Had Tony Soprano been under his care, Aaron Beck says he could have cured his panic attacks in two sessions. Instead, Dr. Melfi kept the Sopranos mob boss on the couch for years with traditional psychoanalysis, delving into his childhood and deconstructing his dreams.
Beck, the University of Pennsylvania psychiatrist who founded the burgeoning field of cognitive therapy, says he and Tony together would have set up short-term goals, then strategized behavior changes to attain them.As for Dr. Melfi, "she was just following the old road - it's all due to his mother - rather than getting from him what he feels and thinks."
Old roads don't interest Beck. His development of cognitive therapy in the early 1960s revolutionized psychiatry and triggered serious anger issues in classical Freudians.
Psychiatrist John Rush, a leading authority on depression, calls Beck the most important figure in the history of the field, ahead of even Freud.Rush says that Freud made a monumental contribution, unquestionably, but that Beck's therapy treats a broader range of mental illnesses and has been proved in clinical trials to be more effective.
"His work changed the paradigm - how we do things, how we think about things," says Rush, 65, a professor at the University of Texas Southwestern Medical School and a former resident under Beck.
"Somebody like him comes along every 50, 100 years. We're talking about a rare bird."
In the early days, psychoanalysts considered cognitive therapy so heretical that some would leave the room when Beck presented papers at professional conferences.Academic journals rejected much of his work, so he started his own periodical, Cognitive Therapy and Research. (He has 520 published papers to his credit.) When grants fell through, he wrote books. Eighteen at last count.
It's not difficult to understand why cognitive therapy flipped out Freudians, who focus on unconscious motivations, sometimes for decades. "The patient talks or free associates forever. The therapist listens and interprets," Alford says. "If the patient rejects the therapist's interpretation, he's labeled 'in denial.'"
Cognitive therapy works on conscious thoughts, restructuring them to spur behavior changes. The process generally takes six to 12 sessions.For example: A depressed patient says "it's too hard" to get out of bed, and, besides, he knows his day will be awful. Using cognitive therapy, a therapist would help him "reframe" his negative thinking and suggest practical solutions.For starters, he could move the alarm clock so he has to get up to turn it off. He could set fewer, more attainable daily goals.With such techniques, cognitive therapy can reverse serious mental illnesses including major depression, panic disorder and substance abuse, allowing the patient to feel and function better.
Ironically, cognitive therapy grew out of Beck's early attempts to prove, by analyzing patients' dreams, Freud's theory of depression as repressed anger. Instead of anger, he found "a sense of defeat, failure or loss," says Marjorie Weishaar, 58, a Brown University psychiatrist who studied under Beck at Penn and wrote his biography.
The discovery "gave him the idea of parallel lines. We report one thing when something else is also going on. He began to demystify therapy. Teaching people to be their own therapists gave them access to deeper thoughts and feelings."
In 1949, as a first-year neurology resident at a veterans hospital outside Boston, he had to do a six-month rotation in psychiatry. There weren't enough therapists to handle the influx of GIs returning from World War II.
What he saw in the wards appalled him."There were patients who were recently lobotomized. They looked like a bunch of zombies," he recalls. "There were people receiving shock treatments. They were either convulsing or in a coma. I thought I was in the Middle Ages."
He began treating veterans on an outpatient basis. It was frustrating, particularly for a scientist who considered psychology "a little fluffy.""I could work with them, but I had absolutely no structure," he says. The traditional method was "to just sit back and listen to the patient go on and on and unravel like a ball of yarn."
Still, Beck was so intrigued by the challenge, he decided to pursue psychiatry.
One day, at the end of a session with an attractive, middle-aged woman who "regaled him" regularly with tales of her sexual adventures, he asked her how she was feeling. She said she felt anxious. He assumed it was because she was afraid of his judgment about her sexuality. No, she said, she was afraid she was boring him. She had the same feeling all the time, with everyone, she said.
It was a key moment for Beck. Suddenly, he realized that, along with more directed thoughts, people have an almost continuous, parallel stream of "automatic thoughts." More closely connected to emotions, they can be distorted and negative.
Over time, Beck's theories began to bear fruit. He conducted clinical trials, slowly convincing skeptics of cognitive therapy's success in treating numerous disorders.Today, cognitive therapy is the most-practiced and fastest-growing form of psychotherapy in the world. In this country, it is required training for psychiatric residents.