Crossing the Rubicon: from psychoanalysis to cognitive therapy

Abstract

In this study we describe some of the reasons that lead Aaron T Beck to move away from psychoanalysis and participate in the creation of cognitive therapy. With this aim in view, we describe the research developed by Beck between 1959 and 1962. In these studies the data that promotes the fall of the psychoanalytic explanatory hypothesis for depression began to be processed. Within this analysis we include some elements that we consider essential to understand this process of change: From Beck´s obtaining a grant to investigate depression and his starting to work with collaborators like Marvin Hurvich and Sigmour Feshbach, whose new tools and methodologies helped Beck to test a psychoanalytic hypothesis of depression. Finally, we will include questions related to the research policies of the National Institute of Mental Health, and some commentaries about personal and institutional policy reasons that influenced Beck’s work.

Keywords:
cognitive therapy; psychoanalysis; National Institute of Mental Health

Resumen

En este trabajo nos proponemos describir algunas de las causas que llevan a Aaron T. Beck a abandonar el psicoanálisis y a participar de la creación de la terapia cognitiva. Para ello, describiremos los trabajos de investigación desarrollados por Beck entre los años 1959 y 1962. En ellos se empiezan a procesar los datos que darán lugar a la caída de la hipótesis explicativa psicoanalítica de la depresión. Dentro de este análisis incluiremos algunos elementos que consideramos esenciales para entender este proceso de cambio: la obtención de un subsidio para investigar la depresión y la aparición de colaboradores como Marvin Hurvich y Seygmour Feshbach, cuyas nuevas herramientas y metodologías ayudaron a Beck a poner a prueba la hipótesis psicoanalítica de la depresión. Por último, incluiremos cuestiones referidas a las políticas de investigación del Instituto Nacional de Salud Mental, así como motivos personales y de la política institucional.

Palabras clave:
terapia cognitiva; psicoanálisis; Instituto Nacional de Salud Mental

Résumé

Cet article a l’objectif de décrire quelques-unes des causes qui mènent Aaron T. Beck à abandonner le psychanalyse et de participer à la création de la thérapie cognitive. Avec cet intérêt, l’article explore ce travail de recherche développé par Beck entre les années 1959 et 1962. Dans cette période, se commencent à traiter les données qui mèneront à la chute de l’hypothèse explicative psychanalytique de la dépression. Dans cette analyse l’article inclut certains éléments que nous considérons essentiels afin de comprendre ce processus de changement : l’obtention d’une subvention pour étudier la dépression et l’entrée en scène de collaborateurs comme Marvin Hurvich et Seymour Feshbach, qui ont apporté de nouveaux outils et méthodologies pour tester l’hypothèse psychanalytique de la dépression. Enfin, nous allons inclure des questions liées à la recherche sur les politiques à l’Institut National de la Santé Mentale, ainsi que des raisons personnelles et de la politique institutionnelle.

Mots-clés:
thérapie cognitive; psychanalyse; Institut National de la Santé Mentale

Resumo

Neste trabalho, descrevemos algumas das causas que levam Aaron T. Beck a abandonar a psicanálise e participar da criação da terapia cognitiva. Com este objetivo, vamos descrever os trabalhos de investigação desenvolvidos por Beck entre 1959 e 1962, quando começa a processar os dados que derrubarão a hipótese explicativa psicanalítica da depressão. Nesta análise, incluiremos alguns elementos que consideramos essenciais para entender esse processo de mudança: a obtenção de um subsídio para pesquisar a depressão e a presença de colaboradores como Marvin Hurvich e Seygmour Feshbach, cujas novas ferramentas e metodologias ajudaram Beck a testar a hipótese psicanalítica da depressão. Por último, incluiremos questões que se referem às políticas de investigação do Instituto Nacional de Saúde Mental, assim como motivos pessoais e de política institucional.

Palavras-chave:
terapia cognitiva; psicanálise; Instituto Nacional de Saúde Mental

Introduction

The emergence of a new theory or disciplinary field cannot be described using only one cause. The development of Cognitive-behavioral Therapy (CBT) can be understood in the field, focusing on innovation and knowledge, and from a broader perspective, in its relationship with psychoanalysis, scientific policies and institutional transformations. The theoretical models are affected by personal histories and their controversies; in addition, it is important to consider the more general cultural and social transformations in an extended period of time, such as the context of sociological studies of subjectivity, cultural beliefs and the definition of “therapy.”

Most of those who have written, based on the CBT clinic, about the recent history of psychology focus on specific aspects of the phenomenon, without integrating the development of the discipline into the context of socio-historical changes like the personal histories that characterize them (Rosner, 2012). Some authors, inspired by a positivist perspective, consider that behavioral therapies were the root of the success of the cognitive model and believe that CBT is a supplementary product of research in basic psychology (Rachman, 1997; Fishman, Rego, & Muller, 2013). Other authors highlight the continuity and changes that arise in the psychoanalytic tradition (Rosner, 1999, 2014) and suggest that the origins of CBT are linked to the popularization of the criterion of effectiveness in the USA and its consequent crisis in psychoanalysis (Plas, 2008; Semerari, 2002). Others, who are more interested in the institutional conception of psychology, observe the psychoanalytic formation of the founders of CBT (Hollon & DiGiuseppe, 2013).

When the people who personally embody the occurrence of this phenomenon are mentioned, the different readings coincide to point out three personalities as the main pioneers of the discipline: Aaron T. Beck, Albert Ellis and Donald Meichenbaum; who are often identified as the “fathers” of cognitive behavioral therapy (Mahoney & Arnkooff, 1978; Weishaar, 1993). Despite the fact that the developments by Ellis are previous, and that Beck recognizes that he took of him the model ABC⁴ (Weishaar, 1993), the work of Beck has gained more attention in research development and in clinical aspects. It may be why Ellis’s work is more anecdotal, and Beck’s work has, especially in its beginnings, a definite and concrete object of study, such as depression, detail that allowed him to base his developments on the data provided by the scientific investigation. This is a fact that would be relevant to the intimate relationship that will be established between cognitive therapy and research (Kendall et al., 1995).

On this occasion, we will analyze the origins of CBT based on the study from the initial years of Beck’s work (1959-1962), this period, in Beck’s own terms, is the one that initiates the conceptualization of what happened since the end of the 80s, which we know as CBT. We will describe the characteristics from which he analyzes the psychoanalytic hypothesis of self hostility as the etiological basis of depression, and we will describe some biographical events that may have influenced theoretical and personal decisions that contributed to the emergence of the discipline at hand.

We start from a brief characterization of the psychoanalytic formation of Beck and review his first research about depression so as to observe the methodological efforts and conceptual developments that require advancement in the systematicity of research. We analyze the consequences and the steps that were necessary to test the hypotheses formulated at that first stage of his investigation on depression, while adding some personal events which may have impacted the subsequent development of CBT.

Psychoanalysis and research

When the Second World War ended, many psychiatrists used to believe that psychoanalytic psychotherapy could be a treatment for various kinds of human suffering (Rosner, 2014). These theoretical systems emphasized the interaction of the person with the environment and a psychosocial model was imposed to think about mental illness.

Beck’s academic background in psychiatry coincides with the postwar period. During the war, the application of psychoanalytic strategies in soldiers had demonstrated the utility of this model; the therapists who had the best results combined the psychoanalytic model with more steering contributions coming from the hygienist model in mental health (Hale, 1995). In the Cushing Veterans Administration Hospital, where Beck had his medical residency (1948-1950), one of the teachers -Felix Deutsch- developed a brief form of psychoanalytic psychotherapy, with the objective of a fast reduction of symptoms, in which he makes an integration between psychoanalysis, concise psychotherapy and psychosomatic medicine (Rosner, 1999).

Between 1950 and 1952, Beck was a postdoctoral scholarship at the Austen Riggs Center, where Robert Knigh was the medical director, David Rapaport director of the research area (Rosner, 1999, 2012) and Erik Erickson the supervisor (Weishaar, 1993). Beck participated in the seminars and was exposed to a large number of approaches regarding psychotherapeutic practice; the traditional psychoanalysis, the psychology of the self, mental hygiene (Adolf Meyer’s model), group therapy, theories of cognition and experimental research (Rosner, 1999). In this context, the works of Rapaport intended to integrate the principles of experimental science with those of psychoanalysis; for this purpose it was proposed that work be done with hypotheses susceptible to be tested and include the development of normal functions such as perception and intelligence, which would lead to an approach with academic psychology (Hale, 1995).

Beck received psychoanalytic training at Austen Riggs and in Philadelphia Psychoanalytical Institute, places where were made this combination of the aforementioned models (Korman, 2013). In 1959, Beck became assistant professor of Psychiatry at the University of Pennsylvania and in the same year received his first research grant from the National Institute of Mental Health (Weishaar, 1993). This project had two objectives: to define psychometrically depression and masochism; to test the hypothesis that masochism was the cause of depression.

Beck was partnered with two young students in the department of psychology at the University of Pennsylvania who were his first collaborators: Symour Feshbach (currently professor emeritus of the University of California, Los Angeles) and Marvin Hurvich (a well-known psychoanalyst and professor at Brooklyn University, New York, who was Beck’s patient). They would provide the methodological tools for experimental and statistical psychology that Beck⁵ needed.

In the work that we are going to describe, Beck intended to test the psychoanalytic hypothesis that he considered evident in clinical practice: depression is caused by self-hostility and, the via regia being the dreams of the unconscious, it is possible to corroborate this hypothesis if we analyze the dreams of depressed patients. Beck had already written a first paper about depression that was published in 1953 with Sigmund Valin, “Psychotic depressive reactions in soldiers who accidentally killed their buddies”. In this work they demonstrated a detailed analysis of hallucinations, fantasies and dreams and they found evidence of the self-hostility and the desire to be punished (Korman, 2013).

Beck probably chose to investigate this issue one more time for various reasons; on the one hand, for several years he had been working with depressed patients in private practice; on the other, he and his second analyst -Leon Saul- were conducting research about dreams (Saul, 1940; Saul & Sheppard, 1956); and, especially, because he thought the theory of depression was correct, therefore plausible to be tested in a research project (Weishaar, 1993).

Research on depression

In 1959, Beck and Hurvich wrote “Psychological correlates of depression: 1. Frequency of ‘masochistic’ dream content in a private practice sample”. This text marks the beginning of the systematic research about depression by Beck and his partners. It coincides with the obtaining of the research grant from the National Institute of Mental Health (Weishaar, 1993). In the same year, Beck became an assistant professor of Psychiatry at the University of Pennsylvania.

We will guide ourselves using this text with the aim of describing the main ideas that it exposes and the new research technologies with which the researcher tests his hypotheses.

The text begins by citing the work of Sandor Rado, “Psychodynamics of Depression from the Etiologic Point of View” (1951), to suggest that depression has been seen as a psychosomatic disorder, and to describe some aspects and conditions of neurotic depressions. Ten of the fourteen citations in the text corresponds to authors framed in the psychoanalytic model; there is a reference to the description carried out by Abraham in 1911 regarding manic depressive psychosis and to the work of Freud “Mourning and melancholia” (1946).

In the text they express the difficulties to investigate, to generate control groups and to test dreams; mentioning the work that attempts to compare depressive patients to other groups of patients, as is in Gibson’s text (1957), which includes a comparison of depressed patients to a control group of schizophrenics. Following the reflections of (Saul, 1940), Beck points out that the manifest content of dreams is an important area of research, he observes that the application of quantitative methods with the purpose of evaluating psychoanalytic material can already be read in the work of (Alexander and Wilson, 1935).

The text mentions that Beck has been dedicated to the treatment of depressive patients for five years up until publication, and observes that the hypothesis about the self-hostility and the desire to self-punish can be corroborated in depressed patients. In this study, we analyze the accounts of dreams from six female patients diagnosed with neurotic depression, comparing them with six non-depressed patients in the same vital conditions (control group). All of whom were patients undergoing intensive treatment with Beck, two to four times a week, depending on the case.

The study shows an clear attempt to homogenize categories and find comparable parameters. Also, there are segments and details of what information will be included as a reference and what is discarded, leaving aside the “free associations, associations about the dream, residues of dreams during the day, and latent thoughts about the dream” (Beck & Hurvitch, 1959, p. 51).

To establish the diagnosis of neurotic depression, the patients had to present a combined characteristics group: 1 depressed emotional state, 2 discouragement, 3 unjustified pessimism, 4 feeling of not deserving the things they have - unworthiness-, 5 self-criticism and self-reproach, 6 inertia or apathy, 7 sleep disturbance, 8 anorexia, 9 suicidal fantasies, 10 physical signs such as psychomotor retardation, 11 weight loss, 12 melancholic faces, 13 crying and grief. Each patient considered as depressed would have at least eleven of the thirteen signs and diagnostic symptoms and not suffer from a psychotic process. These criteria were designed by the authors without reference to any operational diagnostic system although the DSM-I (1952) had already been published.

Based on the analysis of the patients’ dreams, the dreamer was observed to be rejected, disappointed, frustrated, or criticized during the dream. The term “masochism” is used to identificate (leaving out the sexual connotation of it), to designate the unpleasant characteristic of the dream, because in the manifest content the dreamer himself becomes the receiver of the critic, rejection or other kind of discomfort.

Simultaneous to the diagnostic process, there was an estimation of variables made to evaluate the socioeconomic class of them (they are rated as middle class or upper-middle class) and their intelligence (it is suggested that the sample has a regular intelligence). This kind of analysis is part of the methodological contributions set out by Marvin Hurvich.

The first twenty dreams in the treatment were reviewed by Beck; each was recorded and typed on individual paper sheets. A total of the 240 dreams compiled (20 per patient) were presented to the second author to rank the existence of masochistic elements. This evaluator did not know the patients. The other 220 dreams were evaluated by both evaluators, by blind evaluation, to estimate the reliability of the method, and the agreement occurred at 95%. We can understand this as an attempt to systematize research in a discipline and the investigation in a psychotherapy that occurred during a period of intense development.

Beck and Hurvich concluded that depressive patients have more masochistic dreams than patients from the control group (this group were Beck’s patients who did not present the eleven criteria that discriminate depressed from non-depressed people), although they did point out a kind of weaknesses in their own study and a need to continue the research:

The data confirm that the hypothesis of a higher incidence in depressive patients having dreams with masochistic content relating to non-depressed persons is proved. However this first study has to be improved to support this assertion. The group is very small, only considers women’s dreams and is a specific socio-economic group . . . thus, it is difficult to generalize these results. (Beck & Hurvich, 1959, p. 53).

Despite the shortcomings they point out, the authors confirms the hypothesis they expected to corroborate: that the cause of depression is self-hostility, a fact demonstrable by the higher incidence of dreams with masochistic content. Beck and Hurvich argue that:

The presence of the masochistic dream is the representation of a self-punitive tendency. This is consistent with the psychoanalytic view that depressed people direct hostility toward themselves. At the same time this is consistent with the fact that depressed people feel guilty about their own impulses and use this to resort to self punishment. (Beck & Hurvich, 1959, p. 54).

Fifty years after this research, Beck writes, with his colleague, Brad Alford (2009), an introduction for the reprint of the book Depression: causes and treatments, which was originally published in 1967. In this introduction, Beck and Alford review and explain the early work about depression and the writing process of the book. They return to the text about masochistic dreams in depressed patients and report that there are two psychoanalytic hypotheses to be considered: The first involves understanding that depression is a result of self-hostility and its manifestation in dreams is an expression of the unconscious; the second implies a different perspective in relation to masochistic dreams. These would be a habitual expression of the defensive patterns of the self more than the depressive state in itself. This second hypothesis was in regards to the investigation from 1959, although it did not constitute a relevant change to the study’s conclusions. The question posed by Beck and Hurvich oscillated between them: Are the masochistic elements in dreams explained by self-hostility or by a defensive process of the self? The observation that Beck makes at this time is that some patients who have masochistic dreams still present this pattern in depressive periods. This would mean that people with masochistic characteristics would have more predispositions to generate depression than those who did not have this tendency. At the end of the text, Beck and Hurvich point out the necessity to design another research projects on the patients who have already been depressed in the past, the researchers note that these patients still in treatment could be checked if the content of their dreams preserves the masochistic characteristics.

In pursuit of greater systematicity (1961-1962)

In this section we will comment on some publications written by Beck between 1961 and 1962, which were years of high academic productivity. In this period it is possible to perceive an attempt to intensify the knowledge about different subjects which are open in his previous work, to improve the sample in quantitative terms and continue confronting the different psychoanalytic hypotheses to explain the depression. During this stage, it is constantly necessary to clarify the ideas, returning to the questions that come from the first formulations made in 1959. The beginning of his research was based on a too general hypothesis which will be modified with the emergence of new questions and new explanations.

Recalling that “the father of Cognitive Therapy” has a marked identity as a psychoanalyst (Weishaar, 1993), as manifested in all of his publications of the period, even in those that we consider to be at the sidelines of his investigations about depression, such as the texts of 1961 “Psychodynamics of male homosexuality,” written with Leon Saul, or the text written with Marvin Stein “Psychodynamics.” A possible distribution of the texts, according to the theme, could be: dreams (Beck, 1961; Beck & Hurvich, 1961; Beck & Ward, 1961; Ward, Beck, & Rascoe, 1961), depression (Beck, 1961; Beck & Hurvich, 1961; Beck & Ward, 1961; Beck, Feshbach, & Legg, 1962) and the necessity to generate a reliable diagnostic categories (Beck, 1961, 1962; Beck et al., 1961; Beck et al., 1962; Ward et al., 1961).

The text “Dreams of depressed patients” (Beck & Ward, 1961) is a kind of general explanation of all his research about depression; he develops the general argument of his research in this text. He starts by quoting the article written with Hurvich in 1959 and marks an important change in regards to what was proposed years before. He no longer postulates as hypotheses for discussion but as a statement, the existence of a higher frequency of masochistic dreams in depressed patients and suggests the existence of a masochistic pattern that is still maintained even after the depression subsides. What was previously cataloged as a distinctive pattern now refers to a characteristic of the personality (not to the depression per se). This idea will have a significant weight because Beck was looking for what differentiates a depressed and a non-depressed state. If the hallmark of depression is not the masochistic dreams then maybe a search for another explanation to discriminate what is specific in depression is required.

This study will try to rectify the deficits of the preceding, due to the restriction of the text from 1959, among other shortcomings, by increasing the sample also increased the number of evaluators, so the need to systematize the criteria emerges. An attempt to achieve consistency in diagnosis for what is requested to evaluate depending on the DSM-I (American Psychiatric Association, 1952); nevertheless the degree of agreement they achieve is very low. Based on this problem, the intention is that the evaluators categorize the pathology distinguishing levels of the “depression”: lacking, mild, moderate or severe. Despite these considerations, the degree of agreement remained homogeneous: 56% of total agreement was achieved and 97% of approximate agreement (Beck, 1961).

The problem faced by Beck was that there was no agreement on the diagnosis of depression because professionals with similar experience used to classify the patients in a different way. This is how the need to design the “inventory of depression” arises, which appears in the text “An inventory for measuring depression” (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) to evaluate manifestations of depression from signs and symptoms classifiable. The characteristics are described based on the observation, symptoms and attitudes of depressed patients who undergoing psychoanalytic therapy.

The use of a questionnaire was sufficient to the utility of the ID tool (Inventory for Depression that would be later known as Beck Depression Inventory - BDI). In this study, the same manual was used to rank the dreams in 1959, with 228 dreams obtained. Beck increased the database and tried to continue thinking about the specificity of the depression.

Let us resume the central idea suggested by the text “A systematic investigation of depression” (1961), the search for the specific characteristics of depression.

Reviewing the literature, Beck finds two concepts which have been described as specific: hostility and guilt. He points out that recognizing the self-hostility was a fundamental concern in his work of 1953 (with Valin) and cites the 1959 study, written with Hurvich.

It was still possible to link these findings with both categories that were considered specific from the psychoanalytic model:

These discoveries were considered compatible with formulations of hostility and guilt in depression. Also, alternative interpretations were possible. A comparison of masochistic themes in dreams with specific symptoms and attitudes in depressive patients show interesting similarities. The typical self-degradation of the depressed person, exaggerating the failures and minimizing the achievements, wishing to hurt oneself or to commit suicide can be compared with the masochistic content of dreams in which the dreamer is degraded, fails to achieve what he seeks, and is injured or killed (Beck, 1961, p. 164).

In these dreams the person fails, is assaulted or suffers, just as it happens in wakefulness, when experiencing suffering and aggression. There is no difference between what the person experiences during the dream and during wakefulness. Thus, Beck considers another explanation. Although not clearly stated, there is the suggestion that depression could be explained by a neurotic process and not by self-hostility. The person suffers as much during the dreams as during wakefulness.

Beck attempts to describe the totality of the information collected, with the aim of explaining the reasons why he starts to doubt the hypothesis that he formulated in previous texts. In this work he adds new information that had not previously been published regarding a total of 162 patients; each patient was seen by two different psychiatrists who confirmed the diagnosis of depression. They were also evaluated with the Depression Inventory. Various measures were incorporated to evaluate the presence of masochism. Beck’s goal was to analyze the entire masochistic content in depressed patients, not only in dreams but in the overall life of the patient, incorporating different areas of analysis to evaluate the presence of masochism: the most recent dream, the first three childhood memories that come to the mind of the person, the answer to a test focused on the fantasy and the response to an inventory of masochism. This inventory, composed of 46 items to evaluate masochism and hostility, was never published (Beck, 1961). Each of these studies has specific characteristics; in fact, they were performed at different times and, many times, with different methodologies. Nevertheless, Beck considers that there was good amount of data to allow some inferences regarding depression. During the discussion regarding the data, it his doubts concerning the possibility of affirming with certainty the hypotheses of the presence of masochism in depression were already made clear. He suggests that the negative themes of dreams and the other material could simply reflect a subjective discomfort of the depressive state and would not necessarily imply an unconscious motivation to suffer. Beck suggests, considering that the data are inconclusive, that it is possible to propose that there are patients who still have masochistic dreams, once a reference to depression is made, and that there are patients who have never been depressed who have masochistic dreams.

His initial hypothesis - the existence of a relationship between masochism (or the need for suffering) and depression - seems to have lost the certainty that was with him in 1959, although it was not completely excluded. The conclusion tells us: it may be sustained but may also not be sustained, it is still necessary to explore the theme.

One year later, Beck developed a new study with Feshbach and Legg, “The clinical utility of the digit symbol test”, published in the Journal of Consulting Psychology in 1962. In this work they publish their observations and conclusions about the use of the Digit Symbol test in depressed patients. Patients were considered using psychomotor retardation associated with depression and it was presupposed (the presuppositon being shared by evaluators, patients and the bibliography of that time) that, in consequence of this, the results in the challenges requested by the test would be very poor. Beck mentions the work of (Rapaport, 1945), who reports having tested a group of depressives with a group of schizophrenics and found low scores in the depressed group in the Digit Symbol test. Beck points out that Rapaport’s work had some serious deficiencies in design. The group of depressive patients was significantly older than the schizophrenic patients. To avoid this deficit, he designs a test using digits and symbols; this is an extended form of the test used in WAIS (Wechsler Adult Intelligence Scale, a psychometric Intelligence test for Adults), which consists of giving the patient three minutes and increasing the items from 90 to 140 - and the vocabulary test developed by (Thorndike, 1942) in a sample of 178 psychiatric patients. The objective was to evaluate whether the depressive patients performed worse than the non-depressed patients. The results indicated that the performance in the Digit Symbol test was much more frequently related to the base pathology than with depression. For example, the schizophrenics obtained worse results than the depressed neurotics. The score decreased step by step when the parameters of intelligence and age were considered, and not the diagnosis of depression. When the patients had a lesser vocabulary, they scored lower on the test, independently of whether they were depressed or not. Based on the observations, it is postulated that the Digit Symbol test is not a good tool to evaluate depression. This proposition is opposite of that which Fisher obtained in 1949 to evaluate the changes in patients submitted for electroconvulsive therapy. Beck and his contributors postulated that people with depression do not perform worse than non-depressed people even though they perceive that they will do it wrong. Beck is one step away from postulating that in depression there is a distortion in the processing of information.

The following year Beck would publish what he considered to be the beginning of cognitive therapy (Beck, 2006; Beck & Alford, 2009; Weishaar, 1993): “Thinking and depression. I. Idiosyncratic content and cognitive distorsions” (1963). Beck totally changes the speech and makes a change of authors that is very striking. Different from what happened in previous articles and researches, quotes from psychoanalytic authors are not very common, while the number of references from foreign texts increases: of the eleven references, only one corresponds to a study based on psychoanalysis; and, even in this case, the appearance of this text is linked to certain basic ideas from which he tries to differentiate. References to more experimental studies appear more frequently in relation to the cognitive function in mental disorders.

Other factors that moved Beck away from psychoanalysis

Up to this point we have described the texts between 1959 and 1962 which led to a questioning of the psychoanalytic explanation of depression understood as self-hostility. To enrich this analysis it is necessary to describe personal and institutional factors that could have influenced Beck’s gradual withdrawal from psychoanalysis. Most of the personal information that we will describe in this section belongs to a publication written by historian Rachael (Rosner, 2014), who had access to Beck’s personal letters and notes.

Beck considered the Depression Inventory (Beck, et al., 1961) to be a great possibility of sustenance and economic progress for the department of psychiatry at the University. Kenneth Ellmaker Appel, director of the Department of Psychiatry at the University of Pennsylvania and one of Beck’s mentors⁶, was indifferent to this inventory. In the following year director Appel withdrew from the department and there was intense competition was for his former position at the University. Appel supported the young psychiatrist Marvin Stein to succeed him as director of the department. Beck collaborated with the majority of the members of the department, but he collaborated more and developed a bond of friendship with Marvin Stein (Rosner, 1999, 2012, 2014).

The Dean of the Medicine Faculty wanted psychiatrist Eli Robins, known for his criticism of psychoanalysis, to get the position. The department of psychiatry at the University of Pennsylvania was mainly psychoanalytic, and for that reason there was a revolt regarding the election of the Dean. In January, 1962, Apple encouraged the entire department of psychiatry to sign a petition against Robins. One of the members of the department, Albert Stunkard, refused to sign it because he did not know the applicant and it seemed inappropriate for him to sign a letter against someone he did not know, Beck took the same initiative and decided not to sign the letter (Rosner, 1999, 2014). After this request, the candidate for the Dean of Medicine, Robins, resigned to the postulation for the position. The Dean refused Marvin Stein as director and proposed the name of Stunckard as an alternative.

It is interesting to ask why Beck did not sign the request since not signing it implied a conflict at work and in personal relationships, not just with his colleagues but for not supporting the appointment of his friend Marvin Stein as director of the department. We do not have a clear explanation about this situation; we can only hypothesize that there was a certain situation of discontent with some kinds of psychoanalysis of the time and his psychoanalyst colleagues. In the same year, Beck was rejected as a candidate to join the American Psychoanalysis Association for the second time. Both times they based their rejection on the absence of monitoring (not considering the academic production and the obtaining of the research project). Almost all his colleagues in the department were part of this association. One of the rejections was because the patient’s cure was achieved in few sessions. Beck’s frustration with psychoanalysis occurred systematically. Leon Saul, his mentor and second analyst, who encourages him to investigate depression, rejected Beck’s invitation to write an article in which they would review some of the psychoanalytic hypotheses about depression. Beck, at this time, was beginning to wonder about the psychoanalytic ideas in regards to depression; his clinic experience did not support these hypotheses and for some time he did not believe in an unconscious desire as an explanation for depression.

The crisis in the Department of Psychiatry had great consequences for Beck’s writing. He needed to withdraw from institutional and teaching activity because of the fight between his friends and co-workers. The new director, Stunckard, authorized him to take a sabbatical, which ended up extending to a period of five years away from his teaching role at the university (Rosner, 2014). This extensive sabbatical impacted the development of the main ideas of cognitive Beckean therapy.

Final comments

In this paper we analyzed some of the ideas in the texts published between 1959 and 1962. We deployed theoretical explanations and methodological challenges with which Beck tried to test the psychoanalytic hypotheses on depression and how, based the results of these investigations, he began a gradual questioning of them.

In this short period of time, Beck and his collaborators tried to answer the questions of the research project through different publications.

In order to generalize their results they needed to increase the sample. By increasing the sample it is possible to observe the difference of the clinical criteria among the evaluators, for example, in the diagnosis of depression. This fact led him to develop the inventory of depression (BDI) which allowed them to obtain diagnostic criteria that were more homogenizable than clinical judgment. Repercussions of this work continue until the present day, because the BDI - in its second version - is today a widely used tool.

Another challenge faced by Beck was to achieve a greater specificity in the concepts used. The models generated by psychoanalysis used the same arguments to explain very different things: for example, the oral fixation could be used to understand depression but also alcoholism, schizophrenia and peptic ulcers, among others. The arguments were very generic, and the research conducted by Beck sought to understand the specificity of depression. Converting complex theoretical formulations, such as the proposal by Freud in “Mourning and melancholia” in measurable concepts, was a methodological challenge (Weishaar, 1993). Beck attempted to seek reliable measures for these concepts, and for this he designed different inventories (one of depression and another of masochism, although the last one was never published), generated conceptual categories (negative dream), and he used techniques ranging from an intelligence test, a test focused on fantasy, the Digit-Symbol test, vocabulary tests, among others, with the objective of evaluating and specifying depression.

Beck’s interest, to give scientificity to psychoanalysis, is a generational concern, and is reflected in the background he received from his mentors (Leon Saul, and David Rappaport, and others), who wished to put together experimental psychology and psychoanalysis. Even so, the policies of the National Institute of Mental Health in the United States encouraged those first systematizations with subsidies for clinical research. Beck obtained one of these subsidies which were not only important for economic reasons, but also as it made putting research groups together possible. During this process of investigating, Beck was influenced by his collaborators (Marvin Hurvich and Segmour Feshbach), who not only provided him with the tools of research methodology and statistical analysis, but also gave him the knowledge about the authors on which Beck would be based to formulate his first explanatory models of depression.

Based on the results of his research, Beck began to question the psychoanalytic postulates. At first he made two possible explanations for depression from the psychoanalytic model: The first is based on the fact that masochistic dreams result from self-hostility. The second is that hostility is produced by an unacceptable desire that returns in the same way as hostility. However, guilt and unacceptable desires were not identified in the manifest content of the dream. The depressed patients had masochistic dreams more often, but after the patient recovered from depression, the masochistic pattern was still maintained. This led him to affirm that masochistic dreams are not specific to depression. At the same time, when he administered the Digit-Symbol test and the vocabulary test with depressed and non-depressed patients, he found out that people with depression had no lesser performances than non-depressed people. He concluded that the depressive patients thought they performed badly, but their performance was not worse. What is interesting in this explanation is the idea of postulating depression as a distortion in the processing of information; although the conceptualization of automatic thoughts was developed for the first time in 1959 (Weishaar, 1993). Then, we ask: Why do not we find this information expressed in the texts we have analyzed? Only after breaking from his group, with which he shared his activities in laboratory and his daily life, did he end his process of moving away from unconscious theory and he stabilized his proposals on depression as a thought disorder. It is based on this isolation, and also on the disappointment with his group, as historian Rachel (Rosner, 1999, 2014) suggests, that Beck was ready to cross his Rubicon. This isolation was decisive in the development of his own theory, because of the elaborations and clinical observations that he systematized, and also because of the need for new academic links, which led him to reach out to behavioral therapists who began to work with cognition.

In the texts described in this article it is possible to observe that the psychoanalytic categories used do not explain depression, they are insufficient. After the publication in 1963 there was a change; the modification of postulating depression as a thought disorder. This crossing is part of many transformations that would resonate in the field of psychotherapy. The need to evaluate psychotherapeutic interventions and to transform psychotherapy into a scientific development would be one of the interests of the National Institute of Mental Health in the United States and, as we have already noted, it was with its financial backing that Beck was able to conduct his research on depression. While the National Institute of Mental Health endorsed his research, the American Psychoanalytic Association rejected it for the second time, which he found to be extremely irrational, without any clear arguments and leaving out all rationality (Rosner, 2014). The refusal of Leon Saul to reformulate the theory of depression will continue in this line, finding it difficult to question categories that, according to Beck, required changes.

Beck began to think of his intervention as an empirical approximation from those obtained in the field. The scientific method promoted by the National Institute of Mental Health would also be Beck’s strategy for his patients; test the thoughts of the patients, treat them as if they were hypotheses to be tested. It is not the therapist’s correction of thoughts based on a principle of authority. At the beginning of the Beckean model psychopathology was a deviation which should be discussed based on the data search that can confirm or reject the thoughts. The therapist and the patients behave as researchers, willing to evaluate thoughts as if they were hypotheses. It is not the therapist who has the authority, but rather the search for data from collaborative empiricism, which is the opposite of the principle of authority. It is the model of thinking about the validity of thoughts based on their results and their functionality.

The development of Beck’s works has a pragmatic view of psychotherapeutic practice and research, which is the product of the transformation generated in North American psychoanalysis by research policies, along with the new criteria of legitimacy of the practice that were given by this new field that began developement from 1950 onwards. Thus, research in psychotherapy will shape the new psychotherapeutic legitimacies we know today.

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Publication Dates

• Publication in this collection
  May-Aug 2017

History

• Received
  21 Mar 2016
• Accepted
  06 June 2016