Evolution of Effective Psychotherapy

Aaron T. Beck, M.D.

April 11, 2000

In order to get a sense of the relative value of a specific psychotherapy, it is useful to get some
perspective on the evolution of psychotherapy in the last half of the Twentieth Century.
The 1940s and the 1950s were the heyday of psychotherapy. A significant proportion of
medical students, for example, chose psychiatry as their specialty based on the popularity of
psychotherapy. However, there were many schools of psychotherapy with no clear-cut
distinction as to which offered the most. In addition, even within a particular school, there was
a huge variation in terms of the kind of psychotherapy practiced. There was no quality control,
minimal uniformity. We could call this the pre-scientific era.
The choice of treatment was based more on revelation than research.
Starting in the 1950s, there was a drug/medication revolution. In rapid succession, effective
medications were developed and marketed for depression, anxiety, schizophrenia, bipolar
disorder, and a few of the other disorders.
The pharmacotherapy revolution, unfortunately, has overshadowed a similar revolution in
psychotherapy research. New structured, more-or-less uniform therapies based on a
compatible theoretical framework were developed and tested using the same rigorous criteria
as those used in the development of medications.
First, behavior therapy was successfully applied to a number of conditions, particularly those in
which anxiety played a central role. More recently, cognitive therapy, again using the same
scientific criteria as those used in the application of drugs, has come to the fore.
Now cognitive therapy has been tested and found to be useful for a wide variety of disorders:
depression and all of its subtypes; anxiety; panic; and, more recently, schizophrenia, in addition
to treatment as usual, and also eating disorders.
When it comes to the question of which is superior, the answer becomes somewhat more
complicated. Skilled therapists using the empirically supported therapies have been shown to
get the same degree of successful results in several of these conditions as has medication.
In fifteen or so studies in which cognitive therapy was compared with medication for
depression, cognitive therapy performed as well as antidepressant drugs. In one of the studies,
the highly publicized NIMH collaborative study, cognitive therapy did not do as well as
pharmacotherapy; however, in two other studies, cognitive therapy performed better.

1
How to choose between the two? First, some patients prefer one or the other approaches and
there is some evidence that patients choosing a particular therapy are more likely to have a
good response. In one study, by Adrian Wells, patients choosing cognitive behavior therapy
showed more improvement than those choosing drug therapy. Secondly, cognitive therapy has
been shown to reduce the frequency of relapses and this is a major contribution.

Combination of cognitive therapy and pharmacotherapy.

There are two conditions in which it has been demonstrated that the combination of cognitive
therapy and pharmacotherapy produces a better result than either one alone. In the treatment
of bipolar disorders, the combination of cognitive therapy and lithium has been shown to
markedly increase compliance with medication and also to reduce relapses. Further, the
combination, particularly when given during the prodromal period, reduces the degree of
relapse

Originally published in Cognitive Therapy Today Volume 5, Issue 2. June 2000.

2
3