How Psychotherapy Can Be Placed On A Scientific Basis: 5 Easy Lessons
How did psychoanalysis, once a major mode for treating non-psychotic mental disorders fall so badly in the estimation of the medical community in the United States and in the estimation of the public at large. How could it be reversed? Let me try to address this question putting it in a bit of historical perspective.
While an undergraduate at Harvard College I was drawn to Psychiatry—and specifically to Psychoanalysis. During my training from 1960-1965, psychotherapy was the major mode of treating mental illness and this therapy was derived from psychoanalysis and was based on the belief that one needed to understand mental symptoms in terms of their historical roots in childhood. These therapies tended to take years and neither the outcome nor the mechanisms were studied systematically because this was thought to be very difficult. Psychotherapy and in the limit psychoanalysis when successful allowed people to work a bit better and to love a bit and these were dimensions that were thought to be difficult to measure.
In the 1960s Aaron Beck changed all that by introducing five major obvious, but nevertheless elegant and beautiful innovations:
First, he introduced instruments for measuring mental illness. Up until the time of Beck's work, psychiatric research was hampered by a dearth of techniques for operationalizing the various disorders and measuring their severity. Beck developed a number of instruments, beginning with a Depression Inventory, a Hopelessness Scale, and a Suicide Intent Scale. These scales helped to objectify research in psychopathology and facilitated the establishment of better clinical outcome trials.
Second, Beck introduced a new short-term, evidence-based therapy he called Cognitive Behavioral Therapy.
Third, Beck manualized the treatments. He wrote a cookbook so method could be reliably taught to others. You and I could in principle learn to do Cognitive Behavioral Therapy.
Fourth, he carried out with the help of several colleagues, progressively better controlled studies which documented that Cognitive Behavioral Therapy worked more effectively than placebo and as effectively as antidepressants in mild and moderate depression. In severe depression it did not act as effectively as an anti-depressant but acted synergistically with them to enhance recovery.
Fifth and finally, Beck's work was picked up by Helen Mayberg, another one of my heroes in psychiatry. She carried out FMRI studies of depressed patients and discovered that Brodmann area 25 was a focus of abnormal activity in depression. She went on to find that if—and only if—a patient responded to cognitive behavior therapy or to antidepressants SSRI's (selective serotonin reuptake inhibitors) this abnormality reverted to normal.
What I find so interesting in this recital is the Edge question: What elegant, deep explanation did Aaron Beck bring to his work that differentiated him from the rest of my generation of psychotherapists and allowed him to be so original?
Aaron Beck trained as a psychoanalyst in Philadelphia, but soon became impressed with the radical idea that the central issue in many psychiatric disorders is not unconscious conflict but distorted patterns of thinking. Beck conceived of this novel idea from listening with a critical—and open—mind to his patients with depression. In his early work on depression Aaron set out to test a specific psychoanalytic idea: that depression was due to "introjected anger." Patients with depression, it was argued, experienced deep hostility and anger toward someone they loved. They could not deal with having hostile feelings toward someone they valued and so they would repress their anger and direct it inward toward themselves. Beck tested this idea by comparing the dreams—the royal road to the unconscious—of depressed patients with those of non-depressed patients and found that in their dreams depressed patients showed—if anything—less hostility than non-depressed patients. Instead Beck found that in their dreams as in their waking lives depressed patients have a systematic negative bias in their cognitive style, in the way they thought about themselves and their future. They saw themselves as "losers."
Aaron saw these distorted patterns of thinking not simply as a symptom—a reflection of a conflict lying deep within the psyche—but as a key etiological agent in maintaining the disorders.
This led Beck to develop a systematic psychological treatment for depression that focused on distorted thinking. He found that by increasing the patients' objectivity regarding their misinterpretation of situations or their cognitive distortions and their negative expectancies, the patients experienced substantial shifts in their thinking and subsequently improvements in their affect and behavior.
In the course of his work on depression Beck focused on suicide and provided for the first time a rational basis for the classification and assessment of suicidal behaviors that made it possible to identify high-risk individuals. His prospective study of 9,000 patients led to the formulation of an algorithm for predicting future suicide that has proven to have high predictive power. Of particular importance was his identification of clinical and psychological variables such as hopelessness and helplessness to predict future suicides. These proved to be better predictors of suicide than clinical depression per se. Beck's work on suicide, and that of others such as John Mann at Columbia, demonstrated that a short-term cognitive intervention can significantly reduce subsequent suicide attempts when compared to a control group.
In the 1970s, Beck carried out the randomized controlled trials I referred to earlier. Later, the NIMH did similar trials and together these established cognitive therapy as the first ever-psychological treatment that could objectively be shown to be effective in clinical depression.
As soon as cognitive therapy had been found to be effective in the treatment of depression, Beck turned to other disorders. In a number of controlled clinical trials he demonstrated that cognitive therapy is effective in panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. In fact even earlier than Helen Mayberg's work on depression—Lewis Baxter at UCLA had imaged patients with obsessive-compulsive disorder and found they had an abnormality in the caudate nucleus that was reversed when patients improved with cognitive behavioral therapy.
Aaron Beck has recently turned his attention to patients with schizophrenia—and has found that cognitive therapy helps improve their cognitive and negative symptoms, particularly their motivational deficits. Another amazing advance.
So—the answer to the decline of psychoanalysis may not simply lie in the limitation of Freud's thought—but perhaps much more so in the lack of a deep, critical scientific attitude of many of the subsequent generation of therapists. I have little doubt that insight therapy is extremely useful as a therapy. And there are studies that support that contention. But an elegant, deep and beautiful proof requires putting a set of highly validated approaches together to make the point in a convincing manner and perhaps even an idea of how the therapeutic result is achieved.