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Cognitive-behavioral
therapists believe that conscious thought, rather than
unconscious motivation, determines behavior. Thus, with
the proper guidance, individuals can learn to change
their attitudes and behavior toward other people. Cognitive
therapy is more actively structured, time limited, and
goal directed than dynamic therapy, with the therapist
seeking an active intellectual collaboration with the
patient. The basic proposition is that specific ideas-the
now familiar schema-have been adopted as we learn about
ourselves and the way the world is organized. Some of
these ideas are inaccurate, distorted by the circumstances
under which they were acquired. Nonetheless, they become
automatic representations of what we believe the world
to be, a kind of self-fulfilling prophecy, continuing
to distort our emotional vision, regardless of the truth
of the matter.
These
automatic thoughts are in many instances the prelude
to depressed mood, fostering negative thinking about
ourselves, others, and the world in general-what Beck
has called the cognitive triad of depression. Thus the
vicious cycle is established, disturbing our emotional
view of the world and creating stress, which in turn
generates further disturbances of emotional expression
and interpretation. The goal of cognitive therapy is
to break this cycle, and to provide patients with problem-solving
skills. The time spent with the therapist is extended
by personal "homework" when, through cognitive re- education,
patients learn how to monitor their own thoughts and
behavior, instruct themselves in novel circumstances,
and objectively evaluate situations when things go wrong,
or cause anxiety. The goal is not only to change behavior
but also to revise the perceptual schema (the automatic
thoughts, or attributional style) that drive the maladaptive
behavior, until ultimately the therapist is no longer
required, and the patient becomes his or her own mentor.
Some of these therapies have been compared, head-to-
head, with antidepressant drugs in the treatment of
acute episodes of depression, and found to be effective,
especially in milder illness.
This
is especially good news for those who suffer a single
episode of depression, and where the illness falls short
of the profound disturbances in emotion, thinking, and
body housekeeping that are characteristic of melancholia.
It also confirms, and follows logically from our understanding
of the limbic apparatus as a homeostatic system, that
ultimately "psychosocial" and "biological" interventions
both facilitate a common pathway of regulation. In treating
minor episodes of depression it is unnecessary to employ
the perturbing power of the antidepressant drugs, if
re-education can achieve the same result. This is especially
so if antidepressants, as some psychiatrists have argued,
can sensitize and destabili ze limbic pathways, even
in patients without bipolar illness.
In
recurrent depression, without mania, the story is different.
Professors Ellen Frank and David Kupfer and their colleagues
at the University of Pittsburgh, in a carefully conducted
study where patients with recurrent unipolar depression
were followed for three years, found that a maintenance
dose of tricyclic antidepressant provided a significant
advantage in preventing reoccurrence. Those individuals
who, after their initial recovery from an episode of
depression did not receive antidepressant medication,
lapsed rapidly into illness. These findings have been
confirmed by other researchers and resonate with the
brain imaging studies of psychiatrist Wayne Drevets,
which I described in Chapter Six. Doctor Drevets found
that in patients who had recovered from recurrent episodes
of depression, and who were no longer receiving treatment,
there were residual disturbances of blood-flow in the
region of the amygdala. In a subsequent study Dr. Drevets'
determined that it was only in those patients receiving
maintenance antidepressants that the limbic blood-flow
returned to a normal distribution.
However,
of particular interest in the Pittsburgh study was the
observation that those patients who received interpersonal
psychotherapy in addition to medication, had the best
outcome of all patient groups. Eighty-four percent of
those individuals who received a combination of psychotherapy
and the antidepressant drug imipramine, remained well
for the duration of the three year study. In these results
we see the multiplying power of combining what are generally
described as "biological" and "psychological" interventions.
The superior outcome of their combination emphasizes
that, while operating at a different level of the scientific
staircase, each treatment contributes in a significant
way to emotional homeostasis.
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