Book Review
Mood Disorders, Psychotherapy
Treatment for Chronic Depression: Cognitive Behavioral
Analysis System of Psychotherapy. JP McCullough Jr. New York:
Guilford Press; 2000. 326 p. US$37.00 .
Reviewer
rating*: Very Good
Review by John I Telner, PhD, CPsych, Robert J Bialik ,PhD, CPsych
Ottawa, Ontario
A recent paper in the New England Journal of Medicine (1) has been
well publicized as the first study to show that combination treatment
with antidepressant medication (nefazodone) and a particular variant
of cognitive therapy—cognitive-behavioural analysis system
of psychotherapy (CBASP)—is more effective than either treatment
alone in cases of chronic depression. This approach is the core
of this comprehensive textbook discussing CBASP in the treatment
of chronic depression. The book starts out with 2 interesting chapters
on well-known problems encountered by therapists treating patients
with chronic depression. The author lists these in capsule form
and frames the questions we all at some time ask ourselves, such
as Why do I keep feeling that nothing I do will make a difference?
How can I effectively treat a patient who is unmotivated to change?
and Why do I keep having feelings of inadequacy and helplessness
when I am with this patient? The stage is thus set for presenting
not only the problems inherent in the treatment of chronic depression
but also, and more importantly, a treatment strategy that differs
notably from what has been offered previously.
Dr McCullough tells us that he was motivated to develop this particular
approach to psychotherapy by the less-than-optimal response of patients
to more traditional cognitive therapies. His model aims to explain
why patients get stuck in therapy and do not benefit from the standard
cognitive-behavioural approaches to modifying attitudes and core
beliefs. The book is divided into 3 sections. In the first section,
the author explains his model, CBASP, and how it accounts for psychopathology.
Here, he develops his rationale for the goal of therapy with these
patients, which is to facilitate blocked or delayed cognitive-emotional
development. McCullough takes a rather elongated and intricate route
to convince us that his approach is sound. Although we do not entirely
agree with his rationale, we agree with his conclusion. There is
common ground between McCullough and Marvin Goldfried, the author
of the the book’s forward, which emphasizes cognitive-affective
development. In addition, McCullough’s model is not dissimilar
to that of Jeffrey Young, which goes beyond cognitive schemas and
directly addresses affective systems.
The second part of this book focuses on actual methods and procedures
used with the CBASP approach. This section is what most people would
look for in such a text; readers should not be disappointed. McCullough
divides this section into 5 major chapters that range from strategies
to enhance motivation for change to measuring outcome. Chapter 6
very clearly describes the 6 steps used in situational analysis
and provides relative case material. Chapter 8 focuses on the therapist–patient
relationship as an important aspect of modifying behaviour—something
that many cognitive therapists may find foreign but is in keeping
with McCullough’s interpersonal and integrative approach. The
third and final part of this volume deals with the history and other
aspects of CBASP. This section contains a chapter that compares
CBASP with both Beck’s cognitive therapy and Klerman’s
interpersonal psychotherapy. A most welcome chapter is the final
chapter, which deals with common patient problems and the lack of
positive outcome with this approach. Personal responsibility is
an important component of this treatment. On the one hand, McCullough
argues that patients are not responsible for their illness because
they have not learned the appropriate coping skills or have learned
maladaptive coping skills from early experiences. On the other hand,
he advocates that patients take responsibility (that is, ownership)
and take charge of what they can do about their illness. As Goldfried
points out, McCullough is a strong advocate for letting the patient
do the work of therapy.
Early in his book, McCullough identifies changes that he is trying
to facilitate with this approach to psychotherapy. The most central
concepts in our minds are captured by the following statement:
Teaching preoperational patients formal operations problem-solving
techniques makes it possible for them to become perceptually aware
of behavioural consequences (p. 17).
On page 33, he describes how most patients with chronic depression
have 3 important preoperational views: 1) they experience unpleasant
emotions (for example, sadness and anger) as unending experiences,
2) they generalize negative experiences with a single person (or
type of person) to all somewhat similar people, and 3) they cannot
separate their past experiences with parents and family from a potentially
different present. Therefore, McCullough suggests that “the
perception of time literally stops for the chronic patient, such
that the past defines interpersonal possibilities in the present
and future” (page #?) It follows that a detailed analysis and
focused encouragement to experience, perceive, and behave in new
ways is required if these patients are to make therapeutic gains.
This book should interest therapists from various orientations
who work with individuals suffering from chronic depression. It
is a well-written treatise on a novel approach to treating a difficult
and at times frustrating disorder. Technically, the book is attractive,
seems free from production errors, and is well-priced.
Reference
1. Keller MB, McCullough JP, Klein DN, Arnow B, Dunner
DL, Gelenberg AJ, Markowitz JC, Nemeroff CB, Russell JM, Thase ME,
Trivedi MH and Zajecka J. A comparison of nefazodone, the cognitive
behavioural-analysis system of psychotherapy, and their combination
for the treatment of chronic-depression. New Eng J Med 2000; 342:1460–70.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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