Abstract
‘Cognitive therapy of depression’: the jet engine of psychotherapy books?
When one reflects on the great intellectual achievements and thinkers of the twentieth century certain names easily spring to mind. Darwin, Freud, Einstein, and many others are celebrated for their intellectual achievements, and are seen as defining the scientific underpinnings of contemporary society and life-style. Much less often cited in this list are Dr Hans von Ohain and Sir Frank Whittle. These men were responsible for the development of the jet engine, an achievement that might be considered more technological than strictly intellectual, and yet, it could be argued that the jet engine and its reverberating effects on things such as global travel, cultural exchange and trade, warfare, and so forth, has shaped contemporary society in a more profound and pervasive way than the work of any of the more celebrated thinkers.
Obviously I wish to draw a parallel here between the achievements of Von Ohain and Whittle and those of Beck and colleagues with the publication of Cognitive therapy of depression in 1979 [1]. When it comes to books about psychotherapy there are many that deal more profoundly with issues of human suffering, there are many that are more erudite, and there are many that lay out a more detailed model of personality or psychopathology (including numerous books on the cognitive model, such as those by Guidano and Lotti, 1983 [2]; and Mahoney, 1991 [3]; as well as Beck's own previous books, such as Depression: clinical, experimental and theoretical aspects (1967) [4]). However, I would argue that there are few books that are likely to have a more pervasive influence on the way in which psychotherapy is actually conducted, and furthermore, on the way in which psychotherapy fits into the all important public health debate about the most appropriate and effective treatments for mental illness. The reason for this is that the major achievements of this book were technological, rather than intellectual. Like many other technological achievements, it represented an incremental step rather than a quantum leap. It also represented the cumulative efforts of a group of researchers, rather than a single vision. But also like many other influential technological achievements, it crystallized these ideas at a critical time in the history of psychotherapy and intervention research.
Probably the major achievement of Cognitive therapy of depression was that it was a clear and comprehensive treatment manual. The idea of manualized psychotherapy sits uncomfortably with some psychotherapists. Surely, they argue, psychotherapy is one of the most ideographic forms of intervention. Psychological makeup is unique to each individual, and it is the psychotherapist's job to understand each patient's personality in all its nuance and idiosyncrasy. Only then can interventions be planned and implemented. Of course even in the most artless forms of therapy there is still some technique, but the real question is one of balance between flexibility and structure. In the behavioural tradition there have been many attempts to specify treatment procedures in such rigid detail that they could be delivered by specialist and nonspecialist alike (or indeed, could be administered without a therapist at all, as in the case of bibliotherapy [5]). However, while such specific detail may have been feasible for guiding the treatment of phobic anxiety with exposure and systematic desensitization techniques, the application of such guidelines to depression was always going to be problematic. The clinical presentation of depression is too varied, both in terms of symptom profile, severity, and associated personality characteristics, to lend itself to rigid prescriptive guidelines. Furthermore, the necessary emphasis on cognitive phenomena in depression was always going to render treatment of depression more idiosyncratic.
Nevertheless, it was vital to specify the treatment of depression to some degree, so that one could satisfactorily answer the question ‘does it work?’ Or to put it another way, ‘does doing this work better than doing something else?’ In order to answer such questions it was necessary to be able to specify what ‘this’ and ‘something else’ were, and to have independent observers able to differentiate them [6]. To my mind one of the great achievements of Cognitive therapy of depression was that it operationalized treatment to a sufficient degree to allow consistency in its delivery and distinctiveness from other therapies, without reducing clinical flexibility to the extent that the treatment was not applicable to a wide variety of individuals suffering from affective disorders. Not only were the treatment techniques operationalized, but so were the concepts and constructs to which these techniques were directed. This is true of both the critical outcomes of therapy (i.e. the symptoms to be reduced) as well as the intervening psychological mechanisms that the therapy aimed to change. Therefore, the therapy had no trouble assessing changes in levels of depressive symptoms, suicidal ideation and risk, dysfunctional thoughts, or indeed the competence of therapists. Indeed, ratings scales for each of these are provided in the appendices, including the highly influential Beck Depression Inventory. In this respect, Cognitive therapy of depression offered a therapy that was much more ‘research ready’ than any of the previous psychodynamic or humanistic approaches to depression, wherein not only were the critical psychological processes often considered unmeasurable, but there was often debate as to what phenomena the therapy was actually trying to change.
These matters point to another important reason why Cognitive therapy of depression has been so influential: it was published during the era of the randomized controlled drug trial. In the face of the scientific demonstration of effective antidepressant drug treatment, a psychotherapy that provided manualized procedures, and clear assessment of outcomes and processes, provided a model of psychotherapy for depression that could be easily compared with pharmacological approaches. An appendix to the book even provides a research protocol for outcome studies on cognitive therapy. The early demonstration that cognitive therapy was of comparable efficacy to antidepressant medication was critical to its influence [7–9]. More recently, it has become clear that cognitive therapy provides better prevention of relapse than does antidepressant medication alone [10–12]. This fact, along with the demonstration that cognitive therapy can assist in the prevention of relapse among those with residual symptoms after treatment with antidepressants [13], or those suffering from recurrent depression [14], suggests that cognitive therapy may not just be a treatment option, but is in fact the treatment of choice (along with adequate medication) for those with a high risk of relapse.
The other major reason for the wide influence of Cognitive therapy of depression is that it is one of the clearest descriptions of a psychotherapy process that one can read. I have used this text with clinical psychology students in training for years, and I still receive comments that this book is one of the best that they have read. In a context where many previous psychotherapy training texts seemed to treat obfuscation and mystification of the therapy process as a virtue, and where many approaches to psychotherapy training required personal therapy and lengthy supervision, a text like Cognitive therapy of depression has had an enormously democratizing effect. Professionals with proper clinical training from all around the world were able to use Cognitive therapy of depression, along with the many audio and video-taped demonstration interviews that were available, to train themselves in the use of these techniques – even if they were not able to travel to Philadelphia to sit at Beck's feet. (This is not to detract from the fact that intensive supervision is an important part of training in cognitive therapy, it is just that this book was sufficiently clear that therapists were able to start using these techniques without necessarily receiving such supervision. This strongly contributed to the dissemination of the treatment approach, especially outside the United States.)
Importantly, although the text is clear, it is not simplistic. It deals explicitly with many of the more complex issues associated with psychotherapy of depressed patients, including techniques for suicidal patients, integration of homework into therapy, combining cognitive therapy with antidepressant medication, problems with termination and relapse, and an entire chapter on technical problems.
Another important aspect of the success of the book is that its focus was largely right. The techniques described in Cognitive therapy of depression specifically addressed the two (nonaffective) symptoms often most prominent in depressive disorders; behavioural withdrawal and negative thinking. This approach therefore was highly acceptable to patients, who felt that the techniques were strongly focused on phenomena that were important to them. The aspect of depressive phenomenology that was perhaps underemphasized in Cognitive therapy of depression was the area of interpersonal processes, especially sensitivity to interpersonal rejection and problems with assertiveness. Of course, these aspects of depressive symptomatology are explicitly emphasized in another influential brief, manualized psychotherapy for depression, interpersonal psychotherapy [15]. However, cognitive therapists have long argued (and with some justification) that although cognitive therapy does not reify interpersonal processes into a special class of techniques or interventions, interpersonal issues are a persistent focus (i.e. most behavioural withdrawal is from interpersonal contexts, most negative thoughts are about interpersonal situations). More recent work within the cognitive therapy tradition has also made integration of interpersonal processes in the therapy more explicit [16].
If I could identify one relative weakness in this classic text, it would be its treatment of techniques for changing underlying dysfunctional attitudes. The general approach of cognitive therapy is to first try to change the ‘surface level’ of cognition, especially automatic negative thoughts, and then, by deducing important themes underlying this surface cognitive material, to go on to change the more profound dysfunctional assumptions that are at the heart of depressive vulnerability. Although Cognitive therapy of depression has a chapter dealing specifically with this phase of therapy, it is probably fair to say that it is this aspect of the therapy that has required the most elaboration in subsequent literature. This elaboration was necessitated by a recognition that there are some dysfunctional attitudes that are highly resistant to change and that, in such situations, an alteration to standard cognitive therapy techniques will be required. For instance, Jeffrey Young's ‘schema focused therapy’ for personality disorders has outlined a number of assumptions of short-term cognitive therapy that may not apply to those with long-term personality based difficulties [17]. Other issues that arise out of attempts to change more enduring cognitive characteristics are addressed in the work of Guidano and Liotti [2], and Linehan, 1993 [18], both of whom place greater emphasis on the therapeutic relationship, the role of emotion, and distinguishing between ‘core’ and ‘peripheral’ schemata. In other words, it does seem that the therapy must become more interpersonal and psychodynamic in its focus in order to target these schema-based (read, personality-based) processes.
Having said that, it is valid to ask the question, ‘is it actually necessary to change underlying psychological structures in order to achieve therapeutic success, or for that matter, prevention of relapse?’ Attempting to change psychological traits within the context of a relatively brief psychotherapy (or perhaps any psychotherapy) might be unrealistic. Barber and DeRubeis [19] have discussed three models of how cognitive therapy brings about change. The first is the ‘accommodation’ model, which suggests that cognitive therapy directly changes the depressive schema. The second model is the ‘activation-deactivation’ model, which suggests that cognitive therapy does not change the underlying schema, but rather makes another schema more available. Finally, the compensatory skill model states that cognitive therapy does not reduce the likelihood that depressives will generate negative thoughts and images, but rather it equips the client with set of compensatory skills that help them deal with these thoughts without having their negative mood escalate. Barber and DeRubeis [19] concluded that most of the evidence supported the compensatory skills model. It may be that one of the great insights of the cognitive therapy approach is to demonstrate that significant clinical improvement and reduction of vulnerability, can be achieved without more profound psychological change, if effective skills for regulating emotional and cognitive processes can be imparted to the patient.
There can be no doubt that Cognitive therapy of depression is one of the most influential psychotherapy books ever published. The reasons for this influence are that it presented a blending of theory with detailed practical guidelines for treatment, and did so in a way that facilitated rather than frustrated attempts to asses the outcome and processes of the therapy. This is vital if modern approaches to psychotherapy are going to take their rightful place within evidence-based medicine, and in this respect cognitive therapy has been a leader. Although I have characterized the achievements of this book as primarily technological, it has to be emphasized that intellectual advancement in treatment that does not have a concomitant technology of delivery and dissemination is destined to failure. In this respect, Beck and colleagues can take their place beside Dr Hans von Ohain and Sir Frank Whittle among those whose technological advances have had a profound impact on modern life.