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Treatment for Chronic DepressionReview - Treatment for Chronic Depression
Cognitive Behavioral Analysis System of Psychotherapy
by James P. McCullough
Guilford Press, 2000
Review by Jennifer Radden, D. Phil.
Nov 2nd 2000 (Volume 4, Issue 44)

As its title suggests, this book has a single, limited focus: a psychotherapeutic approach designed for one patient group (chronically depressed outpatients) which applies cognitive behavioral techniques to the specific end of changing these patients’ attitudes and behavior and teaching them problem solving and relational skills. Chronic depression is identified, the technique is described, and an evaluation of the technique’s success is included. This narrow focus is one of the book’s strengths. It provides a careful, close discussion, and a how-to for a therapist engaging in this work. For such a therapist, it would be a useful practical guide.

The book has other strengths. First, it gives a thorough and comprehensible account of the research about and profile of the chronically depressed patient, who suffers one or some variant on: dysthymic disorder, double depression (multiple episodes of depression), recurring major depression lasting two years or more without full recovery between episodes, or chronic major depression. Studies cited suggest these patients are high on neuroticism, defined here as poor emotional control, have poor social coping skills, and apprehendthemeselves the victim of outside forces such as fate, or socio-policitical factors. The characteristic of the chronic depressive which is the key to treatment, according to this author, is that he or she is stuck in the immature mode of what Piaget called ‘pre-operational’ thinking. Typically, such pre-operational thinking is found in young children. It is characterised by an inability to reason from cause to effect, for example, and an imperviousness to “logical reasoning and the reality-based views “ of others. The author’s thesis is that this patient group also lacks the ability to engage in these higher level cognitive functions and needs to be trained to engage in such functions.

Another strength of the book rests in its attention to outcomes and effectiveness. This is a characteristic we have come to expect of work in cognitive behavioural therapy, but it is no less deserving of praise for that reason. That said, despite elaborate efforts to evaluate effectiveness, the actual outcome measures are not as satisfactory as one might hope. The author establishes the outcomes by examining changes in such categories as “symptom intensity,” “coping style,” “psychosocial functioning” and “interpersonal functioning.” The enormous challenges involved in evaluating therapeutic success in any terms, behavioral or otherwise, can never be overestimated, of course. But the ‘softness’ of indices such as “coping style” and “interpersonal functioning,” and the narrow interpretation of these measures employed, is bothersome. Interpreted broadly, the behavior making up a response like “interpersonal functioning” opens itself to interpretation, subjective bias and other impediments to accurate measurement; on the other hand, interpreted in narrowly behavioral terms, “interpersonal functioning” becomes a parody of the multi-faceted, rich category that expression seems to connote.

Those interested to know how the author’s particular CBASP (Cognitive Behavioural Analysis System of Psychotherapy) differs from other forms of cognitive therapy such as Beck’s Cognitive Therapy or Klerman’s Interpersonal Psychotherapy will find some contrasts laid out in Chapter 12. Most of these are alleged to stem from the idiosyncratic pathology of the chronically depressed adult - although these other therapies, while not designed solely for the chronically depressed patient, can and have been applied to that patient population. But the author also contrasts the different aetiological theories underlying each model: CBASP is said to presuppose that depression arises from “faulty coping.. which results in perceptual disengagement of the patient from his/her environment,” while Cognitive Therapy focuses on “cognitive distortion of reality” and IPT “describes aetiology and psychopathology in both medical-disease and psychosocial (interpersonal problems) terms.” This chapter is somewhat helpful in placing the author’s particular innovations. But as these passages indicate, it offers a superficial and inadequate differentiation. (Cognitive distortion of reality might equally be said to result in perceptual disengagement, and both CBASP and CT can equally be described as employing medical-disease and psychosocial terms, for example)

With too many, and sometimes confusingly arranged categories, headings and sub-headings, this book lacks narrative flow and is difficult to read. The ‘discussion’ is often little more than a series of check lists - as if the chapters had been pasted together from the author’s slides. Slide presentations, when successful, are tied together by the narrative connections provided by the presenter’s voice over: but this unifying voice over is lamentably absent here.

To the philosopher, the frequent verbatim reports of and discussions about therapeutic exchanges which pepper this book manifest a troubling kind of misplaced concreteness, akin to that noted in the book’s efforts to evaluate outcomes and to the above mentioned problems of organization and narrative flow. The quicksilver of interpersonal exchange is not satisfactorily captured in this kind of writing, and the stiffness, artificiality and triteness of these verbatim passages and discussion of them makes reading them a frustrating exercise. Overall then, the book may prove a practical guide to therapists, but little more.

Jennifer Radden received her graduate training at Oxford University and is Professor of Philosophy at the University of Massachusetts, Boston Campus. She has a long-standing interest in issues concerning mental disorder and is currently President of the Association for the Advancement of Philosophy and Psychiatry. Her published work includes Divided Minds and Successive Selves: Ethical Issues in Disorders of Identity and Personality (MIT 1996) and she has edited The Nature of Melancholy: From Aristotle to Kristeva (Oxford University Press).


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