Depression-Focused Psychotherapies: Behavior Therapy
Behavioral treatments of depression are derived from operant conditioning, social learning theory, and, to a lesser extent, classical conditioning to various psychopathological states. These approaches share a common focus on changing observable, problematic behaviors and the use of functional analysis to modify the contingencies that shape and maintain the depressed patient’s behavior.
From the vantage point of operant conditioning, the depressed patient is “on” a prolonged extinction schedule, in which there are fewer reinforcers and progressively fewer adaptive behaviors for which the patient will receive positive reinforcement. The despair experienced by the depressed person may be understood, in part, as analogous to the emotional behaviors seen in a variety of organisms during extinction paradigms. Classical conditioning models, as best exemplified by Wolpe’s application of systematic desensitization, posit a relationship between sustained dysphoric arousal and induction of depressed mood and behavior. Incorporation of principles of social learning theory broadened behavior therapy to include cognitive or representational constructs, such as Bandura’s formulation of self-efficacy and Rehm’s concept of self-control. Thus, depressed persons’ decreased confidence in their ability to solve their problems and minimization of their successes are posited to reduce the likelihood of coping behavior and worsen dysphoric emotional states.
Shared Features of Depression-Focused Psychotherapies
The model of learned helplessness developed by Seligman parallels the work of Wolpe, which was originally based on classical conditioning. For example, in animal studies, exposure to inescapable noncontingent shocks initially results in increased emotional arousal, with a more depressive-like state of passivity ultimately resulting from prolonged exposure. It is not clear, however, whether it is the neurochemical effects of prolonged stress or the perception that one’s situation is hopeless that is more integral to depression in humans.
Contemporary behavioral approaches also emphasize the reciprocity between the depressed patient’s behavior and that of his or her significant others, friends, and co-workers. For example, research has shown that although acute changes in one’s mood and behavior (e.g., crying or complaining) may evoke responses of support and sympathy from others, sustained contact with a depressed person typically results in avoidance and detachment. The depressed person may respond to such withdrawal with threats or demands to try to coerce the desired response from family members. Alternatively, the “sick role” may be adopted in which dependent, help-seeking behaviors are inadvertently reinforced by intermittently helpful loved ones. The dysfunctional communication patterns that characterize the relationships of many depressed patients create an environment that certainly maintains, and possibly triggers, some clinical depressions.
Behavioral treatments of depression include the social learning approaches of McLean and Lewinsohn and colleagues, Rehm’s model of self-control therapy, social skills training, and Nezu’s structured problem-solving therapy. These approaches offer multicomponent treatment packages that have many more similarities than differences. Each model of therapy is time-limited, offering 8-16 weeks of therapy; all emphasize a functional analysis of the relationship between the presumed difficulty (e.g., deficient social reinforcement, poor social skills, or inefficient problem-solving strategies) and the onset and/or maintenance of the depressive syndrome. Each approach utilizes explicit, stepwise strategies to improve recognition of problem areas and to begin to implement the targeted changes in thoughts, feelings, or behavior. Behavioral therapies generally follow a model in which the desired behavior change is accomplished via education, observation, guided practice, social reinforcement of successive approximations, and individualized homework assignments.
Common strategies that are used in behavior therapy include self-monitoring, self-reinforcement, graded task assignments, activity scheduling, and targeted improvements in social skills through assertiveness training, modeling, and role-playing. Relaxation training, which may be more parsimoniously viewed as a self-control skill rather than a counterconditioning procedure, is also widely incorporated as a means to cope with anxiety or insomnia. Indeed, relaxation training may have a modest primary antidepressant effect, whether used alone or in combination with pharmacotherapy.
Behavioral distraction techniques, such as thought stopping, are sometimes used to help patients gain some control over intrusive depressive ruminations. Behavioral therapies do not place a specific emphasis on the relationship between the therapist and the patient. Nevertheless, there is broad recognition that the core therapeutic qualities of empathy, genuineness, and respect help to strengthen the therapeutic alliance and to facilitate a treatment milieu conducive to learning and mastery of the targeted therapeutic task.
Each form of behavior therapy emphasizes continued application of skills learned in treatment to reduce risk of relapse. More specific attention to relapse prevention is provided in several models of behavior therapy, in which patients may attend periodic “booster” sessions or monthly sessions for continuation therapy.
The behavior therapies have received much attention in group formats, which can be advocated as an efficient means to teach the model and strategies of behavior therapy. As in IPT, modifications for marital treatment are quite feasible.
Behavior therapy has largely been the domain of clinical psychologists, although not exclusively so. Nevertheless, many of the manual-guided behavioral therapies are easily learned by master’s degree-prepared professionals of other disciplines. None of the treatment programs developed to date have been specifically intended for combination with pharmacotherapy, although their concomitant use is hardly contraindicated.
Revision date: July 6, 2011
Last revised: by Jorge P. Ribeiro, MD