A Conversation with Aaron T. Beck

I'm Judith Beck and today I'm interviewing my father Dr Aaron back we are respectively the university professor amerus of Psychiatry and I'm clinical associate professor we're both at the University of Pennsylvania perilman school of medicine and my father is the president am Meritus and I am the President of the Beck Institute for cognitive behavior therapy in Philadelphia and we have a number of questions that span your career's work how did you get into Psychiatry well you know that's a story of a big flip-flop uh when I was in medical school I was really turned off

by Psychiatry the um chairman of Psychiatry at that time uh had been a student of kin and um he saw psychiatric patients is falling into one of two categories either they were psychotic or they had Psychopathic personality disorder Psychopathic personality is what he call that and neither were treatable uh so that wasn't a very favorable introduction to somebody who wanted to actually help people and then there was I believe one psychoanalyst on the staff who did some teaching and the way he talked was so esoteric I really could not understand him so when it came

time for me to write an essay as part of my clinical clerkship on uh psychiatric patient I really wasn't able to do it and I had some kind of a mental block so one of my friends Marty Gorden actually helped me to write the paper so I then went through my internship and I really could not see much value to Psychiatry at least the way it was uh presented in those days but I was very much interested in neurology and the thing that attracted to me about neurology was in a sense it was so scientific

you could locate a very precise area in the brain which could accom for a whole multitude of neurological symptoms and I found that very interesting and very engaging and so I decided to do my uh residency in neurology and I had two years of Neurology and worked out very nicely and I was planning to have a whole career as a neurologist maybe do some teaching and some research as well as clinical practice then the chief of neuropsychiatry decided that all neurolog ology residents should take a six months rotation through Psychiatry and I fought it but

he said well you have to do it and the reason was that they were short of uh psychiatric residents at the time so I said okay so I I did my six months and I felt te I've invested whole six months here and I I really don't have any kind of grip as to what Psychiatry is about or what definitely what it has to offer I remember at times I would be uh in a doing group therapy with a group of psychotic patients and I really had no idea of what to do with them they

would just be sitting around there some would be talking continuously and the others would be zoned out and U so on but I had several friends there who really were very um involved very pass passionate about Psychiatry so I went by them and they said well why don't you take another six months so instead of going back to neurology I spent another six months and at the end of that time I decided Well maybe I'll go back to neurology I just don't dig Psychiatry and one of my friends good friends said you know your big

reason the reason you can't really understand what's going on is you haven't been analyzed and I said well what does that have to do with it and said well you know you have these kind of personality problems and when you're with these psychiatric patients they stir up all kinds of unconscious conflicts and that's why Psychiatry is so aversive to you uh because your it is bubbling all over and you get into all your defenses and defenses prevent you from really understanding what's going on so I said well you know as long as I've invested six

months I'll take a leave of absence from uh neurology and uh I'll try to find out more about psychoanalysis so then went to the Austin rig Center in in Stockbridge Mass and um I did not get analyzed there but there was kind of an analytic atmosphere and it began to dawn on me that psychoanalysis really did have the answer not only to Neurosis but to all kinds of human problems War and Peace and even medical problems like cancer could be due to some kind of psychodynamic conflict that people had so when I came to Philadelphia

I decided to get analyzed and um I went through my whole analysis and at the end of the analysis I thought well psychoanalysis is really okay and it really does have an awful lot of answers uh but I didn't like the psychoanalytic establishment and so um I thought they were very arbitrary and they were very ritualistic and uh was a little bit like like a religion and in fact I applied of creditation by uh the American psychoanalytic Society having already gotten my credentials as an analyst and I got turned down twice and the first time

was because I hadn't been analyzed long enough I'd been only analyzed for two years and they didn't like that and then I had had four cases in analysis but they all got better within a year and they thought that I really was not really imbued with a whole psychoanalytic ethos so they turned me down a second time and so um anyhow so I I still stayed in the uh field of psychoanalytic therapy for a while but uh but anyhow that was my transition from neurology to Psychiatry they still probably have me a the books in

Boston as being on a leave of absence how did you move from Psychiatry to cognitive therapy well I moved from being a committed psychoanalyst to being an uncommitted psychoanalyst to being something nebulous to being a cognitive therapist so there's series of stages and basically I it was due to a number of some very surprising incidents that took place so when I uh finished my analysis this was in the late 50s you're talking about yes in the very late 50s I had finished my analysis and I was interested in depression for a couple of reasons one

is uh I had a lot of patients who were depressed and so I was interested in in just being able to treat them as well as I could and secondly I was very much interested in evaluating U the whole psychoanalytic notion of depression and it's at that particular time there were two schools of thought in psychology uh one believed in psychoanalysis and the more academically oriented uh psychologists are really quite skeptical about psychoanalysis so I thought that if I could do some good solid research on some of the psychoanalytic hypothesis that this could help to

persuade the uh very skeptical academic psychologist that there was something to it the psychoanalyst psychoanalysts didn't need any persuasion uh they already were uh committed it just reminded me of a story one of my friends told me that um he had done some um tests of psychoanalytic theory and um it turned out that Freud's notion according to his testing was correct and he thought he said you know should I write to Dr Freud and um tell him that I've now confirmed one of his theories and um he then uh he he asked one of his

friends about this and the friend said well telling this would be like telling the Pope that you now have evidence in the existence of the Trinity interesting and so uh so anyhow but I I was not deterred by this and I I thought it would be really very useful for society to be able to have some confirmation of the psychoanalytic theory now Depression was a very good topic to research and the reason for this is that the theory was very clear-cut but psych according to psychotic Theory people have a lot of hostility for some reason

or another but the hostility is not acceptable to them and so they repress the hostility and when it gets repressed it runs against this bar of defense mechanisms and it then gets deflected inwardly something that we call the theory of retroflect hostility and when the hostility gets reflected inwardly it then is manifested in a whole series of U uh symptoms and one of the symptoms obviously is that the person is very self-critical they feel very bad about themselves and even in the more ultimate phase they might even become suicidal and want to commit suicide and

this is all due to hostility against the South and it made very good sense clinically but the big problem was there was no independent evidence to support this and so I thought that I would do some research to try to support it and where to look for support comes the question well it occurred to me that if I could look at the dreams of my depressed patients and compare these with the dreams of non-depressed patients I could look for the evidence of a hostility in the dreams and I could then get into the unconscious as

you know uh the dreams are the royal road to the unconscious so I worked with a psychologist graduate student by the name of Marvin hervic we prepared a manual for grading the um hostility in the dreams and we went through the usual uh scientific comparisons and statistical analyses and so on looked at the dreams of the depressed patients and after we did all the analyses to my surprise that was surprise number one the um dreams of the depressed patients showed less h ility than the dreams of the non-depressed patients and so this was really a

puzzle and it would seem to not really support uh the hypothesis but that didn't seem to be possible so we started to look for other explanations then we when we looked at the dreams again we saw that there was a peculiar feature of the dreams of the depressed patients and that was that the dep depressed patient in the dreams was always subject of some unpleasant occurrence uh that they would be rejected be abandoned depreciated uh desolated diseased whatever uh and this seemed to be a current that ran through all of the uh dreams of the

depressed patients uh one of the patients for example would have a dream of going to a formal dance and uh would discover that she only had shoes for the left foot or somebody would be in a desert would put a nickel in a Coke machine in the desert and all that would happen they get Fizz so Marvin and I talked about this and then the light bulb flashed in my mind and we thought well there's still the unconscious hostility but the way it's showing up in the dreams is that the patient has a need to

suffer and the need to suffer is then being expressed in these negative dreams and so we called this the masochistic dreams and we published a paper in 1959 on masochistic dreams and depressed patients and so it looked here as though I did have some validation of the psychoanalytic theory however I did want to get some independent confirmation of um the um the whole masochistic Theory so we did several other studies um which should show that the depressed patients have a need to suffer but when we did these studies they were nonverbal studies experimental studies of

various types that far from having a need to suffer the depressed patients would show a need for being reassured for getting affection uh for getting praise and so on and so if there was any motivation it seemed from these other studies that the motivation was not to suffer but to get positive reinforcement of some type and so this was the second surprise so when I then started to rethink this it occurred to me that maybe I should take the dreams at the face value and instead of seeing the dreams as being motivated uh by uh

some unconscious Drive I could see the dreams as simply a representation of the way the patient perceives himself or herself and the way they perceive their experiences and that this could be the rock bottom and so I started to look around and I I saw that in the literature there was some work done on what was called cognition and so I started to think well maybe there are certain thinking processes that are involved and the thinking processes in the pration take a negative turn and so that was the experimental work that I did and then

I went on and did some more clinical work and then how did you develop the theory in therapy of depression okay so so over here now we have the beginnings of my theory of depression because I'm already starting to think that uh depression is related to cognitive processes but that was only one piece of the action the other piece of the action was based on the clinical work that I was doing so I was seeing patients and two or three four times a week and they're on the couch and free associating and then one time

I had an unusual experience uh for me it was unusual and that one of the women patients that I was seeing started to regail me with all kinds of stories about um her sexual escapades and so on and she continued on through the entire session doing all that at the end of the session I asked her now how do you feel and she said well doctor I I feel quite anxious and so I gave her a good psychoanalytic formulation and I said well you see the big problem is in talking about sex it triggers anxiety

because you consider the sex is somehow unacceptable and um it then triggers anxiety and some kind of fear of disapproval from me or from society maybe from your parents and she said yes doctor that makes very good sense uh but and I I said well what's the butd thinking she was going to show a resistance now and she said well actually what I was really thinking about was that I was boring you and I said what and I said well how many times did you have that thought and she said well I was thinking this

all through the session and I said oh well that's interesting uh do you ever have these thoughts any other times and she says well I always have it and I'm always anxious that I'm boring people so then another light went off in my head and I started to think this seems to be totally contradictory to the way I was thinking thinking because what she is doing is she's reporting having some thoughts that don't fit into my theory and it's these thoughts themselves that seem to be stirring up the anxiety not the uh the sexual material

but it's these thoughts and the thoughts have to do with self-critical thoughts so then I I started to ask other patients during the session what thoughts they were having during the session and it turned out that they were having same type of negative self-deprecatory thoughts and after having seen this in a number of patients it occurred to me that there's a whole stream of kind of preconscious thinking that goes on that people don't generally report to the Analyst at least they weren't reporting it to me and that these thoughts that they were having had to

do with some kind of internal communication system not the kind of things that one reports to other people but the kind of automatic thoughts that one has such as when you're driving you have an automatic thought there's a bump in the road I'll steer around it uh these thoughts happen automatically and they're uh not only very quick uh but they go away very quickly and people don't pay too much attention to them but even though they don't pay much attention to them they can trigger all kinds of emotions anger Euphoria sadness and so on so

now I was getting another piece of material from my patients and at that point and this has to do with the therapy part at that point I decided that instead of having them on the couch I would sit my patients up and um we would uh kind of focus on things in general but also on automatic thought so for example one of the women that I was treating at the time uh she actually was coming in for the first interview uh and she had told me that she was really depressed and hopeless uh and the

reason for that her husband had just gone off to jail and she didn't have any money she had some children to support and uh she then said can you help me and I said well we'll work together the two of us will help you with the problem and I then saw a shadow go across brush her face and I went on to another question then I came back and I said you know you look kind of sad when I made that comment there were work together on this and I said uh the key cognitive therapy

question which is what was going through your mind just then and she said well I just thought you were telling me you weren't going to help me and I said well C to me this is a distortion and so now first I discovered there automatic thought and this was like the thought that she had the flash thought I wasn't going to help her but also was a misinterpretation and so as I collected more material I found that these patients were misinterpreting what I had to tell them quite a bit and eventually I noted that the

misinterpretations fell into lot of categories one was called selective abstraction one I gave that name to where they would take one little element and then uh and then see everything through just that one little element like one little mistake uh which seem to them to represent everything related to that was overgeneralization and then I noticed they tended to have dichotomus thinking that everything was either good or bad up or down and so on and so I started to see that there were a whole series of cognitive distortions that were taking place particularly in patient who

were depressed now I put everything together so from my research work I was getting the idea that patients depressed patients had a negative representation of the self as indicated in the dreams and then I saw that they were having cognitive distortions and so I got the notion that people had negative beliefs and the negative beliefs would act as a kind of prism and it would block out positive things and only allow in NE negative things and it was also a warped prism so that the uh interpretations that people would make of what was going on

we um uh distorted so now we have the representations and we have the distortions and then the question is what do you do about it well at that particular time I became aware of the work of Albert Ellis and Ellis had actually come before me in terms of seeing the relationship between uh people's thinking and their affect or their thinking and their behavior so he had already written a book on this and he had developed a therapy uh which he called rational motive therapy um and so I borrowed some of his thoughts some of Ellis's

techniques and I would have people now start to examine their thinking I challenge them which was Ellis's term but start to explore investigate evaluate their automatic thoughts and we would do this in a variety of ways one is if a person had a negative thought such as my wife doesn't love me because she ran off without saying goodbye so we'd say uh first of all um is this the only time she's done this or does she do this a lot uh second uh that's selective abstraction uh are you making some general statement this is over

over generalization and so on and then we say now is there some alternative explanation or does it logically follow that the reason she uh went off is because she didn't care for you a whole variety of techniques now this is what happened and this was my next surprise is when I started to have people looking at their automatic thoughts they started to get better and while I could have patients doing Analytics therapy with me for 2 3 years after about 10 or 12 sessions the patient would say well doctor you've helped me a lot bye-bye

and my case load shrunk and pretty soon I was down to very few patients and at that point uh the chairman of my department Micky stun said well Tim you don't seem to be doing so well in private practice why don't you come fulltime to the university and that's how I then got going on a full academic career where I did research and some clinical practice and teaching and that was the birth of cogntive therapy but then you put cognitive therapy uh of depression to the test and you were involved in an outcome study can

you talk a little bit about that yes okay so now I'm doing academic work and um I'm still doing some research and I set up a little organization um which we called the mood Clinic what I wanted to do was to um do further research on my cognitive model of depression which I had developed at that particular time um and I wanted to do research but in order to do research I had to get patience in order to get patience I had to offer them something um and so uh we had to offer them therapy

but in order to offer them therapy I had to have therapists so I hooked up with the residency training people and I said well send your residents over and I'll teach them a new type of therapy this is at the University of Pennsylvania at the University of Pennsylvania so we had the three things were all at once I was doing able to do research I did service and training and then one day the uh one of the residents by the name of John Rush said well Tim I think you've uh got something there with this

cognitive therapy I'd already given it the name cognitive therapy based on the fact that was dealing with cognitions said you know you developed a good therapy but nobody's ever going to believe it unless you do a clinical trial so I said well you know so they won't believe it uh I'm not interested at this point in spreading it I'm just interested in doing the research he said yes but it's a very good therapy and you really should be able to disseminate this so I said okay but I'm not going to do a clinical trial so

he said I'll tell you what why don't you train the resident in cognitive therapy and out do the clinical trial out do the research part and and he did that and that actually was the first uh clinical trial using Psychotherapy specifically for depression randomized control study and what we did is we compared uh cognitive therapy with aamine and depending upon you hand the way you manipulate the statistic you could say cognitive therapy did just as well or you could say cotherapy did better but that was kind of a complicated thing the patient were just in

treatment for 12 weeks and both groups did get better in 12 weeks and then ma Kovac did a follow-up study uh I think a year later and it turned out the cogni therapy people still maintain their Improvement that um the drug treated people didn't do quite as well and I know there's been some recent research in cognitive therapy for even very severe depression can you tell us a little bit about that research the general thinking in the field is that um depression is is best treated uh at least in the mild and moderate stages either

with drugs or with uh some kind of therapy inter personal therapy or cognitive therapy but for the severe depressives you need to have um pharmacotherapy so that's that's the general belief however a number of studies some by um mostly by Rob Dar rubis who's at the University of Pennsylvania have shown in a number of studies that even the severe depressives will respond to cognitive therapy without the use of drugs however as with anything else the cogni therapy has to be adapted to the particular patient problems so when a patient is in severe depression you can't

necessarily start with a cognitive restructuring such as what are the alternative explanations does it logically follow and so on uh what they have to do is they have to get activated they're in a state of tarper uh basically and you and by getting them activated then you can help to neutralize their negative beliefs about themselves such as I'm useless worthless I'm I'm never going to get better and things are only going to get worse and so on and so um this is something that we I described in a book that I wrote with a couple

of other authors several years ago called cognitive therapy of depression so we use what's called behavioral activation and that consists of giving the patient a whole series of activities and have them rate the activities um and so many of them will have the attitude well okay so it was very hard for me to make a phone call uh but I follow your advice and I made a phone call uh but what does that matter no anybody can make a phone call and then you say no but that's a Mastery experience because for you making a

phone call is very difficult and so what you have is a good Mastery experience you have to rate this as a Mastery experience and then the other thing is we would have them um note down anything that they did that was pleasurable ordinarily if you ask a highly depressed patient if they had any pleasurable experiences during the week they will say uh no but as it happens if they go hour by hour they do have pleasurable experiences but they don't remember them and so what we try to do is to get this really indented into

their minds that they are having pleasurable experience is and that life is not as unpleasant as it seems and so that was really how we developed the Corpus of depression what formulations have you made of the development of depression that is the longitudinal cognitive model of depression oh yeah so so that's something that I've struggled with for a long time and has to do with the whole idea of the blue jean and so I'll just tell you how the blue jeans get into it so way back in the early 60s when I I started a

whole research program on depression I was very much interested in uh what's the longitudinal course of depression as it happens in those days the whole study of depression was Virgin Territory there were practically no psychological studies going on in depression so there were an awful lot of questions that would be in my mind and uh there were no answers kind of the prevailing notion was a person had some kind of unpleasant event that would happen and then they'd get depressed but of course people have a lot of unpleasant events and they don't necessarily get depressed

so the question is do people have a certain vulnerability to depression is there a diathesis for depression as there is for other disorders so we did a study of um quite a large number of patients who were severely depressed moderately depressed or non-depressed and we took some case histories this was all retrospective although later on prospective studies were done and this is what we found that for the severely depressed patient there was a very high incidence of a loss of a parent in childhood the um parental loss was quite high in those days uh much

higher than nowadays because of a lot of our patients had lost a parent as a result of World War I or or as result of the influenza epidemic so there was a relatively High rate of uh parental loss now the parental loss occurred significantly only in the severely depressed patients not so much in the moderately depressed patients and minimally uh in the non-depressed patients so then we could get a nice formulation people become vulnerable because they lose a parent in childhood then they have some unpleasant event which seems to be consistent with the early loss

dealing with separation or abandonment or loss of some type it could be a loss of status in some cases and then they get depressed but at this point we didn't know the second part of the equation which is the lost in the doubt hood and so one of my uh doctor students by name of DD sethy did a study and he showed that the um parental loss was also paralleled by a similar loss and adulthood so there is some correlation between childhood loss and adult loss so that was neat this was a good thing and

it was published and uh this then be becomes part of the law that childhood trauma can predispose people to bad things happening later on becoming depressed but there was one thing that bothered me and the thing that bothered me is not everybody who has a childhood loss and has an adulthood loss the two of them go together get depressed so I thought well maybe there's something constitutionally that makes some people much more vulnerable to trauma than other people and I had to wait a long time I think this paper was published around 1961 or 62

and around the year 2000 a group headed by Casp who was um worked at The Institute in uh Institute of Psychiatry I believe in London showed that people who had a variant of the serotonin transporter gene what called the short form of the Gene and had childhood trauma uh were much more likely to become depressed than people who did not have this Gene which I call the blue Gene so if they did not have the blue gene they didn't get depressed if they had the blue Gene but did not have childhood trauma they did not

get depressed but if they had the blue Gene and the childhood trauma then they did get depressed now I could say that there's a lot of controversy about uh the uh whether these genetic findings hold in some cases they hold and some cases they don't hold and um and so on personally I do believe that there is something to it but depending upon the nature of the sample uh you may or may not show this genetic influence how however what does that have to do with cognitive therapy or the cognitive model well this is what

it has to do if people have this blue Gene the serotonin short form children have this and they're subjected to if they then receive certain uh psychological manipulations it's shown that they already at that age have a negative cognitive bias that is they're much more likely to see at a at a preconscious level at a sub threshold level uh negative faces uh than happy faces and at a much lower level than people who uh uh who do not have the gene so already there seems to be some cognitive predisposition which is represented in a uh

negative cognitive bias and when they these children are followed they're much more likely to one to be the ones that develop depressive symptoms later on in addition to that and I'll be coming to this later uh I hope is that they also show negative attitudes uh there's a scale that we uh developed which is called a dysfunctional attitude scale it's been developed for children um and this has a lot of negative attitudes in the uh in the scale and if they have the blue Gene and they have the negative bias they also are more likely

to have the negative attitudes and they're more likely than to have get depressive symptoms later on if they're subjected to particular types of stress so anyhow so this now pulls together observations that we made many decades earlier and we now get kind of a biological um uh explanation for it and kind of a uh a neurobiological namely the negative cognitive bias now is is demonstrated to be part of the whole picture so we now have a much more complete picture of um how how depression develops and now includes then the biological as well as the

psychological now some depressed patients become suicidal can you describe the various investigations into suicide Behavior with suicide studies to my mind were the most elegant studies that I've done because they were done in a very specific sequence it's the only group of studies that I had planned beforehand and extended over many decades uh and uh then came to fairly good results so when I first started my Suicide work uh there was very little in the literature that cast any light as to what happens with suicidal people and very little bit very little on how to

treat them um however in my patient with my work with depressed patients I did make the following observations that if they were suicidal they had a very high level of hopelessness they would see the future as something painful and unending and unendurable just extending totally into the future so I made the observation that this there was a connection between their depression their hopelessness and even if they weren't very depressed if they were high in hopelessness even if their major diagnosis might have been anxiety if they were high in hopelessness they were far more likely to

be suicidal so I then embarked on a program first of all was classification I set up a classification system and then a system for evaluation evaluation of the um uh suicide and then validation of the uh suicidal uh instruments that I had developed then prediction of future suicides and finally treatment so the classification came about like this the uh n imh u National Institute of Mental Health uh uh had a task force on classification of suicide at that particular time all types of suicidal Behavior were kind of lumped together people who thought about suicide uh

were lumped together with people who actually attempted suicide and they were lumped together sometimes with people actually uh killed themselves and so we set up a classification system we talked about suicide ideates people think about it and have a wish to do it um people attempt suicide we call the attemps so the id8 is the attempts and people completed suicide of the completers so then we have the classification system but there was no way at that point of assessing the degree of suicide ideation uh either people who just ideators or people who are attemps and

then um measuring the degree of suicide ideation of those who had completed suicide where we'd have to get the information not from the patient obviously uh but we could get this suicide ideation from the family so the next step was to so we developed instruments for these three categories we then found uh that there was a definite correlation um uh between the degree of uh suicide I iation and the likelihood that the person would uh make a suicide attempt and the degree of suicide ideation and the attempt is and the likelihood they would make a

future attempt so we then got into prediction we had the scales that would then predict ultimate suicide or um suicide attempts now where does the hopelessness come into it we found that hopelessness Carl related with suicide ideation and it also was of the best predictor we had at the time of ultimate suicides so we did a 10-year followup on patients who had uh High suicide ideation and hopelessness and we found that the hopelessness then was able to predict uh ultimate suicide we I suddenly worked with Amy wiel and we did a 50-year followup on these

patients and we found that it was a a very good uh prediction of our our variables so here we have um a good deal of material on prediction but we don't have anything yet on uh treatment and treatment itself is like a quas experiment if you have a hypothesis about the suicide and you attack the hypothesis during the treatment and get good results then you've got a made and um I teamed up I think around 19 year 2005 many years later after we had formulated this when we were able to get funding for a suicide

intervention and we had a 10 study uh a 10 session uh intervention for people who had attempted suicide and they had the 10 session intervention of cognitive therapy intervention and then we followed them for a year after the intervention and had a control group and as compared to the control group the uh reattempts of suicide was about half so we were able to save about half of the uh people uh who would reattempt uh from actually doing it so that finally clenched it so we went step by step over a period of many decades and

finally clenched uh the whole thing so this last study you uh have just been talking about was really a landmark study in the field of psychology Psychiatry suicidology um I believe you did that with Greg Brown yes that was a study by Greg Brown and it was considered Landmark it was published in the Journal of American Medical Association which was the only time I had an article published there course it was considered of landmark and of general interest so we've been talking a lot about depression a lot about suicide when you first started off with

the cognitive model and your cognitive theories and uh you developed a treatment for depression did you ever think that you would or anyone would ever apply it to a condition such as schizophrenia well back in 1952 I actually published a study of Psychotherapy with the patient with schizophrenia and um this was a young man who had the belief that he was being followed by the gmen was the U predecessors of the FBI and he thought that the gmen were following him all around and particularly in the workplace where uh his his father was working and

he was working for his father and I developed a very strong growing therapeutic relationship with him and I felt the therapeutic relationship had a lot to do with his ultimate Improvement but one of the techniques that I used with him was the following I said you know you have these gmen following you all around but how would I know what they they look like if I was you know if I wanted to help you maybe in some way help you with with them and he um he said well I can't exactly tell you but I

just feel that person is so I asked him to describe the uh one of the CH men and so he came through with a description he started to look at them and he would describe them and each time I would ask them I'd ask them to keep looking for them so we'd be able to identify them and see who they were but as he was able to really focus on them he did not see them quite the same way and so he started to discriminate between the Gman and the non-g man and the more he

was discriminating the fewer there were and finally he was down to just three and at that point uh he thought that in the course of time uh that they would disappear he already was beginning to get the sense that maybe he was misinterpreting uh what was going on and so then I wrote that up and so then long time elapses and I did no more work uh in the field and um I did although I had success with that case I did really wonder whether cognitive therapy could have any really enduring effect on patients with

schizophrenia other than maybe some stabilization some improvement of but but nothing very drastic and then a group of then I was one time I was at a meeting in Brighton England uh meeting of the Royal College of psychiatrist and I saw a poster there and it said 60 patients treated with treated successfully with cogn theapy and I knew nothing about the study 60 schizophrenic patients 60 schizophrenic patients right treated in a was one of the state hospitals in Britain so I managed to track down the authors were uh trickington and kington with the two authors

and um one of the things that intrigued me about this was that they had cited my 1952 paper so then I I checked in with them and it turned out that they were using cognitive techniques with the uh particularly with the Positive symptoms with the um depression I'm sorry that they use depression techniques uh with the uh delusions the hallucinations and even with the thinking disorder but predominantly with the delusions hallucinations and they they would ask questions such as uh what is the evidence for your belief and there are other alternative explanations and then as

far as the hallucinations were concerned they would ask about beliefs about the voices and so on but within a very easy gradual empathetic framework uh and then subsequently uh many several other groups in Britain almost simultaneously were using uh cognitive therapy or what they call cognitive behavior therapy uh with the uh with their patients and then ultimately I I realized how many groups in England uh uh using cogn therapy and so I invited them all to come to Phil Philadelphia come to the Beck Institute and for the first time this group had actually started talking

to each other and so they developed a group of um of uh cogni therapy or CBT of schizophrenia researchers however the one aspect of schizophrenia that they did not tackle very much though they they did somewhat but they didn't have any manuals for treating this group and that were the people with negative symptoms and negative symptoms consist of primarily of kind of social withdrawal very poor work efficiency um General inertia so on the typical patient with negative symptoms would be sitting at home uh smoking and watching television kind of total withdrawn from the mainstream of

society very low functioning schizophrenic very low functioning that's right they're low functioning and the general belief at that time and still to this day is that this is all due to certain neurocognitive problems that they have they have great difficulties in attention and in memory and executive function and cognitive flexibility and so on they they simply are not functioning well and uh can't concentrate very long on things and so on and there's actually a very good correlation between this cognitive neurocognitive dysfunction and the behavior that they show but that didn't strike me as plausible there

may be a correlation uh but I could not see where difficulty in concentration would necessarily lead to a person withdrawing socially and not being able to do anything at all uh uh and not doing anything so it occurred to me there's a missing link and The Missing Link has to do with motivation the reason they have withdrawn this way in a sense wrap themselves up into a cocoon is that they've given up and if they've given up then they're not motivated to do things so they might have a hidden capacity that goes Way Beyond uh

what they're showing so the question is how do you tap into that hidden capacity well first we had to find out what is behind this loss of motivation why are they uh just seemingly complacent uh about their condition so we developed a number of scales I worked with Paul Grant on this and one scale was called the Deus attitude scale which has to do with performance performance and ambition you could say a performance disability and that there are attitudes there such as there's no point in trying anything because I'm only going to fail or failing

at one point failing at one thing is the same thing as failing at a lot of things so we developed that scale we uh we then did a study and what we showed was that the the FST attitudes were a mediating variable between the neurocognitive and the U actual performance that is if you put into the equation the score on the uh defeatist attitudes what it does is it soaks up much more of the variance than does the neurocognitive in terms of performance so now we see that the FST attitudes are a very important part

of why they're not performing so how do you explain how the neist attitudes get in there well in the history of these people with the negative symptoms you find that they have always been functioning or maybe starting in school functioning at somewhat lower level than their peer group and their siblings and in the course of time they have a series of failures and they feel disappointed in themselves and their family's disappointed in them and um they're also subject to bullying and to depreciation and they develop a really negative self-image and uh piled on that self-image

is the attitude is there's no sense in doing anything no sense in trying because I'm only going to fail and later on when they develop their positive sense Illusions and hallucinations this tends to accentuate their negative attitudes and they become stigmatized and so on so the negative attitudes about themselves actually grow and then become Frozen and so so that has to do with performance but we also had a scale in terms of social adjustment and they had negative attitudes about social relations too uh so now we have them Frozen in with these negative attitudes about

dealing with other people which then accounts for the withdrawal and uh negative attitudes about performance which then accounts for their inertia very poor performance well then the question is can cognitive therapy do anything for them well negative attitudes that's the meat and potatoes of cognitive therapy nothing you like more than negative attitudes something we call the schemas uh nothing like schema therapy to get at that and so after we um had done a series of studies such as this and I won't go into the details we then had a very good formulation of what to

do about patients with schizophrenia and at this point uh when we had the formulation all prepared and Paul Grant and I and two other people actually wrote a book on this whole topic um we then felt prepared uh to do a uh a study and we checked around with other people and people say we never going to be able to get funded because nobody's going to believe that cogntive therapy can help these people and so I managed to get funding from a variety of smaller sources and we started a study and we um had 30

patients in the cogn Therapy Group and 30 in got treatment as usual and um so we applied the cognitive therapy technique of dealing with the negative attitudes giving people a giving the patients a lot of positive experiences now I had to draw on what I talked to you earlier about behavioral activation we had to use a lot of Behavioral techniques in order to uh get the patients to see themselves in a different light and there's nothing that succeeds like success for these patients and so we would do video games with them go for walks with

them and show so on and get them to um in a very subtle way to have a series of positive experiences which in themselves would neutralize the negative attitudes that they had and at the end of therapy we found that the patients in general improved a whole order of magnitude Beyond where they were before uh so if the patient had been at home not doing anything maybe get them into a supportive living condition or maybe independent living and get a part-time job or a volunteer job and so on and and so on depending upon what

level they started at they were able to go up to the next level what ideas do you have regarding the trans diagnostic approach that has become so popular recently yeah well the trans diagnostic approach is interesting and in a way it has to do with the lumpers and the splitters um but I'll come back to that in a minute um in a sense um cognitive therapy has always had a trans diagnostic approach um but it's also had a specification approach and so both things are consistent and let me uh explain what I mean um first

of all the mind is not split up into certain areas with each area having to do with a particular diagnostic category uh the same mind is operating whether it's schizophrenia or depression or anxiety or obsessive compulsive disorder and so on and so with each of the disorders there's going to be some effect effect probably on different uh functions different brain or mental functions such as attention and memory and focus uh and beliefs and motivation and behavior so any approach has to take into account uh that all of these functions or any any or many or

all of them may be affected within a particular diagnos framework now the generic cognitive model um is kind of a template and given this template one can look for specific features across any of the disorders and then look at what's actually specific for a given disorder and many times uh when I've done a workshop people would say well do I have to learn something new for each of the disorders uh or is there some some easier way of going about it and my answer to that is that there is this generic cognitive model which runs

across all of the disorders but there's one difference for each of the disorders uh which can account for the disorder and that is the meanings that the patients attribute to their experiences and the meanings have to do with the beliefs that the people have so the disorders are similar in many ways but they're differentiated by the specific beliefs that the people have now the first person to deal with this was actually Albert Alis and he uh postulated what he called the ABC of mental disorders a standing for activating stimulus B for belief and C for

the con consquences and so if a person is exposed to a particular stimulus let's say it's an alcoholic uh uh he's in a bar it stimulates a belief that I have to have a drink or right I can't control this and I have to have it um uh so the activating stimulus is the alcohol smell the belief is I have to have a drink and the consequences then is that uh he uh has the drink now I expanded that and my own work into the following we still get the activating stimulus the activating stimulus though

is often internal as opposed to uh external so it may be an internal activating uh activating stimulus such as stomach rumbling and you think my stomach is rumbling um that might activate the belief that I'm going toh get colitis or I'm going to get cancer with the stomach or something of that nature so it might be a physiological symptom can be a physiological symptom it can be any type of sensation I have a pain in the back uh and that might trigger the belief uh that this pain is going to get worse any pain is

a representation of severe pathology and so on uh if one has an addictive disorder it could be simply the smell or could be white powder uh which could almost by a reflex action uh stimulate the desire to take Coke Co cocaine and so on so you get your inating uh you get your internal activating stimulus or it could be an external activating stimulus such as a student receives a c on a report card so then the next is a belief and the belief would be is in terms of the report card um that uh I'm

a failure I'm a total failure I'm always going to be a failure I'm going to end up and skid R this belief now what's important about the beliefs is that they attach meaning to a particular stimulus so you get your activating stimulus and then you get your reflex which is the meaning that's attached to whatever the stimulus uh is and then you get a whole sequence after that and so you might get uh in the case of the report card you get anxiety or sadness and then finally the uh consequence uh in the in the

case of the alcoholic the consequence obviously is he has a drink the case of the student who doesn't do well the consequence is that uh he gets sad and depressed and withdrawn and won't go to school or whatever now for many years this was the template that I used but then it occurred to me that there's something else that's very important and that's something I called attentional fixation and this really struck me when I was dealing with panic patients so now with panic patients um the activating stimulus may be something like any kind of somatic

sensation or some kind of psychological sensation can be the trigger and so it could be something like pain in the chest or it can be a feeling of faintness or a feeling of depersonalization anything that seems to be a little bit strange or worrisome to the patient and it will vary from person to person now now what the patients what happens next is that a particular belief gets activated and a belief may very well be something such as uh uh faintness could be a sign of having a stroke or it could be a sign of

having a heart attack and so the patient then um gets the belief oh I could be having a heart attack or I I could be having a stroke or I could be dying from this and the patients actually do feel as though they are dying as though they are actually having a heart attack so the imagination starts to play a role in this and some a lot of these patients actually have images of these things happening to them had patients who even would have the image of themselves having the heart attack and ending up in

a coffin and they quickly get that image and so you you get the stimulus you get your belief which gives the meaning and the meaning then can come out in an imaginal pictorial form and just in a verbal form and then the important thing is the focus so the attention that get gets focused on the stimulus and the more it gets focused on the stimulus the worse he gets the more they think of the faint uh the uh the worse they feel and then the consequence of that is that they then will go run to

the emergency room or they'll call somebody and get reassurance that this isn't happening now through something that the learning theorist call um reinforcement positive reinforcement as long as the patients go for reassurance it tends to keep the cycle going and so the consequence itself then the reinforce M or the reassurance that they get uh tends to prevent them from working through the reality now so the therapy then follows very logically from um from this little Paradigm so let's just say the we get the stimulus of the activation might be a pain in the chest say

and of course you do want to get Med iCal clearance if you're actually working with such patient but they can most of the time the pain in the chest may be simply just in the rib cage and you can reproduce this little pain in the chest people get these little pains lots of times but they're not aware of it unless they're hyper sensitive hypervigilant so you can get you can reproduce the pain sometimes by uh just pressing on the uh chest and so you got to give the patient a different explanation for what's going on

the people who feel faint may have something that's called postural hypertension hypotension which means their blood pressure drops and you can get them to um to stop the faint Feeling by squeezing a rubber ball say uh and it isn't just getting the um it's not just a question of getting the think to stop uh it's trying to just confirm this belief that they have so you just confirm the belief through cognitive restructuring uh now another thing as I say they focus on the symptom so another technique to use is to teach them to focus on

something else when they focus on something else the panic attack tends to subside or go away and sometimes if persons in the subway let's say say get them to focus on the uh uh on the advertisements over near the roof of the subway and they say well suppose I'm in a classroom and I get the um I get this attack and I said uh one of the techniques I've used with my people I told them uh review in your own mind the names of the presidents starting with George Washington and some of these verbal techniques

um will be enough of a distraction removes the focus away from the symptom that they're having onto something else and when they remove this the focus the symptom subsides now this in itself is experiential learning because it means that if they just by changing the focus can relieve this then it means it cannot be a fatal life-threatening disease and then the next thing is the anxiety that they feel and they can deal with that through uh something we called applied relaxation uh now the consequence is the thing of seeking reassurance so you try to get

the patient to use any one or all of these techniques you train them with techniques or you do it in your office you demonstrate to them uh how the techniques work and you try to get them not to go to the emergency room or not to call up the doctor and this then uh removes the uh the reinforcement that they were getting so so that's where you can use this template um for anxiety but what's specific then about the anxiety is the belief the belief that they have an immediate life-threatening condition but then there are

other conditions that are not immediately life-threatening such as back pain so a fairly significant proportion of the population are disabled or certainly are very dysphoric because of um chronic back pain so they they start to feel a pain in the back and then they get the thought the belief then is the pain in the back this is terrible it's uncontrollable uh I'm not going to be able to do anything uh they then feel sad and then they withdraw and in these cases you often have to work with a with total withdrawal that they have and

get them not to withdraw because they still can have a capacity to new things so that can then um uh neutralize the idea that this is a disability and actually we've done some research on on this so that's why I'm uh talking about that uh they often become very self-critical they think their other belief is uh I I'm just um an anomaly uh and uh I'm different from everybody else I'm not going to be able to do things for my family and they become very self-critical and so you then can deal with the depressive components

so those are are two elements with totally different types of beliefs oh another another one which fit into the template the template is there but the beliefs differ another thing is a uh had a patient once who had H had pain in the back and whenever she had a a back pain she had the thought I've got cancer of the kidney and she went through all kinds of tests and she kept going for tests but um it it wasn't getting her anywhere and so what I did with her is I said well look you've been

going for test for how many years and she said 15 20 years uh I said how about if you make an agreement with your doctor that you won't go test for about 6 months and let's see what happens well that simple kind of intervention actually helped her because when she stopped going to the doctor and removed this reinforcement that she had and once the reinforcement got removed she was able to face reality and she started to see that the back pain was due to back pain and not due to a cancer of the kidney so

anyhow so that's it so you can use the um uh you can use the general uh template for every condition but you have to be able to specify the different meanings that go with each condition how does the cognitive model account for comorbidities for example yeah I'm glad you asked that because that comes right from the the previous question so let's take depression anxiety I mentioned earlier you have lumpers and Splitters back in the the late 20s 28 and 29 there was u a big debate going on in Britain uh one school of thought believed

that depression and anxiety were lumped together and they were the same basically the same condition and the other school believ that depression anxiety with two separate disorders um now we fast forward to the present excuse me and there's a been a um a big move on to lumping um various conditions that have a certain amount of overlap uh together and this is called the trans diagnostic approach um and so the various anxiety disorders are now being lumped together by by some of the investigators is though there's one single anxiety type of thing that applies across

the board and there there is this comorbidity between depression and anxiety um which uh also raises questions as to just why this is now first of all so that's the lumping first of all I would say that there is a difference between depression and anxiety and in our early in our early work we had a large sample to deal with we found that we could split off patients who had depression no anxiety and anxiety and no depression but the two often go together and the question is why did people why do depression anxiety go together

so much well that's because they're dealing with the same thing basically depression and anxiety have to do with either damage to your self-esteem that is psychological damage or it has to do with uh physical damage now in the case of depression the damage has already occurred so the person has a negative bias and will see everything in terms of I am uh I am useless I am worthless I am inferior I'm inadequate I'm stupid and so on this is the way they see themselves and this is the way they interpret various events they will selectively

interpret events according to this negative self-image now with the anxious patients when there's anxiety there it's the same thing except it hasn't happened yet they know they don't yet see themselves as uh different from other people as inadequate stupid uh uh worthless and so on but they interpret future situations as possibly showing that so A depressed patient in a social situation will think I'm I'm out of it uh people um see that I'm useless and I'm worthless and so on the anxious patient will think I'm in the social situation if I stick my neck out

I may be shown to be worthless stupid inadequate and so on so they're afraid of something that may happen to them they have anxiety about what may happen they're Vigilant about what may happen but with the depressed patient it's already happened and when they think of the future they all always think of the future in terms of something that would definitely happen now to be a little bit more specific so you you know that people have a tendency to catastrophized to think of the worst possible thing that could happen so we did a a study

in which we asked people to have an IM have images of the worst possible thing that could happen to them in particular situations so we had depressed people who were high in depression and people who are high in anxiety now the people who are high in depression would attribute a very high probability of their say ending up and Skid Row if they uh had some kind of uh loss of money or a job problem you you give the same scenario to the um anxious patients and you say what's the worst thing that can happen if

you lose your job or you lose your money and they also see themselves ending up as skidrow but when you ask the anxious patients what are the probabilities of this happening they'll say maybe 40% if you ask the depressed patients what's the probability they say 100% so the anxious patients still see this as as a possibility in the future the Press depressed patients see this is a certainty so what you're having then is between depression and anxiety you're going to have people who may fluctuate from time to time in terms of how much they believe

that they are inadequate or how much they believe that they might be shown up to be inadequate uh and so they could have uh depression and anxiety going on at the same time or another way of looking at it is there are depressive schemas and there are anxious schemas and the the two sets of schemas are very close in terms of content one having to do with the future the other having to do with the certainty of the present and since they overlap somewhat it's not um surprising that people would have both so that's why

you would get coor ability there now let's take this trans diagnostic notion of uh this one big anxiety that manifest itself in panic attacks and um generalized anxiety disorder maybe specific phobias for example a patient may have so particular patient may have social anxiety that is feels anxious and social situations feel that um say uh he's going to get looked down on he's going to be perceived by other people as awkward and inept and U not socially desirable uh might have a ton of phobia might have panic attacks might have panics U it might have

public speaking anxiety so it's true that a particular person may have any of these things or might have only one of them now if they have any of them what's the explanation for that the explanation has to do with one thing is they feel vulnerable and they have a very strong belief about vulnerability and that they see themselves as somehow very fragile and therefore subject to a whole lot of different things or Andor they see the outside world as very threatening and so they might have any one of these things if they have a broad

scheme or broad belief in terms of vulnerability and a broad belief of a dangerous world or it can be then so that's kind of the lumper type of thing that can happen in nature but also you can get the specific so somebody might have a tunel phobia or a bridge phobia or phobia of knives and have nothing else then they just have a very specific vulnerability so you get comorbidity when there's a broad generalization of the vulnerability or you get a specific vulnerability when uh it just has to do with specific situations that's something we

call phobias what's being done in terms of dissemination of cognitive therapy well I'm glad you asked that because dissemination is very important so one of my concerns has been we write these papers and eventually they might get bound into volumes and gather dust on somebody shelf or take up some space in people's computers but it never does anybody any good because it doesn't get out into the community and particular individuals in the community that I've been most concerned about are the lowincome individuals who by and large are not getting uh kind of upto-date therapy um

mostly they're being treated by Master's level uh therapists who have not already uh received any uh uh any of the evidence-based training uh when they were in school and so fortunately um we have a contract with the city of Philadelphia with a subsidiary of the city of Philadelphia which provides services at the various Community Mental Health Centers and so we have been um engaged for several years now in training these Masters level therapists in cognitive therapy and so it breaks down into two types of training or three types of training one is we've been doing

workshops for them and we've probably uh given workshops to well over a thousand perhaps couple of thousand uh of the therapists and then we've been doing intensive training with weekly tape reviews they send in their tapes and um they get the tapes get evaluated and they're given feedback uh every week on the tapes and they originally would get a Year's training we've now doing a study to see if they can reach confidency at uh at 6 months and so that the T their uh tapes are rated at the onset of their onset of their training

and then at the end of the training and about uh 90 about 90% uh reached competency and about 10% uh and a certain percentage about 10% don't or drop out and so we've done very very well in that now the third type of training uh is a webbased training where they get they watch for uh 26 weeks they uh they watch a computer computer-based program on cognitive therapy and we're trying to see how effective that is so that's one form of training now there are also are people and many of them are are actually at

doctoral level postdoctoral level who never received any training in the evidence-based treatments while they were in school or they did not receive enough there's also Master's level people similar to what I was talking about who are in practice who haven't received training and so there are several research centers uh in the us where they can get training and this is very important uh now for example at this at the um Beck Institute for cogn therapy uh we have a series of monthly workshops which include both Basics and then other workshops have are are Advanced so

that we do try to teach the uh the the basic uh tools to people who come to the workshop and then we have specialty work shops say for children or uh Eating Disorders which is very important as a prevention and um schizophrenia and so on but our hope is that the PTI that the the therapist will also um enroll in a year long or a six month long program will'll get the same type of taper review uh that we have in the um uh in the community and so I I think that's really important and

uh many of the people who've been through this training program have themselves become trainers and will train other people and so we've had people from all over the world and what one of the interesting things um is that the the greatest uh interest actually uh comes from the Islamic or the Muslim countries where cognitive therapy for some reason uh that I don't don't know seems to fit better with their culture than certainly psychodynamic therapy does in any event uh we're interested now in not only spreading it out through North America but throughout the world and

uh and so far it's been very successful there are some places such as Australia and um New Zealand where cognitive therapy isn't the dominant therapy from what I hear it's the only therapy that's uh being used and recently U we've set up a uh we're in the process of setting up a program in China uh there's already been a large amount of dissemination uh um uh through Asia through places like South Korea and Japan and Singapore and Hong Kong and so uh it's moving there but the other problem is this lot of nowadays the insurance

companies do tend to favor the evidence-based treatments and so a lot of people are calling themselves cognitive therapists and we ask go to workshops and we ask how many uh how many of you actually uh do a problem list or set an agenda at the beginning how many give feedback and so on it turns out that they're not really doing cognitive therapy uh uh and and um so problem comes up when somebody from K Iowa wants a referral uh what do we do about sending them referral so to solve this problem we set up um

we we participated with our former students in setting up a an organization called The Academy of cognitive therapy and the Academy of cognitive therapy will then certify uh therapists they have to be able to present their credentials uh and and so we're trying to get certified people not only in North America but in other countries in the world who'll be able to do that what do you think the future of cognitive therapy is well I guess the big question is what's the future of therapy and what's the future of uh Psychotherapy so as far as

Psychotherapy is concerned I I think the future is going to really depend on therapies that are maybe one therapy in the future everything will come together which will be based on science and by science I mean the following there has to be a science of Psychopathology and the science of Psychopathology has to be based not only on a whole series of hypotheses but these hypotheses have to be confirmed so it has to be an empirically based Foundation then the therapies have to be cons at least consistent with the theory of Psychopathology and ideally they should

be derivable from the theory from the evidence-based Theory then the therapies themselves do have to not only they have to be derived from the theory which then gives you the template as I mentioned earlier uh but the therapies themselves have to go through validation now there are also other forms of treatment there are variety of biological treatments not only pharmacal therapy but there's uh trans cranial magnetic therapy um and and so on um so question is what therapies are best for individuals and Rob du rubis has been doing some work trying to show that certain

psychological configurations seem to um best predict people's response either pharmacotherapy or to cognitive therapy so that there can be a degree of personalization in the future uh but there's another type of person personalization and that has to do with the genes now it may be that people are genetically better constructed to respond to uh cognitive therapy or they may be better constructed to uh respond say to pharmacotherapy or to some other type of treatment we don't know uh it may be that this is just a fed the idea of uh what they would call a

psycho genomic may be a fed or there may be something to it and it may be that some people won't respond to any therapy uh although that's a nihilistic point of view what's your hope for how cognitive therapy might evolve well I I think cotherapy has evolved and over the years what I've done personally is I've tried to incorporate more and more of the findings uh that have come from various of the psychological disciplines and so I've been quite influenced Say by cognitive psychology and social psychology and experimental psychology uh and all of these um

uh disciplines have findings that are relevant to uh to what I would consider the general theory uh so I think as there are new findings in Psychology uh it's going to be reflected in an expansion of the theory behind cognitive therapy um as far as the techniques are concerned a lot of what techniques are used really depend upon what the therapist is comfortable with what the therapist has learned and also uh the responsiveness of the uh patients it's probably ideal for the ideal therapist if he has a number of approaches um and so with some

patients for example that I've treated in the past who are uh very intellectually oriented and they're very much interested in causation um we can achieve a lot of the cognitive restructuring through talking about childhood experiences let's say or showing the relationship not talking about them because talking about them doesn't do any good but trying to show the relationship between childhood experiences and um uh what their particular problems are right now how the images that they um developed in ch as children are now producing the kind of cognitive biases that are uh going on now so

to get back to your question how do I see it evolving I I see it as um using more and more of the research that's going on and then incorporating the research into the whole Corpus of cognitive therapy how does cognitive therapy view the therapeutic relationship well I used to think way for many years even decades I used to think that the therapeutic relationship was a a crucial vehicle crucial part of the uh the therapy and uh this little bit like a surgeon using anesthesia the anesthesia is essential in order to apply the techniques um

way back I remember having debates with Jerry Frank who was a big believer in the Curative power of the therapeutic relationship itself um I felt at that time and still due today that the technical aspects are really crucial but that the therapeutic relationship might be a is a an extremely important facilitator uh for being able to deliver the particular techniques but recently um there've been a number of different Delivery Systems that have been discussed and they also the different Delivery Systems also seem to be uh effective now the most important work in this area has

been done in Britain and there they uh the British uh clinicians uh will use what's called um uh either low intensity or high intensity interventions uh uh for their patients now low intensity interventions are used let's say for mild or moderate depression and with a low intensity there may not be a therapist involved at all uh the patients may be given bibliotherapy they might be given uh computer uh uh therapy uh they may be um uh given instructions about uh various mental health organizations they can go to for education and so on the thigh intensity

of course would be relevant to having a therapeutic IC Alliance now there also so that's one question is one point is that therapy can be delivered successfully um through methods that do not involve therapeutic relationship although I've been told that even people who get have one of these computer programs for therapy develop a relationship with the computer or with the therapy with a therapist kind of uh who's written the uh the the program uh so they they have kind of a remote relationship um okay now there are two things about the therapeutic relationship itself when

it does go on one is although originally I felt that the was essential for the patient to be warm and empathic um and kind of tuned into the patient feelings and that this was really that a warm empathic supportive relationship was critical to getting better I found that after a certain period of time uh working with patients there were some patients who did not want the um uh kind of nice bedside manner what they wanted was they wanted to know what the tools were they would apply the tools they they come to the sessions when

the session was over they would be pleased to leave at the end of the session they would do the homework very thoroughly they got better very fast they had no great affection for me uh they were satisfied with the therapist and went their own way and then there were other people for whom the therapeutic relationship was very important and they would cling at the end of the session they would make phone calls between sessions and so I did a research a little research study and uh we uh we found that there are two type of

people roughly there's the autonomous and there's the dependent and the autonomous people do very well if you just give them the techniques and they're not interested in anything else and the uh dependent people are largely interested in the relationship and you have to squeeze in the techniques as part of the relationship so anyhow so I imagine that it may be that the autonomous patients may do better with the other types of Delivery Systems that I mentioned now there's a big school of thought that believes that the therapeutical Alliance is the key thing but again getting

back to some work done by Dar rubis uh he finds that the Therapeutic Alliance does not come before the Improvement but comes after the Improvement or to put it another way once the patient starts doing the therapeutic techniques and develops certain of the skills and sees that the skills are effective then the um uh the patient starts to feel that he has a working alliance with the U uh with the therapist so the co sense of the alliance comes after the patient is actually going through and practicing the techniques um the other school of thought

which is the dominant one is you have to have the working Alliance first and then the patient will start using the techniques in any event uh it's still an open question and there are some patients who do get better uh just on the basis of um this the various therapeutic factors such as warmth and empathy and so on they do get better but the question is do they stay better and this is what the research is going to have to show we believe that the people who've um learned the therapeutic skills are the ones who

are less likely to relapse later on because they will have these skills and they can keep exercising them for the rest of their lives so anyhow that's that's what things stand with a Therapeutic Alliance well thank you so much for all of the interesting things that you said today you told a couple of stories that I even I hadn't heard about and um I you know I'd like to uh thank you on behalf of really the psychotherapeutic world for the work that you have done we' get emails constantly at the Beck Institute of how grateful

both uh professionals are and consumers are for the work that you've done well well thank you for for the interview actually it's been going down memory lane for me going back many decades in some cases and and your questions have helped me to piece together things that I've thought about but I haven't really put them together before so thank you so much for this opportunity and uh you you've celebrated your 90th birthday this year it seems that you have the the mind of uh of a much younger person certainly the energy and the work and

I know you still work pretty much 24/7 right well thank you