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Figure 3.2 Aaron Beck

CBT emerged in the 1960s, associated most closely with Aaron Beck (shown in Figure 3.2) and Albert Ellis (Beck et al., 1979; Ellis, 1969). There were some important differences in their approaches: Ellis’ rational emotive behaviour therapy took a more confrontational, challenging approach to the client’s irrational beliefs, while Beck’s preferred method enabled clients to see the irrationality for themselves. However, the approaches shared the core theoretical claim that people’s difficulties are produced by strongly held, maladaptive beliefs and automatic thoughts, which were most likely learnt in familial and social environments. The merging of these ‘cognitive’ approaches with behavioural approaches happened gradually over the course of the 1960s and 1970s. Beck and Ellis were also interested in their therapies changing behaviour, as well as thoughts. Despite the apparent theoretical shift away from behaviourism in terms of the focus on internal thoughts and beliefs, some behavioural therapists embraced these new techniques. They saw that the fundamental emphasis of both approaches was still about learning and conditioning.

In the 1960s, both Beck and Ellis developed their techniques through practice by a process of client observation and by questioning the psychoanalytic theory of depression, in which they had previously been schooled. Their understanding of emotional disorders was built around the idea that depressive or anxious states were caused by a flaw in thought processing. Clients could be reasoned out of these unhelpful patterns of thinking through a process of interpersonal or group therapy, along with written exercises, reading and even (in Ellis’ case) therapeutic song lyrics for clients to sing to popular tunes.

This should also be viewed against the background of the ‘cognitive revolution’ in psychology in the 1960s, when information processing metaphors, driven by early computer technology, were used to challenge the previously dominant behaviourist approach to the mind (Baars, 1986). That said, neither Beck nor Ellis were actively reading developments in non-clinical academic psychology at the time, and it cannot be claimed that cognitive therapy was a direct application of cognitive science. It is perhaps no accident, though, that the image of the brain as an information processing machine came to be a prevalent concept in cultural discourse at the same time that cognitive therapy emerged.

Unlike psychoanalysis, it has only been in very recent years that CBT has begun to be historicised. Historian Rachael Rosner, through carefully researching Beck’s archival papers and extensive oral history interviews, has challenged the orthodox narrative that paints cognitive therapy as a rejection of psychoanalysis. As psychoanalysis – deemed outdated and inefficient – was phased out by the psychology department at the University of Pennsylvania where Beck worked, he had to generate new, scientifically valid approaches that would satisfy his superiors. His formulation of cognitive therapy allowed this, but while Beck agrees that he became disillusioned by the limitations of psychoanalysis during this time, he himself still saw cognitive therapy as essentially neo-Freudian. This may be disturbing to the identity of many CBT practitioners who see their approach as fundamentally different from, and superior to, psychoanalysis (Rosner, 2014).

Rosner has also written about Beck’s approach to ‘manualising’ therapy by delivering it in a way that was amenable to randomised control trials and evidence-based medicine. It became increasingly important to show that a particular psychotherapeutic approach could be evaluated to the same gold standard as other types of medicine. This developed as the Food and Drug Administration became a more powerful regulatory body, following the public outcry over the thalidomide crisis in the 1960s. It was in parallel with this that Beck designed methods to prove CBT’s efficacy (Rosner, 2018). In England and Wales, where the government-funded NHS already favoured randomised control trial data, CBT would become the gold standard.

The National Institute for Health and Care Excellence (NICE), after it was established in the UK in 1999, set out national guidelines for the treatment of particular conditions based on cost–benefit analysis and evidence of efficacy. Consequently, clinical psychologists set about providing evidence to ensure that CBT was included in the guidelines for the treatment of depression, alongside pharmacological interventions (NICE, 2004; Marks, 2015). But it took another few years before substantial government investment was made into the expansion of CBT, predominantly as a result of the initiative of the ‘happiness’ economist and Labour peer Richard Layard, who was concerned at the population-level effect of long-term anxiety and depression on national unemployment (Marks, 2015; Layard, 2011; Pickersgill, 2019). The invention and rise of cognitive behavioural therapies have been inextricably bound up with the increasing importance of evidence and economic efficiency in healthcare and, although the UK and the US have different systems for funding access to psychotherapy, their focus on randomised control trials goes some way to account for why they readily foster these approaches.

The success of cognitive and behavioural therapies has seen a number of other approaches – from mindfulness meditation to eye-movement desensitisation and reprocessing therapy – take shelter under the umbrella of ‘third-wave’ CBT. This suggests that the repertoire of psychotherapy is now much broader than merely a talking cure, with a wide range of approaches making use of the label.