90 The Economist November 13th 2021
Obituary Aaron Beck
By fartheyoungestofAaronBeck’ssubjects,intheverypartial
list of patients he had treated for anxiety and phobias in his
book, “Cognitive Therapy and the Emotional Disorders” (1976),
was an eightyearold boy. This boy, after weeks in hospital with
nearfatal septicaemia, became horribly squeamish about blood,
and the smell of ether would make him faint. How was he treated?
By learning, whenever he felt faint, to focus on other things, even
just naming all America’s presidents in the right order. The feel
ings still followed him into adulthood, but he then confronted
them headon: by going to Yale Medical School, where the smell of
ether was more or less infused in the walls.
The eightyearold boy was himself, and that childhood experi
ence was his first brush with the idea that human thinking moved
on two parallel tracks. Not conscious and deep subconscious, as
Freud had taught, which was the accepted wisdom in the 1950s
when he entered the field, but rational thoughts and “automatic”
ones, both on the surface. Automatic thoughts were sometimes
useful, as when he was driving the car and simultaneously com
posing the next lecture for his students at Penn University, where
he was a professor for half a century. They told him to swerve at a
bump, or slow down, without interrupting his flow of ideas. But
such thoughts were often distorted, blocking out more rational
explanations for the problems that inevitably cropped up in life.
A man might fret, for example, that his wife had not said good
bye to him as he left for work. Did it mean she no longer loved him?
Was he actually unlovable? The rational explanation might be that
she had left milk boiling on the stove. But the negative thoughts
crowded in first, and could lead to fullblown depression. Just one
misinterpretation could convince a beautiful woman that she was
ugly and a teenager that she was fat, and the damage was done.
Anxiety attacks and phobias were usually triggered not by the
thing itself, such as a high balcony, but by a lively negative (andstatistically very unlikely) thought of tumbling over the rail.
He concluded that distorted surface thoughts, rather than
Freud’s longburied childhood traumas and Oedipal desires, ex
plained almost all emotional disorders. To each condition he ap
plied scientific rigour and plain New England common sense, be
sides writing clear, simple manuals for therapists. As the years
passed, his Cognitive Behavioural Therapy (cbt) was found to be
widely effective—needing far fewer sessions than Freudian analy
sis, and lasting longer. It became, and remains, the most popular
treatment for depression and anxiety in the Western world.
His method was gentle and collaborative. He dressed nattily,
with colourful bow ties, and his bright blue eyes were kind. Rather
than making his patients lie on a couch and freeassociate, as
Freudian analysts did, he invited them to sit at a small table just
across from him, an intimate space that just had room for a large
box of tissues. He was less a clinician than a friend who would
help them sort things out together. Then, rather than staying si
lent, he asked constant questions, gently unpicking their
thoughts to expose the distorted ones, and plumbing his patients
for evidence. The basis of cbtwas empirical, and it was Socratic:
“You say you’ve lost everything, but what have you really lost?”
“How likely is it that you would die if you went outside?” “When
you told me that story, what was really going through your mind?”
That was his keystone question, finding the parallel tracks.
Once the fallacies were exposed, patients could begin to help
themselves. They were told to note their feelings day by day, and to
gather countervailing evidence to their negative thoughts. Severe
depressives were trained in “mastery” by being given tasks which,
though easy for most people, had become impossible for them:
getting out of bed, making a phone call. In 1952 he even successful
ly treated a young schizophrenic who was convinced he was being
followed by government agents. “How would I know what they
look like, to help you?” he asked the patient. The patient could not
exactly say. But as he was asked each week to describe the agents
they became fewer and fewer, until they disappeared.
Hard though it was to credit, this revolutioniser of psychiatry
had once been a fervent Freudian. But he became increasingly
bothered by the lack of hard science in it, its mantras and ritual
ism and its cult of celebrity practitioners. Depressives, for exam
ple, were said to have turned their hostility towards a parent in
ward on themselves, but his study of their dreams showed no
more hostility there than in anyone else. Depressives and nonde
pressives alike might dream that they found only an empty Coke
machine as they wandered in the desert.
He wandered in the desert for a while himself, retreating into
private practice, mocked by Freudians and attacked by pharma
ceutical firms whose profits from pills he threatened. In a trial in
1977 cbtshowed better results than imipramine, the best antide
pressant of the time. So he kept going, busily recording patient da
ta in his own journal, Cognitive Therapy and Research, when no one
else would publish him. He was quite certain he was right.
But he was not immediately happy. For 40 years he too checked
his mood twice a day in the Beck Depression Inventory, and
stowed the results in his cellar. The fact was that, though he had a
great job, a loving wife and four beautiful children (one of whom,
Judith, became a cbtclinician and cofounded his Beck Institute),
he still suffered from acute selfcriticism. He cared too much for
approval, and felt bound not to get it. The cure? Even more deter
mined rationality.
By the end of his life, nothing daunted his positive outlook. As
a boy, his distorted thoughts about blood and ether had been cor
rected by the actual fact that he had not died, and could busy him
self with the future. As an old man, with his horizons narrowing,
he had learned to see every mishap not as a loss or as confirmation
of some defect, but as an opportunity. If it started to rain just when
he was going out, great! All the more time to get that next paper
written, and to spread the word still wider. nUp off the couchAaron Beck, the psychiatrist who developed Cognitive
Behavioural Therapy, died on November 1st, aged 100