6. Thinking Differently (I)

It is all about relationships

Ratio
Ratio
Aug 22, 2017 · 5 min read

Aaron Beck is a psychiatrist, arguably the world’s most influential psychiatrist, certainly so if understanding and treating depression is the measure. He invented the Beck’s Depression Inventory, a tool for finding out if one is melancholic. As important as they are it is not the measures that interest me here.

For Beck is the also one of the progenitors of Cognitive Behavioural Therapy, or CBT, three letters known to most but understood by only a few. Beck is the man who got us to think differently about challenges in our lives.

The idea came from his own practice. He had a patient. Her name was Lucy. She was anxious. When Beck asked Lucy how the therapy was going she said she felt worse than before it had started. When pushed Lucy revealed that she thought that Beck must find her boring, an idea she hadn’t entertained until the therapy began.

Beck is the man who got us to think differently about challenges in our lives.

Beck came to the conclusion that Lucy was having ‘automatic thoughts,’ notions that popped up in her head. If left unchallenged, by the self or by others, the ideas solidified and became real. So real that they often got in the way of clear thinking about the nature and solution of challenges in our lives.

So the psychiatrist began to look more closely at the way all his patients thought during therapy sessions. He began to think in terms of cognitive therapy. Beck noted how we synthesise previous life experiences into ‘schemas’ or beliefs about ourselves. A depressed person, for example, might think of themselves as ‘unlovable’. They are loveable but they think of themselves as not. This muddy thinking, this cognition, gets in the way of, well, clear thinking.

Beck knew that Lucy wasn’t boring him, but nonetheless the idea was true to Lucy. Beck also knew his depressed patients were not unlovable because he saw great chunks of their lives during which they were clearly loved. By watching and listening he slowly worked out that these kinds of thoughts lay dormant most of the time but were activated by circumstances, negative events, that altered the process of cognition, evoking all kinds of unhelpful emotions and sponsoring a range of distressing behaviours.

A depressed person, for example, might think of themselves as ‘unlovable’. They are loveable but they think of themselves as not. This muddy thinking, this cognition, gets in the way of, well, clear thinking.

Beck got into the habit of helping his patients recapture the link between negative emotions and thoughts -I am boring- with the circumstances in which they arise -I am sitting with a powerful man. This is the basis of cognitive therapy. By clearing the emotion out of the way and getting us to think straight, therapists can begin to help us understand the origin of the behaviours that bother us. This is how we get to Cognitive Behavioural Therapy or CBT.

CBT is delivered by trained therapists, usually psychiatrists and psychologists. They help people to identify and understand the deleterious effects of negative emotions. They deal in the here and now, helping their patients to clear the mind of unpropitious thoughts. They then show how what seem like insurmountable problems can be broken down into manageable chunks, and resolved.

For Freud the therapist was king. For Rogers too. But CBT isn’t set up like psychoanalysis and humanistic therapies where the clinician is thinking on her feet. It is a method. There is a manual with steps. It isn’t true that any Tom, Dick or Harry can do it. Most practitioners are trained doctors of various descriptions.

But we can say that there are self-help versions of CBT, so the patient becomes the therapist, and there are online versions. CBT could certainly become the first therapy to succumb to artificial intelligence. What happens in the interaction between the client and therapist is not a matter of discussion in CBT. There is a goal. To solve the problem the client presented.

And CBT appears to work, or at least with specific challenges in life, and in comparison with conventional therapies. It is probably the most researched therapy in the world, and it is certainly one of the most widely applied. It seems to do well with some forms of depression, anxiety, some substance misuses and eating disorders. For more severe disorders it is often combined with some form of medication. It has become the treatment of choice for children and young people facing mental ill-health.

What happens in the interaction between the client and therapist is not a matter of discussion in CBT. There is a goal. To solve the problem the client presented.

But then there are the naysayers. The evidence of effectiveness is mixed. It really works with some problems, anxiety for example, but less so, hardly at all in fact, with others, for instance bipolar disorders. When there are positive results they don’t last, the patient is un-muddled by the therapy only to become muddled again a year or so later. The best results came in the 1970s and 1980s when the approach was new. When the same trials are run today the results are far less impressive.

There isn’t a single ‘me’, there are lots of ‘me’s’. Which me is so drowned in emotion that I misperceive the world, and is this the part of me that CBT touches?

These variable results get people digging. What is going on? Why the success but also why the failure? One possibility is the mechanism by which CBT is meant to work, and in particular the lack of evidence of any cognitive change in patients. Since the invention of CBT brain science has altered beyond recognition revealing just how complicated it is to get rid of unhelpful thoughts. It turns out we have multiple memory systems and knowledge stores. There isn’t a single ‘me’, there are lots of ‘me’s’. Which me is so drowned in emotion that I misperceive the world, and is this the part of me that CBT touches?

How does CBT make us think differently about responding to disadvantage? Rebeca turns to this question on Thursday.

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The R Word

The R Word is a conversation bringing together policy wonks, scientists, practitioners, philosophers, philanthropists, innovators, people facing down disadvantage, and others who will engage in a series of discussions about relational social policy.

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Ratio

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Ratio

www.ratio.org.uk

The R Word

The R Word is a conversation bringing together policy wonks, scientists, practitioners, philosophers, philanthropists, innovators, people facing down disadvantage, and others who will engage in a series of discussions about relational social policy.

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