Dialogue Is Key to Treating Depression, Pioneer Therapist Says

In the movies, he always has a beard.

His patient lies on a leather couch, spouting free associations while he sits in a chair, quietly scribbling mysterious notes. When he speaks at all, which is rare, his vocabulary seems to consist of just six words: “How did that make you feel?”

He is the prototypical Freudian psychoanalyst.

About 30 years ago, psychiatrist Aaron Beck came up with a different idea. He decided to talk to his patients--to ask questions, lots of them, almost like a journalist quizzing an interviewee.

“I’m terrible at reading people’s minds,” said Beck, 68, a professor of psychiatry at the University of Pennsylvania School of Medicine. “So I say to the patient, ‘What are you thinking?’ ”

Based on that simple philosophy, Beck originated “cognitive therapy”--a method that today is practiced by mental health professionals throughout the world.

His contribution has earned him a place among the most prominent psychotherapists in history, right up there with Sigmund Freud.

The dapper, white-haired gent with a kindly sense of humor visited Orange County last week to hold seminars. He led a discussion about the use of cognitive therapy in treating depression Monday night at the Irvine Marriott hotel. The event was co-sponsored by the Orange County Psychiatric Society and CPC Santa Ana Psychiatric Hospital, which specializes in cognitive therapy.

“I try to get patients to report to me what they think; it takes the burden off the therapist,” Beck said. “As opposed to just sitting back and listening, I found that patients get better faster, and in a much more lasting way, when the therapist is active.”

At the recent seminar on depression, Beck and colleague Christine Padesky, director of the Center for Cognitive Therapy in Newport Beach, demonstrated their technique with a CPC Santa Ana Hospital patient. In front of 450 Southern California mental health professionals, Padesky showed how an active approach could quickly pinpoint some of the patient’s problems.

The anonymous volunteer--a shy yet gutsy woman whose occasional displays of humor softened her poignant revelations--told the audience that she had considered suicide before checking into the hospital.

“I was going to buy a gun and drive to the desert and kill myself,” she said in a tentative voice.

Her job had become too unfulfilling to bear, and her attempts at training herself for a new career only aggravated her stress.

“What thoughts would go through your mind?” asked Padesky, who had not worked with the patient previously.

“I thought, ‘This is all a sham. Even if I get a new job, I’ll still just be me,’ ” the woman said.

That, in cognitive therapy jargon, is an “automatic thought”--a recurring self-criticism undeserved by its target.

“I discovered that at the center of all (psychiatric) patients’ disabling symptoms is a distortion of the real-life situation,” Beck said. “Cognitive therapy is based on the notion that correcting erroneous thinking is the first step in solving the problem.”

In the case of a depressed patient, he said: “The first goal is to get him to view his hopelessness more objectively so that he will lose that degree of exaggeration and will begin to sense that there are some solutions. The suicide risk becomes much less as soon as the hopelessness starts to abate.”

Automatic thoughts overshadow the victim’s focus on good qualities. For instance, the patient at the seminar recalled that she never gave herself credit for the success she earned in her career.

Inpatient therapy has helped her beat back her suicidal fantasies, but the woman must soon face another tough challenge: returning to work and encountering questions from curious co-workers about her absence.

“I’m afraid that I’ll give myself away, that I’ll say something that will hurt myself,” she admitted, expressing another self-criticism.

Still, the patient said, she has learned to replace many of her automatic thoughts (such as, “I hate my job”) with objective thoughts (“It’s time to make a plan and get out of here”).

In addition to its emphasis on defining and clarifying automatic thoughts, cognitive therapy distinguishes itself from psychoanalysis by setting goals and time schedules.

“Many depressions and panic disorders can be treated (through outpatient care) within 12 to 20 weeks,” Beck said. “However, it takes much longer to deal with personality disorders, where the patient has had difficulties for much of his life.”

When appropriate, short-term therapy saves the patient money and also prevents him from becoming dependent on his counselor, Beck noted.

Beck further set cognitive therapy apart from other methods by encouraging its practitioners to request comments from patients regarding the therapist’s effectiveness.

“The patient is the consumer, as it were, and it’s your job to please the consumer,” Beck said. “It makes the patient feel more in control if you occasionally ask him how he thinks the therapy is going.

“Of course,” Beck wryly added, “you want to do it in such a way that you don’t make the patient feel you’re inept.”

And what if the patient responds with a less than flattering critique?

Beck facetiously offered a snappy retort: “You say, ‘So sue me.’ ”