Challenging Freud, starting a revolution

A residency requirement became a passion for one doctor and changed the field of psychiatry.

As a neurology resident at the Cushing VA Hospital in Framingham, Mass., Aaron T. Beck, M.D. ’46, was required to do a rotation in psychiatry. But what began as an academic obligation soon became a career-altering opportunity, as Beck saw the value of using psychological tools to help some patients.

“I got stuck in psychiatry and never got out of it,” Beck says today, five decades later. “In neurology there wasn’t much you could do in terms of treatment in those days. What fascinated me about psychiatry was that people with neuroses could actually be treated and made better.”

Beck went on to become one of the most influential figures in American psychiatry. As a young doctor in the 1960s, he challenged the theories of Sigmund Freud and triggered a revolution in psychology, founding a treatment method known as cognitive therapy. He recently received the 2004 University of Louisville Grawemeyer Award for Psychology, which includes a $200,000 prize, for his groundbreaking contribution to the field of psychology.

“He is the latest of the great system creators in psychotherapy,” says Bruce J. Rounsaville, M.D., FW ’78, professor of psychiatry at the School of Medicine. “In the same tradition as Sigmund Freud and Carl Rogers, he made a major difference in the way people approach psychotherapy.”

Early in his career Beck adhered to the teachings of Freud, specifically the value of psychoanalysis. But when he began noticing that his patients weren’t getting any better, he developed an alternative treatment that focused on the patient’s immediate feelings and perceptions rather than unearthing repressed fears and conflicts, as is central to Freudian psychoanalysis. “Since patients are aware of their conscious thoughts, it’s not as difficult [as traditional psychotherapy, which requires the exhumation of buried memories] to correct misperceptions,” he says during a phone interview from his office in Philadelphia.

Cognitive therapy is based on a specific understanding of how the human mind works, Beck says. “People with certain types of neurotic disorders distort the way they view themselves. They see through a negative lens, so all experiences are twisted around to something negative. Cognitive therapy offers strategies to identify that negative distorted thinking and to help the patient correct it.” Unlike adherents of Freudian psychotherapy, Beck doesn’t believe one has to trace the origin of an emotional problem in order to treat it. “It’s not necessary to go back to early trauma,” he says. “What’s important is addressing the problem that has arrived.”

Cognitive therapy has been used to treat a range of patients, from depressed housewives to schizophrenics. Most recently, Beck has applied his theories to analyzing the minds of terrorists. In his 1999 book, Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence (HarperCollins), Beck concludes that the terrorist mind-set is “just as distorted as those of neurotic patients.” He describes how terrorists make sweeping generalizations about their enemies. This, in turn, makes it easier to demonize them, so that the use of terror becomes equated, in the terrorist’s mind, with survival. Beck’s theories have been used by the National Center for Conciliation in Northern Ireland to help defuse tensions there.

Experts in the field of psychology at Yale agree that one of Beck’s most significant contributions is that he identified treatment components that could be tested empirically, and then he conducted the tests.

“Everyone has a therapy they think works,” says Alan E. Kazdin, Ph.D., the John M. Musser Professor of Psychology and director of the Child Study Center. “But Dr. Beck took it to the next step. He developed a therapeutic model, a therapeutic technique and then he did the research.”

Beck, who developed treatment techniques for depression, wanted to test the commonly held belief that there is a correlation between depression and suicide. Through controlled studies, which have been replicated, he was able to show that it’s not depression per se, but rather feelings of hopelessness (which may or may not be associated with depression) that are predictive of suicide.

“Dr. Beck was not only able to show the efficacy of cognitive behavioral therapy for depression, but along the way, he developed tools like the Beck Depression Inventory that have become staples of clinical research,” says John H. Krystal, M.D. ’84, the Robert L. McNeil Jr. Professor of Clinical Pharmacology and deputy chair for research for the Department of Psychiatry. He added that Beck’s work, while primarily directed toward psychotherapy research, has stimulated research on the common neurological mechanisms underlying psychotherapy and pharmacotherapy. “Many psychiatrists like myself found the emergence of cognitive behavioral therapy to be a factor that stimulated interest in the mechanisms underlying the interactions of pharmacologic and psychosocial treatments. Studying these complex interactions has become a major research focus.”

Kazdin says the treatment methods used for some aggressive and violent children at the Child Conduct Clinic, a specialty clinic affiliated with the Child Study Center, are “within the general rubric” of the techniques pioneered by Beck. “His techniques have been used primarily for adults diagnosed with depression and later, anxiety,” Kazdin says, “but there are variants of it that can be effective when used for children.”

“He’s grounded in the research tradition,” says Rounsaville. “He’s committed to seeing it through, to making sure his therapies meet the standards for efficacy.” Rounsaville, who is the director of the substance abuse treatment unit at Yale’s psychiatry department, said a new manual prepared by the unit draws on cognitive behavioral therapy techniques to help cocaine addicts. “This derives directly from Dr. Beck’s work,” he says.

Beck, 83, University Professor Emeritus of Psychiatry at the University of Pennsylvania School of Medicine and a member of the Institute of Medicine and the National Academy of Sciences, was awarded the Rhoda and Bernard Sarnat International Prize in Mental Health last year. He still has an active research unit at Penn, studying the effectiveness of treating schizophrenic patients with a combination of medication and cognitive therapy. He has written or co-written 17 books on cognitive therapy, depression and other emotional disorders.

Beck said Yale’s philosophy of encouraging students to be curious and critical taught him to play with ideas and not just memorize facts. “It was the best possible system for my own personal development,” he says. “I learned to have an open mind and treasure learning for its own sake.”

—Jennifer Kaylin

Familiar Faces

Public health alumna watches over a growing cohort of female veterans

Irene Trowell-Harris’ brothers and sisters must have thought she was joking when she pointed to a plane flying over their family’s farm in rural South Carolina and declared: “One day I’m going to fly and work on an airplane.”

“We all laughed,” recalls Trowell-Harris, R.N., M.P.H. ’73, Ed.D. It did seem unlikely on that day in 1954 that their 14-year-old sister would ever set foot on an airplane. The children lived in a farmhouse that initially lacked running water in Aiken, S.C., and attended an all-black school. True, if anyone from the family was going to make it, it might be Irene, the third of 11 children. “I always had a lot of responsibility. I was the one who always stayed focused, made sure everybody did their schoolwork and housework and farm work,” recalls Trowell-Harris.

Trowell-Harris did find a way to fly, as an Air National Guard nurse. And she rose steadily in the Air National Guard to reach the rank of major general—the first African-American woman to achieve that rank in the National Guard. A month after retiring from the Guard in September 2001, she accepted an appointment by President Bush as director of the Department of Veterans Affairs Center for Women Veterans. Her office monitors the welfare of the 1.7 million women who have served in the Armed Forces.

To get this far, Trowell-Harris combined realism with idealism. She made decisions that would give her maximum support in overcoming the barriers of poverty and racism. She chose nursing because she knew she would always have a job, and she sought a career in the military because its rules to some extent protected her against discrimination (although it was not until 1974 that Congress required the Armed Services to drop its 2 percent cap on women in the military).

“I wanted to be successful. … So I decided I would use my skills to work within the system. But all along, my goal was to help change the system later on, not just for myself, but for others.”

As director of the Center for Women Veterans, Trowell-Harris works to ensure that female veterans know about the benefits available to them, including inpatient and outpatient health care, counseling, insurance and home and business loans. She also works with veterans affairs committees in Congress to introduce legislation that benefits female veterans. For instance, Trowell-Harris helped back a new law that provides money and services for disabled children of women exposed to the herbicide Agent Orange in Vietnam.

Trowell-Harris notes that services to female veterans will become increasingly important as the proportion of women in the military increases. Women now constitute 6.5 percent of the nation’s 26 million living veterans, and the percentage will increase for two reasons: first, because the number of women in active service has risen, to 17 percent; and second, because male veterans, mostly from World War II, are dying at a rate of 1,400 per day.

Trowell-Harris was born just two generations away from slavery: her grandfather, Jim Trowell, was enslaved until he was in his early 20s. After the Civil War, a white family took him under its wing, bequeathing him 50 acres in South Carolina that Trowell-Harris’ parents gradually enlarged into a 200-acre farm. Trowell-Harris was born in the farmhouse in 1939 and grew up helping her parents raise cotton, corn, peas and watermelon and tend cattle, pigs and chickens. The family would pile into a mule-drawn wagon to go to town and to attend the Mount Hill Baptist Church on Sundays.

When Trowell-Harris finished high school, she considered her options. In 1955, “African-American females had three choices: secretary, teacher or nurse.” Nursing would not only provide steady work, but it would allow her to earn money as an aide while she was a student, helping finance college for her brothers and sisters. (Among them would be another nurse, a pilot, three small-business owners and a physician.)

Trowell-Harris earned her nursing diploma on a Friday in the spring of 1959, and by Monday she was working two jobs. A hurricane had destroyed the family farm, and she was helping her family financially. “I felt frustrated, but I knew if I didn’t help, we would lose the whole farm.” It took two years for the family to get back on its feet, and then Trowell-Harris went north. She got further training as a psychiatric nurse at New York Hospital-Cornell Medical Center in White Plains, and then relocated to New York City where she would work for 20 years. There she heard from a fellow nurse about the Air National Guard.

She signed up in 1963, and a year later she flew for the first time. On weekends, during vacations and during stints of active duty, she worked as a flight nurse on jets evacuating patients from battlefields, and she saw the world.

While serving in the Air National Guard, she spent two years at Yale studying for her master’s in public health. The School of Public Health recognized her in June 2001 by naming her to its Alumni Public Service Honor Roll. She also earned her doctorate in education from Columbia University.

Now, in her spare time, Trowell-Harris attends the nationally known Mount Olive Baptist church in Arlington, Va., plays racquetball and rides on the bike trails near her suburban Virginia home. She was married for a decade, divorcing in 1983, and has no children, but she has helped 14 of her 32 nieces and nephews pay for college. At the family reunions she organizes every three years, she tells them to stay in touch, to keep their lives in balance and to keep learning. She advises them “to turn obstacles into steppingstones” and that persistence pays off. One of her stories illustrates this: early in her career in the Guard, a chief nurse warned her that she’d never make it past major, “no matter how good I was. I just thanked her and said ‘OK.’” She went four ranks beyond major, to major general.

“Why do you think I have worked so hard within the system?” she asks. “To get it changed.”

—Cathy Shufro

“Population doctor” applying tools of genomics in quest for prevention strategies

Seven years after his graduation, Gualberto Ruaño, Ph.D. ’92, M.D. ’97, isn’t content to treat one patient at a time. Instead he is continuing a long-term effort to personalize medicine through a population approach. “I really think of myself as treating the world,” he said.

From 1992 to 1996, Ruaño was chief scientific officer and then CEO at BIOS Laboratories, a New Haven-based company that manufactured and sold genetics research products. Then, in 1997, he founded Genaissance Pharmaceuticals, a personalized medicine company that uses genomic data to guide drug-discovery strategies. Led by Ruaño as CEO, Genaissance went public in 2000, and the company is still operating at Science Park in New Haven, but Ruaño decided the time was right for a shift in focus—away from treatment and toward prevention.

Last autumn Ruaño launched Genomas, a company that will market diagnostic systems using genetic and physiological markers to assess nonpharmacological strategies for improving patient health. Ruaño predicts that prevention of obesity will be the first significant application of this technology.

“It’s time to look at prevention with the same level of seriousness as we think of drugs,” he said. “Everyone knows that prevention is good, but the results have been very mixed at best. … Now the obesity epidemic will force us in the medical profession to apply cutting-edge science to develop strategies to optimize prevention.”

The goal of Genomas is to apply genomic technologies to understanding the way genes influence patients’ responses to diet, nutrition, exercise and environmental exposures. The first step is to conduct research that will be as exacting and scientifically based as the controlled clinical trials that are required when new drugs are developed. “We have to find out what the genetic markers are and evaluate them,” Ruaño said. At this point Genomas has a handful of employees and is self-funded, but it has licensed research findings in exercise genetics, and in June it became a bricks-and-mortar entity. Ruaño and Hartford Hospital announced a collaboration to explore the role of genetics in the ways people lose weight and respond to exercise. As part of their collaboration Genomas moved into office and laboratory space at the hospital.

Ruaño’s aim is nothing short of creating an operating system for health care of the future. “The more we can customize care based on DNA, the more we can use our understanding of genomics to improve life and create new industries.” But he’s not stopping there. The next step, he said, is mental health. “Psychology is also influenced by the variability in people’s genes, but stay tuned. That’s for the next story.”

—Jennifer Kaylin


			Originally published in Yale Medicine, Summer 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.