The father of cognitive behavioural therapy (CBT), the late Dr Aaron Beck, was fond of saying that ‘there is more to the surface than meets the eye’. But what exactly did he mean by this?
Beck liked to illustrate his point by telling the following story, about a client he was treating in the late 1950s.
Back then, there was no cognitive therapy. Instead, psychoanalysis – a form of Freudian therapy that places much emphasis on the unconscious mind and repressed emotions – was in fashion, and Beck was himself trained in this area.
Anyway, Beck’s story concerned a promiscuous woman he was treating. In the sessions, she would detail her many sexual adventures with men. Near the end of one particular session, Beck asked her how she was feeling.
‘Very anxious, Doctor’, she replied.
Beck’s psychoanalytic training indicated to him that her anxiety must be the result of some hidden unconscious conflict. Thus, he suggested she was anxious because she was having to confront her sexual desires, and she expected him to disapprove.
‘Actually,’ she replied, ‘I was afraid I was boring you.’
Surprised, Beck asked her how often she thought she was boring. Almost all the time, she said. She thought she was boring when she was with Beck, and she thought she was boring when with other people. Her inner voice was constantly telling her she was boring and unattractive.
As she went on, Beck belatedly realised these negative thoughts about herself were driving her feelings and behaviours. She slept around because she thought she was had little else to offer. She told dramatic stories of her sexual escapades in session, so that she would seem less boring. And her feeling of anxiety wasn’t down to some complex unconscious belief – it was driven by the ever-present fear that she was boring to people.
‘I then checked with other patients and similarly determined that when they focused on everything that was going through their minds, they had similar thoughts that they had not been very much aware of previously’, wrote Beck in a 2019 journal article describing the origins and evolution of his therapeutic thinking.
Not only that, Beck began to pay more attention towards his own thoughts, particularly when he experienced an emotional reaction. When he experienced feelings of anxiety or anger or loss or exhilaration, he noticed he would have an intervening automatic thought which explained why he was feeling the way he was.
These automatic thoughts, he noted, were often exaggerations or even misinterpretations of a situation. ‘For example, I might misinterpret somebody’s brief response to a question as a slight and become angry. I found that when I looked for the evidence for the thought, it was either very weak or non-existent’.
Usually, we are barely aware of our thoughts. Beck gives the example of multi-tasking while driving, where you carry on a conversation, listen to the radio, and engage in your own private thoughts about something or other while simultaneously changing lanes and increasing your speed.
However, while these thoughts are automatic and often barely noticed, they are not buried deep in our unconscious; they are conscious. And these negative automatic thoughts (NATs), as Beck called them, are important. “I’ll always fail”, “things will never get better”, “she thinks I’m useless”, “no one cares” – these kind of NATs inform our feelings and behaviours. They hurt our moods and negatively shape our attitudes towards ourselves, others, and the future.
Sometimes, people overcomplicate things because of a complexity bias. Complicated solutions and explanations may sound deeper than a more straightforward approach. But as Beck discovered, his client wasn’t anxious because of repressed sexual desires or some deep-rooted unconscious impulse; she was anxious because she bought into her negative automatic thoughts and assumed she was boring.
Instead of taking a deep dive into the past and searching for unconscious drivers of our feelings and behaviours, the message of CBT is to largely focus on the present and look at your thoughts on a daily basis. If you do so, you will see that Beck was right – there really is more to the the surface than meets the eye.
(First published in Southern Star on 3/8/2023)