The Third Wave of Therapy

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The most prolific cognitive therapist has long been Beck, the University of Pennsylvania psychiatrist who first formulated the role of thoughts in depression in articles in 1963 and 1964. The recipient of virtually all his field's awards, Beck and his 51-year-old daughter Judith Beck, herself an esteemed psychologist, run the Beck Institute for Cognitive Therapy and Research from a corporate building near Philadelphia. Decorated with handmade Amish quilts, the nonprofit feels more like a rural dentist's office than the headquarters of an international psychology movement. But the institute carefully guards the reputation of cognitive therapy. Because of the organization's influence, it can be difficult for cognitive therapists to get referrals without certification from the institute's in-house academy, which involves a $400 application.

Like ACT, cognitive therapy shares a personality with its co-founder. Beck's biographer, Brown psychologist Marjorie Weishaar, writes that in his younger years, Beck had public-speaking anxiety and a phobia about tunnels. He solved both problems by correcting misimpressions he had developed: "One day, approaching the Holland Tunnel, he realized that he was interpreting the tightness in his chest as a sign he was suffocating," Weishaar writes. He wasn't, of course, and when he "worked that through cognitively," the phobia vanished. Similarly, his stage fright eased "with continued practice and challenging his automatic thoughts."

When I first saw Beck at the therapy convention in November, I mistook him for a diffident patrician, an image he seemed to project with his neatly trimmed white hair, bow tie, tweed jacket, gray socks and grandfatherly laugh. In fact, Beck—the son of a Ukrainian socialist father and a "rather dominant" Russian mother, according to Weishaar—is a tireless defender of his therapy. He spoke to me with bemusement about the new wave of therapies. "I don't think you call something a revolution until it's actually happened," he said, chuckling. "You get new, popular approaches that come in, and then they often die out, and they don't have the empirical validation." He compared the new therapies to "touchy-feely type things" in the '60s and '70s. (Hayes critics have compared his workshops to the faddish, cultish est seminars of the '70s, which drew hundreds to hotel ballrooms to get rewired by a former used-car salesman named John Rosenberg, who called himself Werner Erhard.)

Beck did say mindfulness therapies are "worth a try," and he noted that he has always said acceptance of difficult thoughts can have a role early in therapy. But in the weeks after the convention, the debate between Beck's followers and Hayes' turned acrimonious. Having just returned from the conference, Robert Leahy, president-elect of the Academy of Cognitive Therapy (current president: Judith Beck), posted a message on the academy's listserv saying Hayes' language theory "sounds less like a 'science' than a frame of reference for a new religion ... Haven't we all been down that dark pathway before?" Another cognitive therapist, Bradford Richards, responded, "It reminds me a lot of a pseudoscientific cult of personal will."

For his part, Beck co-authored a paper in the most recent Clinical Psychology Review noting that cognitive therapy "is one of the most extensively researched forms of psychotherapy." The paper summarizes the results of 16 studies of a collective 9,995 subjects and finds a large effect for cognitive therapy in the treatment of unipolar depression, generalized anxiety disorder, post-traumatic stress disorder, social phobia and panic disorder—Hayes' condition. Cognitive therapy was also shown to be somewhat superior to antidepressants. After sending me the paper, Beck e-mailed derisively, "The last time there was a claim for a New Wave ... was the proclamation of 'transpersonal psychology,' which purported to demonstrate some mystical forces between individuals, including, I believe, transmigration of the soul."

But even some cognitive therapists admit that despite 40 years of research, some fundamental questions about the therapy haven't been resolved. That's partly because cognitive therapy involves a variety of techniques. In addition to questioning negative thoughts in the therapy office, cognitive therapists use behavioral homework assignments—for instance, phobic patients may be asked to expose themselves to fears (like Beck going through the tunnel). Depressed clients are asked to schedule regular activities. But if cognitive therapy is all those things, critics say, maybe getting better is a matter of merely changing old behaviors, not questioning negative beliefs.

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