Depression in Context: Strategies for Guided Action

This book on depression is draped in crepe, yet optimistic. It opens with acknowledgments by the coauthors and widow of the late Neil Jacobson, whose death was a great blow to behaviorism and to psychotherapy research. His collaborators on an important study of behavioral activation, an antidepressant treatment, have written this testament to his ongoing work. It is a labor of love and an impressive document.

Although behavior therapy has a long history and data support its use for depression, the strategy of increasing pleasurable activities and decreasing unpleasurable ones has struck many therapists as simplistic. Over decades, especially in the United States, behavioral therapy withered as an independent modality and was incorporated into cognitive behavior therapy, which uses behaviors mainly to test the validity of underlying automatic, irrational thoughts. That is, behaviors were subordinated to cognitions. In 1996, however, Jacobson and colleagues (1) dismantled cognitive behavior therapy in a randomized, controlled three-cell trial of 150 patients with DSM-III-R major depression. They found that behavioral activation, a purely behavioral intervention, worked as efficaciously as full cognitive behavior therapy—without addressing negative cognitions. A study is now comparing behavioral activation, cognitive behavior therapy, paroxetine, and placebo (S. Hollon, personal communication, Jan. 2003).

This book is a behavioral activation manual. It is coherent, serviceably written (although it wants proofreading), and clinically useful. It provides therapeutic prescriptions, proscriptions, contingencies for difficult patients, and case examples, while omitting a few points such as the length of the treatment (possibly 20 sessions). Because few psychiatrists have received good behavioral training, they should benefit from reading and using this book.

Readers may struggle with the behavioral activation focus on the patient’s behavior rather than on inner intention or feeling. The authors contrast behavioral activation to the inward-focused cognitive, psychodynamic, and biological explanations of depression. By counterintuitively minimizing attention to feelings and thinking, behavioral activation offers a very different view of depression—as a narrow repertoire of passive, avoidant behaviors responding to deprivation and conditioned by negative reinforcement. “Behavior matters” (p. 106): depression disrupts activities and comfortable daily routines. Behavioral activation “activates” patients to broaden their behavioral repertoires in handling the environment, increasing positive reinforcement and mastery through graded task assignments. The authors thus resurrect behavioral therapy as an “antimentalistic,” externally oriented therapy of environmental “context” focusing on the relationship of depression to external situations (e.g., losing a job) rather than on the intrapsychic. They present this as a “radical” idea (p. 16).

This raises two points. One concerns the insularity and parochialism of psychotherapies: one school often does not know another. These behaviorist authors mainly compare behavioral activation with cognitive therapy and, more distantly, psychodynamic and biological approaches. They seem unsure of the latter and blind to the overlap of their environmental outlook with interpersonal psychotherapy (2), an antidepressant approach since the 1970s that stems from a more-than-50-year tradition (3). Like interpersonal psychotherapy, behavioral activation is “pragmatic” (p. 40) and problem-solving (p. 126), debriefs patients’ weekly activities (p. 55), links mood to life situation, explores options (p. 123), coaches testing effective responses to the environment, uses role playing (p. 114), and serially assesses symptoms (p. 108). The two treatments differ considerably, but the interpersonal psychotherapy manual receives only one passing mention (p. 7), and interpersonal psychotherapy and behavioral activation never receive the close comparison they deserve. Nor do the authors acknowledge “CBASP” (cognitive behavior analysis system of psychotherapy), a more eclectic but heavily behavioral treatment for chronic depression (4).

The second point concerns dismantling designs. The 1996 report comparing cognitive behavior therapy and behavioral activation leads readers to imagine that behavioral activation is simply the stripped down behavioral component of cognitive behavior therapy. As this book clarifies, however, the researchers perforce developed a treatment with a separate outlook, rationale, and theory. Since, as the authors reiterate, behavioral activation is not standard old behaviorism, it is not merely the “B” in “CBT.” Indeed, they have developed a behaviorism that seems to overlap with a rival psychotherapy, interpersonal psychotherapy. Dismantling psychotherapies to test the efficacy of their component ingredients is an important aspect of psychotherapy outcome research, but a complicated and easily confounded one.