Professor Aaron Temkin Beck, American Psychiatrist and the founder of cognitive behaviour therapy, passed away earlier this month, aged 100. I have a shortlist of "psychology heroes", and Beck – everyone calls him Beck – is on that list. His ideas about the causes of depression and how to treat it just make plain sense. His legacy, cognitive behavioural therapy (CBT), has spread globally and is in greater demand than ever.
With Beck's approach to therapy, there is no need for navel gazing or uncovering deep dark secrets. Beckian CBT is firmly rooted in the here-and-now, where unhelpful thinking patterns can prolong moods and lead to maladaptive behaviours. The clarity and accessibility of Beck's ideas transformed how we treat depression and many other psychological conditions.
There was a hot debate about which works best: antidepressants, CBT, or some other form of talk therapy? However, in the treatment of depression, you could argue that everything works equally well. A variety of pills, based on different chemical compounds, can be effective. As can various forms of talk therapy. Psychologists call this situation the dodo bird verdict: "Everyone has won, and all must have prizes," declares the dodo bird in Lewis Carroll's Alice in Wonderland.
If everything helps people get better, a more useful question is: which approach helps people stay better? Relapse rates in depression are, unfortunately, very high. People recover and then relapse, recover and relapse again. This, however, is where CBT really comes into its own. The outstanding benefits of CBT kick in after treatment ends. Patients treated with CBT are less likely to relapse than those treated with antidepressants alone, or even other forms of talk therapy. Thus, CBT has the edge when it comes to keeping us well.
A study published in the Lancet medical journal in 2016 describes the long-term effects of CBT over and above other treatments, such as antidepressants and brain stimulation therapies. The study, known as the CoBalT trial, followed 469 depressed patients for three and a half years. The findings were clear: antidepressant drugs and brain stimulation treatments were generally only lastingly effective if treatment remained ongoing. CBT, however, provided longer-term recovery without any need for continued treatment or booster sessions. Of course, CBT is not perfect. Patients treated with CBT still relapse, but it outperforms all other brief interventions when it comes to promoting enduring recovery.
CBT's longer-lasting (maintenance) effects are almost certainly due to participants learning skills they continue practising after treatment ends. What new life skills do we acquire by simply taking pills alone? Beck's idea was that CBT should involve patients developing the skills needed to become their own therapists. Even today, this still strikes many people as revolutionary. For example, when I introduce undergraduate students to CBT, they're generally surprised by how much work the client is expected to do. The idea of the client as an equal collaborator, challenges the classic media image of a passive patient lying on a couch while a sage-like therapist nods and scribbles notes. Often in CBT it is the patient who will be taking the notes.
CBT's record for helping achieve lasting recovery meant that when researchers started looking at preventative approaches to depression, CBT was an excellent place to start. As a result, we now have Mindfulness-Based Cognitive Therapy (MBCT). The evidence supporting this approach to preventing relapse in depression is compelling. So compelling that in 2009, the UK's National Institute of Health and Clinical Excellence (NICE) included MBCT in its national clinical guidelines for the treatment of depression. Best practice, the guideline suggests, is that MBCT should be offered to people who are currently well but have experienced three or more previous episodes of depression.
CBT, of course, is not a panacea, nor is it for everybody. Some individuals may not gel well with their CBT therapist. Others may find CBT too complex, or perhaps not sophisticated enough. That said, CBT remains one of the most effective treatments we have across a broad range of psychological complaints, from depression and social anxiety to eating disorders and behavioural addictions. Frequently, demand outstrips supply, forcing many nations to implement ambitious initiatives to address this issue of "unmet need". For example, in 2008, the UK government launched the improving access to psychological therapies (IAPT) programme. Similarly, researchers and clinicians are actively exploring digital technologies to help improve further access to CBT and its various offshoots.
CBT is a gift that keeps on giving, and Beck's legacy is in greater demand than ever. Jonathan Haidt, co-author of The Coddling of the American Mind, argues that rates of common mental health problems are higher for Gen Z (born after 1996) than any previous generation. So how will things be when Gen Alpha (born after 2010) reach young adulthood?
Common mental health problems – depression, anxiety, substance misuse, eating disorders – have reached epidemic proportions in many nations. These problems disproportionately affect young people. As a result, preventing the onset of these problems has become a public health priority. Beck's ideas still have a crucial role in our search for innovative and increasingly effective approaches to mental health promotion and illness prevention. In the words of Beck, "the stronger person is not the one making the most noise but the one who can quietly direct the conversation toward defining and solving problems".