Depression in Context

This book is written for therapists practicing in the field of behavioral therapy for the treatment of depression. It is clearly presented, systematic, and thorough, with useful case studies to illustrate therapeutic points.

The authors begin by providing a rationale for their therapeutic approach, stating that research has shown that  treating depression by helping to activate people is just as effective as helping them to change their thinking. They summarize the scientific research on biochemical, genetic and neurotransmitter aspects of depression causation, and conclude that there has not been a definitive finding that any of these are wholly responsible.

They present their own possible reasons for why the internal causation model of depression is so popular, including avoidance of the 'culture of blame' by referring to depression as an illness, mental health advocacy, and the pressure for fast cures with medication.

They emphasize that their form of behavioral therapy is more empathic than the traditional or stereotypical view of behaviorism. They base it on avoiding defect models of depression, viewing the condition as a set of actions in context which make sense given the person's life history and current state. The therapist is viewed more as a life coach than a medical counselor, someone who can help their clients make specific changes to overcome the 'stuck' aspects of depression, by using the 'outside-in' (behaviors change feeling) rather than 'inside-out' (feelings change behavior) approach.   

Context is all important here: viewing clients contextually means seeing them in their environment, so that the depression becomes a set of actions or behaviors occurring in a particular set of (always changing) life events. They emphasize that people are 'historical acts', that is an integration of all the past and present details of their lives: no actions occur in a vacuum.

The authors go on to describe Behavioral Activation as a treatment, and outline the principles and essential elements of this approach: for example, that there are a variety of reasons for people becoming depressed and that secondary coping behaviors play a significant role in the development of depression. The therapist and client need to act according to a plan rather than the client's internal state and to trace patterns of responding to life events that maintain the depressive state. In other words, the client is taught a 'functional analysis' of their behavior by the therapist.

They outline the targets of treatment, avoidance patterns being the foremost of these, and discuss the importance of activity charts. The importance of the meetings between therapist and client being collaborative is reiterated. Nothing will be achieved if the client is lectured at by the therapist, or doesn't understand everything that occurs in the session.

I was pleased to read the following: 'Western culture emphasizes an ideal of happiness that can cause people to see any form of suffering as pathological' (93). Theirs is not a quick-fix method, but a realistic and empathic approach, one that focuses not on the 'cure' of depression, but on ways to help the client's mood improve through addressing the secondary problems that arise from it. They recognize that depression can be a natural result of difficult life events, and that there is nothing 'wrong' as such with the client. Importantly they stress that trying to change feelings or thinking is not useful, that the power lies in the attempt to change the context in which their low mood occurs.   Sometimes this is difficult, and the authors do not pretend that it will come easily to depressed people to try to act as if they were not depressed. They emphasize the importance of a supportive client-therapist relationship.

Choice is an interesting factor that comes up in the chapter concerning the teaching of clients to view depression contextually. In outlining the ACTION approach to analyzing behavior (Assess, Choose, Try, Integrate, Observe, Never give up), the question of a client choosing to remain depressed is raised. This can be either to have a break from the energetic task of activation, or to engage in avoidance behavior for a particular reason, for example. The authors stress the need for care here, but argue that as long as the therapist does not make any judgements about the client, the very fact that passivity and reaction can be changed to activity and control is good for the client's perception of the situation.

This issue of choice comes up later in a discussion of the treatment approach to suicidal clients. This is a very delicate and difficult area, and I praise the authors for their sensitive approach, and recognition of the difficulty. They repeat the need for the therapist to constantly assess the danger to the client of their suicidal ideation, and to do whatever they can to save the life of the client by providing alternatives to the taking of life as a solution to problems. These are challenging, but well thought out and presented sections.

There is a very concise and clear summary of the main points about Behavioral Activation in the concluding chapter, along with a sample activity chart and an example of a 'self-help manual' for clients in the appendix. A thorough list of references and a useful index round out this professionally written and thoroughly researched book. Sadly, one of the authors, Neil Jacobson, died just as they were starting to write this book, and his contribution to the field of behavioral therapy is acknowledged at the beginning. 

© 2003 Sue Bond

Sue Bond has degrees in medicine and literature and a Master of Arts in Creative Writing. Reviews for online and print publications. She lives in Queensland,  Australia.