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Challenging Freud, starting a revolution

Yale Medicine Magazine, 2004 - Summer


A residency requirement became a passion for one doctor and changed the field of psychiatry.

As a neurology resident at the Cushing VA Hospital in Framingham, Mass., Aaron T. Beck, M.D. ’46, was required to do a rotation in psychiatry. But what began as an academic obligation soon became a career-altering opportunity, as Beck saw the value of using psychological tools to help some patients.

“I got stuck in psychiatry and never got out of it,” Beck says today, five decades later. “In neurology there wasn’t much you could do in terms of treatment in those days. What fascinated me about psychiatry was that people with neuroses could actually be treated and made better.”

Beck went on to become one of the most influential figures in American psychiatry. As a young doctor in the 1960s, he challenged the theories of Sigmund Freud and triggered a revolution in psychology, founding a treatment method known as cognitive therapy. He recently received the 2004 University of Louisville Grawemeyer Award for Psychology, which includes a $200,000 prize, for his groundbreaking contribution to the field of psychology.

“He is the latest of the great system creators in psychotherapy,” says Bruce J. Rounsaville, M.D., FW ’78, professor of psychiatry at the School of Medicine. “In the same tradition as Sigmund Freud and Carl Rogers, he made a major difference in the way people approach psychotherapy.”

Early in his career Beck adhered to the teachings of Freud, specifically the value of psychoanalysis. But when he began noticing that his patients weren’t getting any better, he developed an alternative treatment that focused on the patient’s immediate feelings and perceptions rather than unearthing repressed fears and conflicts, as is central to Freudian psychoanalysis. “Since patients are aware of their conscious thoughts, it’s not as difficult [as traditional psychotherapy, which requires the exhumation of buried memories] to correct misperceptions,” he says during a phone interview from his office in Philadelphia.

Cognitive therapy is based on a specific understanding of how the human mind works, Beck says. “People with certain types of neurotic disorders distort the way they view themselves. They see through a negative lens, so all experiences are twisted around to something negative. Cognitive therapy offers strategies to identify that negative distorted thinking and to help the patient correct it.” Unlike adherents of Freudian psychotherapy, Beck doesn’t believe one has to trace the origin of an emotional problem in order to treat it. “It’s not necessary to go back to early trauma,” he says. “What’s important is addressing the problem that has arrived.”

Cognitive therapy has been used to treat a range of patients, from depressed housewives to schizophrenics. Most recently, Beck has applied his theories to analyzing the minds of terrorists. In his 1999 book, Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence (HarperCollins), Beck concludes that the terrorist mind-set is “just as distorted as those of neurotic patients.” He describes how terrorists make sweeping generalizations about their enemies. This, in turn, makes it easier to demonize them, so that the use of terror becomes equated, in the terrorist’s mind, with survival. Beck’s theories have been used by the National Center for Conciliation in Northern Ireland to help defuse tensions there.

Experts in the field of psychology at Yale agree that one of Beck’s most significant contributions is that he identified treatment components that could be tested empirically, and then he conducted the tests.

“Everyone has a therapy they think works,” says Alan E. Kazdin, Ph.D., the John M. Musser Professor of Psychology and director of the Child Study Center. “But Dr. Beck took it to the next step. He developed a therapeutic model, a therapeutic technique and then he did the research.”

Beck, who developed treatment techniques for depression, wanted to test the commonly held belief that there is a correlation between depression and suicide. Through controlled studies, which have been replicated, he was able to show that it’s not depression per se, but rather feelings of hopelessness (which may or may not be associated with depression) that are predictive of suicide.

“Dr. Beck was not only able to show the efficacy of cognitive behavioral therapy for depression, but along the way, he developed tools like the Beck Depression Inventory that have become staples of clinical research,” says John H. Krystal, M.D. ’84, the Robert L. McNeil Jr. Professor of Clinical Pharmacology and deputy chair for research for the Department of Psychiatry. He added that Beck’s work, while primarily directed toward psychotherapy research, has stimulated research on the common neurological mechanisms underlying psychotherapy and pharmacotherapy. “Many psychiatrists like myself found the emergence of cognitive behavioral therapy to be a factor that stimulated interest in the mechanisms underlying the interactions of pharmacologic and psychosocial treatments. Studying these complex interactions has become a major research focus.”

Kazdin says the treatment methods used for some aggressive and violent children at the Child Conduct Clinic, a specialty clinic affiliated with the Child Study Center, are “within the general rubric” of the techniques pioneered by Beck. “His techniques have been used primarily for adults diagnosed with depression and later, anxiety,” Kazdin says, “but there are variants of it that can be effective when used for children.”

“He’s grounded in the research tradition,” says Rounsaville. “He’s committed to seeing it through, to making sure his therapies meet the standards for efficacy.” Rounsaville, who is the director of the substance abuse treatment unit at Yale’s psychiatry department, said a new manual prepared by the unit draws on cognitive behavioral therapy techniques to help cocaine addicts. “This derives directly from Dr. Beck’s work,” he says.

Beck, 83, University Professor Emeritus of Psychiatry at the University of Pennsylvania School of Medicine and a member of the Institute of Medicine and the National Academy of Sciences, was awarded the Rhoda and Bernard Sarnat International Prize in Mental Health last year. He still has an active research unit at Penn, studying the effectiveness of treating schizophrenic patients with a combination of medication and cognitive therapy. He has written or co-written 17 books on cognitive therapy, depression and other emotional disorders.

Beck said Yale’s philosophy of encouraging students to be curious and critical taught him to play with ideas and not just memorize facts. “It was the best possible system for my own personal development,” he says. “I learned to have an open mind and treasure learning for its own sake.”

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