From the Editor
The fourth child of Russian Jewish immigrants. A Yale medicine graduate. A snappy dresser who loved bow ties.
Dr. Aaron Beck, who died last week at the age of 100, was also a psychiatrist who significantly changed the way we treat patients and learn to treat them. Today, millions have broken the shackles of mood and anxiety problems by using cognitive behavioural therapy; residents of psychiatry learn about the Beck’s Cognitive Triad as a core part of their training.
Dr. Aaron Beck
I asked Dr. Ari Zaretsky, the Psychiatrist-in-Chief and Vice President Education of the Sunnybrook Health Sciences Centre, to write about him – his work and legacy. In his essay, Dr. Zaretsky notes: “His life story is that of a former psychoanalyst who rejected the dogmatism of mainstream Freudian psychoanalysis during the 1950s and 1960s and in doing so permanently changed the paradigm and transformed psychotherapy.”
For those who wish to read more about Dr. Beck, I’ve included links, including to The New York Times obituary.
DG
The Life and Legacy of Dr. Aaron Beck
Ari Zaretsky
It is not unusual for leaders of psychotherapy to be prone to hagiography. The recent death on November 1, 2021 of Aaron Temkin Beck, or Tim as he was known to his family and colleagues, will only amplify that hagiography because for many mental health practitioners like myself, Dr. Beck was our personal hero: a unique individual who profoundly altered our professional lives and provided hope and healing to countless people suffering from mental illness.
His life story is that of a former psychoanalyst who rejected the dogmatism of mainstream Freudian psychoanalysis during the 1950s and 1960s and in doing so permanently changed the paradigm and transformed psychotherapy. Although tensions still exist between psychotherapists who emphasize common factors and the therapeutic relationship and psychotherapists who emphasize their own distinctive strategies and techniques, all contemporary psychotherapies today – short-term psychodynamic psychotherapy, interpersonal psychotherapy, dialectical behaviour therapy, motivational interviewing – are deeply indebted to Beck’s rigorous scientific approach of testing and refining psychotherapy and evaluating its actual impact on symptoms and functioning.
Beck saved psychotherapy from itself, and also saved the field of psychiatry, with its increasing focus on the brain, from itself. Beck’s therapy was still a depth psychology and it prevented psychiatry from going too far and becoming “mindless” and reductionistic. Beck was named by the American Psychologist in 1989 as one of the five most influential psychotherapists of all time and was awarded the Albert Lasker Award (the “American Nobel Prize” so called because half of recipients go on to actually win the Nobel Prize) in 2006 in recognition of his work in shaping modern psychotherapy.
Beck’s life story is a story of emotional and physical resilience, tenacity and faith in the rational mind that goes all the way back to his childhood years. He was born in 1921 and grew up in a middle-class neighbourhood of Providence, Rhode Island, the third son of Russian Jewish immigrants. His father was a printer with strong socialist beliefs and his overprotective mother, a seamstress, was a woman prone to moodiness, who forcefully managed the home.
A month-long hospitalization at age 8 for a staph. septicemia after breaking an arm became an early defining event, forcing the active sport-oriented Beck to become more reflective and studious and leading to a phobia of blood and injury that young Beck conquered through an informal process of cognitive restructuring and “graded exposure”.
After completing an English degree in 1942 from Brown University, Beck studied medicine at Yale graduating in 1946. Like Freud, Beck originally chose to specialize in neurology but changed to psychiatry and like many of his peers, trained in psychoanalysis. After military service and residency at the Cushing Veterans Administration Hospital in Framingham, Massachusetts, and a fellowship at Austen Riggs, Beck joined the Department of Psychiatry at the University of Pennsylvania in 1954, where he saw patients in psychoanalytic psychotherapy and also conducted research. He graduated from the Philadelphia Psychoanalytic Institute in 1958.
Beck’s cognitive model of depression grew out of frustration with the psychoanalytic model of psychopathology and the passive stance of the traditional psychoanalytic psychotherapist in the 1950s. Beck had conducted research and had systematically examined the dreams of depressed patients hoping to validate Freud’s model of introjected rage. If dreams were really the “royal road to the unconscious”, Beck hypothesized that the dreams of depressed patients should focus on aggressive, angry or violent themes revealing repressed anger. Instead, Beck found that the content of dreams of depressed patients were no different than their thoughts when awake. The dreams primarily focused on defeat, deprivation and loss.
Other related research by Beck in 1962, involving a rigged card-sorting test with depressed individuals disconfirmed the Freudian concept of “depressive realism” and found that depressed people who actually succeeded on the initial test actually experienced a rise in self-esteem and better performance than non-depressed subjects. Beck also learned through clinical experience that by focusing more directly on patient’s automatic thoughts rather than trying to discover emergent themes passively through free-association, he could more rapidly and effectively treat depression and anxiety. By 1959, Beck’s office no longer had a psychoanalytic couch.
Although many view Beck as the inventor of cognitive behaviour therapy (CBT), this is not accurate. The basic concepts inherent in CBT actually go back all the way to the Greek Stoic philosophers and there are related concepts found in Buddhism. Beck himself acknowledges the intellectual influence of the German psychoanalyst Karen Horney and the American psychologist George Kelly whose concept of “personal scientist” resonated powerfully with Beck, who was developing and refining his style of Socratic questioning even during the time he was a psychoanalyst. In addition, Beck acknowledges his debt to Albert Ellis whose Rational Emotive Therapy with its emphasis on cognitive reframing, actually preceded Beck’s own Cognitive Therapy school of CBT by over a decade.
In the 1960s, Beck was actively conducting research and developing his theories about psychopathology and treatment for depression. Beck can be considered one of the earliest adopters of measurement-based care in clinical practice. In 1961, he developed the Beck Depression Inventory, a self-report scale of key symptoms of depression has been used almost universally for six decades to measure the severity of depression. In the 1970s, Beck evaluated CBT’s efficacy compared to antidepressant pharmacotherapy for depression and found that it had a similar capacity to reduce symptoms of depression.
At this time, Beck was a pariah, rejected by the psychoanalytic community for offering a “superficial and simplistic treatment” and rejected also by many biological psychiatrists who initially disputed his research on CBT’s comparative efficacy. Over time, however, Beck’s CBT became the darling of evidence-based medicine and a gold standard in the treatment of major depression, suicidal ideation, panic disorder, generalized anxiety disorder, social anxiety disorder and bulimia nervosa. One of the pivotal studies published in the mid-1980s, the NIMH Treatment of Depression Collaborative Research Program, compared imipramine, CBT and IPT and despite some of the methodological shortcomings in the design and execution, essentially found all treatments to be equally effective. These finding were validated many times but most famously in the more recent STAR-D study published approximately two decades later, which found that switching to CBT after failure to respond to citalopram, yielded the same reduction in depression as adding or switching to a different antidepressant medication like buproprion or venlafaxine. In addition to these “acute phase” studies, CBT also demonstrated powerful relapse prevention properties for most psychiatric diagnoses and achieved this in less sessions than many other forms of psychotherapy.
Although subsequent rigorous psychotherapy research demonstrated that CBT did not have a monopoly on the psychological treatment for depression, it became one of the most popular treatments in psychotherapy because the cognitive model was more simple to understand by patients and therapists alike, the treatment was pragmatic and it could be more easily manualized so that training could be scaled up for a population. The Improving Access to Psychological Therapies (IAPT) initiative in the United Kingdom is a powerful example on how CBT can be deployed to improve the mental health of a large population.
In the 1994, Beck with his daughter Judith Beck, set up the not-for-profit Beck Institute for Cognitive Behaviour Therapy in Philadelphia. Over the last thirty years, tens of thousands of therapists have been trained in more than 100 countries in the world by the Beck Institute. CBT itself has changed. It has been adapted to be more relevant to other cultures and has become more trauma and socio-culturally informed. In addition, over time CBT has become less “rational”. Through influences from mindfulness, which emphasizes de-centring and tolerating and accepting negative thoughts and emotions, as well as many other schools of psychotherapy such as positive psychology, which emphasizes building on strengths, CBT has continued to evolve.
Over the course of his 70-year career, Beck wrote or co-wrote 600 peer-reviewed papers and 25 books. He developed tools to measure symptoms of depression, anxiety and suicide that are invaluable to clinicians and researchers today. Working well into his 90’s, Beck returned back to the diagnosis that he had focused on earlier in his career on when he was initially developing CBT: schizophrenia. His “recovery-oriented cognitive therapy” for severe mental illness is now, like all of his CBT treatments, is being empirically tested.
My own interactions with Dr. Aaron Beck were limited. During my residency and fellowship, I had the great fortune of being trained by Dr. Brian Shaw, the third author on the famous 1979 cognitive therapy manual that essentially launched CBT into the limelight: Cognitive Therapy for Depression. Through my relationship with Dr. Brian Shaw and Dr. Zindel Segal, my CBT teachers and supervisors, I had the opportunity to organize Psychotherapy Day for the U of T Department of Psychiatry in 1997 and invited Dr. Aaron Beck. I recall the delight of the audience watching Dr. Beck role-play with a standardized patient with depression who was instructed by me “not to be easy”. Later at lunch, I recall the Dr. Beck as many others do, as a warm, grandfatherly type, wearing his signature red bow-tie. I challenged him on how the CBT model could adequately explain irrational human phenomena such as sadism and masochism. I don’t recall the details of his answer, but I do recall his lack of dogmatism, his warmth and his genuine interest in my research on CBT for bipolar disorder.
Twenty years later, in 2017, I met Tim for lunch at a deli in Balla Cynwyd, near the Beck Institute. Together with his daughter Dr. Judy Beck, and now in a wheelchair, Tim glossed over his medical problems and personal health when I inquired. We spoke about how CBT had changed over time and about the enormous promise and power of computerised CBT and virtual CBT. Beck expressed particular excitement about the new model of CBT (recovery-oriented CBT) that his colleagues at the Beck Institute were developing for people neglected by American society-people suffering from severe mental illness and addiction problems.
Drs. Beck and Zaretsky
Despite his physical frailty, Dr. Aaron Beck remained active until the last few years of his life. Dr. Beck will be missed by psychiatrists, psychologists and mental health practitioners across the world who have been profoundly influenced by his impact on the field of psychotherapy.
Dr. Ari Zaretsky
November 2021
Bibliography
- Beck AT: Thinking and depression. Arch Gen Psychiatry 1963; 9:324–333
- Beck AT: Thinking and depression, II: theory and therapy. Arch Gen Psychiatry 1964; 10:561–571
- Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979
- Beck AT, Freeman A, et al: Cognitive Therapy of Personality Disorders. New York, Guilford, 1990
- DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD: Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am J Psychiatry 1999; 156:1007–1013
- Keller MB, McCullough JP, Klein DN, Arnow B, Dunner DL, Gelenberg AJ, Markowitz JC, Nemeroff CB, Russell JM, Thase ME, Trivedi MH, Zajecka J: A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342:1462–1470
- Butler AC, Beck JS: Cognitive therapy outcomes: a review of meta-analyses. J Norwegian Psychol Assoc 2000; 37:1–9
- Rector NA, Beck AT: Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis 2001; 189:278–287
- Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, Parr-Davis G, Sham P: A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry 2003; 60:145–152
- Turkington D, Dudley R, Warman D, Beck AT: Cognitive-behavior therapy for schizophrenia: a review. J Psychiatric Pract 2004; 10:5–16
- Beck AT: The current state of cognitive therapy: a 40-year retrospective. Arch Gen Psychiatry 2005; 62:953–959
- Beck AT: The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 2008; 165 (8): 969-977
For more on Dr. Beck:
The New York Times obituary:
https://www.nytimes.com/2021/11/01/health/dr-aaron-t-beck-dead.html
Statement by Dr. Judith Beck:
https://beckinstitute.org/draaronbeck/
Linda Kelcey writes about how CBT changed her life:
https://www.dailymail.co.uk/femail/article-10175117/Debt-owe-man-brought-millions-brink.html
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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