Verified by 
Depression
Beck on Why a “Unified Theory” Is the Future of Therapy
A.T. Beck on why the future of psychotherapy will be a unified theory.
Posted December 5, 2014
My former supervisor and mentor, Aaron T. Beck, is, undoubtedly, the most famous and influential living figure in the field of psychotherapy today (he is 93). As the originator of cognitive therapy, more than anyone else it has been his pioneering vision and efforts that are responsible for modern Cognitive Behavior Therapy or “CBT”, which is the therapy orientation most frequently taught in professional psychology training programs. He is a true visionary, and I learned an enormous amount in my four years working under him at the University of Pennsylvania.
I left UPENN and came to direct the clinical-school doctoral program at JMU in part because I had my own vision for the future of the field. I always believed that cognitive therapy was a significant advance over what had come before it—psychoanalysis, client centered therapy, and traditional behavior therapy—for a host of reasons. But even though it was better than the other major schools, it was still clearly a “single school” of thought, meaning that it emphasized its own key sets of terms and had its own specific lens and set of assumptions (namely, that the root of psychopathology was “cognitive” in nature) that did not mesh very well with the key insights from the other schools of thought. It also did not address the massive fragmentation in the field of psychology nor its conceptual and philosophical problems. Thus, it was not really fully grounded in a coherent vision of human psychology.
Over the course of his long and illustrious career, Beck himself varied quite a bit on how strongly he was committed to the cognitive model as the “truth” (i.e., a single school version of reality) versus how much he saw it as a useful perspective among many other useful perspectives (i.e., an integrative version of reality). The recent change in the official way his therapy is referred to--from Cognitive Therapy (CT) to Cognitive Behavior Therapy (see J. Beck, 2011)--is a testament to some of the ways the approach has been reframed and broadened.
For myself, I always had an integrative version of reality. Consistent with Beck, it was clear to me that the “cognitive system” was crucial in understanding psychopathology. That is, the way people explicitly formed beliefs about their environment, themselves and others, along with how they developed expectancies and drew conclusions about their situation were absolutely essential for understanding psychological problems and neurotic symptoms (i.e., maladaptive levels of anxiety and depression). And a cognitive lens offered up a helpful venue for therapeutic intervention.
But it was also clear to me that the cognitive system was not the only mental system that was involved in psychopathology. For example, people’s habits are separable from their conscious thoughts and operate on different kinds of mental systems. I bite my nails. I don’t want to bite my nails, and my nail-biting is not a function of my explicit interpretations or expectancies. My nail biting behavior is rooted in my “habit” or procedural system, and it does not have much to do with my explicit conscious beliefs.
In a similar way, traditional cognitive therapy failed to address the emotional system in the right way. Consider, for example, the case of simple phobias. Most phobics will tell you their fear is irrational, that it makes no sense, and that they know, “cognitively”, that the spider or the enclosed space or whatever will not really damage them. And, yet, they still demonstrate intense emotional reactions. This analysis holds with many feelings associated with social anxiety and many episodes of depression or PTSD symptoms following trauma. In other words, it is often more appropriate to locate the focus in the “emotional/experiential system” rather than the higher thinking/cognitive system (even when we acknowledge the two are intimately intertwined).
The other elements that seemed to be missing from the traditional cognitive model had to do with how people intuitively formed relationships, how they were guided by internal working models of others based on early attachments, and core personality structures (like the tendency to be agreeable or not). Although Beck did write about such things, they were not readily accounted for by a straightforward cognitive model. In addition, people developed conscious identities that were often at odds with their underlying feeling and relational needs, and they would exhibit defenses that blocked or inhibited or dissociated feelings or needs that were painful or not congruent with their identity. This defensive filtering process was often key to understanding psychopathology, but the cognitive model was awkward in dealing with these observations.
Finally, the cognitive model was an individual level approach. It did not offer much in the way of insights into societal context or social systems or the larger forces of power and privilege and socially constructed versions of reality.
Of course, folks who are familiar with psychotherapy models will be able to see my point here, which is that where the cognitive model is weak are areas that other established models that are strong. Traditional behavioral perspectives are useful in understanding “noncognitive” habit formation, like my nail biting. [Years ago my youngest brother used to bite his nails, but rather than addressing his thoughts, my grandmother paid him $100 to stop and he did. She offered me the same, but my habit was too strong (or will too weak).] Experiential therapies, like Les Greenberg and Sue Johnson's Emotion Focused Therapy, take as their starting point the way emotional processes organize and impact consciousness and relationships, and highlight the importance of emotional attunement and the extent to which emotions are over- or under-regulated as crucial to understanding psychopathology. Modern psychodynamic theories emphasize relational patterns, early attachments, and the way folks defend against images, feelings or impulses that are not readily integrated into their explicit consciousness. Finally, social constructionist approaches (like feminism and narrative thought) and family systems perspectives offer more of a “top down”, social contextual systemic approach to understanding individual actions and problems.
It always seemed to me that a cognitive theorist/therapist had one of two choices in dealing with the above observations. One option was to engage in mental gymnastics, and morph the word “cognitive” so that, no matter what, it becomes essential problem. But if one does that, then the meanings of one's constructs begins to break down. The other option is to soften one’s commitment to the cognitive model and realize that the cognitive system is only part of the whole. It offers key insights, but is only part of the big picture. What we really need is a holistic model that offers a unified vision of all the systems and their interactions, and furthermore places the person in their biological, historical and social context in a way that makes sense of both their character and their problems. That is the vision I sought with the "unified theory”.
I was very heartened when yesterday a student of mind shared with me the following clip from Beck, which was put up on the web a couple of weeks ago. Always the visionary, Beck articulates here how he sees CBT evolving in the future. Specifically, he envisions a “unified theory” that will allow psychotherapy to transcend the single schools into a more unified view.
Precisely as I have articulated several times on this blog (e.g., see here and here), in this clip Beck makes the analogy with modern medicine, and points out that medicine is largely unified because the specializations in medicine recognize they focus on parts that make up the whole system. Thus, folks in medicine don’t look at biological health from either a “circulatory” or “digestive” system perspective in competing ways. Rather they readily acknowledge that both circulation and digestive processes are two somewhat separable and also somewhat related systems that are both necessary for healthy biological functioning of the whole person. Likewise, Beck sees that in the future we will drop commitments to viewing psychopathology from only the perspective of attachments or defenses or cognitions or habits or feelings but will recognize that these systems of character adaptation function together to produce to whole of individual psychology in context.
My hat is off to Beck and I couldn’t agree more with what he says in the clip. And, in watching it, I’d like to think that, perhaps, I wasn’t the only one who was learning things during my time at Penn.
