Depression-Focused Psychotherapies: Historical Overview
The depression-focused psychotherapies grew out of a series of developments in the mental health field between the late 1950s and early 1980s. First, there was the slowly growing perception that more traditional psychodynamic approaches to psychotherapy were not well suited for the treatment of depression. For example, the reflective and nondirective methods commonly used in psychodynamic psychotherapy were viewed as sometimes counterproductive in work with more severely depressed patients, who seemed to benefit from more active therapeutic support, structure, and guidance. This was particularly a concern vis-a-vis the more predictable and rapid effects observed during acute-phase antidepressant pharmacotherapy, which were convincingly established by the mid-1960s.
Second, whether or not these perceptions were accurate was somewhat moot because, unlike pharmacotherapists, the opinion leaders of the traditionally oriented psychotherapies were often reluctant or unwilling to subject their work to the empirical scrutiny of randomized controlled clinical trials. This position, however understandable in historical context, ultimately served to undermine the power base of psychodynamic psychotherapy in terms of allocation of research funds and publication in peer-reviewed general psychiatry journals (i.e., the “currency” of status within academic departments and medical schools). Moreover, psychiatry’s at times tenuous relationship with the other branches of clinical medicine was not enhanced by such a nonempirical stance. The issue of treatment efficacy ultimately involved medicolegal concerns, as illustrated by the controversial case of Osheroff v. Chestnut Lodge.
Shared Features of Depression-Focused Psychotherapies
Third, aside from issues of empiricism, recognition of the high prevalence of milder, ambulatory cases of depression provided a compelling rationale for training large numbers of mental health specialists of diverse disciplines. The broader availability of ambulatory mental health services was reflected in both the community mental health movement of the 1960s and the growth of outpatient private practices. There were simply not enough traditionally trained psychotherapists to treat all those persons seeking services. This was particularly true among patient groups who could not afford the types of psychotherapy performed by private practitioners.
Fourth, these trends coincided with the emergence of alternative, nonmedical paradigms to the problems of psychopathology and therapeutics. The behavioral approach, stemming largely from academic clinical psychology, introduced models of treatment originating from research using classical and operant conditioning models to change or modify overt behavior. CT, as best reflected in the clinical work of Beck (1976), built on behavioral formulations by incorporating similar attention to covert processes, such as thoughts, attitudes, and beliefs. From neoanalytical schools of psychotherapy, social psychiatry, marital counseling, and social work also came a growing appreciation of the interpersonal and relational contexts of depressions, culminating in the model of therapy developed by Klerman and Weissman and their associates.
Fifth, the issues of efficacy and reimbursement for health care services slowly but progressively became intertwined as concerns about the cost-effectiveness of mental health treatments mounted. The issue of reimbursement for psychotherapy is hardly a new one, and skepticism about the cost-effectiveness of psychotherapy has persisted for nearly 50 years. Research concerning the relative efficacy of various treatments has been stimulated by the need to demonstrate to third-party payers and governmental agencies that psychotherapy is a cost-effective endeavor.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD