In the interest of moving away from the curmudgeonly, nay-saying tone I've struck in spite of myself in my recent posts, I would like to express my sincere gratitude and genuine positive regard (as it were) for the Jacobson, et al paper on Behavioral Activation - because of the thorough and clarifying job it did of confirming my suspicion that the best "behavioral therapies" are every bit as cognitive as they are behavioral. To explain, let me cite a few examples from their own characterization of the treatment they've developed (which, say I as a long-time CT/RET devotee, truly does appeal to me a great deal): In outlining the approach they take in presenting the treatment model to the client (which is step 1 of the program, together with establishing rapport), they report highlighting "the vicious cycle that can develop between depressed mood, decreased activation/withdrawal/avoidance, and worsened depression"; that "activation is a way to break this cycle... and address the problems in their lives that precipitated or have been maintaining their depression"; that "behavior needs to be goal directed rather than mood directed," and so on. If the presentation of these ideas about the external, rather than internal, causes of their moods and life problems ("what? I'm not to blame for everything bad that's been happening to me?") and of the importance of directing their focus outward at the clearly defined external goals they want to achieve rather than inward at what their emotions seem to be telling them ("what? I should be processing information and directing my mental focus in a different way than I have been?" - not in those words, of course, but that's the implicit message) isn't a cognitive treatment mechanism, I don't know what is. Moreover, once the therapist proceeds to step 2 of the treatment program and begins working with the client on developing specific treatment goals, the emphasis switches to "the importance of focused activation" - which the authors explain to mean that each individual will be motivated by different, uniquely personal reinforcements, and that it is important to identify what behaviors and activities will be positively reinforcing for the individual client. If this strategy of highlighting a client's personal interests and passions, and of emphasizing their unique importance and value in promoting the client's well-being ("what? My secret fascination with ancient Egyptian pottery or the pleasure I take in going out salsa dancing are actually good things about me? So you're saying that relaxing and indulging my desires on occasion doesn't make me a bad person, but that it can actually make me healthier?") - if such an approach doesn't serve to validate and strengthen the client's self-worth to some extent, on at least an implicit level, I would be quite surprised.
And the same goes for the next step of the program, the actual development and implementation of treatment goals: the authors describe many clients' tendency to articulate nonspecific goals such as "feeling better" or "getting a life," which the therapist guides the client in re-formulating into more specific, tangible action-steps. This, incidentally, is a case of learning to think differently - a distinctively cognitive process which the authors appear to regard as a prerequisite to acting differently. Clients are also taught to distinguish between long-term and short-term goals, and to focus on achieving the actual, external outcome rather than on changing their internal mood. The authors describe this as the key feature that distinguishes their "behavioral" approach from the more cognitive therapies for depression: whereas the latter focus on changes in mood as the desired goal or outcome, this intervention focuses on the actual behaviors and actions clients resolve to take as the desired outcome - and are encouraged to celebrate and reward themselves for having achieved those outcomes, rather than waiting to see if their mood changes before calling the goal "complete." But this approach - which I deeply admire and wholeheartedly support - is, as far as I can see, as profoundly cognitive as it is behavioral (and perhaps even more so). In fact, conventional CT and CBT practitioners direct their clients to set broadly the same kinds of goals that the BA therapists do (whether they conceptualize it as "exposure" or "reaity-testing to aid in belief change" or whatever); behaviorally, the actual homework assignments and between-session implementations of the goals formulated in therapy look essentially the same, as far as I can tell. The difference, however, in the approach that the BA model of therapy prescribes, is not in the behaviors themselves but precisely in the cognitive attitude that patients take toward it. Instead of fixating on their mood, which is precisely the kind of self-defeating ruminatory mental mode that's been shown to perpetuate depressive mood in the first place, clients are encouraged to direct their focus outward and to actually alter their criteria for success and self-efficacy - in a way that puts them in control of the outcome (now that each goal is articulated in terms of specific, clearly defined action-steps) and allows them to take pride and experience a sense of efficacy when they have achieved it. Again I say: if this isn't an example of effective cognitive change (accomplished not through restructuring of the content of one's beliefs, but through a change in the way one processes information and interprets outcomes), I don't know what is.
Of course I don't mean to imply by this that it's really just cognitive change that's both necessary and sufficient for recovery from depression, or any other form of psychological distress; it's really the integration of the "cognitive" and "behavioral" components (and let's not forget the "emotional/mood" component!) that I think is key to the efficacy of all of these treatments. Based on everything we've read so far, I think it's safe to say that the most compelling advocates of CBT (and RET, for that matter) absolutely do acknowledge the importance of the “outside-in” as well as the “inside-out” approach, as I think last week’s article by Ellis (the one in which he renames “Rational-Emotive Therapy” to “Rational-Emotive Behavior Therapy,” as it were!) beautifully attested. One of the most appealing aspects of CBT, in my eyes, has always been its recognition of the reciprocal nature of each "point" on the famous theoretical triangle – emotions/mood, thoughts/beliefs (including not just the content but the process by which one thinks, if I may put in a word on behalf of all the research on information processing styles), and, of course, behavior. What each of these “behavioral” interventions we read about this week seems to be highlighting, and, I think, accurately so, is that the "behavior --> emotions/mood" pattern of change is highly potent in and of itself – and sometimes moreso than an intervention focused on the "thoughts/beliefs" --> "emotions/mood" arrow of the triangle while perhaps neglecting or giving insufficient attention to behavior. However, what I think the success of these treatments really demonstrates is the reciprocality of the model, rather than the irrelevance (or functional unimportance) of the cognitive component of CBT. In particular, I think the Behavioral Activation treatment described by Jacobson et al demonstrates the importance of changing one’s process of cognition, rather than the content of one’s beliefs per se - such as by changing the way patients conceptualize and interpret positive outcomes.
I think many of the mechanisms at work in ACT and DBT work in a very similar way (especially the "mindfulness" component of DBT, which explicitly guides clients to accept and not judge themselves on their emotions and to shift their mental focus from the internal workings of their mind to the external, present-moment environment). And I think the lessons we draw from the efficacy of these interventions, especially as we embark on the quest for even more custom-tailorable and, perhaps, even more qualitatively effective therapies, should include the recognition of the role that both cognitive and behavioral components play - and particularly how they work in interaction with each other.
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