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(I am neither a therapist nor a medical professional; I am simply someone using my lifelong experience with an anxiety disorder to highlight material well understood by psychologists. Existence is painful. I like helping.)
GET READY FOLKS, this is a looooooooong one, but it just might get you through the Thanksgiving holiday. The first section is about the childhood of Aaron Beck ("The father of Cognitive Behavioral Therapy" or CBT). The middle section is about Beck finding his focus as a medical practictioner and how he discovered CBT, and the third section will deliver the practical goods.
There are PLENTY of resources at the end of this piece, including downloadable worksheets, and a free sample chapter of David Burns’s excellent book Feeling Good about Cognitive Behavioral Therapy from which many of the techniques in the end originated.
Today's newsletter is about Aaron Beck, the Emily Post of thinking. Dr. Beck discovered how to teach unruly minds to behave with proper etiquette, to "mind" their manners, and stop acting like unshowered and UNINVITED houseguests who have overstayed their welcome since the second they arrived unannounced.
He called it Cognitive Behavioral Therapy, or CBT.
AARON BECK, the psychiatrist who died on November 1, 2021 at the age of 100, is considered one of the five most influential psychotherapists since Freud—and not just in my household. Dr. Beck changed the face of American psychiatry and is the reason that so many of us who struggle with mental anguish (I am NOT a fan of the term “mental illness” and will write about that another time) are not simply standing, but thriving in ways we honestly never believed we could. His contribution to the field of psychology and mental health will outlast him by centuries.
Known as the “Father of Cognitive Therapy,” Aaron Temkin Beck—called Tim by his close friends and family, and ATB by his colleagues—was born in Rhode Island to Jewish Russian immigrants in 1921, the youngest of five children and arriving two years after his parents lost two children amid the influenza pandemic. His mother, who suffered from mood swings, was still grieving her lost babies and remained profoundly depressed when Aaron was born. Beck’s mother was loving, but fiercely and understandably overprotective after losing two children. As he became more consciously aware of his place in his family, he became convinced that he was a replacement for his sister who died in 1920, the year before he was born—he believed his mother was disappointed that he’d not been born a girl.
Despite suffering from chronic asthma, Beck was a typically active young child, a Boy Scout who spent a majority of his time outside either in the woods or with friends playing sports. His parents encouraged his interest in science and his love of nature, and he credited these early explorations with bird watching, learning to identify plants and trees, becoming a naturalist and a camp counselor, as the origin of his curiosity about “what makes people tick; particularly what makes them happy or sad, and confident or insecure.”
Yet, like many children throughout the history of time, especially the outdoorsy types, he broke his arm when he was around 7—an injury that greatly impacted his quality of life. Now, instead of racing around with his friends and playing sports, he was relegated to more sedentary, indoor arts, like reading (my favorite athletic sport). To add injury to injury, because of his physical inactivity, and perhaps the less sophisticated medical care of the time, Beck developed a near-fatal blood infection at the site of his broken bone and was immediately hospitalized.
But this early experience in the hospital proved to be a traumatic and formative one: Beck would learn much later that his blood infection had a 95% mortality rate, and that he’d nearly lost his arm to amputation. He missed so much school that he was asked to repeat first grade, while the rest of his friends advanced. And, if things weren’t bleak enough, during one of his stays, the surgeon began his incision before young Beck was fully anesthetized, triggering the first cascade of several phobias—hospitals, surgery, blood injuries, and the smell of ether.
Because of the severity of his injury, he understood that he’d not be able to avoid hospitals, and all the attendant sights, sounds, and smells, So this young stoic decided on a rational approach—he’d treat it himself. "I learned not to be concerned about the faint feeling, but just to keep active,” Beck was quoted in a New York Times profile. Through exposure and willpower, he slowly faced his fear of hospitals.
From the Boy Scouts, he learned that he’d have to do things that were really difficult, like find his way through a complicated forest, and swim a mile. While the Scouts showed Beck that he could accomplish difficult tasks, it was his injury and the trauma of becoming critically ill that revealed to him just how resilient he was, and how driven he was to conquer all that stood in his way.
Yet he felt demoralized by having to repeat first grade—it left a deep internal wound because he strongly suspected it was because he was stupid. (As someone who was held back in 6th grade, I relate to this so strongly. The sense that I'm not as smart as everyone else has been with me always, and it's only begun to dissipate in the last few years.) It would be years before he’d work up the courage to ask his mother why he was held back, and only then he'd learn that it had to do with how frequently he was sick, and not to do with his intelligence at all.
Beck was miserable without his classmates. He couldn’t move past the shame of having to repeat a grade—and so, he didn’t. Determined to stick with his friends, he enlisted the help of a tutor and his older brothers, and studied and worked without distraction. Not only did he catch up, but he advanced a grade ahead of his original classmates. This was a psychological turning point for him. "It did show some evidence that I could do things, that if I got into a hole I could dig myself out. I could do it on my own," wrote Beck.
When he caught the whooping cough, made worse by his chronic asthma, Beck developed a second phobia: suffocation. It emerged when he began to drive, in the form of tunnel phobia, manifesting itself as a panic attack while he was behind the wheel. His fear of suffocation in tunnels sprouted other fears—of heights and public speaking. As he’d done when he was much younger, he resolved to treat these fears himself, approaching each phobia cognitively.
In 1938, Beck graduated from Hope High School at the top of his class and headed to Brown University, and then earned his MD from Yale medical school. This was a truly trying period, as he had to confront his phobia of the sights, sounds, and smells of hospitals, blood, and surgery. But once again, he relied on self-treatment— whenever he felt faint, he would expose himself to the operating room in an effort to desensitize himself. When he had to assist with surgery, he distracted himself by continuously keeping busy. “I wasn't fazed at all as long as I was . . . doing something. I learned an awful lot from my own experience,” he wrote. “As long as you're actively involved in something, anxiety tends to hold back."
When he eventually overcame his fear, he would pinpoint this as the possible root of his belief that it was possible to overcome the symptoms that paralyze and upend a life.
During his residency at the Cushing Veterans Administration Hospital in Massachusetts, Beck did a rotation in psychiatry, when he became interested in the treatment of mental illness and psychoanalytic theory, in particular Freudian theory, to which he subscribed whole cloth at the time. This inspired him to become a psychotherapist, and he used his research to bolster Freud’s claims that disorders were rooted in unconscious fears and conflicts.
What Beck didn’t anticipate was that his studies did not match Freud’s theory at all. In fact, Beck discovered it wasn’t the unconscious drive of the patient that needed to be accessed, but consciousness. This meant that only the patient’s immediate feelings and perceptions had to be challenged; diving deep wasn't necessary. If consciousness, and not unconsciousness, was the apartment where our distressing views lived, then we would have a much easier time accessing the space in order to rearrange the living situation, and the inhabitants who lived there.
“Since patients are aware of their conscious thoughts, it’s not as difficult [as traditional psychotherapy, which requires the exhumation of buried memories] to correct misperceptions,” said Beck in 2004.
Instead of investigating for confirmation of the Freudian model as planned, Beck began to examine, identify, and treat the patterns of his patients’ distorted thoughts as they emerged. With his help, his patients were able to reframe negative information and biases and learn more adaptive behavior. This was an entirely new strand of analysis, which he called “cognitive therapy.” He defined cognitive therapy as "an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders...based on an underlying theoretical rationale that an individual's affect and behavior are largely determined by the way in which he structures the world."
Freud also theorized that depressed patients were driven by an unconscious need to suffer. However, when Beck gave his depressed patients neuropsychological tests where they had to match cards, their reactions were positive when they were correct, and they gained more self-esteem and performed better on the remaining tests. This upended Freud’s “need to suffer” theory. Had his patients been devoted to their pain as was previously suspected, their successes would have led to distress. The incongruity between Freudian theory and Beck’s research led him to reassess his position on the unconscious.
This refutation opened up windows of opportunity to apply cognitive therapy to other disorders like anxiety, suicidality, drug addiction, personality disorders. He developed a comprehensive theory, laid the groundwork for treatment, and applied standardized methods of evaluation to test the validity and efficacy of the therapy.
Beck posited that the human mind organizes cognition into a variety of verbal and pictorial “events,” and they are arranged in varying degrees of accessibility and changeability. There are four levels of cognition that Beck identified:
Voluntary thoughts. These are our stream of consciousness thoughts. They are the most easily accessible group of thoughts in our conscious mind.
Automatic thoughts. These are less accessible cognitions. They surface most often when a patient is under stress. These cognitions are difficult to block.
Assumptions and values. These are associations filled with the meanings patients attributed to them during the situations and events in which they originally occurred.
Schemas. Schemas operate below the level of conscious awareness and are formed early in life from learning experiences. These cognitions are theories based on our core beliefs, and remain dormant until specific life events trigger them. When they are activated, they act as the lens or representation through which we interpret events.
The therapeutic method that Beck arrived at disregards excavating unconscious causes of fear. This is why Cognitive Behavioral Therapy or CBT doesn’t require as much time as talk therapy. The fears that are examined and confronted are rational and conscious.
CBT is based upon the idea that a patient’s interpretation of an event influences their reaction more than the actual situation itself. This is because the patient’s interpretations are based on inaccurate underlying beliefs they have about themselves and are therefore distorted and unhelpful. These interpretations are what we call “automatic thoughts.” Beck discovered that when he helped his patients re-evaluate their distorted thinking and provided them with a more adaptive method to modify their behavior, they improved, felt better, and the effects were long-lasting.
In 2015, Alix Spiegel produced an episode of her NPR show "Invisibilia" called "Dark Thoughts." The thesis: What should we think about our thoughts? In that episode, she introduced listeners to Dr. Aaron Beck. Here’s a transcribed excerpt from that recording.
ALIX SPIEGEL: When I met him, Beck, I think, was around 80 - this kind of white-haired, old man in an Orville Redenbacher bow tie - who, like everyone else in his generation, had started his career practicing Freud's therapy, psychoanalysis.
AARON BECK: I then had a couple of experiences which made me shift gears.
SPIEGEL: “You see, one day in the late 1960s, Beck was in a session with a patient, a woman who was explaining to him she'd been at a party where she'd been having a difficult time connecting to people and had found herself overcome by these thoughts”
BECK: "Nobody cares for me. I'm just a social outcast. Nobody will ever care for me."
SPIEGEL: And for some reason that day, Beck did not go down the traditional path. He turned to the woman, and he asked, “How do you know that those thoughts are true just realistically?”
BECK: Explore the evidence for ‘Nobody cares for me.’ And she then could list a dozen people who obviously did care for her.
SPIEGEL: Which made Beck think something which, in his world, was revolutionary. Maybe people shouldn't always take their thoughts so seriously, particularly a certain subset of their thoughts.
UNIDENTIFIED PERSON: I'll always be alone. No one will love me.
SPIEGEL: You remember these thoughts, right?
BECK: You are stupid.
UNIDENTIFIED PERSON: I'm stupid.
BECK: They're going to dislike you.
UNIDENTIFIED PERSON: I'm a failure.
BECK: And so on.
SPIEGEL: Beck had a special name for them: automatic negative thoughts.
BECK: What's interesting about the automatic thought—and this is true of everybody—is that people tend to accept them at their face value.
SPIEGEL: So Beck started trying this with all of his patients. Don't trust the thought. Challenge the thought.
BECK: To test out to see whether they're really true.
SPIEGEL: And what he found was that when his patients contradicted their negative thoughts...
BECK: The patient started to get better sooner.
(SOUNDBITE OF MUSIC)
SPIEGEL: Instead of it taking years, as it often did with Freudian therapy, they were getting better in a couple of months.
BECK: "Well, Dr. Beck, you've helped me a lot, and I don't think I need any more therapy."
SPIEGEL: And thus began what is now called cognitive behavioral therapy, or CBT, a new system of therapy that does not believe that the thoughts in your head are necessarily indicative of anything deep about you. And over the last 30 years, this kind of therapy has slowly but surely been displacing Freudian-based therapies.
End of excerpt
Beck found many ways for us to tackle our cognitive distortions. Once we realize that our thinking influences our emotional and behavioral states and experiences and that our emotional and behavioral states influence our thinking, we have a ground to walk on.
One automatic belief that many of us share is the maladaptive worry that our feelings determine our worth. This just isn’t true. It’s also not true that our thoughts and behaviors determine our worth. What IS true is that with dedication and resolve, we can actually modify the way we think, feel, and behave. Having maladaptive behavior in the first place, behavior that isn’t serving us and that we are moved to change, does not make us bad people with low worth. What that recognition actually means is that we know how good we are—and that we are more than capable of doing the work to arrive at a place that we know is better for us.
The best part about this work is that there is nothing we need to ADD. All we need to work on is turning off the critical voice that is driving us to believe things that aren’t true. When we believe the distorted viewpoint of our conscious self, we are believing a conspiracy theory, and as we all know, theories that have been proven true do not contain the word “conspiracy.” In other words, we can believe that we’re terrible people, and that our abusive inner voice is correct, but then we also have to believe the illogical, distorted thinking of all the people who believe the world is flat, or that Elvis is still alive.
FROM FEELING GOOD:
“As indicated in Figure 5–1, the relationship between your thoughts, feelings, and behaviors is reciprocal—all your emotions and actions are the results of your thoughts and attitudes. Similarly, your feelings and behavior patterns influence your perceptions in a wide variety of ways. It follows from this model that all emotional change is ultimately brought about by cognitions; changing your behavior will help you feel better about yourself if it exerts a positive influence on the way you are thinking. Thus, you can modify your self-defeating mental set if you change your behavior in such a way that you are simultaneously putting the lie to the self-defeating attitudes that represent the core of your motivational problem. Similarly, as you change the way you think, you will feel more in the mood to do things, and this will have an even stronger positive effect on your thinking patterns” Burns, David D. . Feeling Good (p. 72). Harper. Kindle Edition.
Now, let’s get into some of the tools and methods of Cognitive Behavioral Therapy. These are all taken from a variety of sources that are listed at the end of this article. A majority of techniques are from the book FEELING GOOD by David Burns because I think it's an excellent resource.
BREAK IT ALL DOWN
1. Let’s say you’re overwhelmed and you have too much to do. Familiar? Same. First, break everything down into the smallest possible parts. Spend no more than 20 minutes on figuring this out, and then go do something you enjoy. EX: This morning I will spend 15 minutes responding to email, then I will work on my novel for 45 minutes. Then I will spend 20 minutes returning phone calls. Then I will spend 10 minutes to answer texts...You get the idea.
2. Imagine you have a talk coming up and you’re afraid. Set aside ten minutes every day and imagine yourself doing the entire talk perfectly. Include the Q&A at the end, if there will be one.
3. Eliminate “should” and “must” from your vocabulary and come up with alternate ways to talk to yourself. Instead of: “You should stop feeling so damn depressed and sorry for yourself and GET OUT OF BED RIGHT NOW,” try: “I know I’ll feel better when I get out of bed. I also know that at first, it will be hard. While it’s alright if this doesn’t happen, I have a feeling I’ll be glad I did this for myself. Perhaps I will discover that I am allowed to enjoy things that I do that are good for me.”
4. Make a list of advantages and disadvantages for not doing the thing you know will be better left done.
Take action and don’t wait for motivation.
A lot of people (read: writers) wait until they feel motivated to work on their book. This is, well, ridiculous. Inspiration doesn’t come to you and announce that it’s here; it shows up when you allow the space for it. Likewise, people who are prone to procrastination often confuse motivation with action. When we wait until we’re in the mood to do something, we’ll consistently keep putting it off. When we spend more time putting things off, we invite depression and ennui. So, whenever we don’t feel motivated, it’s our chance to say, “Oh! I’m unmotivated! This would be an ideal time to take action.”
To read your thoughts, start by reading your body.
When you suffer from anxiety throughout the day and you have no clear trigger, your thinking might be to blame. You just might be practicing the unhealing art of Cognitive distortion.
Oftentimes, when we’re feeling stressed out, we’re actually anxious. If we feel tense and have a racing heart or feel agitated, it’s a clue that anxiety might be lurking.
Now is the time to ask yourself these questions:
What is my mind focusing on? Is it on the task at hand, or something else?
Do I feel tense? Where in my body do I feel tense?
Does my stomach hurt or ache? Is my heart racing? Are my palms sweaty? Do I have symptoms of “stage fright” when there is no stage I need to appear on?
At what point in the day did these physical sensations begin?
If you do recognize that you’re having symptoms or signs of anxiety, move your focus from your body to your thoughts and see whether they might be the cause for your anxiety.
When you practice doing this, in time you’ll begin to connect the un-triggered race of your heart to a specific thought or pattern of thinking. The more you pay attention to the cues of your body, the better you’ll be able to notice your disruptive thoughts and work on them.
If someone talked to a loved one the way you talk to yourself, how would you react?
Let’s say that your landlord stopped your sister on the street and said, “No one actually likes you. They’re all just pretending, and when they get together without you, they laugh at you for hours.”
What can you see in that scenario with your landlord that you’re unable to see when you speak to yourself like that? You’d be able to see how wrong they are, and why they’re wrong.
Examine the evidence.
Separate facts from feelings. “She didn’t call me, so she hates me” is a feeling. When you don’t know the reason someone did or didn’t do something you begin to fill in the reasons based on your feelings. Instead, try to think up factual evidence for why they may or may not have done something. Perhaps the storm knocked out their power? Perhaps they are stuck on the subway where there is no cell service. Maybe their battery died. Maybe they forgot their phone. Maybe they are at a meeting or an appointment that ran long and can’t access their phone without being rude. There are always more reasons for something that we realize. Try to list all the reasons for something that have nothing to do with you.
When you notice that you’re belittling yourself, look for evidence of all the ways you are valuable.
If you can’t stop thinking about something you said that you regret at a party, or in a meeting, see if you can find other things you’ve said that you don’t regret.
Cognitive distortions are usually based on our exaggerated opinions and don’t correspond with facts.
Sum of its parts.
When you decide that you’re a failure or a loser or so boring based on an incident, examine whether these broad-stroke labels apply to other people who might have had a similar incident. When you do this, you can often see that one label can not possibly apply to the entirety of a person.
Avoid the urge to generalize.
When you overgeneralize, you often take one negative incident and apply it to everything and everyone— saying something that turns out to not be true doesn’t mean that you don’t know “anything.” Learn to reframe these situations using the opposite-three technique.
Think of three opposites.
Every time you are convinced that an overgeneralization is correct, force yourself to think of three opposites to the situation. So, when you think “I fail at everything,” mentally identify three things at which you have been successful.
Before you assume the reason a person is acting a certain way toward you (e.g., “They’re going to break up with me”), ask them what is wrong. More often than not, you’ll discover, to stick with this example, your partner might be dealing with something unrelated to you, and you are suffering from cognitive distortion. Your own negative thinking patterns are most often not based on facts.
Replace “shoulds” with something positive.
When we “should,” we’re chastising ourselves, which leads to negative thinking. The fact is, we know we “should” do something because, in the past, it made us feel better. Instead of skipping over this and going straight to “should,” consider replacing “should” with “I’d like to,” or “it would be nice if.” This helps motivate more than any should could, and also relieves the pressure and the judgment of “should.”
Often we overlook the cost and benefits of certain thinking styles. When you have a negative or critical thought that isn’t serving you, ask how this style of thinking or this particular thought helps you. And if it doesn’t help you, how does it hurt you? Be specific.
It’s possible to fix cognitive distortion and negative thinking. It takes work, but we are worth it. The more we work on reframing our negative thoughts, the more our moods will improve.
If you are in a collaborative frame of mind, try working with a therapist. If that’s not financially possible, or the timing won’t work, I have included a lot of resources below to get you started.
Have you ever done CBT before? Was it helpful? What did you learn from it that you can share in the comments with readers?
One more thing before you go. I want you to remember something …
YOU GOT THIS. You are not alone. I promise.
Until next week, I remain,
P.S. Thank you to Aaron Beck for your contribution to mental health. Rest (if this is even a thing that can happen in death) in peace and cognitive clarity.
WORKSHEETS & A SAMPLE CHAPTER
Before you plunk down $$, read a sample chapter from David Burns’s book Feeling Good:Understanding Your Moods: You Feel the Way You Think.
Download some CBT worksheets (password: temkin)
How to Live is a newsletter about all things psychological. To read more and subscribe go to amandastern.bulletin.com
If you want to know more about me, you can read my memoir Little Panic: Dispatches from an Anxious Life.