The Story of Psychology (116 page)

The patient later found out that her son was, in fact, willing to go to the movies with her.

As this example illustrates, the crucial aspect of Beck’s style of cognitive therapy is Socratic questioning to get the patient to produce information contradicting his or her assumptions or conclusions, thereby correcting these cognitive distortions. The technique is even more apparent in this excerpt from a therapy session with a twenty-five-year-old woman who wanted to commit suicide because her husband was unfaithful and she regarded her life as “finished”:

Following this session the patient no longer felt suicidal; she began questioning her assumption “Unless I am loved, I am nothing,” and after thinking over the questions Beck had asked her, she decided to seek a legal separation. Eventually she got a divorce and went on to lead a normal life.

Although by the 1970s many therapists had tinkered with Beck’s detailed prescriptions, cognitive therapy technique had become fairly standardized. It generally required anywhere from six sessions (Beck prefers to call them “interviews”) to many months. At each one, the therapist and patient review the latter’s reactions to the previous session and its results, plan the coming steps in therapy, agree on the next tasks and homework, and apply logic, investigation, and reality testing to the patient’s current perceptions and thoughts about what is happening to him or her.

By the 1980s, cognitive psychotherapy had become part of the mainstream, and in addition to the one third of all psychotherapists who were primarily cognitive-behavioral, about another third were eclectic, most of them using cognitive-behavior therapy at times.
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It had become widely considered the treatment of choice for certain problems, particularly depression and low self-esteem. Beck, by then white-haired and benign, had become a doyen of psychotherapy. In 1989 the American Psychological Association gave him its Distinguished Scientific Award for Applications of Psychology, citing him thus:

That’s not all. In 2004 the Grawemeyer Foundation of the University of Louisville gave him its annual $200,000 prize for outstanding ideas in the field of psychology—and in 2006 he was the recipient of the prestigious Lasker Award for Clinical Medical Research, which consisted of $100,000 and acknowledgment of the “major advance” he had made in psychotherapy.

By the time of Beck’s APA award in 1989, cognitive therapy and cognitive-behavior therapy were on the rise, and since then their use has caught on almost throughout the field among professionals of many orientations. For several decades, but especially the past one, Beck, his colleagues, and other cognitive therapists have been modifying and expanding cognitive therapy to enable them to apply it to a wide variety of disorders. His original focus was on the use of cognitive therapy (CT) to treat depression, but by now special variants of it have been developed to treat such disparate problems as suicidal tendencies, anxiety disorders and phobias, panic disorder, personality disorders, substance abuse, and the psychical miseries engendered by a variety of physical ailments.

Among these variant forms of cognitive therapy are, for instance, teaching emotional regulation skills to highly reactive patients, having phobic or anxious patients expose themselves to feared situations, restructuring the meaning of early trauma through imagery, and working through a fear hierarchy with a panic disorder patient (getting the patient to tolerate a minimal fear object, then a slightly worse one, and so on step by step).
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A mass of research has validated the use of CT, CBT (cognitive behavior therapy), and their variants. There are now some four hundred research reports of outcome studies of CT and nearly as many of CBT.
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Summing up the results, a number of meta-analyses—sophisticated statistical poolings of the results of these research studies—have reported various levels of positive effects, most of them relatively large. A few of the findings: large effect sizes for unipolar depression, generalized anxiety disorder, panic disorder, and a few other disorders; moderate effect sizes for CBT of marital distress, anger, and chronic pain; and small effect sizes for sexual offenders.
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There is no available statistic concerning the total number of people currently receiving CT and CBT, but it is undoubtedly large—and would be considerably larger except for the recent trend toward the medication of mood disorders. “Where have all the ‘easy cases’ gone?”

Aaron Beck recently mused. “Our hunch is that most patients respond reasonably well to their first-line treatment—by primary care doctors or psychopharmacologists. The relative nonresponders eventually may be referred to cognitive therapy—which now represents a secondary or even a tertiary—level of care.”
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But in his introduction to a book by Judith Beck about treating these more difficult cases, he points out that she regards them as a challenge rather than a burden. Such is the admirable ethos of the cognitive therapist.
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The three families of therapy we have looked at—dynamic, behavior, and cognitive—are presently the major forms of psychotherapy, but a great many other kinds are available, nearly all said by their developers to be more effective, cheaper, quicker, or better in various ways than any of the big three. Before 1950, there were only about a dozen or so versions of psychotherapy, but by the early 1970s Morris Parloff, then director of psychotherapy research at the National Institute of Mental Health, counted 130; by 1988 Alan Kazdin, of the University of Pittsburgh School of Medicine, searched the key resource material and offered “a conservative estimate” of over 230 alternative treatments; and currently Paul Crits-Christoph, who, you will recall, is the director of the Center for Psychotherapy Research at the University of Pennsylvania, says that recent estimates have put the number at around 600.
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Bewildering as this may seem, the therapies actually fit into a relatively small number of categories: the three we have already seen, a few others that have had some significant impact on psychotherapeutic thinking and practice, and a host of others that have been flashy and newsworthy but account for very little in the real world of psychological treatment.

First, then, some of the few that are serious entrants in the historical record:

Humanistic therapies:
In the 1950s humanistic psychology, the core of the “human potential movement”—whose leading spokesman was Maslow—emerged as a “Third Force” or alternative to Freudian psychoanalysis on the one hand and behaviorist psychology on the other.

The humanists, more philosophic than scientific, objected to the psychoanalytic
doctrine that the individual’s personality and behavior are totally determined by his or her life experiences, especially those of childhood, and also to the behaviorist view that the individual’s behavior is only a set of conditioned responses to stimuli. Humanistic psychology stressed the individual’s power to choose how to behave and the right to fulfill oneself in one’s own way; it held that behavior should be judged not in terms of supposedly objective scientific standards but in terms of the individual’s own frame of reference. If a person considered an easygoing, noncompetitive, “laid-back” life ideal, that was a valid goal for him or her, not a symptom of a character flaw; so, too, with singleness rather than marriage, sexual freedom rather than monogamy, and other departures from social norms. Humanist psychology therefore had great appeal, especially for the young, during the individualistic, rebellious 1960s.

Out of this psychology emerged a crop of variant related therapies. Though widely disparate, they are all based on the doctrine that everyone possesses inner resources for growth and self-healing and that the goal of therapy is not to change the client but to remove obstacles, such as poor self-image or the denial of feelings, to the client’s use of these inner resources. The therapist does not guide clients toward a scientific ideal of mental health but helps them grow toward their own best selves. In the late 1980s about 6 percent of clinical psychologists and probably a like percentage of other psychotherapists considered themselves primarily humanistic.
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Today the figure is undoubtedly smaller because of the dominance of the big three and the availability of psychotropic medications.

Client-centered therapy:
This, the most important of the humanistic therapies, was the creation of Carl Rogers, who, born and raised on a midwestern farm, started out to become a minister. He switched to psychology and was trained in psychoanalysis but after some years concluded that it was unproductive, and made another major switch to a very different form of therapy of his own devising. A chronically optimistic man, Rogers felt that therapy should focus on present problems, not past causative factors. He also believed that people are naturally good and can solve their own problems once they accept that they are in charge of their fate, and he translated these views into a technique in which the therapist echoes or reflects what the client—Rogers rejected the term “patient”—says. This is supposed to convey a sense of respect
of the client and “faith or belief in the capacity of the individual to deal with his psychological situation and with himself.”
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Here is a sample of the process from a session (abridged here) with a depressed twenty-year-old woman:

This may sound like a parody of therapy, but Rogers deeply believed that by his method he created “a facilitative climate in which [the client] can explore her feelings in the way that she desires and move toward the goals that she wishes to achieve.”
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Most dynamically oriented therapists were unimpressed with Rogers’s method, but in the 1950s and 1960s client-centered therapy was widely adopted and practiced by those psychologists and other psychotherapists who had not had training in dealing with unconscious processes.
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Thereafter its influence waned; today it is the preferred technique of only a few clinical psychologists and other psychotherapists, although its humane philosophy is said to affect the way many therapists treat their clients.
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Gestalt therapy:
Quite unlike Rogers’s method, though sharing its philosophy of human health and self-direction, this is the technique developed by Frederick (Fritz) Perls, a psychiatrist. He called it Gestalt therapy, although, as noted earlier, it has little in common with Gestalt psychology. Perls’s aim was to make patients aware of feelings, desires,
and impulses they had “disowned” but that were actually part of them, and to get them to recognize those they think are a genuine part of themselves but were actually borrowed or adopted from others.
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