Abstract
More than 20 years has elapsed since the publication of the key theoretical and clinical text in which Aaron Beck and colleagues set out the rationale and procedures for cognitive therapy of depression [1]. Over the course of these decades, cognitive therapy has assumed such a dominant position, that it is now:
1. almost synonymous with the profession of clinical psychology
2. a serious threat to psychodynamic therapy as the prevailing psychotherapeutic paradigm in psychiatry
3. increasingly finding its way into the training and further education programs of a wide range of health professionals, including nursing, occupational therapy and general practice.
It is therefore timely to reconsider one of the founding works in the cognitive therapy of depression and to track the circumstances that marked the rise of this model as well as to consider its future.
The rise and rise of cognitive therapy
The rise to pre-eminence of cognitive therapy was not achieved without a struggle. In its early phases it had to contend with two groups of critics. Behaviourists viewed its focus on intangible and immeasurable cognitive processes rather than behaviour with suspicion. From the perspective of a radical behaviourist, cognitive therapy was as intellectually bankrupt as psychoanalysis in its preoccupation with thoughts instead of action. However, cognitive therapy found no support from traditional psychodynamic, getstalt and client-centered therapists who viewed it as arid, simplistic and tied to a dehumanizing behaviourist tradition.
How then do we account for the rise and rise of cognitive therapy through the seventies, eighties and nineties? The causes are undoubtedly highly complex but a number of factors are worthy of consideration:
The implosion of psychoanalysis
Psychoanalysis achieved a dominance in American psychiatry that was unparalleled elsewhere in the world and was completely disproportionate to its therapeutic capacities. This dominance was maintained in part through its identification with psychiatry (and the exclusion of nonmedical practitioners) and in part through the operation of an archaic training system that required uncritical submission to the masters [2]. It also flourished in an optimistic culture that was ready to believe that science and medicine could eliminate human unhappiness.
These features ensured that psychoanalysis played a major part in the training and practice of any psychiatrist with an interest in psychotherapy but also made for extreme vulnerability – not so much to reform as to revolution. It is no accident that the two most eminent and successful proselytizers for cognitive therapy were Ellis and Beck rather than psychologists, who had been sniping from the sidelines for some time. Ellis and Beck were not only psychiatrists but had been trained as psychoanalysts and became in effect, dissidents working in exile with psychologists and other professionals.
The psychiatric establishment in the USA was not seriously shaken by the cognitive revolution until the results of research designed and conducted by friends of psychoanalysis in two of its spiritual homes, Chestnut Lodge in Maryland [3] and Menninger Clinic in Topeka, Kansas, [4] began to penetrate the profession. Both studies failed to find any evidence to support the expectation of superior outcome or deeper psychological change for people treated by psychoanalytic means. Psychoanalysis in America took an intellectual blow from which it is yet to recover.
The rise of managed care and evidence-based practice
When insurance companies decided that doctors could not be trusted to make rational clinical decisions, the pressure was on for clinicians to self regulate or lose clinical autonomy. In psychiatry, this meant that drug therapies achieved a significant advantage over psychotherapy and that psychotherapy with an evidence-base for efficacy and especially cost effectiveness was at a major advantage over other approaches.
Beyond the medical profession, psychologists, the other major psychotherapy provider group, were trained in the ‘scientist-practitioner’ model [5]. This training inculcated respect for experimental methods and empirical evaluation of psychotherapy. Clinical procedures without an evidence base were viewed with suspicion. This suspicion had an emotional edge in the USA, where the exclusion of psychologists from psychoanalytic training created a substantial professional body, barred from the dominant therapeutic paradigm and ready to embrace any new model that was both inclusive and consistent with the ‘scientist-practitioner’ model. As managed care impinged more directly on psychiatric practice, there emerged a previously unknown confluence between the clinical framework of the professions of psychiatry and psychology providing, through cognitive therapy, a basis for partnership rather than rivalry.
The limitations of behavioural technologies
Behaviour therapy reached its apogee in systematic desensitization for treatment of simple phobias. Beyond this application behaviour therapy, for all its theoretical elegance and impressive foundation in animal research, was at best equivalent to nonbehavioural procedures. In the absence of compelling superiority in clinical outcome, the rather alienating quality of the therapy that resulted from its disregard of the thoughts of the client, made it unappealing to both therapists and clients. The prospect of a therapy that had the scientific credibility of behaviourism and legitimized client therapist interaction was, not surprisingly, appealing to many therapists.
The decline of medical paternalism
The shift from a paternalistic to a partnership model of medical care has been well documented and reflected in a range of legislative and ethical codes and in approaches to medical training [6]. In psychiatry, treatment approaches that respect client autonomy and encourage active participation and collaboration in the treatment process are much more in keeping with the contemporary ethos than treatments that are directed unilaterally by the practitioner. Cognitive behaviour therapy is manifestly transparent. Its basic premises are uncomplicated and shared directly with the patient at the beginning of treatment. There is nothing that the therapist knows that is hidden from the patient. Interventions are not strategic or manipulative. The overall aim is to empower the patient. While in 1979 this approach may have seemed a little radical to a more conservative psychiatric establishment, the movement during the subsequent years has been in the direction favoured by cognitive behaviour therapy which now seems to offer an exemplary model for the ethics of client therapist relationship.
Beck's cognitive therapy of depression
The themes discussed above pervaded, to a greater or lesser extent, Cognitive therapy of depression [1]. While Beck had little to say about psychoanalysis and refrained from polemics, he provided the rather sad personal observation that ‘… I became somewhat painfully aware that the early promise of psychoanalysis that I had observed in the 1950s was not borne out by the middle or late fifties – as my fellow psychoanalytic students and other colleagues entered their sixth and seventh year of psychoanalysis with no striking improvement in their behaviour or feeling’. Equally, Beck avoided a major polemic with behaviour therapy, preferring to take a pragmatic approach and recommending the utilization of behaviourist approaches such as activity scheduling and assertiveness training as components of a cognitive therapy. However, it is notable that he made it clear that the use of such techniques is secondary to the main game: ‘The impact of the therapeutic techniques derived from a strictly behavioural or conditioning model is limited because of the restriction to observable behaviour and selective exclusion of information regarding the patient's attitudes, beliefs, and thoughts – his cognitions…. For the behaviour therapist, the modification of behaviour is an end in itself; for the cognitive therapist it is a means to an end – namely, cognitive change.’ [pp.118–119]
Cognitive therapy of depression was primarily a clinical handbook or manual, illustrated by numerous case examples and clinical anecdotes rather than supported by the results of extensive empirical research. Nonetheless, Beck placed considerable emphasis both on the scientific status of his cognitive theory of depression and on the importance of an evidence-based approach to practice. With respect to the former, Beck displayed a naïveté, grandiosity and ignorance of the philosophy of science that was at least the equal of Freud, and, given the lapse of the best part of a century, is less easily excluded. Beck wrote: The scientific paradigm – (in the sense used by Kuhn, 1962) – that encompasses the Cognitive Model of Depression includes much more than a theory and a therapy. It also includes a previously neglected domain (the cognitive organization), a technology and conceptual tools for obtaining data in this domain, a set of generally acceptable principles for constructing the theory, finally, a specialized technology to collect and evaluate evidence to support the theory’.
With respect to the evidence base, Beck sought to emphasize the selective application of the therapy to depression stating ‘Although we are sympathetic to the philosophy of “treating the patient rather than the disease”, there are substantial reasons for separating psychological disturbances into classes and, consequently, for applying sensitive techniques for arriving at the correct diagnosis’ [p.23]. He went on to argue that cognitive therapy for depression was specific in its effects not only to depression but indeed to certain subclasses of depression. He proposed a distinction between depression that was primarily psychological in its character and for which cognitive therapy was most clearly indicated and depression with a biological foundation for which pharmacotherapy and/or ECT provided an alternative or adjunct to cognitive therapy. There is an element of pseudo-science here that equates exactness of category with precision of clinical effect. The final chapter was devoted to empirical evidence for cognitive therapy, but Beck was required to acknowledge that this was thin and at best promising.
Perhaps surprisingly, in retrospect, the real strength of Cognitive therapy for depression is not so much its scientific or technical material but rather its careful consideration of the ethics of treatment and the therapist-client relationship. This is a pervasive theme but most clearly developed in a chapter on the therapeutic relationship in which he argued that collaboration is such a fundamental component of the treatment that it excludes the utilization of potentially effective techniques such as paradoxical intention. He stated that ‘… we avoid techniques that do not allow for the patient's conscious awareness and full understanding of the purpose of the methods as well as his voluntary participation in these procedures.’[p.57]. Beck argues that the brevity and focus of cognitive therapy diminishes the risk of the development of emotional responses to the therapist that subvert a collaboration. However, he does give specific consideration to transference and countertransference in which he warns against encouraging idealization of the therapist and alerts the therapist to the risk that insensitive application of cognitive techniques may be experienced by the patient as abrasive.
The future of cognitive therapy for depression
So far the focus of this review has been on the development of an argument to explain how cognitive therapy has come to be such a dominant force in the treatment of depression. It is now time to consider whether its future is likely to be as successful as its recent past. There are a number of reasons to think this is unlikely.
The first is that the scientific status of cognitive therapy in treatment of depression looks much weaker now than was the case a decade ago. Cognitive therapy has been found to have equivalent efficacy to medication but is not demonstrably superior to a range of other therapy approaches including basic counselling [7]. When cognitive therapies are split into cognitive and behavioural components, outcomes are as good for the behavioural components alone as for the cognitive components alone and equivalent to outcomes for combined therapy [8]. Higher usage rates for cognitive interventions predicts poorer rather than superior outcome [9] and superior Dysfunctional Attitude Scale scores at the end of treatment fail to predict better longer-term outcome. Beck's claim that the cognitive theory of depression amounts to a scientific revolution has not been substantiated and the empirical literature provides more than enough comfort for practitioners of other approaches who wish to operate within an evidence-based framework. It is increasingly evident that therapeutic alliance rather than therapeutic technique is the major factor in psychotherapy outcome [10] and the ‘dodo bird’ hypothesis that ‘all have won and all must have prizes’ owes more to this fact that to technical equivalence.
The second is that the limited evidence available so far suggests that cognitive therapy may have specific deficits with respect to consumer acceptance. Blatt et al. found that Interpersonal Therapy was associated with higher levels of client satisfaction with treatment on 18-month follow up [11]. Earlier, Scott and Freeman had found significantly higher client satisfaction at treatment endpoint for clients who received counselling from social workers compared with clients who received cognitive therapy from clinical psychologists [12]. It was notable in the latter study that cognitive therapy was rated as having met fewer client needs than brief contacts with general practitioners providing usual care. While practitioners who attend closely to Beck's recommendations will recognize the risks of an overly narrow and technique driven approach to therapy, the belief that is inculcated among cognitive therapists that it is a superior technique, based on superior theory and empirically validated technique does not encourage flexibility and openness to client concerns. This problem is increasingly acknowledged among cognitive therapists [13] but will be difficult to address in a therapy that is so technique driven.
In this respect, the collaborative ethos of cognitive therapy collides with its ideological raison d'etre. As Castonguay [9] suggests, when the pressure is on, technique wins out even if the outcome is poor clinical response. Paradoxically, therapies that are less technique or theory driven are better placed to achieve the collaborative ideal propounded by Beck than is his own cognitive therapy. We may yet achieve a more ‘postmodern’ therapy environment for depression in which choice of therapy is more a matter of patient and therapist preferences than of imposed treatment guidelines.
However, there are three reasons to suspect that cognitive therapy will occupy a prominent place in treatment of depression for some time yet. First, there is an entire generation of psychologists who have been trained in little else. This generation is increasingly being joined by a generation of psychiatrists and other health professionals. While some will go on to find their own distinctive therapeutic path, I expect that the imprint of core training will continue to influence practice for many if not most. Second, cognitive therapy is well suited to research and is likely to remain the first choice in many research designs. It is standardized and manualized and offers a large normative database of outcome studies. Third, technique is very reassuring to the novice therapist and a therapy that offers a simple theory and a clearly developed technique is likely to appeal to many people who feel uncomfortable dealing with something as amorphous as therapeutic alliance.
Twenty-two years after its first publication Cognitive therapy of depression remains therefore a work of more than just historical interest if something less than a timeless and enduring classic.