate this construct. I hit upon the idea of looking for hostility in the dreams of depressed patients and comparing that with the dreams of non-depressed patients. I had on hand a system for rating hostility in dreams prepared by Dr. Leon Saul. My elaborate study found, however, that the dreams of depressed patients contained less hostility than did those of non-depressed patients. I did note, however, a special idiosyncratic theme in the dreams of the depressives. Specifically, the patients pictured themselves in the dreams as victims: They were defeated, deserted, or defective.
I then was faced with a dilemma: Either I did not go deep enough, or that was as deep as I was going to get. I thought that perhaps looking at the associations to the dreams would get down to more of the hostility, but as might be expected, the associations were more superficial in a sense. But interestingly, these associations related to life events which had the same negative themes as the dreams! This observation had a later bearing on my theory.
At this point it became necessary to reformulate my hypothesis. Perhaps the unconscious hostility would always remain inaccessible to observation but was reflected in the negative themes in the dreams as derivatives of the retroflected hostility. I then set up the hypothesis: The hostility towards the self is manifested in the need to suffer, which seemed to be ubiquitous in the depressive symptomatology (selfcriticism, suicidal wishes, etc.). Expressed in a different way, the guilt over the unacceptable hostility is expressed as self-punitiveness.
I tested the need to suffer in a number of studies using a success-failure or a reward-punishment paradigm. Contrary to the hypothesis, the patients courted success rather than failure and rewards versus punishment. This then led to the alternative hypothesis: "What we see is what we have." The negative way in which the patients actually see themselves is the rock bottom problem. We did not need to go any deeper than that. This was then the beginning of the substitution of a cognitive model for the psychodynamic motivational model. The negative content in the dreams led to a different way of looking at the patients' symptoms. If we think of the negative view of the self, past history, the experiences and the future as the controlling or independent variables, then the other symptoms of depression can be regarded as the dependent variables. If the patient sees himself as defective and helpless, his future as hopeless, and his life as full of insurmountable problems, he is likely to feel sad, be self-critical, give up, and think of suicide as an escape from unrelenting pain.
Meanwhile, I was exploring another source of data. I discovered that patients in psychoanalysis were generally not reporting a crucial part of what was going through their mind, namely their automatic thoughts. I found that their experiences of sadness, frustration, and immobility were often preceded by a very rapid thought, which they were generally not very much aware of. When they learned to detect these automatic thoughts, however, they were able to recognize a wide array of negative thoughts, usually negatively distorted interpretations of ordinary life experiences. These interpretations exacerbated their sadness, loss of motivation, and suicidal wishes. As the patients were able to reality test their interpretations, their depression started to clear up. Their experiences formed the basis for the development of the cognitive therapy of depression, which will be discussed in a future issue of Cognitive Therapy Today.
* From: Beck Institute Newsletter - Spring 2006 - Volume II Issue 1