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In the s, Beck conducted the first rigorous study of any type of 'talk therapy'. He pitted cognitive therapy against the best antidepressant drug at the time — imipramine — in a prospective, randomized, controlled clinical trial designed to test how effectively these two approaches ameliorated symptoms of a particular disorder: depression. In this head-to-head comparison, cognitive therapy outperformed the drug after a treatment period of up to 12 weeks. Furthermore, the benefits persisted a year later. In contrast, the effectiveness of psychoanalysis, whose normal course is years, has not been proven, as it has not been subjected to this type of randomized, controlled study.

This work established cognitive therapy as a powerful clinical intervention and set a new standard for evaluating the effectiveness of any kind of psychotherapy. Numerous studies since then have reaffirmed that the approach is equal or better at combating depression than are antidepressant drugs; furthermore, it is better at preventing relapse.

Beck and his trainees spent the next three decades adapting cognitive therapy to treat additional problems—such as anxiety disorders, panic disorders, and social phobias—and testing its utility. As part of this enterprise, he developed powerful instruments with which to measure the severity of symptoms associated with various psychiatric illnesses.

Prior to this work, a dearth of techniques for measuring the severity of such disturbances hampered psychiatric research. Among his major achievements, Beck has made dramatic advances in helping people with suicidal urges, in part by providing a classification and assessment scheme for predicting suicidal behavior. Beck recognized that the feeling of hopelessness is crucial for evaluating suicidal patients. He developed a "hopelessness scale" — a series of simple questions — that measure the degree to which an individual feels as if current problems are solvable.

Beck and his colleagues have tracked patients for more than 30 years, and have found that this tool can indicate the likelihood of a person to commit suicide, particularly for individuals at high risk. In a seven-year study of outpatients, the test pinpointed 16 of the 17 people who killed themselves during that period; individuals who scored above a particular hopelessness rating were eleven times more likely to commit suicide than were the low scorers. Thus, the risk of hopeless patients eventually dying as a result of suicide was approximately the same as that of heavy smokers dying from lung cancer.

In , Beck and his colleagues published a paper that demonstrated the effectiveness of cognitive therapy for suicidal individuals. Participants in the cognitive-therapy group were almost 50 percent less likely than non-participants to attempt suicide during the month follow-up period. In the United States, more than 30, people die each year from suicide, making it the eleventh leading cause of death; among people between the ages of 15 and 24, it is the third biggest killer.

Worldwide, suicide is among the three leading causes of death among individuals between 15 and 44 years old. Because Beck has invented a simple tool with which to predict future suicidal behavior and a therapy that dramatically reduces attempts, his work has enormous potential for slashing those figures. Furthermore, it could tremendously benefit especially high-risk populations, such as those on college campuses. Cognitive therapy has become a mainstay in the practices of many mental health practitioners worldwide.

The American Psychiatric Association's guidelines state that cognitive behavioral therapy an offshoot of cognitive therapy is one of the two best-documented psychotherapies for treating major depression. Health systems in Europe recommend it for treating a number of common psychiatric disorders. If results are favorable, the government will expand the program and expects to save millions of dollars by helping people with mild to moderate depression get back to work and off disability benefits.

Beck's development of cognitive therapy and his discovery that it effectively treats serious mental illnesses has major public health significance. Countless individuals owe their sense of well-being — and their lives — to Beck's work. Beck, A. Thinking and depression II. Theory and therapy. Treatment of depression with cognitive therapy and amitriptyline.

Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. The current state of cognitive therapy: A year retrospective Arch. Brown, G. Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Butler, A. The empirical status of cognitive behavioral therapy: A review of meta-analyses.

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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 s, some of the specifics of his theory, such as the infamous idea that all neurosis was rooted in sexual repression, were wearing thin.

Sophie Ambrose: ASHFoundation New Century Scholars Research Grant Recipient

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?

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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. 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 , 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.

Extensive studies of the conceptual taxonomies of clinicians have found that they do not match those of DSM or of ICD in structure [ , , , , , , ]. Usually included are mood disorders excluding bipolar and cyclothymic , anxiety disorders, substance abuse disorders, eating disorders, externalizing childhood disorders, developmental disabilities, schizophrenia, and dependent and paranoid personality disorders [ ]. Experienced clinicians group together anorexia nervosa and bulimia nervosa, as well as substance dependence with substance abuse, conduct disorder with oppositional defiant disorder, panic disorder with phobias and GAD, and mental retardation with autism [ ].

Psychiatrists have been found to prefer fewer categories, and with flexible ICDtype guidance rather than strict criteria-based diagnoses [ ]. The same preference for ICDtype flexible guidelines over DSMlike strict criteria has been found among psychologists [ ]. Such categories are not formal diagnoses. The HiTOP consortium [ 49 ] has revealed a transdiagnostic, empirically-derived, hierarchical dimensional model of classification of mental disorders.

A nascent micro classification system of PMCs is already in clinical use and is taught in several postgraduate clinical programs [ , ]. However, this listing is ad hoc, idiosyncratic, and unlikely in such an embryonic state to provide codings that would achieve broad acceptance. An effort by teams of clinicians and researchers corresponding to some meaningful fraction of the effort devoted to the development of the DSMs, is required to construct a systematic, exhaustive, and evidence-based taxonomy of CPPs in the form of distinct, identifiable PMCs.

However, in the interim, a proposed classification and coding system is presented in Appendix B. For example, the PMCs illustrated in Fig. Such a framework can systematically summarize and stimulate the currently disparate streams of research on assessment, case formulation, and therapeutic intervention in clinical psychology. For example, instead of assessing the efficacy of a particular Cognitive Therapy package in helping a diagnostically uniform but psychologically heterogeneous sample of sad people, subjects could be selected based upon identification, through an assessment and case formulation, of the presence or functioning of PMC 2.

Such would be infinitely more logical, and just as methodologically sound in a randomized controlled trial. Only the nature and level of causal elements within their formulated PMCs vary. For example, the movement toward integration of models of psychotherapy [ , ], has frequently pointed to cyclic processes between internal psychodynamic states and external cognitive-behavioral events [ ]. Short-term existential interventions have been explained as ways to break vicious circles of emotion [ ]. Family systems theorists have long emphasised cyclical formulations with psychodynamic elements [ ].

Nor is defining the essence of a clinical problem in terms of vicious circles or PMCs particular to clinical psychology. It has been proposed or enacted within forensic psychology [ , ], organizational psychology [ ], and crossculturally [ ]. Much of medicine describes vicious circles of organic pathology fever, organ failure, etc.

Therefore, theorists and researchers from many theoretical orientations are able to contribute, and to utilize, the new taxonomy, only providing that the focus is on problem maintenance, and the relevant PMCs and implied treatments are evidence-based. Its only comparative drawback is its relative complexity. Life is complex.


People are complex. And DSM has over simplified them. It simply lists discovered cyclic causal sequences. Whether they are viewed as desirable or undesirable is a value judgement. They do not merely work to cheer up a sad person or to relax an anxious person. The PMC taxonomy lists problematic ongoing underlying mechanisms or processes that must be addressed. A PMC taxonomy defines and lists clinical psychological problems as perpetuating cyclic processes. This simple intuitive concept at once confers an essence to CPPs, that is parsimonious one criterion, not seven or eight , categorical not dimensional, and has intrinsic clinical utility and treatment-relevance.

The identification of a depression PMC is informative. It tells us much about the person involved. Anxiety PMCs are historically invariant. We know of phobic PMCs from Roman times. Such problems are discrete. There are definable boundaries. They are uniform. People trapped in eating problem PMCs have many similarities. They are, by definition, immutable.

They rarely spontaneously remit. There is one necessary feature a full causal PMC. They are inherent ; there is a sameness under the symptoms. But, given the cyclic nature of scientific research and theory construction, the taxonomy can improve the focus and organisation of research efforts, and the reporting and assemblage of research results. Communicability will be enhanced not only among clinical psychologists. The medical model and PMC theory are compatible and complementary. Already, clinical psychologists accept referrals of diagnosed mental disorders, understand what is meant, do their own functional analyses and case formulations, and often feed these back to the psychiatric or physician referrer, who understands them perfectly well, and may even appreciate a PMC code summary of this formulation.

A taxonomy of PMCs can increase the reliability of case formulation as well as its communicability through standardization of nomenclature. A PMC-based model is also very comprehensible and communicable to clients. Quite complex graphically presented individual case formulations can be simplified, standardized, and described by separating out the individual PMCs involved. A person who is offered a PMC-based case formulation of their CPP with its explained mechanisms, treatment implications, openings for self-help, and overlap with normality is likely to find this more comprehensible, more optimistic, more empowering, and less stigmatizing than being conferred with a diagnosis of a psychopathology or mental disorder.

Comorbidity is no longer a theoretical quandary. However, as the primary criterion for any clinical taxonomy is its treatment-relevance [ 21 , 31 , 99 , ], the real test of PMC theory is whether it results in more treatment success. As research around the world has been so completely dominated by the mental disorder model, it is hard to find exceptions in which problem assessment and assessment of improvement are based on a case formulation rather than a diagnosis, let alone comparisons of the two approaches with the same population.

Among the few that have been undertaken, the results are clear. This has been true for behavioural therapies based on functional analyses, and then more recently CBT based on case conceptualizations. With behavioural interventions firstly, Carr and Durand [ ] found that the treatment of disruptive behaviour needed to depend on the function it was serving its maintainer — whether the behaviour serves an escape function or an attention-seeking function.

Durand and Crimmins [ ] found that the successful treatment of self-injurious behaviour also depended upon analysis and discrimination as to whether it was maintained by an attention-getting motivation, or was escape-maintained, tangibly-maintained, or sensory-maintained. Schneider and Bryne [ ] produced a significantly greater boost in observed social skills and cooperative play among children with various behaviour problems when treatment was individualized rather than standardized. In a post hoc analysis, Eifert et al. Iwata et al. For example, Jacobson et al. When Litt et al.

In a similar vein, when the reasons for drug use are analysed so that brief coping skills interventions can be matched to personality-specific motives PMCs for the substance abuse, treatment efficacy is improved [ ]. Persons et al. In one of the few direct comparison treatment studies, Weisz et al.

Fairburn et al. So, when they added four more maintaining mechanisms to their model e. So, when case formulations are used to guide treatment rather than clumsy, theory-bereft diagnoses, indications to date are that the subsequent tailored treatments improve our effectiveness. The next step appears to be to improve the reliability, standardization, and validity of case formulation and treatment selection by basing therapeutic trials and outcome studies on PMC-defined rather than DSM-diagnosed experimental groups.

It is proposed that the next logical step in the scientific development of the discipline of clinical psychology is the formation and dissemination of a taxonomy of CPPs based on its own conceptual scheme and operating primarily at a psychological level. The independent conceptual, research, and clinical development of the profession has advanced sufficiently for this critical step. The development of the various iterations of the DSM has involved the assignment and coordination of vast numbers of contributors, panels, committees, and task forces.

For example, three of the five volumes of the DSM-IV Sourcebook [ ] alone commissioned reviews of the literature on psychological disorders. However, these reviews were based on research that was conducted largely within the DSM framework, so much circular reasoning occurred, and alternative approaches or conceptualizations were not considered [ 31 ]. It is a very leaky virtuous circle. It is an assumption — a convention — constructed for pragmatic, sociological, or political reasons, just as the disease model of alcohol problems and the chemical imbalance theory of depression were. In fact, some highly deleterious effects on self-esteem, self-efficacy, confidence in treatment, and expectation of recovery have ensued [ ].

Ironically, a diagnosis can thus become a self-fulfilling prophecy, and cause negative feelings, thoughts, or behaviour via vicious circles, such as through instilling shame or hopelessness [ 14 ] p. There is psychological-level evidence for the existence and operation of every one of these causal links. In fact such evidence led to the development of this model. It is an evidence-based model of a CPP, which in turn directly implies therapy choice.

The proposed new taxonomy of CPPs is therefore theory-based, treatment-relevant, evidence-informed, and pragmatic. Much research required for its development has already been undertaken. It is now a matter of framing the results e. The independence and standing of the discipline and profession may then be restored, and, more importantly, the millions of people experiencing crippling CPPs may be offered more therapeutically relevant, less stigmatising, more empowering, more evidence-based, and more comprehensible, reliable, and systematic formulations of their problems. Many uncertainties will remain despite such a clarifying taxonomy.

A PMC taxonomy can at least clarify the conceptual issues, and guide research to address the therapeutic issues.

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