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.     

Collaboration and Guided Discovery

Collaboration and guided discovery, collectively described as collaborative empiricism, are two primary features of Aaron T. Beck’s Cognitive Therapy (CT) that remained central to his work throughout his long and productive career. This commentary highlights how collaboration and guided discovery were described during the early development of CT. In addition, conversations with Beck are cited that reveal how his own life may have influenced their inclusion and importance in his therapy.     

Obsessions and Compulsions

Aaron T. Beck, M.D., is among the most impactful figures in the entire history of mental health treatment and his ideas have made important contributions to the understanding and treatment of OCD. I am honored to have the opportunity to write this essay in his memory. His legacy of alleviating suffering and improving the lives of people with emotional problems, and taking the time to carefully train others who continue this important work, will live on.     

A Special Feature in Commemoration of Aaron T. Beck’s Contributions to the Science and Practice of CBT

This special feature in Cognitive and Behavioral Practice is a commemoration to Aaron T. Beck’s contributions to the science and practice of CBT. The fact that so many leading scholars participated, including several Past Presidents of the Association for Behavioral and Cognitive Therapies, speaks volumes about the high regard held for Beck. Included are papers that cover the Beckian model of depression, its refinement and application to obsessions, compulsions, hoarding, as well as how the model addresses interpretational biases in emotional psychopathology and has been adapted for youth. Additionally there are papers conveying how Beck’s phenomenological approach to understanding the client’s perspective is useful in attending to cultural differences, and in mitigating the mental health impact of marginalization and discrimination. Expert commentaries are extended to relational processes (case formulation, therapeutic relationship, collaboration and guided discovery, alliance, rupture repair, homework), change processes (cognitive reappraisal, dialectical thinking, acceptance and defusion, emotional schemas), and to important scientific advances (conceptualizing processes within techniques, data analytic advances that bridge the scientist-practitioner gap, and technology augmentation). Many of the contributions herein also include brief personal stories to help illustrate the enormity of Beck’s contributions.     

Hoarding

This commentary highlights areas of research during my career that have been very positively influenced by Dr. Aaron T. Beck’s work on cognitive theory, assessment, and treatment of behavioral disorders. These include collaborative efforts to develop assessment of beliefs and interpretations, as well as cognitive therapy for obsessive-compulsive disorder, and especially recent work on assessing, understanding beliefs about possessions, and cognitive behavior therapy for hoarding disorder.     

Data-Informed Advances and Technology Augmentation

The augmentation of technology to the delivery of CBT has enormously increased in recent years. This commemoration of Dr. Aaron T. Beck’s contribution to the field focuses on examples such as CBT internet treatments, video treatments, but especially on data-informed CBT, precision mental health and digitally based treatment navigation systems. It ends with an outlook on continuous outcome measurement as the basis for a broader understanding of clinical concepts and data-driven clinical practice in the future.     

Mitigating the Mental Health Impact of Marginalization and Discrimination

In honor of the life and work of Aaron T. Beck, this paper describes the application of cognitive therapy to management of marginalization stress among minoritized communities. Collaborative empiricism, cognitive restructuring, and behavioral interventions are highlighted as being particularly useful in a contemporary multicultural approach for the anxiety, depression, stress, and other sequelae of marginalization due to a stigmatized identity. Although primarily illustrated through recent work with transgender and gender diverse adults, the discussion extends to other groups including racial, ethnic, and sexual minorities and immigrants. This work illustrates the power of Dr. Beck’s approach to address the presenting concerns of contemporary clinical work.     

Phenomenology and Cultural Considerations

The author discusses how his early exposure to Dr. Beck’s work shaped and directed his development as an emerging psychologist. Focusing on Beck’s assessment of hopelessness, the author discusses how he developed an appreciation for both the multidimensionality and multifunctionality of the construct in his own works focusing on cultural differences. The author argues that Beck’s early strategy to use a phenomenological approach to understanding clinical conditions remains important for appreciating the different functional meanings that cognitions might embody for different individuals.     

Homework

In commemoration of Dr. Aaron T. Beck’s enormous contributions to our field, I comment on the state of our knowledge regarding the role of homework in cognitive behavioral therapy. The available evidence suggests homework is a contributor to positive therapeutic outcomes in cognitive behavioral therapy. Although therapists play an important role in facilitating clients’ engagement with homework as they develop greater facility with CBT skills, little is known about the contributions of specific approaches to promoting homework engagement. I highlight some of these strategies and discuss the need for researchers to empirically evaluate them.     

Introduction to the Beck Commemorative Special Feature

My father, Aaron Beck (“Tim” to those closest to him), would have been proud of this special issue of Cognitive and Behavioral Practice, and so honored. Anyone who knew my father, knew he was a scientist at heart. His curiosity, intelligence, and humility made him a great scientist and a productive researcher. This introduction shares a personal perspective and context for his contributions, including his lifelong commitment to enhancing the evidence for cognitive and behavioral practice.     

Alliance

The alliance highlights the qualities of coordination, sincerity, and trust that run through the various (CBT) interventions. This commemoration of Dr. Aaron T. Beck’s contribution to the field focuses on the alliance that emerges as one of the best-studied process characteristics in psychotherapy, with hundreds of studies on different orientations, treatment conditions, and mental health services. Overall, there is a robust meta-analytic predictive relation between alliance during therapy and therapy outcome (Cohen's d = .58). However, socio-cultural aspects such as the existence of substance use disorder or ethnic minorities partly moderates this relation. In addition, therapist effects are likely. Clinical implications are discussed based on the excellent meta-analytic empirical evidence.     

Acceptance and Defusion

The waves and generations of behavioral and cognitive therapy are normal features of a progressive science. Two of the key processes in modern CBT are briefly examined: defusion and acceptance. Both had important antecedents in the work of Aaron Beck, among others; at the same time, they both represent meaningful changes. This dialectic of continuity and change is to be celebrated—it means our current work stands on the shoulders of past intellectual giants. The entire field owes a permanent debt of gratitude to Aaron T. Beck.     

Aaron T. Beck's drawings and the psychoanalytic origin story of cognitive therapy

In this essay the author challenges the standard origin story of cognitive therapy, namely, that its founder Aaron T. Beck broke with psychoanalysis to pursue a more pragmatic, parsimonious, and experimentalist cognitive model. It is true that Beck broke with psychoanalysis in large measure as a result of his experimental disconfirmation of key psychoanalytic ideas. His new school of cognitive therapy brought the experimental ethos into every corner of psychological life, extending outward into the largest multisite randomized controlled studies of psychotherapy ever attempted and inward into the deepest recesses of our private worlds. But newly discovered hand-sketched drawings from 1964 of the schema, a conceptual centerpiece of cognitive therapy, as well as unpublished personal correspondence show that Beck continued to think psychoanalytically even after he broke with psychoanalysis. The drawings urge us to consider an origin story much more complex than the one of inherited tradition. This new, multifaceted origin story of cognitive therapy reaches beyond sectarian disagreements and speaks to a broader understanding of the theoretical underpinnings of cognitive therapy.     

Cognitive Reappraisal

A central tenet of Beck’s cognitive therapy (or cognitive behavior therapy) of the emotional disorders is that change in negative thought and beliefs is necessary for clinically significant symptom reduction in anxiety, depression, and other psychological conditions. Cognitive restructuring, a uniquely Beckian innovation, is a treatment strategy that directly targets cognitive reappraisal as the change mechanism responsible for symptom reduction. This commentary considers the origins of cognitive reappraisal in Beck’s cognitive therapy through the lens of cognitive restructuring and what treatment process research tells us about the mechanisms of change in cognitive restructuring.     

Interpretational Biases in Emotional Psychopathology

Many psychological disorders are characterized by interpretational processing biases, and Aaron T. Beck's work provided a crucial theoretical foundation for assessing, treating, and researching them. The present commentary aims to sketch a brief historical overview of how this work evolved and developed, and how it has been translated into concrete assessment techniques for use in treatment and led to innovative research lines in clinical research.     

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck’s cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.     

Overcoming Philosophy: Heidegger, Metaphysics, and the Transformation to Thinking

Heidegger’s critique of metaphysics is central to his attempt to re-instantiate the question of being. This paper examines Heidegger’s critique of metaphysics by looking at the relationship between metaphysics and thought. This entails an identification of the intimate relationship Heidegger maintains exists between philosophy and metaphysics, an analysis of Heidegger’s critique of this association, and a discussion of his proposal that philosophy has been so damaged by its association with metaphysics that it must be replaced with meditative thinking. It is not quite clear, however, how the overcoming of metaphysical thinking is to occur especially given Heidegger’s insistence that relying on human will to effect an alteration in thinking simply re-instantiates the metaphysical perspective to be overcome. While several critics have argued Heidegger has no solution to this issue, instead holding that thought must simply be open to being’s ‘self’-transformation if and when it occurs, I turn to Heidegger’s notion of trace and a number of scattered comments on the relationship between meditative thinking and willing as non-willing to show Heidegger: (a) was aware of this issue; and (b) tried to resolve it by recognising a reconceptualised notion of willing not based on or emanating from the aggressive willing of metaphysics.     

Introduction

According to cognitive therapy as espoused by Aaron T. Beck, the transfer and maintenance of behavioral and cognitive skills into practical and sustainable real-life application ultimately determines positive therapeutic outcomes. However, the optimal process for ensuring this transfer and maintenance has not been explicitly studied. This particular series of C&BP adds to the growing body of literature on cognitive therapy for complex and chronic problems. A case conference and supervision recommendations are presented as a resource for cognitive and behavioral practice. The focus of this series is the integration of homework assignments into therapy. Developing a collaborative therapeutic relationship and individualized cognitive conceptualization were part of the original formulation of standard cognitive therapy (A. T. Beck, Rush, Shaw, & Emery, 1979), and are essential foundations to therapeutic work with challenging patient problems (J. Beck, 2005). Therefore, in keeping with the spirit of cognitive therapy, this series of C&BP places emphasis on the therapeutic collaboration and cognitive conceptualization processes that greatly enhance the effective use of homework assignments.