Invited essay
Can depression be de-medicalized in the 21st century: scientific revolutions, counter-revolutions and the magnetic field of normal science

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Abstract

This article is about our scientific investigations of the change mechanisms in cognitive therapy (CT) for depression. In a previous clinical trial, we found that so-called `cognitive' interventions were not necessary for the success of CT: the behavioral activation (BA) component, a treatment precluding attempts to change thinking, worked as well as the entire CT package, both in maximizing acute treatment response and in relapse prevention over a two year period. We tentatively suggested at the time of publication [Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E. T., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treament for depression. Journal of Consulting and Clinical Psychology, 64, 295–304; Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral treatment for depression: relapse prevention. Journal of Consulting and Clinical Psychology, 66, 377–384.] that the `cognitive' components of CT may not only be unnecessary but potentially a liability, since they result in a less parsimonious treatment package that may be not be cost effective. In this article, we not only defend this contention, but counteract the skepticism expressed by some CT advocates that the quality of our CT was deficient. Finally, we describe a study designed to confirm our conclusions from the earlier trial and, in the process, reintroduce a contextual perspective on depression, one which counters the currently dominant defect models reflected in both Beck's cognitive model and in theories that emphasize biological causation.

Introduction

Like many readers of this journal, we fancy ourselves clinical scientists, whose job it is to search for truth and follow our data wherever those data may lead. At the same time, we are well aware of the all too human fallibilities that produce allegiance to an a priori position, and complicate the sober appraisal of findings that are inconsistent with the most cherished beliefs in the profession (Jacobson, in press). Although our laboratory has been engaged in the scientific study of depression for almost 15 years, we find ourselves in the midst of an unanticipated controversy, one that was certainly not our guiding motive when we began our work. This controversy reflects the constant tension in clinical science between the reinforcers associated with `being right' and the obligations to let findings speak for themselves, regardless of whether such findings point in a direction that proves one's original hypotheses.

This tension is not new to our laboratory. After Jacobson documented the effectiveness of behavioral couple therapy (BCT; Jacobson & Margolin, 1979) in a series of randomized clinical trials (RCT's; Jacobson & Addis, 1993), BCT became the first empirically supported treatment for couples in the history of psychotherapy research. However, after our initial enthusiasm, we began to look more carefully at the effectiveness of BCT. We discovered that although BCT proved to be more effective than nothing, the rate of improvement was not clinically significant (Jacobson et al., 1984). Despite heartfelt allegiance and investment in the BCT model, as scientists we were compelled to follow a fundamental rule of clinical research: let the data speak. And this rule served us (and science, as a whole) well; it motivated us to develop a new theory and, with the help of Andrew Christensen, spurred us on to develop a whole new treatment model Jacobson, & Christensen, 1996, Christensen, & Jacobson, in press, which is now facing the same unbiased scrutiny that BCT was subjected to.

In the field of depression, the data are not always allowed to speak for themselves (Jacobson & Hollon, 1996): included among the plethora of creative thinkers in this field are those with a gift for coming up with post hoc arguments to discount findings that are inconsistent with prior cherished beliefs, thus leaving normal science intact. Jacobson and Hollon (1996) had previously noted the facility with which disease model advocates interpret ambiguous findings in a way which affirms their favorite anti-depressant medications and in the process discounts the potential of psychosocial interventions. Since then, we have come to learn that our biological colleagues do not have a monopoly on the post hoc defense. Since our findings became controversial (Jacobson et al., 1996; Gortner, Gollan, Dobson & Jacobson, 1998), we have been on the defensive ourselves. Here is how it happened.

Section snippets

Our component analysis of cognitive therapy (CT): an attempt to uncover mechanisms of change

We began a study in 1990 (Jacobson et al., 1996) attempting to test the cognitive theory of change in depression put forth by Beck, Rush, Shaw and Emery (1979). The idea for this study came from an earlier experiment where CT had served as a control group to evaluate BCT for co-existing depression and marital discord Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991, Jacobson, Fruzzetti, Dobson, Whisman, & Hops, 1993. Jacobson was introduced for the first time to state-of-the-art CT, as

Reactions by and to our critics

The first article describing our study was published as a Special Feature of the Journal of Consulting and Clinical Psychology (Jacobson et al., 1996). To us, this was both gratifying and somewhat surprising. It was gratifying that both the Editor and the reviewers seemed to have such a positive reaction to the study. However, it was also surprising, since the study had a serious methodological limitation: in the absence of a control group, it was impossible to know for sure whether all three

The politics of competence certification

Responding to continued questioning about the quality of our CT, we subjected our tapes to the ratings of outside experts, recognized master CT therapists who had no other connection to the study. After consulting with the Center in Philadelphia, we identified two experts who seemed satisfactory to all concerned. Each of them rated a randomly selected portion of our tapes on the Cognitive Therapy Scale, which is an instrument specifically developed to measure competence in CT. Table 1 shows the

Toward a more cost effective method of treatment depression: behavioral activation

In response to the praise as well as the criticism we received for our last trial, we tried to design a replication and extension that would more definitively test the potency of these brief psychosocial treatments for depression. We modified our design in several ways, partly to overcome some of the limitations that we ourselves perceived in our previous trial and partly to respond to the assertions of both CT and pharmacotherapy advocates. We want to be sure that, by the end of this study, we

Conclusion

We began with a description of a RCT which produced null findings. The null findings, although open to multiple interpretations, pointed to the possibility that cognitive interventions are neither necessary nor desirable in an optimal psychosocial treatment for depression. Our study stirred up controversy, enough to inspire this paper, despite the absence of written critiques. We ended with the description of a new study, which is in part an attempt to replicate our findings to the satisfaction

Acknowledgements

Preparation of this article was supported by National Institute of Mental Health Grants 2R01 MH44063-06 and 5K02 MH00868-05.

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