A Road Paved by Reason

Psychological problems result from the erroneous meanings that people attach to events, not from the events themselves.

This central principle of cognitive therapy, identified by Aaron “Tim” Beck in the early 1960s, has provided no less than a basic structure for understanding human nature, particularly with respect to emotional disorders. Today Beck, 87, is among those considering new applications for cognitive therapy even as he receives recognition for its development and use in mood disorders such as depression.

According to the central principle, depressed patients, for example, interpret their experiences in terms of their sense of failure and helplessness. Patients with anxiety think in terms of threats to their physical well-being or social acceptance. People with obsessions perceive their thoughts as dangerous, disgusting or immoral.

In cognitive therapy, patients learn through a variety of strategies to test their faulty beliefs. They then learn to appraise themselves and their futures in a way that is realistic, unbiased and constructive.

Beginnings

Although cognitive therapy has proved highly successful at improving the lives of people with depression and many other conditions, this success would not have been possible without a detailed understanding of what goes on in these patients’ minds. Indeed, Beck feels that his greatest contribution was to delineate the inner workings of depression. His work with his own patients, plus his persistent questioning of then-available methods, touched off a chain of reasoning by which he worked out the process of depression in the troubled mind. He found that people who are depressed systematically block out the positive aspects of their life, seeing only the negative. They interpret ambiguous events in a negative way, which he describes as cognitive distortion. If something genuinely negative does occur, they tend to exaggerate its magnitude, significance and consequences. A minor error becomes a major catastrophe. A normal problem becomes an insoluble dilemma. The result of such negative thinking is that the individual feels sad and hopeless, withdraws from other people and may become suicidal.

“I was privileged to start my research on depression at a time when the modern era of systematic clinical and biological research was just getting under way,” says Beck. “Consequently, the climate was friendly for such research, and the field for new investigations was wide open.” It was the late 1950s. The National Institute of Mental Health had only recently begun funding research and providing salary support for full-time clinical investigators. A national organization called the Group for Advancement of Psychiatry, under the leadership of professionals who were dissatisfied with the field’s lack of scientific underpinnings, was providing guidelines, as well as the impetus, for clinical research.

Caught up in the spirit of the times, Beck was prompted to start his own line of research. He was particularly intrigued by the paradox of depression. The disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct and the pleasure principle. All of these normal human yearnings were dulled or reversed by depression. Even vital biological functions like eating or sleeping were attenuated.

Beck had a “eureka moment” in the early 1960s while reviewing findings from his clinical research in depression. “In talking to my wife about this, everything seemed to click into place all at once.” The various components of Beck’s research came together: the discovery that negative beliefs shaped his patients’ interpretations and that these negative interpretations (or cognitions) then led to the sad feelings, social withdrawal and, especially, suicidal wishes. When the beliefs and cognitions were modified in therapy, the distorted interpretations and the symptoms of depression diminished. Because the distorted cognitions became the focus of treatment and the process of change depended on cognitive restructuring, Beck applied the label “cognitive therapy” to the treatment.

Tools for Patient and Therapist

Although cognitive therapy usually focuses on problem solving in the present, by doing that task the patients also develop lifelong skills. With the therapist’s help, they learn to identify distorted thinking, modify beliefs, relate to others in different ways and change their behavior. Early in the process the patient sets goals for improving relationships, work, moods and symptoms. Other desired areas of improvement might include pursuing spiritual, intellectual or cultural interests; increasing exercise; decreasing bad habits; or learning new interpersonal or management skills, at work or at home.

In addition to providing strategies to re-pattern negative cognitions, throughout the 1960s Beck developed a number of scales to specifically measure depression, anxiety and suicidality. These are based on the patients’ descriptions of their symptoms, feelings, thoughts, wishes and behaviors. The descriptions are converted into items or questions, and each is given a numerical weight. The total scores are then correlated with the clinician’s evaluations of the severity of the particular illness. These scales have proved to be effective tools in measuring the extent of the patient’s disorder.

Beck’s scale that is used for evaluating suicidal behavior, for example, not only predicts who is most likely to make another attempt at suicide but can offer a means of prevention. Called the Beck Hopelessness Scale, it details the individual’s evaluation of his or her future. In a 20-year prospective study published in 2000, and a 30-year study now in press, Beck found that a high initial score on the hopelessness questionnaire is a reliable predictor of who will commit suicide. The information has been used successfully to intervene in suicide: Working with patients who have previously attempted it, Beck and colleagues have found that cognitive therapy specifically targeting hopelessness can reduce the likelihood of a subsequent attempt by almost half, as well as reducing both hopelessness and depression.¹

As Good as Medication, or Better

In terms of treating depression, Beck says some studies show that cognitive therapy can be just as effective as pharmacotherapy, and superior in preventing relapse. For example, a study in the April 2005 Archives of General Psychiatry found that the benefits of cognitive therapy endure well beyond the end of treatment.¹ Patients first underwent 16 weeks of treatment with either cognitive therapy or antidepressants. Those who responded well to each regimen entered a second, yearlong phase of the study. At the beginning of this phase, patients who had received cognitive therapy stopped their treatment, with only three “booster” sessions throughout the year. Patients who had received medication were randomly assigned to either continue their medication or be switched to a placebo on a double-blind basis.

The results reported in the study: Only 30 percent of patients who concluded cognitive therapy relapsed into depressive symptoms, compared to 76 percent of the patients withdrawn from medication and 47 percent of those continuing with medication.

The authors speculated that the lasting effects of cognitive therapy reflect the patients’ newfound ability to “do the therapy for themselves.” They remarked that the strategies learned “eventually become second nature, coinciding with a parallel change from problematic underlying beliefs to more adaptive ones.” In this way, the patient is less likely to become distressed in situations that previously would have spiraled into a depression-producing pattern of thought.

In 2006 Beck published a meta-analysis of more than 100 studies that found similar success for cognitive therapy when compared with medication.² In a study published online March 5 of this year in the Journal of Clinical Psychiatry, a team of researchers screened more than a thousand studies of cognitive therapy used to treat anxiety disorders. Narrowing the field to 27 randomized, placebo-controlled trials, the authors found that cognitive therapy yielded significantly greater benefits than placebo treatment and may be even more successful when combined with pharmacotherapy.³

Brain Basis for Cognitive Therapy

Several imaging studies of cognitive therapy used to treat phobias, obsessive-compulsive disorder and anxiety show restored balance of brain activity in areas often over- or under-activated in patients with these conditions. A neuroimaging study of depression published in the January 2004 Archives of General Psychiatry found that cognitive therapy and pharmacotherapy bring about similar changes, but through different pathways.⁴

Antidepressants are often described as working from the bottom up. They adjust the exchange of chemical messengers at the synapse, the point of connection between neurons. With balance restored among the various chemicals—typically serotonin, dopamine and norepinephrine—a chain of events begins that ultimately results in the depressed patient’s beginning to feel better. Exactly what goes on in the brain is not well understood, and the process takes some time. Most patients are on medication for at least three weeks before noticing a difference in mood.

Cognitive therapy, on the other hand, works “top down.” Patients learn to monitor, question and redirect their negative interpretations of events—thus bringing much of their emotional state under conscious control. The resulting improvement in mood has ramifications throughout the brain, presumably restoring balance in many specific aspects of the brain’s functioning.

Helen Mayberg and colleagues, then at the University of Toronto, used positron-emission tomography (PET) to study the brain changes brought about by cognitive therapy. In a study published in 2004, fourteen patients were scanned before and after they completed 15 to 20 sessions of therapy. The scans were then compared with published imaging studies of the brain in depression, both with and without antidepressant treatment.⁴

The results suggest that “top down” and “bottom up” are not mere metaphors. Cognitive therapy produced changes in several parts of the prefrontal cortex, the brain’s topmost layer. These areas handle “higher” functions such as working memory, processing of personally relevant information, and “cognitive rumination.” These functions tend to be impaired in people with depression, and imaging studies often show abnormally high activity in these regions. Cognitive therapy decreased the activity in the prefrontal areas, suggesting improved functioning. On the other hand, the therapy caused increased activity in other areas deeper or “lower” in the brain: the anterior cingulate, involved in directed attention and monitoring of emotions, and the hippocampus, a nexus of memory encoding and consolidation.

The authors of the Toronto study postulated that the pattern of brain changes represents the neural counterpart of cognitive therapy. As patients learn to observe their emotional responses to life events, block the automatic resurgence of distressing memories, and reduce their tendency to brood and overanalyze irrelevant information, the relevant parts of the brain return to a balanced level of activity.

Antidepressant treatment affected many of the same areas but in mirror-image ways—decreased activity in the memory- and attention-serving areas such as the hippocampus and cingulate, and increased activity in the frontal regions that help bring thoughts, possibly feelings, under conscious control. The finding supports the idea that the treatment approaches work in complementary ways—cognitive therapy from the top down, and medication from the bottom up—ultimately stabilizing a complex pathway running between the hippocampal and prefrontal areas.

These visible, measurable effects on the brain may provide one of the best answers to the criticisms that are aimed at cognitive therapy. Among those who sound a cautionary note are members of an original “bottom-up” school of thought: psychoanalysis. In the Freudian tradition, emotional disorders result from past traumas carved so deeply into the psyche that the patient is unaware of them; curing the disorder means excavating these conflicts from the unconscious through the lengthy process of psychoanalysis. Cognitive therapy de-emphasizes the importance of circumstances and events, putting the conscious mind firmly in control.

Peter Fonagy, a professor of psychoanalysis and head of the Anna Freud Center in London (a center for treating children and families with psychological problems), does not suggest that cognitive therapy is ineffective. He does, however, argue that psychoanalysis remains a valuable tool for many patients. Citing studies showing that the benefits of cognitive therapy in anxiety disorders fade over time, Fonagy told the British magazine Prospect that cognitive therapy is “marketed as an antibiotic when it’s really an aspirin.”

In the May 2003 American Journal of Psychiatry,⁵ psychiatrist Gordon Parker of the University of New South Wales, Australia, and colleagues reviewed many of the studies showing the superiority of cognitive therapy over other forms of psychotherapy. Again, although the authors did not question the effectiveness of cognitive therapy, they did question the designs of studies that showed it to be universally applicable. Too often, the authors observed, psychotherapies (and medications, too) are tested in a group of patients whose disorder is classified according to its severity—not according to how it manifests in patients, which may be affected by causes ranging from ongoing life difficulties to poor interpersonal skills to biochemical imbalance.

Arguing that cancer treatment modalities, for example, are prescribed according to the nature, not the severity, of the patient’s cancer, Parker and his co-authors contend that different types of treatment, including medication, may be warranted for different types of depression. To accurately assess whether cognitive therapy is superior—and for whom—the authors suggest studies of the patients that do respond well, not just those who improve initially but those who continue without relapsing. Pinpointing the “responders” would draw a clearer picture of the success and limitations of cognitive therapy—providing a targeted approach to treating psychological disorders.

Practitioners of cognitive therapy are open to incorporating tools from other psychotherapeutic approaches, such as psychoanalysis, and treatment with cognitive therapy can and often does include medication. In Beck’s view, brain imaging studies offer the best counter to claims that cognitive therapy doesn’t get at the “real” cause of psychological disorder. “The changes that cognitive therapy produces in key brain regions, and the more enduring effects compared to pharmacotherapy, would not happen if the therapy simply addressed the symptoms. It must be getting at the causes,” says Beck. The brain is known to rewire itself according to experience, in a process known as plasticity. Thus the changes brought about by treatment—observable in imaging studies—can literally reconfigure the old circuitry that would otherwise have continued the depression-producing thought processes indefinitely.

Future Directions for Cognitive Therapy

Beck is not done with considering how cognitive therapy works and how else it could be applied. Its principles are offering hope not just for mood disorders and mental illness but also for a number of conditions not typically considered “psychological.” Beck is conducting a trial of cognitive therapy to ameliorate the “negative” symptoms of schizophrenia, such as apathy and social withdrawal (as opposed to what scientists term “positive” symptoms, such as auditory hallucinations, which are still treated with medication). The therapy has also proved useful in treating medical conditions resulting from the two Gulf Wars, such as post-concussion syndrome and post-traumatic stress disorder.

Beck believes that, in addition to effectively treating the classic psychiatric disorders, cognitive therapy will be increasingly used to treat more “medical” problems such as hypertension, chronic fatigue syndrome and chronic back pain. “A variety of dysfunctional cognitive reactions can lead to medical conditions,” he notes. “For example, an inappropriate level of anger can aggravate hypertension. Excessive attention to physical feelings, and exaggerated interpretation of their significance, can play a role in chronic fatigue syndrome and lower back pain. In general, negative thoughts and distorted interpretations can exacerbate almost any physical symptoms.” Cognitive therapy is increasingly used, often in conjunction with medication, both to relieve the stress that aggravates these disorders and to enhance the patient’s adherence to the more “medical” end of the regime.

Beck is also researching the neurobiological correlates of the cognitive model in depression, with an aim toward pinpointing the changes that cognitive therapy produces in the brain in a variety of disorders. He expects to see further integration of cognitive therapy with other psychotherapeutic approaches that have been proved to be valid. “I doubt that there will be as much fragmentation in the psychotherapeutic field. In all likelihood, there will be one psychotherapy incorporating a variety of approaches, depending upon the patient’s characteristics and the nature of the disorder.”

Beck, who directs the Center for the Treatment and Prevention of Suicide, based at the University of Pennsylvania, and works with city-run mental health organizations throughout Philadelphia, also anticipates greater dissemination of cognitive therapy into the community.

He views with satisfaction the widespread acceptance of cognitive therapy in institutional and community settings. “Various managed-care companies and mental health centers now expect their therapists to be trained in cognitive therapy. The British government has recently set up a large program for training over 6,000 mental health workers to do cognitive therapy. There are now dozens, if not hundreds, of researchers focusing on the theoretical underpinnings of cognitive therapy, or on its applications.”

In the end, Beck returns to the continuing promise of cognitive therapy for fields in which it has already proved so effective. “One of the most promising directions for the present and future is in preventing mental disorders from taking hold,” he concludes. “Several studies have been done, and others are under way, to identify those at risk for depression and suicide. With the tools of cognitive therapy, early intervention can help prevent negative thought patterns from developing into full-blown mental illnesses.”

Sidebar: Interpersonal Therapy

Another form of psychotherapy was inspired by Aaron “Tim” Beck’s early efforts to hold cognitive therapy up to the same rigorous scrutiny as pharmacological interventions. In the 1970s, psychiatric epidemiologist Myrna Weissman and psychiatrist Gerald Klerman, both then at Yale University, developed what came to be known as interpersonal therapy as part of the first large-scale clinical trial using both drugs and psychotherapy to treat depression.

Interpersonal therapy is based on the premise that depression often occurs along with the onset of a major life event involving relationships—such as ongoing difficulties with a spouse, friend, co-worker or family member; the loss of a loved one; or the inability to form close attachments. In interpersonal therapy, the patient and therapist agree at the outset on an appropriate length of time for their work together—anything from a few weeks to more than a year, with a few months being typical. They then address depression specifically as it manifests in the patient’s life situation and relationships. Rather than focusing on thought processes about an event, the therapist will explore what led to the problem—disputes in job or family relationships, for example—and work out strategies to either improve the situation or move on from it. With better coping tools in place, the patient is more likely to respond to future problems in productive ways that don’t lead to depression.

Klerman strongly emphasized the need for psychotherapy to mimic clinical practice. Beck used his own not-yet-published manual, Cognitive Therapy of Depression, widely in his clinical trials. But most patients with depression received various untested therapies lumped together as “supportive therapy.” Klerman advocated describing interpersonal therapy with the same clinical rigor that Beck had used in his manual.

“We felt strongly that we had to test the efficacy of interpersonal therapy before advocating its widespread use,” says Weissman, who is now at Columbia University (Klerman died in 1992). Throughout the 1980s, she and others conducted their own clinical trials. Their manual was published in 1984 and has been revised several times; 2007 saw the publication of the Clinician’s Quick Guide to Interpersonal Psychotherapy, from Oxford University Press.

“Practitioners of interpersonal therapy share a close affiliation with Dr. Beck,” Weissman notes. “Both therapies are time-limited, although the limits can vary from a few months to several years. Both have guidelines strictly set down in manuals, have a strong diagnostic component and are designed to overcome depression.”

Cognitive therapy and interpersonal therapy remain the most widely used therapies for depression, Weissman says—and not only in affluent, industrialized countries. “We got a call one day from Paul Bolton at Johns Hopkins University, saying that World Vision International [a nongovernmental humanitarian organization] was interested in treating depression in Uganda. Dr. Bolton wanted to use interpersonal therapy,” says Weissman. “It was the most interesting request I’d had in a long time.”

Trials of interpersonal therapy in Uganda, a country ravaged by war, poverty and AIDS, have shown the approach to be remarkably effective, especially among women. Specifically, Uganda has had notable success in reducing the incidence of AIDS. Health workers there feel that combating depression is an important aspect of this success, since depressed people often engage in risky behavior. With the intensive involvement of local health workers, Bolton and Weissman, along with Helen Verdeli and Kathleen Clougherty of Columbia, tailored interpersonal therapy to a uniquely African setting—taking into account many differences in communication styles. For example: “When a woman in Uganda is angry at her husband, she doesn’t chew him out. She cooks him bad food,” says Weissman.

In an initial small clinical trial in Uganda, published in 2003 in the Journal of the American Medical Association, interpersonal therapy proved highly effective in reducing depression: after therapy only 6 percent of the treated group met the criteria for major depression, compared with more than half of the untreated control group.¹

A 2007 study found similar results with another high-risk Ugandan group—teenagers displaced by war to refugee camps.² Again, the difference was more striking among women. The reason is unclear, but Weissman suspects that alcoholism, much more prevalent in men, may play a role. She adds that interpersonal therapy and cognitive therapy are used all over the world, with texts translated into numerous languages. An international society of interpersonal therapy will be meeting in New York in March 2009.

Sidebar References:

1. P. Bolton, J. Bass, R. Neugebauer, H. Verdeli, K. F. Clougherty, P. Wickramaratne, L. Speelman, L. Ndgoni and M. Weissman. 2003. Group interpersonal psychotherapy for depression in rural Uganda. JAMA 289:3117–3124.
2. P. Bolton, J. Bass, T. Betancourt, L. Speelman, G. Onyango, K. Clougherty, R. Neugebauer, L. Murray, and H. Verdeli. 2007. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: A randomized controlled trial. JAMA 298:519–527.