Albert Lasker
Clinical Medical Research Award

By the end of the 19th century, the discoveries of medical pioneers such as Louis Pasteur and Robert Koch had led us into the era of modern medicine. They understood disease to be caused by some physical disturbance rather than evil spirits or an imbalance of the humours. This was not just an advance for those suffering from illnesses that wiped out whole townships, but it also spelled progress for the insane. Neurologists began to show that brain diseases such as syphilis or tumors could produce bizarre changes in personality. Even if treatments were slow to come, the insane could be viewed with more compassion, as suffering actual brain damage rather than demonic possession.

But what of those cases, where a physical disturbance could not be found? Even worse, what about those cases where a physical problem seemed impossible? Take, for example, that prototypical 19th-century illness, hysteria. Hysterical patients displayed puzzling symptoms, such as a numbness of the hand that stopped abruptly at the wrist, which did not make sense with the wiring of the nervous system. Enter Sigmund Freud.

Freud was trained as a neurologist and studied with the great French neurologist Jean-Martin Charcot. Charcot attributed hysterical symptoms to some undefined inflammation of the nerves—this was very much a physical model of disease. Freud made the monumental leap that neuroses could be caused by psychic distress. This incredible notion that feelings and ideas could produce illness created a new category of disorders defined as mental illness that is distinct from diseases that damage the brain. In the process, Freud described the unconscious, a powerful inner world of drives and conflicts that could explain everything from slips of the tongue to hysterical paralysis. Freud's general concepts of neurosis and the unconscious were firmly embedded in both medical and popular culture. But by the 1950s, some of the specifics of his theory, such as the infamous idea that all neurosis was rooted in sexual repression, were wearing thin. While medicine had been reaping the benefits of the scientific method, no one had put psychoanalysis to the test. Yet that was the dominant form of therapy. Clearly, Psychiatry was heading for a crisis. Enter a young psychoanalyst named Aaron Timothy Beck.

One afternoon, Beck was treating a young woman who was having difficulties with men. As she lay on the couch describing her sexual encounters, Beck asked her: "How does talking about this make you feel?" Now, as a psychoanalyst he was not supposed to ask such a question, but rather let the patient's unconscious bubble to the surface. Nevertheless, he followed his curiosity, and the patient replied that she felt anxious. Beck proposed that she felt anxious because she expected disapproval of her sexual desires. Breaking another cardinal rule of psychoanalysis, he asked the patient to sit up and face him, so she could see from his expression that there was no disapproval. At this point, the patient broke with expectations and confessed: "No, I don't think you're disapproving; I think I'm boring you." This was the Eureka moment for Beck. He realized that if patients were concerned with what their therapists think there was little use in waiting for unconscious thoughts to bubble up. He abandoned probing for unconscious sexual conflicts and began focusing on the patterns of thoughts that made his patients depressed or anxious. Thus was born a new type of treatment to become known as cognitive therapy.

Like Charcot and Freud, Beck started his career as a neurologist. During his neurology residency he was required to train for six months in psychiatry, which he initially thought was a distraction. But he quickly became fascinated by psychoanalysis as a tool to probe the workings of the mind. Beck switched fields and became a Freudian psychoanalyst. Many scientists were skeptical about the effectiveness of psychoanalysis, so Beck set out to confirm the tenets of the psychoanalytic theory through research. His initial focus was on depression.

According to psychoanalytic theory, depression can be caused by unconscious anger towards another person. Because such outward hostility is unacceptable, depressed patients direct the anger toward themselves (which results in low self-esteem). Since Freud argued that dreams are the "Royal Road to the Unconscious," Beck decided to search for hostility in the dreams of depressed patients. What struck him most was not hostility but that depressed patients saw themselves in their dreams exactly as they did in their waking hours: as hopeless and helpless. He also noticed that his depressed patients had "automatic thoughts" that colored innocuous events with dark meaning. These negative interpretations in many cases could precipitate a depression.

For example, take a man whose wife leaves in the morning without giving him the customary kiss. He might fear that she does not love him anymore and begin accumulating other pieces of neutral data to support his dismal conclusion, becoming more and more distraught. A cognitive therapist will ask the patient to recount the morning conversation he had with his wife. During this process he recalls that she told him she was in a hurry to make an early meeting at the office. Beck helped his patients identify these subtle but powerful automatic thoughts, question the unhelpful and destructive ones and replace them with more realistic thoughts. Thus, the tenet of cognitive therapy is that our cognition (how we think) determines our feelings and behavior.

In contrast to the years of undirected exploration of the unconscious in psychoanalysis, cognitive therapy focuses on the preconscious that is not quite in awareness but is accessible. Within weeks, this therapy provides patients with the skills to recognize negative, self-defeating thoughts when they occur and to step back from them, effecting a slow but steady improvement in mood and function. In 1977, Beck conducted the first rigorous clinical trial of any type of psychotherapy in depression. He compared the effectiveness of cognitive therapy to imipramine (the best antidepressant at the time). Twelve weeks of cognitive therapy proved superior to pharmacotherapy, and its benefits persisted a year later. These findings established cognitive therapy as a powerful and effective intervention for depression and set a standard for evaluating the clinical benefits of any type of psychotherapy.

When Beck recognized the need for sensitive rating instruments, he developed the Beck Depression Inventory (which became one of the most widely used measures of depression symptoms in the world). Beck and his trainees went on to adapt cognitive therapy for a variety of psychiatric disorders and showed that it is effective therapy for generalized anxiety, panic disorders, post-traumatic stress disorder, phobias, and bulimia.

Cognitive therapy has proven to be beneficial in so many illnesses that departments of psychiatry are now required to teach cognitive therapy to their residents. The National Institute of Clinical Excellence in England now states that cognitive behavior therapy should be available as a therapeutic option for all mental disorders. The Labour Government made a commitment to train 10,000 therapists so that at least 1 million psychiatric patients can access this treatment. This unique initiative is predicted to save the government 10 billion pounds each year and to make the society healthier and happier.

One in five adults will suffer from a diagnosable mental disorder in a given year in the U.S. Thirty thousand people will commit suicide each year—that's twice the number of homicides in the States. Mental illness, including suicide, accounts for 15 percent of the burden of disease in established market economies. This is more than the disease burden caused by ALL cancers. At least 60 million Americans suffer from depression or anxiety disorders. There is no doubt that formal training of more individuals in cognitive therapy will significantly decrease the burden of psychiatric diseases.

Aaron Beck is often described as a "giant" by psychiatrists, but inside this giant there is a kind and creative man who is always searching for the best ways to help people. His greatest passions are psychiatry and science. Although he plays tennis and enjoys reading history books, most of his time is spent reading scientific journals or thinking about how to better diagnose and treat psychiatric disorders. Thus it is not surprising that at the age of 85 years he received two NIH grants to support his research. The medical community is fortunate that Aaron Beck took on the challenging psychiatric disorders and showed us that the mind is plastic and adaptable if we let the brain's cognitive power take control.