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.

Categories: Depression, Psychotherapy