Manualizing psychotherapy: Aaron T. Beck and the origins of Cognitive Therapy of Depression

Abstract

This paper examines the origins of psychiatrist Aaron T. Beck’s 1979 Cognitive Therapy of Depression (CTOD). CTOD was the first psychotherapy manual designed to be used in a randomized controlled trial (RCT). Making psychotherapy amenable to the RCT design had been a ‘holy grail’ for leading American psychotherapy researchers since the late 1960s. Beck’s CTOD – which standardized his treatment so it could be compared with drug treatments in a clinical trial – delivered that holy grail, and ushered in the manualized treatment revolution. Manuals are now a sine qua non in psychotherapy research. In this paper, I explore some of the personal, political, and economic variables that made the idea of a manual irresistible to Beck and to those who first championed him.     

Design of randomized controlled trials: Principles and methods applied to a treatment for early stuttering

The “gold standard” methodology for treatment efficacy research is the randomized controlled trial (RCT), which is used extensively in medical research and in other areas such as psychology. Results from a well designed and conducted RCT, which show a new treatment to be clinically and statistically superior to current standard practice, can lead to a change in clinical practice. This paper presents a tutorial on RCTs, presenting and discussing the following principles and methods: the trial protocol, choice of control treatment, eligibility criteria, random allocation, outcomes and hypotheses, sample size, subject recruitment, analysis by intention to treat, interim analysis, stopping rules, safety data monitoring/trial management, and study documentation. RCTs are a complicated and logistically involved methodology. Hence, prior to the commitment of resources to such a trial in the development of a new treatment, the safety and clinical promise of the new treatment needs to be demonstrated with preliminary studies. Such preliminary studies have been completed for the Lidcombe Program (LP) of early stuttering intervention, and an RCT of that treatment is being conducted at the time of writing. The principles and methods of RCTs are illustrated with reference to that study.

Educational objectives: The reader will understand the design principles and methods of RCTs. The reader will understand the logistics of conducting a RCT of a treatment for early stuttering.     

Addressing confounding errors when using non-experimental, observational data to make causal claims

In their recent book, Is Inequality Bad for Our Health?, Daniels, Kennedy, and Kawachi claim that to “act justly in health policy, we must have knowledge about the causal pathways through which socioeconomic (and other) inequalities work to produce differential health outcomes.” One of the central problems with this approach is its dependency on “knowledge about the causal pathways.” A widely held belief is that the randomized clinical trial (RCT) is, and ought to be the “gold standard” of evaluating the causal efficacy of interventions. However, often the only data available are non-experimental, observational data. For such data, the necessary randomization is missing. Because the randomization is missing, it seems to follow that it is not possible to make epistemically warranted claims about the causal pathways. Although we are not sanguine about the difficulty in using observational data to make warranted causal claims, we are not as pessimistic as those who believe that the only warranted causal claims are claims based on data from (idealized) RCTs. We argue that careful, thoughtful study design, informed by expert knowledge, that incorporates propensity score matching methods in conjunction with instrumental variable analyses, provides the possibility of warranted causal claims using observational data.     

Beyond a single standard: levels of evidence approach for evaluating marriage and family therapy research and practice

Randomized clinical trial (RCT) research has come to dominate the research landscape of marriage and family therapy (MFT). Despite becoming the ‘gold standard’ for evaluating clinical research and clinical practices, there is a growing debate regarding the reliance on RCTs as the primary basis for evaluating clinical intervention in MFT. Given the natural diversity of clients, settings and clinical problems faced by practitioners and the relational and recursive interactional process of MFT, one of the major challenges for the field of MFT will be to come to grips with the research–practice gap by moving beyond a single methodological standard through adopting a ‘levels of evidence’ approach as a framework that promotes diverse research methods, different methodological criteria (depending on the method), and evaluation based on the accumulated type of evidence needed to answer a specific policy, clinical practice choice, or within a model clinical decision.     

Jean Baker Miller,MD, Visionary Pragmatist

ABSTRACT

Jean Baker Miller’s 1976 book, Toward a New Psychology of Women, was an overnight success. It struck a deep chord in many women because it was based on listening to women’s stories. Instead of seeing women through the lens of male psychology with its emphasis on separation and autonomy, Jean suggested that relationships are central to women’s experience of themselves and the world. Traits that were typically pathologized (needing other people, attending to the messages of emotions, wanting to participate in growth fostering relationships for all involved) were revisited by Jean and her colleagues who discovered strengths where others had seen weakness. The resulting work is known as Relational-Cultural Theory (RCT) and has offered new understandings of women’s and men’s development with a special emphasis on the impact of power and marginalization on personal and collective wellbeing. Jean’s work is carried forward by members of a collaborative group with whom Jean worked for many years. RCT theorists have written and edited over 20 books, 115 works in progress, and numerous chapters and articles that continue to elaborate on Jean’s groundbreaking work. RCT is applied to both clinical and social justice settings. Jean was devoted to contributing to the creation of a more just society.     

Spirituality and spiritual care – missing concepts from core undergraduate children’s nursing textbooks

Background: Spiritual care is espoused to be fundamental in children’s nursing; however, the extent to which current fundamental children’s nursing textbooks support and advocate spiritual care delivery by children’s nurses and nursing students is unknown. Aim and objectives: To examine whether or not fundamental undergraduate children’s nursing textbooks include spiritual care content. Methods: Five hundred and nineteen books were sampled from the Nursing and Midwifery Core Collection list (UK) using a survey, the Spirituality Textbook Analysis Tool (STAT) to collect data. Analysis and Results: 519 books were included in the study using the STAT and 13 books included content on children’s spirituality. There were a variety of textbooks in the audit of those that made reference to the search terms in the STAT, it was found that content mainly addressed only two areas; religious faiths and the dying child. Recommendations: Children’s nurses require education about children’s spiritual developmental stage and age appropriate spiritual assessment. A lack of detailed information in core children’s nursing textbooks means that this area of nursing practice may be taught as an adjunct to care and not as an element of holistic care which is the gold standard that children’s nurses should strive for.     

Personalizing Behavioral Interventions Through Single‐Patient (N‐of‐1) Trials

Behavioral interventions are typically studied with the use of a conventional between‐subject randomized controlled trial (RCT) design. In this design, the effect of an intervention on one group of patients is compared with the effect of a control condition on another group of patients, such that a between‐subject change is tested. A between‐subject design has an underlying assumption that there is a homogenous treatment effect for a behavioral intervention, drug, or psychotherapy and that the way the intervention operates in the study will tend to operate in the same way in many other patients. We review some of the philosophical and practical problems with the use of this design when a clinician is attempting to decide on a course of behavioral treatment aimed at within‐subject change in patients who are likely to have heterogeneous or unique responses to behavioral treatment. We also review the biases inherent in our current clinical practice model, which does not use any empirical data collection or design for testing if a treatment is useful, and also in the conventional between‐subject personalized medicine RCT designs. We propose increased use of single‐patient (also known as N‐of‐1) trials that employ within‐subject designs, in cases where treatment response is heterogeneous – as is the case for most psychological and behavioral treatments. Limitations of such designs include that they can only be used when the treatment is potentially reversible, the patient can act as their own control, and the outcome can be measured repeatedly. Increased use of within‐subject trials may address in many more instances the more clinically relevant question of how a specific patient will respond to a specific treatment and could introduce a more harmonious scientific approach into the way we treat our patients. We have incorporated a case presentation that illustrates the complexities of applying evidence drawn from these different designs to selecting and evaluating treatments for the behavioral issues commonly faced by clinicians and patients.     

Facing being: the significance of Thomist ontological epistemology to realism in post-Kantian philosophy

The Kantian ‘Copernican Revolution’ contained in his Prologomena and The Critique of Pure Reason deemed metaphysical statements to be ‘transcendental illusions’, so directing metaphysics to its dearth. As a consequence, no longer could objects be known ‘in-themselves’ by the sensorily-reliant human. This perceived impossibility of metaphysical knowledge in the turn to the subject from Kant through Nietzsche's rejection of true knowledge has heavily inclined Continental Philosophy to an anti-metaphysical quandary. Analytic Philosophy is no different following the influence of Carnap, Wittgenstein and Rorty upon its own ‘linguistic turn’. An inevitable consequence of things not being knowable in themselves is the philosophical distance from ‘the world’, which Stephen Hawking has argued, makes the philosophical enterprise ‘dead’. In dialogue with this widespread decline in metaphysics, I will attempt to reclaim realist metaphysics through the employment of a Thomist paradigm. If philosophy is to be relevant to the knowledge economy, it is compelled to be in relation with what is. Thus, in my theoretical framework, being will be considered as central to all knowledge systems seeking to correspond to ‘hard’ science. The Thomist realist natural philosophy of ‘scientia’ – wherein truth is conformed with being – will be at the core of the argument. This paper challenges the ignoring of being because extant reality is composed of all that is, continuously faced and never evadable. Consequently, Thomism is recaptured as significant to post-Kantian philosophy as Aquinas articulated a means through which the thinking subject engages with being through sensation and cognition.     

Fixing Descartes: Ethical Intellectualism in Spinoza's Early Writings

This paper aims at reconstructing the ethical issues raised by Spinoza's early Treatise on the Emendation of the Intellect. Specifically, I argue that Spinoza takes issue with Descartes’ epistemology in order to support a form of “ethical intellectualism” in which knowledge is envisaged as both necessary and sufficient to reach the supreme good. First, I reconstruct how Descartes exploits the distinction between truth and certainty in his Discourse on the Method. On the one hand, this distinction acts as the basis for Descartes’ epistemological rules while, on the other hand, it implies a “morale par provision” in which adequate knowledge is not strictly necessary to practice virtue. Second, I show that Spinoza rejects the distinction between truth and certainty and thus the methodological doubt. This move leads Spinoza to substitute the Cartesian Cogito with the idea of God as the only adequate standard of knowledge, through which the mind can attain the rules to reach the supreme good. Third, I demonstrate that in the Short Treatise Spinoza develops this view by equating intellect and will and thus maintaining that only adequate knowledge can help to contrast affects. However, I also insist that Spinoza's early epistemology is unable to explain why human beings drop conceive of the idea of God inadequately. Thus, I suggest that in his later writings Spinoza accounts for the insufficiency of adequate knowledge in opposing the power of the imagination and passions by reconnecting the nature of ideas with the mind's conatus.     

The Distinction between Reason and Intuitive Knowledge in Spinoza's Ethics

While both intuitive knowledge (scientia intuitiva) and reason (ratio) are adequate ways of knowing for Spinoza, they are not equal. Intuitive knowledge, which Spinoza describes as the ‘greatest virtue of mind’, is superior to reason. The nature of this superiority has been the subject of some controversy due to Spinoza's notoriously parsimonious treatment of the distinction between reason and intuitive knowledge in the Ethics. In this paper, I argue that intuitive knowledge differs from reason not only in terms of its method of cognition—but also in terms of its content. More specifically, I maintain that there is something that is known by intuition, namely the unique essences of things, that is not known by reason. My argument is supported by an examination of Spinoza's account of essences in the Ethics, which reveals that he is committed to both unique and shared essences. Based on this dual commitment, I argue that whereas for Spinoza both reason and intuition can be said to reach adequate knowledge of the shared essence of a thing, the unique essence of a singular thing, which is nothing but its actual essence, can only be known through intuitive knowledge.     

Alter-Standardizing Clinical Trials: The Gold Standard in the Crossfire

ABSTRACT

The international landscape of medical research is in the midst of a process of diversification and change. The randomized controlled trial (RCT), long considered the global gold standard for clinical research, has become increasingly contested and is partly replaced by alternative methodologies, standards and forms of evidence. The contours of mainstream medical research are changing as a result. Regulatory paradigms and standards are, literally, being rewritten, at a global level. The evidence-based medicine (EBM) hierarchy of evidence is redefined. This special issue explores these developments through the concept of ‘alter-standardization’. The term refers to the processes, controversies and negotiations through which multiphase RCTs and the EBM system are challenged and gradually superseded by alternative methodological and regulatory forms and standards. This special issue examines the conceptual, practical and theoretical implications of these changes, and the ways in which these transformations influence the situation and possibilities of patients, knowledge producers, physicians, large pharmaceutical corporations, smaller biotech companies, as well as regulatory bodies, civil societal organizations and national health care systems. The articles in this special issue make use of comparative and historical perspectives that focus on scientific, social, economic and regulatory developments in the European Union, China, India, Japan, Argentina, the UK and the USA. They show that the alter-standardizing of clinical trials arises in a pluralistic way, that is driven by a variety of often conflicting factors, developments and expectations. These changes reflect a broad transformation in the culture and politics of biomedicine today, with implications for the ways in which new medicinal products, devices, procedures and technologies are developed, approved for clinical use, sold to consumers, and licensed by health care systems.     

Derrida's “Antigonanette”: On the Quasi‐Transcendental

In this article, I rely both on Derrida's 1974 work Glas, as well as Derrida's 1971–72 lecture course, “La famille de Hegel,” to argue that the concept of the quasi‐transcendental is central to Derrida's reading of Hegel and to trace its implications beyond the Hegelian system. I follow Derrida's analysis of the role of Antigone—or, as the lecture course has it, “Antigonanette”—in Hegel's thought to argue that the quasi‐transcendental indicates a re(con)striction of empirical difference into the transcendental, which is thereby only ever provisionally transcendental. I then argue that the economy of difference indicated by the quasi‐transcendental is neither a general economy, nor is it in each case singular, but rather it ambivalently oscillates between these two. Finally, I treat the temporality of the quasi‐transcendental, arguing that the economy of difference indicated by the quasi‐transcendental is not prior to the re(con)striction of empirical difference, but is paradoxically produced by it by being retroactively constituted. I take up this analysis for the sake of describing what I contend is the quasi‐transcendental structure of constitutive exclusion, a way of understanding the conceptual structure of political bodies, and the political structure of concepts.     

What's Formal about Formal Indication? Heidegger's Method in Sein und Zeit 1

Against the background of a recent exchange between Cristina Lafont and Hubert Dreyfus, I argue that Heidegger's method of “formal indication” is at the heart of his attempt in Sein und Zeit to answer “the ontological question of the being of the ‘sum’” (SZ, p. 46). This method works reflexively, by picking out certain essential features of one's first-person singular being at the outset of its investigation that are implicit in the question “what is it to be the entity I am?” On the basis of these features, various further a priori, ontological structures (care and temporality) that constitute one as a first-person singular entity then become accessible. Formal indication is thus formal in two senses: it officially designates or signals certain first-person singular phenomena as the topic of investigation, and it picks out features which define the ontological form of the entity in question. It is thereby the method by which a legitimately transcendental account of our being may be begun to be generated by each of us from out of our factical, immanent existence.     

Improving the quality of medical care: the normativity of evidence-based performance standards

Poor quality medical care is sometimes attributed to physicians?? unwillingness to act on evidence about what works best. Evidence-based performance standards (EBPSs) are one response to this problem, and they are increasingly employed by health care regulators and payers. Evidence in this instance is judged according to the precepts of evidence-based medicine (EBM); it is probabilistic, and the randomized controlled trial (RCT) is the gold standard. This means that EBPSs suffer all the infirmities of EBM generally??well rehearsed problems with the external validity of research findings as well as the inferential leap from study results in the aggregate to individual patient care. These theoretical weaknesses promise to have a practical impact on the care of patients. To avoid this, EBPSs should be understood as guidelines indicative of average effectiveness rather than standards to be applied in every case.     

Are clinical diagnoses of Alzheimer's disease and other dementias affected by education and self-reported race?

A randomized controlled trial examined whether the diagnostic process for Alzheimer's disease and other dementias may be influenced by knowledge of the patient's education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, "gold standard" diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the "knows race only" group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the "knows race only" group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer's disease prevention, the authors of which called for information about and standardization of the diagnostic process. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Monism and Material Constitution

Are the sculpture and the mass of gold which permanently makes it up one object or two? In this article, we argue that the monist, who answers ‘one object’, cannot accommodate the asymmetry of material constitution. To say ‘the mass of gold materially constitutes the sculpture, whereas the sculpture does not materially constitute the mass of gold’, the monist must treat ‘materially constitutes’ as an Abelardian predicate, whose denotation is sensitive to the linguistic context in which it appears. We motivate this approach in terms of modal analyses of material constitution, but argue that ultimately it fails. The monist must instead accept a deflationary, symmetrical use of ‘materially constitutes’. We argue that this is a serious cost for her approach.     

Using experiential optimization to build lexical representations

To account for natural variability in cognitive processing, it is standard practice to optimize a model’s parameters by fitting it to behavioral data. Although most language-related theories acknowledge a large role for experience in language processing, variability reflecting that knowledge is usually ignored when evaluating a model’s fit to representative data. We fit language-based behavioral data using experiential optimization, a method that optimizes the materials that a model is given while retaining the learning and processing mechanisms of standard practice. Rather than using default materials, experiential optimization selects the optimal linguistic sources to create a memory representation that maximizes task performance. We demonstrate performance on multiple benchmark tasks by optimizing the experience on which a model’s representation is based.

     

Formality of logic and Frege’s Begriffsschrift

This paper challenges a standard interpretation according to which Frege’s conception of logic (early and late) is at odds with the contemporary one, because on the latter’s view logic is formal, while on Frege’s view it is not, given that logic’s subject matter is reality’s most general features. I argue that Frege – in Begriffsschrift – retained the idea that logic is formal; Frege sees logic as providing the ‘logical cement’ that ties up together the contentful concepts of specific sciences, not the most general truths. Finally, I discuss how Frege conceives of the application of Begriffsschrift, and of its status as a ‘lingua characteristica’.     

Historiography taking issue: analyzing an experiment with heroin abusers

This article discusses the predicament of historians becoming part of the history they are investigating and illustrates the issue in a particular case. The case is that of the randomized controlled trial (RCT)-more specifically, its use for testing the effects of providing heroin to severe heroin abusers. I counter the established view of the RCT as a matter of timeless logic and argue that this research design was developed in the context of administrative knowledge making under twentieth-century economic liberalism of which it epitomizes some central values. I also argue that the applicability of the RCT depends on the degree to which its advocates can define the issue to be studied according to its inherent values. Next, I demonstrate how advocates of an RCT with heroin provision in the Netherlands steered the political discussion on heroin provision and how the values of economic liberalism also shaped the results of the Dutch maintenance experiment. In addition, I relate how my analysis of this experiment became part of political debates in the Netherlands. Contrary to my intentions, adversaries of heroin maintenance used my critique on the heroin RCT as an argument against heroin maintenance. Such risks are inherent to historiography and sociology of science aiming at practical relevance while challenging treasured scientific beliefs. I conclude that it still seems better to expose arguments on unjustified certainties than to suppress them for strategic reasons.