Seven Questions for Judith Beck

[Daniel E.]

Seven Questions for Judith Beck
By Ryan Howes, Ph.D.
Psychology Today In Therapy Blog
Feb. 20, 2009

Internationally renowned cognitive therapist Judith Beck shares her thoughts on the Seven Questions. Considering she wrote the book on Cognitive Therapy, sharing thoughts is a pretty big deal.

Judith S. Beck (Ph.D. University of Pennsylvania, 1983) is Director of the Beck Institute for Cognitive Therapy and Research, past president of the Academy of Cognitive Therapy and Clinical Associate Professor at the University of Pennsylvania. She is also the daughter of Aaron T. Beck, M.D., the influential founder of Cognitive Therapy.

(If I had an eighth question, I'd ask if she ever gets tired of being mentioned as "the daughter of..." She has a noteworthy track record of her own without the mention of her famous father. Some kids who follow their prominent parent's footsteps bristle when lineage is mentioned - names like Dylan and Bush come to mind. But here I go, thinking about psychodynamics. If she ever did have a problem with it, I'm sure it was resolved through thought stopping or systematic desensitization long ago.)

If you are a cognitive therapist, chances are you've read Judith Beck's Cognitive Therapy: Basics and Beyond. If you've been a client in cognitive therapy your therapist probably read it. The bestselling text is a graduate school standard that has been translated into over 20 languages. Through the miracle of Youtube, you can see her cognitive therapy in action here: Judith Beck Recently, Dr. Beck has applied her considerable CT knowledge to the world of diet and weight loss. Her New York Times bestselling The Beck Diet Solution was recently joined by The Complete Beck Diet for Life in a popular new approach to wellness. The cognitive component to weight loss is a crucial element, apparently. According to Beck:

...dieters needed a complete program for weight loss, that incorporates a psychological approach (e.g., what to do when you're feeling discouraged, disappointed, or deprived), dieting skills, an enjoyable eating plan, and techniques for keeping motivated for life. Most people think that just following a diet will be enough. I had previously thought that just learning essential skills was enough. But now it's apparent-you need both.
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This quote comes straight from her blog right here on PT named Thinking Thin. I actually invited her to participate before I knew we were blolleagues. Welcome, Dr. Beck! PT is proud to count you as a member.

Dr. Beck generously donated her time to the Seven Questions project. CBT is often misrepresented as an aloof, technical business transaction, but Dr. Beck's responses show that warmth and empathy are central elements of any therapy. She even chides therapists for not being personable and collaborative enough in session (Q3). Enjoy this response from a highly respected therapist and author who happens to have a famous last name.

Seven Questions for Judith Beck:

1. How would you respond to a new client who asks: "What should I talk about?"

Clients don't usually ask me that question, because as a cognitive therapist, I spend a little time early in the first session describing cognitive therapy and how treatment usually proceeds. (Then I make sure the process of therapy makes sense to them and feels right.) I say something such as: "Toward the beginning of every session, I'm going to ask you what problem or problems you want my help in solving. I'll also ask you whether there's anything else that's important to you that you want to discuss. That's what we call ‘setting the agenda.' How does that sound to you?"

2. What do clients find most difficult about the therapeutic process?

It varies from client to client, but generally changing their core beliefs, their most fundamental (negative and unhelpful) ideas about themselves, others, and/or their worlds can be difficult, if they've held these beliefs for a long time. But cognitive therapy offers very effective techniques to make the process easier.

3. What mistakes do therapists make that hinder the therapeutic process?

There are so many! But here are a few:
1. They don't let their normal warm and caring personalities come through.
2. They aren't collaborative with patients. They don't act as a team and make joint decisions about what to talk about and how to tackle a problem. Either they don't focus on problem-solving and helping clients change their unhelpful thinking or behavior, or they do so, but not in a collaborative way.
3. They don't ask for feedback from their patients, either during sessions when they notice clients have become upset ("What was just going through your mind?") or at the end of sessions ("What did you think of the session? Was there anything that bothered you or anything you thought I got wrong? Is there anything you'd like to do differently next session?"). They don't make sure that clients understand and agree with what they're saying.
4. They don't help clients figure out what will be helpful to do between sessions to solve problems and feel better.

4. In your opinion, what is the ultimate goal of therapy?

To reduce suffering as soon as possible, to help clients reach their goals, to facilitate a remission of clients' disorders, and to teach clients skills (particularly in changing their thinking and behavior) to prevent relapse.

5. What is the toughest part of being a therapist?

The toughest part of being a cognitive therapist is learning the specific conceptualization (the key ideas and behaviors on which to focus) and treatment for the various psychiatric and psychological disorders from which clients suffer. The treatment for depression, for example, varies in important ways from the treatment of anxiety disorders, or eating disorders, or substance abuse, or personality disorders. Many therapists use the same approach, regardless of diagnosis. No wonder clients don't necessarily feel better at the end of the session, are ill-equipped to deal with problems they encounter between sessions, and/or stay in treatment for long periods of time without significant improvement.

6. What is the most enjoyable or rewarding part of being a therapist?

Seeing clients improve quickly and stay better.

7. What is one pearl of wisdom you would offer clients about therapy?

All psychotherapy is not the same! One particular form, cognitive therapy (also known as cognitive behavioral therapy) has several hundred research studies demonstrating its efficacy for the range of psychiatric disorders, psychological problems, and many medical conditions with psychological components No other psychotherapy has been validated by so much research. If I had a medical problem, such as trouble breathing, I would go to my doctor and ask for the treatment that research has shown to be the most effective. The same should hold true for emotional problems.

Ryan Howes, Ph.D. is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

 

[Daniel E.]

Re: The Seven Questions Project: Summary

More on the "Seven Questions" About Psychotherapy
Psychology Today blog: Evil Deeds
by Stephen Diamond, PhD

Following in the footsteps of fellow PT bloggers Drs. Jared DeFife and Judith Beck (Dr. Aaron Beck's daughter), I'd like to offer a response of my own to Dr. Ryan Howes' interesting and revealing series of interviews on the "Seven Questions." My comments are based on my more than thirty years of clinical practice in psychotherapy. I hope this will underscore for readers some of the differences and similarities between Cognitive-Behavioral Therapy (CBT) as discussed by Dr. Beck in her recent response, and an orientation to treatment which I call existential depth psychology: a synthesis of psychoanalytic, Jungian, and existential psychotherapy.

1. How would you respond to a new client who asks: "What should I talk about?"
First session: "What brings you in to see me today?" "How did you find me?" "Why now and not six months ago?"
Second session on: "This is your session. You can talk about whatever you like." "Where are you right now?"

2. What do clients find most difficult about the therapeutic process?
While I agree with Dr. Beck's response that patients struggle with changing or restructuring their "schemata" or "core beliefs" about themselves (e.g., I am unlovable, unworthy of love, bad, stupid, evil, ugly, etc.), I would say that the greater difficulty has to do with accepting reality, past and present, which I refer to as the "bitter pill ": confronting the harsh reality of what happened during childhood, and the reality of evil in life. This is an emotional rather than merely cognitive process of consciously and affectively acknowledging the childhood wounding and dissociated feelings which frequently underlie the presenting problem, symptoms and distorted cognitions. Altering cognitions or providing intellectual insight alone is not enough. These affects--grief, fear, sorrow, anger, rage-- have typically been defended against for years, chronically denied, and are associated with abandonment, betrayal, loss, rejection, neglect or outright cruelty by parents, caretakers, peers, siblings or others. So confronting these socially unacceptable, nasty feelings or impulses in oneself, particularly anger or rage, can be frightening, shameful and painful, and is experienced, to cite Jung, as a "defeat to the ego." Swallowing that bitter pill involves tolerating the anxiety of changing or modifying one‘s self-image, relinquishing the old protective persona (with its outdated or irrational core beliefs) and creating a new, more appropriate perception of oneself and the world. This willing acceptance rather than avoidance of anxiety, the daimonic and the "existential facts of life" is very difficult, requiring courage, commitment, honesty and tenacity. The medicine may be bitter, but therapeutic. Patients also typically struggle with either taking too much or too little responsibility for themselves and their problems. And with recognizing and taking responsibility for loving, disciplining and supervising the inner little boy or girl all adults still have living within themselves.

3. What mistakes do therapists make that hinder the therapeutic process?
They try too hard to relieve the patient's suffering. They want to tone down, dampen or neutralize the daimonic. It is the patient's suffering that brings him or her into treatment. As Jung once said, "Neurosis is always a substitute for legitimate suffering." What he meant is that some suffering in life is inevitable, and must be accepted and tolerated. It is sometimes the refusal to accept natural suffering that leads to psychopathology. Suffering may have meaning. Even value. It may be the primary motivation to change. So rushing to alleviate the patient's suffering is not always necessarily in his or her best interest, since it may play into their already problematical dissociative, escapist or avoidant tendencies. I disagree here with Dr. Beck. Feelings like sadness, grief, anxiety, loneliness, anger, rage, pain, shame need to be accepted and experienced, not necessarily "reduced as soon as possible," as she suggests. (Though this may certainly at times be required, depending on severity and debilitation.)

Therapists (new ones especially) also tend to take on too much responsibility for the patient's healing, which permits the client to continue to slough off their responsibility for helping and healing themselves. So psychotherapists need to strike the right balance between caring and detachment in the Buddhist sense. Psychotherapy is fundamentally a process of self-healing, which is why Dr. Beck is right in emphasizing the importance of equipping patients to help themselves "to solve problems and feel better" between sessions--and, ultimately, beyond therapy. Finally, therapists sometimes fail to adequately address ruptures in the relationship: seemingly minor slights or irritants, which, when ignored, can lead to resentment and premature termination by the patient. Or they allow the patient to remain dependent on therapy (and them) for too long.

4. In your opinion, what is the ultimate goal of therapy?
I believe it is the patient's responsibility to decide the goal of therapy, and how far they wish to go. Ultimately, for me, what I want for the patient is to be able to stand on his or her own two feet in the world, deal constructively or even creatively with reality, and find and fulfill his or her destiny. I grow ever more appreciative of Freud's oft misunderstood remark that the goal of psychotherapy is to transform "neurotic misery into common unhappiness." This, to me, is a deeply spiritual acceptance of life as it is, rather than how we wish it to be. There is no cure for life. Nor does there need to be. My job is to help the patient get to the point where they no longer need to be my patient. Are ready to "fly solo."

5. What is the toughest part of being a therapist?
The toughest part of being a psychotherapist is dealing constructively with what we call "counter-transference," recognizing our own limitations, preconceptions, complexes, biases, and avoiding dogmatism and "burnout." It is hard but rewarding work to wrestle with emotional demons day in and day out, and as Freud observed, no therapist comes away from that task totally unscathed. Doing psychotherapy is, to some extent, staring evil and human suffering in the face each day. This constant exposure to human suffering can take its toll. So it is vitally important for psychotherapists to take especially good care of themselves physically, psychologically and spiritually. Staying somewhat flexible, open and creative in one's approach to treatment is also vital, as opposed to falling into the trap of "Procrusteanism": forcing every patient to conform to the therapist's theoretical or technical orientation and treating every patient identically. When it comes to psychotherapy, one size doesn't fit all.

6. What is the most enjoyable or rewarding part of being a therapist?
To have the high honor and adventure of accompanying patients on their difficult and sometimes extensive journey toward finding and fulfilling their destiny. Even after more than thirty years, I still find this sacred and soul-restoring process intellectually and emotionally stimulating, energizing, inspiring, sometimes even thrilling.

7. What is one pearl of wisdom you would offer clients about therapy?
Don't expect it to be quick or easy. At the same time, don't assume it must take "years," though this is sometimes the case. I agree with Dr. Beck's comment that "all psychotherapy is not the same!" Of course, each patient is different, and demands a treatment approach partially tailored to his or her needs. Therapists should possess some technical flexibility. Psychotherapy depends primarily on the psychotherapist: his or her training, background, orientation, personality, experience, philosophy, creativity, insight, intuition and world-view. And on the human relationship between patient and therapist. So I think that rather than seeking a certain kind of generic psychotherapy, patients would do well to seek instead a specific psychotherapist with whom they feel they can effectively work on their problems. Psychotherapy is not quite like car repair. It is not a primarily mechanical, technical, prescribed, by-the-book process, but rather a dynamic human relationship between a helping professional and patient or client. It is more about chemistry (or alchemy) than technique. Meta-analysis of psychotherapy outcome suggests that no one particular technical approach to psychotherapy is superior to another. But I would say that some approaches work better for certain patients than others. And different therapists have different ways of helping. So I suggest prospective patients consult several competent therapists from different theoretical orientations when seeking assistance to see with whom they feel most comfortable, encouraged and understood. Trust your instincts. If after several sessions or certainly months you feel no sense of progress or encouragement, talk to your therapist about it, and consider trying a different tack.

Dr. Stephen Diamond is a practicing clinical and forensic psychologist in Los Angeles, and is affiliated with the Existential-Humanistic Institute, which provides training in existential psychotherapy. He is the author of Anger, Madness, and the Daimonic (1996) and is working on a new book tentatively titled Restoring the Soul: Thirty-Three Therapeutic Secrets for Emotional and Spiritual Self-Healing.