I encountered this scenario on a few dark mornings while driving to teach in a notorious neighborhood within Atlanta, Georgia. I bring up this reality to respond directly to the claims made by psychologists who are proponents of Behavioral Activation Treatment for Depression. There are two major flaws within the theory of activating behavior without addressing the cognition:
1) Severely depressed patients may not have options to change their environments.
2) If we engage in “coaching,” we have no jobs as psychologists.
In my situation above, I was so depressed that I did in fact follow the behavioral patterns of people within the reading by Jacobson et al. The cyclical nature of depression is a beast, because surely the behaviors that we engage in cause further depression, and intensified depression only leads to further social withdrawal and personal negligence. It took phone calls from my at-the-time-boyfriend to my roommate, in fact, to force me to eat and get out of my dark room where I would lay in bed from the time I got home from school to the time I woke up. This routine antagonized my depression, but the reality was that only those few behaviors could be addressed. The essence of my depression – the school environment that I encountered every day – was still there, waiting for me, mocking me. I was able to address the fact that my behavior was exacerbating my depression, but I was not able to get to the root of it, as Jacobson’s title even suggests Behavioral Activation (BA) does. It wasn’t until my cognitions about my work environment were addressed that I could truly wake up in the mornings ready for the challenge of a new day.
Additionally, if we engage in the coaching techniques described within the model of BA, even if through terminology, we are in essence diminishing our profession to someone who guides the actions of others. In that realm, we could have forgone school and the 6 years of intensive training of empirically based techniques to partake in a counseling model that simply aims to shift individuals’ cognitions through behavioral modification. Perhaps this is just being egregious, but I have the skills and will have the knowledge to affect substantial change within clients’ lives that goes beyond activity charts and forced social engagement. I’m quite sure that some mindset changes will come as a result of those things, but I’m more confident that addressing the behavior as well as the cognitions surrounding it will provide the client with a more suitable way of coping with the impending stress involved with his/her environment. Viva la CBT!
i wonder if psychodynamic training will toss you further into the throws its mystery and the infinite possibilites of the core of depression, or will it hurl you back towards CBT, using a finite set of schemas with which to frame activity sheets, thought logs, and other forms of cognition/behavior tracking.
ReplyDeletestay tuned!
Riana, I may need to write my blog in praise of the pragmatism of BA! Right on--what if you can't change you're environment? Thanks for the challenge! More tomorrow!
ReplyDeleteYou raise a very important couple of points. Here's my first impressions, but we'll discuss more in class.
ReplyDeleteNone of the therapies we are talking about account for ALL of the variance in recovery. Most of the therapies cover some of the variance in recovery. Therefore, the pragmatic approach of monitoring whether something--whatever you are doing--is working, is ultimately the best idea. If BA wasn't working for you, Jacobson, before most people, would urge you to try something else. My own preference within the CBT domain is for REBT, because I prefer the broader philosophical take it provides. But there is also a place for thinking about life's meaning--including the meaning that can be, in a sense, manufactured from striving and suffering. Victor Frankl had a lot to say about this. But keep in mind that even "simple" BA interventions can create changes in thinking--even changes in philosophical perspective. We don't understand fully yet how that occurs, but we know that it does.
On your second point, I'll tell you honestly that I believe that most psychological technologies are pretty easy to train. Some are not, but most are. Philosophically, as well as politically, it is my position that our moral responsibility is to "give psychology away" to the extent it is possible. It is true--undeniably--that doing so would jeopardize Psychologist jobs. But if it's the right thing to do, it's the right thing to do. Should be an interesting class today!