A New Paradigm
In his early investigations, Beck challenged the validity of the widely accepted psychoanalytic theory and therapy. His development of a novel approach to psychopathology and to treatment constituted a paradigm shift in the field (1). He made careful observations and determined that depressed patients showed a systematic bias in their interpretations and expectations. In a break with the psychoanalytic theory of unconscious conflicts, he developed an innovative cognitive model based on dysfunctional beliefs leading to the cognitive biases (1). He conducted clinical evaluations to test and refine his model. In place of long-term psychoanalytic therapy, he introduced a short-term, active treatment and tested it in a randomized controlled trial. (2)
Beck’s Cognitive Model
Beck developed a comprehensive theoretical model, which could be applied across the broad range of psychological disorders (3). He used this model as a template to generate different mini-models for particular disorders. These models were then utilized to develop specific formulations for individual cases. Beck was able to validate this Generic Model and the derived specific models across many disorders such as depression, anxiety, panic disorder, personality disorders, addictions, and schizophrenia. Other investigators, many of them former students, followed the same theoretical model and research strategy to develop new approaches to a wide variety of other disorders such as obsessive compulsive disorder, post traumatic stress disorder, hypochondrias, and chronic fatigue syndrome.
To validate his theory and therapy, Dr. Beck developed sophisticated instruments that assessed specific psychological and clinical variables. Until the time of Dr. Beck’s work, psychopathology was hampered by a dearth of instruments for operationalizing and identifying the various disorders. His development of the Beck Depression Inventory and the Beck Anxiety Inventory not only facilitated his own research but stimulated a whole generation of depression and anxiety researchers. These measures are the most widely used instruments in clinical practice and investigation in the field. His other widely used influential measures in widespread use include the Suicide Lethality Scale, Defeatist Attitude Scale (schizophrenia), and Cognitive Insight Scale (schizophrenia). As well as Dysfunctional Attitude Scale (depression), Hopelessness Scale (suicide and depression), Personality Belief Questionnaire, Obsessive Compulsive Scale, Beliefs about Using Scale, and the Panic Belief Questionnaire. The availability of these innovative measures has facilitated rigorous basic and applied research, including outcome trials and moderation and mediation analyses.
Beck’s Cognitive Therapy
The essence of Beck’s psychotherapy (also known as Cognitive Behavioral Therapy due to the inclusion of behavioral strategies) is the application of the scientific method to the patients’ dysfunctional or inappropriate interpretations and expectations. Patients learn to question their dysfunctional beliefs and misinterpretations, prompting them to examine the evidence for their conclusions, look for and consider alternative explanations, and analyze the logic that leads to their inferences. He also introduced the strategy of behavioral experiments, which are designed to test the validity of patients’ beliefs. Other strategies directed towards modifying dysfunctional belief systems have been added over time, and Beck has conducted a series of studies to test the efficacy of his therapy.
Beck and his associates broke new ground with the development of distinct approaches to and randomized controlled trials of anxiety, panic (4), addiction (5), suicide attempts, and schizophrenia. His contributions to the understanding and treatment of mental disorders are illustrated by three areas of investigations: Depression, Suicide, and Schizophrenia.
Dr. Beck’s initial work indicated that the symptomatology of depression results from a systematic negative bias in perception and interpretation of experience. Dr. Beck’s novel model of depression also has received substantial support in psychological literature (6). Furthermore, investigations in neuroscience have confirmed his thesis of a negative cognitive bias. Dr. Beck and his colleagues have formulated a comprehensive psychobiological model of depression, integrating genetic and neural findings with the original cognitive model (7,8).
The original randomized controlled trial represented the first successful psychosocial intervention for depression. Cognitive therapy was superior to imipramine both at the end of treatment and after one year follow up (2). This finding was confirmed by other investigators and established that cognitive therapy for depression was at least as effective as pharmacotherapy in the short term and had a lower relapse rate. Dr. Beck’s treatment was based on the volume, Cognitive Therapy for Depression.
Dr. Beck’s studies of suicide provided a rational framework for the classification and assessment of suicidal behaviors for the first time. The classification systems and the instruments he devised have provided the tools for other investigators. Of particular importance, he identified the clinical and psychological variables, most prominently hopelessness, to predict future suicides. Hopelessness was shown to be exquisitely responsive to cognitive therapy, thus reducing suicidal risk (9). He and his group demonstrated that a very brief (10 sessions) cognitive intervention can reduce suicidal reattempts over a sustained time period.
He and his staff have conducted extensive research on the psychological underpinnings and psychosocial treatment of chronic, low functioning patients with schizophrenia. These studies showed that the basis of their tendency to withdraw from the major life spheres is their defeatist attitudes about performance and socialization, the result of a lifetime of failure and rejection experiences (10). This new understanding was formulated into a book for this disorder: Schizophrenia: Cognitive Theory and Therapy (11).
Dr. Beck and his associates then conducted a randomized controlled trial for low functioning patients with chronic schizophrenia. The results showed that the functioning of this group can be improved to a new level. In addition to substantial improvements in social and vocational adjustment, the patients also showed a marked reduction in delusions and hallucinations (12). This finding is especially remarkable in this group of patients is generally considered to be refractory to all psychological and pharmacological interventions.
Broad Applications of cognitive therapy
A survey of 16 meta-analyses of Cognitive Therapy/ Cognitive Behavior Therapy, covering several hundred studies and several thousand patients, found it to be effective for a wide variety of psychological disorders. Effect sizes were determined to be large, on average, for studies of unipolar depression, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, social phobia, childhood depression, schizophrenia, and bulimia. Moderate effect sizes were found for eight other psychological problems, as well as many other disorders. Cognitive therapy also has been shown to be effective in many other conditions for which meta-analyses are not available. Among these are anorexia nervosa, chronic fatigue syndrome, hypochondriasis, gastrointestinal problems, and depression associated with other medical disorders.
Dr. Beck’s Worldwide Influence
Dr. Beck’s work has provided the impetus for the formation of a vast and extensive network of researchers and psychotherapists throughout the world. At least 40 national organizations are devoted to the dissemination of cognitive behavior therapy and findings from research on the intervention have been established. A 1982 survey in the American Psychologist listed Dr. Beck among the leading psychotherapists in the United States. A 2009 survey of practicing psychologists also named him among the most influential (13). An international survey in eight countries, including the United States, showed that cognitive therapy was more widely used by mental health professionals than any other form of psychotherapy (14). The Center for Clinical Excellence of the British Health Service recommends cognitive behavioral therapy as the preferred or optional treatment for depression, and as an option for a wide variety of other disorders. Mental health services throughout the world also recommend Cognitive Therapy/ Cognitive Behavioral Therapy as a preferred treatment.